SUMMARY OF BENEFITS

University Family Care Plan

2024
Effective Date 01/01/2024
As permitted by the Patient Protection and Affordable Care Act (the Affordable Care Act), a
grandfathered health plan can preserve certain basic health coverage that was already in effect when
the law was enacted. Being a grandfathered health plan means that your plan may not include certain
consumer protections of the Affordable Care Act that apply to other plans, for example, the
requirement for the provision of preventative health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the Affordable
Care Act, for example, the elimination of lifetime limits on benefits. This group health plan believes
this coverage is a “grandfathered health plan” under the Affordable Care Act.

Questions regarding which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be
directed to Human Resources at 2 1 0 - 358-2275. You may contact the Employee Benefits Security
Administration, U.S. Department of Labor at 1-866-444-3272 or
https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act. You may also
contact the U.S. Department of Health and Human Services at www.healthcare.gov.
ADMINISTERED BY
COMMUNITY FIRST HEALTH PLANS
12238 Silicon Drive, Suite 100
San Antonio, Texas 78249
TELEPHONE 210-358-6090
Or
1-800-434-2347

UH-FCP 2023
Attachment B
IMPORTANT NOTICE AVISO IMPORTANTE

To obtain information or make a complaint: Para obtener informacion o para someter una
queja:
You may call Community First for
information or to file a complaint at 210- 358- Usted puede llamar a Community First para
6090 Local San Antonio Area 1- informacion o para someter una queja al
800-434-2347 Toll Free
210-358-6090 Local San Antonio Area 1-
800-434-2347 Toll Free
CLAIM DISPUTES:
DISPUTAS SOBRE SU PREMIO O
Should you have a dispute concerning your RECLAMOS:
premium or about a claim, you should first
contact Community First. Si tiene una disputa concerniente a su premio
o a un reclamo, debe comunicarse con
Community First primero.

UH-FCP 2023 i
 TABLE OF CONTENTS

Page

EMPLOYEE HEALTH BENEFIT PLAN (PLAN) .................................................................................1

I. WHO IS ELIGIBLE TO BECOME COVERED ............................................................2

A. FOR EMPLOYEE COVERAGE .............................................................................2
1. You are eligible for Employee Coverage ..................................................2
2. You are not eligible for Employee Coverage............................................2
B. FOR DEPENDENT COVERAGE ...........................................................................2
1. You are eligible for Dependent Coverage.................................................2
2. Dependents eligible for Coverage ..............................................................2
3. Exception(s).................................................................................................4
4. A child will not be considered a Dependent
of more than one Employee .......................................................................4
5. You are not eligible for Dependent Coverage ..........................................4
6. Your Dependent Coverage becomes effective ..........................................4

II. AUDIT PROCESS..............................................................................................................4

A. DEPENDENT VERIFICATION PROCESS ............................................................4
B. DOCUMENTATION REQUIRED WHEN ENROLLING
A NEW DEPENDENT ...............................................................................4
C. RANDOM DEPENDENT ELIGIBILITY AUDITS .................................................5

III. WHEN YOU BECOME COVERED ................................................................................5

A. INITIAL ENROLLMENT PERIOD........................................................................5
1. General Rule: When You Become an Eligible Employee ......................5
2. General Rule: Acquiring New Dependents .............................................5
3. Default Health Care Coverage ..................................................................5
4. Special Dependent Coverage Rules for Newborn and Adopted
Children ......................................................................................................6
B. OPEN ENROLLMENT PERIODS ..........................................................................6
C. SPECIAL ENROLLMENT PERIODS .....................................................................7
1. Special Enrollment Period for Employees and Dependents Who Lose
Coverage......................................................................................................7
2. Special Enrollment Period for Court-Ordered Coverage of a Spouse or
Child ............................................................................................................8
3. Special Enrollment Period for Changes in Family Circumstances.........8
D. NOTICE OF CHANGE IN FAMILY STATUS .......................................................9
E. SPECIAL COVERAGE RULES IN CASE OF AN INPATIENT
CONFINEMENT .....................................................................................................9

UH-UFCP 2023 ii
Community First Health Plans
IV. HEALTH CARE COVERAGE ........................................................................................ 9
A. FOR YOU AND YOUR DEPENDENTS ................................................................ 9
1. In General, .................................................................................................. 9
2. Primary Care Physician (PCP) Selection ................................................ 10
3. OB/GYN Selection .................................................................................... 10
4. Changing Your PCP................................................................................. 10
B. COVERED SERVICES AND SUPPLIES ............................................................. 10
1. In General, ................................................................................................ 10
2. Participant’s Authorization and Financial Responsibility .................... 14
3. Covered Services ...................................................................................... 17
C. LIMITATIONS ...................................................................................................... 32
D. EXCLUSIONS ....................................................................................................... 35

V. RIGHT OF SUBROGATION AND REIMBURSEMENT UNDER THE PLAN ....... 40

VI. GENERAL RULES FOR COORDINATION OF BENEFITS..................................... 45

A. DEFINITIONS ....................................................................................................... 45
1. Health Care Program ............................................................................... 45
2. Separate Programs ................................................................................... 45
3. Primary or Secondary Plan ..................................................................... 45
4. Allowable Expense.................................................................................... 46
5. Managed Care Provisions ........................................................................ 46
6. Claim Determination Period.................................................................... 46
B. EFFECT ON BENEFITS ....................................................................................... 47
1. This Plan’s Rules for the Order in which Benefits are
Determined................................................................................................ 47
2. Effect of Reduction in Benefits ................................................................ 49
C. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION ..................48
D. FACILITY OF PAYMENT .................................................................................... 49
E. RIGHT OF RECOVERY ....................................................................................... 49
F. LOCAL/IN-NETWORK vs. OUT OF NETWORK/OUT OF STATE ................... 49

VII. COORDINATING BENEFITS WITH MEDICARE .................................................... 49

A. WHEN MEDICARE IS THE PRIMARY PAYER ............................................... 49
B. WHEN THE PLAN IS THE PRIMARY PAYER ................................................ 50
C. RETIREES UNDER 65 RECEIVING SOCIAL SECURITY DISABILITY....... 51

VIII. CLAIMS RULES.............................................................................................................. 51

A. REIMBURSEMENT PROVISIONS FOR NON-PARTICIPATING
PROVIDERS OR OUT-OF-AREA CLAIMS ........................................................ 51
B. PROOF OF LOSS .................................................................................................. 52
C. PHYSICAL EXAM ................................................................................................ 52
D. LEGAL ACTION ................................................................................................... 52
IX. GENERAL INFORMATION ............................................................................................. 52

UH-UFCP 2023 ii
Community First Health Plans
 A. COMPLAINT/APPEALS PROCESS..................................................................... 52
1. Where to File a Complaints/Complaint Appeals ................................... 52
2. General ...................................................................................................... 52
3. Process for Complaint Resolution ........................................................... 53
4. Appeals Process ........................................................................................ 53
5. Maintenance of Records .......................................................................... 54
6. Appeal of an Adverse Determination...................................................... 54
7. Process for Requesting Independent Review
of an Adverse Determination ................................................................... 56
8. Expedited IPRO Appeals of Adverse Determination............................. 56
B. IDENTIFICATION CARDS................................................................................... 58
C. CONFIDENTIAL NATURE OF MEDICAL RECORDS ...................................... 58
D. ASSIGNMENTS .................................................................................................... 58
E. NOTICES AND OTHER INFORMATION........................................................... 59
F. WHEN YOUR COVERAGE ENDS ...................................................................... 59
1. Employee and Dependent Coverage ....................................................... 59
G. CONTINUATION PRIVILEGE ............................................................................ 62
1. Continued Coverage for an Incapacitated Child ................................... 62
2. Continued Coverage at You and Your Dependent’s Option ................ 62

X. HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA) ................................................................. 64
XI. DEFINITIONS ................................................................................................................. 65
Schedule of Benefits and Copayments
Outpatient Prescription Medication Rider

UH-UFCP 2023 ii
Community First Health Plans
 THE UNIVERSITY HEALTH (UH)
EMPLOYEE HEALTH BENEFIT PLAN (PLAN)

• COMMUNITY FIRST HEALTH PLANS, INC. (COMMUNITY FIRST) certifies that it will
administer the Plan to you and your dependents, in accordance with the terms of the Plan
Administrator Agreement.
.
Covered Employee: You are eligible to become covered if you are in the “Covered
Classes” shown below and meet the requirements in the “Who is
Eligible to Become Covered” section. The “When You Become
Covered” section states how and when you may become covered.
Your Coverage will end when the rules in the “When Your Coverage
Ends” section so provide.

Plan Sponsor: University Health

Group Contract No.: 004012-0006, 004012-0007, 004012-0008, 04012-0009, 004012-

00010, 004012-0011

Effective Date: January 1, 2024 This Summary of Benefits describes the benefits
under the Employee Health Benefit Plan.

Covered Classes: All eligible employees who live, work, or reside in the service area.

Limiting Age for Up to age 26 for children. However, this age Dependent(s)
limitation does not apply to a child who is medically certified as
disabled and dependent on the parent. See Dependent Coverage
for more details.

Service Area Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina

and Wilson County. The expanded network “PPO Network” is
now available n a t i o n wide.

Administrator Community First Health Plan’s, Inc.

Mailing Address: 12238 Silicon Drive, Suite 100, San Antonio,
Texas 78249
Physical Address: 12238 Silicon Drive, Suite 100, San Antonio,
Texas 78249
Community First’s
Telephone Number: 210-358-6090

Member Services Number: 210-358-6090 or 1-800-434-2347

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I. WHO IS ELIGIBLE TO BECOME COVERED

A. FOR EMPLOYEE COVERAGE

1. You are eligible for Employee Coverage while:

• You are an Eligible Retiree.

• You are an Eligible Employee.
• You are in the Covered Classes; and have completed any
employment waiting period required by the Employer.

UH determines the covered classes. This will be done under its rules, on
dates it sets. UH will not discriminate among persons in like situations and
cannot exclude you from a covered class based on a health status related
factor.

2. You are not eligible for Employee Coverage if your coverage under any
Community First group health care coverage was terminated for cause, as
described in the “When Your Coverage Ends” section.

B. FOR DEPENDENT COVERAGE

1. You are eligible for Dependent Coverage while:

• You are an eligible employee; and

• You have a qualified dependent.

2. Dependents eligible for coverage:

• Your legal spouse.

• Your common law spouse.
• Your eligible children. The definition of an eligible child includes:
o Your natural born child.
o Your stepchild.
o Your adopted child or a child placed with you for adoption;
o A dependent covered under a Qualified Medical
Child Support Order.
o A child for whom you are an appointed legal guardian.
• Court ordered dependents that reside outside of
the service area may be covered under the UFCP
plan but must obtain care through the UFCP or
UFCP Expanded Network (applicable out of
pocket costs will apply such as deductible and
coinsurance. Services obtained outside of the
UFCP or

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 UFCP Expanded Network without a prior authorization will
be the member’s responsibility.
• Plus one Qualifying Adult. The definition of Plus one Qualifying
Adult includes:
o Must have resided together in the same residence for at least
12 months and must continue to do so for the Plus One
Qualifying Adult to remain eligible for benefits.
o Must be 18 years of age or older.
o Must be financially interdependent with the University Health
employee, sharing common financial obligations as
evidenced by 3 or more of the following documents:
All 3 Evidenced Items Must be turned in and Certified
before Benefits are Effective
o Joint Deed or mortgage agreement to demonstrate
common ownership of real property or a common
leasehold interest in real property.
o A title or vehicle registration showing
common ownership of a motor vehicle.
o Proof of joint bank accounts or credit accounts.
o Proof of designation as the primary beneficiary for life
insurance or retirement benefits.
o Assignment of a durable property power of attorney or
health care power of attorney.
o Out of State Marriage License or Civil Certificate.

Please note that the following individuals are not eligible for
designation as a Plus One Qualifying Adult:
o Parents
o Parents' other descendants
o Grandparents and other descendants
o Step relatives
o Renters, boarders, tenants
o Employees of University Health cannot be added as a
Plus One (spouse or domestic partner) if they
separately enrolled in the UFCP

Qualifying Children:
▪ Medical - Up to age 26.

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 3. Exception(s)

a. Children who have a behavioral or physical disability are eligible

to continue coverage after they have attained these age limits
provided that they are incapable of self-sustaining employment
because of the disability and are chiefly dependent on you for
financial support and maintenance. Contact Human Resources for
additional information.

b. Your spouse or child does not qualify as your dependent while

covered under the Plan as an employee.

c. Grandchildren are not covered unless the qualifications are met as

listed above in Dependents eligible for coverage.

4. A child will not be considered a Dependent of more than one

Employee.

5. You are not eligible for Dependent Coverage if your coverage under any
Community First group health care coverage was terminated for cause, as
described in the “When Your Coverage Ends” section.

6. Your Dependent Coverage becomes effective as described in the “When

You Become Covered” section.

II. AUDIT PROCESS

A. Dependent Verification Process

The purpose of the Dependent Verification Process is to ensure UH provides

high-quality, cost-effective healthcare coverage to eligible employees and their
dependents.

B. Documentation Required When Enrolling a New Dependent

Dependents added to coverage must complete an eligibility verification process.

When a participant enrolls a new dependent, they will receive a notice from the UH
Human Resources department and will be required to submit appropriate
documentation. Participants electing and/or adding dependent coverage have 30
days as a new enrollee, 31 days for a qualifying event and the entire annual open
enrollment period to return the appropriate documentation. If verification is not
completed by the deadline, UH will retroactively drop the dependent as of the
coverage effective date.

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 C. Random Dependent Eligibility Audits

UH conducts random checks to ensure only eligible dependents are covered. Severe
penalties, including the loss of coverage and liability for repayment, could apply if
you knowingly attempt to cover or continue to cover anyone who is not eligible.

During the random check process, UH will select participants covering any type of
dependent and require them to submit documentation of eligibility (includes
spouse, common law spouse, dependent child).

Participants must submit the required documentation by the deadline indicated by

UH (see section II.B). If a participant does not respond by the date indicated, the
dependent will be dropped from all coverages.

If a participant was previously selected for the audit but did not provide appropriate
documentation and was dropped from coverage, they must provide the
documentation before adding the dependent to coverage during annual open
enrollment.

III. WHEN YOU BECOME COVERED

You may only enroll yourself or your dependents during the enrollment periods described
below:

A. INITIAL ENROLLMENT PERIOD

1. General Rule: When You Become an Eligible Employee You may

enroll yourself and your dependents within 30 days after first becoming an
eligible employee. Coverage will not begin sooner than the first day of the
month following the end of the waiting period.

2. General Rule: Acquiring New Dependents You may enroll a qualified

dependent within 31 days after you acquire the dependent through
marriage, birth or adoption.

3. Default Health Care Coverage UH requires all eligible employees, as a

condition of employment, to carry health care coverage, whether under a
component plan or a plan or policy not provided by UHS. Employees who
fail to carry health care coverage shall be automatically enrolled in a default
plan, as identified by UH. If UH becomes aware of an employee’s lack of
health care coverage by the date that compensation reduction contributions
would otherwise begin, UH shall automatically withhold premiums for the
employee’s default coverage on a pre-tax basis under this Plan. If UH
becomes aware of an employee’s lack of health care coverage at any other
time, the premiums will be withheld on an after-

5
 tax basis for the remainder of the plan year of the employee’s hire, or until
a special election period begins, if sooner. Default health care coverage is
provided for the employee only and the employee shall be allowed to add
family members only during the next open enrollment period unless access
to health care coverage is required under HIPAA or other applicable law.

4. Special Dependent Coverage Rules for Newborn and Adopted

Children If a child is born to you or adopted by you while you are
covered for employee coverage, your child will be covered from the date
of the child’s birth, or date the child becomes the subject of a suit for
adoption. Coverage for the child is subject to the “When Your Coverage
Ends” section and to the following provisions:

a. the coverage for the child will not end during the (31) day period
starting with the child’s birth or adoption because you fail to pay
any required contribution for that coverage.

b. The coverage for the child will not continue beyond the end of that
(31) day period unless, before the end of that period, you have
notified the UH Human Resources department of the birth and paid
any additional premium you owe for the added dependent coverage.
If you do not provide notice of the birth, coverage for the child
terminates on the 32nd day after the birth even if you do not owe
additional premium for the child.

c. If your dependent becomes pregnant during the plan year,

coverage is limited to prenatal care and delivery only. The
dependents dependent is not eligible for coverage unless the
child meets the eligibility requirements listed under I. Who is
Eligible to Become Covered, B. For Dependent Coverage.

B. OPEN ENROLLMENT PERIODS

1. During the open enrollment period, you may elect to cover yourself and
qualified dependents if:

a. You and your qualified dependents are covered under other health
care coverage, and you wish to switch coverage to the Plan; or

b. You first become eligible for employee coverage during the open
enrollment period; or

c. You were previously eligible to enroll for employee coverage but

did not enroll or are no longer enrolled.

6
 2. If you elect for yourself and your dependents to become covered under the
Plan during the open enrollment period, your or your dependent’s coverage
will begin on the open enrollment date established by UH, if all the
conditions below are met on that date:

a. You are eligible for employee coverage.

b. You have enrolled for the coverage via the UH online website or
completed the benefits enrollment form and, agreed to pay the
required contributions.

c. You reside, live or work in the Service Area.

C. SPECIAL ENROLLMENT PERIODS.

1. Special Enrollment Period for Employees and Dependents Who Lose

Coverage Eligible employees and dependents that lose other coverage
shall have 31 days to enroll in the Plan, if the following conditions are
met:

a. The eligible employee or dependent is eligible for coverage and he

or she failed to enroll when first eligible; and

b. When enrollment was previously offered and declined, the eligible

employee or dependent had other coverage; and

c. When enrollment was declined, the eligible employee stated in

writing that he or she was declining coverage because he or she or
the dependent had other coverage; and

When enrollment was declined:

(1) The eligible employee or dependent was covered under COBRA or

state continuation periods and the continuation period has since
been exhausted; or

(2) When enrollment was declined, the eligible employee had coverage
other than COBRA or state continuation coverage that has since
terminated due to loss of eligibility or because the employer ceased
contributions to the plan.

Loss of eligibility includes a loss of coverage as a result of a legal

separation, divorce, death, termination of employment, reduction in
hours, and any loss of eligibility.

7
 (3) A special enrollment period is not available to an eligible person
and/or dependents if previous coverage was terminated for cause or
failure to timely pay premiums.

2. Special Enrollment Period for Court-Ordered Coverage of a Spouse

or Child

a. Coverage automatic for 30 days If UH receives a medical support

order or notice of a medical support order requiring you to enroll
your spouse or child for coverage, the Plan shall cover the spouse
or child for 30 days after receipt of the order or notice.

b. Enrollment Required to Continue Coverage Coverage for such

spouse or child will end unless you or another person authorized
applies for enrollment of the spouse or child and pays any
additional premium by the last day of the month in which the 30-
day automatic coverage period expires.

c. Removal of Court Order Coverage Coverage of spouse or child

cannot be removed or canceled until UH HR receives a court
order expressing that the respective UH employee is no longer
mandated by the court to sustain coverage for their spouse/child.

3. Special Enrollment Period for Changes in Family Circumstances

a. Enrollment of Eligible Employee An eligible employee may

enroll in the Plan outside of the open enrollment period if the
employee:

(1) Is eligible for the Plan.

(2) Is not enrolled because he or she previously declined
enrollment; and
(3) Applies for enrollment and pays the required contribution
to premium within 31 days after either:
• Acquiring a new dependent through marriage, birth,
adoption, or placement for adoption; or
• UH receives a medical support order or notice of a
medical support order requiring the Employee to
cover his or her spouse or child.

b. Enrollment of Spouse of Eligible Employee An eligible

employee may enroll his or her spouse in the Plan outside of the
open enrollment period if:

(1) The eligible employee and his or her spouse have a child

8
 who becomes a dependent through birth or adoption; and
(2) The eligible employee applies for enrollment and pays the
required contribution for his or her spouse within 31 days
after the child is born or adopted.

D. NOTICE OF CHANGE IN FAMILY STATUS

It is important that you inform the UH Human Resources Department promptly

when:

• You first acquire a qualified dependent.

• A new qualified dependent becomes eligible; or
• A qualified dependent becomes ineligible.

E. SPECIAL COVERAGE RULES IN CASE OF AN INPATIENT

CONFINEMENT

Confined as an Inpatient If you or your dependent are confined in a hospital or

other facility on the date that you or your dependent become enrolled in the Plan,
you must notify the facility and Community First within (2) days or as soon as
reasonably possible and authorize Community First to assume responsibility to
arrange for the confined persons’ health care.

If you fail to notify Community First of the hospitalization or to allow Community

First to coordinate your care, the Plan will not be obligated to pay for any expenses
related to your hospitalization following the first two (2) days after your coverage
begins.

The services are not covered if you or your dependent are covered by another
health plan on that date and the other health plan is responsible for the cost of
services. The Plan will not cover any service that is not a covered benefit under
the Plan. To be covered, you must utilize participating providers and are subject
to all the terms and conditions set forth in the Plan.

