CLICK HERE FOR THE PRINTABLE VERSION OF THE WCSD EMPLOYEE HEALTH CARE PLAN

WCSD Employee Health Care Plan

Webb City R-VII

School District

Webb City School District Crest

your employee

health care plan

Revised 01-01-2026

TABLE OF CONTENTS

Introduction…………………………………………………....2

Summary of Medical Benefits……...………………………….3

Explanation of Medical Benefits……...……………………….6

Medical Exclusions and Limitations………………………....12

Defined Terms…………………………………………….….17

Eligibility & Enrollment……………………………………...30

Termination of Coverage………………………………….….32

Claims Processing…………………………………………….37

Coordination of Benefits/Subrogation…………………….….38

Plan Information……………………………………………...45

WEBB CITY R-VII SCHOOL DISTRICT

EMPLOYEE HEALTH CARE PLAN

PLAN DESCRIPTION

This booklet is the Plan Document, which defines your benefits provided by The Webb City R-VII School District. It is written so that it can be used by you, the Plan Administrator, and Claims Supervisor in administering the Plan. Any definition or policy not specifically addressed in this document is referenced in the Trilogy Claims Administrative Handbook, which is available for your review at PointC. All claims to be filed or inquiries regarding such claims should be directed to PointC., P.O. Box 25217, Overland Park, Ks. 66225, (417) 782-1515 or 1-888-294-1515.

MEDICAL PLAN

MEDICAL PLAN CONCEPTS

In-Network Providers

In an effort to better control costs and promote quality service, the Plan is participating in a managed care program. Employees and their Dependents are given the opportunity to utilize Physicians and Hospitals who have contracted with the Plan, to provide services at discounted prices, also called In-Network Providers. Members of the Aetna Network will serve as this Plan’s primary In-Network Providers. PointC.utilizes several wrap-around Networks. For additional information, contact the PointC office at (417) 782-1515 or (888) 294-1515. The Plan member may choose to use an In-Network Provider or an Out-of-Network Provider. However, if the Plan member utilizes an In-Network Provider, the Plan will pay at a higher benefit percentage than if the member were to see an Out-of-Network Provider. A directory of Hospitals and Physicians in your area who have agreed to handle billing and collections for the Patient will be made available to the Plan member through the Plan Administrator’s benefits office or can be obtained from the Plan Supervisor. The Plan member’s personal identification card will notify the Provider of membership in the program.

Pre-Certification

Pre-Certification is required for all inpatient Hospital stays. Upon learning that he/she will be hospitalized, the covered Plan member must notify the Pre-Certification service 24 hours prior to his/her hospitalization. He/she will be required to give the Physician’s name and telephone number and the group number, which is PCT12609. The number to call is 1-888-241-7370, and is also displayed on your personal ID Card. The Physician or Hospital may provide notification, but the responsibility of contacting the Pre-Certification service rests with the Plan member. Failure to pre-certify will result in a $2,500 reduction in benefits. Additional costs paid by the Participant due to reduction in benefits will not apply to the out-of-pocket maximums. All inpatient Hospital stays which are not certified as requiring an inpatient setting will not be covered.

Additionally, you must notify the Plan of any scheduled outpatient procedures, as well as all referrals to a specialty physician, when referred outside the Aetna Network.

In the case of an emergency, the Patient or Physician must notify the Pre-Certification Department within forty-eight (48) hours or the first business day following hospitalization, to provide the necessary review information. Longer stays than were originally Pre-Certified will require follow-up review by the Pre-Certification Department. If the Pre-Certification Department disagrees with the additional days requested by the Physician, the Patient, Hospital and Physician will be advised. Pre-Certification does not guarantee payment of benefits. All other Plan provisions, limits and exclusions apply to Pre-Certified Hospital admissions.

Weekend Admission PenaltyCase Management

Case Management helps Physicians and Patients to identify ways in which Patients with serious illnesses or special needs can be treated in a cost-effective manner in a Hospital setting or at home, including assistance in negotiating preferred rates with Providers. A Case Management specialist is available through the Utilization Management Department. As defined in the Plan, services can be paid if recommended by the Physician and where Case Management and a Physician are in agreement.

SUMMARY OF MEDICAL BENEFITS

DEDUCTIBLES, CO‑PAYS &CO‑INSURANCE

Deductibles, Individual & Family

Each Plan member is responsible for payment of eligible charges up to the amount of his/her deductible. A maximum of two family members must meet their deductible in any Calendar Year. Combinations are not allowed.

Calendar Year Deductible

Individual	Family
$600	$1200

Co-Insurance

After any deductible amounts have been satisfied, the Plan member is required to pay a percentage of charges called co-insurance, also called out-of-pocket. Unless specified otherwise, the Plan will pay the following co-insurance percentages:

SCHEDULE OF BENEFITS

Service or Care Provided	In-Network	Out-of-Network
Physician Office Visit	80% after deductible	60% after deductible
Preventive Care	100% no deductible	60% after deductible
Includes GYN/Mens Preventive exam, Pap Smear, Routine Mammogram, & PSA test
Other Preventive Care	80% after deductible	60% after deductible
Includes immunizations & other Preventive services deemed appropriate for the patient’s age and health status.
Childhood Immunizations Up to age 18	100% no deductible	100% no deductible
Subject to Centers for Disease Control & Prevention (CDC) recommended ages and frequencies and Usual & Customary amounts
Emergency Room Care Emergency Condition Only – see definition on page 20	80% after deductible	60% after deductible
Emergency Room Care Non-Emergency Conditions	$200 Co-pay then 80% after deductible	$200 Co-pay then 60% after deductible
Ambulance	80% after deductible	80% after deductible
Hospital Room & Board	80% after deductible	60% after deductible
Outpatient Hospital	80% after deductible	60% after deductible
Surgery Inpatient, Outpatient or Physician’s office	80% after deductible	60% after deductible
Maternity Care Dependent daughters not covered	80% after deductible	60% after deductible
Non-Routine Mammograms	80% after deductible	60% after deductible
Colonoscopy Exams (See page 8 for limitations)	80% after deductible	60% after deductible
Temporomandibular Joint (TMJ) Syndrome $1,000 Lifetime maximum	80% after deductible	60% after deductible
Physical/Speech/Occupational Therapies Combined maximum of 60 visits per Calendar Year	80% after deductible	60% after deductible
Chiropractic Care Limited to $500/Calendar Year	80% after deductible	80% after deductible
Home Health Care Limited to 40 visits/Calendar Year	80% after deductible	60% after deductible
Hospice Care	80% after deductible	60% after deductible
Skilled Nursing Facility Care & Inpatient Rehabilitation Limited to 90 days/Calendar Year	80% after deductible	60% after deductible
Durable Medical Equipment, Prosthetics & Orthotics	80% after deductible	60% after deductible
Mental Health Services – Inpatient	80% after deductible	60% after deductible
Mental Health Services – Outpatient	80% after deductible	60% after deductible
Substance Abuse Treatment Inpatient & Outpatient	80% after deductible	60% after deductible
Organ Transplants	80% after deductible	60% after deductible
Prescription Drugs	80% after deductible	80% after deductible
Specialty Medications	Not Covered	Not Covered

Co-insurance Maximums

The Plan will pay the designated percentage of covered charges until co-insurance maximums are reached, at which time the Plan will pay 100% of the remainder of covered charges for the rest of the Calendar Year unless stated otherwise. If care is received from both In-Network and Out-of-Network Providers, the Out-of-Network maximums will apply. The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%: deductible(s), cost-containment penalties and co-payments.

Maximum Out-of-Pocket per Plan Year

In-Network/Out-of-Area

Out-of Network

Individual

$700

$1,800

Family

$1,400

$3,600

EXPLANATION OF MEDICAL BENEFITS

Medical Necessity

The Plan will pay for eligible charges submitted when determined to be Medically Necessary for the diagnosis or treatment of an Injury or Illness for which symptoms are present. If the requested charges are not determined to be Medically Necessary or if the charges are not identified as an established effective medical procedure, the charges will be excluded from coverage.

Inpatient Services

The following are covered benefits for inpatient Hospital services, where the Patient is admitted for an overnight stay (more than 23 hours):

Intensive and cardiac care;
Semi-private room;
Private room charges where semi-private rooms are not available;
Private room charges will be considered at the semi-private room rate in the Hospital where the patient is confined;
Operating room and delivery room;
Surgical preparatory room;
Oxygen and its administration;
Anesthesia and recovery;
Dressings, splints, medical supplies and casts;
Radiation therapy;
Hospital ancillary charges other than room and board and deemed Medically Necessary;
Skilled Nursing care; and
Inpatient palliative care.

Outpatient Services

The following are covered services for outpatient procedures, which may occur at a Hospital, Physicians office, or other medical setting:

Physician’s fees for diagnosis, treatment and surgery;
Charges made by a licensed physiotherapist if prescribed by a Physician;
Diagnostic x-ray and laboratory services;
Charges for pregnancy, childbirth or miscarriage, unless the Patient is covered as a Dependent child under the Plan;
Emergency room charges;
Radiation therapy, chemotherapy and radioactive isotopes;
Hemodialysis;
Ambulatory surgical center services;
Outpatient surgery charges, anesthesia and anesthesia recovery room;
Hospice and Home Health care services;
Oral surgery to remove impacted wisdom teeth; and
Second surgical opinions.

