WASHINGTON COUNTY HEALTH SYSTEM, INC. 

EMPLOYEES’ HEALTH BENEFIT PLAN

SUMMARY PLAN DESCRIPTION

TABLE OF CONTENTS

Page

Schedule of Benefits 3

Eligibility 8

Termination of Coverage 11

Health Care Management 12

The Network Option 14

Medical Expense Benefit 17

Pharmacy Benefit Plan 26

Exclusions 29

Coordination of Benefits 33

How to File a Claim 35

Continuation of Coverage 38

Definitions 40

General Provisions and Information 46

Statement of ERISA Rights 47

Facts about the Plan 48

This booklet is not a contract. It explains in non-technical language the essential features of your Employee Health Benefits Plan.

You should contact your employer if you have any questions concerning your coverage.

Effective: 01/01/94

Restated: 07/01/98

 Schedule of Benefits

NETWORK OPTION / BASIC OPTION

HEALTH CARE MANAGEMENT PROGRAM

PHARMACY BENEFIT PLAN

* Retiree Participants have an annual limit of $1000.00 in covered prescription expenses.

THE NETWORK OPTION

NO BENEFITS ARE PAYABLE (IN NETWORK OR OUT OF NETWORK) WITHOUT A REFERRAL FROM YOUR PRIMARY CARE PHYSICIAN (PCP).

THE BASIC OPTION

* Indicates No Deductible Will Be Taken For These Expenses

** Indicates $10 Co-payment per Visit (Not Reimbursable)

++ Indicates an Additional $300 per Confinement Deductible

 Eligibility

Employee Coverage

All regular full-time, regular part-time, part-time, flexible staffing team and substitute employees of Washington County Health System, Inc. are eligible to participate on the first day of the month following completion of 30 days of active service for newly hired employees or the first day of the month following the date the employee first becomes eligible to participate in the Plan as determined by his/her category of employment.

If you were covered under the employer’s prior plan on the date immediately prior to the effective date of this Plan, you are covered by this Plan.

Dependent Coverage

Each of your dependents will be eligible to be covered on the date you become covered or the date the dependent is acquired by you, whichever is later, and when you agree to contribute toward dependent coverage.

A who is placed with you for adoption will be eligible to be covered on the date you assume and retain legal obligation for total or partial support of a child in anticipation of adopting such child.

Retiree Coverage

You are eligible for coverage is you resigned your regular duties (except in the case of those who transferred to the subpool or FST) for retirement or permanent, total disability reasons. To be eligible, you must enroll within 30 calendar days of the qualifying event.

You may elect to continue coverage for yourself and for you eligible dependents if you were a Washington County Health System employee and were participating in the Plan at retirement and the following criteria are met:

1.) You are at least 55 years of age with 15 years of consecutive Active Service in the Washington County Hospital Employees’ Cash Balance Pension Plan ending at the time of retirement.

2.) You make timely payments of the age based monthly premium.

Age based premiums will equal 100% of the actuarially determined, age based cost of the Plan. Age based premiums will be based upon the retiree’s chronological age at the beginning of the calendar year except that conversion to Medicare Supplemental coverage will occur upon eligibility for Medicare.

You are also eligible if you meet the above criteria but transfer to the subpool or FST status for the benefit of the health system.

Coverage will be reduced to the supplemental coverage upon eligibility for Medicare. Retirees or dependents who satisfy the eligibility requirements but continue working elsewhere will be required to pay the difference between the supplemental contribution rate and the contribution for individual coverage if this coverage is required by Medicare regulations.

Qualified Medical Child Support Order (QMCSO)

If the Plan Administrator determines that a Qualified Medical Child Support Order (QMCSO) meets the requirements of applicable law pertaining to QMCSOs, the child(ren) to whom the QMCSO pertains will be added to the Plan and any required contributions will automatically be taken.

Initial Enrollment Period

The employee/dependent enrollment application must be completed and returned to the employer’s human resources department within the time period specified by the employer.

Special Enrollment Period Due to Loss of Coverage

Either you or your dependent who is eligible but not enrolled in this Plan may enroll upon losing other coverage if each of the following conditions are met:

a. You or your dependent were covered under a group health plan or had health insurance coverage at the time coverage under this Plan was previously offered to the individual; and

b. The coverage of you or your dependent who has lost the coverage was under COBRA and the COBRA coverage was exhausted, or was not under COBRA and either the coverage was terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or employer contributions toward the coverage were terminated; and

c. You request enrollment in this Plan by completing the appropriate enrollment form(s) within 31 days after the date of exhaustion of COBRA coverage or the termination of coverage or employer contributions described above.

When the above conditions are met, coverage will be effective retroactive to the date the other coverage was lost.

If you or your dependent lost the other coverage as a result of the individual’s failure to pay premiums or for cause (such as making a fraudulent claim), that individual does not have a Special Enrollment right.

Dependent Special Enrollment Period

The Dependent Special Enrollment Period is a period of 31 days that begins on the date of a marriage, birth, adoption or placement for adoption.

Dependents newly acquired as a result of marriage, birth, adoption or placement for adoption may be enrolled under this Plan only if you complete the required enrollment request no later than 31 days following the coverage event (i.e., date of birth, date of marriage, date of adoption or placement for adoption).

Coverage will be effective for the dependents, and for you if you are eligible to be enrolled under this Plan but failed to enroll during a previous enrollment period, as follows:

a. When coverage is requested to add a newborn, adopted child or child placed for adoption, coverage will be offered to you, your eligible spouse, and newly acquired child. Coverage will become effective for the you, your spouse and newly acquired child retroactive to the date of birth, adoption or placement for adoption.

b. When coverage is requested to add dependents acquired due to marriage, coverage will be offered to the you and to the dependents acquired as a result of the marriage. Coverage will become effective for you and your dependents acquired as a result of the marriage retroactive to the date of the marriage.

Change in Family Status

You may change benefit plans and/or modify enrollment for yourself and/or your eligible dependents due to a Change in Family Status, as follows:

a. marriage, divorce, death, birth or adoption of a child; or

b. a change in the Employee's spouse's employment status causing loss of medical coverage for the Employee or the Employee's eligible Dependents; or

c. a change in the Employee's employment status causing a loss or gain in benefits.

The request to change benefit plans and/or modify enrollment must be consistent with the reason for the Change in Family Status and must be made within 31 days following the date the change occurred.

When the above conditions are met, the effective date for any change made due to a Change in Family Status will be retroactive to the date the change occurred.

Open Enrollment Period

The Open Enrollment Period is the period of time specified by the employer prior to the start each plan year during which you may change benefit plans and/or modify enrollment. Except for a change in family status (as outlined above), the Open Enrollment Period is the only time you may change benefit options or modify your enrollment.

An active employee whose coverage has been canceled due to non-payment of required contributions will not be allowed to re-enroll in the plan for a period of one year from the date of cancellation. Such employee’s effective date will be January 1 following the end of the one year period.

Termination of Coverage

Your coverage under this Plan will terminate on the earliest of the following dates:

a. the date of termination of the Plan;

b. the date you cease to be eligible for coverage under the Plan; or

c. the date you become a full-time member of the armed forces of any country; or

d. the last day of the month in which the your employment is terminated; or

e. the date you fail to make any required contribution.

Cessation of active service shall be deemed termination of employment. If you are not working due to an approved leave of absence, a sickness or injury, your coverage may be continued in accordance with your employer's standard personnel policies and practices.

Your dependent’s coverage will terminate on the earliest of the following dates:

a. the date the individual ceases to meet the definition of dependent as defined in the Plan;

b. for a Dependent child, the end of the calendar year in which he/she turns 19 (23 if a full-time student);

c. the date your coverage is terminated; or

d. the date you fail to make any required contribution.

If your and/or your dependents’ health benefits terminate due to a qualifying event, you and/or your dependents may elect to continue as participants under this plan. See the section later in this booklet on Continuation of Coverage, for more information.

 Health Care Management

This program monitors your proposed inpatient admission and helps assure that your treatment is medically necessary and appropriate.