Community First may transfer you or your dependent to a participating provider

and/or a participating hospital if the Medical Director, in consultation with your
physician, determines that it is medically safe to do so.

IV. HEALTH CARE COVERAGE

A. FOR YOU AND YOUR DEPENDENTS

1. In General This coverage provides benefits for many of the services and
supplies needed for care and treatment of you or your qualified dependents'
illnesses and injuries, or to maintain your or your qualified dependents'
good health, as determined by your PCP. Not all services and
9
 supplies are eligible; some are eligible only to a limited extent.

2. Primary Care Physician (PCP) Selection Your next choice is to select

who will provide the majority of you and your qualified dependents’
health care services. Your PCP will be the one you call when you need
medical advice, when you are ill and need preventive care such as
immunizations. Each covered participant may select his or her own PCP
from the participating provider directory. Primary medical care includes
the following medical specialties: internal medicine, general, pediatrics
and family practice.

Should you have a chronic, disabling, or life-threatening illness, you may

apply to Community First's Medical Director to utilize a participating
specialty physician as a PCP, provided that (1) the request includes
information specified by Community First, including certification of
medical need, and is signed by you and participating specialty physician
interested in serving as the PCP; (2) the participating specialty physician
meets, and agrees to abide by the Community First requirements for PCP;
and (3) the participating specialty physician is willing to accept the
coordination of all of your health care needs.

If such request is denied, you may appeal the decision through Community
First's established Complaint and Appeals process. Should such request be
approved, the new designation shall not be retroactive and shall in no way
reduce the amount of compensation owed to the original PCP prior to the
date of the new designation.

3. OB/GYN Selection A female participant entitled to coverage shall be

permitted direct access without a referral by the female participant’s PCP
or preauthorization to receive health care services from a participating
obstetrician or gynecologist.

4. Changing Your PCP A strong PCP/participant relationship is critical.

However, we also realize that there may be a need for a participant to
change his/her PCP. If you must change your PCP, you may do so by
calling Community First’s Member Services Department. Requests for
changes received will take effect on the first day of the following month.

B. COVERED SERVICES AND SUPPLIES

1. In General The Plan will arrange or provide for benefits for the covered
services and supplies set forth in this section. You will need a referral from
your PCP in order for the Plan to cover most covered services and supplies
rendered by other participating providers. Some services, such as hospital
confinements, also require Preauthorization by Community First.

10
However, you will not need a referral or preauthorization for:

▪ Emergency Care.
▪ Female participant to have direct access to health care services of a
participating obstetrician or gynecologist.
▪ Behavioral Health with participating providers.

All covered services rendered by non-participating providers, except in the

case of a medical emergency, require preauthorization by the Community
First. Preauthorization is granted on the condition that the participant is
eligible for covered services at the time the covered services are received.
Preauthorization will be denied if the requested supply or service is not a
covered service or supply. If you have any questions about whether a
covered service or supply requires preauthorization, contact your PCP or
Community First’s Member Services Department.

Covered Services are those services and supplies furnished to participants

as described in the paragraph below. Some covered services and/or
supplies below may require medical review for medical necessity and/or
appropriateness prior to preauthorization.

a. Covered Services: All covered services must be furnished to a

participant:

(1) by a PCP.
(2) by another participating provider and authorized by a PCP
or Community First.
(3) by a non-participating provider and authorized by
Community First.
(4) by a participating specialty care physician approved by
Community First's Medical Director to perform the services
of a PCP pursuant to a request of a participant with a chronic,
disabling or life-threatening illness; or
(5) by a participating obstetrician or gynecologist or a
participating behavioral health provider.

It is your responsibility to obtain a referral from your PCP to see

a specialty care physician. Preauthorization may be required to
obtain specific services or supplies from a specialty care
physician or prior to undergoing hospitalization, outpatient
surgery or diagnostic procedures.

Referral A referral is a recommendation by a participant’s PCP

or other treating provider for a patient to be evaluated or treated by
another physician or provider. This does not apply to OB/GYN or
Behavioral Health providers.
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 Authorization Certain services and supplies under this Plan may
require authorization by us to determine if they are covered benefits
under this Plan. Your physician must obtain an approval for certain
services. Benefits are payable only when we determine the care is
clinically appropriate to treat your condition. To be eligible to receive
full benefits, you must follow the preauthorization process and get
Plan approval of your treatment plan.

If medically necessary covered services are not available through a

participating provider, Community First will, at the request of a
participating provider, and within a reasonable time period, allow
referral to a non-participating provider and reimburse the non-
participating provider at the usual and customary rate or at a
negotiated rate. Before such a requested referral can be denied,
Community First may have the request reviewed by a specialist of
the same or similar specialty as the physician or provider to whom
the referral is requested.

b. After Hours Care: Illnesses and injuries often do not happen during
normal office hours. If your call is placed after your PCP’s office
hours, you will be assisted by an answering service that will notify
the physician on call and advise you on how to proceed.
Additionally, participants may call NurseLink, Community First’s
24-hour nurse advice/triage service. You may reach this service
by calling 210-358-3000 or 1-800-434-2347.

c. Urgent Care: In the event of an urgent situation (illness or injury)

that is severe or painful enough to require assessment and/or
treatment within 24 hours, you should contact your PCP who will
direct you based on the symptoms. You may also visit the
University Health’s Express Med Clinic. Additionally, participants
may call NurseLink, Community First’s 24-hour nurse
advice/triage service. You may reach this service by calling 210-
358-3000 or 1-800-434-2347.

An urgent care situation is not as serious as an emergency. Urgent

care includes services other than those for an emergency that result
from an acute injury or illness that is severe or painful enough to
lead a person with an average knowledge of medicine and health
to believe that the condition, illness or injury is such that failure to
get treatment within a reasonable period of time would cause
serious deterioration of his or her health.

Any urgent care provided by a facility other than a University

Health Express Med Urgent Care Clinic will be processed under

12
 the Expanded Network, and corresponding
deductible/coinsurance would be applied to these claims. If a
provider is not currently contracted with the Expanded Network,
you will be responsible for all billed charges.

d. Medical Emergency: Services for a medical emergency are covered

anywhere in the world 24 hours a day. If a medical emergency
occurs, you should go to the nearest participating or non-
participating medical facility. Community First will have
preauthorization staff on duty at phones during regular business
hours.

Emergent care includes, but is not limited to, severe pain that would
lead a prudent layperson, possessing an average knowledge of
medicine and health to believe that his or her condition, sickness, or
injury is of such a nature that failure to get immediate medical care
could result in:

• Placing his or her health in serious jeopardy

• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part
• Serious disfigurement; or
• Serious jeopardy to the health of the fetus in the case of a
pregnant woman

A University Hospital emergency room visit will be processed as

an in-network provider. An emergency room visit provided by a
facility under the First Health Network (Expanded Network) will
be processed at a 30% coinsurance after annual deductible is met.
Hospitals outside of the First Health Network (Expanded
Network), will be processed as an out of network provider and
will be reimbursed at the reasonable and customary rate
according to the emergency diagnosis submitted on the claim.

For Necessary emergency care services within the country, a non-

participating provider will usually submit claim and the member
will pay any applicable copays to provider at time of service. A
non-participating provider will receive Usual and Customary from
Community First Health Plans as payment.

For Necessary emergency care services out of the country,

members will be required to pay out of pocket for cost of services
rendered and submit a claim or receipts for services paid.
Community First Health Plans will review and reimburse the
member at the Usual and Customary Rate. The member may not
13
 be reimbursed in full. Claims will be paid at the current rate of
exchange.

Necessary emergency care services will be provided to participants,

including the treatment and stabilization of a medical emergency,
and any medical screening examination or other evaluation required
by state or federal law necessary to determine if a medical
emergency exists.

If it is determined that a medical emergency does exist, the Plan

will pay for medically necessary emergency care services required
to evaluate and stabilize the medical condition performed by
participating or non-participating providers. Non-participating
providers will be reimbursed at negotiated or usual and customary
rates for the services performed. Community First will approve or
deny coverage of post-stabilization care, as requested by a treating
provider, within the timeframe appropriate to the circumstances,
but in no case to exceed one hour.

If you have received emergency care and the provider who treated
you indicates that you will need follow-up care to complete the
treatment, the follow-up care must be rendered by the participant’s
PCP or the appropriate specialist, not by the provider who treated
you for the medical emergency. The participant, or someone acting
on the participant’s behalf, should contact the participant’s PCP or
the appropriate specialist within 24 hours, or as soon as reasonably
possible, so that he or she may arrange for follow-up care.

Participants should not use the emergency room or urgent care

facility for routine or non-emergent services. If you choose to use
the emergency room or urgent care facilities for routine or non-
emergent services, then you will be responsible for all billed
charges relating to the services. You can use Community First’s
Complaint and Appeals Process to resolve a dispute regarding
emergency care.

If you have any questions regarding whether a situation constitutes a

medical emergency, please contact your PCP. Additionally,
participants may call Community First’s 24-hour nurse advice/triage
service, NurseLink. You can reach this service by calling 210-358-
3000 or 1-800-434-2347.

2. Participant’s Authorization and Financial Responsibility

a. Authorization: Participants hereby authorize licensed physician,

hospital, pharmacy, clinic, health care facility, insurance company,
14
 employer, or organization to release to University Health or its
agents any information regarding the participant or any enrolled
dependents’ medical history, treatment, and/or disability that is
reasonably necessary for the purpose of utilization review,
coordination of benefits, or payment of a claim.

The authorization shall cease to be effective at such time when

participants’ coverage under the Plan terminates. In the event that
participant or dependents have any outstanding claims at time of
termination, the authorization will continue to apply until all the
claims have been settled. Participant understands that UH will
automatically deduct from participants’ wages the amount of any
co-pays the participant or any dependents incur as a result of
receiving medical services or supplies from UH under any UH-
sponsored health plan. See Section X. Health Insurance Portability
and Accountability Act (HIPAA).

b. Accessing Authorized Covered Services: When accessing

authorized covered services from a participating provider, you
will only owe a copayment to that provider. It is the participant’s
responsibility to ensure that the providers from whom you
receive services are contracted with Community First. A
preauthorization will be required prior to services being
rendered outside of the UFCP network should a specific service
or specialty not be available within the UFCP network.

All services received from a non-participating provider require

preauthorization except for emergency care. All out-of-network
services require a preauthorization. You will be liable for all charges
if services are not preauthorized. If you receive preauthorized
services from a non-participating provider, and that provider has not
agreed to a negotiated rate from Community First, then Community
First may pay the usual and customary charge for the services
provided, and you may be responsible for the difference between
the amount paid by Community First and the amount of the full
charge billed by the non-participating provider.

If you pay up front and seek reimbursement for the preauthorized

services you received from a non-participating provider, you will
be reimbursed the usual and customary charge or negotiated rate
less the copayment.

c. Accessing UFCP Expanded Network: If member chooses to

utilize the First Health Expanded benefit, the member will be
subject to the expanded network out-of-pocket costs such as
deductible and coinsurance. UFCP Expanded Network is
15
 available Nationwide.

d. Contract Status of Providers: You should ask about the contract

status of the providers from whom you receive treatment,
especially when you are referred by your PCP to a specialty care
physician and when you receive services at a participating hospital
as some facility based physicians or other health care practitioners
such as anesthesiologist, pathologist, neonatologist, emergency
room physicians and radiologist may not be included in
Community First’s network and may balance bill you for amounts
not paid by Community First. Diagnostic and lab fees are covered
only if testing is performed at UH facilities. If you receive services
from a non-participating provider, and that provider has not agreed
to a negotiated rate from Community First, then Community First
may pay the usual and customary charge for the services provided.
The non-participating providers will be reimbursed usual and
customary charges even if the services are rendered at a
participating facility. Member will be responsible for any
remaining balances.

If you receive a bill from any participating provider asking you

to pay for something other than a copayment or applicable
deductible and/or coinsurance for Expanded Network services,
please notify Community First’s Member Services Department
immediately.

e. Premiums: Participants may pay a premium for Plan coverage. The

premium amount and payment arrangements are made through UH.
UH will determine the fixed price per participant and will determine
how much of that cost to pass along to you.

f. Copayments: In addition to any payroll deduction UH may impose;

you will be responsible for appropriate copayments. The
copayments that apply to certain covered services and are described
in the Schedule of Copayments attached to and made a part of this
Plan. Participating providers will look only to the Plan and not to
you for payment of covered services, except for payment of
applicable copayments.

16
 g. Services or Supplies that are Not Covered under this Plan: If you
receive health care services or supplies that are not covered
services and supplies, you will be financially responsible for the
entire cost of service.

h. Unauthorized Services: You will be held financially

responsible for the entire cost of services if you:

• Obtain health care services, in circumstances other

than a medical emergency, from a non-participating
provider without preauthorization.
• Obtain services from a participating provider who is not
your PCP without a referral from your PCP, except for
the following services, which do not require a referral
or preauthorization:

o Accessing care from a participating provider

o who is an obstetrician or gynecologist.
o Accessing care from a participating Behavioral
health provider.
o Emergency care.

3. Covered Services: The covered services are those that are in the list below.
Section C (“Limitations”) describes any modification of these covered
services for certain illnesses. A service or supply is not a covered service
or supply if excluded. It is excluded to the extent it falls outside any limits
described in Section C (“Limitations”) or is described in Section D
(“Exclusions”). Some covered services and/or supplies below may require
medical review for medical necessity and/or appropriateness prior to
preauthorization.

Acquired Brain Injury Cognitive rehabilitation therapy, cognitive

communication therapy neurocognitive therapy and rehabilitation,
neurobehavioral, neurophysiological, neuropsychological, and
psychophysiological testing and treatment, neurofeedback therapy, and
remediation. Post-acute transition services, community reintegration
services, including outpatient day treatment services, or other post-acute
treatment services. Medically necessary treatment and services can be
obtained at a hospital including an acute or post-acute rehabilitation
hospital or an assisted living facility regulated under Chapter 247, Health
and Safety Code.

Also covered is reasonable expenses related to periodic reevaluation of

the care provided to a participant who has incurred an acquired brain
injury, has been unresponsive to treatment and becomes responsive to
treatment at a later date.
17
Alcohol/Chemical Dependency Medically necessary care and
treatment of alcohol/chemical dependency will be covered the same
as any other physical illness. See Schedule of Benefits and
Copayments.

Allergy and Treatment Medically necessary allergy testing including food

allergy to evaluate and determine the cause of allergy and appropriate allergy
treatments including injections and serum. See Schedule of Benefits and
Copayments.

Ambulance Services Emergency ground or air ambulance transportation

when medically necessary. Community First will pay up to $1,500 of the
usual and customary charge for the services provided, and you will be
responsible for the difference between the amount paid by Community First
and the amount of the full charge billed by the non-participating provider.
Please be advised that currently, there are no contracted ambulance service
providers. See Exclusions.

Amino Acid-Based Elemental Formula is covered if medically necessary

for the treatment of the following:

(1) Milk or soy protein allergies/intolerance

(2) Multiple food protein intolerance

(3) Food protein allergy induced: Eosinophilic esophagitis and

gastroesophageal reflux disease

(4) Other medical conditions requiring an amino acid-based diet, such as:
short bowel syndrome and transition from parenteral to enteral nutrition

Alzheimer’s Disease Demonstrable proof of organic disease or other proof

is required before Community First Health Plans will authorize payment of
benefits for Alzheimer's disease. That proof requirement is satisfied by a
clinical diagnosis of Alzheimer's disease made by a physician licensed in
this state, including a history and physical, neurological, and psychological
or psychiatric evaluations, and laboratory studies.

Anesthetics and their administration.

Asthma Treatment, care and supplies related to asthma, as provided or

prescribed by a participating physician or other qualified participating
provider.

Autism Spectrum Disorder The Plan will cover medically necessary

services that are generally recognized services when prescribed by the
18
participants PCP. Services are limited as outlined on the Schedule of
Benefits. Generally recognized services may include:

1. screening between ages 18 and 24 months

2. evaluation and assessment services
3. applied behavior analysis; *
4. behavior training and behavior management
5. speech therapy
6. occupational therapy
7. physical therapy; or
8. medications or nutritional supplements used to address symptoms of
autism spectrum disorder

An individual providing treatment prescribed must be a health care

practitioner who is licensed, certified, or registered by an appropriate agency
of this state; whose professional credential is recognized and accepted by an
appropriate agency of the United States; or who is certified as a provider
under the military health system. See Exclusions and Schedule of Benefits
for limitations on speech, occupational and physical therapies.

**Applied Behavioral Analysis

Covered diagnoses include Autism, developmental brain disorders
known as Pervasive Developmental Disorders (PDD).
Other covered Pervasive Developmental Disorders not otherwise specified
(PDD-NOS) are Asperger Syndrome, Rett Syndrome and Childhood
Disintegrative Disorder.

• Autistic Disorder
• Atypical Autism
• Childhood Disintegrative Disorder
• Asperger's Disorder
• Rett's Disorder

The member may obtain services through a participating provider via

outpatient services or through their Home Health benefit. Both benefits will
have an applicable copay and no visit limitation with an ABA diagnosis.
**Home Health visits cannot be combined with outpatient therapies benefit.

Behavioral Health Services The Services The following behavioral health

services will be covered as any other illness.

(1) Inpatient Behavioral Health/Alternative Treatment. The Plan will

cover the following inpatient/alternative behavioral health
treatment.

19
 (a) Treatment of behavioral or emotional illness or disorder for a
person when confined in a hospital.
(b) Treatment under the direction and continued medical
supervision of a Doctor of Medicine or doctor of osteopathy in
a psychiatric day treatment facility that provides organizational
structure and individualized treatment plans separate from an
inpatient program.
(c) Treatment at a residential treatment center for children and
adolescents or a crisis stabilization unit for behavioral or emotional
illness which would otherwise necessitate confinement in a
hospital.

Conditions for coverage include the following.

(i) Treatment in a psychiatric day treatment facility must be

obtained under the direction and supervision of a
participating physician.
(ii) Providers of services in a residential treatment center for
children and adolescents and a crisis stabilization unit must
be licensed or operated by the appropriate state agency or
board.
(iii) Treatment rendered in a psychiatric day treatment facility
must be delivered not more than eight hours in any 24-hour
period, the attending physician must certify that the
treatment is in lieu of hospitalization, and the facility must
be accredited by the program of psychiatric facilities, or its
successor, of the Joint Commission on Accreditation of
Healthcare Organizations.
(iv) Treatment in a psychiatric day treatment facility, residential
treatment center for children and adolescents, or crisis
stabilization unit must be based on an individual treatment
plan.
(v) Acute inpatient and outpatient covered services and supplies
for the treatment of behavioral illness.

(2) Outpatient Behavioral Health Outpatient visits for crisis

intervention and evaluation as may be necessary and appropriate
for short-term evaluative behavioral health services, or short-term
treatment.

Coverage under this subsection does not include coverage of addiction to a

controlled substance or illicit drugs that is used in violation of the law, or
behavioral illness resulting from the use of a controlled substance or
20
marijuana in violation of the law.

Biofeedback Therapy Biofeedback therapy is covered when it is reasonable

and medically necessary for the individual for muscle reeducation of specific
muscle groups or for treating pathological muscle abnormalities of spasticity,
incapacitating muscle spasm, or weakness, conventional treatments (heat,
cold, massage, exercise, and support) have not been successful.

Blood and Blood Derivatives Including administration, when prescribed by

a participating provider and determined to be medically necessary.

Breast Cancer Treatment Diagnosis and treatment including coverage for

inpatient care for a participant for a minimum of:

(1) 48 hours following a mastectomy; and

(2) 24 hours following a lymph node dissection for the treatment of
breast cancer.
unless the participant and the attending physician determine that a shorter
period of inpatient care is appropriate.

Breast Pump A manual or non-hospital grade electric breast pump may be

considered for purchase only. The purchase of a breast pump is limited to one
per year per birth through the member’s DME benefit. A member may obtain
a breast pump during their pregnancy or after delivery. A hospital grade pump
may be considered for purchase with the appropriate documentation
supporting medical necessity as an authorization will be required. Supplies
necessary for the use of a breast pump, such as tubing, an adapter, and breast
shields are covered as needed.

Bone-Anchored Hearing Aids Considered a Prosthetic. Unilateral or

bilateral fully or partially implantable bone-conduction (bone-anchored)
hearing aid(s) may be considered medically necessary as an alternative to an
air-conduction hearing aid in patients 5 years of age and older with a
conductive or mixed hearing loss who also meet at least one of the following
medical criteria:

• Congenital or surgically induced malformations of the external ear canal

or middle ear (such as aural atresia)
• Hearing loss secondary to otosclerosis in persons who cannot undergo
stapedectomy
• Severe chronic external otitis or otitis media
• Tumors of the external ear canal and/or tympanic cavity, and
• Meet the following audiologic criteria:

21
 o A pure tone average bone-conduction threshold measured at 0.5, 1,
2, and 3 kHz of better than or equal to 45 dB (OBC and BP100
devices), 55 dB (Intenso device) or 65 dB (Cordele II device).

The BAHA Soft Band is medically indicated for children less than 5 years
of age with the same medical conditions.

