C and O Employees' Hospital Association
Summary of Benefits and Coverage for plans below:
Please find enclosed the following documents:
"Summary of Benefits and Coverage" – the purpose of this document is to provide you with a summary of your health care coverage. If you want more detail about your coverage and costs, please refer to C and O Employees’ Hospital Association Rules & Regulations and Master Plan Document.
"Glossary of Health Coverage and Medical Terms" – this Glossary defines many commonly used terms, but it is not a full list. These Glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your Plan. The underlined text in your "Summary of Benefits and Coverage" indicates a term defined in this Glossary.
"Claims and Appeals Procedures" – this document outlines a new portion of our appeals procedures, which is your right to an external review process.
We have listed below the changes to your 2017 Rules & Regulations and Master Plan Document. Please keep this document with your 2017 Booklet.
Page 4, under Director:
Keith Kerley replaced Matt Thornton as General Chairman for the Brotherhood of Locomotive Engineers.
Page 17, under Plan Four:
Annual Deductible is $1200 effective January 1, 2018
Annual Out-of-Pocket is $1000 effective January 1, 2018
Durable Medical Equipment and Prosthetic Devices are covered at 75% of our fee schedule after the annual deductible has been met
Page 19, under Plan Twelve:
Annual Deductible is $3000 effective January 1, 2018
Annual Out-of-Pocket is $1000 effective January 1, 2018
Pages 22 & 23 under Diabetic Testing Supplies:
Liberty Medical, LLC is now Edgepark Medical Supplies (i.e. RGH Enterprises, Inc., doing business as Edgepark Medical Supplies). Their phone number is 1-800-321-0591.
Pages 23 & 24, under Durable Medical Equipment:
For Plan Four, these type of expenses are covered at 75% of our fee schedule after the annual deductible has been met
Page 27, at the top of the page:
For Plan Two, outpatient therapy is paid at 75% of our fee schedule after annual deductible has been met
Page 29, under Prosthetic Devices:
For Plan Four, these type of expenses are covered at 75% of our fee schedule after the annual deductible has been met
Page 29, under Skilled Nursing Facility Care:
After the yearly deductible has been satisfied, COEHA will cover the facility charge at the appropriate percentage for your Plan. Coverage is limited to 100 days.
Pages 39-41, Claims and Appeals Procedure:
Please refer to enclosed document titled: "Claims and Appeals Procedures", which replaces pages 39-41.
Effective March 1, 2017, we are no longer providing coverage for charges incident to CSX On-Duty-Injuries. You should let the provider know that these type of claims should be filed to the following address with a copy of the treatment notes:
Chief Medical Officer
ATTN: Johnny Delk, RN
CSX Transportation, Inc.
500 Water Street, J290
Jacksonville, FL 32202
If you have any questions, please do not hesitate to give us a call at 1-800-679-9135 or locally at 862-5728.
LiveHealth Online effective January 1,
C AND O EMPLOYEES’ HOSPITAL ASSOCIATION
RULES AND REGULATIONS
MASTER PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION
FOR COMPONENT PLANS ONE, TWO, THREE, FOUR, FIVE, SIX, EIGHT, NINE, ELEVEN, TWELVE AND THIRTEEN
(ACTIVE AND RETIRED, NON-MEDICARE)
The Board of Directors reserves the right to amend, modify or terminate COEHAand any Plan at any time and from time to time. Receipt of these Rules and Regulations does not confer or guarantee eligibility for benefits.
PARTICIPANT’S RESPONSIBILITIES *
INTRODUCTION *COEHA Participants - Eligibility *COEHA NETWORK *COEHA PLANS *
Substance Abuse …………………………………………………………………….......30
Transgender Services ……………………………………………………………………30
SUBROGATION AND REIMBURSEMENT *
ADMINISTRATION OF THE PLAN *
AMENDMENT * CLAIMS AND APPEALS PROCEDURE *
External Review Process and Standards…………………………………………………41
HIPAA PRIVACY AND SECURITY REQUIREMENTS *
NOTICE ABOUT NON-DISCRIMINATION……………………………………………44
IF YOU HAVE ANY QUESTIONS REGARDING BENEFITS, CLAIMS OR ELIGIBILITY UNDER COEHA, CONTACT THEC AND O EMPLOYEES’ HOSPITAL ASSOCIATION AT:
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422-1166
(800) 679-9135 (toll free)
(540) 862-5728 (bell, locally)
(8) 443-1463 (RR)
(540) 862-3552 (claims)
(540) 862-4958 (membership eligibility)
Web site: www.coeha.com
Hours of Operation:
Monday through Friday, 8:30am to 5:00 pm
The Board of Directors of the C and O Employees’ Hospital Association (COEHA) is pleased to provide you with these Rules and Regulations, which also serve as the Summary Plan Description and Plan Document that describes the health and welfare benefits provided to eligible Employees, Retirees and their Dependents. The benefits described herein, unless otherwise noted, are provided directly by COEHA. COEHA is a voluntary employees’ beneficiary association that provides several different plans of benefits.
C and O Employees’ Hospital Association (COEHA)
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422-1166
Employer Identification Number (EIN): 23-7082348
Plan Number: 501
The Plan is self-funded and administered by the Board of Directors of theC and O Employees’ Hospital Association (COEHA), which is a voluntary employees’ beneficiary association. COEHA is located at 511 Main Street, 2nd Floor, Clifton Forge, Virginia 24422-1166 (the "COEHA Office").COEHA is governed by a Board of Directors, and the Board of Directors of COEHA may delegate responsibility for the day-to-day administration of COEHA to an individual or committee.The Board of Directors has delegated the day-to-day operations of COEHA to the Co-Administrators of COEHA.
COEHA provides medical, surgical, and hospital care under its plans of benefits, which are welfare benefit plans.
January 1 through December 31
COEHA was established through a collective bargaining agreement that was negotiated through the Cooperating Railway Labor Organizations and National Railway Labor Conference. Participants and beneficiaries may obtain a copy of such agreement upon written request to the Plan Administrator. The agreement also is available for examination at the COEHA office.
The benefits described in this booklet are provided through contributions from participants through a monthly dues assessment and contributions from Chessie Systems X Transportation (CSXT).All assets are held in trust by the Board of Directors for the purpose of providing benefits to eligible Employees and their dependents and for defraying reasonable administrative expenses.
C and O Employees’ Hospital Association
511 Main Street, 2nd Floor
Clifton Forge, Virginia 24422-1166
Copies of the Plan’s QMCSO procedures will be provided to participants and beneficiaries upon request to the Plan Administrator, without charge.
The types of benefits provided and the Plan’s eligibility requirements are fully described in this booklet. There are some circumstances that may result in denial or loss of any benefits that would otherwise be payable, and these are also described in this booklet. For example, when the Plan’s Coordination of Benefits or Subrogation rules apply, benefits may be reduced or eliminated. Also, when you erroneously receive benefits that are not properly payable under the Plan, the Plan may reduce future benefits, to which you would otherwise be entitled, in order to recover a prior overpayment.
The C and O Employees’ Hospital Association was established in 1897 as a joint effort between the Chesapeake and Ohio Railway Company and its employees to provide certain healthcare benefits for the employees and retirees of the Chesapeake and Ohio Railway Company.
Healthcare benefits will be furnished in accordance with such rules and regulations as may from time to time be approved by the Board of Directors of COEHA, provided, that at all times COEHA shall conduct itself strictly as a non-profit organization pursuant to Section 501(c)(9) of the Internal Revenue Code of 1986, as amended.
All benefits are subject to the limitations and exclusions in these Rules and Regulations and are payable when determined by the Plan to be medically necessary. No oral statementof any personcan modify or otherwise affect the benefits, limitations, and exclusions of these Rules and Regulations, convey or void any coverage, increase or reduce any benefits under this Plan, or be used in the prosecution or defense of a claim under this Plan.
