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ASSOCIATION HEALTH PLANS
2024 EVIDENCE OF COVERAGE
CONTACT INFORMATION
HOMETOWN HEALTH
ATTN: CUSTOMER SERVICE
10315 PROFESSIONAL CIRCLE
RENO, NEVADA 89521
MAIN
(775) 98
2-3232
TOLL FREE
(800) 336-0123
FAX (ATTENTION: CUSTOMER SERVICE)
(775) 982-3741
TTY (SPECIAL EQUIPMENT REQUIRED)
711
ESPAÑOL
(775) 982-3232
CUSTOMER_SERVICE@HOMETOWNHEALTH.COM
www.HometownHealth.com
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This Evidence of Coverage (EOC) describes health insurance policies provided by Hometown
Health Plan, Inc., and Hometown Health Providers Insurance Company, Inc.
Both Hometown Health Plan, Inc. and Hometown Health Providers Insurance Company, Inc.
are licensed by the State of Nevada to provide or arrange for the provision of health care services
on behalf of its members, and Renown Health.
Health Maintenance Organizations (HMO) and Exclusive Provider Organizations (EPO) health
plans are issued by Hometown Health Plan, Inc.. Additionally, Preferred Provider Organization
(PPO) health plans are issued by Hometown Health Providers Insurance Company, Inc.; both
organizations are referred to as Hometown Health (HTH) throughout this document.
This document includes benefits, exclusions, limitations, and applicable administrative policies,
rights, responsibilities, and procedures for HMO, EPO, and PPO health insurance policies. Refer
to your respective Schedule of Benefits (SOB) for Policy-specific Cost Sharing information not
described within this EOC. In case of conflicts between this EOC and your (SOB), this EOC
shall be the document that determines the benefits or interpretation of those documents.
Networks
Renown HMO Network
• The Renown HMO Network (in Northern Nevada) provides access to Renown Health for
Primary and Specialty Care in addition to Community Specialty Care providers. There is
no coverage for services outside the Network unless services are rendered as part of an
Emergency room visit or the member has previously been approved by HTH to be paid at
the HMO Benefit Level. You must select a PCP from the Renown Medical Group (RMG)
or an otherwise approved in-network Pediatrician or Geriatric Care Services provider
and are not required by Hometown Health to receive a referral prior to receiving
services for specialty care.
Clark & Nye Counties Network
• The Clark & Nye Counties Network (in Southern Nevada) provides access to providers
throughout Clark & Nye Counties for primary and specialty care.There is no coverage for
services outside the Network unless services are rendered as part of an Emergency room
visit or the member has previously been approved by HTH to be paid at the HMO Benefit
Level. You may select any PCP within the network and are not required by Hometown
Health to receive a referral prior to receiving services for specialty care.
Nevada EPO Network
• The Nevada EPO Network provides access to providers throughout the state of Nevada
for primary and specialty care. There is no coverage for services outside the Network
unless the services are rendered as part of an Emergency room visit or have been
previously approved by HTH to be paid at the EPO Benefit Level. You may select any
PCP within the network and are not required by Hometown Health to receive a referral
prior to receiving services for specialty care.
Hometown Health PPO Network
• HTH’s PPO Network, provides access to a large Network of In-Network Providers both
in the state of Nevada as well as close surrounding areas who have contracts with
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Hometown Health. Services from In-Network Providers will be paid at the In- Network
benefit level. Members may also seek services from Out-of-Network Providers at a
reduced benefit level (higher cost to the Member). You may select any PCP within the
network and are not required by Hometown Health to receive a referral prior to
receiving services for specialty care.
A directory of providers is available on Our website at www.hometownhealth.com/provider-
directories or by calling Hometown Health, Customer Service at
(775) 982-3232 or (800) 336-0123.
Prescription Drug Coverage. Members must utilize the HometownRx Signature Pharmacy
Network. This Policy does not cover drugs which are purchased from pharmacies that are not
part of the HometownRx Signature Pharmacy Network. Members must work with their doctors
to select drugs that are included in the HometownRx Standard Drug Formulary. This Policy does
not cover drugs which are not included in the HometownRx Standard Drug Formulary.
Geographic Service Area.
HMO plans
• This Policy is available only to employees (and their eligible dependents) who live in
Nevada and whose employer has a physical business location in Carson City, Douglas,
Lyon, Storey , orWashoe Counties for the Renown HMO Network and Clark and Nye
Counties for the Clark & Nye Counties Network. Additional eligibility requirements are
detailed in this EOC.
EPO plans
• This policy is available only to employees (and their eligible dependents) who live in
Nevada and whose employer has a physical business location in Carson City, Churchill,
Clark, Douglas, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye,
Pershing, Storey and Washoe Counties. Additional eligibility requirements are detailed in
the EOC.
PPO plans
• This policy is available only to employees (and their eligible dependents) who live in
Nevada and whose employer has a physical business location in Carson City, Churchill,
Clark, Douglas, Esmeralda, Eureka, Humboldt, Lander, Lincoln, Lyon, Mineral, Nye,
Pershing, Storey, and Washoe Counties. Additional eligibility requirements are detailed
in the EOC.
Minimum Essential Coverage. This Benefit Plan is considered Minimum Essential Coverage as
defined by the ACA, 26 U.S.C. § 5000A(f) and its implementing regulations. Subscribers
enrolled in this plan will receive an IRS Form 1095-B from Hometown Health. Form 1095-B is
used to report certain information to the IRS and to taxpayers about individuals who are covered
by Minimum Essential Coverage and therefore are not liable for the individual shared
responsibility payment for the months during which they are enrolled in this plan.
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Dependent Eligibility. Please contact Your employer to determine who in Your family may be
eligible for coverage under this plan. Your employer may choose to offer coverage to any of the
following groups as selected in the Group Subscription Agreement:
1.
Employees only
2.
Employees and children;
3.
Employees, spouses and children; or
4.
Employees, spouses, domestic partners and children.
If Your employer chooses to limit coverage of dependents, any provisions in this EOC that
discusses eligibility and coverage of dependents is limited to those categories of dependents (if
any) that are eligible for coverage, with the exception of eligible children who are always
covered within the first 31 days following birth, adoption or placement for adoption as described
in Chapter VII – Eligibility and Enrollment, Section A.
Ongoing Regulation. This EOC complies with the requirements of the Patient Protection and
Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, together
referred to as the Affordable Care Act (ACA), the Mental Health Parity and Addiction Equity
Act of 2008 and all other applicable state and federal insurance laws (including Nevada’s
Telehealth law), regulations and guidance effective on the date of publication of this Schedule of
Benefits and the EOC it supports. These laws, regulations and supporting guidance may change.
We will provide coverage under this Policy in accordance with these laws, regulations and
guidance as they are issued.
Your Documents. Copies of Your EOC, Schedule of Benefits, attachments, In-Network Provider
lists and other associated documents are available online at hometownhealth.com. We will
provide You with paper copies of these documents without charge upon Your request to Our
customer services department.
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2024 Health Plans
Renown HMO
• AHP Renown Battle Born Gold HMO
• AHP Renown Gold HMO
• AHP Renown Silver HMO Plus
• AHP Renown Silver HMO HSA
• AHP Renown Bronze HMO Plus
• AHP Renown Bronze HMO HSA
• AHP Renown Bronze HMO
Clark and Nye County
• AHP Renown Battle Born Gold CN HMO
• AHP Renown Gold CN HMO
• AHP Renown Silver CN HMO Plus
• AHP Renown Silver CN HMO HSA
• AHP Renown Bronze CN HMO Plus
• AHP Renown Bronze CN HMO HSA
• AHP Renown Bronze CN HMO
EPO
• AHP Hometown Battle Born Gold EPO
• AHP Hometown Gold EPO
• AHP Hometown Silver EPO Plus
• AHP Hometown Silver EPO HSA
• AHP Hometown Bronze EPO Plus
• AHP Hometown Bronze EPO HSA
• AHP Hometown Bronze EPO
PPO
• AHP Hometown Battle Born Gold PPO
• AHP Hometown Gold PPO
• AHP Hometown Silver PPO Plus
• AHP Hometown Silver PPO HSA
• AHP Hometown Bronze PPO Plus
• AHP Hometown Bronze PPO HSA
• AHP Hometown Bronze PPO
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TABLE OF CONTENTS
I.
NOTICE OF NONDISCRIMINATION ............................................................................................................. 9
II.
NOTICE OF PRIVACY PRACTICES ........................................................................................................... 10
III.
SCHEDULE OF BENEFITS ........................................................................................................................... 17
A.
PROFESSIONAL SERVICES ..................................................................................................................... 17
B.
HOSPITAL, SKILLED NURSING CARE, AND SERVICES IN AN OUTPATIENT SURGICAL
CENTER ............................................................................................................................................. 34
C.
EMERGENCY SERVICES ......................................................................................................................... 36
D.
URGENT CARE SERVICES ..................................................................................................................... 38
E.
BALANCE BILLING .................................................................................................................................. 38
F.
OTHER SERVICES AND SUPPLIES ........................................................................................................ 40
G.
CONTINUED COVERAGE FOLLOWING TERMINATION OF A PROVIDER CONTRACT ........... 44
H.
COVERED SERVICES UNDER THE PHARMACY BENEFIT .............................................................. 45
IV.
EXCLUSIONS AND LIMITATIONS ............................................................................................................. 51
A.
MEDICAL AND GENERAL EXCLUSIONS ............................................................................................ 51
B.
DRUGS (MEDICAL & PHARMACY) BENEFIT EXCLUSIONS ........................................................ 56
C.
OVERALL LIMITATIONS ........................................................................................................................ 60
V.
UTILIZATION MANAGEMENT PROGRAM ............................................................................................. 61
VI.
RELATIONSHIP OF PARTIES ...................................................................................................................... 66
VII.
ELIGIBILITY AND ENROLLMENT ............................................................................................................. 67
A.
WHO IS ELIGIBLE FOR COVERAGE? .............................................................................. 67
B.
WHEN CAN YOU ENROLL OR CHANGE COVERAGE? ..................................................... 70
C.
HOW DO YOU ENROLL IN COVERAGE? .......................................................................... 73
D.
OTHER IMPORTANT INFORMATION ................................................................................................... 74
VIII.
PRIMARY CARE AND SPECIALTY CARE PHYSICIANS ...................................................................... 75
IX.
INSURANCE PREMIUMS ............................................................................................................................. 77
X.
TERMINATION .............................................................................................................................................. 79
XI.
CONTINUATION OF COVERAGE .............................................................................................................. 82
XII.
DOUBLE COVERAGE................................................................................................................................... 86
XIII.
SUBROGATION / RIGHT TO REIMBURSEMENT .................................................................................... 87
XIV.
COORDINATION OF BENEFITS ................................................................................................................. 92
XV.
MEDICARE COORDINATION OF BENEFITS ........................................................................................... 96
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XVI.
MEMBER CLAIMS AND APPEAL PROCEDURES .................................................................................. 97
XVII.
GENERAL PROVISIONS ............................................................................................................................ 107
XVIII.
DEFINITIONS ............................................................................................................................................... 110
A.
GENERAL DEFINITIONS ....................................................................................................................... 110
B.
PHARMACY BENEFIT DEFINITIONS ................................................................................................. 118
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I. NOTICE OF NONDISCRIMINATION
Discrimination is Against the Law
Hometown Health complies with applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or sex. Hometown Health does not
exclude people or treat them differently because of race, color, national origin, age, disability, or
sex.
Hometown Health:
• Provides free aids and services to people with disabilities to communicate effectively
with Us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic
formats, other formats)
• Provides free language services to people whose primary language is not English, such
as:
o Qualified interpreters
o Information written in other languages
If You need these services, contact the Compliance Officer.
If You believe that Hometown Health has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, You can file a
grievance with: Compliance Officer, 10315 Professional Circle, Reno, NV, 89521, 800-611-
5097, (TTY: 1- 800-833-5833). You can file a grievance in person or by mail, fax, or email. If
You need help filing a grievance, the Compliance Officer is available to help You.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F,
HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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II. NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
If You have any questions about this notice, please contact Renown Health Corporate
Compliance/Privacy office at 775-982-8300.
AT A GLANCE
Who can Hometown Health disclose Your information to?
Without Your consent
• Doctors, nurses, and others involved in treating You. This
includes providers at other hospitals, clinics, and offices
who have a treatment relationship with You.
• To insurance companies unless You pay for Your visit in
its entirety out of pocket up front and request Your
insurance not be billed.
• For healthcare operations such as quality reviews, safety
and privacy investigations, or any other business need.
•
As required by law. Nevada and Federal regulations
require reporting of certain conditions, infections,
illnesses, acts of violence, and other situations.
Situations where You have
the opportunity to object
or opt-out
• With Your consent, Our staff may discuss limited
information with Your family and friends about Your
condition or treatment. If You are unable to consent, staff
will use Professional judgment on whether the disclosure
is in Your best interest.
• Hometown Health may disclose information about You
to the Renown Health Foundation for fundraising
purposes. You may opt out of this by calling 775-982-
8300 or by writing to the address below.
Who Will Follow This Notice
This notice describes the practices of Hometown Health. Hometown Health includes it employees,
Physician staff, trainees, volunteer groups, students, interns anyone authorized to enter information
into Your medical record, contracted employees, business associates and their employees, and
other health care personnel. For the purposes of this notice, the entities, will be referred to in this
notice as “Hometown Health.”
Our Pledge Regarding Your Health Information
We understand that medical information about You and Your health is personal. We are committed
to protecting Your health information, including personal financial information related to Your
healthcare. We create a record of Your benefits and eligibility status and claims history. We need
this record to provide You with quality healthcare benefits and to comply with certain legal
requirements. Hospitals, Physicians and other healthcare providers providing healthcare services
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to Hometown Health members may have different policies or notices regarding their uses and
disclosures of Your medical information.
This notice will tell You how We use and disclose health information about You. We also tell You
about Your rights and obligations We have about the use of Your medical information.
We are required by law to:
• Make sure Your health information that identifies You is kept private;
• Give You this notice of Our legal duties and privacy practices with respect to health
information about You; and,
• Follow the terms of the notice that is current in effect.
How We May Use and Disclose Health Information about You
The following categories describe different ways that We use and disclose health information. For
each category of use or disclosures, We will provide examples of the types of ways Your
information may be used. Not every use or disclosure in each category will be listed.
• For Treatment. We may use and disclose Your health information during the provision,
coordination, or management of healthcare and related services among healthcare
providers, consultation between healthcare providers regarding Your care, or the referral
of care from one healthcare Provider to another. For example, a clinician providing a
vaccination to You may need to know if You are sick so that You do not receive a vaccine.
The clinician may refer You to a doctor and may also need to tell the doctor that You are
sick in order to arrange for appropriate medical services, to receive the vaccine at a later
date.
• For Payment. We may use and disclose Your health information in order to pay for Your
medical benefits under Our health plan. These activities may include determining benefit
eligibility, billing and collection activities, coordinating the payment for benefits with other
health plans or third-parties, reviewing healthcare services for Medical Necessity, and
performing utilization review. For example, to make payment for a healthcare claim, We
may review medical information to make sure that the services provided to You were
necessary.
• For Healthcare Operations. We may use and disclose Your health information for health
plan operations. These uses and disclosures are necessary to run the health plan and make
sure that all of Our members receive quality benefits and customer service. For example:
o We may use and disclose general health information but not reveal Your identity in
the publication of newsletters that offer members information on various healthcare
issues such as asthma, diabetes, and breast cancer.
o We may use and disclose Your health information for claims management,
utilization review and management, data and information systems management,
Medical Necessity review, coordination of care, benefits and services, responding
to Member inquiries or requests for services, processing of grievances, appeals and
external reviews, benefits and program analysis and reporting, risk management,
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detection and investigation of fraud and other unlawful conduct, auditing,
underwriting, and ratemaking.
o We may use and disclose Your health information for the operation of disease and
case management programs, through which We or Our contractors perform risk and
health assessments, identify and contact members who may benefit from
participation in disease or case management programs, and send relevant
information to those members who enroll in the programs and their providers.
o We may use and disclose Your health information for quality assessment and
improvement activities, such as peer review and credentialing of In-Network
providers, program development, and accreditation by independent organizations.
o We may use and disclose Your health information to the sponsor of the plan if We
are providing health benefits to You as a beneficiary of an employer-sponsored
group health plan.
o We may use and disclose Your health information for the transition of policies or
contracts from and to other health plans.
• To Your Family and Friends. We may use and disclose Your health information to a
family Member, friend or other person to the extent necessary to help with Your healthcare
or payment for Your healthcare. Before We disclose Your medical information to a person
involved in Your healthcare or payment for Your healthcare, We will provide You with an
opportunity to object to such uses and disclosures. If You are not present, or in the event
of Your incapacity or an Emergency, We will use and disclose Your health information
based on Our Professional judgment of whether the use or disclosure would be in Your
best interest.
• As Required By Law. We will disclose medical information about You when required to
do so by federal, state or local law. We must also share Your medical information with
authorities that monitor Our compliance with privacy laws.
• To Avert a Serious Threat to Health or Safety. We may use and disclose medical
information about You when necessary to prevent a serious threat to Your health and safety
or the health and safety of the public or another person. Any disclosure would only be to
someone able to help prevent the threat.
Special Situations
• Military and Veterans. If You are a Member of the armed forces, We may disclose health
information about You as required by military command authorities. We may also disclose
health information about foreign military personnel to the appropriate foreign military
authority.
• Public Health Risks. As required by law, We may disclose health information about You
for public health activities. These activities may include the following:
o To prevent or control disease, Injury, or disability;
o To report birth and deaths;
o To report the abuse or neglect of children, elders, and dependent adults;
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o To report reactions to medications or problems with products;
o To notify people of recalls of products they may be using;
o To notify a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition; and
o To notify the appropriate government authority if We believe a patient has been the
victim of abuse, neglect, or domestic violence. We will only make the disclosure if
You agree or when required or authorized by law.
• Health Oversight Activities. We may disclose medical information to a health oversight
agency for activities authorized by law. For example: audits, investigations, inspections
and licensure. These activities are necessary for the government to monitor the healthcare
system, government programs and compliance with civil rights laws.
• Lawsuits and Disputes. If You are involved in a lawsuit or a dispute, We may disclose
health information about You in response to a court or administrative order. We may also
disclose health information about You in response to a subpoena, discovery request, or
other lawful process.
• Law Enforcement. We may disclose health information if asked to do so by a law
enforcement official:
o In response to a court order, subpoena, warrant, summons, or similar process;
o To identify or locate a suspect, fugitive, material witness, or missing person;
o About the victim of a crime if, under certain limited circumstances, We are unable
to obtain the person’s agreement;
o About a death We believe may be the result of criminal conduct;
o About criminal conduct at the Hospital; or
o In Emergency circumstances to report a crime; the location of the crime victims; or
the identity, description, or location of the person who committed the crime.
• Nevada Attorney General and Grand Jury Investigations. We may disclose health
information if asked to do so by an investigator for the Nevada Attorney General, or a
grand jury, investigating an alleged violation of Nevada laws prohibiting patient neglect,
elder abuse, or submission of false claims to the Medicaid program. We may also disclose
health information to an investigator for the Nevada Attorney General investigating an
alleged violation of Nevada workers’ compensation laws.
• National Security. We may disclose health information about You to authorized federal
officials for purposes of national security.
• Inmates. An inmate does not have the right to this notice. If You are an inmate of a
correctional facility or are under the custody of a law enforcement official, We may release
health information about You to the correctional institution or law enforcement official.
This release would be necessary to provide You with health care or to protect Your health
and safety or health and safety of others, including the correctional institution.
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Former Members of Hometown Health
Hometown Health does not destroy the health information of individuals who terminate their
coverage with Us. The information is necessary and is used for many purposes described above,
even after an individual leaves a plan, and in many cases is subject to legal retention requirements.
The procedures that protect that information against inappropriate use or disclosure apply
regardless of the status of any individual Member.
Your Rights Regarding Health Information About You
You have the following rights regarding health information We maintain about You:
• Right to Inspect and Copy. You have the right to inspect and copy health information that
may be used to make decisions about Your benefits. Usually, this includes benefits,
eligibility and claims records, but may not include some mental health information.
To inspect and copy health information that may be used to make decisions about You,
You must submit Your request in writing. We may charge You a fee for the cost of copying,
mailing or other supplies associated with Your request.
We may deny Your request to inspect and copy in very limited circumstances. You may
request that a denial be reviewed.
• Right to Amend. If You feel that health information We have about You is incorrect or
incomplete, You may ask Us to amend the information. You have the right to request an
amendment for as long as the information is kept by or for Hometown Health. To request
an amendment to Your record, You must send a written request providing a reason that
supports Your request.
We may deny Your request for an amendment if it is not in writing or does not include a
reason to support the request. We may also deny Your request if You ask Us to amend
information that:
o Was not created by Us, unless the person or entity that created the information is
no longer available to make the amendment;
o Is not part of the records used to make decisions about You;
o Is not part of the information which You would be permitted to inspect and copy;
or
o Is accurate and complete.
• Right to an Accounting of Disclosures. You have the right to receive a list of disclosures
We made with Your health information. This list will not include all disclosures made. This
list will not include disclosures made for treatment, payment, or health care operations,
disclosures made more than six years prior, or disclosures You specifically authorized. To
request this list or an “accounting of disclosures” You must submit Your request in writing.
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• Right to Request Restrictions. You have the right to request a restriction or limitation on
the health information We use or disclose about You to someone who is involved in Your
care or in the payment for Your care, such as a family Member or friend. We are not
required to agree with Your request, unless the request seeks a restriction on the disclosure
of information to a health plan, the disclosure is for the purpose of carrying out payment or
health care operations, and is not otherwise required by law, and the information relates to
an item or service which You, or someone acting for You other than the health plan, has
paid Us in full. If We do agree with Your restriction, We will comply with Your request
unless the information is needed to provide You Emergency treatment. To request
restrictions, You must make Your request in writing.
Your request must tell Us: (1) what information You want to limit; (2) whether You want
to limit Our use, disclosure, or both; and (3) to whom You want the limits to apply (for
example, disclosures to Your spouse)
• Right to Request Confidential Communications. You have the right to request that We
communicate with You about health matters in a certain way or at a certain locations. For
example, You can ask that We only contact You by mail or at work. We will accommodate
all reasonable requests. You must make Your request in writing.
• Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice.
You may ask Us to give You a copy of this notice at any time. Even if You have agreed to
receive this notice electronically, You are still entitled to a paper copy of this notice. You
may obtain a current copy of this notice at www.HometownHealth.com.
• To make a request for: inspection of Your health record, amendment to Your health record,
accounting of disclosures, restrictions on information We may release, or confidential
communications, please submit Your request in writing to:
Hometown Health Compliance Officer
10315 Professional Circle Mail Stop T-9
Reno, NV 89521
Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed
notice effective immediately for health information We already have about You as well as any
information We receive in the future. We will post a copy of the current notice in Our facilities
and at www.HometownHealth.com. The notice will contain on the first page, in the top right-hand
corner, the effective date. In addition, each time You enroll in a Hometown Health plan, We will
offer You a copy of the current notice in effect.
Complaints
If You believe Your privacy rights have been violated, You may file a complaint with Us by
contacting 775-982-8300. You may also file a complaint with the Office for Civil Rights at
www.hhs.gov/ocr or You may file a complaint in writing to:
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Renown Health Chief Compliance/Privacy Officer
1155 Mill St, Mail Stop N-14
Reno, NV 89502
You will not be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of health information not covered by this notice or the laws that apply
to Us will be made only with Your written authorization. If You provide Us permission to use or
disclose health information about You by signing an authorization, You may revoke that
permission, in writing, at any time. If You revoke Your permission, We will no longer use or
disclose health information about You for the reasons covered by Your written authorization. You
understand that We are unable to take back any disclosures We have already made with Your
permission, and that We are required to retain Our records of the care that We provided to You.
Notice to Patients Regarding the Destruction of Health Care Records
In accordance with NRS 629.051, Your regularly maintained health records will be retained for
five years after receipt or production, unless otherwise provided for by federal law. If You are less
than 23 years old on the date of destruction Your records will not be destroyed; after You have
reached 23 years of age, Your records will be destroyed after a five year retention, unless otherwise
provided by federal law.
In accordance with 42 CFR 422.504(d) and (e); 423.505(d) and (e), Hometown Health as a
Medicare Advantage organization, will retain health records for Medicare Advantage
beneficiaries for 10 years, unless otherwise provided for by federal law.
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III. SCHEDULE OF BENEFITS
If You incur expenses for Covered Services, We will pay that Expense less the applicable
Deductible, Copayments, and/or Coinsurance, except as otherwise provided in this EOC. The
specific Deductible, Copayments, and Coinsurance amounts are shown in Your Schedule of
Benefits. We will pay up to the maximum benefit specified for Covered Services.
When We determine that two or more courses of treatment are substantially equivalent, We have
the right to substitute less costly services or benefits for those that We would otherwise cover
under this Policy. This applies regardless of whether We otherwise would cover such less costly
benefits.
Example: If both inpatient care in a skilled nursing facility and intermittent, part-time nursing
care in the home would be medically appropriate, and if inpatient nursing care would be less
costly, We could limit coverage to the inpatient care. We could limit coverage to inpatient
care even if this means extending the inpatient benefit beyond the quantity provided in this
EOC.
The fact that an In-Network Provider prescribed, ordered, recommended, or approved a
service, treatment, or supply does not necessarily make it a Covered Service or Medically
Necessary.
The following is a description of Covered Services. All Covered Services must be Medically
Necessary and are subject to exclusions and limitations as described herein. Prior Authorization
is required for many services. Limitations may apply. All services must be provided by
Providers licensed or certified to provide the service unless otherwise indicated. The fact that an
In-Network Provider prescribed, ordered, recommended, or approved a service, treatment, or
supply does not necessarily make it a Covered Service or Medically Necessary.
This chapter should be read in conjunction with Chapter IV – Exclusions and Limitations and
Your Schedule of Benefits. Your Schedule of Benefits lists specific Cost Sharing information
not listed within this EOC.
A. PROFESSIONAL SERVICES
The following services are Covered Services when provided by a Professional.
1.
Alcohol and Substance Abuse Services (Inpatient and Outpatient).
Medically Necessary inpatient and outpatient alcohol and substance abuse services will
be provided under the terms as noted in the Schedule of Benefits. Substance abuse care
benefits are for Acute medical detoxification and for substance abuse rehabilitation and
counseling. The main purpose of medical detoxification is to rid the body of toxins,
monitor heart rate, blood pressure and other vital signs, manage withdrawal symptoms
and administer medications as needed.
Certain inpatient programs require Prior Authorization, subject to the Utilization
Management Program rules applicable to all medical and mental health services (see
Section V. Utilization Management Program). A full listing of services subject to Prior
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Authorization can be found at hometownhealth.com or by referring to your Schedule of
Benefits. Alcohol and substance abuse Office Visits do not require a referral or a Prior
Authorization. Services subject to Prior Authorization are assessed and monitored on an
ongoing basis to ensure compliance with the Mental Health Parity and Addiction Equity
Act.
This Benefit Plan provides all mental health and substance abuse benefits in accordance
with the Mental Health Parity and Addition Equity Act of 2008.
2.
Allergy Testing and Treatment.
Coverage is provided for Medically Necessary allergy testing, preparation of serum,
serum, and administration of injections.
3.
Alternative Medicine
Alternative medicine is a Covered Service for therapeutic procedures and approaches to
medical diagnosis and therapy that currently may not be considered part of conventional
medical practice. These generally include acupressure, holistic medicine homeopathy,
hypnosis, herbal, vitamin or supplement therapies, naturopathy, biofeedback and
neurofeedback.
Office visits, procedures, and therapies for alternative medicine and related medications
are only covered if prescribed or provided by a licensed Provider (limited to $1,000
maximum benefit per Calendar Year).
4.
Autism Spectrum Disorders
Coverage is provided for Medically Necessary screening for and diagnosis of Autism
Spectrum Disorders (ASD) and for the Medically Necessary treatment of ASD.
Treatment may be provided by licensed provider as defined in NRS
“Autism Spectrum Disorder” means a condition that meets the diagnostic criteria for
Autism Spectrum Disorder published in the current edition of the Diagnostic and
Statistical Manual of Mental Disorders published by the American Psychiatric
Association or the edition thereof that was in effect at the time the condition was
diagnosed or determined.
Treatment of Autism Spectrum Disorders must be identified in a treatment plan and may
include Medically Necessary habilitative or rehabilitative care, prescription care,
psychiatric care, psychological care, behavior therapy, or therapeutic care that is:
• Prescribed for a person diagnosed with an Autism Spectrum Disorder by a
licensed Physician or licensed psychologist; and
• Provided to a person diagnosed with an Autism Spectrum Disorder by a licensed
Physician, licensed psychologist, state certified behavior analyst or other Provider
that is supervised by the licensed Physician, psychologist, or state certified
behavior analyst.
We may request and review a copy of the treatment plan.
Coverage is subject to Copayment, Deductible, and Coinsurance provisions and any other
general exclusion or limitation of this Policy to the same extent as other medical services
or Prescription Drugs covered by Us. Services for applied behavioral analysis treatment
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for ASD require Prior Authorization. Coverage is not provided for reimbursements to a
school for services delivered through school services.