Preventive Care

The Plan will cover mandated benefits as shown in the Schedule of Benefits. The following services are covered::

Preventive Services: aspirin to prevent cardiovascular disease for men ages 45-79 and women ages 55-79, iron supplements for children, chemoprevention of dental cavities (oral fluorides), folic acid supplements, counseling for tobacco use (adults only), and immunizations (subject to CDC recommended ages and frequencies).

Women’s Preventive Services: well woman visits, screening for gestational diabetes, Human Papillomavirus (HPV) testing, counseling for sexually transmitted infections, counseling and screening for Human Immune Deficiency Virus, contraceptive counseling, generic oral contraceptives, breastfeeding support, supplies and counseling, and screening and counseling for interpersonal and domestic violence.

Men’s Preventive Services: includes one annual preventive care visit, metabolic panel and PSA test.

Childhood Immunizations

Childhood immunizations will be covered for children up to age 18, subject to CDC recommended ages and frequencies.

Routine Mammography Services

Routine mammography services received by non-symptomatic women for screening purposes are covered at 100%.. Limitations on the frequency of this service are as follows:

Age 35 through 39, one mammogram every other year or more frequent if recommended by a Physician; and
Age 40 and over, one mammogram annually.

Regardless of age, women who have a history of breast cancer, or whose mother or sister has a prior history of breast cancer may receive one annual mammogram if recommended by their Physician.

Colonoscopy Exams

The Plan will cover a colonoscopy exam for Covered Persons subject to CDC recommended ages and frequencies .. The Plan will also cover a colonoscopy exam when the Covered Person has an immediate family member (such as a parent or sibling) who has been diagnosed with malignant colon cancer. Charges will be covered as shown in the Schedule of Benefits and are subject to the Calendar Year deductible and out-of-pocket maximums.

Physician Office Visits

Services and supplies provided by a Physician in a professional office are subject to the Calendar Year deductible and co-insurance maximums.

Co‑Pay MaximumThe Plan has a per member lifetime maximum for all benefits of $2,000,000.Ambulance Services

Emergency transportation by a local professional ground ambulance service is covered if taken to the nearest Hospital facility equipped to treat the emergency. Emergency helicopter transportation will only be approved if documentation supports that the medical condition was life or limb threatening and could not safely be done by a ground ambulance.

Emergency Room Treatment

Services incurred for emergency room services are payable as shown in the Schedule of Benefits. The member will be responsible for an additional $200 co-pay per visit if services are a result of a Non-Emergency Condition (see definition of an Emergency Condition on page 20).

Chiropractic/Manipulative Care

Chiropractic/Manipulative Care includes the detection and correction by manual or mechanical means of structural imbalance, distortion or subluxation. All services provided in the Chiropractor office are considered as part of this Benefit, which are payable as shown in the Schedule of Benefits and limited to $500 per Calendar Year.

Physical, Speech & Occupational Therapy

Physical and Occupational Therapy services are subject to the deductible and out-of-pocket maximums and are subject to a combined limit of 60 visits per Calendar Year. All therapy must be prescribed by a Physician.

Temporomandibular Joint Dysfunction

Regular Plan benefits are payable for covered services and supplies necessary to treat TMJ or related disorders. Covered expenses include services or supplies that are recognized by the medical or dental profession as effective and appropriate treatment for TMJ. Orthodontic services and/or appliances are not covered. Benefits are subject to a Lifetime Maximum of $1,000.

Skilled/Extended Care Facility & Inpatient Rehabilitation

Stays in Skilled Nursing/Extended Care or Inpatient Rehabilitation facilities must be initiated, approved and monitored by Case Management. The Plan will pay at regular plan benefits. Benefits are limited to 90 days per Calendar Year.

Home Health Care

Payment for Home Health Care services is subject to review by Case Management to identify medical criteria and cost-effective alternatives. If provided in accordance with a Home Health care plan established by a Physician and recommended by Case Management, the Plan will cover charges for Home Health Care up to 40 visits per Calendar Year if services are provided by the following: R.N., L.P.N., Home Health aide, Physical Therapist, Occupational Therapist or Speech Therapist. Home respiratory and infusion therapy services are also covered under this benefit.

Hospice Care

The benefits include inpatient and outpatient Hospice care, only if approved by Case Management. Charges must be deemed Medically Necessary and for the treatment of the Plan member who is totally disabled as a result of a terminal Illness. Benefits are limited to $50,000 Lifetime Maximum and include:

Medications and drugs requiring a Physician’s written prescription;
Psychological counseling and therapy rendered solely to the Plan member or their immediate family by an M.D., Ph.D., or licensed social worker (M.S.W.);
Rental, up to the purchase price, of Hospital-type equipment, such as a Hospital bed, oxygen or a wheelchair; and
Inpatient palliative care.

Medical Equipment and Supplies

The following are covered benefits under the Plan, provided they are prescribed by a Physician as a result of Illness, Disease or Injury and are deemed Medically Necessary. Prior approval is required for charges in excess of $500:

Oxygen and the rental or purchase of equipment for its administration, including but not limited to tubing, filters and masks (2 masks per year);
Rental (up to the purchase price) of a Hospital-type bed, wheelchair, or similar durable medical equipment required for medical care or treatment which has no personal use in the absence of the condition for which prescribed;
Orthotic appliances and prosthetic devices when prescribed by a Physician and custom made. No coverage is provided for repair or replacement except when necessitated by normal wear or a change in medical condition;
First pair of eyeglasses or contact lenses following cataract surgery;
One breast prosthesis per breast following a mastectomy;
One wig following radiation to the head or chemotherapy;
Two mastectomy bras per Calendar Year; and
Two pairs of compression stockings per Calendar Year.

Organ Transplants

All charges associated with tissue and organ transplants must be reviewed by Case Management prior to service, however the review may be waived in the case of an emergency. Covered services include:

Charges for human organ and tissue transplants, limited to heart, lung, bone marrow, kidney, liver, cornea and pancreas, and other transplants which become non-experimental as determined by the Plan Administrator; and
Immunosuppressants used in connection with covered human organ and tissue transplants;
All services in connection with organ transplants, including but not limited to, laboratory testing.

Benefits are also payable for donor-related expenses. These charges are subject to the Participant’s Annual Maximum benefit outlined above. All experimental transplants are excluded from coverage, including experimental bone marrow transplants. In the event of a dispute or appeal as to whether a transplant or related charges are considered experimental in nature, the final decision will be rendered by the Plan Administrator.

Dialysis Services

The Plan will cover Dialysis services subject to the Calendar Year deductible and out-of-pocket maximums. All professional charges, equipment charges, facility charges and laboratory services associated with Dialysis therapy will be considered by the Plan at 110% of the Medicare allowable charge. All medications related to Dialysis therapy will be considered by the Plan at 110% of Average Wholesale Price (AWP).

Prescription Drug Benefits

Members must present their ID card at the pharmacy to receive discount pricing for prescription drugs. Members who do not utilize their ID card will be responsible for the cost difference between the discount price and full retail price of their prescription drugs.

Benefits include coverage for contraceptives, but only when the member utilizes oral contraceptives in generic form.

Members must submit prescription drug receipts to PointC. for reimbursement, unless the member’s pharmacy agrees to bill PointC. directly for prescription drug expenses. Benefits are limited to FDA and PDR approved quantities and uses.

Specialty Pharmaceutical Drugs are no longer included in your Major Medical Plan. Notwithstanding the foregoing, the Plan MAY cover the charges for a Specialty Pharmaceutical Drug for one 30 day period during a calendar year for each Specialty Pharmaceutical Drug when an urgent fill of medication is required, unless otherwise excluded elsewhere in the Plan.

Specialty Pharmaceutical Drug(s) are those federal legend drugs that are any drug, regardless of route of administration, which are classified by the pharmacy benefit manager as “specialty” medications. A drug is considered a “specialty” medication if it includes one or more of the following characteristics:

Requires patient participation in a medical management program that includes review of medication use, patient training, coordination of care and management of successful use.
Continual monitoring and training is needed
A FDA-mandated Risk Evaluation and Mitigation Strategy program is utilized in order to approve medication
Medication has particular handling, distribution, and/or administration requirements
Medication has a high cost
Medication is administered orally, inhaled, infused or injected
Medication is used to target chronic or complex diseases
Medication can be produced through biological processes
Medication is used to treat rare diseases and is referred to as orphan drugs

Newborn’s Act

Benefits for Hospital stays in connection for Childbirth are as follows: 1) 48 hours for both the mother and the newborn for normal vaginal delivery; 2) 96 hours for both the mother and the newborn following a Caesarean section. A shorter stay may be agreed to by the mother and the attending Physician. The Plan’s Pre-Certification penalties will not apply to Hospital stays that do not exceed these 48 or 96-hour periods.Pregnancy Expenses

Women’s Health and Cancer Rights Act (WHCRA)

Benefits will be provided by the Plan for breast reconstruction as follows: 1) reconstruction of the breast for which a mastectomy has been performed, 2) surgery and reconstruction of the other breast to produce a symmetrical appearance, and 3) prosthesis and treatment of the physical complications in all stages of mastectomy, including lymphedemas. This benefit is subject to deductible and out-of-pocket maximums.