COEHA is governed by a Board of Directors, and the current members are:
The COEHA Co-Administrators are:
COEHA Participants - Eligibility
Individuals eligible to participate in the Plan are: (1) Brotherhood of Locomotive Engineers (BLE) or United Transportation Union (UTU) employees or former employees who work in the COEHA Territory (defined below under eligibility for Plan One), and (2) other individuals, which the Board of Directors may from time to time identify in writing in its sole discretion, subject to applicable law.
Individuals eligible to participate in the Plan are eligible for certain plans of benefits as outlined below.UTU employees become participants in the Plan based on the timing as set forth in the CSXT Labor Agreement No. 4-037-09, by and between CSXT and UTU, as amended.
For members obtaining employment elsewhere and receiving healthcare benefits from such other employment, COEHA will only provide such benefits that are in excess of the other plan benefits and in accordance with the Rules and Regulations governing operation of COEHA. In no instance will COEHA provide a duplication of benefits. Please refer to the section entitled "COEHA Plans" for a summary of your benefits. The section entitled "Benefits" provides coverage information regarding specific healthcare services.
As a cost containment measure for participants not actively working and paying dues directly, COEHA has instituted an automatic dues deduction program for monthly premiums from the participant’s checking account. You will be required to participate in the automatic dues deduction program or you may remit your dues directly to COEHA either quarterly, semi-annually, or annually. Your check should be made payable to "The C and O Employees’ Hospital Association," and the COEHA Office must receive your check by the 5th of each month. If you choose to participate in the automatic dues deduction program, your premiums will be deducted on the fifth (5th) day of each month unless the 5th of the month is on a weekend or holiday, in which case your premiums will be deducted on the next following business day.
Any participant under COEHA who fails to submit current premiums shall be notified by certified mail of the delinquency and given ninety (90) days to bring premiums up to date. Failure to comply with this delinquency notice will result in termination of coverage under COEHA, retroactive to the date the premium was due.
Any request for reinstatement must be submitted to the COEHA Office in accordance with the guidelines outlined in the section entitled "Claims and Appeals Procedures."
The following individuals are eligible to participate in the component benefit plans:
The following individuals are eligible to participate in Plan One:
If a Furloughed Member becomes disabled while covered as a furloughed employee during the initial four-month period, coverage under COEHA will continue as long as disability is the only reason the employee does not perform work in his regular occupation if recalled, and member will be covered by the provisions for Disabled Members. COEHA may require medical certification from the member’s attending physician stating member is under medical care and unable to return to work.
Beginning with the fifth (5th) month following the month last compensated service was performed, the Furloughed Member is eligible to continue benefits under Plan One through COBRA upon payment of premiums (see section below on "Right to Continuation Coverage"). Once COBRA coverage has been exhausted, the member is eligible for continuation of benefits under Plan Twelve, but there will be a change in benefits and premiums.
The following individuals are eligible to participate in Plan Four:
Active members who: (A) retire at 60 years of age or older, (B) with 30 or more years of service with the Railroad Retirement Board, and (C) are not yet 65 years of age ("60/30 Major Medical Members"). Certain members who retire on disability may be eligible for this benefit upon attaining age 60 and should contact the COEHA Office for additional information.
Dependents of Active Members and spouses of 60/30 Major Medical Members, who are covered by the National Health and Welfare Plan and eligible for supplemental coverage with COEHA upon payment of dues premiums.
BLE and UTU members who are actively employed with CSXT who are transferred out of the COEHA Territory ("Off-Line Members"). Off-Line Members are covered by the National Health and Welfare Plan as their primary insurer and under Plan Eight of COEHA as the secondary insurer.
Off Sick Members who have exhausted their waiver of premium under Plan One and who have elected 75% coverage with waiver of premium.
Off Sick Members who have exhausted their waiver of premium and who have elected full or 95% coverage with a premium.
The following individuals are eligible to participate in Plan Twelve:
An individual who qualifies as an Off Sick Member and is receiving a disability annuity ("Disabled Members"). Disabled Members are eligible for coverage under Plan Thirteen for the remainder of the year in which they last rendered compensated service or received vacation pay and the following calendar year. They will be entitled to benefits identical to those of an Active Member without payment of premiums as long as they continue to be out of service on account of illness, injury, disability or pregnancy, which continues to prevent their return to service to CSXT. Disabled Members are no longer eligible for coverage under COEHA without payment of premiums should they accept other regular employment or their disability ends. After the initial calendar year, Disabled Members may choose coverage under Plan Two, Plan Three or Plan Four of COEHA, and Disabled Members are no longer eligible for coverage under Plan Thirteen.
For Off Sick Members and Disabled Members:
Once a participant is eligible for Medicare benefits, participation under COEHA must be converted into Plan Seven or Plan Ten, commonly referred to as the "Medicare Supplemental Plan." For more information on the Medicare Supplemental Plans, please see the Medicare Supplemental Handbook.
An employee who returns to work after a status of furloughed, separated, suspended, dismissed, leave of absence or disability will be eligible for coverage as an Active Member on the first day of the month following the month in which he has worked at least seven (7) calendar days. For example, if an employee returns to work in January, and works seven days in January, the employee will be eligible for coverage on February 1st. In the event such employee returns to work at a time during a month when there is no opportunity to render compensated service on at least seven calendar days during that month, such employee will be deemed to have satisfied the seven-day rule, provided that he is available or actually works at every available work opportunity during the month in which the employee returns to work.
An eligible active employee who returns to work after completion of service in the armed forces of the United States will be eligible for coverage on the day he first renders compensated service upon return.
Under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, (COBRA), participants may be entitled to elect to continue participation in COEHA, for a limited period of time, if the member loses his regular coverage under the Plan as a result of either of the following events commonly referred to as "Qualifying Events":
(1) Termination of employment (for reasons other than gross misconduct); or
(2) A reduction in hours of work.
A "loss of Plan coverage" includes an increase in the premiums the member is required to pay.
If a member’s spouse is covered under the COEHA, he or she also has the right to elect Continuation Coverage if he or she loses coverage under the medical option as a result of any of the following events also known as "Qualifying Events":
(1) The end of the member’s employment (for reasons other than gross misconduct);
(2) A reduction in the member’s hours of work;
(3) The death of the member;
(4) Divorce or legal separation from the member; or
(5) The member becomes entitled to Medicare benefits under Title XVIII of the Social Security Act.
A member’s covered dependent child also has the right to elect Continuation Coverage for himself or herself if he or she loses regular coverage under the Plan as a result of any of the following events also known as "Qualifying Events":
(1) The end of the covered parent’s employment relationship (for reasons other than gross misconduct);
(2) A reduction in the covered parent’s hours of work;
(3) The death of a covered parent;
(4) The parents’ divorce or legal separation;
(5) The covered parent becomes entitled to Medicare benefits under Title XVIII of the Social Security Act; or
(6) The child loses dependent status under the terms of the Plan.
A dependent child includes a child born to or placed for adoption with a covered employee during the period of COBRA coverage.
If there is a choice among types of coverage under the Plan, each person who is eligible for Continuation Coverage (known as a "Qualified Beneficiary") is entitled to make a separate election among the types of coverage. Thus, a spouse or dependent child is entitled to elect Continuation Coverage even if the covered employee does not make that election. Similarly, a spouse or dependent child may elect different coverage from the coverage that the covered employee elects.
A covered employee or family member has the responsibility to inform the Plan Administrator of a divorce, legal separation, or a child’s loss of dependent status under the Plan within 60 days of the event or the date on which regular Plan coverage would be lost because of the event. In addition, the covered employee or a family member must inform the Plan Administrator, before the end of the original 18-month Continuation Coverage period, and within 60 days of a determination by the Social Security Administration, that the individual concerned was disabled at the time of the covered employee’s termination of employment relationship or reduction in hours of employment. The individual may extend Continuation Coverage if they were disabled at any time during the first 60 days of Continuation Coverage. The extension of Continuation Coverage due to disability is also available to the non-disabled spouse and dependent children of the disabled individual.