Non-Emergency Admissions

If your physician decides you or your dependent needs to be admitted, show him or his staff member your benefits ID card. If you are enrolled in the Network Option, your PCP will notify InforMed’s Health Care Management of your admission. If you are enrolled in the Basic Option, you must call InforMed’s toll-free number to report your admission. Ask for Health Care Management and be prepared to give the following information:

1. Your name, address, phone number, and social security number.

2. Your employer’s name

3. The patient’s name, date of birth, address and phone number

4. The admitting physician’s name and phone number

5. The name of the facility or hospice

6. The date of admission

7. The condition for which the patient is bring admitted.

Emergency Admissions

Within 48 hours following the admission, the same notification as listed above must be given. Remember, if you are enrolled in the Network Option, your PCP will notify InforMed for you. If you are enrolled in the Basic Option, this notification is your responsibility.

Maternity Admissions

You are not required to call InforMed regarding your stay in a birthing facility or hospital in connection with childbirth unless your stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section.

Covered expenses for a covered stay in a birthing facility or hospital following a normal vaginal delivery will include a minimum of 48 hours for both the mother and the newborn child unless a shorter stay is agreed to by both the mother and her attending physician. Covered expenses for a covered hospital stay in connection with childbirth following cesarean section will include a minimum of 96 hours for both the mother and the newborn child unless a shorter stay is agreed to by both the mother and her attending physician.

Second Surgical Opinion Requirement

If you are enrolled in the Basic Option, second surgical opinions may be required by the Health Care Management nurse for certain inpatient surgical procedures. If you do not obtain a second surgical opinion when it is required, charges related to the admission may not be covered.

Toll-Free Number

Nationwide 1-800-459-2110

Monday - Friday 8:30 A.M. to 5:00 P.M.

(A recording device is available at all other times)

If you do not notify InforMed

If you do not use this pre-admission review program, covered facility charges will be reduced by $500 from what they would have been had the program been used (for example, if you incur $1,000 of covered hospital charges, only $500 will be considered.)

Note: If you are enrolled in the Basic Option, you are responsible for making the required call. Notification of your admission by the facility may not fulfill your obligation to make the call.

Large Case Management

Large Case Management identifies and manages individual cases that demonstrate a potential for large dollar savings through alternative forms of health care.

The Health Care Management Nurse will work with the patient, the patient’s family, the attending physician, and other providers to health care to identify alternative treatment programs that offer both quality care and cost savings.

The  Network Option

The Network Option is a program in which Primary Care Physicians (PCP) contract to provide healthcare to employees, retirees and their covered dependents. A PCP is a Physician who is in general practice, family practice, pediatrics or general internal medicine. The PCP acts as a Case Manager, that is, the PCP's role is to treat your illness or injury and determine if additional medical treatment by a specialist is necessary. Your PCP will then help select the specialist who is right for you and direct all phases of your care by communicating with you and your specialist.

PCP Selection

1) Each family member chooses a PCP from a list provided by the Human Resources Department.

2) Each family member may change their PCP once per calendar year. Contact the Human Resources Department to make a change.

Benefits

1) ALL Primary Care must be rendered by the PCP or no benefits are payable (except for care received by a dependent who resides out-of area as defined below.)

2) ALL Specialty Care requires a referral from the PCP or no benefits are payable. (No referral is required for an Inpatient Consultation if the consult is requested by the PCP or Specialist previously referred by the PCP).

3) Specialty Care may be received by an Out-of-Network specialist but a referral is still required and the benefit is reduced to 60% subject to deductible.

Referral Process

1) The PCP completes a form authorizing specific treatment to be rendered by the specialist.

2) The PCP sends the form to the specialist via the internet.

3) If the specialist believes that additional treatment is needed, he/she must contact the PCP for another referral.

4) Benefits are not payable if a patient self-refers to a specialist. (Covered females may see an In-Network OB/GYN Physician twice per calendar year for Preventive Care without a PCP referral.)

5) Retroactive Referrals will not be given.

"On Call" Physicians

1) If the PCP or specialist is unavailable, benefits will be paid at the In-Network level for the "On Call" physician. The patient must use the PCP's or specialist's "On Call" physician or no benefits will be payable.

Network Claim Submission

1) The PCP will bill the InforMed directly for all primary care medical expenses.

2) You are responsible for submitting specialist and other medical expenses to InforMed. See the section later in this booklet for instructions of How to File a Claim.

Full-time Students

1) Full-time students must select a PCP for use while they are at home.

2) Emergency care at school will be paid at 100%/$10 Co-payment.

3) Non-emergency care at school does not require a referral from the PCP but benefits without a referral will be paid at the applicable rate from the Basic Option.

Dependent Children Residing Out-of-Area

1) Dependent children must select a PCP for use while In-Area.

2) Emergency care will be paid at 100%/$10 Co-payment.

3) Non-emergency care when Out-of-Area does not require a referral from the PCP but benefits without a referral will be paid at the applicable rate from the Basic Option.

Vacation or Traveling Out-of-Area

1) Emergency care will be paid at 100%/$10 Co-payment.

2) Non-emergency care requires a referral from the PCP or no benefits are payable. Benefits will be paid at the In-Network benefit level with a referral.

The Network and the Employee Assistance Program (EAP)

1) When you initially seeks treatment through the WCHA EAP and the EAP recommends treatment for psychiatric or chemical dependency care on either an outpatient or inpatient basis, the EAP counselor must contact the PCP for a referral prior to your receiving the proposed services.

2) If you do not have a PCP referral, there will be no benefits for the proposed services.

Coordination of Benefits with Health Maintenance Organizations (HMO)

1) If you or your dependent is also enrolled in an HMO (and the HMO plan is the primary payor), the covered person must comply with the HMO's rules and regulations for treatment. Compliance with the HMO will satisfy this Plan's PCP referral requirements. Deductibles and co-payments incurred for covered treatment provided by the HMO will be considered as covered expenses under this Plan (provided the services are otherwise covered by this Plan). You must provide an explanation of benefits (EOB) statement from the HMO for the expenses to be considered by this Plan. See the later section of this booklet for more information on how Coordination of Benefits works.

Cash Deductible

The Network Option or Basic Option Medical Expense Benefit Deductible, as indicated in the Schedule of Benefits, applies only once during a calendar year to each covered person's covered expenses. Your family, however, will not be required to meet more than the amount of the per family deductible in any calendar year. Any number of family members may help to meet the family deductible amount, but no more than the per person deductible amount will be taken from any one family member's expenses.

Out of Pocket

After the deductible is satisfied, the Plan pays charges for covered expenses each calendar year in accordance with the Schedule of Benefits.

Program Maximum

The Maximum amount available for all injuries or sicknesses for each covered person under the Plan is shown in the Schedule of Benefits.

Covered Expenses

Covered Expenses mean the amounts and limitations specified in the Schedule of Benefits for the services and supplies listed below, but only if the expenses are incurred after a you or your dependent becomes covered and only to the extent that the services or supplies are recommended by an appropriate professional provider, are medically necessary for the care and treatment of an injury or sickness and are rendered by a covered facility or professional provider. Charges in excess of the usual and customary charge will not be considered covered expenses.

Facility Charges

1) Covered Expenses for room and board are limited to the semiprivate room rate. Private room, intensive care, coronary care and other specialized care units of a facility are covered when such special care or isolation is consistent with professional standards for the care of the patient's condition. When room and board for other than semiprivate care is at the convenience of the patient, payment will be made only for semiprivate accommodations.

Facility ancillary expenses for necessary services and supplies include admission fees, use of operating, delivery, and treatment rooms; prescribed drugs; whole blood, administration of blood, blood processing, and blood derivatives (to the extent blood or blood derivatives are not donated or otherwise replaced); anesthesia, anesthesia supplies and the administration of anesthesia by an employee of the facility; medical and surgical dressings, supplies, casts and splints, diagnostic services; and therapy services; but not services of a physician or private duty nurse, or drugs or supplies not consumed or used in the facility.

2) The necessary services and supplies described above will also be covered when furnished by an Ambulatory Surgical Facility, including all follow-up care within 72 hours of the procedure.

Inpatient facility charges for oral surgery or dental treatment that ordinarily could be performed in the provider's office will be covered only if the patient has a concurrent hazardous medical condition that prohibits doing the treatment safely in an outpatient setting.