Cancer Care, Chemotherapy, and Radiation Therapy Treatment

Therapy Treatment by x-ray, radium, or any other radioactive substance, or
by chemotherapy. Prescribed orally administered anticancer medication that
is used to kill or slow the growth of cancerous cells on a basis no less
favorable than intravenously administered or injected cancer medications.

Chiropractic Care Services and supplies furnished in connection with

correction by manual or mechanical means, of subluxation of the spine.

Dental Treatment & Dental Services that Must Be Performed in a

Hospital Setting The Plan will cover certain services provided to a
participant who is unable to undergo dental treatment in an office setting or
under local anesthesia due to a documented physical, behavioral, or medical
reason as determined by the participant’s PCP and the dentist. These
services include the hospital or facility, and/or anesthesia charges only.
Authorization will be required if services are provided outside of University
Health, which includes The MARC OP Surgery Center only.
Injury to Sound Natural Teeth Restoration and correction of damage
caused by external violent accidental injury to healthy, natural teeth
occurring while covered under this Plan and provided within 24 months of
the date of the accident.

Developmental Delays Services must be provided by an early intervention

agency. Evaluations and therapies require a referral by a PCP. Children Pre-
K and up are expected to receive their primary speech services in the school
system.

Rehabilitative and habilitative therapies include:

• Occupational therapy evaluations and services

• Physical therapy evaluations and services
• Speech therapy evaluations and services; and
• Dietary or nutritional evaluations

Diabetes Care Covered services and supplies include diabetes treatment,

equipment, supplies, medications, and self-management training,
prescribed or provided by a participating physician or other participating
provider. Member may be eligible for a continuous glucose monitoring
system based on diagnosis and current drug formulary. Equipment may

22
include insulin pumps, transmitter, glucometers, CGMs etc. See Schedule
of Benefits and Copayments.

Diagnostic Laboratory and Radiological Services Including professional

fees. Diagnostic and lab fees are covered only if testing is performed at UH
facilities.

Durable Medical Equipment Rental or purchase that is medically

necessary and approved by Community First and will require prior
authorization to establish medical necessity. Coverage is provided for the
initial, standard equipment only. Any customizations, customized fits or
upgrades to standard equipment will require prior authorization to establish
medical necessity. If medical necessity is not established, any costs
associated with customizations or customized fits and upgrades to standard
equipment will be the member’s responsibility.

Benefits for rental are limited to, and will not exceed, the purchase price of
the equipment. For equipment purchased at the Plan’s option, this item
includes repair if not due to neglect or abuse, and necessary maintenance of
purchased equipment not provided under a manufacturer’s warranty or a
purchase agreement. See Schedule of Benefits and Copayments for the
maximum contract year limitation.

Eye Exam and Vision Care Your health plan coverage provides an annual
medical eye exam through a network physician with a referral for certain
medical conditions and may allow more than one eye exam based on medical
necessity. This includes an annual diabetic eye exam for members diagnosed
with diabetes and diabetic retinopathy.
Glaucoma testing every 12 months if you meet one of the following criteria:
• Diabetes diagnosis
• A family history of glaucoma
• African American and over 50 years of age
• Hispanic and over 65 years of age

Certain tests and treatments of eye diseases and conditions may be covered
with a diagnosis of age-related macular degeneration

Routine eye exams or eye refractions for eyeglasses or contact lenses are not
part of your medical benefit. This benefit is covered by your vision provider.
All Community First Health Plans’ members are automatically enrolled in
Envolve vision which provides an annual vision benefit. Members may also
enroll in additional routine vision coverage through EyeMed during Open
Enrollment. Please see Envolve Vision and/or EyeMed for routine vision
copayments and out of pocket costs.
23
Family Planning and Infertility Services related to the diagnosis of
infertility shall be provided as medically necessary and as prescribed and
authorized by a participating provider. Please see exclusions under Infertility
Diagnosis and Treatment. The following services are covered:
(1) Counseling
(2) sex education instruction in accordance with medically acceptable
standards
(3) contraceptive devices
(4) placement of contraceptive devices
(5) vasectomies
(6) tubal ligations
(7) diagnostic infertility services to determine the cause of
infertility (see Exclusions
(8) surgical procedures to repair medical causes of infertility, to include
intrauterine insemination. (See Exclusions)
(9) infertility medications to stimulate ovulation, and not part of a treatment
plan of in-vitro fertilization or artificial insemination and similar
procedures (see Exclusions).

Foot Care Services and supplies for the care and treatment of diseases of, or
injuries to the feet, when prescribed by the PCP and determined to be
medically necessary by Community First.

Routine foot care may include:

• Cutting or removal of corns and calluses
• Clipping, trimming, or debridement of nails
• Shaving, paring, cutting or removal of keratoma, tyloma, and heloma
• Non-definitive simple, palliative treatments like shaving or paring of
plantar warts which do not require thermal or chemical cautery and
curettage

The following conditions represent systemic conditions that may result in the
need for routine foot care:

• Amyotrophic Lateral Sclerosis (ALS)

• Arteritis of the feet
• Chronic indurated cellulitis
• Chronic venous insufficiency
• Intractable edema-secondary to a specific disease (e.g., congestive heart
failure, kidney disease, hypothyroidism)
• Lymphedema-secondary to a specific disease (e.g., Milroy's disease,
malignancy)
• Peripheral vascular disease
• Raynaud's disease

24
Shoe orthotics, insoles, shoe inserts or other supportive devices of the feet are
covered only when prescribed as part of a treatment plan for someone with a
primary diagnosis of diabetes. Orthopedic shoes are covered only when the
shoe is an integral part of a medically necessary leg brace. Covered foot
orthotics are limited to two per plan year and shoes are limited to two pair
per plan year. See Exclusions.

Formulas Dietary formulas, if medically necessary for the treatment of

Phenylketonuria and other Heritable Diseases. See exclusions.

Genetic Testing and Counseling As medically appropriate with prior

authorization.

Health Education Services including, but not limited to, the following:

(1) Information about covered services, including recommendations

on generally accepted medical standards for the use and frequency
of such services.

(2) Diabetes self-management training provided by a participating

provider who is licensed in Texas to provide such services. Self-
management training includes, but is not limited to:

(a) training provided to a participant after the initial diagnosis

of diabetes in the care and management of that condition,
including nutritional counseling and proper use of diabetes
equipment and supplies.
(b) additional training required as a result of a significant change
in the participant’s symptoms or condition.
(c) periodic continuing education training when prescribed by
a participating physician as warranted by the development
of new techniques and treatments for diabetes.
(d) All diabetes self-management training is subject to Medical
Director Review.
(3) Other disease specific health education programs provided by or
approved by Community First.
(4) Prenatal education classes provided by Community First.
(5) Nutritional counseling and education provided by or
approved by Community First.

Hearing Aids (including batteries) See Schedule of Copayments and

Benefits for limitations.

25
Hearing Aid Exam Hearing aid examination and selection; binaural and
monaural.

Home Health Care/ Skilled Nursing Services Skilled nursing provided by

or supervised by a registered nurse (R.N.). The services must be provided
by a participating home health agency; your PCP refers you or arranges the
services and is preauthorized by Community First. Services may include
physical, occupational, speech or respiratory therapy. Services are only
provided for members who are homebound.

Homebound members are those who have a physical condition such that there
is a normal inability to leave the home. Certain diagnoses or medical
conditions may require initial home health care and transition to outpatient
therapy based on medical necessity. Home Health visits cannot be combined
with outpatient therapy benefit. In these instances, a preauthorization along
with the physician treatment plan will be required. The skilled nursing services
are of a temporary nature and will lead to rehabilitation and increased ability
to function.

Hospice Care Services and Supplies Covered if authorized by a

participating physician as part of a Hospice Care Program for a participant
who is terminally ill.

(1) Hospice care services including pain relief, symptom

management and supportive services to terminally ill participants
and their immediate families on both an outpatient and inpatient
basis.
(2) Counseling Services provided by a Hospice Provider.

Hospital Inpatient Services and Supplies Semi-private room and board.

This includes normal daily services and supplies furnished by the hospital.

For any day on which a PCP authorizes the participant’s stay in a private
room in a hospital that has no semi-private rooms, hospital private room
and board, including normal daily services and supplies, will be included as
eligible services and supplies.

Hospital private room and board, including normal daily services and
supplies, may also be included as eligible services and supplies for any day
on which:
(1) the person is being isolated in a private room because of the
person's communicable disease; or
(2) use of a private room is medically necessary for treatment of the
person's illness or injury.

26
Hospital Outpatient Services and Supplies Covered services and supplies
in connection with surgical treatment, including operating room and
treatment, medical supplies such as splints and casts, and non- experimental
drugs and medications furnished by and administered at the hospital or
facility.

Implantables An object or device that is surgically implanted, embedded,

inserted, or otherwise applied and related equipment necessary to operate,
program and recharge the implantable. See Schedule of Benefits and
Copayments for limitations.

Immunotherapy
Covered benefit in connection to treatment of cancer with applicable
benefit level based on network option.

Injectables Medically necessary injectable drugs administered by a

participating physician and subject to pre-authorization. Certain
medications are subject to age restrictions. See Schedule of Benefits and
Copayments.

Lymphedema Compression Treatment. Items mean standard and custom

fitted gradient compression garments and other items determined by the
Secretary that are;
1). Furnished on or after January 1, 2023, to an individual with a diagnosis of
lymphedema for the treatment of such condition;
2). Primarily and customarily used to serve a medical purpose and for the
treatment of lymphedema, as determined by the Secretary; and
3). Prescribed by a physician (or a physician assistant, nurse practitioner, or
clinical nurse specialist).
Two garments at one time (or two sets of garments, if your treatment requires
more than one piece) replaced every 6 months.

Maternity Inpatient Care The maternity benefit offered herein includes

coverage for inpatient care for a mother and her newborn child in a health
care facility for a minimum of:
(1) 48 hours following an uncomplicated vaginal delivery; and
(2) 96 hours following an uncomplicated delivery by caesarean section
unless the participant and her attending physician determine that a
shorter period of inpatient care is appropriate.

This benefit also covers maternity inpatient care for pregnant dependents. See
I.B.2. Dependents Eligible for Coverage and III A.4.c. Special Dependent
Coverage Rules for Newborn and Adopted Children.

Note: Group health plans and health insurance issuers generally may not,
under Federal law, restrict benefits for any hospital length of stay in
27
connection with childbirth for the mother and newborn child to less than 48
hours following a vaginal delivery, or 96 hours following a cesarean
section. However, Federal law generally does not prohibit the mother’s or
newborn’s provider, after consulting with the mother, from discharging the
mother or her newborn earlier than 48 hours (or 96 hours as applicable). In
any case, plans and issuers may not, under Federal law, require that a
provider obtain authorization from the plan or the insurance issuer for
prescribing a length of stay not in excess of 48 hours or (96 hours).

If services are not rendered at UH facility, member may have additional out
of pocket expenses i.e., supplies etc.

Obesity Drugs and Treatment Please see Limitations on page 33. Requires
Preauthorization.

Ophthalmological Services Covered services and supplies needed

for the diagnosis and treatment of diseases of the eye, or injury to the
eye.

Orthotics Prescribed by a participating provider and determined to be

medically necessary. Repair and replacement is covered unless due to misuse
or loss. See Schedule of Benefits.

Outpatient Therapy Short term outpatient services which meet or exceed

the Participants treatment goals and must be performed by a licensed therapy
provider under the direction of a Physician. Therapies include physical,
occupational, speech and hearing, pulmonary rehabilitation, and cardiac
rehabilitation. See Schedule of Benefits for limitations. For a physically
disabled person, treatment goals must include improvement or maintenance
of functioning, or prevention of or slowing of further deterioration.
Outpatient Therapy visits cannot be combined with Home Health Therapy
benefits. See Schedule of Benefits for limitation.

Oxygen Oxygen and rental of equipment for use of oxygen, when medically
necessary and prescribed by a participating physician.

Pain Management Services Medically necessary pain management

treatment and related services that are ordered by a participating provider
and preauthorized by Community First. Services can be expected to meet or
exceed treatment goals and are scientifically proven and evidence-based to
improve your medical condition.

Physicians' Services For surgical procedures and for other medical care.

28
Preventive Health Services The following preventive health services are
covered:

(1) Well-baby and well childcare including childhood screening tests for
hearing loss, as required by law, from birth through the date the child
is 30 days old and any necessary diagnostic follow-up care related to
the screening test from birth through the date the child is 24 months
old;

(2) Annual eye and ear examination for children through age 17, to
determine the need for vision and hearing correction.
(3) Periodic adult health evaluations.
(4) Pediatric and adult immunizations in accordance with Community
First’s clinical guidelines and/or as required by law.
(5) Medically appropriate COVID-19 tests must be FDA-authorized or
approved and be ordered or reviewed by a health care professional
to either 1) diagnose if the virus is present in a person due to
symptoms or potential exposure, or 2) help in the treatment of the
virus for a person. PCR testing for traveling purposes is limited to 2
per year per member.
(6) Annual well-woman exam including, but not limited to, periodic
screening for breast and cervical cancer. A conventional pap smear
screening or a screening using liquid-based cytology methods alone
or in combination with a test for the detection of the human
papillomavirus. Comprehensive lactation support and counseling,
by a trained provider during pregnancy and/or in the postpartum
period.
Annual diagnostic testing for the detection of prostate cancer.
Coverage is provided for:
(a) ) a physical examination for the detection of prostate cancer; and
(b) a prostate-specific antigen test used for the detection of prostate
cancer for each male who is:
(1) at least 50 years of age and asymptomatic; or
(2) at least 40 years of age with a family history of prostate
cancer or another prostate cancer risk factor.
(7) For qualified individuals, medically accepted bone mass
measurement for the detection of low bone mass and to determine
the risk of osteoporosis and fractures associated with osteoporosis.
Qualified individual means:

(a) postmenopausal woman who is not receiving estrogen

29
 replacement therapy.

(b) an individual with:

(1) vertebral abnormalities.

(2) primary hyperparathyroidism; or
(3) a history of bone fractures; or
(c) an individual who is:
(1) receiving long-term glucocorticoid therapy; or
(2) being monitored to assess the response to or
efficacy of an approved osteoporosis drug therapy.
(8) Medically necessary screenings for colorectal cancer. Multi-target
Stool DNA Testing for colorectal Cancer Screening such as
Cologuard. Cologuard is intended for the qualitative detection of
colorectal neoplasia associated DNA markers and for the presence of
occult hemoglobin in human stool.

Note: Under the Affordable Care Act, certain preventive health

services are paid at 100% (i.e., Well Woman exam, Tests for
detection of colorectal cancer, coverage for cervical cancer, benefits
or detection and prevention of osteoporosis at no cost to the member)
dependent upon physician billing and diagnosis. In some cases, you
will be responsible for payment of some services. Specifically (1) if
a recommended preventive service is billed separately from an office
visit, then a plan may impose cost-sharing requirements with respect
to the office visit, (2) if a recommended preventive service is not
billed separately from an office visit and the primary purpose of the
office visit is the delivery of a preventive service, then a plan may not
impose cost-sharing requirements with respect to the office visit, and
(3) if a recommended preventive service is not billed separately from
an office visit and the primary purpose of the office visit is not the
delivery of a preventive service, then a plan may impose cost-sharing
requirements with respect to the office visit.

Prosthesis An external or removable artificial device that replaces a body

part or function and is determined by Community First to be medically
necessary. This benefit includes repair and replacement when due to growth
and within the scope of normal wear and tear. Medically necessary criteria
must be met. See Schedule of Benefits and Copayments.

Reconstructive Surgery After Mastectomy Surgery to provide coverage

for (1) reconstruction of the breast on which the mastectomy has been
performed; (2) surgery and reconstruction of the other breast to achieve a
symmetrical appearance; and (3) prostheses and treatment of physical
complications, including lymphedemas, at all stages of mastectomy.
30
Reconstructive Surgery for Craniofacial Abnormalities in a Child
younger than 18 years of age Surgery determined by Community First to
be Medically Necessary to improve the function of, or to attempt to create
a normal appearance of, an abnormal structure caused by congenital defects,
developmental deformities, trauma, tumors, infections, or disease. See
Exclusions.

Renal Dialysis Services and supplies furnished in connection with dialysis

for renal disease.

Respiratory Therapy The performance of preventive, maintenance and

rehabilitative airway-related techniques and procedures.

Sexually-Transmitted Infections (STI) Education, diagnosis and treatment

for STIs, including HIV, AIDS, and AIDS-related illnesses.

Skilled Nursing Facility Services Covered Services and Supplies are

subject to the conditions set forth below.
- Your PCP or attending specialist refers you and
- Certifies that the participant needs 24-hour-a-day nursing care.
See Schedule of Benefits for limitations.
Smoking Cessation service or supply furnished to assist with smoking
cessation program. This benefit applies to prescribed smoking cessation
products.. See Schedule of Benefits, the UH Drug Rider and the University
Family Care Plan Preferred Drug List (PDL). Some products are covered
with a prescription from your Healthcare Provider.

Supplies Prescribed by a participating provider and determined to be

medically necessary and appropriate by Community First. Medical supplies
are non-reusable, disposable, and are not useful in the absence of illness or
injury. To be considered “medically necessary or appropriate”, a medical
supply must be determined by Community First to meet all of these
conditions and must not be listed under Exclusions. The supply(ies):
(1) Must be part of a participating provider’s treatment plan.
(2) Must be based on current treatment protocols.
(3) Must be obtained from a participating provider.
(4) Must be required such that its omission would adversely affect the
participant’s health;
(5) Must be recognized as safe and effective for its intended use.
(6) Must be used in a manner that is consistent with generally accepted
United States medical standards or guidelines.

Examples of medical supplies may include, but not be limited to, diabetic

31
supplies, ostomy supplies, job stockings, sterile dressings, and urinary
catheters. See non-covered supplies under Exclusions.

Telemedicine Services provided through telehealth services and

telemedicine medical services, to the extent that coverage is required by
Section 1455.004 of the Texas Insurance Code. Providers or specialists
that are under contract with the University Family Care Plan (UFCP) to
provide telemedicine or telehealth services will be available to members
of the UFCP. The amount of the deductible, copayment, or coinsurance
may not exceed the amount of the deductible, copayment, or coinsurance
required for the covered health care service or procedure provided through
an in-person consultation.
Temporomandibular Joint (TMJ) Medically necessary services for the
diagnosis and surgical treatment of conditions affecting the
temporomandibular joint which includes the jaw and the craniomandibular
joint resulting from an accident, trauma, congenital defect, developmental
defect, or pathology.

Transplant services Covered medical services including evaluation and

supplies for medically necessary and appropriate transplant services
including:
(1) Heart transplant
(2) Lung transplant
(3) Heart/Lung transplant
(4) Kidney transplant
(5) Kidney/pancreas transplant
(6) Liver transplant
(7) Liver/small bowel transplant
(8) Pancreas transplant
(9) Small bowel transplant
(9) Corneal transplant
(10) Bone marrow transplant for aplastic anemia, leukemia, severe
combined immuno-deficiency disease, and Wiskott Aldrich
syndrome.
Donor or prospective donor expenses are covered. The cost of artificial
organs are excluded from coverage. Services or procedures considered
experimental and/or investigational under current medical policy guidelines
also are excluded. See Exclusions.

The Plan will not require that a participant travel out-of-state to receive
transplant services unless the informed consent of the participant has been
obtained, which explains the benefits and detriments of in-state and out-of-
state options.
If the participant satisfies medical criteria developed by the Plan for receiving
32
 transplant services, Community First will provide a written authorization for
care to a transplant facility selected by Community First from a list of
facilities it has approved. If, after referral, either the Plan or the medical
staff of the referral facility determines that the participant does not satisfy its
respective criteria for the services involved, the Plan’s obligation is limited
to paying for covered services provided prior to such determination
according to the Schedule of Copayments.

C. LIMITATIONS

This section describes limits for the covered services under section B above.
It also describes any modifications of those covered services for certain
illnesses.

1. Major Disaster or Epidemic Community First will consistently

make a good faith effort to provide or arrange for covered services,
taking into account existing conditions and events. If there is a major
disaster or an epidemic, Community First will provide or arrange for
covered services to the extent possible or practical Community First
nor any participating provider will have any liability or obligation on
account of delay or failure to provide or arrange for covered services.

2. Circumstances Beyond the Control of Community First or

Participating Providers Due to circumstances not within the control
of Community First or participating providers, there may be a delay in
providing or arranging for Covered Services, or it may not be practical
or possible to do so. Community First nor any participating provider
will have any liability or obligation on account of delay or failure to
provide or arrange for covered services if a good faith effort has been
made to do so. Some examples of such circumstances are complete or
partial destruction of facilities because of war, riot, or civil
insurrection; the disability of a significant number of participating
providers; and other similar causes.

3. Continuity of Treatment in the Event of the Termination of a PCP

Community First will notify you no less than thirty (30) days in advance if
a participating physician or other provider treating you is going to be leaving
the Community First network. If the physician or other provider is treating
you under a “special circumstance” and the treating physician or provider
makes the request, then Community First will continue to compensate the
physician or other provider, on your behalf, for up to ninety (90) days, for
up to nine (9) months in the case of a terminally ill
person, or, in the case of a participant who is past the 24th week of
pregnancy, for delivery of the child, immediate postpartum care, and the
follow-up checkup within the first six (6) weeks of delivery. “Special
circumstance” means a condition such that your physician or provider
33
 reasonably believes discontinuation of care could cause harm to you.