If, during Continuation Coverage, the covered employee or family member is later determined by the Social Security Administration as no longer being disabled, the individual must inform the Plan Administrator within 30 days of the date the re-determination was made. When the Plan Administrator is notified that one of these events has occurred, the member will be notified of his or her Continuation Coverage rights.Election of Continuation Coverage
Under COBRA, a Qualified Beneficiary is entitled to have an election period of 60 days to decide whether to elect Continuation Coverage. The 60-day election period begins on the later of (1) the date the individual would lose regular Plan coverage because of one of the qualifying events described on the previous page or (2) the date the individual is sent a notice of the right to elect Continuation Coverage. If a Qualified Beneficiary informs the COEHA within the 60-day election period that he or she wants Continuation Coverage, Continuation Coverage begins on the date the individual’s regular Plan coverage ends. There is one exception, however. If a Qualified Beneficiary waives Continuation Coverage, he or she may revoke the waiver at any time before the 60-day election period ends. In that case, the Continuation Coverage begins on the date the waiver is revoked. Coverage will not be provided for the period between the date regular Plan coverage ends and the date the waiver is revoked.
If a Qualified Beneficiary dies or becomes legally incapacitated before the 60-day election period ends, then a personal representative has the right to make an election on the Qualified Beneficiary’s behalf, provided the election is made before the end of the 60-day election period. The period between the date of death or legal incapacity and the date the personal representative is appointed will not be included for purposes of calculating such 60-day period.
If a Qualified Beneficiary does not choose Continuation Coverage within the 60 day election period, the individual’s eligibility for Continuation Coverage will end.Cost of Continuation Coverage
The cost of regular Continuation Coverage is the full cost of the monthly premium plus a two percent administrative charge. The cost of Continuation Coverage provided after the 18th month on account of disability under Title II or XVI of the Social Security Act is 150 percent of the full cost of the monthly premium. If you experience a Qualifying Event, you will be notified about the premium rates and the due dates for payments. The premium costs will increase during the Qualified Beneficiary’s period of Continuation Coverage to the extent such premium increases have increased for non-COBRA coverage under the Plan.
The initial premium for Continuation Coverage will be due 45 days after the date of the initial Continuation Coverage election. There is a 30-day grace period after the due date for each of the subsequent premiums.
The Continuation Coverage is identical to the coverage then being provided under the Plan to similarly situated employees, their spouses, and their dependent children who have not experienced a qualifying event. If their coverage changes, Continuation Coverage will change in the same way. COEHA reserves the right to terminate Continuation Coverage retroactively for an individual determined to be ineligible for such coverage.
If the member or a covered family member loses regular Plan coverage due to a termination of employment or a reduction in hours of work, Continuation Coverage generally may last for only 18 months.
If a Qualified Beneficiary loses regular Plan coverage due to a termination of employment or a reduction in hours of employment and is determined to have been disabled under Title II or XVI of the Social Security Act at the time of the termination or reduction in hours or within the first 60 days of COBRA coverage, then Continuation Coverage may last for up to 29 months, provided, however, that COEHA is notified of the disability determination before the end of the regular 18-month period and within 60 days of the date the determination is made. (A Qualified Beneficiary must also notify COEHA within 30 days if a final determination is made that the member is no longer disabled under Title II or XVI of the Social Security Act).
This 18-month (or 29- month) period of Continuation Coverage may be extended for up to 36 months if a second "qualifying event" (for example, death, divorce or legal separation, or Medicare entitlement) occurs during the 18-month (or 29-month) period, but only for those individuals who were Qualified Beneficiaries in connection with the first qualifying event and are Qualified Beneficiaries at the time of the second qualifying event. For example, if a terminated employee chooses Continuation Coverage for himself and his spouse and the employee dies before the 18-month (or 29-month) period ends, the spouse may elect to receive Continuation Coverage for a total of 36 months. The 36 months would be measured from the date of the employee’s termination of employment. A termination that follows a reduction in hours is not a Qualifying Event that creates a right to Continuation Coverage.
COBRA provides that Continuation Coverage will be terminated, if any of the following events occur:
To give you the highest quality medical care available, COEHA has an extensive network of healthcare providers by partnering with Anthem Blue Cross Blue Shield. Anthem offers COEHA and its members access to the BlueCard program. This program electronically links all Blue Cross and Blue Shield Plans and their providers—creating one large, national network. The network includes more than 96 percent of the hospitals and 91 percent of the physicians in the United States, and Participants under COEHA have access to this national network of providers.
COEHA has an open network, which means you can use the services of providers who belong to our network without first getting a referral from another physician.
COEHA’s designation of a physician or other provider as a participating provider is not an endorsement of that provider. Except as to the payment of benefits for covered services, COEHA has no responsibility for the care or services rendered by a participating provider or for the manner in which that care or service is rendered.
You can easily find a participating provider online at www.anthem.com or call 1-800-810-BLUE (2583). The Anthem web site address and the phone number are located on the back of your ID card. You can also call your provider directly and ask if they participate in the BlueCard PPO network. As always, the COEHA Office is available if additional assistance is required.
Whenever possible, you should seek medical care from participating providers in the COEHA network.
Full or 95% benefit payment is made for most medically necessary treatment from COEHA participating providers for covered services, less applicable co-pays and/or deductibles. (Please see the section entitled "COEHA Plans" for your appropriate deductible and the section entitled "Benefits" for payment percentage on a particular benefit.)
Some categories of our membership are eligible for out-of-network coverage. If you choose to utilize this option, your services are paid at a reduced level of benefits as outlined below:
Some benefits are only covered as outlined below (referred to herein as "75/25 Coverage"):
Please refer to the section entitled "Benefits" for the services to which 75/25 Coverage is applicable.
Non-covered services, deductibles, $25 co-payments, and charges in excess of our fee schedule are not included in the $2,000 out-of-pocket expense. Example: member with a $650 deductible would pay $2,650 out of pocket before expenses would be covered at 100%--$650 deductible + $2,000 out-of-pocket=$2,650.
COEHA members may select any participating provider in our network without a referral. Some members live in towns or cities where no participating providers are available. If this is the case for you, locate the nearest town or city where COEHA providers are available. If the closest COEHA provider is within 30 miles by road, you must utilize those providers, unless you are eligible for the out-of-network coverage outlined above and you prefer to utilize your out-of-network benefits at a reduced rate.
There are some areas where network providers have not yet been contracted and the nearest COEHA provider is more than 30 miles away. Members in these areas are permitted to use providers of their choice. However, if you choose a physician more than 30 miles away in an area where the specialty is available in-network, you should seek the services of our network physician unless you are eligible for the out-of-network coverage outlined above and you prefer to utilize your out-of-network benefits at a reduced rate.
Out-of-network referrals are covered if the required specialty is not participating in your area within 30 miles by road and if the referral comes from a participating physician. Referrals must be approved prior to treatment in order to receive full benefit payment.
Requests made by a patient to see a different physician who is not a COEHA provider are not considered approved referrals and are not covered unless you are eligible for out-of-network coverage at a reduced rate.
Plan benefits are highlighted below. For specific benefits, please refer to the "Benefits" Section.