3) Confinement in a skilled nursing facility must commence within 14 days of a Hospital stay of at least three days for the same cause or causes, and may not exceed a total of 120 days of covered confinement. To be covered, the facility must meet the definition of a skilled nursing facility in the Plan Document (available from your employer). If your physician recommends care in a skilled nursing facility, be sure to call the Health Care Management nurse for approval of the services.

Two or more periods of confinement shall be considered one period of confinement unless they are separated by a period of 90 consecutive days.

4) Charges incurred through and billed by a home health care agency for the following services and supplies:

a) part-time or intermittent skilled nursing care by a Nurse;

c) physical, respiratory, occupational, and speech therapy;

d) medical and surgical supplies;

e) oxygen and its administration;

f) medical social service consultations.

Covered Expenses under the the Network Option’s Out-of-Network choice and Basic Option shall not exceed a total of 40 home health care visits in a calendar year. A visit by a member of a home health care team and four hours of home health aide service will each be considered one home health care visit.

No home health care benefits will be provided for dietitian services, homemaker services (except as may be specifically provided herein), maintenance therapy, dialysis treatment, food or home delivered meals, rental or purchase of durable medical equipment or prescription or non-prescription drugs or biologicals. Home health care must be prescribed by the attending physician and be approved by the Plan.

5) Charges incurred through and billed by a hospice for the following services and supplies:

a) Inpatient care;

b) nutrition counseling and special meals;

c) part-time nursing;

d) homemaker services;

e) bereavement counseling limited to a combined maximum of 6 visits, for immediate family members (husband, wife and children) during the six month period following the date of death;

f) physical and chemical therapy.

The maximum lifetime benefit is 210 days of covered services per covered person per lifetime. To be covered, the hospice program must be licensed and the attending physician must certify that the terminally ill covered person has a life expectancy of six months or less. Charges incurred during periods of remission are not eligible under this provision of the Plan.

Hospice is a health care program providing a coordinated set of services rendered at home, in outpatient settings, or in institutional settings for covered persons suffering a condition that has a terminal prognosis. If your physician recommends inpatient hospice care, be sure to notify the Health Care Management nurse for approval of the services.

Professional Charges

1) Surgery for the treatment of disease or Injury, and sterilization procedures. Separate payment will not be made for Inpatient pre-operative care or post-operative care normally provided by the surgeon as part of the surgical procedure.

For related operations or procedures performed through the same incision or in the same operative field, the Plan shall consider as eligible the surgical allowance for the highest paying procedure plus 50% of the surgical allowance for the second highest paying procedure and 25% of the surgical allowance for each additional procedure.

When two or more unrelated operations or procedures are performed at the same operative session, the Plan shall consider as eligible the surgical allowance for each procedure.

Benefits may also be provided for services of a physician who actively assists the operating surgeon when it is determined that the condition of the patient or the type of surgical service requires such assistance.

The Plan will pay surgical benefits for cutting procedures for the treatment of diseases, injuries, fractures and dislocations of the jaw, and extraction of bone or soft tissue impacted teeth, when the service is performed by a physician or dentist. Normal extractions and care of teeth and structures directly supporting the teeth are not included.

The Plan will pay for certain surgical podiatry services, including incision and drainage of infected tissues of the foot, removal of lesions of the foot, removal or debridement of infected toenails, and treatment of fractures and dislocations of bones of the foot.

2) Administration of anesthesia, other than local infiltration anesthesia, in connection with a covered surgical procedure, and provided the anesthesia is administered and charged for by a physician other than the operating surgeon or his assistant.

Anesthesia means the administration of spinal anesthetic, or the administration of rectal anesthetic, or the administration of a drug or other anesthetic agent by injection or inhalation, or acupuncture, the purpose of which administration is the obtaining of muscular relaxation, loss of sensation, or loss of consciousness.

3) Medical care rendered by the professional provider in charge of the case to a covered person who is an Inpatient in a covered facility for a condition not otherwise payable as surgery, maternity services, therapy services, or psychiatric or chemical dependency care.

Such care includes Inpatient intensive care rendered to a covered person whose condition requires a professional provider's constant attendance and treatment for a prolonged period of time.

Also included is care rendered to an Inpatient of a covered facility by a professional provider whose particular skills are required for the treatment of complicated conditions. This does not include observation or reassurance of the covered person, stand-by services, routine pre-operative physical examinations or care routinely performed in the pre- or post-operative or pre-or post-natal periods or care required by a facility provider's rules and regulations.

4) Consultation services when rendered to an Inpatient in a covered facility at the request of the attending professional provider. Consultations do not include staff consultations which are required by a facility provider's rules and regulations.

Other Charges

1) Diagnostic Services

a) Diagnostic x-ray, consisting of radiology, ultrasound, nuclear medicine and magnetic resonance imaging.

b) Diagnostic laboratory and pathology tests.

c) Diagnostic medical procedures consisting of ECG, EEG, and other electronic diagnostic medical procedures.

d) Pre-admission presurgical tests which are made prior to a covered person's inpatient or outpatient surgery.

e) Allergy testing consisting of percutaneous, intracutaneous and patch tests.

2) The following therapy services when used for the treatment of a sickness or injury to promote the recovery of the covered person. To be covered, the therapy services must be rendered in accordance with a physician's written treatment plan.

a) Radiation Therapy - the treatment of disease by x-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes.

b) Chemotherapy - the treatment of malignant disease by chemical or biological antineoplastic agents. The cost of the antineoplastic agent is included in this provision.

c) Physical Therapy - the treatment by physical means, hydrotherapy, heat, or similar modalities; physical agents; bio-mechanical and neuro-physical principles; and devices to relieve pain, restore maximum function lost or impaired by disease or accidental Injury, and prevent disability following disease, Injury or loss of body part.

d) Respiratory Therapy - the introduction of dry or moist gases into the lungs for treatment purposes.

e) Occupational Therapy - the treatment of a physically disabled person by means of constructive activities designed and adapted to promote the functional restoration of the person's abilities lost or impaired by disease or accidental Injury, to satisfactorily accomplish the ordinary tasks of daily living.

f) Speech Therapy - the treatment for the correction of a speech impairment when therapy is aimed at restoring the level of speech that the individual had attained prior to the onset of a disease, surgery, or occurrence of an accidental Injury.

g) Dialysis Treatment - the treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body, to include hemodialysis or peritoneal dialysis.

3) Emergency Services

a) Emergency Accident Care

Facility and professional provider services and supplies for the initial treatment and all follow-up care of traumatic bodily injuries resulting from an accident. However, if the accident services are classified as surgery (e.g., suturing, burn care, fracture care, etc.) payment will be made as a surgical benefit.

b) Emergency Medical Care

Facility and professional provider services and supplies for the initial treatment of a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in:

(1) permanently placing the covered person's health in jeopardy,

(2) causing other serious medical consequences,

(3) causing serious impairment to bodily functions, or

(4) causing serious and permanent dysfunction of any bodily organ or part.

4) Second Surgical Opinion

If a covered person's professional provider recommends elective surgery, the Plan will provide payment in accordance with the Schedule of Benefits for a second surgical opinion consultation to determine the medical necessity of the procedure. Elective surgery is surgery which is not of an emergency or life threatening nature.

The second surgical opinion consultation must be rendered by a board-certified specialist in the treatment of the particular medical condition, who is not associated professionally or financially with the physician that provided the first surgical opinion consultation. One additional consultation, as a third opinion, is eligible under this benefit provision in cases where the second opinion disagrees with the first.

To avoid any unnecessary duplicate testing, the covered person should provide the specialists rendering the surgical opinions with any test results from the professional provider who initially recommended surgery.

A second surgical opinion is required prior to receiving sclerotherapy. If a second surgical opinion is not obtained prior to receiving sclerotherapy, the Plan will not pay any benefit for expenses for, or related to, the sclerotherapy.

5) Organ or Tissue Transplant

The Plan will pay covered expenses for human to human organ or tissue transplants incurred by you or your covered dependent as a recipient.

Covered expenses incurred by the donor of an organ or tissue for transplant are covered the same as any other sickness when the donor and the recipient are covered under this Plan.