5.
Blood Services for Surgery
Medically Necessary blood and related supplies provided during a surgical or other
procedure that requires blood replacement are Covered Services.
6.
Chemotherapy
Chemotherapy and other drug therapies that are Medically Necessary to treat cancers and
other diseases and conditions in an outpatient hospital, outpatient facility or Physician’s
office are Covered Services.
7.
Clinical Trials
The routine medical treatment costs, including reasonable and necessary items and
services used to prevent, diagnose and treat complications arising from participation in a
qualifying clinical, may be covered. Benefits are available only when the Covered Person
is clinically eligible for participation in the qualifying clinical trial as defined by the
researcher.
Approved clinical trial means a Phase I, Phase II, Phase III, or Phase IV clinical trial that
is conducted in relation to the prevention, detection, or treatment of cancer or other life-
threatening disease or condition and meets the requirements under Criteria for Approved
Clinical Trials.
Criteria for Approved Clinical Trials
The Clinical Trial must be described in one of the main bullets below:
• National Institutes of Health (NIH) [includes National Cancer Institute (NCI)]
• Centers for Disease Control and Prevention (CDC)
• Agency for Healthcare Research and Quality (AHRQ)
• Centers for Medicare and Medicaid Services (CMS)
• A cooperative group or center of any of the entities described above or the
Department of Defense (DOD) or the Veterans Administration (VA)
• A qualified non-governmental research entity identified in the guidelines
issued by the National Institutes of Health for center support grants
• The Department of Veterans Affairs, the Department of Defense or the
Department of Energy as long as the study or investigation has been reviewed
and approved through a system of peer review that is determined by the
Secretary of Health and Human Services to meet both of the following
criteria:
o
Comparable to the system of peer review of studies and investigations
used by the National Institutes of Health;
o
Ensures unbiased review of the highest scientific standards by
qualified individuals who have no interest in the outcome of the
review;
i.
OR
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• The study or investigation is conducted under an investigational new drug
application reviewed by the U.S. Food and Drug Administration; or
• The study or investigation is a drug trial that is exempt from having such an
investigational new drug application.
• There is no medical treatment available that is considered a more appropriate
alternative medical treatment than the medical treatment provided in the clinical
trial or study;
• There is a reasonable expectation based on clinical data that the medical treatment
provided in the clinical trial or study will be at least as effective as any other
medical treatment;
• You have signed, before Your participation in the clinical trial or study, a
statement of consent indicating that You have been informed of, without
limitation:
i. The procedure to be undertaken;
ii. Alternative methods of treatment; and
iii. The risks associated with participation in the clinical trial or study,
including, without limitation, the general nature and extent of such risks;
and
• The medical treatment is limited to:
i.
Coverage for any drug or device that is FDA-Approved for sale without
regard to whether the approved drug or device has been approved for use
in Your medical treatment;
ii.
The cost of any reasonable necessary health care services that are required
as a result of the medical treatment provided in a Phase II, Phase III, or
Phase IV clinical trial or study or as a result of any complication arising
out of the medical treatment provided in a Phase II, Phase III, or Phase IV
clinical trial or study, to the extent that such health care services would
otherwise be Covered Services;
iii.
The cost of any routine health care services that would otherwise be
Covered Services for Your participation in a Phase I clinical trial;
iv.
The initial consultation to determine whether You are eligible to
participate in the clinical trial or study; or
v.
Health care services required for the clinically appropriate monitoring of
You during a Phase II, Phase III, or Phase IV clinical trial or study.
Services for the following clinical trial services are excluded:
• Any portion of the clinical trial or study that is customarily paid for by a
government or a biotechnical, pharmaceutical, or medical industry;
• Coverage for a drug or device described above that is paid for by the
manufacturer, distributor, or Provider of the drug or device;
• Health care services that are specifically excluded from coverage in this EOC,
regardless of whether such services are provided under the clinical trial or study;
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• Health care services that are customarily provided by the sponsors of the clinical
trial or study free of charge to participants in the trial or study;
• Extraneous expenses related to You in the clinical trial or study including but not
limited to travel, housing, and other expenses that You may incur;
• Any expenses incurred by a person who accompanies You during the clinical trial
or study;
• Any item or service that is provided solely to satisfy a need or desire for data
collection or analysis that is not directly related to the clinical management of
You; and
• Any costs for the management of research relating to the clinical trial or study.
8.
Diabetic Services for Type 1, Type 2, and Gestational Diabetes
Coverage is provided for the Medically Necessary management and treatment of
diabetes, including infusion pumps and related supplies, medication, equipment, supplies,
and appliances for the treatment of diabetes.
Coverage is provided for the Medically Necessary self-management of diabetes for
training and education provided after You are diagnosed with diabetes for the care and
management of diabetes, including, counseling in nutrition and the proper use of
equipment and supplies for the treatment of diabetes.
9.
Family Planning
Coverage is provided for vasectomies and tubal ligations. Reversals of prior sterilization
procedures, including, but not limited to tubal ligation and vasectomy reversals are
excluded.
10.
Gastric Restrictive Services (Bariatric)
Covered Services include Medically Necessary surgical interventions to accomplish
weight loss in individuals who are obese or morbidly obese with associated Illnesses.
These services will not be covered unless You receive Prior Authorization.
In order to receive Prior Authorization You must:
a)
Have a body mass index (BMI) of more than 40kg/m2, or;
b)
Have a BMI greater than 35kg/m2 with significant co-morbidities; and
c)
Provide documented evidence that weight-loss attempts are ineffective; and
d)
Provide documentation of a recommendation for Gastric Restrictive Services from a
psychologist or psychiatrist; and
e)
Are at least 18 years old.
Hometown Health will also require proof of attendance at a medically supervised weight-
loss program for at least three (3) months within the last twenty-four (24) and
documentation of weight-loss failure within the program. Hometown Health will require
clinical evidence that Your weight is affecting Your overall health and is a threat to Your
life. Hometown Health may also require participation in a post-operative therapy
program.
Benefits for gastric restrictive services are limited to one (1) surgery per lifetime.
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Surgical or invasive treatments for obesity or morbid obesity including but not limited to
gastric restrictive services, reversals, and treatments to resolve complications are
generally excluded, unless Medically Necessary and are covered as described above.
Medically Necessary treatment for complications resulting from Gastric Restrictive
Surgical Services will be covered the same as any other Illness.
11.
Genetic Counseling/Testing
Covered Services include Medically Necessary genetic disease testing. Genetic disease
testing is the analysis of human DNA, chromosomes, proteins, or other gene products to
determine the presence of disease-related genotypes, phenotypes, karyotypes, or
mutations for clinical purposes. Such purposes include those tests meeting criteria for the
medically accepted standard of care for the prediction of disease risk, identification of
carriers, monitoring, diagnosis, or prognosis within the confines of the statements in this
definition. Coverage is not available for tests solely for research, or for the benefit of
individuals not covered under the Policy.
Covered services also include the explanation by a genetic counselor of medical and
scientific information about an inherited condition, birth defect, or other genome-related
effects to an individual or family. Genetic counselors are trained to review family
histories and medical records, discuss genetic conditions and how they are inherited,
explain inheritance patterns, assess risk and review testing options, where available.
Genetic testing may only be done after consultation with an appropriately certified
genetic counselor and/or, in Our discretion, as approved by a Physician that We may
designate to review the utilization, Medical Necessity, clinical appropriateness, and
quality of such genetic testing.
Medically Necessary genetic counseling will be covered in connection with pregnancy
management with respect to the following individuals:
• Parents of a child born with a genetic disorder, birth defect, inborn error of
metabolism, or chromosome abnormality;
• Parents of a child with developmental disability, autism, Down syndrome, trisomy
conditions, or fragile X syndrome;
• Pregnant women who, based on prenatal ultrasound tests or an abnormal multiple
marker screening test, maternal serum alpha-fetoprotein test, test for sickle cell
anemia, or tests for other genetic abnormalities, have been told their pregnancy
may be at increased risk for complications or birth defects; or
• Parents affected with an autosomal dominant disorder who are contemplating
pregnancy; or Women who are known to be, or who are likely to be, carriers of an
X-linked recessive disorder.
Covered services include genetic testing of heritable disorders as Medically Necessary
when the following conditions are met:
• The results will directly impact clinical decision-making and/or clinical outcome
for the individual;
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• The testing method is considered scientifically valid for identification of a
genetically-linked heritable disease; and
• One of the following conditions is met:
i.
The Member demonstrates signs/symptoms of a genetically-linked
heritable disease; or
ii.
The Member or fetus has a direct risk factor (e.g., based on family history
or pedigree analysis) for the development of a genetically-linked heritable
disease.
Additional genetic testing will be covered as required by Federal or state mandates.
In the absence of specific information regarding advances in the knowledge of mutation
characteristics for a particular disorder, the current literature indicates that genetic tests
for inherited disease need only be conducted once per lifetime of the Member.
Routine panel screening for preconception genetic diseases, routine chorionic villous
sampling, or amniocentesis panel screening testing, and pre-implantation embryonic
testing will not be covered unless the testing is endorsed by the American College of
Obstetrics and Gynecology, or mandated by federal or state law.
12.
Home Health Care
Medically Necessary home health care is covered if such care is provided by an
organization or Professional licensed by the state to render home health services. Such
care will not be available if it is substantially or primarily for the Member’s convenience
or the convenience of a caregiver. Home care is covered in the home only on a part-time
and temporary basis and to the extent that such care is performed by a licensed or
registered nurse or appropriate therapist. See the section entitled “Other Services and
Supplies” for coverage for other home health care services.
13.
Mastectomy Reconstructive Surgery
Breast reconstructive surgery and the internal or external prosthetic devices are covered
for Members who have undergone mastectomies or other treatments for breast cancer.
Treatment will be provided in a manner determined in consultation with the Physician
and the Member.
Subject to all the terms and conditions of this EOC, if a covered mastectomy or other
breast cancer treatment is performed, We will also provide coverage for:
• All stages of reconstruction of the breast on which the mastectomy has been
performed;
• Surgery and reconstruction of the other breast to produce a symmetrical structure;
• Prostheses; and
• Physical complications for all stages of mastectomy, including lymphedemas.
If reconstructive surgery occurs within three years after a mastectomy, the amount of the
benefits for that surgery will equal the amounts provided for in the Policy at the time of
the mastectomy. If the surgery occurs more than three years after the mastectomy, the
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benefits provided are subject to all the terms, conditions, and exclusions contained in the
Policy at the time of reconstructive surgery.
14.
Medical Care
Medically Necessary medical care and services, performed by a Physician or other
Professional on an inpatient and outpatient basis, are covered, including:
• Office visits and consultations;
• Hospital and skilled nursing facility services;
• Ambulatory surgical center services;
• Home health care services;
• Surgery; and
• Other Professional services.
15.
Medical Pharmacy
Cost Sharing resulting from receipt of Medical Pharmacy benefits described in this
section apply to the medical or combined Deductible, as applicable. These benefits do
not apply to any separate pharmacy Deductible if the pharmacy Deductible is separate
from the medical Deductible.
This benefit includes the distribution, administration, and/or supply of pharmaceuticals
and immunizations, frequently in conjunction with other services provided at a Medical
Pharmacy. This benefit does not include other types of pharmaceuticals, which may be
covered as described elsewhere in this EOC.
Medically Necessary immunizations, biologics, Injectables, or other Specialty
Pharmaceuticals, implantable rods (birth control rods), copper-based and progesterone-
based intrauterine devices (IUDs) and contraceptive diaphragms (one device per a 12-
month period, unless otherwise prescribed by an In-Network Physician) distributed,
administered, or supplied by a Medical Pharmacy (except as described below) are
covered.
Specialty Pharmaceuticals, which include Injectables, and medications given by other
routes of delivery, may be delivered in any setting. Specialty Pharmaceuticals are
pharmaceuticals that typically have:
• Limited access;
• Complicated treatment regimens;
• Compliance issues;
• Special storage requirements; or
• Manufacturer reporting requirements.
We maintain and update a list of Specialty Pharmaceuticals at hometownhealth.com.
16.
Mental Health Services
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Medically Necessary mental health services, including screenings for depression,
provided by a doctor, clinical psychologist, clinical social worker, clinical nurse
Specialist, nurse practitioner, Physician assistant, or other qualified mental health care
Professional are covered according to the limits provided in the Schedule of Benefits.
Direct payment to Out-of-Network mental health and substance abuse providers can be
made with a written assignment of benefits.
1
Inpatient services are subject to Prior Authorization, whether for medical or mental health
services. A full listing of services subject to Prior Authorization can be found at
hometownhealth.com or by referring to your Schedule of Benefits. Mental Health Office
Visits do not require a referral or a Prior Authorization.
This Benefit Plan provides all mental health and substance abuse benefits in accordance
with the Mental Health Parity and Addition Equity Act of 2008.
17.
Newborns and Maternity Care
Medically Necessary maternity services for pregnant Members are covered, including
prenatal and postpartum care, related delivery room and ancillary services and newborn
care. Additionally, if a patient giving birth at a hospital requests the insertion of long-
acting reversible contraception, the hospital shall provide for the insertion or injection of
the long-acting reversible contraception immediately after birth. Newborn care includes
care and treatment of medically diagnosed congenital defects, birth abnormalities, or
prematurity, and transportation costs of newborn to and from the nearest facility staffed
and equipped to treat the newborn’s condition. Newborn care is subject to the eligibility
requirements as defined in this EOC. Newborn care and
treatment may be subject to the Newborn’s policy coverage and applicable deductibles,
copays and/or coinsurance.
Hometown Health covers newborn and maternity care in a Hospital for no less than 48
hours for a normal vaginal delivery and no less than 96 hours for a cesarean section or as
otherwise provided in the guidelines established by the American College of
Obstetricians and Gynecologists and the American Academy of Pediatrics.
Notwithstanding anything in this EOC to the contrary, a Member does not need Prior
Authorization to obtain access to gynecological care from a Professional in Our Network
who specializes in obstetrics or gynecology. The Professional, however, may be required
to comply with certain procedures, including obtaining Prior Authorization for certain
services, following a pre-approved treatment plan, or procedures for making referrals.
For a list of In-Network Professionals who specialize in obstetrics or gynecology, go to
hometownhealth.com.
Notwithstanding anything in this EOC to the contrary, in the case of a person who has a
child enrolled in coverage, We will permit such person to designate any pediatrician as a
PCP if such pediatrician is an In-Network Provider.
Services that are not covered include:
• Amniocentesis to the extent that it is performed to determine the sex of the child.
• Non-newborn circumcisions after eight weeks of age unless Medically Necessary
and We provide a Prior Authorization.
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18.
Oral Surgery, Dental Services, and Temporomandibular Joint Disorder
Although dental services are not Covered Services, except as otherwise provide in Part
IV – Schedule of Benefits, the following Oral Surgical Services are Covered Services:
• For Members up to age 19, services include the Medically Necessary treatment of:
a)
Oral cancer;
b)
Dental Fractures; and
c)
Dental Biopsies
• Treatment for tumors and cysts requiring pathological examination of the jaws,
cheeks, lips, tongue, and roof and floor of the mouth;
• Treatment required to stabilize sound natural teeth, the jawbones, or surrounding
tissues after an Injury (not to include injuries caused by chewing) when the treatment
starts within the first ten (10) days after the Injury and ends within sixty (60) days.
No benefits are provided for removable dental prosthetics, dentures (partial or complete)
or subsequent restoration of teeth, including permanent crowns.
• Non-dental surgical procedures and hospitalization required for newly born and
children placed for adoption or newly adopted to treat congenital defects, such as cleft
lip and cleft palate;
• Repair and restoration of sound and natural teeth from injuries that arise from non-
gustatory trauma;
• Extraction of teeth when related to radiation therapy or in advance of an organ
transplant (other than a corneal transplant);
• Medical or surgical procedures occurring within or adjacent to the oral cavity or
sinuses including treatment of fractures; and
• Dental general anesthesia for a dependent child when services are rendered in a
Hospital or outpatient surgical facility, when enrolled dependent child is being
referred because, in the opinion of the dentist, the child:
i.
Is under 18 and has a physical, mental, or medically compromising condition;
ii.
Is under 18 and has dental needs for which local anesthesia is ineffective because
of an Acute infection, an anatomic anomaly or an allergy; or
iii.
Is under age five (5).
Temporomandibular Joint Disorder (TMJ) and dysfunction services and supplies
including night guards are covered only when the required services are not recognized
dental procedures. Member Cost Sharing for covered TMJ services follows the same
benefit allowance as other Medically Necessary services, subject to applicable
deductibles, copayments and Coinsurance. TMJ surgeries are covered under the medical
benefits based on Medical Necessity and are limited to an annual maximum of one (1)
surgery and a lifetime maximum of two (2) surgeries.
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Prior Authorization is required for dental general anesthesia in a Hospital or outpatient
surgical facility. Dental anesthesiology services are covered only for procedures
performed by a qualified Specialist in pediatric dentistry, a dentist educationally qualified
in a recognized dental specialty for which Hospital privileges are granted or who is
certified by virtue of completion of an accredited program of post-graduate Hospital
training to be granted Hospital privileges.
Only the services and supplies described above are covered, even if the condition is due
to a genetic, congenital, or acquired characteristic. Exclusions include:
• Under the medical benefits, except as described above as an inclusion, services
involving treatment to the teeth; extraction of teeth; repair of injured teeth;
general dental services; treatment of dental abscesses or granulomas; treatment of
gingival tissues (other than for tumors); dental examinations; restoration of the
mouth, teeth, or jaws because of Injuries from biting, chewing, or accidents;
artificial implanted devices; braces; periodontal care or surgery; teeth prosthetics
and bone grafts regardless of etiology of the disease process; and repairs and
restorations except for appliances that are Medically Necessary to stabilize or
repair sound and natural teeth after an Injury as set forth above;
• Dental and or medical care including mandibular or maxillary surgery,
orthodontia treatment, oral surgery, pre-prosthetic surgery, any procedure
involving osteotomy to the jaw, and any other dental product or service except as
set forth above;
• Treatment to the gums and treatment of pain or infection known or thought to be
due to dental or medical cause and in close proximity to the teeth or jaw, braces,
bridges, dental plates or other dental orthosis or prosthesis, including the
replacement of metal dental fillings; and
• Other supplies and services including but not limited to cosmetic restorations,
implants, cosmetic replacements of serviceable restorations, and materials (such
as precious metals).
19.
Orthopedic Devices and Prosthetic Devices
Coverage for orthopedic devices is limited to Medically Necessary braces for problems
requiring complete immobilization or for support, or if the braces are custom fitted or
have rigid bar or flat steel supports and stays, splints, devices for congenital disorders,
post and pre-operative devices.
One (1) Medically Necessary prosthetic device, approved by the Centers for Medicare &
Medicaid (CMS), is covered for each missing or non-functioning body part or organ
every three (3) years. Coverage is limited to:
• Devices that are required to substitute for the missing or non-functioning body
part or organ;
• Devices provided in connection to an Illness or Injury that occurred subsequent to
Your effective date of coverage;
• Adjustment of initial prosthetic device; and
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• The first pair of eyeglasses or contact lenses (up to the Medicare allowable)
immediately following cataract surgery.
• Replacement in limited situations involving mastectomy reconstructive
surgery
20.
Ostomy Care Supplies
Coverage is provided for Medically Necessary care and supplies after colon, ileum, or
bladder surgery to assist in carrying on normal activities with a minimum of
inconvenience.
21.
Partial Hospitalization Services
Partial hospitalization services are covered for mental Illness and substance abuse
according to the benefits listed in the Schedule of Benefits that accompanies this EOC.
The same services covered for inpatient services are also covered for Partial
Hospitalization. One inpatient day is defined as an admission to a facility for more than
12 hours of treatment. One partial treatment day is defined as no less than three and no
more than 12 hours of therapy per day. Partial day treatment is covered only when the
Member receives care through a day treatment program. Every two partial-day
treatments count as one full inpatient..
22.
Physician to Physician eConsult
Coverage is provided for eConsults initiated by Your Primary Care Physician (PCP) to a
Specialist in order to receive advice or treatment recommendation for Your care.
23.
Plan Approved Medical Necessity Travel Benefit
The Plan Travel Benefit is meant to offset the cost of travel for members and/or their
support person or family members when the Utilization Management Department
approves services at a Tertiary Care facility (evaluation and/or treatment) in either
southern Nevada or in the state of Utah. The specific tertiary care facility must be
approved by the Utilization Management Department and agreed upon by the member’s
referring physician.
Any care administered while following theHTH Utilization Management Care Plan will
be subject to in-network cost sharing by the member.
A tertiary care facility provides highly specialized medical care that involves advanced
and complex procedures and treatments performed by medical specialists. Examples of
tertiary care are specialized cancer care, neurosurgery, cardiovascular and burn care.
• To qualify for Medical Necessity Travel Benefit, the following must apply:
1.
The member and/or their treating physician has requested a referral for a
service that is not available within the primary network and will require
travel outside of the geographic service area to either southern Nevada or
Utah.
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2.
Utilization Management has determined that the requested services are
medically necessary and tertiary care cannot be provided in the primary
network.
3.
Utilization Management has approved the tertiary care at a medical facility
capable of providing the medically necessary level of care.
4.
Covered Person has agreed to be in Case Management, and followed by
Case Manager while in tertiary care.
5.
Prior to travel for tertiary care, the member must advise the RN Case
Manager of travel to receive the benefit.
• Covered Travel Expenses:
1.
For a member under the age of 19, travel expenses will be reimbursed at
$250 per person for the member and two parents or two legal guardians.
2.
For an adult member age 19 or older, travel expenses will be reimbursed at
$250 for the member and one additional person/caregiver.
3.
Coverage will include the day prior to a scheduled service and the day
following the scheduled service not to exceed $2,500 per episode of care.
4.
The maximum travel reimbursement per calendar year is $10,000.
5.
After approved travel, complete a Medical Necessity Travel
Reimbursement Benefit form, attach all receipts and submit to the
Utilization Management Department at HTH.
24.
Podiatry Services
Podiatry services are covered for the Medically Necessary treatment of Acute conditions
of the foot such as infections, inflammation, or Injury and other foot care that is disease
related.
The following services are not covered:
• Non-symptomatic foot care such as the removal of warts (except plantar warts);
corns or calluses; and including but not limited to podiatry treatment of bunions,
toenails, flat feet, fallen arches, and Chronic foot strain; and
• Routine foot care.
25.
Preventive Services
Notwithstanding anything to the contrary in this EOC, the following preventive services
will be covered without any Member Cost Sharing if such services are provided by an In-
Network Provider:
• One wellness physical examination per calendar year is covered for members
older than two or as frequently as mandated by ACA and routine immunizations;
• Coverage for smoking cessation programs for an enrollee who is 18 years of age
or older;
• Prostate Specific Antigen (PSA) screen;
• Counseling for sexually transmitted infections (STI);
• HIV counseling, testing, and prescription drugs without the need for a
prescription;
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• Breastfeeding support, supplies and counseling;
• Screening for interpersonal and domestic violence;
• Screening for depression
• Coverage for condoms of insureds who are 13 years of age or older
• Screening for blood pressure abnormalities and diabetes, including gestational
diabetes, after at least 24 weeks of gestation or as ordered by a Provider of
healthcare;
• High-risk human papillomavirus (HPV) testing;
• Annual well-woman preventive visits as recommended by the Health Resources
and Services Administration for women 14 years of age or older.
• Routine gynecologic examination (one per calendar year), including annual
cytologic screening test (Pap smear) for women 21 to 65 years of age, pelvic
examination, urinalysis, and breast examination;
• Screening mammograms annually for insureds 40 years of age or older;
• Well-baby care, including immunizations in accordance with the American
Academy of Pediatrics;
• Colorectal cancer screening starting at age 45 years and continuing until age 75
years in accordance with:
i.
The guidelines concerning such screening that are published by the
American Cancer Society; or
ii.
Other guidelines or reports concerning such screening that are published
by nationally recognized Professional organizations and that include
current or prevailing supporting scientific data;
• Lung Cancer screening with low dose computed tomography (LDCT) for
qualified individual every 12 month
i.
Eligible members are people aged 50 years or older and
ii.
have no signs or symptoms of lung cancer
iii.
history of tobacco smoking of at least 20 pack-years and
iv.
who currently smokes or has quit smoking within the last 15 years and
v.
receives an order for lung cancer screening with LDCT.
vi.
Before the beneficiary’s first lung cancer LDCT screening, the beneficiary
must receive a counseling and shared decision-making visit that meets all
of the following criteria, and is appropriately documented in the
beneficiary’s medical records:
vii.
Determination of beneficiary eligibility;
viii.
Shared decision-making, including the use of one or more decision
aids;
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ix.
Counseling on the importance of adherence to annual lung cancer LDCT
screening, impact of comorbidities and ability or willingness to undergo
diagnosis and treatment; and
• Counseling on the importance of maintaining cigarette smoking abstinence if former
smoker; or the importance of smoking cessation if current smoker and, if appropriate,
furnishing of information about tobacco cessation interventions.
• Immunizations, including influenza, pneumococcal, haemophilus influenza B,
hepatitis A, hepatitis B, hepatitis C, rubella, measles, diphtheria, human
papillomavirus (HPV), pertussis (whooping cough), poliovirus, rotavirus,
varicella (chickenpox), shingles (herpes zoster) and tetanus, if such
immunizations have in effect a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention with
respect to the individual involved;
• Hearing and vision screening for children through age 17 to determine the need
for hearing and vision correction;
• Evidence-based items or services that have an “A” or “B” Recommendation of the
United States Preventive Services Task Force, provided that the recommendation
does not conflict with a more recent “A” or “B” Recommendation of the United
States Preventive Services Task Force;
• With respect to infants, children, and adolescents, evidence-informed preventive
care and screenings provided for in comprehensive guidelines supported by the
Health Resources and Services Administration of the U.S. Department of Health
and Human Services; and
• With respect to women, such additional preventive care and screenings not
described under this section as provided for in comprehensive guidelines
supported by the Health Resources and Services Administration of the U.S.
Department of Health and Human Services.
• With respect to women, contraceptives are covered as preventive services. The
following services are covered under Your medical benefit, subject to Prior
Authorization as is required for any surgical procedure:
i.
Voluntary sterilization for women (once per lifetime); and
ii.
Surgical sterilization implants for women (once per lifetime);
See Part H – Covered Services under the Pharmacy Benefit, Section 7 –
Contraceptive Products below for contraceptive methods covered under the
Hometown Health Prescription Drug benefit.
For more information see: http://doi.nv.gov/Healthcare-Reform/Individuals-
Families/Preventive-Care/
26.
Radiation Therapy
Medically Necessary Professional services related to radiation therapy in an outpatient
hospital, outpatient facility or Physician’s office, are covered.
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27.
Rehabilitative and Habilitative Therapy
Coverage is provided for Medically Necessary physical, speech, occupational, cardiac,
and pulmonary therapy habilitative and rehabilitation services. Such services must be
performed by a Physician or by a therapy Provider licensed in accordance with state
regulations for that therapy discipline.
Rehabilitative and habilitative services may require Prior Authorization depending on the
setting in which the services are provided.
Coverage for these services is available for Acute conditions arising from Illness or
Injury, as well as Chronic or developmental conditions up to the benefit limits as defined
in the Benefit Plan.
28.
Remote Monitoring
Coverage is provided for Medically Necessary remote patient monitoring, including the
collection, storage, and evaluation of health information through live monitoring via
devices that transmit information from the home or care facility to Your provider.
29.
Skin Lesions
Coverage is provided for Medically Necessary removal of skin lesions and related
pathological analysis of such lesions.
30.
Spinal Manipulation (Non-Surgical)
Coverage is provided for up to 20 visits per year, for Medically Necessary spinal
manipulations and adjustments, except for treatment for Chronic or recurring conditions.
Spinal manipulation and adjustment means the detection, treatment, and correction of
structural imbalance, subluxation, or misalignment of the vertebral column in the human
body, for the purpose of alleviating pressure on the spinal nerves and its associated
effects related to such structural imbalance, misalignment, or distortion, by physical or
mechanical means.
31.
Transplant Services
Medically Necessary organ transplants at a Hometown Health approved Center of
Excellence are covered when You are the organ recipient in the following cases:
• Bone marrow;
• Cornea;
• Heart;
• Heart and lung;
• Intestinal and liver;
• Kidney;
• Liver;
• Lung;
• Pancreas;
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• Pancreas and kidney; or
• Stem cell.
Centers of Excellence are facilities that meet Hometown Health’s vigorous credentialing
requirements for the specific type of organ transplant. A facility that is designated as a
Center of Excellence for one type of organ transplant may not be designated as a Center
of Excellence for another type of organ transplant. Designation as a Center of Excellence
is at Hometown Health’s sole discretion.
Organ transplants are only covered where the organ donor’s suitability meets the
OPTN/UNOS (Organ Procurement and Transplantation Network/United Network for
Organ Sharing) donor evaluation and guideline criteria, when applicable.