(Active, COBRA, Leave of Absence, Suspended, Furloughed)
For other services:
Annual Deductible - $200.00
Annual Out-of-Pocket - $500.00
(Disabled Members, who have elected 75% coverage with waiver of premium)
(Disabled Members, who have elected full coverage with premium payments)
(Early Retirementand Disability Members)
(60/30 Major Medical Members)
(Dependents of Active Members and spouses of 60/30 Major Medical Members who are primarily covered by the National Health and Welfare Plan)
(Active Off-Line Member)
(Off Sick Members who have elected 75% coverage with waiver of premium)
(Off Sick Members who have elected full coverage with a premium)
(Separated Employees who are not receiving an annuity and Members with Continuation Coverage Rights)
(Disabled Members receiving an annuity and a waiver of premium)
For other services:
Annual Deductible - $200.00
Annual Out-of-Pocket - $500.00
This provision shall apply to all benefits provided under any section of the C and O Employees’ Hospital Association Active and Retired, Non-Medicare Plans.
Your membership identification card identifies you as a member of COEHA. It contains a unique member identification number which helps COEHA protect you against possible identity theft. To ensure your provider has the proper insurance information, have the provider copy the front and back of your card. Please have this number available when you call COEHA. Also, please list this number on any correspondence sent to COEHA.
Your membership card does not guarantee coverage of all services or current eligibility. You or your provider can verify your eligibility by contacting COEHA. Should your membership card become lost, stolen or damaged, you can call COEHA with a replacement request at 1-800-679-9135 or locally at 862-5728.
All claims for services provided our members must be received within one year from the date the services were rendered to be eligible for payment by COEHA. All corrected rebills should be received within one year from the original denial date to be eligible for payment by COEHA.
Your network provider will file your claims for you to the local Blue Cross and Blue Shield Plan. Many healthcare providers will file your claims with the local Blue Cross and Blue Shield Plan even if they are not participating in the network. If a non-participating provider will not file the claim for you, you will be responsible for filing the claim. Assistance with filing the claim will be provided by COEHA.
Claims should contain the following information:
All benefits described in this Section are subject to individual plan limitations and benefit exclusions.
Your plan of membership and type of service is subject to a $200, $300, $650, $750 or $1500 annual deductible. This deductible must be satisfied before any of the benefits described in this Section are covered with the exception of office/urgent care visits, emergency room services, preventative services, the prescription drug benefit through our prescription drug program and the diabetic testing supply benefit through Liberty Medical LLC/Neighborhood Diabetes. Most services, subject to a deductible, are covered at 95% unless otherwise defined under the appropriate benefit.
COEHA will provide medically necessary service to the nearest treatment facility under emergency circumstances. In the event necessary specialty service is not available at this facility, COEHA will provide medically necessary ambulance service to the nearest designated facility where specialty service is available.
COEHA covers these services when they are prescribed by a COEHA network provider.
Oral chemotherapy will be classified as prescription drugs and handled accordingly. Please refer to your Benefit Section for prescription drug coverage.
Chiropractic services are a covered benefit under plans that offer 75/25 Coverage (PlansOne, Three, Five, Eleven& Thirteen). Plans Two and Nine also cover eligible chiropractic benefits at 75%. Plans Six andEight are eligible for chiropractic benefits under the guidelines summarized in the section entitled "COEHA Plans."The terms for coverage of chiropractic benefits under plans that offer 75/25 Coverage and Plans Two and Nine are outlined below:
Coverage for hospital and/or professional services in connection with cosmetic surgery shall be limited to the repair or alleviation of damage to the person caused solely by bodily injury sustained while the member is covered. Repairs shall be made within one (1) year of the injury unless special extension is requested by the attending surgeon, and preauthorization by COEHA is required.
Elective or routine dental work, not associated with injury, is provided through the National Dental Plan for active employees of CSXT and is not a benefit provided by COEHA.
COEHA coverage is limited to the expense of necessary dental repair to natural teeth due to accidental injuries resulting from a direct blow to the mouth. This expense must have prior approval from the COEHA Offices. Repairs shall be made within six (6) months of the injury unless special extension is requested by the attending physician.
Emergency services involving acute dental problems and requiring the services of a medical doctor rather than a dentist, and which do not involve direct repair to natural teeth, are considered the responsibility of COEHA.
Neither the cost for dentures nor implants is covered under any circumstances.
For Members covered under Plans One, Two, Three, Five, Nine, Eleven, Twelve& Thirteen:
COEHA has entered into a partnership with Liberty Medical, LLC/Neighborhood Diabetes, a fully accredited organization, for diabetic testing supplies. If you expect coverage from COEHA for the cost of your diabetic testing supplies, you are required to purchase these supplies through Liberty Medical, LLC/Neighborhood Diabetes.
When you enroll with Liberty Medical, LLC/Neighborhood Diabetes, you will not be required to get a new prescription from your physician for the diabetic testing supplies. Once you contact Liberty Medical, LLC/Neighborhood Diabetes, they will contact your physician and get all of the necessary information. However, you must initially contact Liberty Medical, LLC/Neighborhood Diabetes to enroll, and you will need to answer a few questions.
Liberty Medical, LLC/Neighborhood Diabetes is a mail order program. They will provide you with a 90-day supply of the following test items and you will be responsible for a co-payment for each supply. Your co-payment can be paid by credit or debit card at the time of your order with Liberty Medical, LLC/Neighborhood Diabetes.
You are also eligible for a free Prodigy Autocode blood glucose meter. The Prodigy Autocode requires very little blood, is easy to use with no coding required, and will ‘speak’ your results in English or Spanish. If you are comfortable with your existing meter and you prefer not to change, Liberty Medical, LLC/Neighborhood Diabetes will be able to provide supplies for your existing meter.
You can reach Liberty Medical, LLC/Neighborhood Diabetes at 1-800-633-2001.
Diabetic medications, such as insulin and syringes are still covered through our prescription drug plan with Navitus Health Solutions.
For Members covered under Plan Four:
You are eligible to order your supplies from Liberty Medical, LLC/Neighborhood Diabetes at a discounted price. You are not required to change vendors. You may still get your testing supplies through Navitus Health Solutions; however, you should be aware that Liberty Medical, LLC/Neighborhood Diabetes is another available provider which may provide the supplies ata lower cost.
COEHA covers the charge for medically necessary diagnostic testing such as laboratory and radiology services when such services are provided by COEHA network providers.
This is equipment needed for medical reasons which is sturdy enough to be used many times without wearing out. COEHA covers certain durable equipment items such as oxygen, oxygen equipment, wheelchairs, and hospital beds. Only one of each article is covered. COEHA does not cover maintenance, repair, or replacement of such items.
For durable medical equipment, coverage for purchase vs. rental is based on length of time for which this equipment is prescribed. COEHA will not pay more than the purchase price for rentals.
Not all durable medical equipment is covered. To qualify for coverage, you must provide certification of medical necessity and related documentation, including a copy of the physician’s orders showing length of time equipment is needed, and preauthorization by COEHA is required. Please contact the COEHA office for specific information on coverage for durable medical equipment.
For members eligible for 75/25 Coverage: (Plans One, Three, Five, Eleven & Thirteen)
These items will be covered under the terms of 75/25 Coverage level, as described in the section entitled "COEHA Network."
For Plans Two, Nine& Twelve:
Covered at 75%.
Plans Four, Six and Eight are eligible for appliance benefits under the guidelines summarized in the Plans’ Section for such members.
The term "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that an individual could reasonably expect that the absence of immediate medical attention could result in a condition that: (i) places the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) causes serious impairment to bodily functions, or (iii) causes serious dysfunction of any bodily organ or part.
In case of life-threatening or physically impairing emergencies, participants are expected to get care immediately regardless of the provider’s network affiliation. Please notify the COEHA Office within 24 hours if these emergency services are obtained from providers not participating in the COEHA network.
Member is responsible for a $75 co-pay for services rendered in the emergency room. The remaining emergency room services are covered at 100%. In cases where the member is admitted to the hospital or to observation through the emergency room, the co-pay will be waived.
Payment for services rendered in hospital emergency rooms is limited to treatment of emergency problems only. Although a particular hospital may be a COEHA network facility, COEHA will not cover treatment in an emergency room for non-emergency problems that can be handled in the offices of in-network providers of COEHA or at an Urgent Care Center.