Other Covered ChargesHospice Care EXCLUSIONS AND LIMITATIONS

Coverage under the Plan is limited to services incurred during the Plan year. The following are exclusions and limitations for which the Plan does not pay benefits, and shall apply to services described herein:

1. Abortion: when performed for any reason other than to prevent the death of a covered female Employee or Spouse;

2. Acupuncture and Acupressure: regardless of the type of Provider;

Alcohol: services, supplies, care or treatment to a Covered Person for an Injury or Illness which occurred as a result of that Covered Person’s illegal use of alcohol. The arresting officer’s determination of inebriation will be sufficient for this exclusion. Expenses will be covered for injured Covered Persons other than the person illegally using alcohol;

4. Armed Forces: injuries occurring while engaged in the services of any branch of Armed Forces or in any act of war whether declared or undeclared;

5. Biofeedback: techniques whereby one seeks to consciously regulate a bodily function by using an instrument to monitor and signal changes in the function;

Breast Implant Removals: except for post-mastectomy Patients;
Charges for Which Payment is not Required: or charges which the Covered Person is not legally obliged to pay;
Chelation Therapy: except for the treatment of heavy metal poisoning;
Chiropractic Manipulation: when performed under anesthesia.
Complications of Non-Covered Treatment: care, services or treatment required as a result of complications from a treatment not covered under the Plan;
Contraceptive Devices; except that generic, oral contraceptives are covered
Cosmetic Treatment except to correct birth defects or disfigurement caused while the Patient was a Covered Person of this Plan;
Court Ordered Treatment: charges for any care ordered by the court and the Police or Sheriffs Department;

Custodial Care: such as sitter’s or homemaker’s services providing care in a place that serves the Patient primarily as a residence and where Skilled Nursing or Physician supervision is not required;
Dental Care: charges for dental care, except for dental services required to treat an accidental injury to sound natural teeth (the individual must be covered under the Plan at the time of the accident and services must be provided within 6 months of the date of the injury) and oral surgery, when required for removal of impacted wisdom teeth;
Drugs or Medication: that do not require a Physician’s prescription (over-the-counter) or have not been approved by the Food & Drug Administration for general marketing. Medication must be FDA approved for the Illness or Injury it is prescribed for. Off-label use of medications is also excluded;
Educational and/or Institutional: charges for testing, training or education whether inpatient or outpatient, to include, but not limited to, developmental delay and learning disorders. One diabetic education session will be covered;
Exercise or Wellness programs unless provided for by the Plan;
Experimental or Investigational Treatment: including charges for care, treatment, services or supplies that are Experimental or Investigational in nature. If Reliable Evidence shows that the drug, device, medical treatment, or procedure is the subject of clinical trials, is in research, experimental, study or investigation arm of ongoing clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, or its efficacy as compared with a standard means of treatment or diagnosis, it will be considered Experimental and Investigational;
Eye Care: including Radiokeratotomy or any other eye surgery to correct near sightedness. Eyeglasses or contact lenses and the fitting, and one refraction following Cataract surgery will be covered;
Foot Care: to include corrective shoes, insoles or other items of normal wearing apparel, treatment of corns or calluses, or strapping. Orthotics must be ordered by a Physician and be custom-made. This exclusion does not apply to medical or surgical treatment for members with diabetes;
Foreign Travel: care, treatment or supplies out of the United States if travel is for the sole purpose of obtaining medical services;
Growth Hormone: charges incurred for testing or diagnosis over the age of 18 and any related lab charges or medications;
Hair Loss: care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician. One wig for hair loss due to chemotherapy or radiation therapy to the head will be covered;
Hazardous Hobby or Activity: care and treatment of an Illness or Injury that results from the pursuit of additional interests or hobbies of a hazardous nature, including but not limited to, skydiving, hang gliding, bungee cord jumping or other aeronautical device, all terrain vehicle or other off-road activities. Competition involving pay, profit or gain, including, but not limited to, organized racing, organized fighting or participating in a rodeo is also excluded;
Hearing Aids: including devices, exams, fittings and repair;
Hearing Loss: any treatment, care or surgical procedures for persons over the age of 50 (fifty) if it is correctable with the use of a hearing aid. Sensory hearing loss is also excluded;
Homeopathic and Alternative Medicine: any form of alternative medicine used in place of conventional medicine;
Hospital Employees: professional services billed by a Physician or nurse who is an Employee of the Hospital or Skilled Nursing facility and paid by the Hospital or facility for the service;
Illegal Acts: expenses incurred for Injuries and/or Illnesses sustained during the commission or attempted commission of any criminal or illegal act involving, but not limited to: 1) use of drugs or alcohol, including but not limited to, driving under the influence of an illegal substance or alcohol. Medical laboratory test results or the arresting officer’s determination of inebriation or being under the influence of an illegal substance will be sufficient for this exclusion; 2) any act involving violence or the threat of violence to another person including, but not limited to, assault or other felonious behavior, or by participating in a riot or public disturbance. This exclusion does not include domestic violence; 3) illegally operating a motor vehicle or motorcycle, including but not limited to, failure to wear a seatbelt or helmet or operating without a valid driver’s license or insurance coverage; and 4) the use of a firearm, explosive or other weapon likely to cause physical harm or death if used by a Covered Person. Services provided as a result of a medical condition, either physical or mental, are not included in this exclusion;
Immediate Family: charges from a Provider who usually resides in the same

household as the Covered Person, or who is a member of his/her immediate family or the family of his/her spouse;

Infertility Services and Artificial Insemination: charges for in-vitro fertilization procedures or drugs, GIFT (Gamete Intra-Fallopian Transfer) procedures, artificial insemination or other procedures, studies or drugs related to the treatment or diagnosis of infertility;
Maternity related charges incurred by a newborn child of a Dependent child covered under this Plan;
Medically Unnecessary: services which are not Medically Necessary for the diagnosis or treatment of a condition with which symptoms are present, including more than one sonogram per pregnancy when no complications are present or any monitoring or diagnostic devices, except for diabetic supplies and monitoring devices. Family history by itself does not meet criteria for medical necessity. Routine or preventive screening services will not be covered if there are no symptoms present. (See page 7 for additional details regarding mammograms);
Medical Records: to include payment for any records or documents associated with a request for enrollment in the Plan, determination of eligible charges, or any appeal by a Plan member;
Motorcycle & ATV Helmet Requirements: charges for head injuries sustained while riding a motorcycle or ATV unless the rider or passenger is wearing an approved helmet. This exclusion applies regardless of individual state laws on helmet usage and age limits;
No Obligation to Pay: charges incurred for which the Plan has no legal obligation to pay;
No Physician Recommendation: care, treatment, services or supplies not recommended and approved by a Physician, or treatment, services or supplies when a Covered Person is not under the regular care of a Physician. Regular care means ongoing medical supervision or treatment which is appropriate care for the Injury or Sickness;
Non-Implantable Communication-Assist Devices: including, but not limited to, communication boards and computers;
Non-Physician Care: charges for care or services not provided by a covered Provider;
Non-Reasonable or Customary Charges: charges which are in excess of the reasonable and customary charges for services and materials as determined by Medical Data Resources (MDR) guidelines;
Nutrition: even if the only source of nutrition, such as tube feedings or special diets, including nutritional supplements, unless it is during a Covered Person’s inpatient hospitalization;
Personal Comfort Items: such as TV, telephone, air conditioning, humidifiers, physical fitness equipment and items generally useful outside the Hospital;
Physician Care: which is not within the scope of his/her license;
Plan Design Exclusions: charges exclude by the Plan design as mentioned in the Document;
Remicade Infusions: if more frequently than every 8 weeks past the initial therapy;
Routine Examinations: except as specifically indicated in this Plan Document;
Self-Inflicted Injury or Illness: charges for intentionally self-inflicted Sickness or Injury unless it is a result of a medical condition (either physical or mental);
Self-Injectable Medication: medication purchased at, and/or billed by a Physician’s office;
Services Before or After Coverage: care, treatment or supplies for which a charge was incurred before a person was covered under this Plan or after coverage ceased under this Plan;
Service Covered by Other Insurance Policies: this Plan will pay only secondary to any third-party policy, to include, but not limited to, no fault or personal injury protection, catastrophic funds mandated by motor vehicle or other state law, uninsured motorist, motor vehicle medical reimbursement, (regardless whether it is purchased by the Plan member or Dependent), Homeowner’s insurance, Premises policy, or any monies collected for pain and suffering;
Sex Changes: care, services or treatment for non-congenital transsexualism, gender dysphoria or sexual reassignment or change. This exclusion includes medications, implants, hormone therapy, surgery, and medical or psychiatric treatment;
Sexual Dysfunctions: including charges related to changing the sex of an individual, and any services for sexual dysfunctions or inadequacies, surgical insertion of a penile prosthesis including the cost of the prosthesis and complications thereof, regardless of diagnosis;
Sleep Disorders: care and treatment for sleep disorders unless deemed Medically Necessary;
Smoking Cessation: including any care or treatment for smoking cessation;
Social Counseling: including marital counseling, religious counseling, vocational/employment counseling and sexual disorder therapy. Counseling in connection with Hospice Care is covered as shown in the Explanation of Benefits section.
Speech Therapy: unless due to Injury or Illness (see definition on page 29);
Sterilization: charges in connection with sterilizations, including the reversal of a sterilization;
Telephone Charges: for telephone consultations or e-mail or internet consultations;
Travel or Accommodations: charges for travel or accommodations, whether or not recommended by a Physician, except for ambulance charges as defined as a covered expense;
U. S. Government: charges for services or supplies furnished by an agency of the federal, state, or local government, or a foreign government agency, unless required by law;
Vision Therapy: including any form of supervised therapy aimed at improving visual skills;
Vitamins or Minerals: except prenatal vitamins for pregnant women and Rx Potassium supplement;
Vocational Rehabilitation by any name called;
Weight Management: treatment provided for weight loss or redirection of obesity, including surgical procedures, even if the individual has other health conditions which might be helped by weight loss or reduction of obesity; and
Work Related Injury or Illness: which arises out of the course of any employment, including, but not limited to self-employment, ranching, farming, roofing, mechanics or other trade.