Covered expenses include organ or tissue procurement from a cadaver consisting of removing, preserving and transporting the donated part; services and supplies furnished by a facility provider; treatment and surgery by a professional provider; and drug therapy to prevent rejection of the transplanted organ or tissue.

Surgical, storage and transportation costs directly related to the procurement of an organ or tissue used in a transplant described above will be covered for each such procedure completed. If an organ or tissue is sold rather than donated, no benefits will be payable for the purchase price of such organ or tissue.

If a covered transplant procedure is not done as scheduled due to the intended recipient's medical condition or death, benefits will be paid for charges incurred for organ or tissue procurement as described above

Covered expenses incurred by the donor of an organ or tissue for transplant when the donor is not a covered person under this Plan are covered to the extent any benefits remaining after payment of the covered person’s expenses as a recipient, when the donor’s expenses are not covered under any group of individual insurance policy or benefit plan and are charged to the recipient.

6) Charges of a Facility and/or professional provider related to or because of a condition of pregnancy for female employees or spouses of male employees or dependent daughters.

Such charges include services rendered in a birthing facility, provided the physician in charge is acting within the scope of his license and the birthing facility meets all legal requirements.

Midwife delivery services are eligible provided the State in which such services are performed has legally recognized midwife delivery, and the person(s) performing midwife delivery and the facility available for these services are licensed at the time delivery is performed.

7) Charges for newborn care. nursery charges, other hospital services and supplies and physician's charges for circumcision of a newborn male child and for hospital visits for newborn children.

8) Charges for temporomandibular joint disorders, myofascial pain dysfunction or orthognathic treatment (including surgery), limited to physical therapy, oral surgery and intra-oral orthotic devices (excluding orthodontia and prosthetic devices) prescribed by a physician or dentist.

If a physician or dentist recommends a course of treatment for or in connection with temporomandibular joint disorders, myofascial pain dysfunction or orthognathic treatment, a covered person may submit the treatment plan, including x-rays and study models, for pre-determination of benefits under the Plan. InforMed will determine if the treatment is a covered expense and will notify the covered person in writing.

9) Charges for acupuncture performed by a physician to induce surgical anesthesia or for therapeutic purposes.

10) Charges of a facility and/or professional provider related to or because of mental illness or chemical dependency (drug abuse and alcoholism). Covered expenses include:

a) Inpatient facility charges,

b) individual psychotherapy,

c) group psychotherapy,

d) psychological testing,

e) family counseling (counseling with family members to assist the covered person's diagnosis and treatment),

f) Electro-Convulsive Therapy (electroshock treatment) or convulsive drug therapy, including anesthesia when administered concurrently with the treatment by the same professional provider.

Inpatient treatment is limited to 30 days per calendar year.

The benefits above are also available to a covered person receiving treatment in a planned therapeutic program during the day only or during the night only at a day/night psychiatric facility or at a chemical dependency detoxification and/or rehabilitation facility.

11) Expenses for the outpatient medical services of a professional provider.

12) Drugs and medicines, including contraceptive drugs and devices, requiring a written prescription order and which are approved for general use by the Food and Drug Administration, and prescribed insulin and syringes used by a diabetic. Such drugs and medicines must be dispensed by a licensed pharmacist.

13) Rental or, at the discretion of the Plan, purchase of durable medical equipment which is prescribed by a physician and is not for the convenience of the patient.

If purchased, charges for repair or medically necessary replacement of durable medical equipment will be considered a covered expense. If rented, charges for rental may not exceed the usual and customary purchase price of the equipment.

Claims for equipment containing features of an aesthetic nature or features of a medical nature which are not required by the patient's condition, or where there exists a reasonably feasible and medically appropriate alternative piece of equipment which is less costly than the equipment furnished, will be paid based on the reasonable charge for the equipment which meets the patient's medical needs.

14) Charges for prosthetic devices (other than dental) to replace all or part of an absent body organ (including contiguous tissue) or to replace all or part of the function of a permanently inoperative or malfunctioning body organ, including charges for repair or Medically Necessary replacement.

15) Charges for orthotic devices (a rigid or semi-rigid supportive device which restricts or eliminates motion for a weak or diseased body part), but excluding orthopedic shoes, unless they are an integral part of a leg brace, and other supportive devices for the feet. To be covered, InforMed must concur with the physician's certification that the device is medically necessary.

16) Professional ambulance services when used to transport a covered person from the place of accidental injury or serious medical incident to the nearest facility where treatment can be given. Professional ambulance service is covered in a non-emergency situation only to transport the patient to or from a facility or between facilities for required treatment when such transportation is certified by the attending physician as medically necessary. No other charges for transportation or travel will be covered.

17) Dental services rendered by a physician or dentist which are required as a result of accidental Injury to the jaws, sound natural teeth, mouth or face. Injury to the teeth as a result of chewing or biting shall not be considered an accidental Injury.

18) Surgical dressings and other medical supplies ordered by an appropriate professional provider in connection with medical treatment, but not common first-aid supplies.

19) Chiropractic care, including charges for detection and correction by manual or mechanical means of nerve interference resulting from or related to misalignment or partial dislocation of or in the vertebral column. Coverage includes initial consultation, work-up, X-rays and treatment (but not maintenance care) to a maximum payment of $500 per covered person per calendar year.

20) Preventive care as follows.

a) Periodic examination and management of a healthy dependent child from birth through age 6 years up to a maximum of 12 visits including appropriate immunizations and laboratory charges.

b) Periodic reevaluation and management of a healthy individual requiring a comprehensive history and physical examination including appropriate immunizations and routine laboratory tests for employees, retirees, and their covered dependents.

Preventive care also includes two routine gynecological examinations, Pap test and one mammogram per covered female per calendar year in addition to the above benefits.

21) Outpatient artificial reproductive services and procedures, including artificial insemination, in vitro fertilization (IVF) and fertility drugs for married females as follows.

Charges for in vitro fertilization (IVF) procedures for married females, limited to three attempts per lifetime and to participants who had at least one attempt covered by this Plan prior to July 1, 1998. For the services to be covered the physician must certify that:

a) The covered female and her spouse have had a period of continuous infertility for at least five consecutive years of their married life immediately prior to these services; or

b) The covered female's infertility is related to the condition of endometriosis and/or exposure in utero to diethylstilbestrol (DES) and/or blockage or surgical removal of one or both fallopian tubes (excluding previous elective sterilization); and

c) The fertilization is induced by use of the egg of the covered female and the sperm of her spouse; and

d) The covered female has had no success in attaining a pregnancy through any other less costly covered treatment.

Outpatient charges for artificial insemination for covered married females are available when:

a) The covered female has received a recommendation for this procedure as a result of a complete fertility evaluation; and

b) The sperm inseminated is donated by the covered female's spouse.

 Pharmacy Benefit Plan

Prescription Drug Program

If you or your dependent incurs expense for prescription drugs, the Plan will pay the charges in accordance with the Schedule of Benefits and the provisions outlined here.

Home Care Pharmacy

If you purchase prescription drugs from a WCHS pharmacy:

1) Whenever possible, the generic product will be dispensed subject to a $5 co-payment for each prescription and refill as ordered by the physician; not to exceed a one month (34 day) supply or 100 unit doses, whichever is lesser.

2) A select group of maintenance drugs will be dispensed in quantities of a 34 day supply or 100 unit doses, whichever is greater.

3) If a generic is not available or if the physician specifies, a name brand product will be dispensed subject to a $10 co-payment for each prescription and refill. If a generic is available and you request a name brand product instead, you will be responsible for the difference between the generic cost and the name brand cost in addition to the $10 co-payment.

If the prescription as written by the physician exceeds a one month supply, you may request that it be dispensed as written; the co-payment amount will be multiplied by the number of months of supply.

Other Pharmacy

You may choose to have prescriptions filled at other than a WCHA pharmacy. The Plan will pay expenses up to the usual and customary amount in accordance with the Schedule of Benefits.

Drugs Covered

1) legend drugs;

2) compounded medication of which at least one ingredient is a prescription legend drug;

3) insulin, insulin syringes and needles;

4) oral contraceptives; and

5) any other drug which under the applicable state law may only be dispensed upon the written prescription of a qualified prescriber.