Examples include:

a. A person who has a disability.

b. A person with an acute condition.
c. A person with a Life-Threatening illness.
d. A person who is past the 24th week of pregnancy.

4. Non-Participating Provider and Out-of-Area Services and Benefits

Only emergency care services are covered outside the network and/or
service area, unless medically necessary covered services are not available
through the Plan participating providers. If medically necessary covered
services are not available through the Plan’s participating providers, the
Plan will allow, upon the request of a participating provider and within the
time appropriate to the circumstances (but in no event to exceed five
working days after receipt of reasonably requested documentation), a
referral to a non-participating provider. Before Community First denies
such referral, you may request a review by a specialist of the same or similar
specialty as the type of physician or provider to whom a referral is
requested.

5. Obesity Treatment
Benefits for the surgical treatment of morbid obesity, performed on an
inpatient or outpatient basis, are subject to the pre-surgical requirements
listed below. The member must meet all the requirements.
a. Diagnosis of morbid obesity (severe obesity is defined as a Body
Mass Index ≥40 kg/m2, or ≥35 kg/m2 in the presence of
comorbidities) for a period of 2 years prior to surgery;
b. Participation in a medically supervised weight loss program,
including nutritional counseling, for at least 3 months prior to the
date of the surgery. (Note: Benefits are not available for
commercial weight loss programs; see page 24 for our coverage of
nutritional counseling services under Health Education);
c. Pre-operative nutritional assessment and nutritional counseling
about pre-and post-operative nutrition, eating and exercise –
Evidence that attempt at weight loss in the 1 year prior to surgery
have been ineffective.
d. Psychological clearance of the member’s ability to understand and
adhere to the pre-and post-operative program, based on a
psychological assessment performed by a licensed psychologist or
psychiatrist (see page 19 for behavioral health benefits).
e. Preoperative thyroid functions that are within normal range.
Normalization of thyroid functions may take as long as 8 to 10
weeks if hypothyroidism is diagnosed.
34
 f. A preoperative screening examination by a PCP or cardiologist
who evaluate preoperative risk for surgery.
g. Member has not smoked in the 6 months prior to surgery.
h. Member has not been treated for substance abuse for 1 year.
i. See Schedule of Benefits/Copayments for applicable benefit
maximums that apply to morbid obesity treatment. Authorization
is required and may be performed at University Hospital
ONLY.

6. Telemedicine/Telehealth
a. These services can only be rendered by providers and specialists that
are contracted with the University Family Care Plan (UFCP) to
provide telemedicine and/or telehealth consultation services.

7. Smoking Cessation
a. Benefit has a yearly maximum of $300
b. Only for prescriptions/medications.

8. Bone Anchored Hearing Aids

a. Benefit will be considered a prosthesis. The implantable device benefit
will not apply here.

D. EXCLUSIONS

All services and benefits for care and conditions within each of the following
classifications shall be excluded from coverage:

Abortion Services Unless determined to be medically necessary by a

Participating Provider to preserve the life of the mother, or in the case of
congenital anomalies incompatible with life.

Acupuncture

Ambulance Services Transport services for non-emergency services are

excluded unless pre-authorization is obtained prior to service being rendered to
establish medical necessity. If you are not transported, you will be responsible
for billed charges.
Artificial Internal Organs and Animal Organs

Allowable cost of Covered Services Coverage normally provided for a Covered

Service may not be applied toward the cost of a non-covered Service or Supply.

35
Alternative Treatments That includes but not limited to acupressure,
acupuncture, aquatic therapy, aromatherapy, hypnotism, massage therapy,
rolfing, art therapy, music therapy, dance therapy and horseback therapy.

Assisted Living Facility Room and Board for Acquired Brain Injury when
the participant is capable of living at home and only needs a structured day
program and when 24-hour care is not medically necessary.

Autism Spectrum Disorder Services considered to be investigational or

experimental will not be covered if they fall outside the scope of generally
recognized services.
Biofeedback Therapy Excluded for the treatment of ordinary muscle tension states
or psychosomatic conditions.

Charges for Broken Appointments

Charges for completion of any forms

Charges made by the Employer or a close relative Services or supplies

furnished by:
(1) the Employer; or
(2) You, Your spouse, or a child, brother, sister, or parent of You or Your
spouse.
Chelation therapy Excluded except when used in the treatment of heavy metal
poisoning.

Chemical Dependency aftercare services Services including, but not limited to,
AA/NA, support or education groups, and/or other services that primarily focus
on relapse prevention to the participant who completed treatment and/or their
family members.

Clothing, shoes, and diapers unless specifically covered by this Certificate

(e.g., correctional shoes or inserts associated with diabetes are covered).

Compounded Drugs that are experimental and/or not FDA approved are not
covered

Corrective appliances and artificial aids Including, but not limited to,
communication devices, wigs and eyeglasses or contact lenses of any type, except
initial replacements for loss of the natural lens. Exceptions: One pair of
eyeglasses or contact lenses after each cataract surgery with insertion of an
intraocular lens. Eye care services are available for members enrolled in separate
vision benefit.

Cosmetic surgery Services and supplies including cosmetic, furnished mainly to

36
change a person’s appearance are excluded. This includes surgery performed to
treat a behavioral, psychoneurotic or personality disorder through change in
appearance. Certain procedures may be considered as a covered benefit based on
medical necessity and preauthorization will be required.

Once a member has been discharged from a hospital stay in which the member
received noncovered services, medical and hospital services required to treat a
condition or complication that arises as a result of the prior non-covered services
may be covered when they are reasonable and necessary in all other respects.

Custodial Care Services or supplies furnished in connection with custodial care.

Dental care, oral surgery or treatment of teeth or periodontium Services

and supplies not covered unless the services (i) are for medically necessary
diagnostic and/or surgical treatment of the temporomandibular (jaw or
craniomandibular) joint (TMJ); or (ii) are received in connection with an Injury
to sound natural teeth except for an Injury resulting from biting or chewing. See
covered services and supplies.

Dental braces, dental implants or any treatment related to the preparation or fitting
of dentures are not covered. Oral appliances and devices to treat bruxism, or as
part of an orthodontia care plan are not covered.

The Plan will not exclude a participant from coverage who is unable to undergo
dental treatment in an office setting or under local anesthesia due to a documented
physical, behavioral, or medical reason as determined by the participant’s PCP
and the dentist.

Diagnostic tests to establish paternity of a child and tests to determine sex of an

unborn child.

Educational Testing and Therapy motor or language skills or services that are
educational in nature or are for vocational testing or training

Environmental consultations and modifications Consultations of an

environmental engineer, air conditioners, humidifiers, dehumidifiers, purifiers,
elevators, and chair lifts.
Experimental or Investigational Services and Supplies Services and supplies,
including new and emerging health care technologies that are determined by the
Plan to be Experimental or Investigational.

The Plan may, however, deem an experimental or investigational service or supply

covered for treating a life-threatening illness or condition if it is determined by the
Plan, through an Ombudsman Program, that the experimental or investigational
service or supply at the time of the determination:
37
(1) is proved to be safe with promising efficacy; and
(2) is provided in a clinically controlled research setting; and
(3) uses a specific research protocol that meets standards equivalent to those
defined by the National Institutes of Health.

Eye Surgery Services and supplies furnished in connection with eye surgery such
as radial keratotomy and lasik, when the primary purpose is to correct myopia
(nearsightedness), hyperopia (farsightedness) or astigmatism (blurring).

Foot care Routine foot care, treatment of flat feet and treatment of subluxations
of the feet are excluded. Orthopedic shoes are not covered, except as an integral
part of a medically necessary leg brace. This does not include treatment of
fractures or other acute injuries.

Gene Therapies Gene Therapy and Other Rare Diseases Includes, but not
limited to, all treatment, services, surgical or invasive procedures, supplies or
complications arising from or connected in any way to the administration of the
procedure or treatment. Regardless of medical necessity.

Home and automobile modifications or improvements Excluded even when

necessary to accommodate installation of covered services or to facilitate entrance
or exit.

Hospital private room Excluded unless determined to be medically necessary.

Infertility drugs Drug therapy for infertility which involves:

(1) non-FDA approved indications.
(2) non-standard dosages, length of treatment, or cycles of therapy; or
(3) in-vitro fertilization procedures.

Infertility Diagnosis and Treatment Services or supplies furnished in

connection with any procedures which involve harvesting, storage and/or
manipulation of eggs and sperm for in-vitro fertilization. Other procedures
excluded, but are not limited to:
(1) In-vitro fertilization
(2) Gamete or zygote intrafallopian transfer and similar procedures
(3) Reversal of voluntary induced sterility
(4) Surrogate parent services and fertilizations
(5) Donor egg or sperm
(6) Embryo transfer
(7) Embryo freezing
Infertility benefits excluded from coverage include transsexual surgery, gender
38
reassignment, and any services or supplies used in any procedures performed in
preparation for or immediately after any of the above-referenced procedures.

Injectable Medications which have not been proven safe and effective for a
specific disease or approved for a mode of treatment by the Food and Drug
Administration and the National Institute of Health.

Medical record charges Charges associated with copying or transferring

medical records.

Military Service Connected Disabilities Services and supplies furnished in

connection with military service-connected disabilities for which the participant
is legally entitled to services and for which facilities are reasonably available to
the participant.

Obesity Treatment Any treatment after the $30,000 lifetime maximum is met.
Includes, but not limited to, all treatment, services, surgical or invasive
procedures or complications arising from or connected in any way, for treatment
of obesity, services and supplies furnished in connection with any weight loss
program or food supplements used to achieve weight loss, liposuction, gastric
bypass, jejunal bypass and balloon procedures.

Over-the-counter medications and supplies Any care, treatment, service,

supply or item that is available without a physician’s recommendation or written
prescription, including a dietary formula, is excluded unless expressly covered
under this Plan (e.g., over-the-counter diabetic supplies are covered, as are
dietary formulas necessary for the treatment of Phenylketonuria and other
heritable diseases). Examples of over-the-counter items not covered: band- aids,
tape, gauze bandages, ACE bandages, elastic joint supports, TED hose, paper
towels, etc.

Personal comfort items Including but not limited to, personal care kits provided
on admission to a hospital or comparable facility, telephone, newborn infant
photographs, meals for guests of the patient, and other articles which are
not determined to be medically necessary or appropriate for the specific
treatment of the illness or injury.

Physical examinations provided solely for the purpose of travel out of the
country, other employment, or school abroad and sports physicals.

Prescription Medications Unless (i) furnished by a hospital during a hospital

inpatient stay, (ii) specifically listed in the “Covered Services” section above.
This is specifically related to Behavioral Health Services for Inpatient and
Residential Treatment and should be written by a licensed physician.

Private Duty Nursing

Public Facility Services and supplies furnished in connection with conditions

39
that state or local law requires be treated in a public facility.

Reconstructive Surgery for Craniofacial Abnormalities for anyone 18 years of

age or older. See Covered Services.

Recreational, educational and sleep therapy including any related diagnostic

services.

Reduction Mammoplasty for cosmetic purposes, except for post-mastectomy

reduction of the unaffected breast to achieve a symmetrical appearance.

School-based therapy services

Services and supplies Services and supplies that meet the following conditions.

a. Unnecessary services and supplies. Services and supplies that are not
medically necessary or appropriate for the diagnosis and/or treatment of an
illness or injury. Examples are rubber sheets, incontinent pads, diapers, non-
sterile rubber gloves, emesis basins, powder, batteries (except for hearing aid
batteries) etc.

b. Required by a court decree regarding a divorce action, a motor vehicle

violation or other judgment not directly related to this Plan, if they would not
be covered in the absence of such a decree.
c. Related to preservation and/or storage of body parts, fluids or tissues, except
for autologous blood and related collection and storage costs in connection
with covered non-experimental services and supplies.
d. Not furnished or authorized by a PCP.

e. Furnished for cosmetic surgery except what is listed under covered services.

f. Over-the-counter supplies.
g. Received from a nurse who does not require the skill and training of a nurse.

Sex changes All services, medications and/or supplies furnished in conjunction

with the sex change process. This includes hormonal medications required before
and after surgery.

Sex therapy, sex counseling and sexual dysfunction or inadequacies that do not
have a physiological or organic basis.

Therapies including speech, occupational and physical on an outpatient basis

in conjunction with Home Health Care/Therapies. Certain diagnoses or medical
conditions may require initial home health care and transition to outpatient
therapy based on medical necessity. See Home Health Care/Skilled Nursing
Services under Covered Services.
40
 Thermograms and thermography measuring the temperature variations at the
body surface.

Vaccines provided for the purpose of travel out of the country, obtaining other
employment or school abroad.

Vocational rehabilitation

Voluntary sterilization reversal of a previous surgical procedure intended to

induce permanent infertility.

Work Related Injury or Illness Services and supplies for any work-related
injury if any other source of coverage or reimbursement which is in force and in
effect for the services. Sources of coverage or reimbursement available to you
may include your employer, a work-related benefit plan maintained by your
employer, and any Workers’ Compensation, occupational disease, or similar
program under local, state, or federal law.

V. RIGHT OF SUBROGATION AND REIMBURSEMENT UNDER THE PLAN

If the Plan pays or provides medical benefits for an illness or injury that was caused by an act
or omission of any person or entity, the Plan will be subrogated to all rights of recovery
of a plan participant, to the extent of such benefits provided or the reasonable value of services
or benefits provided by the Plan. The Plan, once it has provided any benefits, is granted a lien
on the proceeds of any payment, settlement, judgment, or other remuneration received by the
plan participant from any sources, including but not limited to:
• a third party or any insurance company on behalf of a third party, including but not
limited to premises, homeowners, professional, DRAM shop, or any other applicable
liability or excess insurance policy.
• underinsured/uninsured automobile insurance coverage regardless of the source.
• no fault insurance coverage, such as personal injury or medical payments protection
regardless of the source.
• any award, settlement or benefit paid under any worker’s compensation of law
claim or award.
• any indemnity agreement or contract.
• any other payment designated, delineated, earmarked or intended to be paid to a
plan participant as compensation, restitution, remuneration for injuries sustained or
illness suffered as a result of the negligence or liability, including contractual, of any
individual or entity.
• any source that reimburses, arranges, or pays for the cost of care.

Assignment

41
Upon being provided any benefits from the Plan, a plan participant is considered to have
assigned his or her rights of recovery from any source including those listed herein to the Plan
to the extent of the reasonable value of services as determined by the Plan or benefits provided
by the Plan

No plan participant may assign, waive, compromise, or settle any rights or causes of action
that he/she or any dependent may have against any person or entity who causes an injury or
illness without the express prior written consent of the Plan and/or the Plan administrator.

Reimbursement

The Plan, by providing benefits, acquires the right to be reimbursed for the reasonable
value of services or benefits provided to a plan participant, and this right is independent
and separate and apart from the subrogation, lien and/or assignment rights acquired by the
Plan and set forth herein.

The Plan is also entitled to recover from plan participant the value of benefits and services
provided, arranged, or paid for, by anyone including those listed herein.

If a plan participant does not reimburse the Plan from any settlement, judgment, insurance
proceeds or other source of payment, including those identified herein, the Plan is entitled to
reduce current or future benefits payable to or on behalf of a plan participant until the Plan has
been fully reimbursed.

Plan’s Actions

The Plan in furtherance of the rights obtained herein may take any action it deems necessary
to protect its interest, which will include, but not be limited to:
• place a lien against a responsible party or insurance company to the extent benefits have
been paid.
• bring an action on its own behalf, or on the plan participant’s behalf, against the person,
entity or insurance company.
• cease paying the plan participant’s benefits until the plan participant provides the Plan
Sponsor with the documents necessary for the Plan to exercise its rights and privileges;
and
• the Plan may take any further action it deems necessary to protect its interest.

Obligations of the Plan Participant to the Plan

• If a plan participant receives services or benefits under the Plan, the plan participant must
immediately notify the Plan Sponsor of the name of any individual or entity against whom
the plan participant might have a claim as a result of illness or injury (including any
insurance company that provides coverage for any party to the claim) regardless of whether
or not the plan participant intends to make a claim. For example, if a plan participant is
injured in an automobile accident and the person who hit the plan participant was at fault, the
person who hit the plan participant is a person whose act or omission has caused the plan
42
 participant’s illness or injury.

• A plan participant must also notify any third-party and any other individual or entity acting
on behalf of the third-party and the plan participant’s own insurance carriers of the Plan’s
rights of subrogation, lien, reimbursement, and assignment.

• A plan participant must cooperate with the Plan to provide information about the plan
participant’s illness or injury including, but not limited to providing information about all
anticipated future treatment related to the subject injury or illness.

• The plan participant authorizes the Plan and The Bratton Firm, to pursue, sue, compromise
and/or settle any claims described herein, including but not limited to, subrogation, lien,
assignment, and reimbursement claims in the name of the plan participant and/or Plan. The
plan participant agrees to fully cooperate with the Plan in the prosecution of such a claim.
The plan participant agrees and fully authorizes the Plan and the Bratton Firm to obtain
and share medical information on the plan participant necessary to investigate, pursue, sue,
compromise and/or settle the above-described claims. The Plan and The Bratton Firm
specifically are granted by the plan participant the authorization to share this information
with those individuals or entities responsible for reimbursing the Plan through claims of
subrogation, lien, assignment, or reimbursement in an effort to recoup those funds owed to
the Plan. This authorization includes, but is not limited to, granting to the Plan and The
Bratton Firm the right to discuss the plan participant’s medical care and treatment and the
cost of same with third and first-party insurance carriers responsible for the incident in
question. Should a written medical authorization be required for the Plan to investigate,
pursue, sue, compromise, prosecute and/or settle the above-described claims, the plan
participant agrees to sign such medical authorization, or any other necessary documents
needed to protect the Plan’s interests.

• Additionally, should litigation ensue, the plan participant agrees to and is obligated to
cooperate with the Plan and/or any and all representatives of the Plan, including subrogation
counsel, in completing discovery, obtaining depositions and/or attending and/or cooperating
in trial in order to affect the Plan’s subrogation, lien, assignment or reimbursement rights.

• The plan participant agrees to obtain consent of the Plan before settling any claim or suit or
releasing any party from liability for the payment of medical expenses resulting from an
injury or illness. The plan participant also agrees to refrain from taking any action to
prejudice the Plan’s recovery rights.

• Furthermore, it is prohibited for plan participant to settle a claim against a third party for
non-medical elements of damages, by eliminating damages relating to medical expenses
incurred. It is prohibited for a plan participant to waive a claim for medical expenses
incurred by plan participants who are minors.

• To the extent that a plan participant makes a claim individually or by or through an attorney
for an injury or illness for which services or benefits were provided by the Plan, the plan
participant agrees to keep the plan updated with the investigation and prosecution of said
43
 claim, including, but not limited to providing all correspondence transmitted by and between
any potential defendant or source of payment; all demands for payment or settlement; all
offers of compromise; accident/incident reports or investigation by any source; name,
address, and telephone number of any insurance adjuster involved in investigating the claim;
and copies of all documents exchanged in litigation should a suit be filed.

• Nothing in these provisions requires the Plan to pursue the plan participant’s claim against
any party for damages or claims or causes of action that the plan participant might have
against such party as a result of injury or illness.

• The Plan may designate a person, agency, or organization to act for it in matters related to
the Plan’s rights described herein, and the plan participant agrees to cooperate with
such designated person, agency, or organization the same as if dealing with the Plan itself.

Made Whole Doctrine

The Plan’s right of subrogation, lien, assignment, or reimbursement as set forth herein will not
be affected, reduced, or eliminated by the “made whole doctrine” and/or any other equitable
doctrine or law which requires that the plan participant be “made whole” before the Plan is
reimbursed. The Plan has the right to be repaid 100% first from any settlement, judgment,
remuneration, insurance proceeds or other source of funds a plan participant receives. The Plan
has the right to be reimbursed first whether or not a portion of the settlement, judgment,
remuneration, insurance proceeds or other source of funds are identified as a reimbursement
for medical expenses. The plan has the right to be reimbursed first whether or not a plan
participant makes a claim for medical expenses.

Attorneys’ Fees

The Plan will not be responsible for any expenses, fees, costs, or other monies incurred by the
attorney for the plan participant and/or his or her beneficiaries, commonly known as the
common fund doctrine. The Plan participant is specifically prohibited from incurring any
expenses, costs, or fees on behalf of the Plan in pursuit of his rights of recovery against
a third-party or Plan’s subrogation, lien, assignment, or reimbursement rights as set forth
herein. No court cost, filing fees, experts’ fees, attorneys’ fees, or other cost of a litigation
nature may be deducted from the Plan’s recovery without prior, express written consent of the
Plan.

A plan participant must not reimburse their attorney for fees or expenses before the Plan has
been paid in full. The Plan has the right to be repaid first from any settlement, judgment, or
insurance proceeds a plan participant receives. The Plan has a right to reimbursement whether
or not a portion of the settlement, judgment, insurance proceeds or any other source or payment
was identified as a reimbursement of medical expenses.