DEFINED TERMS

The following terms have special meanings and when used in this Plan will be capitalized.

Active Employee is an Employee who is on the regular payroll of the Employer and who is scheduled to perform the duties of his or her job with the Employer on a full-time basis.

Acute Care is a pattern of health care in which a Patient is treated for an acute episode of Illness, for the sequelae of an accident or other trauma, or during recovery from surgery. Acute care is usually given in a Hospital by specialized personnel using complex and sophisticated technical equipment and materials, and it may involve intensive care or emergency care. This pattern of care is often necessary for only a short time, unlike chronic care.

Allowable Charge is based on amounts accepted by other Providers in the area for like treatment, care, services, or supplies. For charges rendered by any In-Network Provider (including, but not limited to, a Designated Transplant Facility), the Allowable Charge is the amount based on the fee schedule negotiated with the In-Network Provider. Our determination of what is an Allowable Charge is final for the purpose of determining benefits payable under the Plan.

Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery, has a staff of Physicians, has continuous Physician and nursing care by registered nurses (R.N.s) and does not provide for overnight stays.

Baseline shall mean the initial test results to which the results in future years will be compared in order to detect abnormalities.

Benefit Year means a new deductible and co-insurance maximum must be served at the beginning of each new Calendar Year. The benefit year begins January 1 and ends December 31 of each year.

Benefits refers to the coverage your program provides. The benefits we provide for covered services are calculated starting with the billed charge or our allowed amount, whichever is less. We then subtract any deductible, charges not covered by the Plan and co-insurance amounts. These amounts are your share of the cost. The remaining portion of the charges are your benefits.

Birthing Center means any freestanding health facility, place, professional office or institution (which is not a Hospital) or in a Hospital, where births occur in a home-like atmosphere. This facility must be licensed and operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the facility is located.

The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse-midwife; and have a written agreement with a Hospital in the same locality for immediate acceptance of Patients who develop complications or require pre- or post-delivery confinement.

Breast Reduction Criteria

Must provide documentation of pain in upper back, pain in neck, pain in shoulders, headaches or pain/ulceration from bra straps cutting into shoulders; and
Photographic documentation of severe breast hypertrophy; and
At least 500 grams of breast tissue per breast must be removed for coverage. Body Surface Area (BSA) criteria will be taken into account when determining benefits.

Calendar Year means January 1^st through December 31^st of the same year.

Certification (see Pre-Certification or Certification - page 27).

COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Co-Insurance or Out-of-Pocket is the percentage of covered charges not paid by the Plan that is the Participant’s responsibility. Refer to page 6 for member maximum out-of-pocket. Charges not covered by the Plan do not accumulate to the out-of-pocket.

Complication of Pregnancy means non-elective Caesarean section, non-elective abortion, ectopic pregnancy which is terminated, spontaneous termination of pregnancy which occurs during a period of pregnancy in which a viable birth is not possible, or a grave condition (one usually requiring Hospital confinement) where the diagnosis is distinct from pregnancy but the condition is caused by or adversely affected by pregnancy.

Such conditions include acute nephritis, nephrosis, cardiac decompensation, missed abortion, severe hyperemesis gravidarum, eclampsia, and similar conditions of like severity.

Such conditions do not include false labor, occasional spotting, rest prescribed by a qualified Provider during the period of pregnancy, morning Sickness, mild preeclampsia, and similar conditions of like severity associated with the management of a difficult pregnancy.

Cosmetic Dentistry means dentally unnecessary procedures.

Cosmetic Treatment is a procedure directed at improving the Patient’s appearance which does not meaningfully promote the proper function of the body or prevent or treat Illness or Disease, unless the procedure is necessary to ameliorate a deformity arising from, or directly related to:

A congenital abnormality;
A personal injury resulting from an accident or trauma; or
A disfiguring disease.

Covered Charge is the actual charge for Medically Necessary and Appropriate treatment of Injury or Illness, not to exceed the Allowable Charge.

Covered Person is an Employee or Dependent who is covered under this Plan.

Creditable Coverage includes most health coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO membership, an individual health insurance policy, Medicaid or Medicare.

Creditable coverage does not include coverage consisting solely of dental or vision benefits.

Custodial Care is care (including room and board needed to provide that care) that is given principally for personal hygiene or for assistance in daily activities and can, according to generally accepted medical standards, be performed by persons who have no medical training. Examples of Custodial Care include help in walking and supervision over medication which could normally be self-administered.

Deductible is the dollar amount of eligible expenses that you are responsible for paying before you are eligible for benefits for most care. You must meet your deductible once each Calendar Year.

Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license.

Dependent means any of the following persons:

An Employee’s spouse, unless legally separated or divorced, that does not have Employer-sponsored coverage available to them;
An Employee’s children from birth up to age 26, including natural children, legally adopted children, stepchildren and children placed in the Employee’s physical custody for the purpose of adoption; or
A covered Dependent child, regardless of age, who is mentally or physically handicapped and classified as disabled before the limiting age of 26.

These persons are excluded as Dependents:

The legally separated or divorced former spouse of the Employee;
Any person who is on active duty in any military service or any country; or
Any person who is eligible for coverage under the Plan as an Employee.

If husband and wife are both covered as Employees under the Plan, their children will be covered as Dependents of the husband or the wife, but not both.

Dialysis is the process by which toxic substances are removed from the blood artificially when kidney function has failed.

Drug Abuse (see Substance Abuse, page 30).

Durable Medical Equipment means equipment which:

a) Can withstand repeated use;

b) Is primarily and customarily used to serve a medical purpose;

c) Generally, is not useful to a person in the absence of an Illness/Injury; and

d) Is appropriate for use in the home.

Eligible Employee means a member of one of the following classes of Employees:

Regular full-time Employees scheduled to work a minimum of 30 hours per week on a regular basis; or
Eligible retirees who qualify for benefits from either the Public-School Retirement System of MO or the Public Education Employee Retirement System of MO.

For those Employees not actively meeting the above criteria, an Eligible Employee also includes any Employee on vacation, sick leave, extended sick leave, FMLA leave, short-term or long-term disability leave (with or without pay), COBRA, and any other person designated as an Eligible Employee by the Employer’s Human Resource department.

Emergency Condition means health services provided in a hospital emergency facility or comparable facility to evaluate and stabilize a medical condition of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the person’s condition, sickness or injury is of such a nature that failure to get immediate medical care could result in placing the person’s health in serious jeopardy, serious impairment to bodily functions, serious dysfunction of a bodily organ or part, serious disfigurement or in the case of a pregnant woman, serious jeopardy to the health of the fetus.

Employer is the Webb City R-VII School District.

Enrollment Date means the actual date of enrollment, or if earlier, the first day of the waiting period for enrollment.

Experimental and/or Investigational means services, supplies, care and treatment which do not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of care of a reasonably substantial, qualified, responsible, relevant segment of the medical and dental community or government oversight agencies at the time services were rendered.

The Plan Administrator must make an independent evaluation of the Experimental/Non-experimental standings of specific technologies. The Plan Administrator shall be guided by a reasonable interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim and the proposed treatment. The decision of the Plan Administrator will be guided by the following principles:

(1) If the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished; or

(2) If the drug, device, medical treatment or procedure, or the Patient informed consent document utilized with the drug, device, treatment or procedure, was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, or if federal law requires such review or approval; or

(3) If Reliable Evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I or phase II clinical trials, is the research, experimental study or Investigational arm of on-going phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or

(4) If Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis.

Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved by the Food and Drug Administration for general use.

Family Unit is the covered Employee and the family members who are covered as Dependents under the Plan.

FMLA shall mean the Family Medical Leave Act of 1993, as amended. FMLA Leave shall mean a leave of absence, which the company is required to extend to an Employee under the provisions of FMLA.

Full-Time Student means one who is attending classes at an accredited college, university or technical school with a regular teaching staff, curriculum, and student body. Attendance must be full-time. Full-time is considered to be the number of credits or courses required for full-time students as determined by the school.

Generally Accepted means that the treatment of service:

Has been accepted as the standard of practice according to the prevailing opinion among experts as shown by (or in) articles published in authoritative, peer-reviewed medical and scientific literature; and
Is in general use in the medical community; and
Is not under continued scientific testing or research as a therapy for the particular Injury or Sickness which is the subject of the claim.

Generic Drug means a Prescription Drug which has the equivalency of the brand name drug with the same use and metabolic disintegration. This Plan will consider as a Generic Drug any Food and Drug Administration approved generic pharmaceutical dispensed according to the professional standards of a licensed pharmacist and clearly designated by the pharmacist as being generic.

Genetic Information means information about genes, gene products and inherited characteristics that may derive from an individual or family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes.

HIPAA shall mean the Health Insurance Portability and Accountability Act of 1996, as amended.

Home Health Care Agency is an organization that meets all of these tests:

Its main function is to provide Home Health Care Services and Supplies;
It is federally certified as a Home Health Care Agency; and
It is licensed by the state in which it is located if licensing is required.

Home Health Care Plan must meet these tests:

It must be a formal written Plan made by the Patient’s attending Physician which is reviewed at least every 30 days; and
It must state the diagnosis; and
It must certify that the Home Health care is in place of Hospital confinement;
It must specify the type and extent of Home Health Care required for the treatment of the Patient.