Charges determined to be of a non-emergency nature will be handled at a reduced rate under the 75/25 Coverage level for those eligible for this coverage, and denied for members not eligible for75/25 Coverage.
Prior authorization by COEHA is required. This surgery is limited to $25,000 and is defined as all services included during the visit for the actual procedure with exceptions listed on the next page. This surgery will only be covered once.
Hearing Examination/Hearing Aids/Cochlear Implants or Ossteo integrated Hearing Devices
Coverage for Active Members Only:
Up to a maximum of $600 each calendar year for:
Members entitled to 75/25 Coverage are eligible for home health services under the terms of 75/25 Coverage, as described in the section entitled "COEHA Network." (Plans One, Three, Five, Eleven & Thirteen)
Plans Two, Nine & Twelve: Covered at 75%.
Plans Six and Eight are also eligible for the home health services as listed below under the guidelines summarized in the COEHA Plans Section for such members.
Part-time nursing care rendered by or supervised by a registered nurse or licensed practical nurse and prescribed by the attending physician.
Semi-private room accommodations and ancillary charges (e.g., supplies) provided in COEHA network facilities are covered.
Private rooms are covered when it has been determined by the attending physician that it is medically necessary.
COEHA will provide private duty nursing care only to the extent such services are certified as medically necessary and prescribed by the attending physician. Services beyond such certified period will not be covered. Private duty nursing is limited to fifteen (15) shifts during any one spell of illness. A spell of illness is defined as successive periods of hospital confinement separated by less than sixty (60) days and due to the same or related causes. Special duty nursing is also limited to services provided by a registered nurse or licensed practical nurse.
All inpatient hospital admissions must be precertified. HealthLink, a separately branded division of Anthem, Inc., handles this for our members. Either you, the hospital, or your admitting physician should contact HealthLink, at 1-877-284-0102, prior to a scheduled admission or within 24-48 hours after an emergency admission. Members will be subject to a $500 penalty for all admissions not precertified.
Inpatient rehabilitation in a hospital or rehabilitation center is limited to 30 days per spell of illness or injury.
Payment for treatment in connection with the temporomandibular joint (jaw joint) and the complex of muscles, nerves and other tissues related to this joint.
This benefit is limited to thirty (30) months during which time it will be the member’s responsibility to enroll in Medicare (both Parts A & B) benefits for end-stage renal disease (ESRD). COEHA will be the primary insurer during this 30-month period. Medicare will be the primary insurer once this 30-month period has been exhausted.
Effective January 1, 2006, COEHA is the primary insurer for any pregnancy related claims for active female members for both inpatient and outpatient services.
Members in a furloughed, leave of absence, disabled, suspended, or separated status will be provided obstetrical benefits (both inpatient and outpatient services) for as long as their coverage in applicable category is defined. (See the relevant category in the section entitled "COEHA Participants – Eligibility.")
For those eligible members, COEHA shall provide benefits for a hospital stay in connection with childbirth for the mother and newborn child for (i) 48 hours following a vaginal delivery and (ii) 96 hours following a cesarean section, except to the extent the attending provider, in consultation with the mother, discharged the mother or newborn child prior to the expiration of the applicable minimum length of stay.
Effective January 1, 2010, coverage for mental health will be identical to the benefits provided under medical and surgical. Please refer to Benefits Section entitled: Outpatient Office Visits, Consultations & Diagnostic Testing and Hospitalization for coverage guidelines.
Routine eye examinations are covered through the National Vision Plan for active employees of CSXT. Ophthalmological services which are other than routine are covered through COEHA. Please keep in mind that although your routine eye care may be covered by a National Vision Plan provider, this provider may not be in the COEHA network. If you utilize the services of a National Vision Plan provider for a routine eye exam, andduring the examination, other medical services are indicated to be necessary, please keep in mind that you should seek those services from a COEHA network provider in order for your expense to be handled at your highest level of benefits.
For other non-active members, coverage for ophthalmological services is provided by COEHA.
COEHA covers human kidney, cornea, bone marrow, liver and heart transplants. Transplant services must be preauthorized by COEHA. COEHA does not cover transplant cases which are considered experimental.
These are items serving to protect, restore or improve function. COEHA covers certain orthotic devices such as braces and supports when these items are prescribed by a COEHA network provider. Only one of each article is covered. Repair, replacement or maintenance of such item is not covered.
For foot orthotics, please refer to provisions in the section entitled "Benefits" regarding "Podiatry."
Not all orthotic devices are covered. To qualify for coverage, you must provide certification of medical necessity and related documentation, and preauthorization by COEHA is required. Please contact the COEHA office for specific information on coverage for orthotic devices.
Member is responsible for a $25 co-pay per office visit or urgent care center. COEHA covers the remaining charge at 100% when services are provided by COEHA network physicians. The $25 co-pay is not due for an office visit when only laboratory and/or radiology procedures are performed and there is no charge by the physician for the office visit. However, services other than office/urgent care visits, such as lab and radiology are covered at 95% after the appropriate deductible has been met.
For Plans One, Nine, Eleven and Twelve, outpatient therapy is paid at 80% of our fee schedule to the extent such therapy is certified as necessary and prescribed by an authorized physician.
Non-prescribed treatments will be the responsibility of the member.
For Plans Two, Three, Four, Five and Thirteen, outpatient therapy is paid at 80% of our fee schedule to the extent such therapy is certified as necessary and prescribed by an authorized physician.
Plans Six& Eight are eligible for therapy benefits under the guidelines summarized in the COEHA Plans Section for such members.
Non-prescribed treatments will be the responsibility of the member.
The services of a Podiatrist are covered only when such services are not provided by a COEHA network orthopedist.
General foot care is not covered.
Foot orthotics, such as inserts, are covered for those members eligible for 75/25 Coverage under the terms of 75/25 Coverage, as described in the section entitled "COEHA Network." (Plans One, Three, Five, Eleven & Thirteen). For Plans Two& Nine, they are covered at 75%. Arch supports are not covered for any plan of membership.
For Members covered under Plans One, Two, Three, Five, Nine, Eleven, Twelve & Thirteen:
Prescription drug coverage is provided through our prescription drug program. Under this program you have a prescription drug card for use in local participating pharmacies (retail) for up to a thirty (30) day supply of generic and brand name medications. For a ninety (90) day supply of generic and brand name medications, you may use the Medication Supply Program.
You are not required to use the mail order program to get a 90-day supply of medication; however, your co-payments for Tiers 2 and 3 will be less expensive by mail order. You can also get a 90-day supply through some retail network pharmacies; however, your co-payments will be higher for Tiers 2 and 3. For Tier 1, some retail pharmacies may agree to accept the mail order co-pay for a 90-day supply of medication. (For Tier 1 drugs, all Walmart, Kroger, Rite Aid, CVS and Target Pharmacies will handle 90 day fills for mail order copays.)There are also a few independent pharmacies that have agreed to do this.
Mandatory 90-day Medication Supply Program:
This program requires that you begin to fill your medication for a 90-day supply after you receive two 30-day fills of a maintenance medication.
You are responsible for co-payments on both the retail pharmacy and the mail order pharmacy medications. These co-pays are not refundable. COEHA has a 3-tier plan as listed below:
Medications that have a less expensive generic (or bio equivalent) will become Tier 3 medications. Tier 3 medications are considered non-preferred.
COEHA encourages our members to use generic medications when a generic is available. For example, if your doctor writes a prescription for a medication that has a generic available, but you choose the brand name medication, you will be responsible for paying the higher Tier 3 co-payment, plus the cost difference between the brand name drug and the generic drug.
Utilization Management: For certain prescription drugs, there are additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. The following are management tools for the utilization management:
For Members covered under Plan Four:
You are eligible for a consumer drug card through our prescription drug program which entitles you to group discounts when purchasing drugs through this drug program.