Wrongful Death/Survivorship Claims

44
In the event that the plan participant dies as a result of his/her injuries and a wrongful death or
survivorship claim is asserted the plan participant’s obligations become the obligations of the
plan participant’s wrongful death beneficiaries, heirs and/or estate.

Death of Plan Participant

Should a plan participant die, all obligations set forth herein shall become the obligations of
his heirs, survivors and/or estate.

Control of Settlement Proceeds

A plan participant may not use an annuity or any form of trust to hold/own settlement proceeds
in an effort to bypass obligations set forth herein. A plan participant agrees that they have
actual control over the settlement proceeds from the underlying tort claim from which they are
to reimburse the plan whether or not they are the individual or entity to which the settlement
proceeds are paid.

Payment

The plan participant agrees to include the Plan’s name as a co-payee on any and all settlement
drafts or payments from any source. The fact that the Plan does not initially assert or invoke its
rights until a time after a plan participant, acting without prior written approval of the
authorized Plan representative, has made any settlement or other disposition of, or has received
any proceeds as full or partial satisfaction of, plan participant’s loss recovery rights, shall
not relieve the plan participant of his/her obligation to reimburse the Plan in the full amount
of the Plan’s rights.

Severability

In the event that any section of these provisions is considered invalid or illegal for any reason,
said invalidity or illegality shall not affect the remaining sections of the Plan. The Plan shall be
construed and enforced as if such invalid or illegal sections had never been inserted in the
plan.

Incurred Benefits

The Plan reserves the right to reverse any decision associated with the reduction or waiver of
charges related to services or benefits provided if and when the Plan discovers that the plan
participant has been involved in an injury or accident and may be compensated by one of
the sources set forth herein. Should this occur, the plan participant is deemed to have incurred
the full billed charges or the full cost of the benefits or services rendered.

Non-exclusive Rights

45
 The rights expressed in this document in favor of the Plan are cumulative and do not exclude
any other rights or remedies available at law or in equity to the Plan or anyone in privity with
the Plan.

The Provisions herein bind the plan participant, as well as the plan participant’s spouse,
dependents, or any members of the plan participant’s family, who receives services or
benefits from the Plan individually or through the plan participant.

VI. GENERAL RULES FOR COORDINATION OF BENEFITS

If a participant is eligible to receive benefits under other health care plan(s). The Plan
Administrator will coordinate our benefits with those of any other plan(s) that provides
benefits to you.

A. DEFINITIONS

1. Health Care Program: Any of the following which provide benefits or

services for, or by reason of, medical, dental, vision care or treatment:

a. Coverage under a governmental plan or required or provided by law.

This does not include a state plan under Medicaid or any law or plan
when, by law, its benefits are excess to those of any private
insurance program or other non-governmental program.

b. Group insurance or other coverage for persons in a group, whether

insured or uninsured. This includes prepayment, group practice or
individual practice coverage. But this does not include school
accident-type coverage for grammar school, high school, and
college students.

2. Separate Programs: Each contract or other arrangement for coverage

listed above is a Separate Program. If an arrangement has two parts and
the Coordination of Benefits rules apply to one of the two, each of the
parts is a separate program.

3. Primary or Secondary Plan: The rules establishing the order of benefit

determination whether this plan is Primary or Secondary.

a. Primary Plan benefits are determined before those of the other

plan.

b. If a health care plan does not contain a Coordination of Benefits

provision, that health care plan is primary. The primary health care
plan pays benefits before the secondary health care plan pays. If the
46
 Plan is determined to be the secondary payor, then the Plan will be
liable only for the amount due under the secondary plan rules,
regardless of whether or not a payment is made by the primary plan.

4. Allowable Expense: The usual and prevailing charge or negotiated rate,

whichever is less, for a needed service or supply, when the charge, service
or supply is covered at least in part by one or more Programs of the same
type (Dental, Vision Care, or Medical Program) covering the person for
who claim is made.

When a Program provides benefits in the form of services, the Reasonable

Cash Value for each service rendered will be considered both an Allowable
Expense and a benefit paid. When payment under a Program is based on a
contracted fee, that fee or the physician’s usual charge, whichever is less,
will be considered the Allowable Expense.

If a participant has expenses for a stay in a hospital private room, the term
Allowable Expense does not include the difference between the charge for
the Hospital private room and the eligible charge for a hospital room under
this Program, unless:

a. the Hospital private room charges are a covered expense under one
of the Programs; or

b. the participant’s stay in a hospital private room is Medically

Necessary in terms of generally accepted medical practice.

The term Allowable Expense does not include any amount that is not
payable by the Plan because a participant does not adhere to the Managed
Care Provisions (as defined below).

5. Managed Care Provisions: Those provisions that are intended to reduce

unnecessary medical care or to make medical services and supplies
available at a reduced cost. Examples of Managed Care Provisions
include, but are not limited to, second surgical opinion programs and
Preauthorization programs.

6. Claim Determination Period: A Contract Year does not include any part
of the Contract Year while the person has no coverage under this Plan or
any part of the Contract Year before the date these or similar rules take
effect.

B. EFFECT ON BENEFITS

47
1. This Plan’s Rules for the Order in which Benefits are Determined:
When a participant’s health care is the basis for a claim, this Plan
determines its order of benefits using the first of the following rules that
applies:

a. Non-Dependent/Dependent: The benefits of a Plan that covers the

person as a subscriber are determined before those of the Plan
which covers the participant as a dependent, except if the
participant is also a Medicare beneficiary and as a result of the rule
established by Title XVII of the Social Security Act and
implementing regulations, Medicare is:

(1) Secondary to the Plan covering the participant as a

dependent; and

(2) Primary to the Plan covering the participant as other than a

dependent (e.g., a retired employee), then the benefits of the
Plan covering the participant as a dependent are determined
before those of the Plan covering that participant as other
than a dependent.

b. Dependent Child/Parents Not Separated or Divorced: Except as

stated below when this Plan and another Plan cover the same child
as a dependent of different persons, called “parents”:

(1) the benefits of the Plan of the parent whose birthday falls
earlier in a year are determined before those of the Plan of
the parent whose birthday falls later in that year; but

(2) if both parents have the same birthday, the benefits of the
Plan which covered the parent longer are determined before
those of the Plan which covered the other parent for a shorter
period of time.

However, if the other Plan does not have the rule immediately
above, but instead has a rule based on gender of the parent, and if
as a result the Plans do not agree on the order of benefits, the rule
on the other Plan will determine the order of benefits.

c. Dependent Child/Separated or Divorced Parents: If two or more

Plans cover a person who is a dependent child of divorced or
separated parents, benefits for the child are determined in this
order:

(1) first, the Plan of the parent with custody of the child.
(2) then, the Plan of the spouse of the parent with custody of
48
 the child; and
(3) finally, the Plan of the parent not having custody of the
child.

However, the following exceptions apply:

(1) If the specific terms of a court decree state that one of the
parents is responsible for the health care expenses of the
child, and the entity obligated to pay or provide the benefits
of the Plan of that parent has actual knowledge of those
terms, the benefits of that Plan are determined first. This
paragraph does not apply when any benefits are actually
paid or provided before the entity has that actual knowledge.
(2) If the specific terms of a court decree state that the parents
shall share joint custody, without stating that one of the
parents is responsible for the health care expenses of the
child, benefits for the child are determined as outlined
above. (“Dependent Child/Parents Not Separated or
Divorced”).

d. Active/Inactive Eligible Employee: The benefits of a Plan which

covers a person as an employee who is neither laid off nor retired,
or as that employee’s dependent, are determined before those of a
Plan which covers that person as a laid off or retired employee or
as that employee’s dependent. If the other Plan does not have this
rule, and if, as a result, the Plans do not agree on the order of
benefits, this rule is ignored.

e. Continuation Coverage: If a participant whose coverage is

provided under a right of continuation pursuant to federal or state
law also is covered under another Plan, benefits for the participant
are determined in this order:
(1) first, the benefits of the Plan covering the person as an
employee, or as that person’s dependent.
(2) second, the benefits under the continuation coverage.
(3) If the other Plan does not have the rule described above,
and if as a result, the Plans do not agree on the order of
benefits, this rule is ignored.

f. Longer/Shorter Length of Coverage: If none of the above rules

determine the order of benefits, the benefits of the Plan which
covered a participant longer are determined before those of the
Plan which covered that person for the shorter term.

2. Effect of Reduction in Benefits: When these rules reduce this Plan’s

benefits, each benefit is reduced in proportion. It is then charged against
any applicable benefit limit of this Plan.
49
 C. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION

Certain facts are needed to apply this coordination of benefits rules. The Plan has
the right to decide which facts it needs. It may get needed facts for, or give them
to, any other organization or person as allowable by law. The Plan need not tell, or
get the consent of, any person to do this. Each person claiming benefits under this
Plan must give Community First any facts it needs to pay the claim.

D. FACILITY OF PAYMENT

A payment made under another Plan may include an amount which should have
been paid under this Plan. If it does, the Plan may pay that amount to the
organization which made that payment. That amount will then be treated as
though it were a benefit provided under this Plan. The Plan will have no further
liability with respect to that amount. The term “payment made” includes
providing benefits in the form of services, in which case the payment made shall
be deemed to be the actual costs of any benefits provided in the form of services.

E. RIGHT OF RECOVERY

If payments have been made by the Plan that are more than what should have been
paid under the coordination of benefits provisions, the Plan shall have the right to
recover only the excess amount that we paid from one or more of the persons or
organizations that may be responsible for the services and benefits provided.

F. Local/In-Network vs Out of Network/Out of State

1. If an employee and/or dependent is utilizing other insurance (i.e., Humana,

Blue Cross Blue Shield, etc.) then, CFHP will coordinate benefits as the
secondary payer. Please keep in mind that the services obtained outside of
the UFCP Network must be within the Primary Insurance’s network in
order for CFHP to coordinate benefits as secondary payer.

2. Please keep in mind any services, including emergency services outside of

UH Network, will not be covered by the University Family Care Plan as a
secondary payer.

VII. COORDINATING BENEFITS WITH MEDICARE

A. WHEN MEDICARE IS THE PRIMARY PAYER

Eligible Retirees If you are an eligible retiree, and elected Medicare Part A&B or
Part C your health care coverage will be determined under Medicare before the Plan
determines benefits.

Coordination of Benefits
50
 .
If you elect to accept Part A only
Part A: Community First will pay all of the Medicare Part A deductible, less any
applicable Copayment/Percentage Copayment for an in-network provider through the
UFCP Network.
For PPO providers, Community First will pay the PPO deductible and co-insurance. If
the provider is not in network with UFCP Network or First Health, there will be no
secondary coverage.

Part B: If the member has not elected Part B coverage, Community First will pay as
the primary payor and will pay per the Schedule of Benefits.

Local/In-Network vs Out of Network/Out of State

1. When Medicare is primary: CFHP will coordinate benefits as secondary payer

when utilization of benefits occurs outside of the UFCP Network but within
Bexar County.

2. When Medicare is primary: CFHP will not coordinate benefits as secondary

payer when utilization of benefits occurs outside of the UFCP Network and
outside Bexar County.

B. WHEN THE PLAN IS THE PRIMARY PAYER

If Community First is Primary, then the UFCP Network must be utilized.

1. Active employees aged 65 or older If you are an active employee aged

65 or older and are eligible for Medicare, you may continue to be
covered under this Plan on the same basis as an employee under age 65.

2. Spouses aged 65 and older of active employees If you are an active

employee and your spouse is age 65 or older, and you have enrolled your
spouse for dependent coverage, the Plan will be the primary payer for your
spouse’s health care coverage and will determine your spouse’s benefits
under this Plan before Medicare pays benefits.

3. Active employees and dependents under age 65 and eligible for

Medicare because of a disability If you are an employee or dependent,
are eligible for Medicare because of a disability, the Plan will be the
primary payer for your health care coverage and will determine your
benefits under this Plan before Medicare pays benefits.

4. Active employees or dependents who are eligible for Medicare only

because of End Stage Renal Disease (ESRD) If you are an employee or
dependent and are diagnosed with ESRD, Community First will be primary
for the first 30 months after you become eligible to join Medicare.
51
 Medicare will become the primary once the 30-month period has passed.

C. RETIREES UNDER AGE 65 RECEIVING SOCIAL SECURITY DISABILITY

Community First shall provide only secondary benefits as if Part B coverage is in

force, even if Part B is not purchased by the eligible participant. Community First
will not require members to purchase Medicare Part B Coverage.

VIII. CLAIM RULES

These rules apply if a charge is made to a participant for any covered service or
supply under the Plan.

A. REIMBURSEMENT PROVISIONS FOR NON-PARTICIPATING PROVIDERS

OR OUT-OF-AREA CLAIMS

Only emergency care is covered outside of the Plan’s network and/or service area,
unless medically necessary covered services are not available through
participating providers. The Plan will reimburse the non-participating provider at
the negotiated or usual and customary rate for medically necessary covered
services, requested by participating providers and approved by Community First
within forty-five (45) days of Community First's receipt of a claim with the
documentation reasonably necessary to process the claim, unless a different time
frame is provided for by written agreement between the parties.

Non-participating providers may require immediate payment for their services and
supplies. If you pay a bill for covered services, then submit a copy of the paid bill
along with a completed claim form to Community First’s Member Services
Department requesting reimbursement (Claim forms may be obtained from the
Member Services Department). Include all of the following information on your
request:

1. The patient’s name, address and the identification number and Group
number and your relationship to the Subscriber from Your identification
card.

2. Name and address of the provider of your service (if not on the bill).

3. If you receive a bill for authorized covered services from a non-

participating provider, you may ask Community First to pay the provider
directly. Send the bill to Community First according to the procedures
listed above.

B. PROOF OF LOSS

52
 Community First must be given written proof of the loss for which claim is made
under the Plan. This proof must cover the occurrence, character, and extent of that
loss. It must be furnished within sixty (60) days after the date of the loss.
However, it may not be reasonably possible to do so. In that case, the claim will
still be considered valid if the proof is furnished as soon as reasonably possible.

C. PHYSICAL EXAM

The Plan, at its own expense, has the right to examine the person whose loss is the
basis of claim. The Plan may do this when and as often as is reasonable while the
claim is pending.

D. LEGAL ACTION

No action at law or in equity will be brought to recover on the Plan until 60 days
after the written proof described above is furnished. No such action will be brought
more than one year after the end of the time within which proof of loss is required.

IX. GENERAL INFORMATION

A. COMPLAINT/APPEAL PROCESS

1. Where to File a Complaints/Complaint Appeals should be directed to

Community First’s Member Services Department at 1-800-434-2347 or
210-358-6090 or in writing to: 12238 Silicon Drive, Suite 100, San
Antonio, Texas 78249.

2. General. Participants are required to submit all Complaints through

Community First’s internal Complaints and Appeals process, which we
have outlined for you below.

The Plan encourages the informal resolution of complaints. The Plan will
not retaliate against you, including cancellation of coverage or refusal to
renew coverage, simply because you, or a person acting on your behalf,
have filed a complaint against the Plan or Community First or appealed a
decision of Community First.

If you would like assistance in filing a complaint or wish to designate

someone to represent you in resolving your complaint, please contact
Community First’s Member Services Department at the number above.

3. Process for Complaint Resolution

Complaints will be handled in the following manner:

53
 Step Action

a. You, or someone acting on your behalf, notifies Community First

orally, or in writing, of a complaint.

b. Upon receipt of a written complaint, we will send you a letter

acknowledging receipt of your complaint within five working days.
The letter will include the date Community First received the
complaint, as well as a description of the complaint and Appeal
process and timeframes.

If we have received an oral complaint, you will receive a one-page

complaint form, which should be completed and returned
immediately for prompt resolution of the complaint.

c. Community First will investigate the written complaint and send

you a letter explaining the resolution of your complaint.
Community First will acknowledge, investigate and resolve your
written Complaint within 30 calendar days after the date of receipt
of your written complaint, or a completed complaint form.

Community First will investigate complaints received within one

year from the date of service, otherwise the complaint will be
deemed ineligible for the complaint and appeals process.

4. Appeal Process
Appeals will be handled in the following manner:

Step Action

a. If you are not satisfied with Community First’s resolution of your

complaint, you or a person acting on your behalf may notify
Community First, in writing, of your wish to appeal a Complaint
decision, within 90 calendar days after the date of the decision, as
indicated on your complaint resolution letter.

b. Community First will send you a letter acknowledging receipt of

your request for a complaint appeal within five working days after
the date of receipt of your written request for a complaint appeal. If
we have received an oral appeal, we will include an appeal form,
which should be completed and returned immediately for prompt
resolution of the appeal.

c. Community First will schedule a Complaint Appeal Committee to

54
 review your appeal, which will consist of Community First
representatives from the following departments and a Medical
Director: Network Management, Health Services Management,
Member Services, and Claims.

No individual serving on the panel may have previously been

involved in the disputed decision that is the subject of the Appeal.
You, or a person acting on your behalf, may present written
alternative expert testimony, valid Summary of Benefits language to
support your request for appeal, and submit any additional pertinent
information which was not previously considered by Community
First. Relevant documents will be reviewed by the Complaint
Appeals Committee and considered along with additional
information gathered during the investigation of the complaint
appeal.

d. The Complaint Appeal Committee will render a decision and

Community First will notify you or the person acting on your
behalf, in writing, within 30 calendar days after the date of receipt
of your written request for a complaint appeal.

e. The decision rendered by the Complaint Appeal Committee will

be deemed final and binding on you and the Plan.

5. Maintenance of Records. The Plan or Community First will maintain a

record of each complaint and/or appeal as well as any proceedings and any
actions taken on a complaint and/or appeal for three years from the date of
receipt of a complaint, or as required by law. You may obtain a copy of
the record on your complaint, appeal and any proceedings.

6. Appeal of an adverse determination

a. Appeals of adverse determination should be directed to:

Population Health Management Resolution Department

Community First Health Plans
12238 Silicon Drive, Suite 100
San Antonio, Texas 78249
210-358-6050

b. General. Participants are required to submit all appeals through

Community First’s internal Complaint and Appeal process, which
we have outlined for you below

c. Appeals of Adverse Determinations will be handled in the

55
 following manner:

Step Action

(1) You, or someone acting on your behalf, notifies

Community First orally, or in writing, of an appeal.
(2) An appeal acknowledgment letter will be sent to the
appealing party within 5 working days of receipt. The letter
will include:

(a) the date Community First received the appeal,

(b) a reasonable list of documents to be submitted by
the appealing party to CFHP for the Appeal.
(c) a medical record request form may be sent by CFHP
to the provider of service.
(d) an appeal form to the appellant if the appeal was
oral.

(3) The Community First PHM Resolution Department will

refer the appeal to an appropriate clinical consultant who
was not involved in the initial adverse determination. A
clinical consultant who has expertise in the field of physical
or behavioral medicine that is appropriate for the service at
issue makes the appeal decision.

(4) Community First will provide written notification to the

participant, provider of record, and PCP of record, when
applicable, of the determination of the appeal as soon as
practical, but in no case later than 30 days after it receives
the oral or written Appeal.

(5) An appropriate health care provider will make all Appeal

decisions for adverse determination. If the Appeal is denied,
and within ten (10) Working Days the health care provider
sets forth, in writing, good cause for having a particular type
of a specialty Provider review the case, the denial will be
reviewed by a health care provider in the same or similar
specialty as typically manages the medical, dental, or
specialty condition, procedure, or treatment under discussion
for review. Such specialty review will be completed within
fifteen (15) Working Days of receipt of the request.

7. Process for Requesting Independent Review of an Adverse

Determination:
56
 Step Action

a. You, or someone acting on your behalf whose appeal of an adverse

determination is denied by Community First on behalf of UH may
seek review of that determination by an Independent Peer Review
Organization.

b. The request for the IPRO must be in writing.

c. An IPRO appeal acknowledgment letter will be sent to the

appealing party within 5 working days of receipt. The
acknowledgment letter will include:

(1) the date CFHP received the IPRO appeal.

(2) a reasonable list of documents to be submitted by the
appealing party to CFHP for the IPRO appeal;
(3) a medical record request form may be sent by CFHP to the
provider of service.
(4) a one-page Appeal Form to the Appellant if the IPRO
appeal is oral.

d. The resolution staff will notify the participant/participant

representative, and UH of the final determination: within 30
calendar days of receipt of the original request for IPRO for
standard Appeals,

e. There is no right of appeal of the IPRO determination by

either the participant/ participant representative, however, the
participant may complain to UH.at any time.

8. Expedited IPRO Appeals of Adverse Determinations

Expedited IPRO Appeals may be requested for denials of care for life-
threatening conditions, which would seriously jeopardize the participant’s
life or health, and denials of continued stays for hospitalized patients.

● a health care practitioner with knowledge of the participants’

medical condition (e.g., a treating practitioner) may act as the
authorized representative of the participant.
● the request must be written.