Home Health Care Services and Supplies include: part-time or intermittent nursing care by or under the supervision of a registered nurse (R.N.); part-time or intermittent home health aide services provided through a Home Health Care Agency (this does not include general housekeeping services); physical, occupational and speech therapy; medical supplies; and laboratory services by or on behalf of the Hospital.

Hospice Agency is an organization where its main function is to provide Hospice Care Services and Supplies and it is licensed by the state in which it is located if licensing is required.

Hospice Care Plan is a Plan of terminal Patient care that is established and conducted by a Hospice Agency and supervised by a Physician.

Hospice Care Services and Supplies are those provided through a Hospice Agency and under a Hospice Care Plan and include inpatient care in a Hospice Unit or other licensed facility, home care, and family counseling during the bereavement period.

Hospice Care Team means a group that provides coordinated Hospice Care Services and normally includes a Physician, a patient care coordinator (Physician or nurse who serves as an intermediary between the program and the attending Physician), a nurse, a mental health specialist, a social worker, a chaplain and lay volunteers.

Hospice Unit is a facility or separate Hospital Unit that provides treatment under a Hospice Care Plan and admits at least two unrelated persons who are expected to die within six months.

Hospital is an institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient’s expense and which fully meets these tests: it is accredited as a Hospital by the Joint Commission on Accreditation of Healthcare Organizations; it is approved by Medicare as a Hospital; it maintains diagnostic and therapeutic facilities on the premises for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of Physicians; it continuously provides on the premises 24-hour-a-day nursing services by or under the supervision of registered nurses (R.N.’s); and it is operated continuously with organized facilities for operative surgery on the premises.

The definition of “Hospital” shall be expanded to include the following:

- A facility operating legally as a psychiatric Hospital or residential treatment facility for mental health and licensed as such by the state in which the facility operates; and

- A facility operating primarily for the treatment of Substance Abuse if it meets these tests: maintains permanent and full-time facilities for bed care and full-time confinement of at least 15 resident patients; has a Physician in regular attendance; continuously provides 24-hour a day nursing service by a registered nurse (R.N.); has a full-time psychiatrist or psychologist on the staff; and is primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Substance Abuse.

Illness means a bodily disorder, Disease, physical Sickness or Mental Disorder. Illness includes pregnancy, childbirth, miscarriage or complications of pregnancy.

Injury means an accidental physical Injury to the body caused by unexpected external means.

Inpatient means treatment in an approved facility during the period when charges are made for room and board or the length of stay exceeds 24 hours.

Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within a Hospital solely for the care and treatment of Patients who are critically ill. This also includes what is referred to as a “coronary care unit” or an “acute care unit.” It has: facilities for special nursing care not available in regular rooms and wards of the Hospital; special life saving equipment which is immediately available at all time; at least two beds for the accommodation of the critically ill; and at least one registered nurse (R.N.) in continuous and constant attendance 24 hours a day.

Investigational means care that has not been proven conclusively to be beneficial, based on available medical information. Investigational care is not covered by the Plan.

Legal Guardian is a person recognized by a court of law as having the duty of taking care of and managing the property and rights of a Dependent.

Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations. Lifetime is understood to mean while covered under this Plan. Under no circumstances does Lifetime mean during the lifetime of the Covered Person.

Managed Care Provisions is the part of your program that is designed to encourage appropriate use of benefits. Managed Care examples include Case Management, Pre-Certification and Re-certification.

Medical Care Facility means a Hospital or a facility that treats one or more specific ailments or any type of Skilled Nursing facility.

Medical Emergency means a sudden onset of a condition with acute symptoms requiring immediate medical care and includes such conditions as heart attacks, cerebral vascular accidents, poisonings, loss of consciousness or respiration, convulsions or other such acute life or limb threatening medical conditions.

Medically Necessary and Appropriate means only those services, treatments, or supplies provided by a Hospital, Physician or other qualified Provider of medical services or supplies that are required to treat an Injury or Sickness and which:

a) Are consistent with the symptoms and treatment of the individual’s condition, disease, ailment or Injury;

b) Are appropriate according the standards of good medical practice;

c) Represent the most appropriate level of care, meaning the frequency of services, the duration of services, and the site of services (Hospital or Physician’s office);

d) Are not solely for the convenience of the individual, Physician or Hospital; and

e) Are not experimental or investigative.

All of these criteria must be met; merely because a Physician recommends or approves certain care does not mean that it is Medically Necessary and Appropriate.

The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary and Appropriate.

Medicare is the Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act, as amended.

Mental Disorder means any Disease or condition, regardless of whether the cause is organic, that is classified as a Mental Disorder in the current edition of International Classification of Diseases, published by the US. Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.

Morbid Obesity is a diagnosed condition in which the body weight exceeds the recommended weight by either 100 pounds or is twice the medically recommended weight for a person the same height, age, bone structure and mobility as the Covered Person and conventional weight reduction measures have failed and the excess weight is causing or has caused a medical condition such as physical trauma, pulmonary and circulatory insufficiency, diabetes or heart disease.

Multiple Surgical Procedure means the appropriateness of a bill for multiple surgical procedures must be clearly documented before a payment allowance is determined. The allowance for documented multiple surgical procedures, whether related or not, is 100% of the prevailing fee for the greater procedure and 50% for each lesser procedure during the same operative session.

Exceptions to the Multiple Procedure Rule: The following lists situations where exceptions to the multiple procedure rule would be appropriate.

Fractures: When reduction (or treatment) of one or more separate and distinct fractures takes place (such as an arm or leg), 100% of the prevailing fee is allowable for each fracture; and
More than One Surgeon: When the skills of two or more Physicians are required and each surgeon performs a separate operation (e.g., a procedure is performed by a thoracic surgeon and fracture care is provided by an orthopedic surgeon), the allowance is 100% of the prevailing fee for each procedure, provided each Physician bills separately for the procedure he performed. This applies even though both procedures were performed at the same operative session.

This is a partial guideline. The complete guideline as established by Trilogy and PointC. will be taken into account when determining benefits.

Network Provider is any Provider having a contractual relationship with the Plan, at the time treatment, care, services or supplies are provided. This will include any Provider that negotiates with PointC. before or after services are rendered. PointC negotiations will always be paid at the PPO level of benefits. A Network Provider may also include any Provider who is contracted with one of PoincC’s national wrap-around PPO’s, if allowed by the Plan.

No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.

Nurse is a licensed registered nurse or a licensed practical nurse.

Office Visit means the evaluation and management of a new or established Patient to acquire past medical history, examination and medical decision making for treatment of Sickness or Injury. Laboratory, X-ray or surgical procedures are not included.

Out-of-Network Provider is any Provider not meeting the Plan definition of an In-Network Provider at the time treatment, care, services or supplies are provided.

Outpatient Care and/or Services is treatment including services, supplies and medicines provided and used at a Hospital under the direction of a Physician by a person not admitted as a registered bed Patient; or services rendered in a Physician’s office, laboratory or x-ray facility, an Ambulatory Surgical Center, or the Patient’s home.

Pharmacy means a licensed establishment where covered Prescription Drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices.

Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor, Licensed Professional Physical Therapist, Midwife, Occupational Therapist, Optometrist (O.D.), Physiotherapist, Psychiatrist, Psychologist (Ph.D.), Speech Language Pathologist and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license.

Plan means the Employer’s Employee Health Care Plan, which is a benefits plan for certain Employees as described in this Document.

Plan Administrator is the person in your group who is primarily responsible for handling your benefits program.

Plan Participant is any Employee or Dependent who is covered under this Plan.

Plan Year is the 12-month period beginning on either the effective date of the Plan or on the day following the end of the first Plan Year which is a short Plan Year.

Pre-Certification or Certification is a term for obtaining authorization to receive care. If you do not obtain certification when required, your benefits will be reduced.

Pregnancy is childbirth and conditions associated with being pregnant, including complications.

Prescription Drug means any of the following: a Food and Drug Administration-approved drug or medicine which, under federal law, is required to bear the legend: “Caution: federal law prohibits dispensing without prescription”. Also covered are injectable insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed Physician. Such drug must be Medically Necessary in the treatment of a Sickness or Injury.

Second Surgical Opinion is the written opinion of a qualified Provider, based on his or her physical examination of a Patient, for the purpose of determining that Patient’s need for surgery or another procedure, but only if the Provider:

Is a board-certified specialist in the condition for which the procedure is proposed or has been referred to you (or your Dependent) by a local medical society; and
Does not perform or assist with the procedure if it is performed; and
Does not have any business or financial association with the qualified Provider performing the procedure if it is performed.

Sickness is:

(1) For a covered Employee and covered Spouse: Illness, Disease or Pregnancy;

(2) For a covered Dependent other than Spouse: Illness or Disease, not including Pregnancy or its complications.

Skilled Nursing Facility is a facility that fully meets all of these tests:

(1) It is licensed to provide professional nursing services on an inpatient basis to persons convalescing from Injury or Sickness. The service must be rendered by a registered nurse (R.N.) or by a licensed practical nurse (L.P.N.) under the direction of a registered nurse. Services to help restore patients to self-care in essential daily living activities must be provided; and

(2) Its services are provided for compensation and under the full-time supervision of a Physician; and

(3) It provides 24-hour-per-day nursing services by licensed nurses, under the direction of a full-time registered nurse; and

(4) It maintains a complete medical record on each Patient; and

(5) It has an effective utilization review Plan; and

(6) It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mental retardates, custodial or educational care or care of Mental Disorders; and

(7) It is approved and licensed by Medicare.