Coverage for related transplant services is limited to:
• Tests necessary to identify an organ donor;
• The reasonable Expense of acquiring the donor organ;
• One (1) procurement per transplant benefit period. The transplant benefit period
begins on the date the Member first receives services directly related to evaluation
as candidate for a covered transplant procedure, and ends on the earlier of the date
12 months after the Covered Transplant is performed, or the date the Member
ceases to be a Member, subject to Nevada’s Essential Health Benefits.
• Transportation of the donor organ (but not the donor), and life support where such
support is for the sole purpose of removing the donor organ;
• Storage costs of an organ, but only as part of an authorized treatment protocol;
and
• Follow-up care.
Services excluded from coverage include, but are not limited to:
• Services provided at a facility that has not been designated as a Hometown Health
Center of Excellence are excluded.
• Services provided to an organ donor are excluded.
• Services provided in connection with purchasing or selling organs are excluded.
• Transplants utilizing any animal organs are excluded.
• Any transportation of the donor (as opposed to transportation of the donor organ
only) is excluded.
• Any expenses associated with an organ transplant where an alternative remedy is
available are excluded.
• Artificial heart implantation is excluded.
• Services for which government funding or other insurance coverage is available
are excluded.
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• Any expenses for transportation, lodging, and meals for services associated with
the transplant including evaluations and the transplant and post-transplant periods
for the donor, donor’s family, recipient, or recipient’s family are excluded.
• Tissue transplants (whether natural or artificial replacement materials or devices
are used) or oral implants, including the treatment for complications arising from
tissue or organ transplants or replacement are excluded, except as described
above.
32.
Sickle Cell Disease and It’s Variants
Benefits for treatment of Sickle Cell Disease and Its Variants, including Medically Necessary
Prescription Drugs and necessary care management services through Hometown Health's
Utilization Management Program to assist patients in managing complex patient care
B. HOSPITAL, SKILLED NURSING CARE, AND SERVICES IN AN OUTPATIENT
SURGICAL CENTER
1.
Inpatient Care
Medically Necessary inpatient Hospital care is covered. Services include, but are not
limited to:
• Services for medical conditions treated in an Acute care Hospital inpatient
environment;
• Semi-private room and board (private room when Medically Necessary);
• General nursing care facilities, services, and supplies on an inpatient basis;
• Diagnostic services that are provided in a facility, whether such facility is a
Hospital or a freestanding facility (see “Other Services and Supplies for related
Covered Services);
• Surgical and obstetrical procedures, including the services of a surgeon or
Specialist, assistant, and anesthetist or anesthesiologist together with preoperative
and postoperative care;
• Maternity and newborn care for up to 48 hours of inpatient care for a mother and
her newborn child following a vaginal delivery and up to 96 hours of inpatient
care for a mother and her newborn child following a Cesarean delivery. The
time-periods will commence at the time of the delivery. Any decision to shorten
the length of inpatient stay to less than those time-periods will be made by the
attending Physician after conferring with the mother;
• Inpatient, short-term rehabilitative services, limited to treatment of conditions that
are subject to significant clinical improvement over a continuous 30-day period
from the date inpatient therapy commences in a distinct rehabilitation unit of a
Hospital, or other facility approved by Us (limited to 120 days per calendar year);
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• Inpatient alcohol and substance abuse rehabilitation services in a Hospital,
residential treatment facility, or day treatment program; and
• Inpatient mental health services.
Inpatient services to treat mental healthconditions are subject to medical Policy and
Medical Necessity. . Provider visits received during a covered admission are also
covered. Benefits are provided for Medically Necessary inpatient care, outpatient care,
Partial Hospitalization, and Provider office services for the diagnosis, crisis intervention
and treatment of severe mental Illness conditions and substance abuse conditions as noted
in the Schedule of Benefits. Inpatient services must be provided by a licensed Hospital,
psychiatric Hospital, alcoholism treatment center, or residential treatment center.
The Member should contact Hometown Health to determine Medical Necessity,
appropriate treatment level and appropriate setting. Inpatient services are subject to Prior
Authorization notification guidelines to avoid potential penalties related to non-
notification of services.
Hometown Health must be notified for all Emergency admissions by the next business
day unless the Member is unable to do so.
2.
Skilled Nursing Care
Medically Necessary care at a skilled nursing facility for non-Custodial Care is covered
(limited to 60 days per calendar year). A skilled nursing facility is a facility that is duly
licensed by the state and/or federal government and that provides inpatient skilled nursing
care, rehabilitation services, or other related health services that are not custodial or
convenience in nature. Skilled nursing care includes Medically Necessary services that
are considered by Medicare to be eligible for Medicare coverage as meeting a skilled
need and that can only be performed by, or under the supervision of, a licensed or
registered nurse. Hometown Health does not cover skilled nursing care that is not
covered by CMS. Prior care in a Hospital is not required before being eligible for
coverage for care in a skilled nursing facility.
3.
Outpatient Care
Medically Necessary outpatient Hospital or outpatient surgical center care is covered.
Services furnished in a Hospital’s or outpatient surgical center premises are covered,
including use of a bed and periodic monitoring by a Hospital’s nursing or other staff that
are Medically Necessary to evaluate an outpatient’s condition or determine the need for a
possible admission to the Hospital. If a Hospital intends to keep a patient in observation
status for more than 48 hours, observation status will become an inpatient admission for
administration of benefits.
All coverage for the following benefits are dependent upon the coverage described in the
Schedule of Benefits for each plan.
Outpatient services include, but are not limited to:
• Services for medical conditions treated in an Acute care Hospital outpatient
environment;
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• Semi-private room and board (private room when Medically Necessary) if patient
is in observation status;
• General nursing care facilities, services, and supplies on an outpatient basis;
• Diagnostic services that are provided in a facility, whether such facility is a
Hospital or a freestanding facility;
• Surgical procedures, including the services of a surgeon or Specialist, assistant,
and anesthetist or anesthesiologist together with preoperative and postoperative
care;
• Outpatient, short-term rehabilitative services;
• Outpatient alcohol and substance abuse rehabilitation services in a Hospital,
Hospital residential treatment facility, or day treatment program; and
• Outpatient mental health services.
Medically Necessary short-term outpatient habilitative and rehabilitative services are
covered for:
• Short-term speech, physical, and occupational habilitative and rehabilitative
therapy for Acute conditions that are subject to significant clinical improvement
over a 90-day period from the date outpatient therapy commences to maintain
function in an individual (see Schedule of Benefits for visit limits); and
• Services for cardiac rehabilitation and pulmonary rehabilitation (see Schedule of
Benefits for visit limits).
Medically Necessary services such as radiation therapy and chemotherapy (including
chemotherapy drugs), are covered to the extent that such services are delivered in the
most appropriate clinical manner and setting as part of a treatment plan.
Services that are not covered under this benefit include:
• Any services or supplies furnished in an institution that is primarily a place of
rest, a place for the aged, a custodial facility, or any similar institution;
• Private duty nursing and private rooms in an inpatient setting;
• Personal, beautification, or comfort items for use while in a Hospital or skilled
nursing facility; and
• Services related to psychosocial rehabilitation or care received as a custodial
inpatient.
C. EMERGENCY SERVICES
1.
General
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Medically Necessary medical and Hospital services are covered in the case of an
Emergency. Emergency care is available through In-Network Providers 24 hours per
day, seven days per week. If You have an Emergency:
• Get help as soon as possible. Call 911 for help or go to the nearest Emergency
room, Hospital, or other Emergency facility. Call an ambulance if necessary.
• Notify Hometown Health about Your Emergency no later than 24 hours,
the next business day, or as soon as reasonably possible We need to follow up
on Your Emergency care.
Emergency medical and Hospital services are limited to situations that require immediate
and unexpected treatment. You should notify Your PCP and Our customer service
department as soon as possible following receiving Emergency services.
Notwithstanding anything in this EOC to the contrary, coverage for Emergency services
will be provided:
• Without the need for any Prior Authorization;
• Without regard to whether the Provider furnishing the Emergency services is an
In-Network Provider with respect to the services;
• If the Emergency services are provided Out-of-Network, without imposing any
administrative requirement or limitation on coverage that is more restrictive than
the requirements or limitations that apply to Emergency services received from
In-Network Providers and at the Cost Sharing level described in the Schedule of
Benefits; and
• Without regard to any other terms or condition of such coverage other than
exclusion, coordination of benefits or applicable cost-sharing.
2.
Medical care and notification.
Out-of-Network Medically Necessary Emergency services are covered only if We are
notified no more than 24 hours after onset of the Emergency, the next business day, or
as soon as reasonably possible, except as provided in this section.
3.
Extended Notification
If You are unable to contact Us before You receive Emergency medical services or
within 24 hours of the Emergency due to shock, unconsciousness, or otherwise, You
must, at the earliest time reasonably possible, contact Hometown Health Customer
Service at (775)982-3232 or (800)336-0123 to provide Us with information about the
event and relevant circumstances.
4.
Follow-Up Care (outside Our Geographic Service Area/non-contracted facility)
Continuing or follow-up treatment for an Emergency service outside of Our Geographic
Service Area or from an Out-of-Network Provider is limited to care required before You
can, without harmful or injurious consequences, return to Our Geographic Service Area
and receive care from In-Network Providers as determined by Us. Benefits for
continuing or follow-up treatment(s) are otherwise covered only in Our Geographic
Service Area from In-Network Providers, subject to all provisions of this EOC. Routine
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or non-Emergency follow-up care at an Out-of-Network Provider Emergency room
facility is not covered.
5.
Emergencies or Urgent Care Outside of the United States
Claims incurred outside the United States for Emergency or Urgent Care and Treatment of a
member must be submitted in English or with an English translation. Foreign claims must
include the applicable medical records in English to show proper proof of loss and evidence of
payment to the Provider.
D. URGENT CARE SERVICES
1.
Medical Care and Notification
Urgent Care is available through In-Network Providers. Please review the Hometown
Health Provider Directory for In-Network urgent care centers.
2.
Follow-up Care if Temporarily Outside Our Geographic Service Area
Continuing or follow-up care for Urgent Care is limited to care required before You can,
without medically harmful or injurious consequences, return to Our Geographic Service
Area to receive services from In-Network Providers as determined by Us. Routine
follow-up care is not a covered Urgent Care service. You should notify Hometown
Health Customer Service at (775)982-3232 or (800)336-0123 upon Your return to Our
Geographic Service Area to avoid a denial of Your claim.
3.
Limitations
Urgent Care services obtained at a Hospital Emergency facility may cost You more.
Please refer to Your Schedule of Benefits.
E. BALANCE BILLING
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an
in-network hospital or ambulatory surgical center, you are protected from
balance billing. In these cases, you shouldn’t be charged more than your plan’s
copayments, coinsurance and/or deductible.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,
like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the
entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s
network.
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“Out-of-network” means providers and facilities that haven’t signed a contract with your health
plan to provide services. Out-of-network providers may be allowed to bill you for the difference
between what your plan pays and the full amount charged for a service. This is called “balance
billing.” This amount is likely more than in-network costs for the same service and might not
count toward your plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is
involved in your care—like when you have an emergency or when you schedule a visit at an in-
network facility but are unexpectedly treated by an out-of-network provider. Surprise medical
bills could cost thousands of dollars depending on the procedure or service.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network
provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount
(such as copayments, coinsurance, and deductibles). You can’t be balance billed for these
emergency services. This includes services you may get after you’re in stable condition, unless
you give written consent and give up your protections not to be balanced billed for these post-
stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain
providers there may be out-of-network. In these cases, the most those providers can bill you is
your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia,
pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist
services. These providers can’t balance bill you and may not ask you to give up your protections
not to be balance billed.
If you get other types of services at these in-network facilities, out-of-network providers can’t
balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t
required to get out-of-network care. You can choose a provider or facility in your plan’s
network.
When balance billing isn’t allowed, you also have the following protections:
• You’re only responsible for paying your share of the cost (like the copayments,
coinsurance, and deductible that you would pay if the provider or facility was in-
network). Your health plan will pay any additional costs to out-of-network providers and
facilities directly.
• Generally, your health plan must:
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o Cover emergency services without requiring you to get approval for services in
advance (also known as “prior authorization”).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an
in-network provider or facility and show that amount in your explanation of
benefits.
o Count any amount you pay for emergency services or out-of-network services
toward your in-network deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, contact The Centers for Medicare & Medicare
Services at 1-800-985-3059 or visit https://www.cms.gov/nosurprises, or The Nevada
Department of Insurance -
https://doi.nv.gov/Consumers/Health_and_Accident_Insurance/Balance_Billing_FAQs/
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under
federal law.
F. OTHER SERVICES AND SUPPLIES
1.
Ambulance Services
Ambulance services are covered if the services are Medically Necessary and they are:
• Provided in an Emergency; or
• Provided in a non-Emergency setting when a Prior –Authorization is received
from Us.
A non-contracted Provider of ambulance services or the insured may submit a claim for
reimbursement if that Provider does not receive reimbursement from any other source.
Covered Services include Ambulance Services to the nearest appropriate Hospital.
Hometown Health will make direct payment to a Provider of Ambulance Services if the
Provider does not receive payment from any other source. Ambulance Services will be
reviewed on a Retrospective basis to determine Medical Necessity, as defined by:
1)
Use of ambulance transportation by homebound individuals for non-medical
emergencies. These include:
a.
Ambulance trips to the ER for purpose of filling controlled substance
prescriptions (non-emergent pain)
b.
Ambulance trips to the ER for common cold, sore throat etc.
c.
Ambulance trips to the ER for reasons that any medical professional would
consider blatant non-emergent utilization.
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The Member will be fully liable for the cost of Ambulance Services that are not
Medically Necessary.
2.
Durable Medical Equipment (DME)
Coverage is provided for the purchase, rental, repair, or maintenance of durable medical
equipment prescribed by a Provider for a Medically Necessary condition other than
kidney dialysis.
Durable medical equipment is equipment that:
• Can withstand repeated use;
• Is not disposable;
• Is appropriate for use in the home;
• Is not useful in the absence of an Illness or Injury;
• Is prescribed by a Physician;
• Meets CMS guidelines for coverage; and
• Is not primarily for convenience or comfort, but serves a medical purpose.
Durable medical equipment includes, but is not limited to:
• Oxygen equipment (all oxygen and oxygen related equipment, except for oxygen
while traveling on an airline);
• Wheelchairs;
• Hospital beds;
• Glucose monitors (which may be covered under the pharmacy benefits); and
• Warning or monitoring devices for infants (defined as a child 24 months old or
less) suffering from recurrent apnea.
Coverage will be based on an amount equal to the generally accepted cost of durable
medical equipment that provides the Medically Necessary level of care at the lowest cost.
In determining Our liability, We will be guided by nationally established standards of the
rental or purchase of such equipment.
Items not covered under this benefit include, but are not limited to: dressings, any
equipment or supply to condition the air, appliances, ambulatory apparatus, arch
supports, support stockings, corrective footwear, orthotics or other supportive devices for
the feet, heating pads, personal hygiene, comfort, care, convenience or beautification
items, deluxe equipment, hearing aids, and any other primarily non-medical equipment,
except as otherwise covered and described within this EOC.
Also excluded are exercising equipment, vibratory or negative gravity equipment,
swimming or therapy pools, spas, and whirlpools (even if recommended by a
Professional to treat a medical condition).
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3.
Enteral Formulas and Special Food Products
Enteral formulas and special food products are covered if they are Medically Necessary
for the treatment of an inherited metabolic disease. An inherited metabolic disease is a
disease caused by an inherited abnormality of the body chemistry of a person
characterized by congenital defects or defects arising shortly after birth resulting in
deficient metabolism, or malabsorption originating from amino acid, organic acid,
carbohydrate, or fat. Inherited metabolic diseases do not include obesity. Special food
products do not include foods that are naturally low in protein.
Special food products are only covered if they are Medically Necessary and specially
formulated to have less than one gram of protein per serving and are consumed under the
direction of a Physician for the Medically Necessary dietary treatment of an inherited
metabolic disease.
Special formulas, food supplements, or special diets including, but not limited to, total
parenteral nutrition, except for Acute episodes, are not covered.
4.
Gym Membership
This policy does not include a gym membership.
5.
Hearing Aids
The fitting and cost of hearing aids including both surgical implanted bone conduction
hearing aids and externally worn hearing aids are not covered under this Policy regardless of
the etiology of the deafness.
6.
Home Health Care
Home health care covered under this section includes skilled nursing care, therapies, and
other health related services provided in the home environment for other than
convenience for patient or patient’s family, personal assistance, or maintenance of
activities of daily living or housekeeping. Covered home health care services under this
part include home health care provided by a Professional as the nature of the Illness
dictates.
Excluded from coverage as home health care are:
• Personal care, Custodial Care, Domiciliary Care, or homemaker services;
• In-home services provided by certified nurse aides or home health aides;
• Over-the-counter medical equipment, over-the-counter supplies, or any
Prescription Drugs, except to the extent that they are covered elsewhere in this
EOC.
7.
Hospice Services
The following hospice care services are covered for Members with a life expectancy of
six (6) months or less as certified by his or her Provider (limited to a lifetime benefit
maximum of 185 days):
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• Part-time intermittent home health or respite care services totaling fewer than
eight (8) hours per day and thirty-five (35) or fewer hours per week.
• Outpatient counseling of the Member and his or her immediate family (limited to
five (5) visits for all family members combined if they are not otherwise eligible
for mental health benefits under their specific Policy). Counseling must be
provided by a psychiatrist, psychologist, or social worker. Members who are
eligible for mental health benefits under their specific Policy should refer to the
applicable description of such benefits to determine coverage. Medically
Necessary mental health services may be covered under this Policy in addition to
the outpatient counseling benefits described above.
• Hospice respite care providing nursing care for a maximum of five (5) inpatient
days or five (5) outpatient visits per ninety (90) days of home hospice care.
Inpatient and outpatient hospice care will be authorized only when We determine
that home respite care is not appropriate or practical.
8.
Kidney Dialysis Services
Kidney dialysis services and related therapeutic services and supplies, (e.g., epogen) are
not covered if a member is covered by Medicare or another federal or state program,
other than Medicaid.
Lab and Diagnostic Services
Coverage is provided for Medically Necessary laboratory and diagnostic procedures,
services, and materials, including:
• Diagnostic x-rays;
• Fluoroscopy;
• Ultrasounds;
• Electrocardiograms;
• Complex imaging and diagnostic services including Computer Tomography (CT,
CTA), Positron Emission Tomography (PET), Magnetic Resonance Imaging
(MRI, MRA), Nuclear Medicine, Angiograms and Myelograms; and
• Laboratory tests.
Coverage is provided for medically necessary biomarker testing for the diagnosis,
treatment, appropriate management, and ongoing monitoring of cancer when such
biomarker testing is supported by medical and scientific evidence.
Coverage for breast cancer screening is covered at no cost to the member. Coverage for
diagnostic breast cancer imaging is covered at no cost share to the member, unless the
member is enrolled in a high deductible health plan, in which the member must satisfy the
minimum deductible of the plan prior to the service being covered at no cost share.
Coverage is also provided for other laboratory and diagnostic screenings as well as
Physician services related to interpreting such tests.
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9.
Telemedicine/Telehealth
Covered telehealth services are provided to facilitate the diagnosis, consultation and
treatment, care management and self-management of a patient’s physical and or/mental
health You may receive services while at an originating site and the provider for
telehealth is at a distant site. Services can be provided through the use of information and
audio-visual communication technology or any other method required by applicable law.
Telemedicine does not include communication through, facsimile or email.
Hometown Health will not prevent the use of Telemedicine in a course of treatment or
evaluation. Hometown Health will not prevent the use of Telemedicine based on where
the Provider is located.
A Provider who uses Telemedicine to provide services is responsible for ensuring he or
she complies with all federal and state laws, including licensure, at the location in which
the patient is located. Hometown Health will not pay claims for services provided by
Providers who are not licensed in the state where the patient is located.
Your Cost Sharing for services received through the use of Telemedicine are the same as
if the service were received in person. However, Hometown Health does not control the
methods of treatment and business arrangements between third parties. Therefore, You
may have to pay both the originating site and the Provider located at the distant site.
Additionally, it is Your responsibility to ensure the Providers You use are In-Network
Providers. Failure to use In-Network Providers will result in a higher cost to You.
10.
Other Items
Hometown Health will not deny a claim, refuse to issue or cancel a Policy of health
insurance solely because the claim involves an act that constitutes domestic violence
pursuant to NRS 33.018, or because the person applying for or covered by the health
insurance Policy was the victim of such an act of domestic violence, regardless of
whether the insured or applicant contributed to any loss or Injury.
Hometown Health will not deny a claim, refuse to issue or cancel a Policy of health
insurance solely because the claim involves an Injury sustained by an insured as a
consequence of being intoxicated or under the influence of a controlled substance or
because an insured has made a claim involving an Injury sustained by the insured as a
consequence of being intoxicated or under the influence of a controlled substance, except
in the case of a felony.
11.
Gender Affirming Care
Coverage is provided for Medically Necessary gender affirming care services in
accordance with Nevada Revised Statue.
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G. CONTINUED COVERAGE FOLLOWING TERMINATION OF A PROVIDER
CONTRACT
If a Member is receiving treatment for a medical condition and the treatment is provided by a
Provider whose contract with Hometown Health is terminated (except for termination due to
medical incompetence or Professional misconduct) during the course of medical treatment, the
Member may continue to obtain that medical treatment from the Provider if:
• The treatment is a Medically Necessary Covered Service;
• The Provider and Member agree that the continuity of care is desirable;
• The Provider agrees to all prior terms of the contract between Hometown Health and the
Provider; and
• The Provider agrees not to seek additional payment from the Member for any medical
service provide by the Provider that the Provider could not have received from the
Member were the Provider still under contract with Hometown Health.
Such coverage will continue until the 120
th
day after the date the contract between the Provider
and Hometown Health is terminated or, if the medical condition is pregnancy, the 90
th
day after
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the end of the pregnancy. Such coverage will not continue if the treatment is no longer
Medically Necessary. Such coverage will not continue beyond the termination date of this
Benefit Plan.
H. COVERED SERVICES UNDER THE PHARMACY BENEFIT
Hometown Health Drug Formulary – The Drug Formulary for this Benefit Plan has been selected
to provide all of the therapeutic categories and classes of medications and the choice of
medications within those classes to meet the Essential Health Benefits formulary requirements
for the State of Nevada. This Drug Formulary may be substantially different from other
Hometown Health formularies and may have different requirements for Prior Authorization and
Step Therapy. If an exemption to step therapy is determined, an updated copy of the step therapy
exemption form is available at hometownhealth.com.There is no coverage for medications that
are not listed on this Drug Formulary.
The costs of those medications will not be counted toward Your In-Network or Out-of-Network
Deductible and Out-of-Pocket Maximum Costs.
The Hometown Health Pharmacy and Therapeutics Committee develops the Drug Formulary and
it is comprised of physicians and pharmacists with various medical specialties. The Committee
reviews medications in all therapeutic categories and selects the agent(s) in each class that meet
its criteria for safety, effectiveness, and cost. The Committee meets at least twice a year to
review new and existing medications to ensure that the Drug Formulary remains responsive to
the needs of Members and Providers. A copy of the Drug Formulary is available online at
hometownhealth.com. Inclusion of a drug in the Drug Formulary does not guarantee that a
Provider will prescribe that drug for a particular medical condition.
Nevada state law permits removal or tier movement of Prescription Drugs on January 1
st
and
July 1
st
each year (with some exceptions). If We remove a drug from the Drug Formulary We
will continue to cover that drug if:
• We had previously approved Your utilization of that drug;
• Your Provider determines, after conducting a reasonable investigation, that none of the
drugs which are currently approved for coverage are medically appropriate; and
• The drug is appropriately prescribed; and
• The drug is considered by the FDA to be safe and effective for treating Your medical
condition.
Coverage is available for Generic Drugs, Preferred Brand Drugs, Non-Preferred Brand Drugs,
Specialty Pharmaceuticals, and Diabetic Supplies. Specific benefit levels are detailed in the
Schedule of Benefits that describes Your plan benefits.
Prior Authorization – For certain outpatient Prescription Drugs, a prescribing Physician must
contact Hometown Health to request and obtain coverage for such drugs. Hometown Health will
respond to the Physician once a decision has been made.An updated copy of the list of
Prescription Drugs requiring Prior Authorization is available at hometownhealth.com.
If Prior Authorization is not obtained when necessary, the Member must pay the In-Network
Retail Pharmacy in full for the cost of the Prescription Drug. To be eligible for reimbursement,
the Member is responsible for submitting a request for reimbursement in writing to Hometown
Health. The request must include a copy of the receipt for the cost of the Prescription Drug and
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documentation from the prescribing Physician that the Prescription Drug is Medically Necessary.
If the claim is approved, Hometown Health will directly reimburse the Member the cost of
HTH’s contracted rate for the Prescription Drug, less the applicable Cost Sharing specified in
Your Schedule of Benefits.
Member Responsibility – Benefits are provided for outpatient Prescription Drugs that meet the
requirements specified in this EOC. Members are responsible for paying their Deductible,
Copayments, Coinsurance and Ancillary Charge to the pharmacy at the time their
prescriptions are filled. For Prescription Drug products covered under a Copayment benefit, the
Member is responsible for paying the lesser of the Copayment or the actual retail price of the
Prescription Drug product.
Hometown Health is not responsible for the cost of any Prescription Drug for which the actual
charge to the Member is less than the required Copayment or payment that applies to the
Deductible or for any drug for which no charge is made to the Member. Hometown Health
retains the right to review all requests for reimbursement and, at its sole discretion make
reimbursement determinations subject to the grievance procedure section of the certificate.
Members are required to present their Hometown Health membership card when filling
prescriptions at a pharmacy. A Member who fails to present the Hometown Health ID card may
not be entitled to direct reimbursement from Hometown Health, and the Member may be
responsible for the entire cost of the prescription. If a Member does not use this Policy (does not
use their insurance card) to purchase a Prescription Drug and then requests reimbursement for
the purchase of the Prescription Drug in a non-Emergency, non-Urgent Care situation,
Hometown Health will only reimburse the Member the amount that Hometown Health would
have paid if the Prescription Drug was purchased using the Policy. Because Hometown Health
has access to contract discounts, the amount that Hometown Health pays could be considerably
less than the amount the Member can get without using this Policy, resulting in a much higher
cost to the Member compared to if the Member used this Policy to purchase the drug.
Amounts paid by a drug manufacturer which offer Copayment offset programs (also called
copay savings cards or coupons) do not count toward meeting the calendar year Deductible or
Out-of-Pocket Maximum. You may continue to use these copay cards/coupons to help reduce
Your out-of-pocket costs, however, the dollar value of the card/coupon does not apply toward
Your Deductible or Out-of-Pocket Maximum under Your plan since You don’t pay that amount.
Only the dollars You actually pay out of pocket will count toward Your annual Deductible or
out-of-pocket totals.
In-Network Pharmacies –Non-Emergency and non-Urgent Care prescriptions will be covered
only when filled at an In-Network Retail Pharmacy or the In-Network Mail Order Pharmacy.
Out-of-Network Pharmacies – Out-of-Network Pharmacies may require payment in full for
prescriptions, however reimbursements may be available if the use of an out-of-network
pharmacy was due to an emergency or urgent care situation. Members may file a claim for
reimbursement from Hometown Health provided the claim is received by Hometown Health
within 120 days from the date the prescription was filled. Claim forms are available upon request
from Hometown Health. Charges in excess of the Maximum Allowed Amount for Prescription
Drug products received from an Out-of-Network Pharmacy are the Member’s responsibility.
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1.
90-Day Supplies
Original and refill prescriptions are limited to a 90-day supply at a In-Network Retail
Pharmacy unless otherwise limited by Hometown Health or the drug manufacturer. A
30-day filled prescription is required prior to a 90-day filled prescription. Most
medications to treat Chronic conditions are prescribed in 30 or 90-day supplies. You
may request to receive Your prescriptions in smaller supplies.
2.
Less than a 30-Day Supply
If Your prescriber or pharmacist determines that filling or refilling a prescription for less
than a 30-day supply of a Chronic medication is in Your best interest and You request
less than a 30-day supply, such prescription will be covered at the standard Cost Sharing
for a 30-day supply of that drug. This requirement does not apply to unit-of-use
packaging for which synchronization is not practicable or to a controlled substance.
3.
Mail Order
Some covered Prescription Drug products are available through an In-Network Mail
Order Pharmacy and will be mailed to Your home. Mail order prescriptions are limited to
a 90-day supply unless otherwise limited by Hometown Health, the drug manufacturer or
the FDA. A 30-day filled prescription is required prior to a 90-day filled prescription.
You may be required to fill the prescription at an In-Network Retail Pharmacy before
utilizing the mail order service.
The Copayment for a 90-day supply of a Prescription Drug filled through an In-Network
Mail Order Pharmacy is two times the Copayment of a 30-day supply.
4.
Maintenance Medications
After a Member has had three (3) fills of a particular Maintenance Medication, not to
exceed a 90-day supply at a retail pharmacy, all future prescription refills for that
medication must be obtained through Hometown Health’s In-Network mail-service
pharmacy. Your Plan allows for three (3) retail fills, not to exceed a 90-day supply at a
retail pharmacy, to ensure that You can tolerate the medication with no side effects that
would cause You to stop taking or change the medication. All future refills at a retail
pharmacy will be denied and You must obtain Your medication through the In-Network
mail-service pharmacy unless Hometown Health approves an exception to this
requirement.