Noncovered Drugs and Medications for All Plans:
Covered for all Plans:
Preventative services as outlined in the guidance provided by the U.S. Services Task Force, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the guidelines supported by the Health Resources and Services Administration for infants, children and adolescents, relevant to the Affordable Care Act are covered at 100%.
Some vaccines are now available through your prescription drug plan at the local retail participating pharmacies with zero co-pay. They are also still covered in the physician’s office; however, if your physician bills for an office visit, you are responsible for the $25.00 office visit co-pay.
This includes artificial substitutes that replace missing body parts. COEHA covers certain prosthetic devices such as artificial limbs, eyes, etc. A copy of the physician’s orders must accompany the bill for these services.Only one of each article is covered. COEHA does not cover maintenance, repair, or replacement of such items.
Prosthetic devices also include items used to replace an internal body part or function.
Not all prosthetic devices are covered. To qualify for coverage, you must provide a certification of medical necessity and related documentation, and preauthorization by COEHA is required. Please contact the COEHA office for specific information on coverage for prosthetic devices.
(See the section entitled "Reconstructive Surgery Following Mastectomy" for coverage on breast prosthetics.)
For members eligible for 75/25 Coverage: (Plans One, Three, Five,Eleven & Thirteen)
These items will be covered under the terms of 75/25 Coverage level, as described in the section entitled "COEHA Network."
For Plans Two, Nine & Twelve:
Covered at 75%.
Plans Four, Six and Eight are eligible for prosthetic benefits under the guidelines summarized in the Plan Section for such members.
In accordance with the Women’s Health and Cancer Rights Act of 1998 (WHCRA), COEHA provides coverage, in the case of a participant who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, (i) all stages of reconstruction of the breast on which the mastectomy has been performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and physical complications of mastectomy, including lymphedemas in a manner determined in consultation with the attending physician and the patient. Such coverage is subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the Plan. Plan limits, deductibles, copayments, and coinsurance apply to these benefits. For more information on WHCRA benefits, contact the COEHA Office.
Prior authorization by COEHA is required. This surgery is paid at 75% and is limited to $7,500 and is defined as all services included during the visit for the actual procedure. The surgery will only be covered once.
Skilled Nursing Facility (SNF) care is healthcare given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care. These skilled care services are needed daily on a short-term basis.
Our benefits for SNF care are similar to what the Medicare Plan covers for a Medicare member. COEHA will cover the first 20 days in a SNF—preauthorization by COEHA is required. If SNF care is required beyond the first 20 days, COEHA will pay the equivalent to what Medicare would pay up to 100 days. The percentage that Medicare does not cover from the 21st to the 100th day changes each calendar year. That percentage would be due by the patient. COEHA will not cover SNF care beyond 100 days for the same spell of illness or injury.
COEHA does not cover custodial care. Custodial care is care that helps you with usual daily activities like walking, eating, or bathing.
COEHA does not cover long-term care facility charges. Long-term care is a variety of services that help people with health or personal needs and activities of daily living over a period of time. Most long-term care is custodial care.
Effective January 1, 2008, COEHA will cover certain medical services provided a member while a resident in a long-term care facility, such as physician visits and physical therapy.
Effective January 1, 2010, coverage for substance abuse will be identical to the benefits provided under medical and surgical. Please refer to Benefits Section entitled: Outpatient Office Visits, Consultations & Diagnostic Testing and Hospitalization for coverage guidelines.
Effective January 1, 2017, coverage is provided for transgender services.
Vasectomy and Tubal Ligation Procedures
These procedures are covered when performed solely for the purpose of voluntary sterilization and only when performed by COEHA network physicians. COEHA will only cover this type of surgery once.
Costs associated with subsequent surgery for the purpose of restoring virility or fertility after previous elective sterilization has been carried out are not covered.
Sterilization procedures are not covered outside of the COEHA network under any circumstances.
Cases may arise involving medical care that is not specified in these Rules and Regulations. In these cases, contact the COEHA Office for instructions.
SUBROGATION AND REIMBURSEMENT
This provision shall apply to all benefits provided under any section of the C and O Employees’ Hospital Association Plan.
Subrogation and reimbursement represent significant C and O Employees’ Hospital Association Plan assets and are vital to the financial stability of the Plan. Subrogation and reimbursement recoveries are used to pay future claims for other C and O Employees’ Hospital Association members. Anyone in possession of these assets holds them as a fiduciary and constructive trustee for the benefit of C and O Employees’ Hospital Association. The Plan Administrator has a fiduciary obligation under ERISA to pursue and recover these Plan assets to the fullest extent possible.
"Another party" shall mean any individual or entity, other than C and O Employees’ Hospital Association, who is liable or legally responsible to pay expenses, compensation or damages in connection with a covered member’s injuriesor illness.
"Another party" shall include the party or parties who caused the injuries or illness; the liability insurer, guarantor or other indemnifier of the party or parties who caused the injuriesor illness; a covered member’s own insurance coverage, suchas uninsured, underinsured, medical payments, no-fault, homeowner’s, renter’s or any other insurer; a workers’ compensation insurer; governmental entity or any other individual, corporation, association or entity that is liable or legally responsible for payment in connection with the injuries or illness.
A "Covered Member" shall mean any person, dependents or representatives, other than C and O Employees’ Hospital Association, who is bound by the terms of the Subrogation and Reimbursement Provision herein.
A "Covered Member" shall include but is not limited to any beneficiary, dependent, spouse or person who has or will receive benefits under a plan of the C and O Employees’ Hospital Association, and any legal or personal representatives of that person, including parents, guardians, attorneys, trustees, administrators or executors of an estate of a covered member, and heirs of the estate.
"Recovery" shall mean any and all monies identified or paid to the covered member through or from another party by way of judgment, award, settlement, covenant, release or otherwise (no matter how those monies may be characterized, designated or allocated) to compensate for any losses caused by, or in connection with, the injuries or illness. A recovery exists as soon as any fund is identified as compensation for a covered member from another party. Any recovery shall be deemed to apply, first, for reimbursement of C and O Employees’ Hospital Association’s lien.
"Subrogation" shall mean C and O Employees’ Hospital Association’sright to pursue the covered member’s claims for medical or other charges paid by the Planagainst another party.
"Reimbursement" shall mean repayment to C and O Employees’ Hospital Association of recovered medical or other benefits that it has paid toward care and treatment of the injuryor illnessfor which there has been a recovery.
The Plan Administrator has maximum discretion to interpret the terms of this provision and to make changes as it deems necessary.
A covered member may incur medical or other charges related to injuries or illness caused in part or in whole by the act or omission of the covered member or another person; or another party may be liable or legally responsible for payment of charges incurred in connection with the injuries or illness. If so, the covered member may have a claim against that other person or another party for payment of the medical or other charges. In that event, the C and O Employees’ Hospital Association Plan will be secondary, not primary. The covered member agrees, if charges are paid by C and O Employees’ Hospital Association, to transfer all rights to recover damages in full to C and O Employees’ Hospital Association.