The HSM Resolution Unit will determine whether the request will be treated
as an expedited appeal based on UR Agent requirements.

a. If the IPRO Appeal will not be expedited, CFHP will:

57
 (1) transfer the IPRO Appeal to the standard IPRO Appeal
process.
(2) provide oral notice to the participant/participant
representative of the decision not to expedite within one (1)
working day from the date of receipt of the IPRO Appeal.
(3) provide written notice within one (1) Working day from
receipt of the appeal.
(4) The notice, which will serve as the IPRO Appeal
acknowledgment letter, will contain the following
information:
• the decision not to expedite the IPRO Appeal
request.
• the request will be processed using the standard
timeframe; iii inform the participant of the right to
file a complaint if he or she disagrees with the
decision not to expedite.
• inform the participant of the right to resubmit a
request for an Expedited IPRO Appeal with any
physician’s support; and
• provide instructions about the complaint process
and its timeframes.

b. If the decision is to expedite the IPRO Appeal, CFHP will assign

the IPRO appeal to a Clinical Consultant that has not previously
reviewed the case and who is of the same or similar specialty as
typically manages the medical condition, procedure, or treatment
under review.
c. The IPRO will submit its determination to CFHP; the CFHP
resolution staff will notify the participant/participant
Representative, and UH of the final determination:

(1) within 30 calendar days of receipt of the original request for

standard IPRO Appeals, or
(2) in the event a Life-threatening Condition, the determination
must be made not later than the earlier of:
(3) the 5th day after the date the IPRO receives the information
necessary to make the determination; or
(4) the 8th day after the date the IPRO receives the request that
the determination be made.

d. Initial notice of the decision may be delivered orally followed by a

written Notification of the determination within one (1) working
day from the expedited IPRO Appeal request to the participant or
participant representative.

e. There is no right of appeal of the IPRO determination by either the

58
 participant or participant representative, however, the participant
may complain to UH at any time.

B. IDENTIFICATION CARDS

Any identification cards (called ID Cards) issued by the Plan, are for identification
only and remain the property of the Plan. Possession of an ID Card does not convey
any rights to benefits under the Plan. Any person who receives services, supplies,
or other benefits to which the person is not entitled by the terms of the Plan will be
charged for the actual costs incurred by the Plan for any such services or supplies
or for the amount of any such benefits. If any participant permits another person to
use the participant’s ID Card, the Plan may:

1. invalidate that participant’s ID Card; and

2. terminate that participant’s coverage as provided in the “WHEN YOUR
COVERAGE ENDS” section.

C. CONFIDENTIAL NATURE OF MEDICAL RECORDS

Any information from a participant’s medical records or received from providers

or hospitals incident to the physician-patient or hospital-patient relationships will
be kept confidential as permitted by applicable law. Such information may not be
disclosed without the consent of the participant, except as is reasonably necessary
in connection with the administration of the Plan, as permitted by law. Each
participant agrees that participating providers or consulting physicians may release
medical records to Community First, and any of its subsidiaries or affiliates, as is
reasonably necessary for claim determination, litigation, or other normal business
activities.

D. ASSIGNMENTS

Benefits provided to a participant under the Plan are personal to the participant
and are not assignable or otherwise transferable.

E. NOTICES AND OTHER INFORMATION

Any notices, documents, or other information under the Plan may be sent by
United States Mail, postage prepaid, addressed as follows:

If to Community First: At its address shown on the first page of this

Summary of Benefits.

59
 If to a participant: To the last address provided by the participant on an
enrollment or change of address form actually delivered to Community
First.

F. WHEN YOUR COVERAGE ENDS

1. Employee and Dependent Coverage.

a. Your Employee Coverage or Your Dependent Coverage will end

when the first of these occurs:

(1) Your membership in the covered classes for the coverage

ends because your employment ends (see “End of
Employment” section below).

(2) You fail to pay, when due, any contribution required for
your Employee Coverage. Failure to contribute for
Dependent Coverage will not cause your Employee
Coverage to end.

(3) You no longer reside, live or work within the Service Area.

(4) You become eligible under Part A of Medicare by reason of

reaching age 65, you elect Medicare as your primary benefit
program (for active Eligible Employees and their Qualified
Dependents) and choose not to continue the Plans Health
Care Coverage.

(5) You fail to enroll in Part A of Medicare, if required by

UH (for retired Eligible Employees and their Qualified
Dependents).

(6) The coverage is dependent coverage, and your employee

coverage ends.

b. Your Dependent Coverage for a Qualified Dependent will end

when that person:

(1) moves his or her permanent residence outside the service

area. Court ordered dependents that reside outside of the
service area may continue to be covered under the UFCP
plan but must obtain care through the UFCP or UFCP
Expanded Network (applicable out of pocket costs will
apply such as deductible and coinsurance. Services obtained
outside of the UFCP or UFCP Expanded Network
without a prior authorization will be the member’s
60
 responsibility.

(2) ceases to be a qualified dependent. (See the section entitled

“Continued Coverage for an Incapacitated Child” below.)

(3) reaches maximum age limit, as stated in section “Who is

Eligible to Become Covered.” Coverage will terminate at
the end of the dependent’s birthday month.

c. End of Employment: For purposes of coverage under the Plan,

your employment ends when you are no longer considered to be
employed by UH. But, for Coverage purposes, UH may consider
you as still employed and in the covered classes during certain
types of absences from work. UH decides whether you are to be
considered as still employed during those types of absences and for
how long. In making such a determination, UH does not
discriminate among persons in like situations.

You may be considered as still employed up to any time limit on

your type of absence. When so considered, your eligible employee
coverage and dependent coverage will be continued only while you
are paying contributions for such coverage at the time and in the
amounts, if any, required by UH (whether or not those coverages
would otherwise be non-contributory coverages). But the coverages
will not be continued after they would end for a reason other than
end of employment. The types of absences and time limits include
disability and leave of absence. Contact the UH Human Resources
Department for further details.

d. Cancellation and Non-Renewal of Coverage: If any of the

following conditions exist, UHS will give written notice to the
participant that the person is no longer a participant for the Plan:

(1) Nonpayment of Amounts Due Under the Contract. UH may

cancel your coverage, after providing you with at least a 30-
day written notice, if you fail to pay the amounts due, such
as failure to pay any copayment or to make any
reimbursement to UH required under the Plan. The Plan is
not required to provide written notice of cancellation for
failure to pay premium, and you may be held responsible for
the cost of services received after the premium due date.

(2) Fraud or Intentional Material Misrepresentation. If you

furnish incorrect or incomplete information in a statement
made for the purpose of effecting coverage under the Plan,
your coverage may be cancelled after not less than 15 days
61
 written notice. This condition is subject to the provisions
of the section entitled “INCONTESTABILITY OF
COVERAGE.”

(3) Fraud in the Use of Your Identification Card, Facilities or

Services. If you permit any other person who is not a
member of the Family Unit to use any identification card
issued by the Plan to you, or if you fraudulently access any
Participating Facilities or services provided by the Plan,
your coverage may be cancelled after not less than 15 days’
written notice.

(4) Untenable Relationship. If you are unable to establish and

maintain a satisfactory relationship with a Participating
Provider, or you fail to abide by the rules and regulations of
the Plan, Community First will send you a 30-day written
notice outlining the unsatisfactory nature of the relationship
and specify the changes necessary to avoid termination. If
you fail to make the necessary changes, coverage may be
cancelled at the end of the thirty (30) days.

(5) Misconduct Detrimental to Safe Plan Operations. Coverage

may be cancelled immediately if a Participant engages in any
misconduct that is detrimental to safe plan operations and
the delivery of services.

(6) Failure to Meet Eligibility Requirements. If a participant

fails to meet eligibility requirements other than the
requirement that he or she reside, live, or work in the
Service Area, coverage may be cancelled immediately,
subject to continuation of coverage provisions.

(7) Failure to Reside, Live or Work in the Service Area. If a

participant neither resides, lives or works in the service area,
coverage may be cancelled after a 30-day written notice, but
only if coverage is terminated uniformly without regard to
any health status related factor of the participant. Coverage
for a court-ordered dependent cannot be cancelled solely
because the child does not reside, live or work in the service
area.

If the Plan gives the participant such written notice of

termination of coverage:
(a) that person will cease to be a participant for the
benefits of the coverage on the date immediately
following thirty (30) days after such written notice
62
 is given by the Plan; and

(b) no benefits will be provided to the person under the

coverage after such date.

Any action by the Plan under these provisions is subject to

review in accordance with the Complaint and Appeals
Process.

G. CONTINUATION PRIVILEGE

1. Continued Coverage for an Incapacitated Child: Your dependent

coverage for a child will not end just because the child has reached a
certain age and both a. and b. below are true:

a. The child is then behaviorally or physically incapable of earning a

living. UH must receive proof of this within the next 30 days: and
b. The child otherwise meets the definition of qualified dependent.

If these two conditions are met, the age limit will not cause the child to stop
being a qualified dependent under the Plan. This will apply as long as the
child remains incapacitated as described in a. above.

2. Continued Coverage at You or Your Dependent’s Option: You or

your dependent may be eligible for continued coverage upon the
occurrence of certain events as described in below.
a. Continued Coverage under COBRA. A participant may be eligible
to continue coverage under the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) with the same benefits as
provided under the Plan upon the occurrence of a qualifying event.
Qualifying events are listed below, along with the length of time
that COBRA coverage is available.

YOUR BENEFITS

DEPENDENTS BENEFITS

Length of Time COBRA

Qualifying Event Coverage is Available

63
 Termination of Your Employment 18 months (29 months for a
(unless due to gross misconduct) person who qualifies for
Social Security disability
benefits)
Reduction in Your work hours 18 months (29 months for a
person who qualifies for
Social Security disability
benefits)
You become entitled to Medicare 36 months
Your death 36 months
Your divorce or legal separation 36 months
Dependent child loses eligibility 36 months

The continuation of coverage periods shown above include any

periods that the participant was covered under any other continuation
of coverage. The continuation of coverage may be terminated sooner
than the indicated length of time when:

- the plan ends.

- the participant fails to timely pay the premium.
- the participant first becomes eligible for Medicare.
- in the case of a participant who is disabled when the
continuation coverage begins, the participant becomes
ineligible for disability benefits under the Social Security
Act; provided, however, this will apply only if the
participant becomes ineligible after such continuation
coverage has been in effect for at least 18 months; or
- the participant becomes covered under another health plan
that does not contain any exclusion or limitation with
respect to any such pre-existing condition of the participant.

Election for continuation of coverage under COBRA must be made within

(60) days of the later of: (i) the occurrence of a qualifying event, or (ii) the
date you or your Dependent receives the appropriate COBRA election
forms that must be provided by the Plan.

X. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

(HIPAA)

A. UH is required by the federal Health Insurance Portability and Accountability

Act of 1996 (HIPAA) to:

64
 1. Make sure that your health information and the health information of your
family members, which UH and/or its business associates, receive and
maintain on behalf of the Plan, is kept private. This health information is
referred to in this section as “your protected health information.”
2. Give to you a Notice of Privacy Practices concerning how UH will comply
with HIPAA with respect to your protected health information. UH has
provided a copy of this notice to all covered employees. A copy is posted
on the UH infoNET UH reserves the right to change the notice at any time.

B. Who May Use Your Protected Health Information.

Under HIPAA, your protected health information, which is held by or for the Plan,
may only be used by or disclosed to the parties that administer the Plan claims, such
as Community First Health Plans, Inc., other business associates who assist UH
with operating the Plan, and certain UH employees in connection with their Plan
responsibilities.

C. How Your Protected Health Information May Be Used

Your protected health information may only be used for Plan payment and
operations and certain other limited purposes, as permitted, or required by HIPAA,
or to the extent you (or in certain circumstances, a family member) have authorized
the use or disclosure of that information. The UH employees and the Plan’s
business associates are bound by these restrictions and conditions concerning your
protected health information.
D. Your Rights Under HIPAA

In addition to protecting the Plan’s use and disclosure of your and your family’s
health information, HIPAA also gives you and your family (collectively, you)
various rights with respect to that information. For example, you have the right to
inspect and copy your protected health information that is held in the Plan’s official
files, with certain exceptions. You also have the right to request that incomplete or
incorrect information be amended. In addition, you have the right to request a list
of certain extraordinary disclosures of your protected health information that may
have been made after April 14, 2003.

If you would like, you may request restrictions or limitation on how, when, and to
whom the Plan sends your protected health information. For example, you may
ask the Plan to send information about your claims and payments to you at a
different address.

E. Questions and Complaints

Additional information on the permissible uses and disclosures of your protected

health information, and your rights under HIPAA, can be found in the Notice of
Privacy Practices. If you have certain questions about your HIPAA privacy rights
65
 of if you believe your rights have been violated, you may contact or file a complaint
with Community First Member Services, or the Secretary of the Department of
Health and Human Services...

XI. DEFINITIONS

Acquired Brain Injury: A neurological insult to the brain, which is not hereditary,
congenital, or degenerative. The injury to the brain has occurred after birth and results in
a change in neuronal activity, which results in an impairment of physical functioning,
sensory processing, cognition, or psychosocial behavior. Covered services include the
following:

1. Cognitive Communication Therapy: Services designed to address modalities of

comprehension and expression, including understanding, reading, writing, and
verbal expression of information.
2. Cognitive Rehabilitation Therapy: Services designed to address therapeutic cognitive
activities, based on an assessment, and understanding of the individual’s brain-
behavioral deficits.
3. Community Reintegration Services: Services that facilitate the continuum of care as
an affected individual transitions into the community.
4. Neurobehavioral Testing: An evaluation of the history of neurological and psychiatric
difficulty, current symptoms, current behavior status, and premorbid history, including
the identification of problematic behavior and the relationship between behavior and
the variables that control behavior. This may include interviews of the individual,
family, or others.
5. Neurobehavioral Treatment: Interventions that focus on behavior and the variables
that control behavior.
6. Neurocognitive Rehabilitation: Services designed to assist cognitively impaired
individuals to compensate for deficits in cognitive functioning by rebuilding
cognitive skills and/or developing compensatory strategies and techniques.
7. Neurocognitive Therapy: Services designed to address neurological deficits in
informational processing and to facilitate the development of higher-level
cognitive abilities.
8. Neurofeedback Therapy: Services that utilize operant conditioning learning procedure
based on electroencephalography (EEG) parameters, and which are designed to result
in improved behavior performance and behavior, and stabilized mood.
9. Neurophysiological testing: An evaluation of the functions of the nervous system.
10. Neurophysiological Treatment: Interventions that focus on the functions of the nervous
system.
11. Neuropsychological Testing: The administering of a comprehensive battery of tests to
evaluate neurocognitive, behavioral, and emotional strengths and weaknesses and
their relationship to normal and abnormal central nervous system functioning.
12. Neuropsychological Treatment: Interventions designed to improve or minimize
deficits in behavioral and cognitive processes.
13. Post-acute Transition Services: Services that facilitate the continuum of care beyond
the initial neurological insult through rehabilitation and community reintegration.
66
14. Psychophysiological Testing: An evaluation of interrelationships between the
nervous system and other bodily organs and behavior.
15. Psychophysiological Treatment: Interventions designed to alleviate or decrease
abnormal physiological responses of the nervous system due to behavioral or emotional
factors.
16 Remediation: The process (es) of restoring or improving a specific function.
17. Outpatient Day Treatment Services: Structured services provided to address deficits in
physiological, behavioral, and/or cognitive functions. Such services may be delivered
in settings that include transitional residential, community integration, or non-
residential treatment settings.
18. Post-Acute Care Treatment Services: Services provided after acute care confinement
and/or treatment that are based on an assessment of the individual’s physical, behavioral,
or cognitive functional deficits, which include a treatment goal of achieving functional
changes by reinforcing, strengthening, or re-establishing previously learned patterns of
behavior and/or establishing new patterns of cognitive activity or compensatory
mechanisms.

Adopted Child: A child for whom an adoption is final or a child who has become subject
of a suit for adoption by an eligible employee. For the purposes of eligibility, an adopted
child must be enrolled, at the option of the eligible employee, within either:

1. (31) days after the eligible employee is a party in a suit for adoption; or
2. (31) days after the date the adoption is final.
Adverse Determination: The determination by Community First, that the health care
services furnished or proposed to be provided or proposed to be provided to a participant
are not medically necessary or are experimental or investigational.

After Hours Care: Health care services provided to a participant for an illness or an injury
that occurs after normal provider office hours.

Alzheimer’s Disease: a neurologic disease characterized by loss of behavior mental

ability severe enough to interfere with normal activities of daily living, lasting at least
six months, and not present from birth. Appeal: A request, orally or in writing, for
reconsideration of a decision reached under the formal Complaint and Appeals process.

Appeals Panel or Panel: A panel, composed of equal numbers of Community First

Staff, Physicians or other providers, and participant’s, which advises Community First
on the resolution of a dispute.

Associated Company: Employers that are the Plan Sponsors (UH) subsidiaries or
affiliates and are included under the Plan.

Autism Spectrum Disorder: A neurobiological disorder that includes Autism,

Syndrome, or Pervasive Developmental Disorder (Not otherwise specified).

Balance Billing: The practice of charging a participant the balance of a non-network health
67
care provider’s fee for services received by the participant that is not fully reimbursed by
the Plan.

Body Mass Index: A particular marker that is used to assess the degree of obesity and is
calculated by dividing the weight in kilograms by the height in meters squared.

Bone-Anchored Hearing Aid (BAHA): Considered a prosthetic, BAHA is a surgically

implantable medical device for treatment of hearing loss that works through direct bone
conduction. For hearing loss caused by damage or blockage to the outer or middle ear
(conductive or mixed hearing loss), or those with single-sided deafness, are candidates for a
BAHA device. These patients typically receive little or no benefit from traditional hearing
aids.

Chemical Dependency: The abuse of, or psychological or physical dependence on, or

addiction to alcohol or a controlled substance.

Chemical Dependency Treatment Center: A facility that provides a program for the
treatment of chemical dependency pursuant to a written treatment plan approved and
monitored by a physician and meets one of these tests:

• Is affiliated with a hospital under a contractual agreement with an established system

of patient referral.
• Is licensed as a chemical dependency treatment program by the Texas Commission
on Alcohol and Drug Abuse.
• Is licensed, certified, or approved as a chemical dependency treatment program or center
by any other state agency having legal authority to so license, certify, or approve.

Children: Includes your natural-born children, an adopted child or children who have
become subject of a suit for adoption by the eligible employee, your stepchildren, foster
children who depend on you for support and maintenance, and any children for whom you
must provide medical support under an order issued under Section 14.061, Family Code,
or enforceable by a Court in this State. Also included is a grandchild of yours and you
have a court order or legal guardianship for.

Community First: Community First Health Plans, Inc.

Complainant: A physician, provider, participant, or other person designated to act on

behalf of a participant, who files a complaint.

Complaint: Any dissatisfaction expressed by a complainant to Community First, orally or

in writing, with any aspect of the organization or operation, including but not limited to,
dissatisfaction with plan administration; procedures related to review or appeal of an adverse
determination; the denial, reduction, or termination of a service for reasons not related to
medical necessity; the way a service is provided; or disenrollment decisions. A complaint
does not include a misunderstanding or a problem of misinformation that is resolved
promptly by clearing up the misunderstanding or supplying the appropriate information to
68
the satisfaction of the participant and does not include a provider’s or participant’s oral or
written dissatisfaction or disagreement with an adverse determination.

Contract Year: The twelve (12) month period, commencing with the effective date of the
Plan, during which coverage is in effect.

Contributory Coverage, Non-contributory Coverage: Contributory coverage is coverage

for which the Plan requires Employee contributions. Non-contributory coverage is coverage
for which the Plan does not require employee contributions.

Controlled Substance: A toxic inhalant or substance designated as a controlled substance

in Chapter 481, Health and Safety Code.

Copayment: An amount required to be paid by a participant, in addition to premium, in

connection with certain covered services and supplies. A copayment may be a set dollar
amount or a percentage of the cost of the service.

Counseling Services: Supportive services provided under a hospice care program by

members of the hospice team in counseling sessions with the family unit. These services
are to assist the family unit in dealing with the death of a terminally ill person.
Court-Ordered Dependent: Dependent children whose eligibility for coverage is
determined by a court-ordered child support or medical support document.

Covered Services and Supplies: The services and supplies covered under the Plan.

Covered Classes: All eligible employees who live, work, or reside in the service area but
are not covered under the Plan.

Crisis Stabilization Unit: A 24-hour inpatient program that is usually short term in nature
and that provides intensive supervision and highly structured activities to persons who are
demonstrating an acute psychiatric crisis of moderate to severe proportions.

Custodial Care: Services which are not intended primarily to treat a specific injury or
illness (including behavioral illness or substance abuse/chemical dependency). These
services may include:

1. services related to watching or protecting a participant.

2. services related to performing or assisting a participant in performing any
activities of daily living, such as walking, grooming, bathing, dressing, getting
in or out of bed, toileting, eating, preparing foods, or taking medications that can
usually be self- administered; and services not required to be performed by
trained or skilled medical or paramedical personnel.