5.
Specialty Pharmaceuticals
Many Specialty Pharmaceuticals are biotech medications, using DNA recombinant
technology (genetic replication) as opposed to chemical processes. Specialty
Pharmaceuticals may be delivered in any setting and may include Injectable Drugs or
medications given by other routes of administration, or oral medications.
Most Specialty Pharmaceuticals must be obtained through a specific specialty pharmacy
designated by Hometown Health and are limited to a 30-day supply per script. A list of
drugs classified as Specialty Pharmaceuticals is subject to change at the sole discretion of
Hometown Health.
6.
Preventive Medications
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There will be no cost to the Member for preventive medications prescribed by a
Physician and purchased at an In-Network Retail Pharmacy or In-Network Mail Order
Pharmacy. To be eligible for no Member Cost Sharing, the medication must be
prescribed in accordance with Recommendations A or B issued by the U.S. Preventive
Services Task Force. A list of preventive medications can be found at
hometownhealth.com.:
7.
Contraceptive Products
FDA approved contraceptive products are covered as required by law. The Member must
submit a request for reimbursement in writing to Hometown Health. The request must
include a copy of the receipt for the cost of the product. The following contraceptive
products are covered under this Prescription Drug benefit and are covered as a preventive
benefit with no Member Cost Sharing if it is included in the Prescription Drug
Formulary
2
:
• Combined estrogen and progestin-based drugs (oral contraceptives);
• Progestin-based drugs (oral contraceptives);
• Extended or continuous regimen drugs;
• Estrogen and progestin-based patches;
• Vaginal contraceptive rings;
• Diaphragms with spermicide: One per 365 consecutive day period;
• Sponges with spermicide;
• Cervical caps with spermicide;
• Female condoms;
• Spermicide;
• Combined estrogen and progestin-based drugs for Emergency contraception or
progestin-based drugs for Emergency contraception; and
• Ulipristal acetate for Emergency contraception;
The In-Network Physician will provide insertion and removal of the device. An Office
Visit Copayment or Coinsurance may apply if services during that visit are for more than
the contraceptive visit. There will be no Copayment or Coinsurance for the contraceptive
devices as noted above if dispensed or inserted by an In-Network Provider. A pharmacist
may dispense a self-administered hormonal contraceptive to a patient, regardless of
whether the patient has obtained a prescription from a practitioner, and must provide a
risk assessment questionnaire to a member that requests a self-administered hormonal
contraceptive. Additional benefits also include education and counseling relating to the
initiation of use of contraception and any necessary follow-up after initiating such use,
including management side effects relating to contraception.
2
Assembly Bill 249 (2017) Section 7 & 11
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Hometown Health will not limit refills for any of the above listed services to less than 12
months for contraceptive purposes. Formulary Generic Drug and Brand Drug oral
contraceptives that do not have a generic equivalent (single source brand) will have no
Copayment for the Member. If the Member purchases Brand Drug oral contraceptives
that have a generic equivalent (multi-source brand) the Member will be required to pay
the difference between the Brand Drug and the Generic Drug, as is the case with other
multi-source Brand Drugs. Non-Formulary Drug Copayments will be applied to Non-
Formulary Drug contraceptives. Brand Drug or Non-Formulary Drug contraceptives may
be covered with no Cost Sharing for Members who receive a Prior Authorization. To
receive the Prior Authorization, the Provider must demonstrate to Hometown Health why
the lower cost alternative is not appropriate and that the prescribed Drug is Medically
Necessary.
8.
Diabetic Supplies
Diabetic supplies include insulin, insulin syringes with needles, pen needles, glucose
blood-testing strips, ketone testing strips, lancets and lancet devices. Diabetic supplies
are covered if Medically Necessary upon prescription or upon Physician’s order only at
an In-Network Retail Pharmacies or In-Network Mail Order Pharmacies. The Member
must pay applicable Deductible, Copayments and Coinsurance. Original and refill
prescriptions are limited to a 90-day supply at In-Network Retail Pharmacies unless
otherwise limited by Hometown Health or the drug manufacturer. A 30-day filled
prescription is required prior to a 90-day filled prescription.
9.
Hormone Replacement Therapy
Hormone Replacement Therapy (HRT) Prescription Drugs are covered if approved by the
FDA or required by state or federal law and lawfully prescribed or ordered by a Physician
when Medically Necessary. Certain HRT Prescription Drugs require Prior Authorization.
10.
Topical Ophthalmic Products
Early refills of topical ophthalmic products due to inadvertent wastage, shall be
completed on a refill basis with a valid prescription and authorization, except as
otherwise provided in the Drug Formulary or through the mail order or online
Prescription Drug program.
11.
Cancer Treatment
Drugs covered under the Drug Formulary for use in the treatment of an Illness, disease or
other medical condition will also be covered for the treatment of cancer when Medically
Necessary and approved by the FDA or when required by state and federal law.
Experimental drugs not approved by the FDA nor required by state and federal law, and
used in the treatment of cancer are not covered. Prescription drugs used for the treatment
of cancer require Prior Authorization from Hometown Health.
Orally Administered Chemotherapy will be paid consistently with classification of the
Prescription Drugs as Formulary Generic, Formulary Brand, Formulary Brand with a
Formulary Generic alternative, or Non-Formulary Generic or Brand without a Formulary
alternative. Except for Members on a High Deductible Health Plan and for Members
who select a Non-Formulary drug with a Formulary alternative, the cost to the Member
for Orally Administered Chemotherapy will not exceed $100 per prescription.
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IV. EXCLUSIONS AND LIMITATIONS
This Policy does not cover certain services. This chapter lists the general medical and pharmacy
benefit exclusions of this Policy. Benefits listed as excluded will not be covered by Hometown
Health unless they are explicitly listed as covered elsewhere in the EOC or are otherwise
explicitly covered through a separately purchased benefit rider. Any amount You pay toward
services that are not covered or otherwise excluded will not count toward Your Deductible and
Out-of-Pocket Maximum. Additional exclusions that apply to only a particular service or benefit
are listed in the description of that service or benefit in the EOC and Schedule of Benefits.
A. MEDICAL AND GENERAL EXCLUSIONS
The following services and benefits are excluded from medical coverage under this Benefit Plan.
They may be covered under the pharmacy benefits that may be included in this Benefit Plan if
explicitly indicated that the benefit is covered.
Additional exclusions that apply to only a particular service or benefit are listed in the
description of that service or benefit.
1.
Services which are not Medically Necessary or are not required in accordance with
accepted standards of medical practice or applicable law are excluded.
2.
Complications resulting from procedures, services, medical treatments or medications
that are not covered by this Benefit Plan are excluded.
3.
Treatment for any Injury or Illness related to employment is excluded.
4.
Charges for care or services provided before the effective date or after the termination
date of coverage are excluded.
5.
Charges for copies, presentation and preparation of Your records, charts or x-rays,
completion of insurance forms, creation of medical or dental reports and costs to forward
or mail any such copies, forms, reports, records, charts, or x-rays are excluded.
6.
Any loss, expenses, or charges for claims incurred for the care of a Member when that
loss, expense or charge was a result of that Member’s action for which that Member is
convicted of a felony are excluded. This exclusion is not intended to limit coverage for
victims of a crime, including victims of domestic violence.
7.
Treatment of an illness or injury which is caused by: (a) an act of war (declared or
undeclared); (b) the inadvertent release of nuclear energy when government funds are
available for treatment of illness or injury arising from such release of nuclear energy; (c)
Your participation in the military service of any country; (d) Your participation in an
insurrection, rebellion, or riot; (e) services received as a direct result of Your commission
of, or attempt to commit a felony (upon a guilty plea or guilty verdict) or as a direct result
of Your engagement in an illegal occupation.
8.
Testing and treatment for, non-medical ancillary services such as vocational
rehabilitation, work-hardening programs, job related training requirements and
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employment training and counseling, including services rendered by or billed by a
school or Member of its staff are excluded.
9.
Services related to job, vocational retraining, or community re-entry are excluded.
10.
Any condition for which benefits are recovered or can be recovered, either by
adjudication, settlement, or otherwise, under any workers’ compensation, employer’s
liability law or occupational disease law, even if You do not claim those benefits.
11.
Care for military service-connected disabilities and conditions for which You are legally
eligible to receive from governmental agencies and for which facilities are reasonably
accessible to You are excluded.
12.
Care for conditions that federal, state, or local law requires be treated in a public facility,
care provided under federally or state funded health care programs (except the Medicaid
program), care required by a public entity and care for which there would not normally be
a charge are excluded.
13.
Routine examinations, care or treatment primarily for insurance, immigration, travel,
licensing, school sports, adoption and employment purposes and other third-party
physicals are excluded.
14.
Medical and psychiatric evaluations, examinations, or treatments, psychological testing,
therapy, laboratory and other diagnostic testing and other services including
hospitalizations or Partial Hospitalizations and residential treatment programs that are
ordered as a condition of processing, parole, probation, or sentencing are excluded, unless
We determine that such services are independently Medically Necessary.
15.
Termination of pregnancy is excluded, except in the case of rape, incest, or for a
pregnancy which, as certified by a doctor, places the women in grave danger.
16.
Any services received outside the United States are excluded except services relating to
Emergency.
17.
Air ambulance services that originate or end outside the United States are excluded.
18.
Any Urgent Care services that are received Out-of-Network are excluded.
19.
Travel expenses, accommodations and travel insurance are not covered. Oxygen
provided while traveling on an airline and oxygen concentrators that are supplied for
purchase or rent specifically to meet airline requirements are excluded.
20.
Costs related to room and board for family members are excluded.
21.
Costs related to room and board for the Member are excluded except if the cost is
charged by the Hospital as part of a Medically Necessary inpatient Hospital admission
and the expenses are incurred between the time of admission and the time of discharge.
22.
Any services or supplies furnished in an institution that is primarily a place of rest, a
place for the aged, a custodial facility, or any similar institution or facility are excluded.
23.
Cosmetic surgery or procedures are excluded. Cosmetic surgery generally includes any
plastic or reconstructive surgery or procedure done to improve the appearance of any
portion of the body or restore bodily form without materially correcting a bodily
malfunction.
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Excluded cosmetic surgery or procedures include:
a.
Surgery or treatment to remove sagging or extra skin; any augmentation or
reduction procedures; electrolysis; liposuction; liposculpting; body contouring or
recontouring to remove excess skin on any part of the body including but not
limited to: tummy tucks, belt lipectomies, breast reductions, enhancements or lifts
are excluded;
b.
Laser treatments, rhinoplasty and associated surgery, epikeratophakia surgery,
kerato-refractive eye surgery including but not limited to implants for correction
of presbyopia, correction of facial or breast asymmetry (except that breast
asymmetry will be provided pursuant to coverage as provided in this EOC for
mastectomy benefits), treatment of male-pattern baldness, electrolysis, waxing or
other methods of hair removal, or hair treatment, keloid scar therapy, any
procedures utilizing an implant that cannot be expected to substantially alter
physiologic functions are excluded;
c.
Treatment or service related complications, insertion, removal or revision of
breast implants unless provided post mastectomy are excluded;
d.
Implants that do not improve physical function are excluded;
e.
Psychological and physical factors including but not limited to self-image,
difficult social or peer relations, embarrassment in social situations, inability to
exercise or participate in recreational activities comfortably, or impact on ability
to perform one’s job duties are excluded;
f.
Complications resulting from excluded cosmetic surgery are excluded; and
g.
Complications of medical procedures that result in conditions that affect the
appearance of the body without commensurate impairment of bodily function are
excluded.
h.
Cosmetic procedures to reduce the appearance of varicose veins are excluded.
24.
Cosmetics are excluded.
25.
Treatment for the removal, ablation, injection, or destruction of varicose veins is
excluded unless deemed Medically Necessary.
26.
The removal of port-wine stains is excluded.
27.
Charges that result from appetite control, food addictions, eating disorders (except
documented cases of bulimia or anorexia that meet standard diagnostic criteria as
determined by Us and present significant symptomatic medical problems) or any
treatment of obesity, unless otherwise provided in the EOC are excluded.
28.
Dietary supplements, anti-aging treatments (even if FDA-Approved for other clinical
indications), vitamins, diet pills, health or beauty aids, vitamin B-12 injections (except for
pernicious anemia, other specified megaloblastic anemias not elsewhere classified,
anemias due to disorders of glutathione metabolism, post-surgery care or other b-
complex deficiencies), antihemophilic factors including tissue plasminogen activator
(TPA), acne preparations, and laxatives (except as otherwise covered and described
within the EOC and Schedule of Benefits) are excluded.
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29.
Natural and herbal remedies that may be purchased without a prescription (over the
counter), through a web site, at a Physician or chiropractor’s office, or at a retail location
are excluded unless otherwise specified in this EOC and Your Schedule of Benefits.
30.
Aroma therapy, massage therapy, reiki therapy, thermograph, orthomolecular therapy,
contact reflex analysis, Bio-Energetic Synchronization Technique (B.E.S.T.), colonic
irrigation, magnetic innervation therapy and electromagnetic therapy are excluded.
31.
Charges related to the acquisition or use of marijuana are excluded, even if used for
medicinal purposes.
32.
Except as otherwise provided in the EOC, drugs, medicines, procedures, services, and
supplies to correct or enhance erectile function, enhance sensitivity, or to alter the shape
or appearance of a sex organ, or for sexual dysfunction (organic or inorganic),
inadequacy, or enhancement, including penile implants and prosthetics, injections, and
durable medical equipment are excluded.
33.
Any off-label use of growth hormone is excluded;
34.
Coverage for human growth hormone or equivalent is excluded unless specifically
covered and described within the EOC.
35.
Cryopreservation or storage charges for collection and storage of biologic materials,
including umbilical cord blood, for artificial reproduction or any other purpose are
excluded.
36.
Platelet rich plasma and stem cell related musculoskeletal injections are excluded.
37.
All experimental or investigational medical, surgical, or other health care procedures and
all transplants are excluded except as otherwise described within the EOC. We will
consider a procedure or treatment as experimental or investigational as follows:
a.
If outcome data from randomized controlled clinical trials, recommendations from
consensus panels, national medical associations, or other technology evaluation
bodies and from authoritative, peer-reviewed US medical or scientific literature:
i.
Is insufficient to show that the procedure or treatment is safe, effective, or
superior to existing therapy; or
ii.
Does not conclusively demonstrate that the service or therapy improves
the net health outcomes for total appropriate population for whom the
service might be rendered or proposed over the current diagnostic or
therapeutic interventions, even in the event that the service, drug,
biological, or treatment may be recognized as a treatment or service for
another condition, screening, or Illness;
b.
If the procedure or treatment has not been deemed consistent with accepted
medical practice by the National Institutes of Health, the Food and Drug
Administration, or Medicare;
c.
When the drug, biologic, device, product, equipment, procedure, treatment,
service, or supply cannot be legally marketed in the United States without the
final approval of the Food and Drug Administration or any other state or federal
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regulatory agency, and such final approval has not been granted for that particular
indication, condition, or disease;
d.
When a nationally recognized medical society states in writing that the procedure
or treatment is experimental; or
e.
When the written protocols used by a facility performing the procedure or
treatment state that it is experimental.
f.
Hometown Health has the sole authority and discretion to identify and weigh all
information and determine all questions pertaining to whether a drug, biologic,
device, diagnostic, product, equipment, procedure, treatment, service or supply is
experimental or investigational.
. Refer to the Clinical Trials section (Chapter III, Part A, Item 7 – Clinical Trials) of this
EOC for more information.
38.
Experimental, ecological, or environmental medicine is excluded, including, but not
limited to the use of chelation or chelation therapy except for Acute arsenic, gold,
mercury, or lead poisoning; orthomolecular substances; use of substance of animal,
vegetable, chemical or mineral origin not FDA-Approved as effective for such treatment;
electrodiagnosis; Hahnemannian dilution and succession; prolotherapy, magnetically
energized geometric patterns, replacement of metal dental fillings, laetrile, and gerovital.
39.
Charges for the fitting and cost of visual aids, vision therapy, eye therapy, orthoptics with
eye exercise therapies, refractive errors including but not limited to eye exams and
surgery done in treating myopia (except for corneal graft), ophthalmological services
provided in connection with the testing of visual acuity for the fitting for eyeglasses or
contact lenses, eyeglasses or contact lenses (except coverage for the first pair of
eyeglasses or contact lenses following cataract surgery) and surgical correction of near or
far vision inefficiencies such as laser and radial keratotomy are excluded, except as
otherwise specified in this EOC and Your Schedule of Benefits.
40.
Orthotic braces that straighten or change the shape of a body part are excluded.
41.
Cranial helmets are excluded except for cranial helmets used to facilitate a successful
post-surgical outcome.
42.
Orthopedic shoes, foot orthotics or other supportive devices of the feet are excluded,
except when such devices are:
a.
An integral part of a covered leg brace and its Expense is included as part of the
cost of the brace:
b.
For diabetes mellitus and for foot deformity, history of pre-ulcerative calluses,
history of previous ulceration, peripheral neuropathy with evidence of callus
formation, poor circulation or previous amputation of the foot or part of the foot:
c.
For rehabilitation prescribed as part of post-surgical or post-traumatic casting
care; or
d.
Prosthetic shoes for members with a partial foot.
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43.
Over-the-counter support hose or compression socks are excluded even if ordered by a
Physician. Custom hose that must be measured and made specifically for the patient will
be covered only for the treatment of burns or lymphedema.
44.
Modifications to vehicles, the purchase of medical vehicles or ambulances and the
purchase of vehicles with or without lifts or other modifications are excluded.
45.
Physician services, supplies, and equipment relating to the administration or monitoring
of a Prescription Drug are excluded unless the Prescription Drug is a Covered Service.
46.
Barrier-free and other home modifications are excluded.
47.
All gym membership fees and/or fees for services received at a gym are excluded,
including:
a.
Gym memberships for You and Your child and/or adult dependents;
b.
Services provided by personal trainers or exercise physiologists are excluded even
if recommended by a Professional to treat a medical condition; and
48.
Membership fees charged by Providers as a condition of treatment, for example,
concierge medicine, are excluded.
49.
Care or treatment of marital or family problems, occupational, religious, or other social
maladjustments, behavior disorders, situational reactions, and hypnotherapy is excluded.
50.
Religious or spiritual counseling is excluded.
51.
Stress reduction therapy or cognitive behavior therapy for sleep disorders is excluded.
52.
Charges for cognitive therapy are excluded unless related to short-term services
necessitated by a catastrophic neurological event to restore functioning for activities of
daily living.
53.
Sleep therapy (except for central or obstructive apnea when Medically Necessary with a
Prior Authorization), behavioral training or therapy, milieu therapy, biofeedback,
behavior modification, sensitivity training, hypnosis, electro hypnosis, electrosleep
therapy, electronarcosis, massage therapy, and gene therapy are excluded.
54.
Treatment of mental retardation or Down Syndrome that a federal or state law mandates
that coverage be provided and paid for by a school district or other governmental agency
is excluded.
55.
HTH does not cover treatments or services that are a primary responsibility of a school or
school district
56.
Services designed to treat infertility conditions are excluded.
57.
Pediatric and adult dental services are excluded, except as otherwise provided in this
EOC.
58.
Pediatric and adult vision services are excluded, except as otherwise provided in this
EOC.
B. DRUGS (MEDICAL & PHARMACY) BENEFIT EXCLUSIONS
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Medically Necessary Prescription Drugs are only covered as set forth in this EOC. The
following services and benefits are excluded from coverage under this Policy.
1.
Drugs not Medically Necessary or not required in accordance with accepted standards of
medical practice or applicable law are excluded.
2.
Drugs to treat complications resulting from procedures, services, medical treatments or
medications that are not covered by this Benefit Plan are excluded.
3.
Any charges for the administration or injection of Prescription Drugs or Injectable insulin
and other Injectable Drugs covered by Hometown Health are excluded.
4.
Any refill or administration of a drug in excess of the amount specified by the
prescription order is excluded. For Prescription Drugs provided as a 30 day supply, any
refill provided prior to 22 days after the previous fill is excluded unless the Member
receives Prior Authorization. Before recognizing charges, Hometown Health may require
a new prescription or evidence as to need if a prescription or refill or administration of a
drug appears excessive under accepted medical practice standards.
5.
Compounded medications except for compounded medications for palliative care with
Prior Authorization are excluded.
6.
Cosmetics or any drugs used for cosmetic purposes or to promote hair growth even for
documented medical conditions, including but not limited to health and beauty aids are
excluded.
7.
Dietary or nutritional products or appetite suppressants or other weight-loss medications
(such as appetite suppressants, including the treatment of obesity) whether prescription or
over-the-counter are excluded.
8.
Vitamins are excluded except those prescribed prenatal vitamins and vitamins with
fluoride that require a prescription and are listed on the Drug Formulary.
9.
Drugs dispensed by other than a In-Network Retail Pharmacy, In-Network Mail Order
Pharmacy, or In-Network Specialty Pharmacy are excluded except as Medically
Necessary for treatment of an Emergency or Urgent Care condition.
10.
Drugs listed on the Formulary Exclusions List (available in the applicable HometownRx
Formulary), designated as Non-Formulary, not included on the Formulary, or included in
the Medical Prior Authorization Matrix Exclusions List are excluded.
11.
Drugs prescribed by a Provider not acting within the scope of his or her license are
excluded.
12.
Drugs listed by the FDA as “less than effective” (DESI drugs) are excluded.
13.
Experimental and investigational drugs, including drugs labeled “Caution-limited by
Federal Law to Investigation use” are excluded.
14.
Drugs either not approved by the FDA as “safe and effective” as of the date this Benefit
Plan was issued or, if so approved, that the FDA has not approved for either inpatient or
outpatient use are excluded.
15.
Drugs prescribed for a use, condition or diagnosis that was not included in the FDA’s
approval of the drug (off-label prescribed drugs) are excluded.
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16.
Fertility drugs, drugs for gene therapy, laxatives unless otherwise provided herein or
pursuant to the EOC and nutritional additives or any prescription medication or
formulation with nutritional or vitamin additives are excluded
17.
Growth hormone drugs for persons 18 years or older are excluded. Growth hormone
therapy for the treatment of documented growth hormone deficiency in children for
whom epiphyseal closure has not occurred is covered when a Prior Authorization is
received and the drugs are supplied by Hometown Health’s In-Network vendor for the
medication.
18.
Immunization or immunological agents, including but not limited to biological sera,
blood, blood plasma or other blood products administered on an outpatient basis,
antihemophilic factors, including tissue plasminogen activator (TPA), allergy sera and
testing materials, unless otherwise provided herein or pursuant to the EOC are excluded.
19.
Medical supplies, devices and equipment and nonmedical supplies or substances are
excluded regardless of their intended use.
20.
Medications approved by the FDA for less than six months are excluded unless the
Hometown Health Pharmacy and Therapeutics Committee, at its sole discretion, decides
to waive this exclusion with respect to a particular drug.
21.
Medications for impotence or erectile/sexual dysfunction are excluded.
22.
Medication consumed or administered at the place where it is dispensed or while a
Member is in a Hospital or similar facility are excluded. Take-home prescriptions
dispensed from a Hospital pharmacy upon discharge are excluded unless the pharmacy is
an In-Network Retail Pharmacy.
23.
Over-the-counter drugs, medicines and other substances for which a prescription order is
not required regardless of whether the drug was prescribed by a Physician, or for which
an over-the-counter product equivalent in strength is available are excluded, unless the
drug is required to be covered by law.
24.
Drugs consumed in a Physician’s office other than immunizations, allergy serum, and
chemotherapy drugs are excluded except as otherwise provided in this EOC.
25.
Performance, athletic performance or lifestyle enhancement drugs and supplies are
excluded.
26.
Prescription drugs purchased from outside of the United States are excluded except from
Canadian pharmacies licensed by the Nevada State Board of Pharmacy. A list of licensed
Canadian pharmacies can be found on the Nevada State Board of Pharmacy website:
www.bop.nv.gov.
27.
Prescription medications that are available without charge under local, state or federal
programs, including worker’s compensation or occupational disease laws, or medication
for which a charge is not made are excluded.
28.
Prescription refills dispensed more than one year from the date the latest prescription
order was written or as otherwise permitted by applicable law of the jurisdiction in which
the drug was dispensed are excluded.
29.
Prophylactic drugs and immunizations for travel are excluded.
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30.
Quantities in excess of a 90-day supply are excluded. Prescriptions requiring quantities
in excess of the above amount, including early refills of ophthalmic products due to
inadvertent wastage, shall be completed on a refill basis with a valid prescription and
authorization, except as otherwise provided in the Drug Formulary or through the mail
order or online Prescription Drug program.
31.
Replacement of lost, stolen, spoiled, expired, spilled or otherwise mishandled medication
is excluded.
32.
Prescription orders filled or Drug orders filled or administered before the effective date or
after the termination date of the coverage provided by this Benefit Plan are excluded.
33.
Test agents and devices are excluded, except for diabetic test agents.
Additional Pharmacy Limitations –
1.
An In-Network Retail Pharmacy may refuse to fill a prescription order or refill when in
the Professional judgment of the pharmacist the prescription should not be filled.
2.
Non-Emergency and non-Urgent Care prescriptions will be covered only when filled at
an In-Network Retail Pharmacy.
3.
After a Member has had three (3) fills of a particular Maintenance Medication, not to
exceed a 90-day supply at a retail pharmacy, all future prescription refills for that
medication must be obtained through Hometown Health’s In-Network mail-service
pharmacy. Your Plan allows for three (3) retail fills, not to exceed a 90-day supply at a
retail pharmacy, to ensure that You can tolerate the medication with no side effects that
would cause You to stop taking or change the medication. All future refills at a retail
pharmacy will be denied and You must obtain Your medication through the In-Network
mail-service pharmacy, unless Hometown Health approves an exception to this
requirement.
4.
Members are required to present their ID cards at the time the prescription is filled. A
Member who fails to verify coverage by presenting the ID card will not be entitled to
direct reimbursement from Hometown Health, and the Member will be responsible for
the entire cost of the prescription.
5.
If a Member does not use this Policy (does not use their insurance card) to purchase a
Prescription Drug and then requests reimbursement for the purchase of the Prescription
Drug in a non-Emergency, non-Urgent Care situation, Hometown Health will only
reimburse the Member the amount that Hometown Health would have paid if the
Prescription Drug were purchased using the Policy. Because Hometown Health has
access to contract discounts, the amount that Hometown Health pays could be
considerably less than the amount the Member can get without using this Policy, resulting
in a much higher cost to the Member compared to if the Member used this Policy to
purchase the drug.
6.
Hometown Health retains the right to review all requests for reimbursement and, at its
sole discretion make reimbursement determinations subject to the grievance procedure
section of the certificate.
7.
Hometown Health is not responsible for the cost of any Prescription Drug for which the
actual charge to the Member is less than the required Copayment or payment that applies
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to the Prescription Drug Deductible amount or for any drug for which no charge is made
to the recipient.
8.
The contracted reimbursement rate for In-Network pharmacies does not include amounts
that Hometown Health may receive under a rebate programs offered at the sole discretion
of individual pharmaceutical manufacturers.
C. OVERALL LIMITATIONS
If the provision of Covered Services provided under this Policy is delayed or rendered
impractical due to circumstances not within Our control, including but not limited to a major
disaster, epidemic, the complete or partial destruction of facilities, riot, civil insurrection,
disability of a significant part of Our Providers’ personnel, or similar causes, We will make a
good faith effort to arrange for an alternative method of providing coverage. In such event, We
and Our Providers will render the Covered Services provided under this Policy insofar as
practical and according to their best judgment; but We and Our Providers shall incur no liability
or obligation for delay, or failure to provide or arrange for services if such failure or delay is
caused by such an event.
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V. UTILIZATION MANAGEMENT PROGRAM
The utilization management program uses set criteria and protocols to ensure that the most cost-
effective preventive, Acute, and Tertiary Care is provided to Our Members consistent with the
provision of quality care. You may be subject to a reduction in benefits if You do not comply
with this utilization management program. Our utilization management program is conducted
with Our written policies and procedures under the direction of Our Medical Director.
B.
Delivery of Services
You are entitled to receive Medically Necessary medical care and services as specified in Your
Schedule of Benefits and this EOC. These include medical, surgical, diagnostic, therapeutic, and
preventive services. . These services generally:
1.
Are provided in Our Geographic Service Area;
2.
Are performed or ordered by an In-Network Provider; and
3.
Require a Prior Authorization according to Our utilization management and quality
assurance protocols, if applicable. If a Prior Authorization is required and You do not
obtain the required Prior Authorization, You may be subject to a reduction in benefits or
the service may not be covered, even if the service is Medically Necessary.
A determination that a service is Medically Necessary is not an authorization to receive that
service from an Out-of-Network Provider.
HMO
EPO
PPO
• As a Member of HTH, Your HMO plan has a Network of healthcare providers
available to You. If the health care services are not available within the Network,
then Your Provider must contact Our Utilization Management department to request
a review for an Out-of-Network Provider. Our determination will be sent to You and
Your Provider and will specify the approved procedure and servicing Provider.