When a right of recovery exists, and as a condition to any payment by C and O Employees’ Hospital Association (including payment of future benefits for other illnesses or injuries), the covered member will execute and deliver all required instruments and papers, including a subrogation and reimbursement agreement provided by C and O Employees’ Hospital Association as well as doing and providing whatever else is needed, to secure C and O Employees’ Hospital Association’s rights of subrogation and reimbursement, before any medical or other benefits will be paid by C and O Employees’ Hospital Association for the injuries or illness. The Plan Administrator may determine, in its sole discretion, that it is in C and O Employees’ Hospital Association’s best interests to pay medical or other benefits for the injuries or illness before these papers are signed (for example, to obtain a prompt payment discount). However, in that event, C and O Employees’ Hospital Association still will be entitled to subrogation and reimbursement. In addition, the covered member will do nothing to prejudice C and O Employees’ Hospital Association’s right to subrogation and reimbursement and acknowledges that the Plan precludes operation of the make-whole and common-fund doctrines. A covered member who receives any recovery (whether by judgment, settlement, compromise, or otherwise) has an absolute obligation to immediately tender the portion of the recovery subject to the Plan’s lien to C and O Employees’ Hospital Association under the terms of this provision. A covered member who receives any such recovery and does not immediately tender the recovery to C and O Employees’ Hospital Association will be deemed to hold the recovery in constructive trust for C and O Employees’ Hospital Association, because the covered member is not the rightful owner of the recovery and should not be in possession of the recovery until C and O Employees’ Hospital Association has been fully reimbursed.
The covered member must:
Any amounts recovered will be subject to subrogation or reimbursement. In no case will the amount subject to subrogation or reimbursement exceed the amount of medical or other benefits paid for the injuries or illness under the Plan and the expenses incurred by C and O Employees’ Hospital Association in collecting this amount. The Plan will be subrogated to all rights the covered member may have against that other person or another party and will be entitled to first priority reimbursement out of any recovery to the extent of the Plan’s payments. In addition, C and O Employees’ Hospital Association shall have the first priority lien against any recovery to the extent of benefits paid and to be payable in the future. C and O Employees’ Hospital Association’s first priority lien supersedes any right that the covered member may have to be "made whole." In other words, C and O Employees’ Hospital Association is entitled to the right of first reimbursement out of any recovery the covered member procures or may be entitled to procure regardless of whether the covered member has received full compensation for any of his or her damages or expenses, including attorneys’ fees or costs; and regardless of whether or not the recovery is designated as payment for medical expenses or otherwise. Additionally, C and O Employees’ Hospital Association’s right of first reimbursement will not be reduced for any reason, including attorneys’ fees, costs, comparative or contributory negligence, limits of collectability or responsibility, characterization of recovery as pain and suffering or otherwise. As a condition to receiving benefits under the Plan, the covered member agrees that acceptance of benefits is constructive notice of this provision.
The covered member’s attorney should recognize that this section precludes the operation of the "make-whole" and "common fund" doctrines, and the attorney must agree not to assert either doctrine against C and O Employees’ Hospital Association in his pursuit of recovery. The Plan will not pay the covered member’s attorneys’ fees and costs associated with the recovery of funds, nor will it reduce its reimbursement pro rata for the payment of the covered member’s attorneys’ fees and costs.
An attorney who receives any recovery (whether by judgment, settlement, compromise, or otherwise) has an absolute obligation to immediately tender the recovery to C and O Employees’ Hospital Association under the terms of this provision. As a possessor of a portion of the recovery, the covered member’s attorney holds the recovery as a constructive trustee and fiduciary and is obligated to tender the recovery immediately over to the Plan. A covered member’s attorney who receives any such recovery and does not immediately tender the recovery to C and O Employees’ Hospital Association will be deemed to hold the recovery in constructive trust for C and O Employees’ Hospital Association, because neither the covered member nor his attorney is the rightful owner of the portion of the recovery subject to C and O Employees’ Hospital Association’s lien.
When the Covered Member is a Minor or is Deceased or Incapacitated
The provisions of this subrogation and reimbursement provision apply with equal force to the parents, trustees, guardians, administrators, or other representatives of a minor covered member and to the heirs or personal and legal representatives of the estate of a deceased or incapacitated covered member, regardless of applicable law and whether or not the representatives have access or control of the recovery. No representative of a covered member listed here may allow proceeds from a recovery to be allocated in a way that reduces or minimizes the C and O Employees’ Hospital Association’s claim by arranging for others to receive proceeds of any judgment, award, settlement, covenant, release or other payment; or releasing any claim in whole or in part without full compensation therefore.
When a covered member does not comply with the provisions of this section, the Plan Administrator shall have the authority, in its sole discretion, to deny payment of any claims for benefits by the covered member and to deny or reduce future benefits payable (including payment of future benefits for other injuries or illnesses) under the C and O Employees’ Hospital Association Plan by the amount due as a dollar for dollar satisfaction for the reimbursement to the Plan. The Plan Administrator may also, in its sole discretion, deny or reduce future benefits (including future benefits for other injuries or illnesses) under any other group benefits plan maintained by C and O Employees’ Hospital Association. The reductions will equal the amount of the required reimbursement. If C and O Employees’ Hospital Association must bring an action against a covered member to enforce the provisions of this section, then that covered member agrees to pay C and O Employees’ Hospital Association’s attorneys’ fees and costs, regardless of the action’s outcome.
In certain circumstances, a covered member may receive a recovery that exceeds the amount of C and O Employees’ Hospital Association’s payments for past and/or present expenses for treatment of the illness or injury that is the subject of the recovery. In other situations, a covered member may have received a prior recovery that was intended, in part or in whole, to be compensation for future expenses for treatment of the illness or injury that is the subject of a current claim for benefits under the Plan. In these situations, the Plan will not cover any present or future expenses related to the illness or injury for which compensation was provided through a current or previous recovery. The covered member is required to submit full and complete documentation of any such recovery in order for C and O Employees’ Hospital Association to consider eligible expenses that exceed the recovery. To the extent a covered member’s recovery exceeds the amount of the C and O Employees’ Hospital Association’s lien, the Plan is entitled to a credit or cushion in that amount against any claims for future benefits relating to the illness or injury. In those situations following any recovery that exceeds the amount of C and O Employees’ Hospital Association’s lien, the covered member will be solely responsible for payment of medical bills related to the illness or injury out of the remaining recovery. The Plan also precludes operation of the make-whole and common-fund doctrines in applying this provision.
The Plan Administrator has sole discretion to determine whether expenses are related to the illness or injury to the extent this provision applies. Acceptance of benefits under the C and O Employees’ Hospital Association Plan for an illness or injury which the covered member has already received a recovery may be considered fraud, and the covered member will be subject to any sanctions determined by the Plan Administrator, in its sole discretion, to be appropriate, including denial of present or future benefits under the Plan.
The Plan Administrator is the named fiduciary of the Plan for all purposes except claim appeals, as specified in Claims and Appeals Procedure. As fiduciary, the Plan Administrator maintains discretionary authority with respect to those responsibilities for which it has been designated named fiduciary, including, but not limited to, interpretation of the terms of the Plan, and determining eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan; any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.
The Board of Directors of COEHA has sole authority to make final determinations regarding any application for benefits. The Board of Directors also has sole authority over the interpretation of the Rules and Regulations and any other regulations, procedures or administrative rules adopted by the Board of Directors. Benefits under COEHA will be paid only if the Board of Directors or persons delegated by them decide, in their discretion, that the member or beneficiary is entitled to benefits under the terms of the Plan. The Board of Trustees’ decisions in such matters are final and binding on all persons dealing with the Plan or claiming a benefit from COEHA. If a decision of the Board of Directors is challenged in court, it is the intention of the parties to the Trust that the Board of Directors’ decision is to be upheld unless it is determined to be arbitrary or capricious.
No one has a vested (that is, non-forfeitable) right to future coverage under COEHA or to the continuation of any given benefit under COEHA. The Board of Directors has the right to modify or discontinue any benefit or any component of any Plan, at any time and from time to time. The Board of Directors also has the right to terminate COEHA.
The Board of Directors of the C and O Employees’ Hospital Association has the sole right to amend the benefits and plans provided by COEHA. Any such amendments shall be in writing, setting forth the modified provisions of the Plan, the effective dateof the modifications, and shall be approved by a majority of the Board of Directors and signed by the President of the Board of Directors.