Dependent: Your dependent is someone who:

• Is your spouse or your child and who meets the eligibility requirements of this Plan,
69
 or another person who is a dependent under eligibility rules that are set by the UH
• is listed by you on the enrollment form, and
• for whom the required premium has been paid
• is a court ordered dependent
• a child of any age who is medically certified as disabled and dependent on the parent.
The Plan requires proof of dependent eligibility status for any dependent over the limiting
age for dependents.

Dependent Coverage: Coverage that applies to a dependent.

Eligible Employee: An employee who works on a full-time basis forty (40 hours) per week
or at least part time twenty (20) hours per week. The term does not include:

1. an employee who works on a, temporary, seasonal, or substitute basis; or

2. an employee who is covered under:

a. another health benefit plan

b. a self-funded or self-insured employee welfare benefit plan that provides health
benefits and that is established and that is established in accordance with the
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et. Seq.
c. the Medicaid program if the employee elects not to be covered.
d. another federal program, including the CHAMPUS program or Medicare
program, if the employee elects not to be covered; or
e. a benefit plan established in another country if the employee elects not to be
covered

Eligible Retiree: A former employee who meets eligibility criteria that have been set by UH.

Emergency Care: Health care services provided in a hospital emergency facility, free
standing emergency medical care facility or comparable emergency facility to evaluate and
stabilize medical conditions, including a behavioral health condition, of a recent onset and
severity including, but not limited to, severe pain that would lead a prudent lay person,
possessing an average knowledge of medicine and health to believe that his or her condition,
illness, or injury is of such a nature that failure to get immediate medical care could result
in:

1. placing his or her health in serious jeopardy.

2. serious impairment to bodily functions.
3. serious dysfunction of any body organ or part.
4. serious disfigurement; or
5. in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Employee Coverage: Coverage that applies to an eligible employee or eligible retiree.

Employer: University Health Collectively, all Associated Companies.

70
Experimental or Investigational: Medical, surgical, diagnostic, psychiatric, substance
abuse or other health care services, technologies, supplies, treatments, procedures, drug
therapies or devices that, at the time Community First makes a determination regarding
coverage in a particular case, meet one of the following criteria:

1. Full and final approval has not been granted by the US Food and Drug Administration
for the treatment of the patient’s medical condition.

2. Specific evidence shows that the service, technology, supply, treatment, procedure,
drug therapy or device is being provided subject to a) phase I or phase II clinical trial
or the experimental arm of a phase III clinical trial, b) a protocol to determine the
safety, toxicity, maximum tolerated dose, efficacy, or efficacy in comparison to the
standard means of treatment or diagnosis, or c) protocol approved by and under the
supervision of an institutional review board.

3. The published authoritative medical and scientific literature a) has not defined, or
supports further research to define, the safety, toxicity, maximum tolerated dose,
efficacy or efficacy in comparison to the standard means of treatment or diagnosis, and
b) does not demonstrate statistically significant improvement in the efficacy or
outcomes for the service, technology, supply, treatment, procedure, drug therapy or
device compared to standard services, technologies, supplies, treatments, procedures,
drug therapies or devices.

Eye Exam: Examinations to determine the need for corrective lenses of any type.

Facility Based Physician: A radiologist, anesthesiologist, pathologist, emergency

department physician or neonatologist to whom a facility has granted clinical privileges and
provides services to patients of the facility.

Family Unit: Collectively, you and your dependents who are participants.

Freestanding Emergency Medical Care Facility: means a facility, structurally separate

and distinct from a hospital that receives an individual and provides emergency care.

Gene Therapy: a medical treatment used to correct defective genes in order to cure a
disease or help the body better fight disease.

Open Enrollment Period: A period of at least thirty (30) days each year, set by UH during
which an Eligible Employee, may:

1. Elect coverage under the Plan.

2. Elect to change benefits under the Plan; or
3. Elect to change from other coverage to the Plan.

Health Care Coverage: The services that are included in this Summary of Benefits.
71
Health Care Facility: A hospital, emergency clinic, outpatient clinic, birthing
center, ambulatory surgical center, or other facility providing health care
services.

Health Status Related Factor: Any of the following in relation to a participant: health
status; medical condition (including both physical and behavioral illnesses); claims
experience; receipt of health care; medical history; genetic information; evidence of
insurability (including conditions arising out of acts of domestic violence, including
family violence; or disability.

Heritable Disease: An inherited disease that may result in intellectual or developmental

disability or death.

Home Health Care: A program, prescribed in writing by a participating physician and

administered by a home health care agency, that provides for the care and treatment of a
person’s illness or injury in the person’s home.

Home Health Care Agency: An organization that has been licensed or certified as a
home health agency in the state of Texas or is a home health agency as defined in
Medicare.

Hospice: An organization that provides short periods of stay for a terminally ill person in
the home or in a home-like setting for either direct care or respite. This organization may
be either freestanding or affiliated with a hospital. It must operate as an integral part of a
hospice care program. If such an organization is required by a state to be licensed, certified,
or registered, it must also meet that requirement to be considered a hospice.

Hospital: An acute care institution licensed by the State of Texas as a hospital, which is
primarily engaged, on an inpatient basis, in providing medical care and treatment of sick
and injured persons through medical, diagnostic, and major surgical facilities, under
supervision of a staff of physicians and with 24-hour a day nursing and physician service;
however, it does not include a nursing home or any institution or part thereof which is used
principally as a custodial facility.

Hospital Inpatient Stay: A hospital stay for which a room and board charge is made by
the hospital.

Illness: Any disorder of the body or mind of a participant, but not an injury.

Immunotherapy: a medical treatment that uses the body's own immune system to help
fight cancer.

Implant: An object or device that is surgically implanted, embedded, inserted, or otherwise

applied and related equipment necessary to operate, program and recharge the implantable
72
(e.g., hip joints, heart pacemakers, penile implants, cochlear implants and implanted
electrical stimulators).

Independent Review Organization: An organization selected as provided under Chapter

4202 of the Texas Insurance Code.

Initial Enrollment Period: The initial period of enrollment after a potential participant
first becomes an eligible employee, or first becomes a qualified dependent.

Injury: Trauma or damage to some part of the body of a participant.

Individual Treatment Plan: A plan with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program.

Life-Threatening Condition: A disease or other medical condition with respect to which

death is probable unless the course of the disease is interrupted. A participant or the
participant's provider of record shall determine the existence of a life-threatening condition
on the basis that a prudent lay person possessing an average knowledge of medicine and
health would believe that his or her disease or condition is life-threatening.

Medicaid: Title XIX (Grants to States for Medical Assistance Programs) of the United
States Social Security Act, as amended from time to time.

Medical Director: A physician who is retained by Community First to coordinate and

supervise the delivery of health care services for participants through participating
physicians and participating providers.

Medical Emergency: A recent onset of a medical and/or behavioral health condition

requiring emergency care.

Medical Necessity or Medically Necessary: Health care services which are determined to
be medically appropriate, and prevent illness or deterioration of medical conditions, or
provide early screening, interventions and/or treatments for conditions that cause suffering
or pain, physical deformity, limitations in function, or endanger life. Such services are
consistent with the diagnosis; provided at appropriate facilities and at the appropriate levels
of care; consistent with health care practice guidelines and standards that are issued by
professionally recognized health care organizations or governmental agencies; and are no
more intrusive or restrictive than necessary.

Medicare: Title XVIII (Health Insurance for the Aged and Disabled) of the United States
Social Security Act, as amended from time to time.

Morbid Obesity: This means the Body Mass Index that is greater than 40 kilograms per
meter squared or greater than 35 kilograms per meter squared with a comorbid medical
condition, including: hypertension; a cardiopulmonary condition; sleep apnea; or diabetes.

73
Participant: An employee who is covered for employee coverage under the Plan or a
dependent with respect to whom an employee is covered for dependent coverage.

Non-Participating Provider: A physician, hospital, or other provider of medical services

or supplies that is not a participating provider, and, therefore, not contracted with
Community First.

Observation Period: A short-term hospital stay lasting less than 24 hours.

Ombudsman Program: Independent medical review program that provides case review
for new and emerging technologies/therapies including, but not limited to, issues pertaining
to the experimental/investigational status of an intervention, clinical trials and research
studies, and other clinical information, for the purpose of assisting Community First in
determining Medical Necessity and appropriateness.

Out-of-Area: Outside the approved service area.

Out-of-Pocket: The copayment amounts that are the participant’s responsibility each
contract year. The specific out-of-pocket maximum copayment that applies under this Plan
is listed in the attached Schedule of Copayments. Community First will assist the participant
in determining when he or she has satisfied the out-of-pocket maximum copayment, so it is
important to keep all receipts for copayments actually paid. Copayments that are paid
toward certain covered services are not applicable to a participant's out-of-pocket as set
forth in the attached Schedule of Copayments.

Orthotics: A custom-fitted or custom-fabricated medical device that is applied to a part of

the human body to correct a deformity, improves function, or relieve symptoms of a disease.

Participating Physician: A physician who is either a (PCP) or a specialty care physician

and who has contracted with Community First to provide services to participants.

Participating Provider: A physician, hospital, or other provider of medical services or

supplies that is licensed or certified in the state in which it is located, and which has
contracted with Community First to arrange for or provide services and supplies for
medical care and treatment of participants.

Phenylketonuria An inherited condition that may cause severe severe intellectual

disability if not treated.

Physician: Any individual licensed to practice medicine by the Texas State Board of
Medical Examiners

Plan: The Summary of Benefits and any addendum, which collectively provides and
defines coverage for particular employees and dependents.

Plan Administrator: University Health

74
Plan Sponsor: University Health

Plan Summary: The information provided to employee’s concerning coverage and

benefits to assist in understanding and using available benefits.

Preauthorization: The verbal or written approval by the Plan Administrator, another payor,
or other permitted person or entity, including a corresponding approval prior to admitting a
participant to a facility, or to providing certain other covered services to a participant, when
approval is required for such services.

Prescription Medication and/or Supplies: This means only:

1. a medicinal substance that, by law, can be dispensed only by prescription.

2. other items that require a prescription order to be dispensed.

Primary Care Physician (PCP): A participating physician (generally an internal

medicine, general medicine, pediatrics or family practice physician) who is chosen by or
for a participant to:

1. providing primary medical care to the participant.

2. maintain the continuity of the participant’s medical care; and initiate referrals
to participating or non-participating physicians and/or other providers.

Prosthesis: An external or removable artificial device that replaces a limb, body part
or function and is determined by Community First as medically necessary.

Psychiatric Day Treatment Facility: A behavior health facility that provides treatment
for individuals suffering from acute, behavior, and nervous disorders in a structured
psychiatric program using Individual treatment plans and that is clinically supervised by a
physician of medicine who is certified in psychiatry by the American Board of Psychiatry
and Neurology.

Reasonable Cash Value: The cash value assigned to a service or supply provided, ordered
or authorized by a participating provider. Community First will base its determination on
the range of charges generally made by providers in the area for a like service or supply
and take into account any unusual circumstances and any medical complications that require
additional time or special skill, experience, and/or facilities in connection with a particular
service.

Referral: A recommendation by a participant’s PCP or other treating provider for a patient

to be evaluated or treated by another physician or provider.

Related Hospital Inpatient Stays: Separate hospital inpatient stays of a person that occur
as a result of the same illness or injury. Hospital inpatient stays will be considered unrelated
75
if:

1. the admission is for a period of thirty (30) days or more between stays.

2. the stays result from wholly unrelated causes.

Residential Treatment Center for Children and Adolescents: A child-care institution

that provides residential care and treatment for emotionally disturbed children and
adolescents and that is licensed or operated by the appropriate state agency or board.

Serious Behavior Illness: The following psychiatric illnesses as defined by the American
Psychiatric Association in the Diagnostic and Statistical Manual (DSM): (A) bipolar
disorders (hypomanic, manic, depressive, and mixed; (B) depression in childhood and
adolescence; (C) major depressive disorders (single episode or recurrent); (D) obsessive-
compulsive disorders; (E) paranoid and other psychotic disorders; (F) schizo-affective
disorders (bipolar or depressive; and
(G) schizophrenia.

Service Area: The geographic area within which covered services and supplies for medical
care and treatment are available and provided, by participating providers, under the Plan,
to participants who live, reside, or work within that geographic area.

Skilled Nursing Facility: An institution that meets all of these tests:

1. Meets all Texas licensing requirements and is legally operated.

2. It mainly provides short-term nursing and rehabilitation services for persons
recovering from Illness or Injury. The services are provided for a fee from its patients
and include both room and board and 24-hour-a-day skilled nursing service.
3. It provides the services under the full-time supervision of a physician or registered
nurse (R.N.); or, if full-time supervision by a physician is not provided, it has the
services of a Physician available under a contractual agreement.
4. Does not include an institution or part of one that is used mainly as a place for custodial
care, rest or for the aged.

Special Enrollment Period: A period outside of the initial enrollment period and the open
enrollment period during which an employee or dependent can enroll in the Plan. The
special enrollment period for both employees and dependents can be activated by:

1. Loss of other coverage (other than for cause or non-payment of premium).

2. A new dependent acquired by an employee through marriage, birth, adoption
or placement for adoption.
3. A court order requiring the employee to cover a spouse or child.

Specialty Care Physician: A participating physician who provides certain specialty

medical care to participants upon referral by a PCP as approved by the Medical Director.
Specialty medical care does not include the following specialties: internal medicine,
76
general medicine, pediatrics, and family practice. But specialty medical care may include
these specialties if approved by the Medical Director.

Surgical Procedure: Typically considered an invasive procedure including, but not limited
to: cutting, suturing, treatment of burns, correction of fracture, reduction of dislocation,
manipulation of joint under general anesthesia, electrocauterization, tapping (paracentesis),
application of plaster casts, endoscopy, or injection of sclerosing solution.

Supplies: Medical supplies are non-reusable, disposable, and are not useful in the absence
of illness or injury. Common household items are not considered medical supplies.

Telehealth Service: A health service, other than a telemedicine medical service, delivered
by a provider acting within the scope of his or her license, who does not perform a
telemedicine medical service that requires the use of advanced telecommunications
technology, other than by telephone or facsimile, including:
• telephone visits
• compressed digital interactive video, audio, or data transmission.
• clinical data transmission using computer imaging by way of still-image capture and
store and forward; and
• other technology that facilitates access to health care services or medical specialty
expertise.

Telemedicine medical service: A health care service initiated by a physician, or another

provider authorized by law to act under physician delegation and supervision, for purposes
of patient assessment by a provider, diagnosis or consultation by a physician, treatment, or
the transfer of medical data, that requires the use of advanced telecommunications
technology, other than by telephone or facsimile, including:

• compressed digital interactive video, audio, or data transmission.

• clinical data transmission using computer imaging by way of still-image capture and
store and forward; and
• other technology that facilitates access to health care services or medical specialty
expertise.

Terminally Ill Person: A person whose life expectancy is six (6) months or less, as certified
by a participating physician.

Toxic Inhalant: A volatile chemical under Chapter 484, Health and Safety Code, or abusable
glue or aerosol paint under Section 485.001, Health and Safety Code.

Urgent Care: Health care services provided in a situation other than an emergency which
are typically provided in settings such as a physician or provider’s office or urgent care
center, as a result of an acute injury or illness, including an urgent behavioral health
situation, that is severe or painful enough to lead a prudent layperson, possessing an average
knowledge of medicine and health, to believe that his or her condition, illness or injury is of
such a nature that failure to obtain treatment within a reasonable period of time would result
77
in serious deterioration of the condition of his or her health.

Utilization Review: A system for prospective, concurrent, or retrospective review of the

Medical Necessity and appropriateness of health care services and a system for prospective,
concurrent, or retrospective review to determine the experimental or investigational nature
of health care services being provided or proposed to be provided to a member. Utilization
Review does not include elective requests for clarification of coverage.

Utilization Review Agent: Community First, or an entity licensed by the Texas Department
of Insurance as a utilization review agent, that conducts utilization review for Community
First.

You and Your: An employee or a participant.

78
 UNIVERSITY FAMILY CARE PLAN
SCHEDULE OF BENEFITS, CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES

The following chart shows eligible services and supplies for your coverage. This schedule is intended to be
a summary. Some of these benefits are subject to limitations and exclusions described in the Summary of
Benefits. Please review the University Family Care Plan Summary of Benefits regarding balance billing for
Non-Participating Providers. The Co-payment and Out-of-Pocket amounts are shown at the right. If there is
no Co-payment, the service or supply shown will be covered at 100 percent (UH Network). Members are
responsible for the payment of Co-payments upon receipt of some of the Covered Services described below.
The maximum Out-of-Pocket payable in each Contract Year is listed below. When a Member or a Family
Unit has paid the applicable maximum Out-of-Pocket, all Covered Services will be provided with no further
Co-payments for the balance of the Contract Year (Expanded Network). Co- payments for prescription
drugs and infertility testing and treatment are not applicable to any annual Out-Of-Pocket
maximums. No lifetime maximum.

Annual Deductible
UH Network Expanded (First Health)
Network
Individual/Family
Annual Out-of-Pocket None $625/$1,250
Maximum (after deductible) None $5,000/$10,000
Individual/Family

Basic Coverage:

CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK
Physician Office Visits $15 co-payment per visit 30% co-insurance after
Services deductible

Telephone Visits $15 co-payment per visit, 30% co-insurance after

UMA PCP Only deductible
Inpatient Hospital Visits
30% co-insurance after
No co-payment
deductible
Allergy Testing and Treatment
$15 co-payment per visit 30% co-insurance after
deductible
Prenatal Visits
$15 co-payment, first visit only 30% co-insurance after
deductible
Specialty Medical Injectable
Office Visit and Medications $15 co-payment per visit 30% co-insurance after
deductible
Smoking Cessation (Annual
benefit limit of $300 for Rx 30% co-insurance after
products only.) $15 co-payment per visit
deductible

Page 1 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK
Preventive Care Pediatric and Adult No co-payment 30% co-insurance after
Services Immunizations deductible

COVID-19 PCR No co-payment 30% co-insurance after

(Furnished, testing limited to 2
authorized or deductible
per year per
arranged by a covered member
Provider during an
office visit.) *Well woman exam - one per 30% co-insurance after
No co-payment
plan year. deductible

Cancer Screenings, including:

1
* Colorectal Cancer Screening No co-payment 30% co-insurance after
(Multi-target Stool DNA Testing deductible
such as Cologuard.)

3 No co-payment 30% co-insurance after

* Cervical Cancer Screening
deductible

*1Exam for Detection and No co-payment 30% co-insurance after

Prevention of Osteoporosis deductible

Well Baby Care /Well Child Care No co-payment 30% co-insurance after
deductible

Physical Examinations (Covered No co-payment 30% co-insurance after

annually.) * deductible
*Tubal Ligation No co-payment 30% co-insurance after
deductible
*When combined with a
Physician Office Visit, only
one Co-payment will apply.

See page27-29 of UH
Summary of Benefits for
details.

Page 2 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK
Family Planning
*Office visits No co-payment 50% co-insurance after
deductible
(Pre- Infertility Testing/Treatment
Authorizati & Office Visit 50% co-payment 50% co-insurance after
on is See page 23-24 & 39 of UH deductible
required Summary of Benefits for details
and exclusions.
for some
Family
Planning Infertility Medications 50% co-payment 50% co-insurance after
services) See page 23 & 37 of UH deductible
Summary of
Benefits for details and
exclusions.

Vasectomy $100 co-payment 50% co-insurance after

See page 23 of UH Summary of deductible
Benefits for details.

Subject to language in 13.4.13.3 of the Description of Benefits (zero cost sharing for certain preventive services under the Affordable Care
Act)

Subject to language in 13.4.13.5 of the Description of Benefits (zero cost sharing for certain preventive services under the Affordable
Care Act)

Page 3 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK

Prescribed Chemotherapy, Radiation No co-payment 30% co-insurance after

Therapy, MRI, PET, CT scan, deductible
Medical SPECT Scans, Mammograms,
Services, X-Rays and Diagnostic
Supplies, Laboratory Tests. Outpatient
Durable Medical only. (Chemotherapy has an
annual benefit limit of
Equipment $250,000.)
(DME) and
Outpatient Durable Medical Equipment No co-payment 30% co-insurance after
Facility (Rental or purchase.) deductible

Breast Pump (A member may No co-payment 30% co-insurance after

(Furnished, obtain a breast pump during their deductible
authorized, or pregnancy or after delivery).
arranged by
provider during an Hearing Aids, All charges over $2,000 All charges over $2,000
office visit) (Includes batteries – annual (after deductible met)
benefit limit of $2,000 max.) Benefit limit still applies

Disposable and Other Eligible $15 co-payment 30% co-insurance after

Supplies deductible

Hearing Aid Exam $15 co-payment 30% co-insurance after

deductible

Diabetes Equipment and $15 co-payment 30% co-insurance after

Supplies. deductible

Prostheses $15 co-payment 30% co-insurance after

(Limit of $10,000 per deductible
occurrence per plan year.)