• As a Member of HTH, Your EPO plan has a Network of healthcare providers
available to You. If the health care services are not available within the Network,
then Your Provider must contact Our Utilization Management department to request
a review for an Out-of-Network Provider. Our determination will be sent to You and
Your Provider and will specify the approved procedure and servicing Provider.
• As a member of HTH, Your plan has a Network of healthcare providers available to
You Under Your PPO plan, You have the flexibility to utilize providers that are not a
part of Our Network. When You choose to see an Out-Of-Network Provider, You may
have to pay the higher, Out-Of-Network Cost Sharing amount and You may be subject
to balance billing. For additional information refer to the Schedule of Benefits for
your plan. If the health care services are not available within the Network, then Your
Provider should contact Our Utilization Management department to request a review.
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Our determination will be sent to You and Your Provider and will specify the
approved procedure and servicing Provider.
As a Member of Hometown Health, Your plan has a Network of healthcare providers available
to You. If the health care services are not available within the Network, then Your Provider must
contact Our Utilization Management department to request a review for an Out-of-Network
Provider. Our determination will be sent to You and Your Provider and will specify the approved
procedure and servicing Provider.
C.
Scope of the Program
Under the utilization management program, a Prior Authorization is required for referrals to
Physicians and Providers for certain services. All benefits listed in this EOC may be subject to
Prior Authorization requirements and concurrent review depending upon the circumstances
associated with the services. Refer to Your Schedule of Benefits for services that require Prior
Authorization. You may find a full list of services that require Prior Authorization at
hometownhealth.com.
We should be notified upon confirmation of pregnancy so We may better manage Your benefits.
You must comply and cooperate with the utilization management program. Services that require
Prior Authorization are subject to all of the terms of Your specific Policy.
D.
Approval and Prior Authorization Process
In certain cases, as set forth below, in order for a benefit to be covered, You must receive a Prior
Authorization for the service. We use nationally recognized criteria and internal medical Policy
guidelines, as reviewed periodically by Our Utilization Management and Quality Improvement
Committee, as the standard measurement tool to determine whether benefits are approved and/or
authorized. Prior Authorization is provided within 14 days for most service requests.
1.
Hospital Admissions
You are responsible for notifying Us of a Hospital stay, and You receive Prior
Authorization, before elective admission to a Hospital to ensure that it is covered. Your
Physician or other Provider may notify Us but it is ultimately Your responsibility to make
sure We are notified. We will review the Provider’s recommendation to determine level of
care and place of service. If We deny authorization for Hospital admission as not covered
or We determine that the services do not meet Our criteria and protocols, We will not pay
the Hospital or related charges.
2.
Inpatient and Outpatient Surgery
You are responsible for making sure We are notified, and You receive Prior
Authorization, before elective inpatient or outpatient surgery is performed to ensure that
it is covered. Your Physician or other Provider may notify Us but it is ultimately Your
responsibility to make sure We are notified. We will review the Physician’s
recommended course of treatment.
We will pay benefits only for inpatient/outpatient surgery that We authorize. We will not
pay for inpatient or outpatient surgery or related charges if We determine that such
charges are not a Covered Service or do not meet Our criteria and protocols.
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3.
Emergency and Urgent Hospital Admissions
An Emergency Hospital admission means an admission for Hospital confinement that
results from a sudden and unexpected onset of a condition that requires medical or
surgical care. In the absence of such care, You could reasonably be expected to suffer
serious bodily Injury or death. Examples of Emergency Hospital admissions include, but
are not limited to, admissions for heart attacks, severe chest pain, burns, loss of
consciousness, serious breathing difficulties, spinal Injuries, and other Acute conditions.
An urgent Hospital admission means an admission for a medical condition resulting from
Injury or serious Illness that is less severe than an Emergency Hospital admission but
requires care within a short time, including complications of pregnancy.
For an Emergency or urgent Hospital admission (including for all covered complications
of pregnancy), You are responsible for making sure that We are notified within 24 hours,
the next business day, or as soon as reasonable after admission. If You are incapacitated
and You (or a friend or relative) cannot notify Us within the above stated times, We must
receive notification as soon as reasonably possible after the admission or You may be
subject to reduced benefits as provided in Your specific Policy.
4.
Healthcare Services and Supplies Review
In-Network Providers may notify Us on Your behalf to obtain Prior Authorization for the
services described in Part C – Scope of the Program above.
Out-of-Network Providers may not know or attempt to notify Us to obtain Prior
Authorization for services. In such a case, You must confirm that a Prior Authorization
has been provided for the service to assure that the service is covered.
We will pay for covered health care services and supplies only if authorized as outlined
above. We will not pay for any healthcare services or supplies that are not Covered
Services or do not meet Our criteria and protocols.
E.
Site of Care
HTH supports efforts, where medically appropriate, to treat patients at nonhospital facilities or in
the comfort of their home.
Providers will utilize a designated site-of-care preferred by Hometown Health for the specified
non-self-administered drug. In-network options include independent infusion centers and home
infusion or the medication may be administered in a physician’s office.
The starting dose(s) of the medication subject to this policy may be given at the physician’s
facility of choice only when multiple administrations are required. This includes hospital
outpatient facilities, non-hospital outpatient facilities and home care. If a therapy is represented
by a single administration, the policy applies to the first administration. All subsequent doses are
subject to the HTH Site of Care for Drug Administration policy, which requires the use of non-
hospital outpatient facilities or home care.
Documentation must be provided for review of Medical Necessity exceptions.
Criteria for medical necessity;
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1.
The member is new to therapy or reinitiating therapy after not being on therapy for at least
6 months.
2.
The member is switching to a product that he/she has not received before.
3.
The member has experienced a gap in therapy.
For situations where administration of the medication does not meet the criteria for outpatient
hospital administration, coverage for the medication is provided when administered in alternative
sites such as; physician office, home infusion or ambulatory care.
F.
Concurrent Review and Case Management
After admission to a facility, We will continue to evaluate the patient’s progress to monitor
appropriate level of care and services. If, after consulting with the Physician or a representative
of Your treatment team or the Hospital case management team, We determine a lower level of
care is appropriate or a service does not meet Our criteria standards, HTH may arrange for the
return of the member to the geographic service area through medical, non-emergent transport
options, that HTH will cover the cost, if the member refuses or is unable to return by their own
means. If these conditions are not met HTH will not extend continued authorization. We use
nationally recognized criteria and internal medical Policy guidelines as the standard
measurement tool for this process for Acute care facilities. We also use nationally recognized
criteria as the standard assessment tool for skilled nursing facilities, rehabilitation facilities and
mental health and substance abuse facilities and programs.
Case management is a service provided by Us to coordinate all services or alternate methods of
medical care or treatment that may be used in replacement of or in combination with Hospital
confinement. Our case managers will work in coordination with the attending Physician or other
Professionals and community resources to develop a plan of treatment per the benefit level of
this Policy. Discharge planning may be initiated at any stage of the process, and begins
immediately upon identification of post discharge needs during Prior Authorization or concurrent
review.
G.
Retrospective Review
We evaluate the medical records of those Members whose medical treatment or Hospital stay
was not reviewed under authorization, Prior Authorization, or concurrent review as described
above.
We will pay benefits only for those days or treatment that would have been authorized under the
utilization management program.
H.
Second Opinions
We will authorize a second opinion upon Your request in accordance with the terms of Your
specific Policy. Examples of instances where a second opinion may be appropriate include:
1.
Your Physician has recommended a procedure and You are unsure whether the procedure
is necessary or reasonable;
2.
You have questions about a diagnosis or plan of care for a condition that threatens
substantial impairment or loss of life, limb, or bodily functions;
3.
You are unclear about the clinical indications about Your condition;
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4.
A diagnosis is in doubt due to conflicting test results;
5.
Your Physician is unable to diagnose Your condition; and
6.
A treatment plan in progress is not improving Your medical condition within a
reasonable period of time.
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VI. RELATIONSHIP OF PARTIES
A.
Independent Contractors
Our relationship with Our In-Network Physicians and Providers is that of an independent
contractor relationship. Providers are not Our agents or employees nor are We, or any of Our
employees, an employee or agent of the Providers. We are not liable for any claim or demand
because of damages arising out of, or in any manner connected with, any Injuries that You suffer
while receiving care from any Provider or in any Provider’s facilities.
B.
Provider Relationship with Patient
We are not responsible for and will not intervene in the provision of medical services by a
Provider to his or her patient. The traditional relationship between a Provider and a patient will
be maintained and the Provider retains full control of and authority of all medical decisions and
recommendations regarding medical treatment. Our determination that a particular course of
medical treatment is not a Covered Service or is inconsistent with Our criteria and protocols shall
not be considered a medical determination. The Provider maintains full authority and
responsibility for all medical determinations regardless of the availability of coverage for any
such medical treatment.
C.
Groups and Members
Neither any Group nor any Member is Our agent or representative.
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VII. ELIGIBILITY AND ENROLLMENT
This chapter describes Hometown Health’s eligibility and enrollment requirements. It provides
the Who, When and How of eligibility and enrollment:
1.
Who is eligible for coverage?
2.
When can You enroll in or change coverage and when are those changes effective?
3.
How do You enroll in coverage?
You and Your dependents may not enroll in this Policy unless You meet the requirements
provided in this chapter, You provide Your enrollment information within the time periods
described here and payment is made by the applicable due dates.
A. WHO IS ELIGIBLE FOR COVERAGE?
The following describes those individuals who may enroll in this Policy.
1.
Subscriber
The Subscriber is a person who meets all applicable eligibility requirements of this EOC,
whose enrollment form has been accepted by Hometown Health and in whose name the
membership is established. The Subscriber is the employee. To be eligible for
membership as a Subscriber under this EOC, You must:
• Be a United States citizen, national or lawfully present non-citizen for the entire
period for which coverage is sought;
• Be a legal resident of the United States;
• Reside in Nevada;
• Be an employee of an employer whose principal place of business is in the
Geographic Service Area where the plan is offered;
• Agree to pay for the cost of Premium as required by Your employer;
• Not be incarcerated (except pending disposition of charges);
• Be an employee who regularly works 30 or more hours per week and satisfy Your
employer’s eligibility provisions, including any probationary or waiting period
requirements;
• Complete and submit all enrollment forms and other required documents; and
• Satisfy any probationary or waiting period requirements.
2.
Dependents
A Subscriber may enroll an eligible dependent during the appropriate enrollment period if
the dependent is listed on the Subscriber’s enrollment application and all other required
documents are completed and submitted to Us. A dependent may not enroll in this
Benefit Plan if the employee is not also enrolled. Please note that Your employer may
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choose to not offer employer sponsored coverage to spouses, domestic partners and/or all
children. Your employer may do this to allow Your dependents to be eligible for tax
credits through the state exchange.
The following is a list of dependents that may be enrolled in a Hometown Health plan, if
eligible pursuant to the other rules found in this EOC and Your employer’s eligibility
provision:
• The Subscriber‘s lawful spouse (We may require You submit a marriage
certificate);
• The Subscriber’s lawful domestic partner if the Subscriber provides to Us a
current Domestic Partnership Certificate issued by a state or county government
upon request;
• A natural child, stepchild, or legally adopted child of either the Subscriber, the
Subscriber’s spouse, or the Subscriber’s domestic partner, provided that the child
is under age 26;
3
i.
A newborn child, adopted child or child placed for adoption will be
eligible for coverage effective on the child’s date of birth, adoption or
placement for adoption (as applicable). Coverage for the child will cease
after 31 days unless the Subscriber enrolls the child within the appropriate
enrollment period. We require a copy of the birth certificate, adoption
certificate or certification of placement by the placing agency.
During the first 31 day-period after birth adoption or placement for
adoption, coverage for the child shall consist of Medically Necessary care
for Injury and sickness, including well child care and treatment of
medically diagnosed congenital defects and birth abnormalities. All
services provided during the first 31 days of coverage are subject to the
Cost Sharing requirements such as Deductibles, Copayments and
Coinsurance that are applicable to other sicknesses, diseases and
conditions otherwise covered.
4
“Placement for adoption” means circumstances under which a Subscriber
assumes or retains a legal obligation to partially or totally support a child
in anticipation of the child’s adoption. Coverage for a child to the child’s
placement for adoption is subject to certification of the child’s placement
by the placement agency. A placement terminates when the legal
obligation for support terminates.
If the Subscriber is not the natural parent or the adoptive parent, but rather,
the spouse or domestic partner is the natural parent or adoptive parent, and
the date of birth, adoption or placement for adoption occurs before the
date of marriage or domestic partnership, eligibility for coverage for the
child begins when the spouse or domestic partner becomes eligible for
coverage.
3
45 CFR § 147.120
4
NRS 689A.043; NRS 689B.033
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ii.
Step-children (children of the spouse or domestic partner) become eligible
for coverage no earlier than the date the spouse or domestic partner
becomes eligible for coverage. If You choose not to enroll Your spouse or
domestic partner, but You would like to enroll Your spouse’s or domestic
partner’s child, in addition to the standard documentation required for a
child, You will also be required to provide the applicable marriage
certificate or domestic partnership certificate linking the child to You
through Your spouse or domestic partner.
• A disabled child age 26 or older is eligible for coverage if all of the following
requirements are met:
i.
The child is a natural child, stepchild, or legally adopted child of either the
Subscriber, the Subscriber’s spouse, or the Subscriber’s domestic partner;
ii.
The child is incapable of self-sustaining employment due to a physical
handicap or an intellectual disability;
iii.
The child is dependent on the Subscriber, the Subscriber’s spouse or the
Subscriber’s domestic partner for support and maintenance;
iv.
The child’s condition originated before the child reached the age of 26;
and
v.
Documentation from the Social Security Administration showing the
dependent child was deemed permanently disabled prior to the age 26.
This document must be received no later than 31 days after the dependent
child turns 26. Once the document is received, the dependent child may
be covered under the Subscriber for the remainder of the Subscriber’s
coverage period provided appropriate premiums are received. If
approved, ongoing documentation from the Social Security Administration
will be required annually and thereafter beginning two years after the child
reaches age 26.
• A child for whom there is a Qualified Medical Child Support Order (QMCSO) or
other court order. Generally, a QMCSO is an order or judgment from a court or
produced as a result of a state-authorized administrative process directing the
Subscriber, covered spouse, or covered domestic partner to provide coverage to
an eligible dependent. The date the court order is effective is the date indicated
on the QMCSO or, if the QMCSO does not include a specific date of coverage,
the date the QMCSO was signed by the court.
• A legal ward of the Subscriber, spouse or domestic partner is eligible for coverage
if the child is a legal ward (pursuant to court order) permanently placed in the
home of the Subscriber, spouse or domestic partner and meets the other eligibility
provisions of this EOC. You will be required to provide a copy of the court order.
Foster children, legal wards not permanently placed in the Subscriber’s home,
children placed in the Subscriber’s home, or any other person not defined within
this section are not eligible dependents.
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• A child born to a surrogate is eligible for coverage in the same manner that a
natural child described in paragraph (c) above is covered if the intended parent is
a Member.
If the intended parent is not a Member, then then child born to a surrogate is not
eligible for coverage, even if the surrogate is a Member. The child is not eligible
for coverage during the first 31 days of life, nor is the child eligible for coverage
as a dependent of the Member.
5
Dependents of a dependent child are not eligible for coverage other than the first 31 days
of life.
B. WHEN CAN YOU ENROLL OR CHANGE COVERAGE?
There are very specific rules regarding when a person can enroll in or change coverage and when
the changes take effect. These rules help protect Us from adverse selection and help Us keep
Your premiums as low as possible. The following enrollment periods describe when You and
Your dependents can enroll or change coverage and when Your coverage will become effective.
There is no coverage for services received or rendered to the Member prior to the effective date
of the Member’s coverage.
1.
Open Enrollment Period
Open Enrollment is just that – open. If You are eligible for coverage under the Benefit
Plan, You may enroll in the Benefit Plan during the Open Enrollment Period, provided
You have satisfied any probationary or waiting period requirements described in Your
employer’s eligibility provisions. Your eligible spouse or domestic partner and
dependents may also enroll in this Benefit Plan during the Open Enrollment Period if
Your employer extends eligibility to spouses, domestic partners or dependents. Coverage
will be effective on the Group’s initial effective date or on the Group’s Policy renewal
date.
6
2.
Qualifying Life Events
There are certain events in Your life, such as a birth or marriage, which allow You to
enroll in coverage
7
. These Qualifying Life Events create a Special Enrollment period
(outside of the annual Open Enrollment Period) during which time You can enroll in this
Benefit Plan or enroll in another plan offered by Your employer (if You are eligible to
enroll in that plan).
In the case of birth, adoption or placement for adoption, You have 31 days to request
special enrollment for this Benefit Plan.
8
If You, Your spouse, or Your dependent has his
or her coverage under a Medicaid plan or State Children’s Health Insurance Program
(CHIP) terminated due to loss of eligibility or becomes eligible for Premium assistance in
5
Assembly Bill 472 (2019)
6
45 CFR § 147.104(b)(1)(i)
7
45 CFR § 146.117(d)
8
NRS 689B.033
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connection with coverage under this Policy through Medicaid or CHIP, You may
retroactively add coverage for that person if You request such coverage no later than 60
days after the date of such termination of coverage or eligibility for Premium assistance
under Medicaid or CHIP.
9
For all other Qualifying Life Events, You have 30 days to
request special enrollment for this Benefit Plan.
10
If You do not complete the enrollment
application in that time period and provide any other necessary documentation upon
request, You and Your dependents will not be allowed to enroll until Your employer’s
next Open Enrollment Period, unless another Qualifying Life Event occurs. If You
change plans due to a Qualifying Life Event, the amounts that You have paid toward
Your Deductible and Out-of-Pocket Maximum in Your old plan will not count toward
Your new plan.
You have the right to enroll (or enroll Your dependent) in this Benefit Plan if You (or
Your dependent) have one of the following Qualifying Life Events:
• Loss of other health plan coverage – You or Your dependent were covered under
another insurance plan or program and You or Your dependent lost coverage due
to legal separation, divorce, dissolution of domestic partnership, cessation of
dependent status, death, termination of employment, reduction in the number of
hours of employment, a permanent move, exhaustion of COBRA benefits,
termination due to a loss of a plan’s availability, or loss of Medicaid or other
government program coverage.
11
Loss of coverage does not include cessation of coverage due to Your failure to
pay premiums, including COBRA premiums prior to the expiration of COBRA
coverage, fraud or situations that allow for a rescission of Your coverage);
12
You must provide proof that You had other coverage and the date such coverage
ended.
• Gain of a dependent – You acquire a new dependent as a result of a birth,
adoption, placement for adoption or through a QMCSO or other court order. You
must provide the birth certificate, certificate of adoption, placement for adoption,
QMCSO or other court order;
• Gain of a dependent through marriage – You acquire a new dependent as a result
of marriage or domestic partnership. To be eligible for coverage, You must
provide the marriage certificate or certificate of domestic partnership;
• New Employee – If You are a new employee, You may be eligible to apply for
coverage after You satisfy any probationary or waiting period as defined by Your
employer’s eligibility provisions. To apply for coverage, You must complete an
enrollment application within 30 days of the initial effective date.
Coverage for newly eligible employees and any dependents meeting the necessary
requirements for enrollment will be effective on the employee’s initial effective
9
29 USC 1181 (f)(3)(A)(i)
10
45 CFR § 147.104(b)(4)(i)
11
45 CFR § 146.117(a); 26 CFR § 54.9801-6(a)
12
45 CFR § 146.117(a)(3)(iii); 45 CFR § 144.103; 26 CFR § 54.9801-6(a)(3)(iii); 26 CFR § 54.9801-2
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date. You may be required to provide additional documentation. Such
documentation must be provided to Hometown Health within 30 days of the
request. If You are a newly eligible employee and do not complete enrollment
application and provide any other necessary documentation by the deadlines
provided above, You and Your dependents will not be allowed to enroll until the
employer’s next Open Enrollment Period unless a qualifying status change event
occurs, as described below.
Only You, Your spouse or domestic partner and the dependent child who has the
Qualifying Life Event is eligible for enrollment. Other individuals who do not have
current coverage, would not be eligible to enroll at this time, unless they also have a
qualifying event.
13
For example, for a birth, the Subscriber may enroll the Subscriber’s spouse/domestic
partner and/or the newborn, together or individually, but not any other siblings. For a
marriage, the Subscriber may enroll the Subscriber’s new spouse/domestic partnership
and the spouse’s/domestic partner’s children, but not the Subscriber’s children.
The following events are not considered Qualifying Life Events and do not create
eligibility for a Special or Limited Enrollment period without an event listed above that is
considered a Qualifying Life Event. This is not a comprehensive list:
• A change in citizenship status is not a Qualifying Life Event;
14
• A change in incarceration status is not a Qualifying Life Event;
15
• Loss or change of Advance Premium Tax Credits or Cost Sharing Reductions
provided through an exchange authorized by the Affordable Care Act is not a
Qualifying Life Event;
16
• A change or maintenance of status as an American Indian or Alaska Native is not
a Qualifying Life Event;
17
• A change in eligibility status for Medicaid, CHIP or other government program is
not a Qualifying Life Event; and
• The completion of a non-Calendar year health insurance plan is not a Qualifying
Life Event.
If You provide the completed enrollment application, including documentation and
payment, coverage is effective as follows:
• For a birth, adoption or placement for adoption, the effective date of coverage is
the date of the event;
18
• For coverage required through a QMCSO or other court order, the effective date
of coverage is the effective date of the court order;
13
45 CFR § 146.117(b)
14
45 CFR § 147.104(b)(2)(i)(A); 45 CFR § 155.420(d)(4); 45 CFR § 155.305(a)(1)
15
45 CFR § 147.104(b)(2)(i)(A); 45 CFR § 155.420(d)(4); 45 CFR § 155.305(a)(2)
16
45 CFR § 147.104(b)(2)(i)(B); 45 CFR § 155.420(d)(6)
17
45 CFR § 147.104(b)(2)(i)(C); 45 CFR § 155.420(d)(8)
18
45 CFR § 146.117(b)(3)(iii)(B);
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• For loss of other coverage, coverage is effective on the date after the date You lost
coverage;
19
• For all other Qualifying Life Events including marriage and domestic partnership,
coverage is effective on either the date of the event, or the 1
st
of the following
month, as determined by Your employer.
20
C. HOW DO YOU ENROLL IN COVERAGE?
To apply for coverage, You must complete an enrollment application and may be required to
submit other necessary documentation. Applications should be submitted through Your
employer. Submission of an application does not guarantee the applicant enrollment or
eligibility for coverage. The enrollment application must be accurate, complete, legible, signed
and delivered to Us within the enrollment periods described in the previous section.
When You apply for coverage, You may also apply for coverage for eligible dependents by
listing the dependents on Your enrollment application and providing supporting documentation,
if requested. If You want to add or delete an eligible dependent from coverage later (due to the
dependent having a Qualifying Life Event), the Subscriber must submit an Enrollment/Change
Form. Additional forms may be required for special dependent status.
We may require other forms and/or supporting documentation as part of the eligibility
verification process. These forms and or documents may include, but are not limited to:
1.
A notice of creditable coverage;
2.
A coordination of benefits form;
3.
A birth certificate;
4.
A marriage certificate;
5.
A Domestic Partnership Certificate issued by a state or county government;
6.
Qualified Medical Child Support Order (QMCSO);
7.
A court order;
8.
Proof of Your legal right to work or reside in the U.S.;
9.
Proof of residency such as a driver’s license, rental agreement or utility bill that includes
the Subscriber’s name and address;
10.
A valid Social Security number;
11.
Adoption papers or certification from placing agency; and
19
45 CFR § 146.117(a)(4)(ii);
20
45 CFR § 146.117(b)(3)(iii)(A)
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12.
Written proof of a child’s incapacity and dependency and proof of continuous coverage
as a disabled dependent since attaining the age of 26. Documentation from the Social
Security Administration showing the dependent child was deemed permanently disabled
prior to age 26 is required to establish eligibility for disability.
You must provide Us with the requested forms or documents no later than 30 days after Our
request. Failure to provide any requested forms or documents within 30 days of the request will
result in Your loss of the right to make a change to Your enrollment status due to the enrollment
event. If We changed Your enrollment, or that of Your dependents, based on an application for
which You did not provide required documentation, Your enrollment and the enrollment of Your
dependents will be corrected back to the enrollment status that would have resulted had You
never provided the application. This could result in the loss of coverage and the transfer of
financial responsibility to You for claims incurred (You may have to pay medical costs) for the
period between the initial change and the correction. We will make every effort to correct Your
eligibility status and the eligibility status of Your dependents and to inform You of the correct
status as quickly as possible.
There is no coverage for services received or rendered to the Member prior to the effective date
of the Member’s enrollment.
D. OTHER IMPORTANT INFORMATION
1.
Notice of Ineligibility
It is Your responsibility to notify Your employer of any changes that can or will affect
Your eligibility or that of Your dependents. Failure to notify Us of any changes affecting
Your eligibility or Your dependents’ eligibility may lead to retroactive termination of
coverage back to the date for which the event took place that caused You or Your
dependents to be ineligible for coverage and You may be responsible for any claims
submitted for care provided to them from the event date forward.
Provisions for eligibility and ineligibility may also be defined within Your employer’s
eligibility provisions or in a separate Benefit Plan document or summary plan
description. You are encouraged to ask Your employer for a complete description of
additional eligibility requirements that Your employer may require.
2.
Medicare-Eligible Members
Medicare Eligible individuals may be covered under this Small Group Plan. For the
purpose of coordination of benefits, Medicare will be the primary payer for Members of
group health plans purchased by employers who have fewer than 20 employees. The
group health plan will be the primary payer for groups that have 20 or more employees.
21
21
42 CFR § 411.100(a)(i)
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VIII. PRIMARY CARE AND SPECIALTY CARE PHYSICIANS
HTH recommends to receive maximum benefits for Covered Services through your health
insurance plan, You must follow the terms of this Policy, including, if applicable, receiving care
from Your PCP, using In-Network Providers, and obtaining any required Prior Authorization.
PCPs include family practice, internal medicine, general practice, and geriatric medicine.
Regardless of Medical Necessity, this Policy will not provide benefits for care that is not a
Covered Service even if performed by Your PCP or other In-Network Provider. If services are
authorized or provided by Your PCP and covered by this Policy, You may receive a higher level
of benefits, as set forth in Your plan-specific Schedule of Benefits.
A.
HMO Requirement for a Primary Care Physician (PCP)
Following the terms of your HMO plan, adult Members must choose a Renown or Geriatric
Specialty Care PCP on the Renown HMO Network at the time of enrollment or HTH will choose
one for You based on Your geographic location. In addition, if you have a child enrolled in
coverage, HTH will permit you to designate any pediatrician, Renown or Community, as the
child’s PCP if such pediatrician is an In-Network Provider. Eligibility of services rendered by a
pediatrician is limited to children between the age of 0 and 18 years and ends the first of the
month after a member achieves their 18
th
birthday. There is no coverage for PCP services outside
of the Renown HMO Network therefor, establishing with an approved PCP is essential to
receiving maximum benefits for covered services on your HMO plan. Family members can
choose the same PCP or different ones. A directory of PCPs is available on Our website at
hometownhealth.com or by calling Hometown Health, Customer Service at (775)982- 3232 or
(800)336-0123.
B.
EPO Selection of Primary Care Physician (PCP)
Members enrolled in a HTH EPO plan may designate any PCP on the HTH Nevada EPO
Network who is available to accept You as a patient. In addition, if You have a child enrolled in
coverage, We will permit You to designate any pediatrician as the child’s PCP if such
pediatrician is an In-Network Provider. Eligibility of services rendered by a pediatrician is
limited to children between the age of 0 and 18 years and ends the first of the month after a
member achieves their 18
th
birthday.
C.
PPO Selection of Primary Care Physician (PCP)
Members enrolled in a HTH PPO plan may designate any PCP on the HTH Network who is
available to accept You as a patient. In addition, if You have a child enrolled in coverage, We
will permit You to designate any pediatrician as the child’s PCP if such pediatrician is an In-
Network Provider. Eligibility of services rendered by a pediatrician is limited to children
between the age of 0 and 18 years and ends the first of the month after a member achieves their
18
th
birthday.
D.
Responsibilities of Your Primary Care Physician
Your PCP provides and coordinates Your overall health care. When You need medical services,
contact Your PCP. Your PCP can provide most of Your care, including routine physical
examinations, treatment of sickness or Injury, and administration of Medically Necessary
injections and immunizations. Hometown Health does not require members to receive a PCP
referral before seeking specialty care services. However, the specialist may require a referral
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before rendering services.
E.
Continuity of Care
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- If You are undergoing a course of treatment and Your PCP or other In-Network Provider withdraws
from Our Network, We will notify You of the withdrawal. In the case of the withdrawal of Your
PCP from the Network, You will be able to choose another. In addition, You may be permitted to
continue receiving care from the withdrawing Provider in accordance with applicable law. Such
coverage will continue until the 120th day after the date the contract between the Provider and
Hometown Health is terminated or, if the medical condition is pregnancy, the 90th day after the end
of the pregnancy.
F.
Referrals
Hometown Health does not require members to receive PCP referral before seeking specialty
care services. However, the specialist may require a referral before rendering services.