Items Not Covered

Not covered under this benefit are charges for:

1) any substance, except insulin, which may be lawfully obtained without a prescription;

2) administration of any prescription drug, insulin, or other substance;

3) any prescription refill in excess of that specified by the prescriber or dispensed more than 12 months after it was prescribed;

4) the amount of any prescription or refill exceeding the greater of a 34-day supply (except maintenance drugs) or 100 unit doses;

5) any prescription directing enteral or parenteral administration of nutrition therapy;

6) any experimental drug or any drug which may not lawfully be dispensed in the United States of America;

7) any medication to be taken by or administered to a covered person while he or she is a patient at a hospital, nursing home or similar institution which operates or allows to be operated on its premises a pharmacy or other facility for dispensing drugs;

8) any therapeutic device or appliance, including syringes (but excluding insulin syringes), support garments, prostheses and contraceptive devices or materials, regardless of their intended use;

9) any immunization agent, biological serum, blood or blood plasma;

10) fertility drugs;

11) Rogaine, unless medically necessary; and

12) Retin-A, unless medically necessary.

Pharmacy Discount Program

This program provides pharmaceuticals, medical equipment, and other health related products stocked in the Home Care Pharmacies to participants at a discounted rate as follows:

a. Pharmaceuticals are dispensed at cost plus a small handling fee.

b. Contract Over-the Counter (OTC) drugs are dispensed at a rate determined once yearly and circulated throughout the hospital.

c. A 10% discount is applied towards all other health related products carried in the store.

The pharmacy discount may also apply toward non-stocked items available through normal ordering channels. In the event an item is not available, the Home Care Pharmacies staff will make every effort to obtain it.

Rules and Regulations

a. The Pharmacy Benefit Plan is maintained for the exclusive benefit of eligible participants (including COBRA participants) whose rights under the Plan are legally enforceable. The Plan has been established with the intention of being maintained for an indefinite period of time. However, conditions could require that the Plan be suspended or amended, and the hospital and affiliates reserve the right to amend, suspend, or terminate the Plan as necessary.

b. Fraudulent use of the Pharmacy Benefit Plan may be grounds for discharge, criminal prosecution or both.

c. Prescription co-payments/discounts will be available only upon presentation of a membership card. (The ID badge is not acceptable.) The Human Resources Department will issue a membership card designating program eligibility to each eligible participant.

d. It is the responsibility of the participant to report changes in family status affecting benefit eligibility to the Human Resources Department immediately for card replacement.

e. Lost cards should be reported to the Human Resources Department immediately for card replacement. There will be a $5 charge for replacement.

f. The Pharmacy Benefit Plan card is non-transferable and remains the property of Washington County Health System, Inc. and must be surrendered upon request.

g. The Pharmacy Benefit Plan is available only at the Home Care Pharmacies.

Additional Benefits/Services Of This Plan

a. Payroll deduction for purchases, minimum $10.

b. Free delivery within a 10 mile radius of the hospital location, minimum $10.

c. Drive-up window.

d. Off hours prescription drop:

1) Home Care Center/Pharmacy location - Deposit slot in door near the visitor's elevators.

2) Home Care Pharmacy/Fennel location - Deposit drawer (24 hours) in drive-thru window booth.

3) Home Care Pharmacy/Smithsburg location - Deposit drawer (24 hours) in drive- thru window booth.

4) Home Care Pharmacy/Robinwood location - Deposit drawer (24 hours).

e. Durable Medical Equipment - items not covered under the medical expense benefit will receive a 10% discount. Items that are covered under the medical expense benefit will not be eligible under this Pharmacy Benefit Plan.

 Exclusions

No payment will be made under this Plan:

1) for or in connection with an injury or sickness arising out of, or in the course of, any employment for wage or profit;

2) for or in connection with a sickness or injury for which a covered person is eligible or covered under Workers' Compensation or similar law;

3) for services provided without cost by any governmental agency, except where such exclusion is prohibited by law;

4) for charges the covered person has no legal obligation to pay;

5) for charges made which are in excess of usual and customary charges or for care or treatment not medically necessary;

6) to the extent that a covered person is reimbursed or in any way indemnified for those expenses by or through Medicare or any other public program;

7) for services, treatment or supplies for which no charge would usually be made or for which such charge, if made, would not usually be collected if no coverage existed; or for services, treatment or supplies to the extent that charges for the care exceed the charge that would have been made and collected if no coverage existed;

8) for custodial care, domiciliary care or rest cures;

9) for education, vocational, work hardening or training programs regardless of diagnosis or symptoms that may be present, or for non-medically necessary education, except as specifically provided in this Plan;

10) for travel, whether or not recommended by a physician, except as specifically provided in this Plan;

11) for any treatment, confinement, or service which is not recommended by, or any operation which is not performed by, an appropriate professional provider;

12) for examination by a physician, related laboratory tests, x-rays and vaccines, which are performed in the absence of specific symptoms on the part of the covered person (except as may be specifically provided herein);

13) for injury sustained or sickness contracted while committing or attempting to commit an assault or felony;

14) for services performed by a physician or other professional provider enrolled in an education or training program when such services are related to the education or training program;

15) for the services of any person who is a member of the covered person's immediate family consisting of the covered person, spouse, child(ren), brothers, sisters or parents or a family member who resides in the covered person's home;

16) for expenses related to surrogate mother, reversal of a sterilization operation, a sex change operation, or treatment of sexual dysfunction not related to organic disease;

17) for wigs, artificial hair pieces, human or artificial hair transplants, or any drug -- prescription or otherwise -- used to eliminate baldness. This provision does not apply when baldness is a result of chemotherapy, radiation therapy or surgery. Under those conditions, coverage for the purchase of a wig or artificial hair piece is limited to one per lifetime;

18) for injury sustained or sickness contracted while on active duty in military service;

19) for injury sustained or sickness contracted as the result of or caused by any act of war, or participation in a riot or civil disobedience;

20) for any expenses incurred as a result of or in connection with treatment that is experimental/investigative in nature or experimental drug usage;

21) for supportive devices for the feet and for orthopedic shoes, unless they are an integral part of a leg brace and the cost is included in the orthotist's charge;

22) for palliative or cosmetic foot care such as treatment of flat feet conditions, subluxation of the foot, corns, calluses, non-surgical care of toenails, fallen arches and other symptomatic complaints of the feet except where surgery is performed;

23) for equipment that does not meet the definition of durable medical equipment, including air conditioners, humidifiers, exercise equipment, etc., whether or not recommended by a physician;

24) for cosmetic surgery, unless the covered person receives an injury which requires the surgery; or the cosmetic surgery is necessary to restore impaired bodily function resulting from disease or previous therapeutic processes;

25) for eye refractions, eyeglasses, contact lenses, or the vision examination for prescribing or fitting eyeglasses or contact lenses (except for aphakic patients and soft lenses or sclera shells intended for use in the treatment of disease or Injury);

26) for services directly related to the care, filling, removal or replacement of teeth or the treatment of injuries to or diseases of the teeth, gums or structures directly supporting or attached to the teeth, except as specifically provided in this Plan. These non-covered services include, but are not limited to, apicoectomy (dental root resection), root canal treatment, soft tissue impaction, alveolectomy and treatment of periodontal disease;

27) for vitamins, except those which by law require a prescription order and are prescribed to treat a specific sickness or injury, or for nutritional supplements;

28) for hearing aids or examinations or treatment for the prescription or fitting of hearing aids;

29) for telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form;

30) for the treatment of medical complications arising from the use of illegally obtained drugs, or for treatment necessitated by the non-medical use of narcotics or hallucinogenic drugs, or drugs or agents of similar effect;

31) for expenses in connection with an Injury arising out of or relating to an accident involving the maintenance or use of a motor vehicle (other than a recreational vehicle not intended for highway use, motorcycle, motor-driven cycle, motorized pedal cycle or like type vehicle). This exclusion shall apply to those expenses up to the minimum amount required by law in the state of residence for any Injury arising out of an accident of the type for which benefits are or would be payable under automobile insurance, regardless of whether or not automobile insurance is in force and regardless of any benefit limits under such insurance. However, this exclusion does not apply to a covered person who is a non-driver when involved in an uninsured motor vehicle accident.