Orthotics No co-payment 30% co-insurance after

deductible

Implantable Devices Inpatient co-pay applies. 30% co-insurance after

deductible
Cochlear Implant No co-payment
(Benefit limit of $2,000 per 30% co-insurance after
plan year.) deductible

Urgent Care Covered Services Received at $20 co-payment per visit 30% co-insurance after
See page 12 of UH an Urgent Care Center (UH Express Med Only) deductible
Summary of Benefits for
Details

Page 4 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK

Emergency Members may be required to $100 co-payment per visit Co-insurance will apply
pay bill in full at a non- If hospitalized, ER Co-pay is after the deductible is met.
Room or participating facility and submit waived. Hospital inpatient co- If hospitalized, hospital
Observation the claim to Community First pay will apply. inpatient co-insurance will
Period Health Plans (CFHP) for apply. See pg. 13 of UH
reimbursement. CFHP will pay Summary of Benefits for details
See pg. 13 of UH for true Emergency Care University Hospital
Summary of Benefits for Services performed by non- Emergency Center is the
details participating providers at the ONLY emergency room in
negotiated, usual, and the UH Network.
customary rate. Member may
be responsible for balance of
billed charges, if any.

Hospital All inpatient covered services $100 co-payment per day 30% co-insurance after
and supplies, ICU, delivery, (Five-day co-pay max per deductible
Inpatient oxygen, hospital, ancillary confinement)
(Authorization charges, and medications.
required if
outside of UH) Newborn Care No co-payment No deductible
(48/96-hour delivery stay) 30% co-insurance will apply

Newborn stay beyond the $100 co-payment per day 30% co-insurance after
48/96-hour period (Five-day co-payment deductible
max per confinement)

Physician’s charges, including No co-payment 30% co-insurance after

surgery deductible

Outpatient Services and supplies in No co-payment 30% co-insurance after

connection with surgical deductible
Surgery treatment
(Preauthorization
required if Outpatient Surgery $100 co-payment per visit 30% co-insurance after
outside of UH) (Hospital or facility) deductible

Physician Charges No co-payment 30% co-insurance after

deductible

Page 5 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK
Obesity See Coverage Limitations on $30,000 Lifetime Maximum This treatment is NOT
Treatment pages 33 & 40 from the covered under the
Summary of Benefits. All co-payments still apply expanded network.
(Preauthorization
Authorization Required.
Required) All procedures and services
must be performed at
University Hospital, no
other facilities.

Outpatient Outpatient Therapy $15 co-payment per visit 30% co-insurance after
deductible
Therapy Physical Therapy - 60 visit max
Physical, per plan year
Occupational, Occupational Therapy – 60 visit
Speech & Hearing max per plan year
60 visits regardless
of diagnosis. Speech and Hearing Therapy -
60 visit max per plan year
Pulmonary Rehabilitation
Therapy – 20 visit max per plan
year
Cardiac Rehabilitation Therapy
– 36 visit max per plan year.

**Outpatient Therapy visits

cannot be combined with
Home Health Therapy
benefits. See Home Health.

Applied Outpatient Therapy $15 co-payment per visit 30% co-insurance after
(No visit limitation with ABA deductible
Behavioral diagnosis)
Analysis
Therapy (ABA)
Home Health Visit $15 co-payment per visit 30% co-insurance after
*Must meet Home Health Visit (No visit limitation with ABA deductible
criteria. See page 25 of UH diagnosis)
Certificate of Coverage for
benefit details.

**Home Health visits cannot **See page 25 of UH Summary

be combined with outpatient of Benefits for details.
therapies benefit.

Page 6 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK

Skilled Nursing All covered services and $15 co-payment per day 30% co-insurance after
supplies up to 60 days per deductible
Facility condition/plan year, including
semi-private room, ancillary
charges, and medications.

Behavioral Inpatient covered services and $100 co-payment per day 30% co-insurance after
supplies. Residential treatment (Five-day co-payment deductible
Health Services center for children and max per related inpatient
(Inpatient & adolescents, crisis stabilization stay)
Outpatient) unit.

Outpatient visits to include day $15 co-payment per visit 30% co-insurance after
treatment facility for behavioral deductible
illness.

Alcoholism/ All medically necessary covered

Chemical services.
Dependency Inpatient $100 co-payment per day 30% co-insurance after
(Five-day co-payment deductible
max per related inpatient
stay)

Outpatient $15 co-payment per visit 30% co-insurance after

deductible

$100 co-payment per day

Services furnished by a hospice (Five-day co-payment max 30% co-insurance after
Hospice Inpatient provider. per related inpatient stay) deductible

Services furnished by a hospice $50 co-payment per day 30% co-insurance after
Hospice (Ten-day co-payment
provider. deductible
Outpatient (In- max)
home)

Page 7 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK
Home Health Including, but not limited to, skilled
Care nursing (RN/LVN), physical, No co-payment 30% co-insurance
occupational, speech or respiratory after deductible.
therapy, medical social services (Total annual limit of
and/or services of a home health
60 visits; per service)
aide under the supervision of an
RN, only for Members who are
homebound or confined to an
institution that is not a hospital.
Homebound Members are those
who have a physical condition such
that there is a normal inability to
leave the home. **Home Health
visits cannot be combined with
outpatient therapies benefit.

Medical Emergency ground or air ambulance Plan will pay up to $1,500 Plan will pay up to
transportation when medically of the Usual and Customary $1,500 of the Usual
Transportation
necessary. * CFHP will pay for and Customary
Emergency Transportation services
performed by non- participating
Providers at the negotiated or usual
and customary rate. Member may
be responsible for balance of billed
charges, if any.

Vision Comprehensive eye exam (one $10 co-payment per visit No In-Network Benefit
Services per year) through Envolve

Other Psychological testing authorized $15 co-payment per visit 30% co-insurance after
or arranged by a physician. deductible
Covered
Services Health education services when No co-payment 30% co-insurance after
provided or authorized by a deductible
physician for a person’s health
education, including, but not
limited to diabetes education,
asthma education, nutritional
counseling, and education, etc.

Services and supplies furnished $15 co-payment per visit 30% co-insurance after
Chiropractic in connection with correction, by deductible and up to
Services manual or mechanical means, of $75 per visit max
subluxation of the spine. Benefit
limited to 10 visits per year.

Page 8 of 9
 CO-PAYMENTS CO-INSURANCE
BENEFIT DESCRIPTION
UH NETWORK EXPANDED
NETWORK

Schedule of Preferred Generic Medications Co-payment waived if $20 (30 day) $40 (90 day)
Tier 1 filled at a University
Co- payments Health Pharmacy.
for
Prescription
Medications Preferred Brand Name Co-payment waived if $40 (30 day) $60 (90 day)
Medications and Select filled at a University
and Generics Tier 2 Health Pharmacy.
Maintenance
Medications Non-Preferred Medications Co-payment waived if $60 (30 day) $100 (90 day)
or Specialty drugs filled at a University
Tier 3 Health Pharmacy.

Download the Refill Pro

App from your iOS or
Android app store.

Mail Order University Health

Pharmacies No co-payment
Prescriptio Prescription must be written by a Licensed Physician.
n Benefit
www.universityhealthsystem.com/rxandgo

Page 9 of 9
 COMMUNITY FIRST HEALTH PLANS, INC.

OUTPATIENT PRESCRIPTION MEDICATION RIDER

Upon presentation of a valid Community First Identification Card that indicates

coverage for outpatient Prescription Medications at a Participating Pharmacy,
Members shall be entitled to have a Prescription Order filled for any of the
outpatient Prescription Medications described below and Community First will
cover same, subject to the conditions, limitations and exclusions stated below
and in the Certificate of Group Health Care Coverage (“Certificate”) and the
underlying Group Contract.

1. General Definitions. All defined terms are capitalized in this Rider. If a

capitalized term is not defined in this Section 1, or in Section 2, below,
please refer to the definitions in the Group Contract or the Certificate of
Group Health Care Coverage.

a. Annual Benefit Maximum. The maximum amount payable by

Community First for covered prescription medications during the
plan year.

b. Brand Name Medication. A Prescription Medication that has been

given a brand or trade name by its manufacturer and is advertised
and sold under this name.

c. Generic Medication. A pharmaceutical equivalent of one or more

Brand Name Medications that is approved by the Food and Drug
Administration as meeting the same standards of safety, purity,
strength, and effectiveness as the Brand Name Medication.

d. Heritable Disease. An inherited disease that may result in

intellectual or developmental disability or death.

e. Maintenance Medication. A Prescription Medication, in certain

therapeutic categories, that Community First’s Pharmaceutical &
Therapeutics (P&T) Committee determines can be used for chronic
medical conditions.

f. Non-Preferred Medications. All Brand Name or Generic

Medications not selected as Preferred Medications by the
Pharmaceutical & Therapeutics Committee.

g. Participating Pharmacy. A pharmacy duly licensed in the State of

Texas contracting with Community First to dispense Prescription
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 Medications to Members who are entitled to coverage for
Prescription Medications. Each Eligible Employee will receive a
listing of all Participating Pharmacies.

h. Pharmacist. A person duly licensed to prepare, compound, and

dispense medication and practicing within the scope of his/her
license.

i. Pharmacy. A licensed establishment where Prescription

Medications are dispensed by a pharmacist.

j. Pharmacy and Therapeutics Committee. A committee of

physicians, pharmacists and Community First staff responsible for
ensuring that the quality and cost-effectiveness of Community
First’s pharmacy benefit are maintained.

k. Phenylketonuria. An inherited condition that may cause severe

intellectual disability if not treated.

l. Preferred Medications (Preferred Product List). A limited listing

of Prescription Medications that have been evaluated by
Community First’s Pharmaceutical & Therapeutics Committee, and
have been determined to be safe, appropriate, and cost-effective.
This listing is provided to all Community First Members and
Participating Providers and is periodically reviewed and updated by
the P&T Committee. This listing may change during the Contract
Year. See description of Tier levels in Section 2, below.

m. Prescription Medication. A medication which, according to

federal law, can be obtained only by a Prescription Order and is
required to bear a label which reads, “Caution: Federal Law
Prohibits Dispensing Without a Prescription”, or is restricted to
prescription dispensing by laws of the State of Texas.

n. Prescription Order. A written or oral order for the preparation and

use of a Prescription Medication or Supplies directly relating to the
treatment of an Illness or Injury and which is issued by the treating
Dentist or Participating Provider within the scope of his or her
professional license.

2. Definition of Tiers in Three-Tier Prescription Medication Plan. This

Outpatient Prescription Drug Rider has three tiers of Co-payments that
apply to both Prescription Medications and Maintenance Medications.
You will pay the lowest for Tier 1 Medications and the highest for Tier 3
Medications. However, your Co-payment on these Medications will not go

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 up during the Contract Year, although our co-payment is subject to
change in subsequent Contract Years.

a. Tier 1—This tier consists of most Preferred Generic Medications.

b. Tier 2—This tier consists of Preferred Brand Name Medications,

and some higher cost Generic Medications. The P&T Committee
determines which Generic Medications are placed in Tier 2.

c. Tier 3—This tier consists of all Non-Preferred Medications. The

P&T Committee determines which medications (Brand and
Generic) are considered non-Preferred.

3. Covered Medications and Supplies

a. Medically Necessary Prescription Medications and Supplies. These

Prescription Medications may be dispensed only with a Prescription
Order from a Dentist or a Participating Provider and may only be
obtained at a Participating Pharmacy, except in the case of those
Prescription Medications or Supplies required as a result of a
Medical Emergency or approved by Community First.

b. Contraceptive Medications and Supplies prescribed by a

Participating Provider.

c. Covered Prescription Medications and Supplies dispensed by non-

Participating Pharmacies located in or outside of Community First’s
Service Area are covered only when dispensed in conjunction with,
and immediately following, an event requiring Emergency Care
where the Member is unable to obtain same from a Participating
Pharmacy. The quantity of Prescription Medications dispensed by
a non-Participating Pharmacy shall be limited to a three (3) day
supply. In such circumstances, the Member must pay for
Prescription Medications and Supplies at the time of dispensing
and submit a claim for reimbursement to Community First.

d. Dietary formulas necessary for the treatment of phenylketonuria

(PKU) and other heritable diseases.

e. Off Label Drugs – Any drug prescribed to treat a Member for a

covered chronic, disabling, or life-threatening illness is covered if
the drug: (1) has been approved by the Food and Drug
Administration (FDA) for at least one indication; and (2) is
recognized for treatment of the indication for which the drug is
prescribed in: (a) a prescription drug compendium approved by the

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 Commission of Insurance; or substantially accepted peer-reviewed
medical literature

4. Limitations. The Prescription Medications described above are subject to

the following limitations.

a. Covered Prescription Medications and/or Supplies must be ordered

by an appropriate Participating Provider and obtained at a
Participating Pharmacy, except when dispensed in conjunction with
and immediately following an event requiring Emergency Care
where the Member is unable to obtain same from a Participating
Pharmacy.

b. This benefit requires the use of generic equivalent medications

when available. If a Brand Name medication is dispensed when a
Generic is available, member will be responsible for the Generic
Co-payment plus the cost difference between the Generic and the
Brand Name medication, even if a Prescription Order is written
“Dispense as Written.” This will require the Member to pay a higher
cost for the Prescription Medication. See the Schedule of Co-
payments at the end of this Rider.

c. Covered Prescription Medications will be limited to the quantity

prescribed by a Community First Participating Provider, not to
exceed a thirty (30) day supply. Some Prescription Medications will
have further quantity limit restrictions for the 30 days supply.
Maintenance Medications will be limited to the quantity prescribed
by a Community First Participating Provider, not to exceed a ninety
(90) day supply.

d. The preceding limitations apply to all Prescription Medications

prescribed for daily administration. Prescription Medications
prescribed “as needed” will be dispensed in a quantity prescribed
by a Participating Provider, not to exceed a thirty (30) day supply,
based on current, clinically accepted treatment protocols and the
limitation related to restricted quantities for certain medications set
forth in the previous subsection. The quantity dispensed may vary
based on the medication and diagnosis.

e. Except for inhalers, “prepackaged” medications that are packaged

in standardized containers from a Prescription Medication
manufacturer shall not be dispensed in more than one standardized
container per Prescription Order. A maximum of two (2) inhalers
per Prescription Order may be obtained at one time during a thirty
(30) day period.

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 f. Coverage for smoking cessation products is based on current or
medically accepted treatment protocols. This benefit applies to
prescribed smoking cessation products..

g. Certain Prescription Medications are subject to Pre-Authorization.

h. Certain Prescription Medications are subject to age restrictions.

5. Exclusions. The Prescription Medications described above are subject to

the following exclusions.

a. Over-the-counter medicines and Supplies or items that may be

purchased without a Physician’s recommendation or written
Prescription Order, unless covered under the Certificate of Group
Health Care Coverage or included in this rider as an exception.

b. Non-prescriptive family planning supplies, except as covered by this

Rider or in the Certificate of Group Health Care Coverage.

c. Prescription Medications or Supplies required solely because a

non-covered service or supply is provided. This provision does not
include Prescription Medications or Supplies dispensed in
connection with a medical condition resulting from a non-Covered
Service or Supply.

d. Prescription Medications or supplies that are Experimental, and

non-experimental prescription medications that are prescribed for
Experimental purposes or indications not approved by the United
States Food and Drug Administration.

e. Prescription Medications or Supplies that are not Medically

Necessary for the treatment of the medical condition for which it is
administered.

f. Cosmetics, health or beauty aids, dietary supplements.. Also

excluded is retinoic acid for cosmetic purposes, medication
prescribed to remove or lessen wrinkles in the skin, and oral or
topical medications to treat baldness due to aging.

g. Placebo injections and medications.

h. Aphrodisiacs.

i. The following Prescription Medications and items are excluded

under this Outpatient Prescription Medication Rider. These may be
covered under the Certificate of Group Health Care Coverage
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 (Medical Plan). Please review the Certificate section entitled
“Covered Services and Supplies” for specific details about
coverage for each of the items below.

(1) Medications to treat infertility or related to in vitro fertilization

procedures.

(2) Implantable medications and devices (e.g., pain control,

Norplant and other contraceptive devices), drug infusion
pumps and release devices.

(3) Biological sera, blood, blood derivations and blood plasma.

(4) Allergy desensitization products.

(5) Medications to be taken by or administered to a member

while the Member is a patient in a nursing home, Hospital,
sanitarium, Skilled Nursing Facility, rest home, convalescent
Hospital, or facility of similar character, except when the
facility becomes the Member’s place of residence, the cost
of which is not covered by CFHP. In such cases,
Prescription Medications must be obtained through a
Participating Pharmacy.

(6) Immunizing agents. Please note some vaccines are covered

such as Influenza, Shingles, and Pneumonia. You may
contact Member Services at 210-358-6090 for covered
immunizations and further explanation.

(7) Durable Medical Equipment.

(8) Oxygen and oxygen supplies.

j. Hormonal medications required before and after sex change

surgery.

k. Growth Hormones unless medically necessary due to a medical

condition and not familial short stature or idiopathic short stature
based on heredity.

l. Medical Foods which are formulated to be consumed or

administered enterally under the supervision of a physician and do
not have approval by the FDA. Individual medical food products do
not have to be registered with FDA.

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 m. Compounded medications that are experimental and/or not FDA
approved are not covered

6. Identification Card Requirement. If a Member must have a Prescription

Order filled and has not received a Community First Identification Card, or
it has been lost or is not in the Member’s possession, or, if newly enrolled,
the Member must pay for Prescription Medications and/or Covered
Supplies at the time they are dispensed and submit a claim for
reimbursement to Community First, subject to a deduction for co-payment.

7. Claims Submission. If you have to pay for Prescription Medications or

Supplies, submit the original of the paid bill along with a completed claim
form. Claim forms may be obtained from the Community First website at
https://commercial.communityfirsthealthplans.com/ or by calling the
Member Services Department at or 210-358-6090. You should submit
your claims to the following address: Community First Health Plans,
12238 Silicon Drive, Suite 100, Attention: Claims Department, San
Antonio, Texas 78249 Your claim will be processed according to the
procedure outlined in the Certificate of Group Health Care Coverage.

8. Refills. Please ask your participating provider to call prescription orders

to your desired participating pharmacy 24 to 48 hours in advance. If you
are going to travel out of the Service Area, please contact Member
Services should You need assistance in obtaining refills, if appropriate.

9. General Provisions.

a. Participating Pharmacies dispensing Prescription Medications or

Supplies to Members pursuant to the Certificate of Group Health
Care Coverage and this Rider do so as an independent contractor.
Community First shall not be liable for any claim or demand on
account of damages arising out of or in any manner connected with
any injuries suffered by Members.

b. Community First shall not be liable for any claim or demand on

account of damages arising out of or in any manner connected with
the manufacturing, compounding, dispensing or use of any
Prescription Medication.

c. If Community First removes a Prescription Medication from the

Preferred Product List or moves a Prescription Medication to a
higher tier Community First will make the drug available to you at
the contracted benefit level until your employer’s plan renewal date.
This section does not preclude a Physician or other health
professional authorized to prescribe a drug from prescribing
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 another drug on Community First’s Preferred Product List that is
medically appropriate for you.

SCHEDULE OF CO-PAYMENTS

1. Schedule of Co-payments for Prescription Medications and

Maintenance Medications. Please note that prescriptions filled at UH
pharmacies have a waived copay.

Prescription Medications Contract Year Deductible – $0

Annual Benefit Maximum – $0
Prescription Medications: As Prescribed by a Community First
Participating Provider, Not to Exceed a 30-Day Supply
Tier Level Types of Medications Covered Co-payment*
One Preferred Generic Medications $20 Co-payment

Two Preferred Brand Name Medications: $40 Co-payment

some high-cost Generic Medications,
as designated by the P&T Committee
Three Non-Preferred Medications, includes $60 Co-payment
some Generic Medications as
designated by the P&T Committee

Prescription Maintenance Medications: As Prescribed by a Community

First Participating Provider, Not to Exceed a 90-Day Supply
Tier Level Types of Medications Covered Co-payment*

One Preferred Generic Maintenance $40 Co-payment

Medications

Two Preferred Maintenance Medications: $60 Co-payment

some high-cost Generic Medications,
as designated by the P&T Committee
Three Non-Preferred Maintenance $100 Co-payment
Medications, includes some Generic
Medications as designated by the P&T
Committee

*
If Community First’s negotiated rate for the Prescription Medication or Supply is less
than the co-payment, you will only be charged for the actual cost of the drug or
supply.

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2. Supplies. Co-payments for Covered Supplies are subject to a $15
copayment.

3. Rx and Go Program. Prescriptions available with No Copay through the

UH Pharmacy Rx and Go Program. See
https://www.universityhealthsystem.com/services/pharmacy/prescriptions
for more details.

4. Receipt of Preferred or Non-Preferred Medication When Generic

Equivalent Available. This benefit requires the use of generic equivalent
medications when available. If a Brand Name medication is dispensed
when a Generic is available, member will be responsible for the Generic
Co-payment plus the cost difference between the Generic and the Brand
Name medication, even if a Prescription Order is written “Dispense as
Written.” This will require the Member to pay a higher cost for the
Prescription Medication. See the Schedule of Co-payments above.

5. Lifetime Maximum Dollar Benefit Limitation.

None.

6. Co-payments paid toward Prescription Medications under this Outpatient

Prescription Medication Rider do not count towards any Out-of-Pocket
maximum under the Certificate of Group Health Care Coverage.

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