G.
Prior Authorizations
Approval from Hometown Health that may be required before You get a service or fill a
prescription. We use utilization management and quality assurance protocols to ensure the
service being requested is Medically Necessary and covered. Prior Authorizations protect You
from expenses that result from receiving services that are not covered, not Medically Necessary
or are otherwise excluded from coverage under this plan. All benefits listed in this EOC and
Your Schedule of Benefits may be subject to Prior Authorization requirements and concurrent
review depending upon the circumstances associated with the services.
There may be Prior Authorization or pre-treatment requirements for pharmacy, dental, and vision
benefits. Refer to Your plan-specific Schedule of Benefits for services that require Prior
Authorization. You may find a full list of services that require Prior Authorization by visiting
Our website at hometownhealth.com or contact Customer Services at 1-800-336-0123.
If Your Specialist needs to extend Your care beyond the initial visit or Prior Authorization, he or
she can do so without involving Your PCP. However, the Specialist must request a Prior
Authorization from Hometown Health if the additional care extends beyond the limits of the
original Prior Authorization. Extension of care beyond one year must be managed by Your PCP.
You may require services that are not available from a In-Network Provider. Your PCP or other
In-Network Provider must contact Us to seek Prior Authorization for You to receive treatment
from a Out-of-Network Provider. A Prior Authorization to receive a service does not necessarily
mean the service will be covered at an Out-of-Network Provider, unless the Prior Authorization
explicitly states that We will cover the service provided by an Out-of-Network Provider.
The amount of Your benefits is determined each time You seek health care services in
accordance with Your plan-specific Schedule of Benefits. For certain services and supplies You
must obtain Our Prior Authorization for such services and supplies. You should refer to Chapter
V – Utilization Management Program of this EOC for more information about certain services
that require Our Prior Authorization.
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IX. INSURANCE PREMIUMS
Premiums are the monthly charges the Member must pay Hometown Health to establish and
maintain coverage. Think of Hometown Health as a pot. Each Subscriber puts their monthly
premiums into the pot. Whenever You go to Your doctor, We pull money out of the pot to pay
Your doctor.
Our goal is to always ensure there is enough money in the pot to pay Your doctor. In fact, the
Nevada Division of Insurance requires that We have a certain level of cash reserves available to
pay claims.
But predicting exactly how much to charge in Premium isn’t easy. We have to predict how
much You and the rest of Your fellow Members are going to utilize services in a given year, take
into account the cost of new drugs and new technologies, predict shifts in Provider usage based
on changes to Our Provider contracts and much, much more.
If We set the premiums too low, We lose money. If We set premiums too high and make too
much money, We are required to pay some of it back to Policy holders. Even if We get the
premiums just high enough to make a little bit of money, because We are Northern Nevada’s
only non-profit health insurance company, any money that We make goes back into the
community or assists Us in keeping premiums as low as possible in the future.
The rate setting process is highly regulated. Every assumption that We make to create Our
premiums is reviewed and studied by the Nevada Division of Insurance. If We have an
assumption that doesn’t make sense, We are required to adjust the assumption and the resulting
premiums. The premiums aren’t approved until the Nevada Division of Insurance agrees that
Our assumptions are reasonable.
Once We have established premiums, Hometown Health will notify Your employer. Your
employer will establish an amount to be paid by the employer and the amount to be paid by each
employee.
A.
How and When to Pay Premiums
Generally, the portion of the Premium paid by employees is paid through payroll deductions, but
each employer is different and the method of payment varies by employer.
In certain circumstances, You may find yourself in a period of Leave Without Pay, Family
Medical Leave Act (FLMA) leave or other unpaid leave status. When You are still an employee
in these unpaid periods of leave and You still qualify for health insurance coverage, You may be
required to pay for a portion or all of Your health insurance. Because this is a group Policy, You
will be required to pay Your portion of the Premium directly to Your employer by the due date
indicated by Your employer. If You do not pay Your employer by the due date, Your coverage
may be terminated retroactively to the last date of the period for which Premium has been paid in
full. Hometown Health will not pay for any services provided to members on or after the date of
termination. All claims paid for services incurred after the date of termination will be
retroactively adjusted.
B.
Refunds
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If Your coverage is terminated, Premiums that We receive for coverage applicable to periods
after the date of termination will be refunded to Your employer within 30 days, less any medical
costs incurred by Us for that period. Employer claims for refunds must be made in writing
within 90 days from the date of termination of Your coverage or otherwise the right to such
refunds will be deemed waived.
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X. TERMINATION
A.
Equality
This Policy is guaranteed issue and guaranteed renewable. Your coverage cannot be denied or
terminated due to Your age, health status, economic status, health care needs, or prospective
health care costs. However, there are some circumstances which may result in the termination of
Your coverage under this Policy.
B.
Termination Events
Hometown Health may terminate this policy upon sixty (60) days written notice to the Group for
the following:
1.
Fraud or material misrepresentation. Any act, practice, or omission that constitutes fraud
or an intentional misrepresentation of material fact could result in termination or
rescission of the Subscriber’s and all dependent’s coverage. See Section C – Termination
for Cause and Rescission below.
2.
Request to terminate. When Hometown Health receives request to cancel coverage for
any Member, coverage will end pursuant to the provisions in the Group Subscription
Agreement.
3.
Group Subscription Agreement is cancelled or terminated. If the Group Subscription
Agreement is cancelled or terminated for any reason, including failure to pay premiums
by the applicable grace period, coverage will terminate pursuant to the termination
provisions provided in the Group Subscription Agreement.
4.
Loss of eligibility. This provision also applies to Your dependents. See Section D –
Dependent Coverage Termination below.
5.
Hometown Health ceases to operate. In the unlikely event that Hometown Health ceases
to operate, Hometown Health will meet all regulations that require for payment for
services rendered during the insured’s coverage period for which premiums had already
been paid.
6.
Out-of-Area. The member no longer meets eligibility requirements for coverage if the
member has temporarily located outside the geographic service area for longer than 90
days.
We will not be liable for the cost of any health care services that are provided after the effective
date of termination of Your coverage.
These provisions also apply to Your dependents.
If Your coverage is terminated, Premiums that We receive for coverage applicable to periods
after the effective date of termination will be refunded within 30 days, less any medical costs
incurred by Us for that period.
C.
Termination for Cause and Rescission
If You perform an act, practice, or omission that constitutes fraud or make an intentional
misrepresentation of material fact in connection with Your coverage, We may retroactively
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terminate Your coverage. This is known as rescission. Your coverage and Your dependents’
coverage can be terminated or rescinded if there is any evidence of the following actions:
1.
You materially misstate information about yourself or Your dependents on Your
enrollment application or any other document provided during the coverage application
process.
2.
You knowingly allow someone else to use Your identity for the purpose of seeking
medical care under this Policy.
3.
You knowingly engage in an activity to defraud Us or any organization that We have
engaged to provide services under Our policies.
4.
You knowingly cause Your employer to allow You or Your dependents to enroll without
meeting the eligibility requirements as defined in the Group Subscription Agreement.
You and Your dependents’ coverage can be terminated if there is any evidence of the following
actions:
1. Your employer purposefully allows You or Your dependents to enroll without meeting
the eligibility requirements as defined in the Group Subscription Agreement.
In some cases Your coverage may be rescinded back to the date of the fraudulent act. If We
rescind Your coverage, We will provide at least 30 days prior written notice in accordance with
applicable law. You will be responsible for the claims submitted for care provided to You after
the effective date of termination or rescission.
If Your coverage is terminated because of Your fraudulent actions, You will not be eligible for
reenrollment.
D.
Dependent Coverage Termination
Your employer may choose to cover spouses, domestic partners and children. This section only
applies to those categories of dependents Your employer chooses to cover.
To remove a dependent from coverage, You must notify Your employer in advance. Coverage
will end pursuant to the provisions in the Group Subscription Agreement.
Coverage for a dependent child ends on the last day of the month in which the dependent child
reaches age 26. If that dependent wants to become a Subscriber under his or her own individual
and family plan, he or she must meet all of the eligibility requirements of a Subscriber as listed
in the plan.
Otherwise, coverage for a dependent ends on the last day of the month during which the
following events occur:
1.
A final divorce decree, legal separation or termination of domestic partnership for a
spouse or domestic partner and any children (who are not also children of the Subscriber)
of the spouse or domestic partner;
2.
Legal custody of a child is terminated; or
3.
The dependent loses status as a dependent for any other reason, including death of the
Subscriber.
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Hometown Health reserves the right to recoup any benefit payments made beyond the
termination date.
E.
Certificate of Creditable Coverage
When a Member’s coverage with Hometown Health terminates, Hometown Health will send the
Subscriber a Certificate of Creditable Coverage, which will identify the length of the Member’s
coverage with Hometown Health. The Member may need this letter as proof of prior coverage
when the Member enrolls with another company.
F.
What Hometown Health Will Pay for After Termination
After the effective date of termination of a Member, Hometown will continue to pay claims that
were incurred by the Member during the period of time the Member was covered under this
Policy. Payment of claims by Hometown Health is subject to normal claim payment procedures
and limitations described elsewhere in this EOC.
Hometown Health will not pay for any services provided after the Member’s coverage ends,
even if a Prior Authorization was received. Hometown Health is only responsible for payment of
expenses for Covered Services provided during the effective period of this Policy. Hometown
Health is not responsible for expenses incurred after coverage under this Policy is terminated or
following any amendment(s) made to this Policy in accordance with applicable law that may
affect a change in such payment. Benefits cease on the date the Member’s coverage ends as
described above. A Member may be responsible for benefit payments made on behalf of the
Member for services provided after the Member’s effective date of termination, even if the
termination was retroactive.
Hometown Health will not cover services received after the Member’s date of the termination
regardless of whether:
1.
Hometown Health issued a Prior authorization for the services;
2.
The services were made necessary by an accident, Illness or other event that occurred
while the coverage was in effect;
3.
The Member was hospitalized at the time of the termination; or
4.
For any other reason.
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XI. CONTINUATION OF COVERAGE
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that
employers with 20 or more employees offer continued medical coverage for eligible employees
and their eligible dependents whose medical insurance would end due to a qualifying event.
Employees of employers with fewer than 20 employees are not eligible for COBRA continuation
of coverage. However, loss of coverage is a qualifying event in the individual and family health
insurance market and You should be able to find comparable coverage for You and Your family.
You should call Your plan administrator or Your employer if You have questions about Your
right to continue coverage under COBRA. If You are no longer eligible for coverage under this
group Policy and You wish to purchase a plan for yourself or Your family, please go to
hometownhealth.com.
To be eligible for continuation coverage under COBRA, You must meet the definition of a
“Qualified Beneficiary.” A Qualified Beneficiary is any of the following persons who is
otherwise eligible for coverage and was a Member on the day before a qualifying event:
1.
An employee;
2.
An employee’s enrolled dependent, including with respect to the employee’s children, a
child born to or placed for adoption with the employee during a period of continuation
coverage under federal law; or
3.
An employee’s former spouse.
A.
Qualifying Events for Continuation Coverage under COBRA
The following table outlines situations in which You may elect to continue coverage under
COBRA for yourself and Your dependents, if eligible, and the maximum length of time You can
receive coverage. These situations are considered qualifying events.
If Coverage Ends Because of the
Following Qualifying Events:
You May Elect COBRA:
For
Yourself
For Your
Spouse
For Your
Child(ren)
Your work hours are reduced
18 months
18 months
18 months
Your employment terminates for any
reason (other than gross misconduct)
18 months 18 months 18 months
You or Your family Member becomes
eligible for Social Security disability
benefits at any time within the first 60
days of losing coverage
29 months
29 months
29 months
You die
N/A
36 months
36 months
You divorce (or legally separate)
N/A
36 months
36 months
Your child is no longer an eligible
family Member (e.g., reaches the
maximum age limit)
N/A
N/A
36 months
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You become entitled to Medicare
N/A
See table below
See table below
Your employer files for bankruptcy
36 months
36 months
36 months
B.
How Your Medicare Eligibility Affects Dependent COBRA Coverage
The table below outlines how Your eligible dependents’ COBRA coverage is impacted if You
become entitled to Medicare.
If Dependent Coverage Ends When:
You May Elect COBRA Dependent
Coverage For UP To:
You become entitled to Medicare and You don’t
experience any additional qualifying events
18 months
You become entitled to Medicare, after which
You experience a second qualifying event*
before the initial 18-month period expires
36 months
You experience a qualifying event*, after which
You become entitled to Medicare before the
initial 18- month period expires and, if absent
this initial qualifying event, Your Medicare
entitlement would have resulted in loss of
dependent coverage under the Plan
36 months
* Your work hours are reduced or Your employment is terminated for reasons other than gross
misconduct.
C.
Getting Started
You will be notified by mail if You become eligible for COBRA coverage as a result of a
reduction in work hours or termination of employment. The notification will give You
instructions for electing COBRA coverage, and advise You of the monthly cost. Your monthly
cost is the full Premium (without employer subsidy), plus a 2% administrative fee and other cost
as permitted by law. The notice will provide information on where to send Your election forms
and Premium payments.
You will have up to 60 days from the date You receive notification or 60 days from the date
Your coverage ends to elect COBRA coverage, whichever is later. You will have 45 days from
the day You elect COBRA coverage to pay the cost of Your COBRA coverage, retroactive to the
date Your coverage under the Policy otherwise would have ended.
While You are covered under the Policy through COBRA, You have the right to change Your
coverage election under certain circumstances.
D.
Notification Requirements
If Your covered dependents lose coverage due to divorce, legal separation, or loss of dependent
status, You or Your dependents must notify Your plan administrator within 60 days of the latest
of:
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1.
The date of the divorce, legal separation, or an enrolled dependent’s loss of eligibility as
an enrolled dependent;
2.
The date Your enrolled dependent would lose coverage under the Policy; or
3.
The date on which You or Your enrolled dependent are informed of Your obligation to
provide notice and the procedures for providing such notice.
You or Your dependents must also notify Your plan administrator when a qualifying event
occurs that will extend continuation coverage.
If You or Your dependents fail to notify Your plan administrator of these events within the 60-
day period, Your plan administrator is not obligated to provide continued coverage to the
affected Qualified Beneficiary. If You are continuing coverage under federal law, You must
notify Your plan administrator within 60 days of the birth or adoption of a child.
Once You have notified Your plan administrator, You will then be notified by mail of Your
election rights under COBRA.
E.
Notification Requirements for Disability Determination
If You extend Your COBRA coverage beyond 18 months because You are eligible for disability
benefits from Social Security, You must provide Your plan administrator with notice of the
Social Security Administration’s determination within 60 days after You receive that
determination, and before the end of Your initial 18-month continuation period.
The notice requirements will be satisfied by providing written notice to Your plan administrator.
The contents of the notice must be such that Your plan administrator is able to determine the
covered employee and Qualified Beneficiary(ies), the qualifying event or disability, and the date
on which the qualifying event occurred.
F.
Trade Act of 2002
The Trade Act of 2002 amended COBRA to provide for a special second 60-day COBRA
election period for certain employees who have experienced a termination or reduction of hours
and who lose group health plan coverage as a result. The special second COBRA election period
is available only to a very limited group of individuals: generally, those who are receiving trade
adjustment assistance (TAA) or “alternative trade adjustment assistance” under a federal law
called the Trade Act of 1974. These employees are entitled to a second opportunity to elect
COBRA coverage for themselves and certain family members (if they did not already elect
COBRA coverage), but only within a limited period of 60 days from the first day of the month
when an individual begins receiving TAA (or would be eligible to receive TAA but for the
requirement that unemployment benefits be exhausted) and only during the six months
immediately after their group health plan coverage ended.
If You qualify or may qualify for assistance under the Trade Act of 1974, You should contact
Your plan administrator or Your employer for additional information. You must contact Your
plan administrator promptly after qualifying for assistance under the Trade Act of 1974 or You
will lose Your special COBRA rights. COBRA coverage elected during the special second
election period is not retroactive to the date that coverage under the Policy was lost, but begins
on the first day of the special second election period.
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G.
When COBRA Ends
COBRA continuation coverage under the Policy will end before the maximum continuation
period shown above if:
1.
You or Your covered dependent becomes covered under another group medical plan or
Policy;
2.
You or Your covered dependent becomes entitled to, and enrolls in, Medicare after
electing COBRA;
3.
A Premium is not paid within 30 days of its due date;
4.
Your employer ceases to offer coverage under the Policy to its similarly situated
employees; or
5.
Coverage would otherwise terminate under the Policy as described in the beginning of
this section.
If You selected continuation coverage under a prior plan or Policy which was then replaced by
coverage under this Policy, continuation coverage will end as scheduled under the prior plan or
in accordance with the terminating events listed in this section, whichever is earlier.
H.
USERRA Leaves of Absence
You may be able to continue coverage under this Policy through Your employer under the
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). The
continuation coverage is equal to the same coverage as the benefits that are provided to other
participants in Your employer’s health plan. These benefits may be available to You if You are
absent from work by reason of service in the United States uniformed service, up to a maximum
24-month period, if You meet the requirements of USERRA. USERRA benefits run
concurrently with any continuation coverage that is available through COBRA.
You must submit an USERRA election notice to Your employer within 60 days after Your call to
active duty. The Premium for USERRA continuation coverage is 102% of the Premium charged
to Your employer.
You should contact Your employer for information about electing USERRA coverage and how
much You must pay for such coverage.
I.
Leaves of Absence
This Policy provides continuing coverage for an employee who is otherwise covered by the
Policy while on leave with or without pay as a result of the Family and Medical Leave Act of
1993 (FMLA) or an employer-approved leave of absence. This coverage is the same as that in
effect for the Employer Group during the period of disability or leave-of-absence.
The coverage required continues until one of the following occurs:
1.
The date that the employment of the employee is terminated;
2.
The date that the employee obtains another Policy of health insurance;
3.
The date that this Policy of group insurance is terminated;
4.
After a total of 12 weeks (consecutive or non-consecutive) during a 12 month period in
which benefits would normally be provided to the eligible employee.
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XII. DOUBLE COVERAGE
A.
Workers’ Compensation
The benefits provided in this Policy are not designed to duplicate any benefit to which such
Members are eligible under applicable workers’ compensation laws. Coverage under this Policy
is not in lieu of, and will not affect any requirements for coverage under such workers’
compensation laws.
B.
Medicare
Except as otherwise provided by applicable law, the benefits under this Policy for Members
otherwise covered by Medicare, do not duplicate any benefit to which such Members are entitled
under Medicare, including Medicare Parts A, B and D. See Chapter XV – Medicare
Coordination of Benefits for information about the coordination of Your benefits with Medicare.
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XIII. SUBROGATION / RIGHT TO REIMBURSEMENT
We have Subrogation and reimbursement rights in certain situations where a third party is
responsible for causing Your Illness or Injury or Your dependents’ Illness or Injury. This
chapter explains Our rights and Your responsibilities in these circumstances and outlines how
benefits are coordinated, how amounts recovered by Us are allocated and how Our rights are
applied.
A.
Background
Sometimes a third party is legally responsible for causing Your Injury or Illness and/or an Injury
or Illness of Your dependents. Often times, We pay for the Injury or Illness initially, even
though the third party is responsible. In these cases, We have a claim to Subrogation and
reimbursement from the third party.
Subrogation and reimbursement can arise in different situations but a common example is when
You or Your dependent is Injured in an accident caused by a third party’s negligence. If We pay
medical benefits to such a Member and the Member recovers damages in a lawsuit against the
third party who caused the accident, We have a right to be reimbursed for the medical expenses it
paid out of the Member’s financial recovery from the third party.
Here are some examples of how Our Subrogation and reimbursement rights might work:
1.
Mr. Smith is covered by this Policy. Mr. Smith’s car is rear-ended by Mr. Jones and Mr.
Smith is injured and receives medical care. We paid medical benefits of $25,000 for Mr.
Smith’s care. Mr. Smith then sues Mr. Jones and recovers $50,000 in the lawsuit. Mr.
Smith is required to repay Us the $25,000 We paid in medical expenses from the $50,000
he recovered in the lawsuit.
2.
Mr. Smith is covered by this Policy. Mr. Smith’s car is rear-ended by Mr. Jones and Mr.
Smith is injured and receives medical care. We paid medical benefits of $25,000 for Mr.
Smith’s care. Mr. Smith then sues Mr. Jones but recovers only $20,000 in the lawsuit.
Mr. Smith is required to pay Us the $20,000 he recovered in the lawsuit to reimburse Us.
Mr. Smith would not be responsible for paying Us the additional $5,000 because he did
not recover those funds in the lawsuit.
Our rights to Subrogation and reimbursement apply regardless of whether a recovery in a lawsuit
is designated by the parties as covering damages (such as property damage or pain and suffering)
other than medical expenses. An example of how this works is as follows:
3.
Mr. Smith is covered by this Policy. Mr. Smith’s car is rear-ended by Mr. Jones and Mr.
Smith is injured and receives medical care. We paid medical benefits of $25,000 for Mr.
Smith’s care. Mr. Smith then sues Mr. Jones and recovers $50,000 in an out-of- court
settlement of the lawsuit. In the settlement, the parties describe the settlement amount as
covering only Mr. Smith’s pain and suffering. Despite the parties’ description of the
payment in the settlement agreement, Mr. Smith is required to repay Us the $25,000 We
paid in medical expenses from the $50,000 Mr. Smith recovered through the settlement.
In asserting Subrogation and reimbursement rights, We seek to conserve its resources for the
benefit of all Members and their dependents, impose the Expense for Injuries or Illness on those
responsible for causing them, and avoid unjust enrichment.
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By accepting benefits under this Policy to pay for treatments, devices, or other products or
services related to such Illness or Injury, You agree that We have rights of recovery,
reimbursement and Subrogation to the extent of any benefits paid for an Illness or Injury that
is caused or compensated by a third party.
B.
Subrogation Rights
Our Subrogation rights come into play when We pay benefits on Your behalf or on behalf of
Your dependent for an Illness or Injury for which You receive, or have a right to receive,
compensation of any kind (whether by a court judgment, settlement, or otherwise). In these
situations, We will be subrogated to Your (or Your dependent’s) recovery, or right to recovery,
of compensation for Your damages from any person, insurance company, other benefits plan or
any other organization. This means that We “stand in Your shoes”—We assume Your right to
receive the compensation from the other person, their insurance company, their benefits plan, or
any other organization to the full extent of the medical benefits paid.
Damages will include, but will not be limited to, compensation received and/or claimed for
personal Injury and/or property loss and/or medical expenses. Our Subrogation rights will not be
decreased, restricted, or eliminated in any way if You or Your dependent recover or have the
right to recover no-fault insurance benefits.
C.
Reimbursement Rights
If You or Your dependent obtain any recovery—regardless of how it’s designated or
structured— from or on behalf of any insurance company or any third party responsible for the
condition giving rise to the medical Expense, You or Your dependent may be responsible for
fully and completely reimbursing Us for all payments made by Us to or on behalf of You and/or
Your dependents for such a medical Expense. We may have the right to a full and complete
reimbursement from You or Your dependents of all payments made by Us, from any recovery
You or Your dependent obtains from any insurance company or any responsible third party even
if You or Your dependents have not or will not be fully compensated or made whole for the
Injuries caused by the responsible third party.
D.
Equitable Lien
By accepting benefits under this Policy, You and Your dependents agree to an equitable lien by
agreement against any recovery You may receive in an action against a third party who caused
an Injury or Illness which resulted in Us paying medical expenses for You or Your dependents.
As a result, You and Your dependents must repay to Us the benefits paid on Your behalf out of
the amounts recovered from the other person or their insurance company, benefits plan, or any
other organization. Our right of reimbursement applies even if Your claims and Your
dependents’ claims are settled without an admission of fault and even if You or Your eligible
dependent recover or have the right to recover no-fault insurance benefits. We have a lien on
any amount recovered by You or Your eligible dependents, regardless of whether the
amount is designated as payment for medical expenses. Our lien arises through operation
of the Policy. No additional reimbursement agreement is necessary. This lien will remain
in effect until We are reimbursed in full.
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E.
Constructive Trust
If You (or Your attorney or other representative) receive any payment through a judgment,
settlement or otherwise—for an Illness or Injury that is caused by a third party for which We
have paid medical expenses, You agree to maintain the funds in a separate, identifiable account
and that We have an equitable lien on the funds. In addition You agree to serve as a constructive
trustee over funds to the extent that We have paid expenses related to that Illness or Injury. This
means that You will be deemed to be in control of the funds.
F.
Our Obligation to Pay Benefits
We will pay covered expenses incurred by You or Your dependent as a result of an Illness or
Injury for which You receive, or may have a right to receive, compensation of any kind from
another person (or entity), an insurance company, or any other organization, only on the
condition that You or Your eligible dependents, or another duly authorized person on Your
behalf, agree to do and will do the following:
1.
Reimburse Us to the extent of covered expenses paid by Us (any amounts credited to
Deductibles will be removed), immediately upon receiving compensation of any kind
(whether by court judgment, settlement or otherwise) for damages that include, but are
not limited to, personal Injury, property loss or medical expenses. Your heirs or Your
eligible dependent’s heirs, beneficiaries, and personal representatives will also be bound
by this obligation;
2.
Serve as constructive trustee for any and all monies paid (or payable) to You or for Your
benefit by any responsible party or other recovery to the extent We paid benefits for such
sickness or Injury;
3.
Sign and deliver requested documents to Us. If You or Your eligible dependents fail or
refuse to sign whatever form or document is requested by Us or Our representative within
30 days of the request, We will no longer have any obligation to pay any covered
Expense incurred by You or Your eligible dependents;
4.
Immediately notify Us in writing whenever You or Your eligible dependent believe or
first learn that any person, insurance company or benefits plan, or any other organization,
is or may be responsible, or has agreed or may agree to pay, either totally or in part, for
any damages You or Your eligible dependent has suffered or may suffer as a result of any
Illness or Injury. Damages include, but are not limited to, any personal Injury and/or
property damage and/or medical expenses;
5.
Immediately notify Us in writing, whenever a representative of any other person (or
entity), insurance company or benefits plan, or any other organization, contacts You or
Your eligible dependent or Your representative, or is contacted by You or Your eligible
dependent or by Your representative, in order to settle, adjust or in any way resolve Your
claim, Your eligible dependent’s claim or estate’s claim for damages. A claim will
include any cause of action filed in any court and/or any verbal or written demand made
by You or Your eligible dependent or on Your behalf, for compensation for damages You
or Your eligible dependent have suffered or may suffer as a result of any Illness or Injury;
6.
Refuse any settlement, adjustment or resolution of Your claim, Your eligible dependent’s
claim or estate’s claim for damages until You or Your eligible dependent or Your
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representative have received Our written authorization allowing You or Your
representative to accept a settlement, adjustment or resolution offered by any person,
insurance company or benefits plan, or any other organization;
7.
Not take any action that would prejudice or harm Our Subrogation and reimbursement
rights;
8.
Cooperate fully with Us in asserting its reimbursement and Subrogation rights, supplying
Us with any and all information, and executing any and all forms We may need for this
purpose; and
9.
Do whatever else is needed to enforce Our Subrogation and reimbursement rights.
By accepting benefit under this Policy, You have agreed to these conditions.
We may obtain reimbursement or satisfy its Subrogation rights by reducing the covered
expenses paid by Us to You or Your eligible dependent for covered expenses already incurred
but not yet paid, and for covered expenses incurred in the future.
We are not subject to the “Make-Whole Doctrine”
Regardless of how the claims of recoveries are classified or characterized by the parties, the
courts or any other entity, this will not affect You or Your eligible dependent’s responsibilities
described above or Our entitlement to first-dollar recovery, regardless of whether You are made
whole. An example of this is as follows:
i.
Mr. Smith is covered by this Policy. Mr. Smith’s car is rear-ended by Mr. Jones
and Mr. Smith is Injured and receives medical care. We paid medical benefits of
$25,000 for Mr. Smith’s care. Mr. Smith then sues Mr. Jones and recovers
$50,000 through an out-of-court settlement of the lawsuit. Mr. Smith, however,
was not “made whole” by the settlement because his damages (including medical
expenses, pain and suffering, and property damage) exceeded the $50,000 he
received in the settlement. Although Mr. Smith was not “made whole” by the
settlement, he is required to repay Us the $25,000 it paid in medical expenses
from the $50,000 he recovered in the lawsuit.
G.
Attorney’s Fees
We will not pay, offset any recovery, or in any way be responsible for any fees or costs
associated with pursuing a claim unless We agree to do so in writing.
An example of this is as follows:
Mr. Smith is covered by this Policy. Mr. Smith’s car is rear-ended by Mr. Jones and Mr. Smith
is injured and receives medical care. We paid medical benefits of $100,000 for Mr. Smith’s care.
Mr. Smith then sues Mr. Jones and recovers $150,000. Although Mr. Smith was awarded
$150,000, he incurred legal fees of $50,000 leaving him with a net recovery of $100,000.
Although Mr. Smith incurred legal fees of $50,000, he is not allowed to reduce his repayment
obligation to Us due to his having incurred legal fees and, therefore, must repay Us the full
$100,000 We paid in medical expenses.
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H.