For the purpose of this exclusion, a non-driver is defined as a covered person who does not have the obligation to obtain automobile insurance because he/she does not have a driver's license or because he/she is not responsible for a motor vehicle;

32) for injury sustained while an active participant in a professional sporting event (engaged in on an individual or group basis for wage or profit) or professional hazardous avocations;

33) for acupuncture, unless performed by a physician;

34) for any surgical technique performed for the correction of myopia or hyperopia, including but not limited to keratomileusis, keratophakia, or radial keratotomy (plastic surgeries on the cornea in lieu of eyeglasses), and all related services;

35) for expenses related to gastric plication and gastroplasty (weight reduction procedures such as stapling the stomach);

36) for expenses related to exercise programs or use of exercise equipment, special diets or diet supplements, Nutri-system Program, Weight Watchers or similar programs and hospital confinements for weight reduction programs;

37) for expenses related to the use of hypnosis;

38) for methods of treatment to alter vertical dimension used in the treatment of temporomandibular joint disorders and to restore an abraded dentition, including orthodontia and intra-oral prosthetic devices used in the treatment of temporomandibular joint disorders;

39) for services provided to an HMO participant by a facility or professional provider which is not a member of that HMO;

40) for a charge refused by another plan as a penalty assessed due to non-compliance with that plan's rules and regulations;

41) for registered Inpatient services if admitted on a Friday, Saturday or Sunday unless required as a result of emergency sickness or accident care. Sunday admissions will be covered if medically necessary for scheduled surgery on Monday morning;

42) for expenses of the donor of an organ or tissue for transplant to a recipient who is not a covered person under this Plan;

43) for the prescription drug cash co-payment applicable to the employer's prescription drug plan;

44) for those services or items any school system is required to provide under any law;

45) for charges for private duty nursing;

46) for primary care services or supplies not provided by the primary care physician to an employee, retiree, or covered dependent enrolled in the Network Option;

47) for services and supplies provided to an employee, retiree or covered dependent enrolled in the Network Option without a referral from the primary care physician, except as outlined above;

48) for any other service or supply except as specifically provided herein.

 Coordination of Benefits

This Plan has been designed to help meet the costs of sickness or injury. Since it is not intended that greater benefits be paid to you than your actual medical expenses, the amount of benefits payable under this Plan will be reduced by taking into account any coverage which you or your dependents have under other plans. The benefits under this Plan will be reduced by the amount of benefits payable under the other plans.

This Plan will always pay either the regular benefits in full or a reduced amount which, when added to the benefits payable by the other plan or plans, will not exceed 100 percent of allowable expenses.

Allowable expenses mean any necessary, usual and customary expenses incurred while you are eligible for benefits under this Plan, part or all of which would be covered under any of the plans, but not any expenses contained in the list of Exclusions. Allowable expenses will not include charges for services provided to an HMO participant by a facility or professional provider which is not a member of that HMO, nor include charges refused by another plan as a penalty assessed due to non-compliance with that plan’s rules and regulations. Plan mean any plan providing benefits or services for or by reason of medical, dental or vision care or treatment, which benefits or services are provided by group insurance, Medicare, self-insurance, or any similar plan or program and coverage under automobile insurance.

When benefits are available under another plan or plans, this Plan will pay after any other plan which:

1. is automobile insurance; or

2. does not have coordination or non-duplication rules; or

3. covers the claimant as an active employee; or

4. for a child, covers the parent whose birthday (month and day, but not year) falls first in each year. When the parents are divorced, this Plan will pay after that of the natural or step-parent with custody of the child or court-decreed financial responsibility for the child’s health care expenses.

AUTOMOBILE BENEFITS

This Plan is not eligible to be elected as primary coverage in lieu of automobile benefits. Payments from automobile insurance will always be primary and this Plan will be secondary only.

EFFECT OF MEDICARE

For active employees and/or their dependents who are eligible for Medicare, this Plan will be primary and Medicare secondary.

EFFECT OF EXCLUSIONS

The provisions of this section shall not be construed to create any independent right to payment of any benefit under this Plan. Any exclusion or limitation contained in the Plan shall supersede any provision of this section regarding coordination of benefits.

EFFECT OF COBRA

The benefits of a plan covering the person on whose expense the claim is based either as a retired employee or as a person who has elected continuation of coverage (or as that person’s dependent) will be determined after the benefits of the other plan covering such person as an employee other than as a retired employee or as a person who has elected continuation of coverage (or as that person’s dependent).

HOW TO FILE A CLAIM

Separate all bills for each family member. A separate claim must be filed for each coverage person.

Claims should be submitted on standard HCFA 1500 forms, UB82s, or Super Bills to avoid unnecessary delay in claim processing. Claim forms are required in certain situations when additional information is necessary to determine proper payment. These situations include all accident or injury claims, possible coordination of benefit claims, and claims requiring investigation.

All bills should include the following information:

1. Employee’s (retiree’s) name, group number, and social security number;

2. Patient’s name

3. Diagnosis with appropriate ICD-9 code

4. Description and date of each service with appropriate CPT-4 code (Professional bills) or ICD-9 code (Facility bills), where applicable.

The following are not acceptable as proof of claim: cash register receipts, canceled checks, money order receipts, personal listings, and balance due statements.

Claims should be submitted as soon as possible after the service is rendered to avoid denial of claims due to late filing. Please make a copy of claims submitted for your records.

NETWORK PHYSICIAN CLAIMS

Network physicians will submit claims to InforMed for direct reimbursement. The Network physician will not charge members at time of service for services rendered if charges are eligible benefits (excluding co-payments and coinsurance payments). A physician can collect for non-eligible services and the Network member should pay according to the physician’s current payment policy.

NON-ELIGIBLE SERVICES

These are services which are not eligible in the benefit plan. A complete list of non-eligible services can be found earlier in this booklet.

Physicians can ask for payment from the patient or bill the patient for non-eligible services. For example, the patient receives cosmetic surgery, then the physician can charge the patient for the costs incurred. If the patient has other medical coverage through a spouse’s employer, they may file the charges for possible reimbursement.

"ON-CALL" PHYSICIAN CLAIMS

There may be times when a physician "covers" for another physician. When a member’s Network physician is unavailable, he/she must see their Network physician’s "On Call" physician to receive coverage equal to care received in the Network. The procedure for submitting is as follows:

PCN PHYSICIAN "ON-CALL"

If a Network physician is acting on behalf of a patient’s Network physician, the claim must indicate "On Call For Dr. ______" on #19 of the claim form and be submitted to InforMed. If super bills are used, this must be appropriately indicated as well. The physician will be paid according to the arrangements made in the Participating Physician Agreement.

NON-PARTICIPATING PHYSICIAN "ON-CALL"

"On Call" physicians do not have to be participants in the Network. The non-participating physician "On Call for" the Network physician should submit claims to InforMed. If the member is charged for services, he/she will need to submit the claim/bill for reimbursement.

Non-Network physicians will be paid at reasonable and customary rates. This should be limited to primary care services only, i.e., office visits, x-ray and lab, hospital visits or minor procedures. "On Call for Dr. _____" should be indicated in #19 of the claim form.

OTHER HEALTH CARE EXPENSES

Prescription Drugs - Secure an itemized bill that shows the following:

1. Name of person for whom drug was prescribed

2. Name of prescribing professional provider

3. Name of drug

4. Prescription number

5. Date prescription was filled

6. Cost of drug (register receipts are not acceptable)

7. Name and address of pharmacy

8. Diagnosis

Oxygen, Durable Medical Equipment, Prosthetics, and Orthotics - Secure an itemized bill that shows the following:

1. Name of patient

2. Dates of services

3. Rental and purchase price of equipment

4. Accurate description of each item

5. Name and address of supplier

6. Professional provider’s written order for the equipment. (The order should include an estimate of the period of need.)

APPEALING CLAIMS IF DENIED

If your claim is denied in whole or in part. you will receive written notification. An Explanation of Benefits (EOB) will be provided by InforMed showing the calculation of the total amount payable, charges not payable, and the reason.