This term also applies to charges incurred in a facility referring to itself as an extended care facility, convalescent nursing home, rehabilitation Hospital or any other similar nomenclature.

Covered Persons must meet ALL of the following criteria before Skilled Nursing Facility benefits are considered:

A Physician’s order for skilled services with documentation of Medical Necessity for the treatment of Illness or Injury. This includes the treatment being consistent with the nature and severity of the Illness or Injury, and consistent with accepted standards of medical practice;
Expectation for significant reportable improvement within a predictable amount of time;
Services must not be possible on an outpatient basis. Examples include, but are not limited to the following:
1. Intramuscular or intravenous injections, infusions, initiation of and training for the care of newly placed tracheostomies, complex wound care involving medication application and sterile technique of Grade 3 or higher decubitus ulcers or widespread skin disorders and complex respiratory care, including frequent suctioning.

4) Restorative Therapy: when the patient’s condition prohibits outpatient therapy, the Plan will cover services designed to restore levels of function that had previously existed but that have been lost as a result of Injury or Sickness. Restorative Therapy services do not include therapy designed to acquire levels of function that had not been previously achieved prior to the Injury or Sickness.

Speech Therapy means therapy administered by a licensed speech therapist. Therapy must be ordered by a Physician and follow either; (i) surgery for correction of a congenital condition of the oral cavity, throat or nasal complex (other than a frenectomy) of a Covered Person; (ii) an Injury; or (iii) a Sickness that is other than a learning or Mental Disorder. For example, cerebral vascular accident (stroke), cerebral tumor, or laryngectomy. Speech therapy for speech delay is excluded by the Plan.

Spinal Manipulation/Chiropractic Care means skeletal adjustments, manipulation or other treatment in connection with the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human body. Such treatment is done by a Physician to remove nerve interference resulting from, or related to, distortion, misalignment or subluxation of, or in, the vertebral column.

Standard of Care is how similarly qualified practitioners, in the same geographical area, would have managed the Patient’s care under the same or similar circumstances.

Substance Abuse is regular excessive compulsive drinking of alcohol and/or physical habitual dependence on drugs. This does not include dependence on tobacco and ordinary caffeine-containing drinks.

Temporomandibular Joint (TMJ) Syndrome is the treatment of jaw joint disorders including conditions of structures linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the temporomandibular joint. Care and treatment shall include, but are not limited to orthodontics, crowns, inlays, physical therapy and any appliance that is attached to or rests on the teeth.

Total Disability (Totally Disabled) means in the case of an Active Employee, the complete inability to perform, because of Injury or Sickness, any and every duty of his or her occupation or employment. In the case of a Dependent or Retired Employee, it means the complete inability to perform the normal activities of a person of like age and sex in good health.

Usual and Reasonable Charge pertains to the amount that the health Plan will recognize for payment. PointC. will take into consideration amounts charged by health care Providers for similar services and supplies when provided in the same general area. PointC. will also consider Provider cost of goods. Usual and Reasonable is not to be interpreted as the fee schedule or PPO allowable. Usual and Reasonable limits may be applied to In-Network or PPO Providers. PointC. has the discretionary authority to decide whether a charge is Usual and Reasonable.

ADMINISTRATION

PLAN ENROLLMENT AND MEMBERSHIP

Eligibility for Plan Membership

An individual is eligible for coverage under the Plan if that individual is a regular full-time Employee scheduled to work a minimum of 30 hours a week on a regular basis, or an eligible retiree who qualifies for benefits from either the Public-School Retirement System of MO or the Public Education Employee Retirement System of MO.

Open Enrollment

The Plan will allow non-covered full-time Employees and Dependents to enroll during the month of December. Coverage will be effective on the following January 1^st.

New Members First Enrollment Period

An individual must complete an enrollment application form, furnished by the Employer, within 31 days from the date of eligibility for coverage. This requirement applies whether the individual is an eligible Employee or a Dependent. Once the application is received, coverage will begin on the first day of the month following 28 days of regular active employment.

Family Coverage

Family coverage includes you, your spouse and any Dependent children who qualify as a Dependent up to age 26. Effective October 1, 2015, spouses are not eligible for coverage if they have other Employer-sponsored coverage available. Disabled Dependent children may be covered regardless of age if classified as disabled before the limiting age of 26. A stepchild or legally adopted child may also be covered. To become and remain covered, proof that the Participant’s child continues to qualify as a Dependent must be furnished to PointC. as it reasonably asks. There shall be no coverage after attaining age 26 unless qualified under other sections of the Plan.

Pursuant to Missouri SB 264, any eligible Dependent of a deceased, Active or Retired Employee may elect to continue coverage if the survivor is eligible for a retirement benefit, elects the group coverage, and pays any required Plan contributions in a timely manner.

QMCSO Provision. This Plan will provide benefits to the child(ren) of a Participant if a Qualified Medical Child Support Order (QMCSO) is issued regardless of whether the child(ren) reside with the Participant. If a QMCSO is issued, then the child(ren) shall become alternative recipient(s) of the benefits under this Plan, subject to the same limitations, restrictions, provisions and procedures as any other Participant. A properly completed National Medical Support Notice (NMSN) will be treated as a QMCSO and will have the same force and effect.

Procedural QMCSO Requirements. Within a reasonable period of time following receipt of a medical child support order, the Plan Administrator will notify the Participant and each child specified in the order whether the order is or is not a Qualified Medical Child Support Order. A QMCSO is an order which creates or recognizes the right of an alternate recipient (Participant’s child who is recognized under the order as having a right to be enrolled under this Plan) or assigns to the alternate recipient the right to receive benefits. To be considered a Qualified Medical Child Support Order, the medical child support order must contain the following information:

The name and last known mailing address of the Participant and the name and address of each child to be covered by this Plan;
A reasonable description of the type of coverage to be provided by this Plan to each named child, or the manner in which the type of coverage is to be determined; and
The period to which such order applies.

If the order is determined to be a Qualified Medical Child Support Order, each named child will be covered by this Plan in the same manner as any other Dependent child is covered by this Plan.

Coverage for a child under a QMCSO will begin on the latest of the following dates:

If the Employee already has coverage in force, the child will be covered as of the date the QMCSO is received;
If the Employee already has coverage in force, the child will be covered as of the date specified by the QMCSO;

3) If the Employee is within the waiting period as specified under the section entitled “Effective Date” the child will become effective the same date the Employee’s coverage is effective; or

If the Employee is otherwise eligible but previously waived coverage, the Employee’s and the child’s coverage will become effective as of the date specified in (1) or (2) above.

Each named child will be considered a Participant under this Plan but may designate another person, such as a custodial parent or legal guardian, to receive copies of explanations of benefits, checks and other material which would otherwise be sent directly to the named child.

If it is determined that the order is not a Qualified Medical Child Support Order, each named child may appeal that decision by submitting a written letter of appeal to the Plan Administrator. The Plan Administrator shall review the appeal and reply in writing within thirty (30) days of receipt of the appeal.

This Plan will not provide any type or form of benefit, or any option, not otherwise provided under this Plan, and all other Dependent eligibility, Enrollment Date and termination provisions will apply.

TERMINATION OF COVERAGE

Termination of Plan Membership

A Plan member’s coverage shall terminate on the date they fail to qualify as an eligible Employee or Dependent.

If coverage terminates because of one of the reasons outlined in this paragraph, the Plan member may continue coverage and that of his/her Dependents for a limited time, (See COBRA Rights). Coverage under this Plan will terminate at 12:00 midnight on the day whichever of the following events occurs first:

The last day of the month in which the member ceases employment in an eligible class;
The date that any contribution required by the Plan member or a qualified beneficiary is due and unpaid; coverage is terminated on the paid-to-date;
The date the Plan is terminated;
The date the Plan member enters the armed forces on active duty;
The date a Dependent child turns 26; or
A Plan member may elect to terminate coverage on an annual basis. Written notification must be received 30 days prior to the end of the Plan year.

COBRA Rights - Continuation of Coverage

If an Employee or Dependent would lose coverage under the Plan as a result of one of the following, the individual losing coverage may elect to continue their coverage under the provisions of COBRA.

The COBRA qualifying events are:

(1) The death of an Employee;

The Employee’s termination of employment (for reasons other than gross misconduct);
A reduction in the Employee’s hours of employment below 20 per week as defined in Missouri retirement guidelines;

The Employee’s entitlement to Medicare;
A divorce or legal separation from an Employee; or
A child’s ceasing to be eligible under the terms of the Plan.

It is the obligation of the Employee to notify the Employer within 60 days of any divorce, legal separation or child’s ceasing to be eligible under the Plan. It is also the responsibility of the Employee to notify the Plan Administrator of any changes in marital status or address. If notice is not received within 60 days of a qualifying event, the provisions of COBRA do not apply.

Maximum Coverage Periods. If the Employee chooses continuation coverage, the Employer is required to give the Employee coverage which, as of the time coverage is being provided, is identical to the coverage provided under the Plan to similarly situated Employees or family members. The law requires that the Employee be afforded the opportunity to maintain continuation coverage for a period of 18 months. This 18-month period may be extended to 36 months if other events (such as death, divorce, legal separation, or Medicare entitlement) occur during the 18-month period.

Multiple Qualifying Events: If COBRA coverage is elected following a Employee’s termination of employment or reduction in work hours, and the another qualifying event occurs during the 18 month continuation period, that Employee’s Dependents may continue their coverage for up to 36 months, rather than 18 by adding an additional 18 months to the original 18 month period.

