2021 LARGE GROUP HEALTH INSURANCE POLICY - Mountain Health CO-OP

2021

LARGE GROUP HEALTH

INSURANCE POLICY

MHC-3 5 0 0

Version 1.0

MHC_Large Group_Policy_2020

MONTANA HEALTH COOPERATIVE

P. O . BO X 5358

H EL EN A , MT 5960 4

8 5 5- 4 4 7- 2 9 0 0

Group Health Insurance Policy

GROUP POLICYHOLDER:

HISway, LLC

GROUP POLICY NUMBER:

EFFECTIVE DATE OF POLICY:

January 1, 2021

PREMIUM DUE DATE: First day of each month

POLICY RENEWAL DATE:

January 1, 2022, and every January 1 thereafter

POLICY ANNIVERSARY DATE:

POLICY DELIVERY STATE:

January 1 of each year

Idaho

In this Group Policy, the Policyholder is referred to as ¡°You¡± or ¡°Your¡±. The Montana Health

Cooperative is referred to as ¡°We¡±, ¡°Our¡±, ¡°Us¡±, or ¡°the Company.

This is a legal contract between the Policyholder and Montana Health Cooperative. We will pay

Covered Medical Expenses for Covered Benefits provided under this Group Policy for Covered

Persons in accordance with the terms, conditions, limitations and exclusions set forth in this

Group Policy.

This Group Policy is issued in consideration of the application and payment of the initial premium

by the Policyholder.

This Group Policy will take effect at 11:59:59 P.M.. on the Policy Effective Date of this Group Policy

as set forth above, provided that it has been signed by the authorized officers of the Montana

Health Cooperative, and the Policyholder has signed the attached application and Group

Policyholder Acceptance form for this Group Policy.

MEMBER RIGHTS: When requested by the insured or the insured¡¯s agent, Montana law requires

Montana Health CO-OP to provide a summary of a Member¡¯s coverage for a specific health care

service or course of treatment when an actual charge or estimate of charges by a health care provider,

surgical center, clinic or Hospital exceeds $500.

PLEASE READ YOUR POLICY CAREFULLY.

Signed for Montana Health CO-OP

Chief Executive Officer

Richard Miltenberger

Secretary

Larry Turney

Non-Contributory

Non-Participating ¨C No Dividends

Table of Contents

IMPORTANT INFORMATION ....................................................................................................... 4

SECTION 1¡ªDEFINITIONS ........................................................................................................... 19

SECTION 2¡ªWHEN COVERAGE TAKES EFFECT AND TERMINATES .............................................. 29

SECTION 3¡ªPREMIUMS ........................................................................................................... 37

SECTION 4 ¨C IN-NETWORK PROVIDER NETWORK OPTION ..................................................... 41

SECTION 5¡ªCOVERED BENEFITS ................................................................................................ 44

SECTION 6 ¨C UTILIZATION REVIEW MANAGEMENT PROGRAM ............................................... 76

HOW TO USE THE UTILIZATION REVIEW PROGRAM ............................................................. 76

SECTION 7¨C COORDINATION OF BENEFITS .............................................................................. 81

SECTION 8 ¨C EXCLUSIONS AND LIMITATIONS ............................................................................ 87

SECTION 9 ¨C CLAIM PROVISIONS .............................................................................................. 91

HOW TO FILE A CLAIM............................................................................................................. 91

SECTION 10 ¨C COMPLAINTS, GRIEVANCES AND APPEALS ......................................................... 94

SECTION 11¨C GENERAL PROVISIONS ..................................................................................... 105

MHC_Large Group_Policy_2020

IMPORTANT INFORMATION

Montana Health CO-OP is pleased to provide You with this Group Policy for Covered Persons. This

Policy provides a Provider Network through which Covered Persons may obtain medical care and

services while maximizing Your Covered Benefits. However, Covered Persons also may elect to

receive services from an Out-of-Network Provider. When Covered Persons receive services from

an In-Network Provider, generally benefits will be payable at a higher level. When services are

provided by an Out-of-Network Provider, generally, benefits are payable at a lower level. You can

obtain a list of In-Network Provider Directory on the Montana Health Cooperative Website at

mhc.coop.

POLICY AND CUSTOMER SERVICES ¨C UNVERSITY OF UTAH HEALTH PLANS

Our Third-Party Administrator, University of Utah Health Plans, (also referred to as ¡°U of U

Health Plans¡± in this Group Policy) administers the following services for this Group Policy.

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Benefit Inquiries

Claims & Customer Service

Preauthorization

Utilization Review Management Program

Complex Care Management

Population Health Management

Prescription Drug Benefit Program

Complaints, Grievances and Appeals

Contact University of Utah Health Plans Customer Service: 844-262-1560

? Customer Service phone number: 844-262-1560

? Address for Claim Submissions:

University of Utah Health Plans

Attn: MH

P.O. Box 45180

Salt Lake City, UT 84145

? Address for Complaints, Grievances and Appeals:

University of Utah Health Plans Appeals Committee Chairperson

Attn: MHC

6053 Fashion Square Dr., Suite 110

Murray, UT 84107



? U.S. Employee Benefits Security Administration: 866-444-EBSA (3272)

? Montana Commissioner of Insurance and Securities

840 Helena Ave. Helena, Montana 59601

Phone: (800) 332-6148 or (406) 444-2040

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