If you have been notified that your claim has been denied, you may request a review by filing a letter with your employer or with InforMed. Upon receipt of your written request for review of a claim, InforMed will review the claim and furnish copies of all documents and all reasons and facts related to the decision. You or your authorized representative may examine pertinent documents which InforMed has and may submit your comments in writing. You must obtain the medical information regarding this decision directly from your physician. Request for review must be filed within 120 days after the denial is received; however, we suggest it be filed as promptly as possible. A decision by the Plan Administrator will be made within 60 days, unless special circumstances require extension. This decision will also be delivered to you in writing setting forth specific reasons for the decision and specific references to the pertinent plan provisions upon which the decision is based. This decision will be final.

FACILITY OF PAYMENT

In the event of your death or mental incompetence at a time when benefits remain unpaid, benefits will be paid to the persons or institutions with whom the covered charges were incurred if the charges have not otherwise been paid.

In the event of a qualified medical support order at a time when benefits remain unpaid, benefits will be paid to the individual who actually incurred the covered expense if the expenses have not otherwise been paid.

NOTICE OF CLAIM

All bills should be submitted as soon as possible and will not be honored 12 months beyond the date of service.

Continuation of Coverage

CONTINUATION OF COVERAGE PROVISIONS OF PUBLIC LAW 99-272 (COBRA)

If you or your dependents’ health benefits terminate due to a qualifying event, you and/or your dependents, as qualified beneficiaries, may elect to continue as participants under this Plan. You and/or your covered dependents are required to pay the premium for this coverage.

1. A qualified beneficiary is:

a. An individual who was covered under this Plan immediately prior to the date of the qualifying event, and

b. A child who is born to or placed for adoption with the employee or former employee during the period of his or her continuation coverage.

2. A qualifying event is any of the following:

a. Your termination of employment (other than for gross misconduct) or reduction of hours worked so as to render you ineligible for coverage;

b. Your death;

c. Divorce or legal separation;

d. For you as a covered retiree or your covered dependent, loss of coverage due to your employer filing for chapter 11 reorganization;

e. For spouse and eligible dependent children, loss of coverage due to you becoming entitled to Medicare; or

f. For a dependent child, ceasing to qualify as a dependent under the terms of the Plan.

3. If elected, the continued coverage will end on the earliest of the following:

a. 18 months after the date of termination of employment (other than for gross misconduct) or reduction of hours worked or bankruptcy filing so as to render you ineligible for coverage;

b. 29 months, if the Social Security Administration determines that you or your eligible dependent was totally disabled at the time of termination or reduction of hours or if the Social Security Administration determines that you or your eligible dependent became totally disabled during the first 60 days of COBRA coverage or 60 days after the date of such determination, whichever is earlier and you inform your employer before the end of the 18 month period;

c. 36 months after the date of any other qualifying event;

d. the date the employer ceases to provide any health plan to any employee;

e. the date you or your dependent fails to make the required payment in a timely fashion;

f. the date you or your dependent becomes:

1. covered under any other group health plan that does not include a preexisting conditions clause that applies to you or your dependent, or

2. entitlement to Medicare.

If during the 18-month or 29-month periods mentioned above, another qualifying event takes place that would entitle you or your eligible dependents to coverage, coverage may be extended again, but in no case will exceed 36 months of continued coverage.

4. Option Period:

The Plan Administrator must send notice to you of your right to the continuing participation following your termination of employment or to your dependents following your death.

You must notify the Plan Administrator within 60 days of a divorce, legal separation, or covered dependent child's attainment of the limiting age. The Plan Administrator must then send you notice of this right to continuation of coverage following receipt of your notice.

You will then have at least 60 days from the date of notification to elect continuation of coverage.

Disabled individuals who elect to extend their coverage beyond the 18-month period otherwise applicable must provide notice to the Plan Administrator of the determination of their disability under Title II or XVI of the Social Security Act prior to the end of the 18-month period or 60 days after the date of such determination, whichever is earlier. If such a disability is determined to cease, the disabled individual must notify the Plan Administrator within 30 days of the determination.

5. Contribution

 Definitions

The following are some of the definitions of terms used in this booklet.

Accident An unforeseen event resulting in Injury.

Covered Person

A person who meets the definition of an Employee and such Employee's Dependents who have satisfied the eligibility requirements of Article II.

Custodial Care

Care provided primarily for maintenance of the patient or which is designed essentially to assist the patient in meeting his/her activities of daily living and which is not primarily provided for its therapeutic value in the treatment of a Sickness, disease, Injury or condition. Custodial care includes, but is not limited to, help in walking, bathing, dressing, feeding, preparation of special diets and supervision over self-administration of medications. Such services are custodial care without regard to the practitioner or provider by whom or by which they are prescribed, recommended or performed.

Dependent

An eligible Dependent is:

1) Your spouse under a legally valid existing marriage between persons of the opposite sex, and with whom you maintains a regular spousal relationship;

2) Your unmarried child who is primarily Dependent upon you for maintenance and support and is not regularly employed by one or more employers on a full-time basis exclusive of scheduled vacation periods, and

a) who is under 19 years of age; or

b) who is 19 years of age and under 23 years of age if enrolled in a full-time curriculum at an accredited secondary school, college, university, or other institution of higher learning.

Dependent children may include a natural child, stepchild, legally adopted child or one for whom legal adoption proceedings have been initiated, or one for whom you have been appointed legal guardian, who depends upon the Employee for maintenance and support; and

A child who, upon attainment of the limiting age, is by reason of a physical or mental handicap incapable of self-support, and is not married will be considered a dependent, while remaining incapacitated and unmarried, subject to your own coverage continuing in effect. To cover a child under this provision, proof of incapacity must be received by the InforMed at the time application for coverage is made or within 31 days after coverage would otherwise terminate. Additional proof of incapacity will be required from time to time.

If your spouse is also employed by the employer, he or she may be covered as an employee rather than as a dependent. Dependent children may be covered by you or your spouse, but not both.

Durable Medical Equipment

Durable medical equipment is medical equipment which a) can withstand repeated use; b) is primarily and customarily used to serve a medical purpose; c) is generally not useful to a person in the absence of a Sickness or Injury; d) is appropriate for use in the home and e) is not for the convenience of the patient. All requirements of the definition must be met before an item can be considered to be durable medical equipment.

Effective Date

12:01 a.m. prevailing time in Hagerstown, Maryland on January 1, 1994.

Employee

A person who is directly employed in the regular business of and is compensated for services by the employer and who works on an active, regular full-time basis, regular part-time basis, part-time basis, or is in the class of employees defined by the employer as flexible staffing team or substitute employee.

Employer

The employer is Washington County Health Systems, Inc. (WCHS) (including Washington County Hospital Association and Antietam Health Services, Inc.), 251 East Antietam Street, Hagerstown, MD 21740.

Enrollment Date

The first day of coverage under the plan, or if there is a waiting period, the first day of the waiting period. The enrollment date for an employee or dependent added during a special enrollment period, in the event of a change in family status, or during an open enrollment period is the first day of coverage.

Experimental Drugs; Experimental Drug Usage

Charges for experimental or investigational drugs that are a) not commercially available for purchase; and/or b) are not approved by the FDA for general use; and/or c) are not being used for the condition or sickness for which they received FDA approval (unlabeled use of drug).

Experimental or Investigative Treatment

The use of any treatment, procedure, facility, equipment, device or supply not accepted as non-experimental for the condition being treated by the American Medical Association, the National Institute of Health, the National Cancer Institute, the American Dental Association and/or the Health Care Financing Administration.

Facility Provider

An institution or other entity licensed where required and performing services within the scope of such license. The covered facility providers include, but are not limited to:

a. Ambulatory Surgical Facility,

b. Birthing Facility,

c. Chemical Dependency Detoxification and/or Rehabilitation Facility,

d. Day/Night Chemical Dependency Facility,

e. Day/Night Psychiatric Facility,

f. Freestanding Dialysis Facility,

g. Home Health Care Agency,

h. Hospice,

i. Hospital,

j. In Vitro Fertilization Center,

k. Lithotriptor Center,

l. Outpatient Imaging Facility,

m. Outpatient Psychiatric Facility,

n. Psychiatric Hospital,

o. Skilled Nursing Facility.