Coordination of Benefits
Notwithstanding any coordination of benefits rules provided in this EOC, benefits under this
Policy will be secondary to any no-fault auto insurance.
I.
Allocation of Amounts Recovered by Us
Our lien includes attorney’s fees and the costs of collection. If Our lien is satisfied by direct
recovery, the remainder, if any, will be paid to You or Your eligible dependent or to Your
representative or estate.
J.
No Benefits Where Compensation Has Already Been Received
We will not pay out benefits to You to the extent You or Your eligible dependent have already
received compensation for Your Injury.
K.
Scope of Rights
These Subrogation and reimbursement provisions will be interpreted by Us, in Our sole
discretion, to permit Us to obtain full satisfaction of any lien or right to reimbursement from You
or Your eligible dependent or any other person who received payment on Your behalf (including,
but not limited to, a parent, spouse, guardian, or estate). We may, in Our sole discretion, allocate
the responsibility for reimbursement or satisfaction of a lien among You, Your eligible
dependents, and any other person, such as Your legal counsel or Your eligible dependents’ legal
counsel.
L.
Right to Receive and Release Information
Subject to the Our obligation under the Health Insurance Portability and Accountability Act of
1996, or any other applicable law, for the purpose of implementing these Subrogation and
reimbursement provisions, We may, without the consent of or notice to any person, release to or
obtain from any insurance company, other organization or person any information that We
regard as necessary, with respect to You or Your eligible dependent claiming benefits under this
Policy. When You are claiming benefits under this Policy, You and Your eligible dependents,
must furnish Us with the information needed to enforce the Subrogation and reimbursement
provisions.
M.
Our Right to Terminate Your Coverage and/or Offset Future Benefits
We may terminate Your coverage and/or offset Your future benefits for the value of benefits
advanced in the event that that We do not recover, if You do not provide the information,
authorizations, or otherwise cooperate in a manner that We considers necessary to exercise its
rights or privileges under this Policy.
N.
Effect of Our Interpretation
We will have the exclusive discretionary power to construe provisions of this Policy.
O.
Heirs and Estate of Any Covered Person
Our rights under this section remain enforceable against the heirs and estate of any covered
person.
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XIV. COORDINATION OF BENEFITS
This section explains how other health Benefit Plans and/or insurance You may have affect Your
coverage under this Policy. Coordination of Benefits (COB) is a process by which other
insurers, Benefit Plan sponsors or other programs that provide health care services (such as
Medicare), may be responsible for claims payment either as the primary or secondary carrier.
The plans that apply to the Coordination of Benefits Provision for this Policy include group
insurance, Hospital, surgical, medical or major medical benefits provided by individual or
family-type coverage, government programs or workers’ compensation.
A.
The Purpose of Coordination of Benefits
Many people have health coverage provided by more than one plan at the same time. Each plan
has rules for coordination of benefits if there is double coverage to prevent the total amount of all
their benefit payments from exceeding the contracted cost of the Covered Services. This
coordination of benefits provision helps to contain the cost of health care coverage.
B.
Benefits Subject to Coordination of Benefits
All the health benefits provided in this EOC are subject to this section. You agree to permit Us
to coordinate its obligations under this Policy with payments under any other eligible plan that
covers You. All provisions of this EOC, including but not limited to the use of In-Network
Providers and Prior Authorization requirements continue to apply whether this Policy is primary
or secondary.
C.
Definitions
Some of the words used in this section have a special meaning to meet the needs of this section.
These words and their meanings when used in this section are:
Allowable Expense – 100 percent of the Allowable for any Medically Necessary, reasonable and
customary item of Expense which is a Covered Service, in whole or in part, as a Hospital,
surgical, medical or major medical Expense under this Policy.
When a plan provides benefits in the form of services rather than cash payments, the
reasonable cash value of each service rendered will be deemed to be an allowable Expense
and a benefit paid.
If the Primary Plan reduces benefits because of the Member’s or Provider’s failure to follow
the Primary Plan’s rules, any such reduction is not part of the Allowable Expense.
Coordination of Benefits Provision – This provision and any other provision which may reduce
an insurer’s liability because of the existence of benefits under other valid coverage.
Plan – An entity providing health care or dental benefits or services through:
• Group or individual insurance or any other arrangement for coverage for individuals
whether on an insured or uninsured basis;
• Group service plan contracts, group practice, individual practice and other
prepayment coverage;
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• Any group coverage for students that is group-sponsored by or provided through
school or other educational institutions, other than accident coverage for grammar
school or high school students for which the parent pays the entire Premium;
• Any coverage under labor management trustee plans, union welfare plans, employer
organization plans, employee benefits plans, or employee benefit organization plans;
• Any group automobile third party insurance required under any law of a state, but
only to the extent of benefits required under such third-party no fault law and only to
the extent coordination of benefits is permitted under such third-party no fault law;
• Coverage under a governmental program, including Medicare and Worker’s
Compensation plans; or
• Any coverage under an Individual plan for the Member.
The term “Plan” will be construed separately with respect to each Policy, contract, or other
arrangement for benefits or services and 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 its benefits and that portion that does not.
Primary or Primary Plan – A Plan that, in accordance with the rules regarding the order of
benefits determination, provides benefits or benefit payments without considering any other
Plan.
Secondary or Secondary Plan – A Plan that, in accordance with the rules regarding the order of
benefit determination, may reduce benefits or benefit payments and/or recover from the
primary Plan benefit payments.
D.
When Coordination of Benefits Applies
Coordination of benefits applies when You are covered under this Policy and You are entitled to
receive payment for, or provision of, some or all of the same Covered Services from another
Plan.
E.
How Coordination of Benefits works
Plans use coordination of benefits to decide which health care coverage programs should be the
Primary Plan for the Covered Service. If the Primary Plan payment is less than the Allowable
Expense for the Covered Service, then the Secondary Plan will apply its allowable Expense to
the unpaid balance. In no event will Hometown Health pay more than it would have paid if it
were the Primary Plan
You must first file a claim with the Primary Plan to receive any benefits from the Secondary
Plan.
Hometown Health may pay benefits to any insurer providing other valid coverage in the event of
overpayment by such insurer. Any such payment shall discharge the liability of Hometown
Health as fully as if the payment had been made directly to the insured or the assignee or
beneficiary of the insured. If Hometown Health pays benefits to the insured or the assignee or
beneficiary of the insured, in excess of the amount which would have been payable if the
existence of other valid coverage had been disclosed, this insurer shall have a right of action
against the insured or the assignee or beneficiary of the insured to recover the amount which
would not have been paid had there been a disclosure of the existence of the other valid
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coverage. The amount of other valid coverage which is on a provision of service basis shall be
computed as the amount the services rendered would have cost in the absence of such coverage.
F.
Determination Rules
The Policy determines the order of benefit determination using the first of the following that
applies:
1. No Coordination of Benefits Provision. If another Plan does not contain a provision
coordinating its benefits with those of this Policy, then the benefits of such other plan will
always be determined before the benefits of this Policy.
1.
Dental Plans. If a claim for services provided by an oral or maxillofacial surgeon is
submitted and the Member is also covered under a Dental Plan, then the Dental Plan is
the Primary Plan.
2.
Non-Dependent/Dependent. The benefits of the Plan that covers a person as a Subscriber
are Primary to those of the Plan that covers the person as a dependent. The benefits of
the plan that covers a newborn, adopted child or child placed for adoption as the enrolled
Subscriber or enrolled dependent are primary to the Plan that is required to cover such
individuals pursuant to NRS 689A.043, 689B.033 or similar requirement but has not
received the required notification and applicable payment to continue coverage beyond
31 days after the date of birth, adoption or placement for adoption.
3.
Dependent Child/Parents Not Separated or Divorced. When this Policy and another Plan
cover the same child as a dependent of different persons, called “parents”:
a.
The Plan of the parent whose birthday falls earlier in the calendar year is Primary
to the Plan of the parent whose birthday falls later in the year; and
b.
If both parents have the same birthday, the benefits of the Policy that covers a
parent longer is the Primary Plan.
4.
Dependent Children/Separated or Divorced Parents. If two or more plans cover a person
as a dependent child of divorced or separated parents, benefits for the child are
determined in this order:
a.
First, the Plan of the parent with custody of the child;
b.
Then, the Plan of the spouse of the parent with custody of the child; and
c.
Finally, the Plan of the parent not having custody of the child;
With respect to a, b, and c above, if there is a court decree that would otherwise establish
financial responsibility for the health care expenses with respect to the child, the benefits
of a plan that covers the child as a dependent of the parent with such financial
responsibility will be determined before the benefits of any other plan that covers the
child as a dependent child.
5.
Active/Inactive Employee. A Plan that covers a person who is neither laid off nor retired
(or that eligible employee’s dependents) is primary to a plan that covers that person as a
laid off or retired eligible employee (or that eligible employee’s dependents). If the other
plan does not have this rule, and if, as a result, the plans do not agree about the benefits,
this rule is ignored;
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6.
COBRA/Non-COBRA. A Plan that covers a person and such coverage is not provided
pursuant to COBRA is primary to a plan that covers that person pursuant to COBRA. If
the other plan does not have this rule, and if, as a result, the plans do not agree about the
benefits, this rule is ignored;
7.
Longer/Shorter Length of Coverage. When none of the above applies, the Plan in effect
for the longest continuous period of time pays first. (The start of a new Plan does not
include a change in the amount or scope of the Plan’s coverage, a change in the entity
that pays, provides, or administers the plan’s coverage, or a change from one type of plan
to another.)
8.
Equal liability. If none of the above rules determine which plan is primary and which is
secondary, the allowable expenses shall be shared equally between the plans.
G.
Right to Receive and Release Information
To decide if this coordination of benefits section (or any other plan’s coordination of benefits
section) applies to a claim, We (without the consent of or notice to any person) have the right to:
1.
Release to any person, insurance company, or organization, the necessary claim
information;
2.
Receive from any person, insurance company, or organization, the necessary claim
information; and
3.
Require any person claiming benefits under this Policy to give Us any information
needed by Us to coordinate those benefits.
H.
Right to Recover Payment
If the amount of benefit payment exceeds the amount needed to satisfy Our obligation under this
section, We have the right to recover the excess amount from one or more of the following:
1.
Any persons to or for whom such payments were made;
2.
Any group insurance companies or service plans; and
3.
Any other organizations.
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XV. MEDICARE COORDINATION OF BENEFITS
If You are age 65 or older, entitled to benefits under Medicare, and work for an employer that
did not employ 20 or more employees for each working day in each of 20 or more calendar
weeks in the current or preceding calendar year, then Medicare is the primary payer for You and
Your spouse. The benefits of this Policy will then be the secondary form of coverage.
If You or Your spouse are age 65 or older, entitled to benefits under Medicare, and work for an
employer that employed 20 or more employees for each working day in each of 20 or more
calendar weeks in the current or preceding calendar year, the following rules apply:
1.
This Policy is primary payer for any person age 65 or older who is an active employee or
the spouse (if Your employer offers coverage to spouses) of an active employee of any
age.
2.
You may decline coverage under the Group contract and elect Medicare as the primary
form of coverage. If You elect Medicare as the primary form of coverage, the Policy, by
law, cannot pay benefits secondary to Medicare for Medicare-covered Members.
However, Your will continue to be covered by the Policy as primary unless:
a.
We are notified in writing, that You do not want benefits under the Policy; or
b.
You otherwise cease to be eligible for coverage under the Policy.
A.
Disability
If You are under age 65, have current employment status with an employer with fewer than 100
employees, and become disabled and entitled to benefits under Medicare due to such disability,
then Medicare will be primary for You and this Policy will be the secondary form of coverage.
If You are under age 65, have current employment status with an employer with at least 100
employees, and You become disabled and entitled to benefits under Medicare due to such
disability (other than ESRD, as discussed below) this Policy will be primary for You and
Medicare will be the secondary form of coverage.
B.
End Stage Renal Disease (ESRD)
This Policy will remain primary for the first 30 months of Your eligibility or entitlement to
Medicare due to end stage renal disease. However, if this Policy is currently paying benefits as
secondary to Medicare for You, this Policy will remain secondary upon Your entitlement to
Medicare due to ESRD.
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XVI. MEMBER CLAIMS AND APPEAL PROCEDURES
C.
Definitions
Some of the words used in this section have a special meaning to meet the needs of this section.
These words and their meanings when used in this section are:
Adverse Benefit Determination – Any of the following:
• Our rescission of Your coverage;
• Our denial, reduction, or termination of, or failure to provide or make payment (in
whole or in part) for, a benefit including a denial, reduction, or termination or failure
to provide or make payment that is based on a determination of Your or Your
beneficiary’s eligibility for coverage under this Policy;
• Our denial, reduction, or termination of, or failure to provide or make payment (in
whole or in part) for, a benefit resulting from the application of Our utilization
management program; or
• Our failure to cover an item or service for which benefits are otherwise provided
because We determine that such item or service is experimental or investigational or
is not Medically Necessary.
Authorized Representative – A person that You designate to act on his or her behalf in pursuing
a claim for benefits, grievance or an appeal of an adverse benefit determination.
Claim for Benefits – A request for a benefit or benefits under this Policy made by You,
including any pre-service claims (requests for Prior Authorization or pre-determination) and
any post-service claims.
Expedited Appeal – The process that You can use to request a review of an adverse benefit
determination of an Urgent Care claim.
Final Internal Adverse Benefit Determination – An adverse benefit determination that We have
upheld at the completion of Our internal review process.
Formal Appeal – The formal process You can use to request review of an adverse benefit
determination.
Grievance- An expression of dissatisfaction with any aspect of the operations, activities or
behavior of a plan or its delegated entity in the provision of health care items, services, or
prescription drugs, regardless of whether remedial action is requested or can be taken. A
grievance does not include, and is distinct from, a dispute of the appeal of an organization
determination or coverage determination.
Informal Appeal – An appeal that You direct to Our Customer Services department via phone or
in person. If an informal appeal is resolved to Your satisfaction, the matter ends. The
informal appeal is a voluntary level of appeal.
Reopening: A remedial action taken to change a binding determination or decision even though
the determination or decision may have been correct at the time it was made based on the
evidence of record.
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Urgent Care Claim – A claim for medical care or treatment for which the application of the time
periods for making non-Urgent Care determinations could seriously jeopardize Your life,
health, or ability to regain maximum function or, in the opinion of a Physician with
knowledge of Your medical condition, would subject You to sever pain that cannot be
adequately managed without the care or treatment that is the subject of the claim. The
determination of whether a claim is an Urgent Care Claim will be made by an individual
acting on Our behalf applying the judgment of a prudent layperson who possesses an average
knowledge of health and medicine.
D.
Internal Claims Procedures
1.
Failure to Obtain Prior Authorization
If You fail to follow Our procedures for filing a pre-service claim, We will notify You of
the failure and the proper procedures to be followed if Your communication to Us is
received by a person or department customarily responsible for handling benefit matters
and the communication specifically names Your name, the specific medical condition or
symptom, and the specific treatment, service, or product for which approval is requested.
We will provide You with this notification as soon as possible, but no later than five days
(72 hours in the case of an Urgent Care claim) following the failure. Our notification
may be oral unless You specifically requested in writing.
2.
Full and Fair Review
We will permit You to review Your claim file and to present evidence and testimony as
part of Our internal claims. Specifically:
• We will provide You, free of charge and sufficiently in advance of the date on
which We provide a final adverse benefit determination to give You a reasonable
opportunity to respond with any new or additional evidence that We consider, rely
upon, or generate in connection with Your claim; and
• Before We issue a final adverse benefit determination based on a new or
additional rationale, We will provide You with such rationale sufficiently in
advance of the date on which We provide a final adverse benefit determination to
give You a reasonable opportunity to respond.
3.
Timing of Notification of Benefit Determination
• Urgent Care Claims
If the claim involves an Urgent Care claim, We will notify You of the benefit
determination (whether adverse or not) as soon as possible taking into account the
medical exigencies, but not later than 72 hours after receipt of the claim, unless
insufficient information to determine whether, or to what extent, benefits are
covered or payable under this Policy.
If We receive insufficient information to decide Your claim, We will notify You
as soon as possible, but not later than 72 hours after receipt of the claim, of the
specific information necessary to complete the claim. You will have a reasonable
amount of time, taking into account the circumstances, but not less than 48 hours,
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to provide the specified information. We will notify You of the benefit
determination as soon as possible, but in no case later than 48 hours after the
earlier of:
i.
Our receipt of the specified information; or
ii.
The end of the period afforded You to provide the specified information.
• Concurrent Care Decisions
If We have approved an ongoing course of treatment to be provided over a period
of time or number of treatments and reduces or terminates coverage of such
course of treatment (other than by plan amendment or termination) before the end
of such period of time or number of treatments, We will notify You at a time
sufficiently in advance of the reduction or termination to allow You to appeal and
obtain a determination before the benefit is reduced or terminated.
We will decide any request by You to extend the course of treatment beyond the
period of time or number of treatments for an Urgent Care claim as soon as
possible. We will notify You within 72 hours after Our receipt of the claim if We
receive the request at least 24 hours prior to the expiration of the authorized
period of time or number of treatments.
• Pre-Service Claims
We will notify You of Our benefit determination (whether adverse or not) within
a reasonable period appropriate to the medical circumstances, but not later than 15
days after Our receipt of the request. We may extend this period one time for up
to 15 days if the extension is necessary due to matters beyond Our control and We
notify You prior to the expiration of the initial 15-day period, of the
circumstances requiring the extension and the date by which the Policy expects to
make a decision. If the extension is necessary due to Your failure to submit the
information necessary to decide the claim, the notice of extension will specifically
describe the required information and You have at least 45 days from receipt of
the notice to provide the information.
• Post-Service Claims
We will notify You of any denial of a post-service claim within a reasonable
period, but no later than 30 days after receipt of the claim. We may extend this
period one time for up to 15 days if the extension is necessary due to matters
beyond Our control and We notify You prior to the expiration of the initial 30-day
period, of the circumstances requiring the extension and the date by which We
expect to render a decision. If the extension is necessary due to Your failure to
submit the information necessary to decide the claim, the notice of extension will
specifically describe the required information and You will be afforded at least 45
days from receipt of the notice to provide the information.
4.
Conflicts of Interest
We will ensure that We adjudicate all claims and appeals in a manner designed to ensure
the independence and impartiality of the persons involved in making the decision.
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Decisions regarding hiring, compensation, termination, promotion, or other similar
matters with respect to any individual will not be based upon the likelihood that the
individual will support a denial of benefits.
5.
Compliance with Law
In all circumstances, Our internal claims and appeals process will initially incorporate the
internal and external claims and appeals procedures (including urgent claims) set forth in
regulation
22
and will update such process in accordance with any applicable standards
established by the U.S. Department of the Treasury, U.S. Department of Labor, the U.S.
Department of Health and Human Services.
E.
Internal Appeals and Grievance Procedures
In order for Us to remain responsive to Your needs, We have established both a grievance process and an
Appeal process. Should you have a problem or question; a Customer Services representative can assist
You. Most problems and questions can be handled in this manner. Requests regarding claim errors, claim
corrections, and claims denied for additional information may be reopened for consideration without
having to invoke the
formal Appeal or Grievance process. You may contact Customer Services at the
telephone number on Your Identification Card. You may also file a written Grievance or Appeal with Us.
Contact Us when You:
1.
Do not understand the reason for the denial;
2.
Do not understand why the health care service or treatment was not fully covered;
3.
Do not understand why a request for coverage of a health care service or treatment was
denied;
4.
Cannot find the applicable provision in Your EOC or Certificate of Coverage;
5.
Want a copy (free of charge) of the guideline, criteria or clinical rationale that We used to
make Our decision; or Disagree with the denial or the amount not covered and You want
to appeal
702. Authorized representative
In order for a person to submit an appeal or grievance on your behalf, You must designate Your
authorized representative in writing unless the claim or appeal involves an Urgent Care claim and
a health care Professional with knowledge of Your medical condition is seeking to act on Your
behalf. You must send Your designation to Our customer service department.
If no authorized representative has been designated, the appeal or grievance will be deemed
waived.
2.
Internal Grievance Procedures
22
26 CFR § 54.9815-2719T – Internal claims and appeals and external review processes; 29 CFR § 2560.503-1 –
Claims procedure; 29 CFR § 2590.715-2719 – Internal claims and appeals and external review processes; 45 CFR §
147.136 – Internal claims and appeals and external review processes
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Grievances typically involve issues such as dissatisfaction about our services, quality of
care, the choice of and accessibility to Hometown Health Providers and network
adequacy.
Concerns about medical services are best handled at the medical service site level before
being brought to Our attention. If You contact Us regarding an issue related to the
medical service site and have not attempted to work with the site staff, You may be
directed to that site to try to solve the problem there. The procedures outlined in this
chapter will be followed if a medical service site matter cannot be resolved at the site or
if the concern involves a claim for benefits.
Upon receipt, Your Grievance will be reviewed and investigated. You will receive a
response within 30 calendar days of Our receipt of Your Grievance. If We are unable to
resolve Your Grievance in 30 calendar days, You will be notified on or before calendar
day 30 that a 15 calendar day extension is required to resolve Your Grievance.
703. Internal Appeals Procedures
Hometown Health is committed to providing a full and fair process for resolving disputes
and responding to requests to reconsider coverage decisions You find unacceptable,
whether the decision is a claim denial or a rescission of coverage. Appeals involve a
request to reverse a previous adverse benefit determination made by Hometown Health.
You have a right to appeal any decision We make that denies payment on Your claim or
Your request for coverage of a health care service or treatment.
Types of Appeals include:
• Post-service claims are all claims other than pre-service claims and Urgent Care
Claims. Post-service claims include claims filed after services are rendered.
• Pre-service claims are claims for a service where the terms of the EOC require the
Member to obtain approval of the benefit, in whole or in part, in advance of
receipt of the service. If You call to receive authorization for a service when
authorization in advance is not required, that claim will be considered a post-
service claim.
• Expedited Appeals are made available when the application of the time period for
making pre-service Appeal decisions could seriously jeopardize the patient’s life,
health or ability to regain maximum function, or in the opinion of the patient’s
physician, would subject the patient to severe pain that cannot be adequately
managed without the care or treatment. Expedited appeals are not available for
appeals regarding post-service claims.
3.
Informal Appeal
If You question the manner that a claim for benefits is decided, You may file an informal
appeal. You must make all informal appeals to Our customer services department within
60 days of an adverse benefit determination. If You do not file an informal appeal in a
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timely manner, We will deem Your appeal waived. The informal appeal is a voluntary
level of appeal and You may immediately make a formal appeal.
Upon the initiation of an informal appeal, Our customer services department will record
at least the following information:
• Name of person on whose behalf the appeal is filed (complainant);
• Complainant’s name and membership number;
• Name of person(s) involved;
• Date(s) of occurrence;
• Location;
• Nature of appeal; and
• Name of person filing the appeal.
Our Customer Services department representative will inform You of the resolution or
proposed resolution of the appeal within 30 days, unless more time is required for fact-
finding.
4.
Formal Appeal
If We do not resolve an informal appeal to Your satisfaction or if You choose not to file
an informal appeal, You may file a formal appeal. You must submit the formal appeal in
writing (or orally, at Your option, in the case of an appeal of an Urgent Care claim) to the
customer services department within 180 days after We inform You of Our resolution of
the informal appeal or within 180 days of the adverse benefit determination if the formal
appeal is Your initial appeal. There is an exception to the 180-day filing timeframe; if
You are able to demonstrate that You were incapacitated and unable to file an appeal
within the standard timeframe, We will grant You a reasonable extension. If You do not
file a formal appeal in a timely manner, We will deem Your appeal waived with respect
to the adverse benefit determination to which the appeal relates.
The formal appeal must contain, at least:
• Your name (or name of You and Your authorized representative), address, and
telephone number;
• Your membership number; and
• A brief statement of the nature of the matter, the reason(s) for the appeal, and why
You feel that the adverse benefit determination was wrong.
Additionally, You may submit any supporting medical records, Physicians’ letters, or other
information that explains why We should cover the claim for benefits. All appeals and
related documentation must be sent to:
Hometown Health Customer Service
10315 Professional Circle
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Reno, NV 89521
The review of your appeal will be made by an individual who is neither the individual
who made the initial adverse benefit determination nor the subordinate of such individual
and will not afford deference to such adverse benefit determination.
When the review is complete, We will inform You in writing of the resolution no later
than:
• 72 hours, in the case of an expedited appeal;
• 15 days, in the case of an appeal of a pre-service claim; or
• 30 days, in the case of an appeal of a post-service claim.
We may extend this period one time for up to 15 days if the extension is necessary due to
matters beyond Our control and We notify You prior to the expiration of the initial 15-
day period, of the circumstances requiring the extension and the date by which the Policy
expects to make a decision.
If the proposed resolution to the formal appeal is not acceptable to You, You may be
entitled to proceed directly to external review outlined below. We will inform You of
this right at the time We inform You of the resolution of Your formal appeal.
You may receive, free of charge, reasonable access to, and copies of, all documents and
records and other information in Our possession relevant to the adverse benefit
determination including, but not limited to, any applicable internal rule or guideline of
ours on which We relied in making the adverse benefit determination and, if the adverse
benefit determination related to Medical Necessity, a statement of the scientific or
clinical judgment for the determination applying the terms of the EOC to Your medical
circumstances.
5.
Appeal Reopening
If you obtain additional information that was not considered by Hometown Health during
the review of your appeal, or you feel as though there was an error made in the
determination of your appeal, you may ask Hometown Health to re-open your appeal. A
request to reopen your appeal must be filed within four (4) months from the date of your
initial appeal determination. There is an exception to the 4 month filing timeframe; if
You are able to demonstrate that You were incapacitated and unable to file an appeal
reopening within the standard timeframe, We will grant You a reasonable extension. If
You do not file a formal appeal in a timely manner, We will deem Your appeal reopening
waived with respect to the adverse benefit determination to which the appeal relates.
There are two circumstances in which Hometown Health will allow an appeal reopening.
• There is new and material evidence that was not available or known at the time of
the determination or decision and may result in a different conclusion.
• The evidence that was considered in making the determination or decision clearly
shows on its face that an obvious error was made at the time of the determination
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or decision. In other words, the decision was clearly incorrect based on all the
evidence presented in the appeal file.
If Hometown Health grants your request to reopen your appeal We will inform You in
writing of the resolution no later than:
• 72 hours, in the case of an expedited appeal;
• 15 days, in the case of an appeal of a pre-service claim; or
• 30 days, in the case of an appeal of a post-service claim.
We may extend this period one time for up to 15 days if the extension is necessary due to
matters beyond Our control and We notify You prior to the expiration of the initial 15-
day period, of the circumstances requiring the extension and the date by which the Policy
expects to make a decision.
F.
External Review of an Appeal or Grievance
If You have been unable to contact or obtain satisfaction from our internal Appeal or
Grievance procedures, You may contact the Nevada Office for Consumer Health Assistance
(OCHA) for review at:
Office for Consumer Health Assistance
555 East Washington #4800
Las Vegas NV 89101
(702) 486-3587
(888) 333-1597
(702) 486-1597 (fax)
http://dhhs.nv.gov/Programs/CHA/
Exhaustion of the internal appeal or grievance procedure is a precondition to filing a
complaint with OCHA. This level of appeal is optional. You or Your authorized
representative must submit this appeal in writing on within four (4) months after You
have been informed of the resolution of the internal appeal or grievance. If You do not
file Your appeal or grievance in a timely manner, We will deem it waived with respect to
the adverse benefit determination to which it relates
G.
External Review of Adverse Utilization Review Decisions
If, upon Our review of your internal appeal, We deny Your claim for benefits and You
disagree with Our decision, You may have the right to request an independent external
review of Our decision by health care professionals who have no association with Us if
our decision involved making a judgment as to the Medical Necessity, appropriateness,
health care setting, level of care, or effectiveness of the health care service or treatment
you requested (including whether the service or treatment was determined to be
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Experimental or Investigative). The external review process is available only if You have
exhausted Our internal appeal procedure.
All external reviews are conducted by an independent third party with clinical and legal
expertise and with no financial or personal conflicts with Us. These third parties are
known as “independent review organizations.” The reviewer will not defer to the
decisions made during the internal review process and will look at Your claim anew. The
reviewer will consider all the information and documents that it receives in a timely
manner when making its decision. If the independent review organization reverses Our
denial of Your claim, the decision will be final and We must immediately provide
coverage or payment.
All requests for external review will be processed as a standard request unless You make
a written or oral request for an expedited external review and the follow criteria is met:
• You have a medical condition where the time for completing the standard review
process would seriously jeopardize Your life, health, or ability to regain
maximum function.
• Your treating Physician certifies in writing that the recommended or requested
service or treatment would be significantly less effective if not promptly initiated.
• You have filed a request for an expedited internal appeal.
• The final adverse benefit determination concerns the admission, availability of
care, continued stay, or health care item or service for which You received
services, but You have not been discharged from a facility.
To request a standard or expedited external review You must submit your request within four
(4) months of the date You receive an adverse benefit determination or final adverse benefit
determination. You may file a request for external review by contacting the Nevada Office
for Consumer Health Assistance (OCHA) at:
Office for Consumer Health Assistance
555 East Washington #4800
Las Vegas NV 89101
(702) 486-3587
(888) 333-1597
(702) 486-1597 (fax)
http://dhhs.nv.gov/Programs/CHA/
When filing a request for external review, You will be required to authorize the release of
any of Your medical records that may be required to be reviewed for the purpose of reaching
a decision on the external review.