Such modification or amendment shall be duly incorporated in writing into the master copy of the Planon file with the C and O Employees’ Hospital Association,or a written copy thereof shall be deposited with such master copy of the Plan. Appropriate filing and reporting of any such modification or amendment with governmental authorities and to covered membersshall be timely made by the C and O Employees’ Hospital Association.
To the extent permitted by law, any such amendment or termination may take effect retroactively or otherwise. In the event of a termination or reduction of benefits, COEHA shall be liable only for benefit payments due and owing as of the effective date of such termination or reduction and no payments scheduled to be made on or after such effective date shall result in any liability to COEHA or the Board of Directors.
This provision shall apply to all benefits provided under any section of the C and O Employees’ Hospital Association Active and Retired, Non-Medicare Plans.
The claims procedures described below are effective January 1, 2003 and supercede any conflicting language in these Rules and Regulations.
If a member’s claim under the Plan is wholly or partially denied, he or she will be notified of the decision, after the Plan’s receipt of the claim, within:
A determination regarding a request for the Plan to approve an on-going course of treatment will be made in sufficient advance of the proposed reduction or termination of treatment to allow the member to appeal before the benefit is reduced or terminated.
Under special circumstances, the notice period may be extended for an additional:
If an extension is required, the member will be notified of the special circumstances involved and the date by which the Plan Administrator expects to render a final decision.
If the member’s claim is denied, the Plan Administrator will provide the member with a written or electronic notification of an adverse benefit determination. The notice will:
In the case of an adverse benefit determination involving a claim for urgent care, the information described above may be provided to the member orally within the permitted time frame provided that written or electronic notification is furnished to the member no later than three days after such oral notification.
If the member’s claim is denied, the member will be provided:
Further, the review must provide that neither the consulted healthcare provider nor his or her subordinate were consulted for the adverse determination which is subject to the appeal. In the case of an urgent care claim, the member is provided an expedited review process, to which their request may be submitted orally or in writing. All necessary information may be transmitted between the Plan and the member by telephone, facsimile, or other available method.
The Plan Administrator will notify the member of the Plan’s benefit determination upon review of a denied claim within:
(i) for an urgent care claim, within 72 hours;
The Plan’s decision on review may be either a written or electronic notification. The notification will set forth for the member:
(i) the specific reason for the adverse determination,
External Review Process and Standards
The Plan is intended to constitute a self-insured group health plan subject to ERISA which shall be administered as a group health plan that follows standards to comply with the Federal External Review regulations and process or private accredited Independent Review Organization (IRO) process as described in regulations and guidance published by the Department of Labor and Internal Revenue Service. The external review process is available at no charge to participants.
You may not bring an action in court to recover benefits from COEHA before you have exhausted all your remedies under the Plan’s claim and appeal procedures as outlined in these Rules and Regulations. Any action in court to recover benefits from COEHA must be brought within one (1) year after the final adverse determination of your claim and must be brought in a federal district court in Virginia. A member may not anticipate, alienate, sell, transfer, pledge, assign, or otherwise encumber any interest in benefits to which he or she is or may become entitled under COEHA. The Board of Directors may, however, honor your assignment of benefits to the provider of covered services.
Neither the Plan nor any Business Associate servicing the Plan will disclose Plan Participants’ protected health information ("PHI") to the Plan Sponsor or the Board of Directors of the C and O Hospital Association, unless the Plan Sponsor certifies that the Plan Documents have been amended to incorporate this Article and that the Plan Sponsor has agreed to abide by this Article.
The Plan and any Business Associate servicing the Plan will disclose Plan Participants’ PHI to the Plan Sponsor only to permit the Plan Sponsor to carry out plan administration functions for the Plan not inconsistent with the requirements of the Health Insurance Portability and Accountability Act of 1996 and its implementing Regulations (45 C.F.R. Parts 160-64). Any disclosure to and use by the Plan Sponsor of Plan Participants’ PHI will be subject to and consistent with the provisions of this Article.
Neither the Plan nor any Business Associate servicing the Plan will disclose Plan Participants’ PHI to the Plan Sponsor unless the disclosures are explained in the Notice of Privacy Practices distributed to the Plan Participants.
Neither the Plan nor any Business Associate servicing the Plan will disclose Plan participants’ PHI to the Plan Sponsor for the purpose of employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.
The Plan Sponsor will neither use nor further disclose Plan Participants’ PHI, except as permitted or required by the Plan Documents, as amended, or as required by law.
The Plan Sponsor will ensure that any agents or subcontractors to whom it provides PHI received from the Plan agree to the restrictions and conditions of the Plan Documents, including this Article, with respect to the Plan Participants’ PHI.
The Plan Sponsor will implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the Plan, as required in the HIPAA Security Standards.
The Plan Sponsor will not use or disclose Plan Participants’ PHI for employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor.
The Plan Sponsor will promptly report to the Privacy Official any use or disclosure inconsistent with the uses or disclosures permitted under this Article.
The Plan Sponsor will make PHI available for inspection to the Plan Participant who is the subject of the information in accordance with 45 C.F.R. § 164.524.
The Plan Sponsor will make PHI available for amendment and will on notice amend Plan Participants’ PHI, in accordance with 45 C.F.R. § 164.526.
The Plan Sponsor will track disclosures it may make of Plan Participants’ PHI so that it can make available the information required for the Plan to provide an accounting of disclosures in accordance with 45 CFR § 164.528.
The Plan Sponsor will make its internal practices and records relating to the use and disclosure of PHI received from the Plan available to the U.S. Department of Health and Human Services to determine compliance with 45 CFR Parts160-64.
The Plan Sponsor will, if feasible, return or destroy all Plan Participant PHI, in whatever form or medium (including in any electronic medium under the Plan Sponsor’s custody or control), received from the Plan, including all copies of and any data or compilations derived from and allowing identification of any Participant who is the subject of the PHI, when the Plan Participants’ PHI is no longer needed for the plan administration functions for which the disclosure was made. If it is not feasible to return or destroy all Plan Participant PHI, the Plan Sponsor will limit the use or disclosure of any Plan Participant PHI it cannot feasibly return or destroy to those purposes that make the return or destruction of the information infeasible.
The following employees or classes of employees or other workforce members under the control of the Plan Sponsor may be given access to the Plan Participants’ PHI received from the Plan or a business associate servicing the Plan:
This list includes every employee or class of employees or other workforce members under the control of the Plan Sponsor who may receive Plan Participants’ PHI relating to payment under, healthcare operations of, or other matters pertaining to the Plan in the ordinary course of business.
The employees, classes of employees or other workforce members identified on the previous page will have access to Plan Participants’ PHI only to perform the plan administration functions that the Plan Sponsor provides for the Plan.
The employees, classes of employees or other workforce members identified on the previous page will be subject to disciplinary action and sanctions, including termination of employment or affiliation with the Plan Sponsor, for any use or disclosure of Plan Participants’ PHI in breach or violation of or noncompliance with the provisions of this Article to the Plan Documents. Plan Sponsor will promptly report such breach, violation or noncompliance to the Plan and will cooperate with the Plan to correct the breach, violation or noncompliance, to impose appropriate disciplinary action or sanctions on each employee or other workforce member causing the breach, violation or noncompliance, and to mitigate any deleterious effect of the breach, violation or noncompliance on any Participant, the privacy of whose PHI may have been compromised by the breach, violation or noncompliance.
NOTICE ABOUT NON-DISCRIMINATION
Discrimination is against the law. COEHA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. COEHA does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
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If you need these services, contact Ms. Michelle Hoke, the Civil Rights Coordinator.
If you believe that COEHA has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Ms. Michelle Hoke, Civil Rights Coordinator, is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA) RIGHTS
As a participant in benefits provided by COEHA, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.
Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.
Continue healthcare coverage for yourself, your spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage.
Review this summary plan description and the documents governing the Plan on the rules regulating your COBRA continuation coverage rights.
In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.