Flexible Staffing Team; Flexible Staffing Team Basis

Active work by an employee who agrees to serve in this capacity with a higher level of compensation in lieu of benefits.

Full-time; Full-time Basis

Active Work by a regular employee who fills a position authorized for not less than 80 hours per biweekly pay period.

Genetic Information

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

Hospital

An institution for care of the sick and injured which is licensed to operate as such, and which has nurses on duty 24 hours a day, a physician on call at all times, and facilities for diagnosis of sickness and for major surgery. A hospital must meet certain other requirements which are more fully described in the Plan Document.

The term hospital, when used in conjunction with inpatient confinement for psychiatric illness or chemical dependency, will be deemed to include an institution which is licensed as a mental hospital or chemical dependency rehabilitation and/or detoxification facility by the regulatory authority having responsibility for such licensing under the laws of the jurisdiction in which it is located.

Injury

Accidental bodily injury which does not arise out of, or in the course of, employment.

Inpatient

A person who is treated as a registered bed patient for 18 consecutive hours or more in a hospital or other covered facility and for whom a room and board charge is made.

Leave of Absence

A period of time during which you, by your own request, do not work for the employer, but which is of a stated duration and after which time you are expected to return to active work. Leaves of absence are granted in accordance with your employer’s standard personnel practices and policies.

Medical Care

Professional services rendered by a professional provider for the treatment of a condition that is not otherwise payable as surgery, maternity services, therapy services, or psychiatric or chemical dependency care.

Medically Necessary (or Medical Necessity)

Treatment, services or supplies which are:

a. appropriate for the symptoms and provided for the diagnosis or treatment of the covered person's condition, sickness, disease (including exposure to an infectious disease), or injury; and

b. in accordance with current standards of medical or dental practice; and

c. not primarily for the convenience of the covered person or the covered person's facility or professional provider; and

d. the most appropriate supply or level of service that can safely be provided to the covered person. When applied to an inpatient admission, this further means that the covered person requires acute care as a bed patient due to the nature of the services rendered or the covered person's condition, and the covered person cannot receive safe or adequate care as an outpatient.

Concurrent and/or periodic review of the medical necessity of treatment will be performed with respect to all inpatient care, regardless of the type of facility, and home health care.

Nurse

A licensed person holding the degree of Registered Nurse (R.N.), Licensed Practical Nurse (L.P.N.) or Licensed Vocational Nurse (L.V.N.) and who is practicing within the scope of the license.

Outpatient

A covered person who receives services and supplies while not an inpatient.

Part-time; Part-time Basis

Active work by an employee who is regularly scheduled to work a minimum of 8 and less than 40 hours per biweekly pay period.

Physician

A person who is a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.), licensed and legally entitled to practice medicine in all of its branches, perform surgery and dispense drugs.

Primary Care

Basic or general health care provided at the person's first contact with the health care system. Usually this contact is for common illnesses. The primary health care provider assumes ongoing responsibility for health maintenance and therapy for illness, including consultation with specialists.

Professional Provider

A person or other entity licensed where required and performing services within the scope of such license. The covered professional providers include, but are not limited to:

a. audiologist,

b. certified addictions counselor,

c. certified registered nurse practitioner,

d. chiropractor,

e. clinical laboratory,

f. clinical licensed social worker (ACSW, LCSW, MSW),

g. clinical psychologist,

h. dentist,

i. nurse,

j. occupational therapist,

k. optician,

l. optometrist,

m. physical therapist,

n. physician,

o. physician's assistant,

p. podiatrist,

q. respiratory therapist, and

r. speech therapist.

Psychiatric or Psychological Illness

An emotional or mental disorder characterized by an abnormal functioning of the mind or emotions and in which psychological, intellectual, emotional or behavioral disturbances are the dominating feature.

Qualified Prescriber

A physician, dentist or other health care practitioner who may, in the legal scope of the license, prescribe drugs or medicines.

Regular Part-time; Regular Part-time Basis

Active work by an employee who is regularly scheduled to work a minimum of 40 and less than 80 hours biweekly.

Retiree

A former employee who has met the requirements of the employer in order to continue coverage under the plan upon retirement.

Sickness

Any pregnancy or illness, other than an Injury, which is not covered by Workers' Compensation or any occupational disease act.

Specialist

A professional provider who has advanced education and training in one clinical area of practice.

Substitute; Substitute Basis

Active Work by a pat-time employee regularly scheduled to work less than 8 hours per biweekly pay period.

Total Disability; Totally Disabled

When you are unable to perform your regular or customary occupation or employment solely because of an injury or sickness, or your dependent’s inability to perform normal activities of a person of like age and sex who is in good health.

Usual and Customary Charge

The usual charge made by a provider of medical services, medicines, or supplies which shall not exceed the general level of charges made by others rendering or furnishing such services, medicines, or supplies within the area in which the charge is incurred for sickness or injury or dental condition comparable in severity and nature to the sickness or injury or dental condition being treated, giving due consideration to any complications or unusual circumstances which require additional time, skill or experience. The usual and customary fee is determined from a statistical review and analysis of the charges for a given procedure in a given area. The term area as it would apply to any particular charge, means a county or such greater area, as is necessary to obtain a representative cross-section of the level of charges.

Waiting Period

The period, as indicated in the Eligibility section, that must pass before an employee or dependent is eligible to enroll under the Plan. If an employee or dependent enrolls on a special enrollment date, in the event of a change in family status or during an open enrollment period, any period before such special enrollment, change in family status or open enrollment is not a waiting period.

 General Provisions and Information

Administration of the Plan

The Plan is administered through the human resources department of the employer. The employer has retained the services of an independent Plan Supervisor (InforMed) experienced in claims processing.

Plan Modification and Amendment of Plan

The employer may modify or amend the Plan from time to time at its sole discretion and such amendments or modifications which affect covered participants will be communicated to participants.

Plan Termination

The employer may terminate the Plan at any time. Upon termination, the rights of you and your dependents to benefits are limited to claims incurred and due up to the date of the termination. Any termination of the Plan will be communicated to participants.

Subrogation

If any payment is made under this Plan, the Plan Administrator will subrogated to all rights of recovery of the covered person to whom or for whose benefit the payment was made, to the extent of the amount paid. The covered person will execute and deliver instruments and papers and do whatever else is necessary to secure these rights and will do nothing to prejudice such rights.

Assignment

The covered person's benefits may not be assigned, except by consent of the Employer, other than to providers of medical services.

Inspection of Plan

The Plan Document is on file at the employer's office at the address shown on the factual summary and can be inspected by you at any time during normal business hours.

STATEMENT OF ERISA RIGHTS

As a participant in the Plan, you are entitled to certain rights and protection under the Employee Retirement Income Security Act of 1974 (ERISA), ERISA provides that all Plan participants shall be entitled to:

1. Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites, all Plan documents, including insurance contracts, collective bargaining agreements, and copies of all documents field by the Plan with the U.S. Department of Labor, such as detailed annual reports and Plan descriptions.

2. Obtain copies of the Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies.

3. Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the Employee Benefit Plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and the other Plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have the Plan Administrator review and reconsider your claim.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay up to $100 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored in whole or in part, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

If you have questions about your Plan, you should contact the plan administrator. If you have questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the Pension and Welfare Benefit Administration, Department of Labor listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefit Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

FACTS ABOUT THE PLAN

NAME OF THE PLAN

Washington County Health System Employees Health Benefit Plan

GROUP NUMBER

NAME AND ADDRESS OF EMPLOYER

Washington County Health System, Inc.

251 East Antietam Street

Hagerstown, MD 21740

EMPLOYER IDENTIFICATION NUMBER

52-0607949

PLAN NUMBER

502

TYPE OF PLAN

Health Benefit Plan - Network Option, Basic Option, and Pharmacy Benefit Plan

PLAN ADMINISTRATOR

Washington County Health System, Inc.

251 East Antietam Street

Hagerstown, MD 21740

PLAN SUPERVISOR

InforMed Physicians Network

AGENT FOR LEGAL PROCESS

Service for legal process may be made upon the Plan Administrator

PLAN YEAR END

December 31

SOURCE OF PLAN CONTRIBUTIONS