Social Security Disability: Special rules for disabled individuals may extend the maximum periods of coverage. If a qualified beneficiary is determined under Title II or XVI of the Social Security Act to have been disabled at the time of termination of employment or reduction in employment hours and the qualified beneficiary notifies the Plan Administrator of the disability determination, the 18-month period is expanded to 29 months. Notification must occur within 60 days of the COBRA coverage effective date.

If the beneficiary is deemed disabled during the 18-month COBRA period, the entitlement date for Social Security disability benefits must occur within the first 60 days of COBRA coverage. Disabled beneficiaries must notify the Plan Administrator of Social Security disability determinations within 60 days of the date listed on the determination letter, and notification must occur prior to expiration of the 18-month period of COBRA coverage. These beneficiaries must also notify the Plan Administrator within 30 days of a final determination that they are no longer disabled.

Termination of COBRA Coverage: COBRA coverage for any individual will be automatically terminated upon the occurrence of any of the following events:

The premium for continuation coverage is not paid on time;
The COBRA member becomes covered by another group Plan that contains no exclusion or limitation of benefits for any Pre-Existing condition or whose Pre-Existing condition limitation or exclusion does not apply to the member due to the requirements of the Health Insurance Portability and Accountability Act of 1996;
The COBRA member becomes entitled to Medicare;
The Employer no longer provides group health coverage to any of its Employees.

Coverage of Newborn or Newly Adopted Children: A child who is born to, adopted by or placed with a COBRA member is also eligible for coverage. That subsequent qualifying event provides the child with independent coverage eligibility up to 36 months beginning on the date of the Employee’s original qualifying event.

Cost and Coverage: The monthly charge for COBRA coverage will be determined by the Plan Administrator. For disabled beneficiaries receiving an additional 11 months of coverage after the initial 18 months, the premium for those additional months may be increased. Premiums due may be increased if the costs to the Plan increases.

The initial premium payment must be made within 45 days after the date of the COBRA election by the qualified beneficiary. Payment generally must cover the period of coverage from the date of COBRA election retroactive to the date of the qualifying event. Premiums for successive periods of coverage are due on the date stated in the Plan with a minimum 30-day grace period for payments.

Specific Notice

A qualified beneficiary must notify the Plan Administrator within 60 days after events such as divorce or legal separation or a child’s ceasing to be a covered as a Dependent under Plan rules.

Certificate of Group Health Plan Coverage

Under 1996 HIPAA regulations, the Plan will provide the terminating member a certificate of group health Plan coverage. This certificate may be necessary for enrolling in a new Plan or in buying insurance. Ask your Plan Administrator for details.

Continuation of Coverage Under FMLA

Continuation of Coverage Under FMLAIf you take a period of leave authorized by the Family and Medical Leave Act (FMLA Leave), you may continue coverage for yourself and your covered Dependents under the Plan during your period of FMLA Leave by making the same contributions you would have made had you continued your employment and participation in the Plan.

If you are entitled to a period of FMLA Leave or are on such Leave, and you inform your Employer that you do not intend to return to active employment, you will have no right to continue coverage under the FMLA provisions. You may have a right to continue coverage under the COBRA provisions described above.

Payment for Coverage:

Paid Leave: If you are on a period of leave that is paid leave, your contributions will be made in the same manner that they would have been made had you continued your employment and participation in the Plan.

Unpaid FMLA Leave: If your FMLA Leave is unpaid, you must make your contributions no later than the time they would have been made had you not taken FMLA Leave but had instead continued your employment and participation in the Plan.
Termination of Coverage: If you are entitled to a period of FMLA Leave, you may elect not to continue your coverage. In that case, all coverage will terminate on the last day of the month for which you pay contributions. However, if you elect to continue coverage during a period of FMLA Leave, your Employee and Dependent coverage will continue until the earliest of:

(1) The date you fail to return to work, following your period of FMLA Leave, after your employment is thereby terminated;

(2) The date you exhaust your entire FMLA Leave;

(3) The 30^th day following the date your contribution was due and unpaid; or

(4) The date the Plan terminates.

Restoration of Coverage: If you are on FMLA Leave and do not continue or fail to pay for your coverage, you and your Dependents are entitled to reinstatement of coverage under the Plan upon your return from FMLA Leave.

Need to Repay Employer Contributions: If you began a period of FMLA Leave and continued coverage under this Plan, and you fail to return to work for at least 30 calendar days, your Employer will have the right to recover the contributions made by the Employer during your leave.

Exception to Repayment Rule: The Employer will not have a right to recover its contributions if you fail to return from FMLA Leave due to a condition that would entitle you to a period of FMLA Leave or other circumstances beyond your control.

Special Rules for Key Employees: If you meet the definition of a Key Employee under the government regulations, special rules apply. If you are entitled to FMLA Leave and the Employer informs you that it does not intend to restore you to your job at the end of your leave because doing so would cause grievous economic Injury to the Employer’s operations, and if you do not, within 30 days after receiving that notice, return to work for the Employer, your coverage will continue until the earliest of:

(a) The date you give notice to your Employer that you no longer wish to return to work;

(b) The date the Employer denies your reinstatement to employment at the end of your FMLA Leave;

(d) The date the Plan terminates.

Need to Repay Employer Contributions: This provision does not apply to Key Employees and their Dependents if the Employer denies employment reinstatement.

Reinstatement of Medical Coverage After Military Leave

In accordance with the Uniformed Services Employment and Re-employment Rights Act of 1994 (USERRA), when your coverage ends because you enter into active service in the United States Armed Forces, you may again be covered if:

You return to active full-time employment with your Employer, and;
You make a written request for reinstatement to the Plan Administrator within:

90 days of your discharge from active service; or

one year following hospitalization which continues after your discharge from active service.

The coverage provided will be the same coverage provided by your Employer to other Employees and Dependents at the time of application. Your coverage will start on the date the Plan receives your request for reinstatement. If you had completed all or part of an exclusionary or waiting period under the Plan before your entry into active military service, you will not be required to complete that period a second time.

Each of your Dependents who were covered under this Plan immediately prior to your entry into active military service will also be reinstated for coverage on the date your coverage begins again, if otherwise eligible. Eligible Dependents born during the period of active military duty will have the same rights as other Dependents under this Plan. No payment will be made for any care or treatment given for an Injury, Illness, or physical or mental condition arising during and occurring as a direct result of your active service in the United States Armed Forces, as determined by the Secretary of Veterans Affairs.

CLAIMS PROCESSING

Filing a Claim

All Participants are required to submit at least one signed claim form each Plan year in order to receive benefits. All claims to be filed or inquiries regarding such claims should be directed to PointC., P.O. Box 25217, Overland Park, Ks. 66225. All claims must be received in the office of PointC. within one year from the date of service to be eligible for coverage under the Plan.

Appeal Procedure

If a claim dispute cannot be resolved with the claims office, a disputed claim review and appeal procedure can be requested.

First Appeal - The first review will begin by a request from the Plan member in writing. The request for a review must be submitted to the Plan within 60 days after the date of the claim office’s benefit and payment determination. The request, addressed to the Claims Supervisor at PointC., should include the Patient’s name and the name of the covered Employee. Only the covered Plan member or Dependent can file an appeal. Please include all the reasons for requesting a review, stating as specifically as possible why it is believed the denial is incorrect. Any supplemental materials, including additional medical information, should also be submitted. PointC.’s determination will be rendered as soon as possible, but no later than 60 days, or no later than 120 days for special circumstances, after receipt of the request for review. The determination will be sent directly to the Plan member. The determination will reference the particular Plan provision(s) and facts upon which it is based.

Urgent Claim - within 72 hours from receipt of the appeal. There can only be one

level of appeal.

Pre-Service Claim - within 15 days from receipt of the appeal.

Post-Service Claim - within 30 days from receipt of the appeal.

Final Appeal - If the decision of PointC. is unsatisfactory, a written request for a final appeal may be submitted by the Plan member to the office of the Plan Administrator or at the office of PointC. The request must be received within 60 days after the date of the first appeal decision. If there is any supplemental material, which has not been previously submitted, it must be submitted along with the notice of appeal. The Plan Administrator will render a determination within 120 days, and any decision shall be considered final.

Pre-Service Claim - within 15 days from receipt of the second appeal.

Post-Service Claim - within 30 days from receipt of the second appeal.

COORDINATION OF BENEFITS & SUBROGATION

Definitions. For purposes of this section, the following definitions shall apply:

“Plan” refers to any entity that provides benefits or services for those items which are listed as covered Medical Benefits under this Plan and not otherwise excluded from coverage, including but not limited to:

group, blanket or franchise insurance coverage;
group Blue Cross/Blue Shield, service Plan contracts, group practice, individual practice and any other prepayment coverage;
any coverage under labor-management trusteed Plans, union welfare Plans, Employer organization Plans, Employee benefit organization Plans or any other arrangement of benefits for individuals of a group;
any coverage under governmental programs and any coverage required or provided by any federal or state statute; and
any individual or family insurance policy or contract or arrangement, excluding only one which provides solely medical benefits, including, but not limited to, automobile accident, no fault or liability insurance.

The term “Plan” shall be construed separately with respect to each policy, contract or other arrangement for benefits or services, and also separately with respect to that portion of any such policy, contract or other arrangement that reserves the right to take the benefits or services of other Plans into consideration in determining benefits and that portion which does not.

“Primary Plan” refers to a Plan whose benefits are to be determined before the benefits of another Plan, in accordance with the provisions of this section.

“Secondary Plan” refers to a Plan whose benefits are to be determined after benefits of another Plan, in accordance with the provisions of this section.