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2.
Standard and Expedited External Review Timeframes
Should You file a request for a standard or expedited external review by the OCHA, You
can anticipate the timeframe for review to be as follows:
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• Within five (5) days after receiving Your request for external review, OCHA will
notify HTH that the request has been filed (within 72 hours for expedited
requests).
• As soon as practicable after receiving Your request, OCHA will assign an
Independent Review Organization (IRO). OCHA will assign the IRO within one
(1)
business day for expedited requests.
• Within five (5) days after receiving notification from OCHA, HTH will provide to
the IRO all documents and materials relating to the adverse determination (within
24 hours for expedited requests).
• Within five (5) days after receiving the request, the IRO will:
i.
Review the request, documents and materials submitted; and
ii.
Notify You if any additional information is required to conduct the review.
• You must provide that information to the IRO within five (5) days after receiving
the request for additional information. Any information submitted to the IRO by
You after five (5) business days has passed, MAY be considered as well. The
IRO will forward to HTH any additional information provided to them within one
(1) day of receipt.
• If We fail to provide the information within the specified time, the IRO may
terminate the review and reverse the adverse determination. The IRO must notify
Us, You and the OCHA of its decision to do so.
• Upon receipt of the information, We may reconsider Our original determination
or terminate the review and immediately provide coverage for the service. We
must notify the IRO, You and OCHA of Our decision to do so.
• The IRO will approve, modify or reverse the adverse determination within fifteen
(15) days (within 48 hours for expedited requests). The IRO will submit its
determination to You, Your Physician, if necessary, and HTH. For expedited
requests, You, Your Physician and HTH will be notified within 24 hours of
completion of the review and a written notice will be provided within 48 hours.
• We will immediately approve the coverage or recommended treatment upon
receipt of a notice reversing the adverse determination.
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NRS 695G.251 through 695G. 271
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XVII. GENERAL PROVISIONS
A.
Assignment
You may not assign this EOC or any of the rights, interests, claims for money due, benefits, or
obligations hereunder without Our prior written consent.
B.
Authorization to Examine Medical Records
By accepting benefits under this Policy, You consent to and authorize all health care Providers
including, but not limited to, Physicians, Hospitals, skilled nursing facilities, and other Providers
to permit the examination and copying of any portion of the Your Hospital and medical records
in accordance with applicable law, when requested by Us.
C.
Balance Billing
If the billed charges exceed the contracted amount agreed to by an In-Network Provider for
Covered Services that You receive, such Provider is prohibited from billing You for the
difference. Because this Provider is an In-Network Provider, You are not responsible for the
difference between the billed charges and the contracted charges.
D.
Charge for Service or Purchase
We will deem the charge for service or purchase to have been incurred on the date the service is
performed or the date the purchase occurs.
E.
Clerical Error
Clerical errors or delays in keeping or reporting data relative to coverage will neither invalidate
coverage that would otherwise be validly in force nor continue coverage that would otherwise be
validly terminated. Upon discovery of such errors or delays, an equitable adjustment of
Premiums will be made. In no event will credits be made retroactive more than two Premium
due dates prior to the date that We are notified in writing in a form satisfactory to Us of a
requested addition/deletion to, or change in, Your coverage status.
F.
Entire EOC
This EOC, the Group Subscription Agreement, the Schedule of Benefits, riders, questionnaires,
and applicable attachments if any, constitute the entire contract between the parties. As of the
effective date of coverage, it supersedes all other agreements between the parties. Any
statements made to Us by the Member shall, in the absence of fraud, be deemed representations
and not warranties. No such statement, unless it is contained in a written application for
coverage, may be used in defense to a claim under this Policy.
G.
Form or Content of EOC
No agent or employee of Us is authorized to change the form or content of this EOC. Such
changes can be made only through endorsement signed by an authorized officer of Us.
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H.
Gender
The use of any gender herein shall include the other gender and the use of the singular shall
include the plural (and vice versa).
I.
Governing Law
Except as preempted by federal law, this EOC will be governed in accordance with the laws of
the state of Nevada and any provision that is required to be in this EOC by state or federal law
shall bind Us and each Member whether or not set forth in this EOC.
J.
Membership Card
Cards that We issue to Members are for identification only. Possession of a membership card
confers no right to services or other benefits under this Policy. To be entitled to such services or
benefits, the holder of the card must, in fact be an eligible Member on whose behalf all
applicable Premiums due under this Policy have actually been paid. Any person receiving
services or other benefits to which he or she is not entitled pursuant to the provisions of this
Policy and any Member assisting such person shall be liable for the actual cost of such services
or benefits.
K.
Modifications
This EOC shall automatically be modified to comply with provisions of applicable federal and
Nevada law. By electing medical and Hospital coverage under this Policy or accepting this
Policy’s benefits, all Members legally capable of contracting, and the legal representative of all
Members incapable of contracting, agree to all terms and conditions hereof.
L.
Notice
You may give any notice under this Policy by United States mail, first class, postage prepaid,
addressed as follows:
Hometown Health
Customer Service Department
10315 Professional Circle
Reno, Nevada 89521.
We will send Our notices to You to the most recent address that We have on file. You are
responsible for notifying Our customer services department of any change in address.
M.
Notice of Claim
If submission of a claim is required to receive benefits under this Policy, such claim will be
allowed only if notice of the claim is submitted to Us within 120 days from the date on which the
covered expenses were first incurred. However, if it was not reasonably possible to give notice
within the above time limit, and notice was furnished, as soon as was reasonably possible, the
submission date will be extended accordingly. However, in no event will We pay benefits if
notice of claim is made beyond one year from the date on which the Expense was incurred.
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N.
Policies and Procedures
We may adopt reasonable policies, procedures, rules, and interpretations to promote the orderly
and efficient administration of this Policy.
O.
Nondiscrimination
We do not discriminate in the delivery of services on the basis of sex, age, race, religion, national
origin, sexual orientation, or genetic information.
P.
Return of Overpayment
Payment made for charges must be returned to Us if found that such charges were paid in error.
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XVIII. DEFINITIONS
The following definitions apply to all provisions of this EOC and to the applicable Schedule of
Benefits.
A. GENERAL DEFINITIONS
Acute – A short Illness or Injury, generally of a sudden onset and/or infrequent occurrence, in
which Illness or Injury is not always present. An Acute condition may become Chronic.
Allowed Amount – The contracted amount for a Covered Service or, except in the case of an
Emergency, if there is not a contracted amount, the lesser of the Usual and Customary
amount or the amount Medicare would pay for the service. In the case of an Emergency, if
there is not a contracted amount, the Allowed Amount shall be increased to comply with state
and federal law.
24
Benefit Plan – The specific health insurance Policy outlined in this EOC and Your Schedule of
Benefits.
Benefit Summary Table – A table found in the Schedule of Benefits that includes the specific
level of Cost Sharing for various benefits that must be paid by the Member upon receipt of
the benefit.
Billing Cycle – The period between the Premium due date and the day before the next Premium
is due. The Premium due date is the day following the date of Subscriber acceptance of
Policy. Eligibility for coverage and membership will not begin until the Premium is
collected and the effective date of coverage will vary depending upon the circumstances
around the enrollment. This is detailed in the eligibility section of the Policy.
Chronic – An Illness, condition, or Injury that continues or is expected to continue for at least
six months that can recur frequently or is always present. Chronic conditions may have
Acute episodes.
Chronic Pain – Ongoing pain that is due to non-life threatening causes may continue for the
remainder of life and that has not responded to currently available treatment methods.
Coinsurance – The percentage of the Allowed Amount for a Covered Service that is due and
payable by the Member to a Provider upon receipt of the service. There may be separate
Coinsurance for medical, pharmacy and other benefits according to the Benefit Plan that is in
place. Coinsurance applies after all Deductibles have been paid, unless otherwise stated
within the Schedule of Benefits or EOC. Coinsurance paid by the Member applies to the
Out-of-Pocket Maximums.
Convenient Care Facility – A facility that provides services for Medically Necessary, non-
urgent Illness or Injury. Examples of such conditions include diagnostic laboratory services,
general health screenings, minor wound treatment and repair, minor illnesses (cold/flu),
treatment of minor burns and sprains and blood pressure checks.
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Assembly Bill 469 (2019) and 45 CFR § 147.138(b)(3)
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Copayment – The dollar amount that a Member must pay to a Provider upon receipt of certain
Covered Services. Copayments apply after all deductibles have been paid, unless otherwise
stated within the Schedule of Benefits or EOC. If there is no Deductible for a particular
service or the applicable Deductible has been reached, and a Copayment is listed, the
Member’s Cost Sharing for that service will be that Copayment. Copayments paid by the
Member apply to the In-Network Out-of-Pocket Maximums.
Cost Sharing – A general term used to describe the amount of Deductible, Copayment,
Coinsurance and other expenses that a Member must pay before Hometown Health pays for
Covered Services. Cost Sharing is used to promote the use of lower high cost and higher
quality services. Charges associated with the following are the Member’s responsibility and
do not accumulate toward the Member’s Deductible and Out-of-Pocket Maximum:
• Costs for services received from an Out-of-Network Provider in excess of the Allowed
Amount;
• Coinsurance for services for which the Member did not receive Prior Authorization when
Prior Authorization is required;
• Costs for Prescription Drugs in excess of the Allowed Amount;
• Non-Covered Services and Prescription Drugs;
• Ancillary Charges
• Denied claims; and
• Prescription drugs received from an Out-of-Network Pharmacy unless in an urgent or
emergent case by case basis
Covered Service – A benefit for services and supplies that We provide or arrange under this
Policy and:
• Is Medically Necessary or otherwise specifically listed as a benefit in the Schedule of
Benefits or EOC;
• Is rendered by a licensed, certified, or registered Provider within the state of the place of
service and within the scope of the license of the Provider performing the service;
• For which We provide a Prior Authorization if Prior Authorization is required; and
• Is not experimental or investigational or otherwise limited or excluded by this EOC.
Services that are not Covered Services do not count toward Your Deductible or Out-of-
Pocket Maximum.
Custodial Care – Health care services or other related services (such as assistance in activities of
daily living) that either:
• Do not seek a cure;
• Are provided during periods when Acute care is not required or when the medical
condition of a Member is not improving;
• Do not require continued administration by licensed medical personnel; or
• Assist in the activities of daily living.
Deductible – The dollar amount that a Member must pay to Providers for Covered Services each
calendar year before Hometown Health pays for services, other than preventive care. There
may be separate Deductibles for medical, pharmacy and other benefits according to the
Benefit Plan that is in place, or they may be combined. Services subject to the Deductible
will be annotated with “CYD” in the Benefit Summary Table. Generally, Copayments or
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Coinsurance are payable once the Member or family has reached the applicable Deductible.
Amounts paid by the Member that are applied to the In-Network Deductible are also applied
to the In-Network Out-of-Pocket Maximum.
The family Deductible is set at twice the individual deductible. Once the family has reached
the family Deductible, benefits are payable to all Members of the family regardless of
whether the Member has met the individual Deductible. Except for certain HDHPs, one
individual family Member cannot contribute more than the individual Deductible amount.
This is called an embedded Deductible.
For certain HDHPs, if enrolled as a family, the family must satisfy the family Deductible
each calendar year before benefits are payable for any individual family Member. HDHPs
cannot cover health plan expenses before Deductibles except for preventive care services.
This is called an umbrella Deductible.
See Your Schedule of Benefits for the definition of Deductible that applies to You.
Developmental Care – Services or supplies that:
• Are provided to a Member who has not previously reached the level of intellectual,
speech, motor, or physical development normally expected for the Member’s age, and
such conditions were not a result of an Injury or Illness;
• Are primarily provided to assist in the development of those skills described above; and
• Are not rehabilitative in nature (for example, restoring fully developed skills that were
lost or impaired due to Injury or Illness).
Domiciliary Care – Services or supplies that:
• Primarily provide a protective environment and assistance with basic personal needs for a
Member;
• Are primarily provided because the Member’s own home arrangements are not
appropriate; and
• Are not part of an active treatment plan intended to or reasonably expected to improve
the Member’s condition of functional ability.
EConsult – A consultation with a specialist from your Primary Care Physician (PCP) in order to
receive advice or treatment recommendation for Your care.
Emergency – A medical condition manifesting itself by symptoms of sufficient severity
(including severe pain) that a Member, as a prudent layperson with an average knowledge of
health and medicine, could reasonably believe that the absence of immediate medical
attention could result in:
• Serious jeopardy to the health of the Member;
• Serious jeopardy to the health of an unborn child;
• Serious impairment of a bodily function; or
• Serious dysfunction of any bodily organ or part.
Evidence of Coverage (EOC) – This document which describes benefits, exclusions, limitations,
and applicable administrative policies, rights, responsibilities, and procedures for Your health
insurance Policy.
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Expense – The cost incurred for a Covered Service or supply. An Expense is considered
incurred on the date that a service or supply is received. A covered Expense does not include
any charge:
• For a service or supply that is determined to not be Medically Necessary by Hometown
Health;
• To the extent that the charge for a service or supply exceeds the lesser of the Usual and
Customary charge or the applicable Medicare reimbursement rate for such service or
supply;
• That is more than the Allowed Amount for the service or supply; or
• That is not a Covered Service under this Policy.
Food and Drug Administration (FDA) Approved – Drugs, medications, and biological agents
that have been approved by the FDA and listed in the United States Pharmacopoeia, the
American MA Drug Evaluations, or the American Hospital Formulary.
Geographic Service Area - Defines the geographic area in which Hometown Health has
contracted In-Network Providers.
Group – An employer or other party that has entered into a Group Subscription Agreement with
Us under which We will arrange and administer health services under this Policy for
Members.
Group Subscription Agreement – The legal agreement between Your employer and Hometown
Health which allows You and Your fellow employees to be covered under a group health
plan in return for Premium payment. The Group Subscription Agreement provides for the
term of coverage, employer specific eligibility rules and other items.
High Deductible Health Plan (HDHP) – A plan as described in IRS Publication 969 and IRS
Revenue Procedure 2018-30, or its successor, in which the plan cannot pay for any benefits,
except for preventive care benefits prior to the individual and family meeting the minimum
Deductible limit as defined by the IRS (additional requirements apply). As such, taxpayers
enrolled in this Benefit Plan may be eligible to make pre-tax contributions to their qualified
Health Savings Account (has). If Your plan hahasHSA” in its name, the plan qualifies as an
HDHP under all IRS requirements. Contact Your tax Professional for more details.
Hospital – A legally operated facility defined as an Acute care or Tertiary Care Hospital that is
licensed by the state and may be approved by the Joint Commission on Accreditation of
Healthcare Organizations (Joint Commission or JCAHO), the American Osteopathic
Association (AOA) or by Medicare.
Illness or Injury – A disorder or disease of the body or mind or an accidental bodily wound. All
illnesses due to the same cause or to a related cause are considered one Illness.
In-Net–work - The receipt of Covered Services or benefits from a Provider who is listed in Our
current Provider directory and who is directly or indirectly under contract with Hometown
Health to provide Covered Services to Members. These Providers are sometimes referred to as
Preferred or Participating Providers. Except for Emergency room visits or as otherwise approved
by Hometown Health in advance all services received from Providers who are not In-Network
Providers will not be covered.
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An In-Network Provider’s agreement with Us or the association of a particular Professional with
an In-Network Provider may terminate, and, in such a case, a Member will be required to use
another In-Network Provider to receive In-Network benefits. Not all Providers who have
contracts with Us are In-Network Providers for the purposes of this particular product. We do
not guarantee the continued availability of any particular Provider. In-Network Providers cannot
determine whether a service is a Covered Service under this Policy or on Our behalf.
You can find Our current Provider directory on Our web site at hometownhealth.com under the
Provider Directory link or You can request one by contacting Our customer service department.
As a Member of Hometown Health, Your plan has a Network of healthcare providers available
to You. If the health care services are not available within the Network, then Your Provider must
contact Our Utilization Management department to request a review for an Out-of-Network
Provider. Our determination will be sent to You and Your Provider and will specify the approved
procedure and servicing Provider.
Licensed Area – The geographic area in which Hometown Health issues health insurance
policies. Hometown Health has a license to provide Benefit Plans throughout the State of
Nevada.
Medically Necessary (Medical Necessity) – Health care services or products that a prudent
Physician would provide to a patient to prevent, diagnose or treat an Illness, Injury or
disease, or any symptoms thereof, that are:
• Provided in accordance with generally accepted standards of medical practice (for
purposes of this document, the phrase “generally accepted standards of medical practice”
is defined as standards that are based on credible scientific evidence published in peer-
reviewed medical literature generally recognized by the relevant medical community,
endorsed through national Physician specialty society recommendations, and the views of
medical practitioners practicing in relevant clinical areas with regard to a patient’s
condition);
• Clinically appropriate with regard to type, frequency, extent, location, and duration;
• Not primarily provided for the convenience of the patient, Physician or other Provider of
health care;
• Required to improve a specific health condition of a Member or to preserve his existing
state of health;
• The most clinically appropriate level of health care that may be safely provided to the
insured;
• Effective as proven by scientific evidence, in materially changing health outcomes;
• Not experimental, investigational, or subject to an exclusion under this Policy;
• Cost-effective compared to alternative interventions, including no intervention or the
same intervention in an alternative setting (“cost effective” does not mean lowest cost). It
does mean that as to the diagnosis or treatment of the Member’s Illness, Injury or disease,
the service is: (1) not more costly than an alternative service or sequence of services that
is medically appropriate, or (2) the service is performed in the least costly setting that is
medically appropriate; and
• Obtained from a Physician and/or licensed, certified, or registered Provider.
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A determination that a service is Medically Necessary is not an authorization to receive that
service from an Out-of-Network Provider.
Medical Director – A Physician licensed by the State of Nevada that We employ or contract with
to monitor and review the utilization and quality of health services that We provide to
Members.
Medical Pharmacy – Drugs, pharmaceuticals, immunizations, or biologics whose distribution,
administration or supply of pharmaceuticals is generally in a healthcare facility, Physician’s
office, and not in a retail pharmacy setting. A complete list of pharmaceuticals that are
covered under the Medical Pharmacy benefit is available at hometownhealth.com.
Member – A Subscriber or the Subscriber’s eligible dependents covered under the Policy.
Network – All of the In-Network Providers with which We have contracted to provide Covered
Services.
Office Visit – An office or outpatient visit consists of counseling and/or coordination of care
with a Physician, a qualified health care Professional, or an agency consistent with the nature
of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s)
are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or
family.
Open Enrollment Period – The period of time prior to the beginning of Your Employer’s Policy
year during which You may enroll in any group Hometown Health plan for which You are
eligible.
Out-of-Area – Outside of Nevada and outside the area in surrounding states that is within 50
miles of the Nevada border.
Out-of-Network – The receipt of services from a Provider with whom Hometown Health is not
contracted to provide discounted covered healthcare services resulting in the Member paying
for the entire cost of the services. These Providers are sometimes referred to as Non-
Preferred or Non-Participating Providers. For Emergency services received from an Out-of-
Network Provider, the Member will pay the standard In-Network Member Cost Sharing for
that service.
Generally, Hometown Health pays a lower, Out-of-Network benefit level, or does not pay a
benefit at all, for services provided by an Out-of-Network Provider. Because Hometown
Health is not contracted with Out-of-Network Providers, the Out-of-Network Provider may
balance bill You for the amount charged in excess of the Allowed Amount paid by
Hometown Health. Additionally, Out-of-Network Providers may not follow appropriate
Prior Authorization procedures which may result in You receiving services that are not
covered, not Medically Necessary or are otherwise excluded from coverage under this
Benefit Plan.
As a Member of Hometown Health, Your plan has a Network of healthcare providers
available to You. If the health care services are not available within the Network, then Your
Provider must contact Our Utilization Management department to request a review for an
Out-of-Network Provider. Our determination will be sent to You and Your Provider and will
specify the approved procedure and servicing Provider.
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If the health care services are not available within the Network, then Your Provider should
contact Our Utilization Management department to request a review. Our determination will
be sent to You and Your Provider and will specify the approved procedure and servicing
Provider.
Out-of-Pocket Maximum – The most a Member or Family will pay for Covered Services in a
calendar year.
Copayments, Coinsurance and Deductibles paid by Members count towards the Out-of-
Pocket Maximum.
The Out-of-Pocket Maximum does not include Premiums, expenses associated with non-
Covered Services or denied claims, Ancillary Charges and amounts that Out-of-Network
Providers bill and are payable that are greater than the Allowed Amount.
If coverage is extended to qualified dependents and the family Out-of-Pocket Maximum has
been paid, no further payment is required to be paid on the Member’s behalf for Covered
Services.
Outpatient Observation – A well-defined set of specific, clinically appropriate services, which
include ongoing short-term treatment, assessment, and reassessment before medical staff
members can decide whether a patient needs additional treatment as an inpatient or can be
discharged from the Hospital, generally limited to a maximum of 48 hours.
Partial Hospitalization – The continuous treatment for at least four hours but not more than 12
hours in any period of 24 consecutive hours. Partial hospitalization services can be
performed in a Hospital or treatment center facility.
Physician – A licensed doctor of medicine, osteopathy, dentistry, or podiatry.
Policy – This Evidence of Coverage (EOC), the Group Subscription Agreement, the Schedule of
Benefits, riders, questionnaires, applicable attachments and amendments.
Premium – A periodic payment, typically monthly, paid to Us for this Policy.
Primary Care Physician (PCP) – A Physician in the fields of Family Practice, Internal Medicine
or Pediatrics who is an In-Network Provider and who a Member designates (or who We
designate on behalf of a Member) to arrange and coordinate all aspects of such Member’s
care.
Prior Authoriz–tion - Approval from Hometown Health that may be required before You get a
service or fill a prescription. We use utilization management and quality assurance protocols
to ensure the service being requested is Medically Necessary and covered. Prior
Authorizations protect You from expenses that result from receiving services that are not
covered, not Medically Necessary or are otherwise excluded from coverage under this plan.
All benefits listed in this EOC and Your Schedule of Benefits may be subject to Prior
Authorization requirements and concurrent review depending upon the circumstances
associated with the services.
• HMO plan: Prior Authorization is required and if not obtained, the service may not
be covered, even if the service is Medically Necessary.
• EPO plan: Prior Authorization is required and if not obtained, the service may not be
covered, even if the service is Medically Necessary.
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• PPO plan: Prior Authorization is required and if not obtained, You may be subject to
a 50% reduction in benefits, even if the service is Medically Necessary.
There may be Prior Authorization or pre-treatment requirements for pharmacy, dental, and vision
benefits. Refer to Your plan-specific Schedule of Benefits for services that require Prior
Authorization. You may find a full list of services that require Prior Authorization by visiting
Our website at hometownhealth.com or contact Customer Service at 1-800-336-0123 for
more information
Professional – A Physician or other health care Professional, including a pharmacist, Physician’s
assistant, nurse practitioner, or autism behavioral interventionist, who is licensed, certified, or
otherwise authorized by the state to provide health care services consistent with state law.
Provider – A Physician, Professional, organization or association of Physicians, Hospital, skilled
nursing facility, any organization licensed by a state to render home health services, or any
other licensed health care institution or health care Professional.
Qualifying Life Event – An event in Your life, such as birth or marriage, which allows You to
enroll or change health insurance coverage.
Remote Monitoring – Remote patient monitoring, including the collection, storage, and
evaluation of health information through live monitoring via devices that transmit
information from the home or care facility to Your provider.
Specialist or Specialty Care Physician – A Professional who provides medical care in a specific
branch of medicine generally referable to a particular bodily system or area.
Subrogation – A legal process whereby Hometown Health may seek reimbursement from a third
party that is legally liable for a claim or a portion thereof.
Subscriber – A person who meets all applicable eligibility requirements of this EOC, whose
enrollment form has been accepted by Hometown Health and in whose name the membership
is established. For group plans, the Subscriber is generally the employee. For individual and
family plans, the Subscriber is the Policy holder.
Schedule of Benefits – The document that describes the Cost Sharing and some of Your rights
and restrictions for Your health insurance Policy provided by Hometown Health. The
Schedule of Benefits is a supplement to this EOC. In case of conflicts between this EOC and
Your Schedule of Benefits, this EOC shall be the document that determines the benefits or
interpretation of those documents.
Telehealth or Telemedicine – The delivery of services from a Provider to a Member at a
different location through the use of information and audio-visual communication
technology, not including facsimile or electronic mail.
Tertiary Care – The highest or most complex level of care for the treatment of a particular
medical condition and not generally available in a community Hospital. Tertiary care is
specialized consultative care, usually on referral from primary or secondary medical care
personnel, by Specialists working in a center that has personnel and facilities for special
investigation and treatment.
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Urgent Care – Medically Necessary services for a condition that requires prompt medical
attention but is not an Emergency.
Urgent Care Center services received from Out-of-Network Providers will be covered at the
Cost Sharing amount described in Your Schedule of Benefits. Because Hometown Health is
not contracted with Out-of-Network Providers, the Out-of-Network Provider may balance
bill You for the amount charged in excess of the Allowed Amount paid by Hometown Health.
Usual and Customary – The lesser of:
• A Provider’s usual charge for furnishing a treatment, service, or supply; or
• The amount Hometown Health determines to be the general rate paid to others who
render or furnish such treatment, service, or supply to individuals who reside in the same
geographic area and whose conditions are comparable in nature and severity.
Virtual Visit – An Urgent Care Telehealth visit delivered via the Member’s audio and video
enabled device.
We, Us, Our, or Hometown Health – Hometown Health Plan, Inc.
You, Your, or Member – A person who meets all applicable eligibility requirements of this EOC
and whose enrollment form We have accepted.
B. PHARMACY BENEFIT DEFINITIONS
Specific terms related to pharmacy benefits that may be used throughout his EOC and to the
applicable Schedule of Benefits are defined as follows.
Ancillary Charge – An additional charge borne by the Member and calculated as the difference
between the contracted reimbursement rate for In-Network pharmacies for the medication
dispensed and the Generic Drug product equivalent. Ancillary Charges do not apply toward
Your Deductible or Out-of-Pocket Maximum.
Brand Drug – A Prescription Drug, including insulin, typically protected under patent by the
drug’s original manufacturer or developer with a proprietary trademarked name.
Diabetic Services – Products for the management and treatment of diabetes, including infusion
pumps and related supplies, medication, equipment, supplies and appliances for the treatment
of diabetes.
Drug Formulary – A comprehensive list of Brand and Generic Drugs, approved by the U.S.
Food and Drug Administration (FDA), covered under this Benefit Plan. The medications
covered under this formulary may be substantially different from other Hometown Health
drug formularies.
Formulary Drug – A Brand Drug or Generic Drug included in the Drug Formulary.
Generic Drug – A Prescription Drug, whether identified by its chemical, proprietary or
nonproprietary name, that is accepted by the FDA as therapeutically equivalent and
interchangeable with a drug having an identical amount of the same active ingredient(s) in
the same proportions, that have the same information printed on the label and that perform in
the same manner as the trademarked, brand-name version of the drug
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Injectable Drug – A Prescription Drug dispensed from a pharmacy (including combination
therapy kits) that are injected directly into the body by the Member or the Member’s
Physician.
Maintenance Medication – Prescriptions Drugs commonly used to treat conditions that are
considered Chronic or long-term. These conditions usually require regular, daily use of
medicines. Examples of Maintenance Medications are those drugs used to treat high blood
pressure, heart disease, asthma, and diabetes.
Maximum Allowed Amount – The lowest available cost to Hometown Health for a Generic
Drug, a Prescription Drug product or a Brand Drug without a Generic Drug equivalent
available at the time a prescription is filled.
Non-Formulary Drug – A drug not listed in the Drug Formulary. There is no coverage for
drugs that are not listed in the Drug Formulary.
Out-of-Network Pharmacy – A Pharmacy with which Hometown Health is not contracted to
provide discounted covered Prescription Drug products to its members.
In-Network Retail Pharmacy – A pharmacy with which Hometown Health, or PBM is
contracted to provide discounted Prescription Drugs to its members.
Pharmacy Benefit Manager (PBM) – A company with which Hometown Health is contracted to
manage the Prescription Drug benefits provided in Your Policy.
Prescription Drug – A medication, product or device approved by the FDA and dispensed under
state or federal law pursuant to a prescription order (script) or refill.
Step Therapy – A treatment process that requires the use of lower cost drugs first (generally
within a specific therapeutic class of drugs) when multiple treatment options exist for a
particular medical condition, before Hometown Health authorizes the use of higher cost
Formulary Drugs.
Specialty Pharmaceuticals – Prescription Drugs having one or more of the following
characteristics: expensive (typically greater than $600 per dosage unit or per prescription);
limited access; complicated treatment regimens; compliance issues; special storage requirements;
or manufacturer reporting requirements.
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Hometown Health is licensed by:
State of Nevada
Department of Business and Industry
Division of Insurance
1818 East College Parkway
Carson City, Nevada 89706
(888) 872-3234
Monday – Friday, 8 a.m. – 5 p.m. PST