Coordination of Benefits

Coordination of Benefits (COB) means that the benefits provided by the Plan will be coordinated with the benefits provided by any other Plans covering the person for whom a claim is made. If the Plan is a secondary Plan, the benefits payable under the Plan may be reduced, so that a Covered Person's total payment from all Plans will not exceed 100% of the amount this Plan would have paid in the absence of the other Plan. Benefits will not be coordinated within the Plan for Employees and Dependents who work for the company.

Order of Benefit Determination. For purposes of Coordination of Benefits, the rules establishing the order of benefit determination are as follows:

(a) A Plan that covers a person other than as a Dependent will be primary to a Plan that covers such person as a Dependent; and

A Plan that covers a person as a Dependent of an Employee whose date of birth occurs earlier in a Calendar Year will be primary to a Plan that covers such person as a Dependent of an Employee whose date of birth occurs later in a Calendar Year.
In the case of a Dependent child whose parents are separated or divorced:

(1) When the parent with custody of the child has not remarried, the Plan that covers the child as a Dependent of the parent with custody will be primary to the Plan that covers the child as a Dependent of the parent without custody; and

(2) When the parent with custody of the child has remarried, the Plan that covers the child as a Dependent of the parent with custody will be primary to the Plan that covers the child as a stepparent, and the Plan that covers the child as a Dependent of the stepparent will be primary to the Plan that covers the child as a Dependent of the parent without custody.

Notwithstanding the above, if there is a court decree which establishes financial responsibility for the medical expenses of the child, the Plan that covers the child as a Dependent of the parent with such responsibility will be primary to any other Plan that covers the child as a Dependent.

When the rules stated above do not determine an order of benefit determination, the Plan that has covered a person for the longer period of time will be primary, provided that the Plan that covers the person as a laid-off or retired Employee, or as a Dependent of such an Employee will be secondary to any Plan that covers such person as an active Employee or as a Dependent of such an Employee.

Payment to Other Organizations: Whenever payments that should have been made under this Plan, in accordance with the coordination of benefits provision, have been made under any other Plans, this Plan may pay to any entity making such other payments any amounts it shall determine to be warranted in order to satisfy the intent of these provisions. Amounts so paid shall be deemed to be benefits paid under this Plan, and to the extent of such payments, this Plan shall be fully discharged from liability.

Reimbursement. If at anytime the amount of benefits provided by this Plan exceed the maximum payment necessary to satisfy the intent of the coordination of benefits provisions, this Plan may recover any excess payments from any one or more of the following: (a) you; (b) if you are a Dependent, the Employee or Retiree whose Dependent you are; (c) any other Plan or person that has received payment; and (d) any other Plan that should have made payment.

Automobile Limitations. When medical payments are available under vehicle insurance, the Plan shall pay excess benefits only, without reimbursement for vehicle Plan deductibles. This Plan shall always be considered the secondary carrier regardless of the individual’s election under PIP (Personal Injury Protection) coverage with the auto carrier. Benefits shall be considered under the provisions of COB, prior to the provisions of subrogation.

Limitation. Benefit payment for covered services will be reduced by benefits that could be paid by Part A or Part B of Medicare. This will apply even if a Covered Person is eligible for Medicare but failed to enroll or maintain eligibility.

Third Party Liability. When medical payments are available under a third-party liability, the Plan shall pay excess benefits only without reimbursement for deductibles. This Plan shall always be considered the secondary carrier regardless of the Participant’s intent to pursue reimbursement from the third party. Benefits shall be considered under the provisions of COB prior to the provisions of subrogation.

Right to Receive and Release Necessary Information. In order to decide if this COB section (or any other Plan’s COB section) applies to a claim, the Administrator (without consent of or notice to any person) has the right to:

Release to any person, insurance company or organization, the necessary claim information; and
Receive from any person, insurance company or organization, the necessary claim information.

Any person claiming benefits under Contract must give information needed to coordinate those benefits.

Subrogation. It is the intent of the Plan to receive full recovery of all benefits considered to you or for a covered person under this Plan on any loss for which a third party is liable, regardless of the date of service or the date of settlement. This should be understood to include the right to offset any and all future claims. Such recovery will be available from any liable third party, including but not limited to:

The persons and entities, either individually or collectively, causing an injury, illness or other loss for which this Plan had or may provide benefits;
Third party insurance;
No-fault or Personal Injury Protection (“PIP”) insurance;
Financial responsibility or catastrophe funds mandated by motor vehicle or other state law;
Uninsured or motorist underinsured insurance;
Motor vehicle reimbursement insurance, regardless of whether or not it is purchased by you or the Dependents; or
Homeowner’s insurance and other premises insurance, including reimbursement coverage.

This Plan is not intended to provide the member with benefits greater than his or her medical expenses. If the Plan member is entitled to payment of his or her medical expenses by another person, plan or entity, whether they request payment or not, this Plan has the right to reduce its payments accordingly so that the plan member is not paid more than they actually owe for medical expenses. If the plan member has a right against any other person, firm, or organization for an injury or illness, or any complications thereof, the Plan has the right to subrogate all benefits considered, or that will be considered, by the Plan because of the illness or injury or any other complications thereof. If the Plan considers benefits which are the responsibility or liability of a third party, the Plan has the right to recover any benefits paid.

Once the Plan Supervisor determines that third party liability may be involved with a claim, if applicable, the plan participant will be asked to sign a subrogation and reimbursement agreement, protecting the Plan against any loss where other parties may be responsible. The Plan Supervisor must have received the signed subrogation agreement before any claims may be considered for payment. If a signed subrogation agreement is not received within 90-days after being provided by the Plan Supervisor, the claims will be denied and the Plan will have no future responsibility for consideration of payment.

If the covered person, or the legal representative, fails to cooperate in fulfilling the responsibilities set forth in this section, no further benefits will be considered under this Plan for charges incurred in connection with or resulting from the condition for which such loss is undergoing recovery proceedings.

The amount of this Plan’s subrogation interest will be deducted first and in full from a covered person’s recovery arising out of the Injury. Neither this Plan nor the Plan Administrator will be required to pay attorney fees or other costs incurred in connection with its recovery unless it consents in writing to make such payment.

For purposes of this provision, any recovery from a third party paid to the plan member by way of judgment, settlement, or otherwise to compensate for any losses, to include pain and suffering, will be deemed to be a recovery for medical, dental, vision and/or prescription drug expenses incurred to the extent of any actual loss due to injury, illness or disability involved, to include any complications thereof.

Once settlement is reached, we will require copies of all documents and/or settlement agreements. Benefits will then be adjudicated according to the rules of Coordination of Benefits.

Clerical Error

Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly terminated. An equitable adjustment of contributions will be made when the error or delay is discovered.

If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, the Plan retains a contractual right to the overpayment. The person or institution receiving the overpayment will be required to return the incorrect amount of money. In the case of a Plan Participant, if it is requested, the amount of overpayment will be deducted from the future benefits payable.

Notice of Privacy Policy

Your privacy is important to the Plan and the Webb City R-VII School District. We have adopted a Privacy Policy and will use our best efforts to ensure that your Private Health Information is protected. Our policy can be viewed or printed at the following website: www.pointchealth.com Click on the Privacy icon to access this policy.

PLAN INFORMATION

Name of Plan: Webb City R-VII School District

Employee Healthcare Plan

Type of Plan: Health & Welfare Plan

Sponsor: Webb City R-VII School District

Tax ID #: 44-6004739

Group #: 3300

Plan Administrator: Webb City R-VII School District

411 North Madison

Webb City, MO 64870

Plan Cost: Contributions to this Plan are made by the Employer and Employees and are based on the amount necessary to provide the Plan’s benefits.

Agent for Service

of Process: Webb City R-VII School District

Plan Benefit Year: January 1^st through December 31^st

Plan Fiscal Year: October 1^st through September 30^th

Plan Supervisor: PointC.

Post Office Box 25217

Overland Park, Ks. 66225

Telephone: (417) 782-1515

Toll Free: (888) 294-1515

Loss of Benefits: Participant must continue to be an eligible member of the class to which the Plan pertains to qualify for benefits.

Fiduciary Name: Webb City R-VII School District

Plan Amendment or Termination: Webb City R-VII School District has the right to amend, modify, or terminate the Plan benefits in any way at any time by written notification to Plan members from the Plan Administrator.

Plan Interpretations: All interpretations of the Plan and all questions concerning its administration and application, including eligibility determination, shall be determined by the Plan Supervisor and the Plan Administrator in its sole and absolute discretion. Such determination shall be final and binding on all persons. Benefits under this Plan will be paid only if the Plan Administrator decides in his discretion, that the Participant is entitled to them.

Executed by:

Dr. Brenten Byrd's Signature

Revised Date: January 1, 2026

This group health plan believes this is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (The Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that this group health 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 preventive health service without any cost sharing. However, grandfathered plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Administered By:

PointC.

P.O. Box 25217

Overland Park, KS. 66225-5217417-782-1515

About Our District

Curriculum

Agendas

Minutes

Policies

Regulations

Breakfast & Lunch Information

Menus

Health Forms

Branding Guide

Title 3

Online Registration

Virtual Instruction

Resources

Our Work

Events

WCSD Employee Health Care Plan

SUMMARY OF MEDICAL BENEFITS

DEDUCTIBLES, CO‑PAYS &CO‑INSURANCE

Health Insurance Handbook

WCSD Employee Health Care Plan

SUMMARY OF MEDICAL BENEFITS

DEDUCTIBLES, CO‑PAYS &CO‑INSURANCE