MARINER FINANCE, LLC PPO 80/60 PLAN PLAN DOCUMENT …

MARINER FINANCE, LLC PPO 80/60 PLAN

PLAN DOCUMENT AND

SUMMARY PLAN DESCRIPTION

Effective Date: July 1, 2016

TABLE OF CONTENTS

SUMMARY PLAN DESCRIPTION.................................................................................. 1

SCHEDULE OF BENEFITS ............................................................................................ 4

Medical Benefits....................................................................................................................................................4 Prescription Drug Program .................................................................................................................................. 12

CIGNA PREFERRED PROVIDER OR NONPREFERRED PROVIDER ...................... 13

Cigna Preferred Providers....................................................................................................................................13 Nonpreferred Providers ....................................................................................................................................... 13 Referrals .............................................................................................................................................................. 13 Exceptions ........................................................................................................................................................... 13

MEDICAL EXPENSE BENEFIT.................................................................................... 15

Copay................................................................................................................................................................... 15 Deductibles .......................................................................................................................................................... 15 Coinsurance ......................................................................................................................................................... 15 Out-of-Pocket Expense Limit .............................................................................................................................. 15 Maximum Benefit ................................................................................................................................................ 16 Hospital/Ambulatory Surgical Facility ................................................................................................................ 16 Facility Providers.................................................................................................................................................16 Ambulance Services ............................................................................................................................................ 16 Emergency Room Services .................................................................................................................................. 17 Immediate Care Center ........................................................................................................................................ 17 In-Store Health Clinic..........................................................................................................................................17 Physician Services and Professional Provider Services.......................................................................................17 Second Surgical Opinion ..................................................................................................................................... 18 Diagnostic Services and Supplies ........................................................................................................................ 18 Transplant ............................................................................................................................................................ 18 Pregnancy ............................................................................................................................................................ 19 Birthing Center .................................................................................................................................................... 19 Birthing Class ...................................................................................................................................................... 19 Sterilization.......................................................................................................................................................... 20 Infertility Services ............................................................................................................................................... 20 Well Newborn Care ............................................................................................................................................. 20 Routine Preventive Care ...................................................................................................................................... 20 Women's Preventive Services ............................................................................................................................. 20 Hearing Benefit for Minor Children (Up to Age 19) ........................................................................................... 21 Outpatient Therapy Services................................................................................................................................21 Extended Care Facility ........................................................................................................................................ 21 Home Health Care ...............................................................................................................................................22 Additional Home Health Care Benefits ...............................................................................................................22 Hospice Care........................................................................................................................................................ 23 Durable Medical Equipment ................................................................................................................................ 24 Prostheses ............................................................................................................................................................ 24 Orthotics .............................................................................................................................................................. 24 Medical Foods ..................................................................................................................................................... 24 Dental Services .................................................................................................................................................... 25 Temporomandibular Joint Dysfunction ............................................................................................................... 25 Orthognathic Disorders........................................................................................................................................25 Special Equipment and Supplies.......................................................................................................................... 25 Cosmetic/Reconstructive Surgery........................................................................................................................25 Mastectomy (Women's Health and Cancer Rights Act of 1998) .........................................................................25

Mental & Nervous Disorders and Chemical Dependency Care...........................................................................26 Prescription Drugs ............................................................................................................................................... 26 Routine Patient Costs for Approved Clinical Trials ............................................................................................ 26 Podiatry Services ................................................................................................................................................. 27 Chiropractic Care.................................................................................................................................................27 Diabetic Education .............................................................................................................................................. 27 Nutritional Counseling/Medical Nutrition Therapy.............................................................................................27 Biofeedback ......................................................................................................................................................... 27 Surgical Treatment of Morbid Obesity ................................................................................................................ 27 Cochlear Implant ................................................................................................................................................. 27 Surcharges ........................................................................................................................................................... 27

MEDICAL EXCLUSIONS.............................................................................................. 28

PRESCRIPTION DRUG PROGRAM ............................................................................ 31

Pharmacy Option ................................................................................................................................................. 31 Pharmacy Option Copay......................................................................................................................................31 Mail Order Option ............................................................................................................................................... 31 Mail Order Option Copay .................................................................................................................................... 31 Covered Prescription Drugs.................................................................................................................................31 Specialty Pharmacy Program...............................................................................................................................32 Limits To This Benefit......................................................................................................................................... 32 Expenses Not Covered.........................................................................................................................................33 Notice of Authorized Representative...................................................................................................................33 Appealing a Denied Post-Service Prescription Drug Claim ................................................................................ 33 Notice of Benefit Determination on a Post-Service Prescription Drug Claim Appeal ........................................34 External Appeal ................................................................................................................................................... 34 Right To External Appeal .................................................................................................................................... 35 Notice of Right to External Appeal ..................................................................................................................... 35 Independent Review Organization.......................................................................................................................35 Notice of External Review Determination...........................................................................................................35 Expedited External Review ................................................................................................................................. 36

PLAN EXCLUSIONS .................................................................................................... 37

ELIGIBILITY, ENROLLMENT AND EFFECTIVE DATE............................................... 39

Employee Eligibility ............................................................................................................................................ 39 Employee Enrollment .......................................................................................................................................... 39 Employee(s) Effective Date.................................................................................................................................39 Dependent(s) Eligibility....................................................................................................................................... 39 Dependent Enrollment ......................................................................................................................................... 40 Dependent(s) Effective Date................................................................................................................................40 Special Enrollment Period (Other Coverage) ...................................................................................................... 41 Special Enrollment Period (Dependent Acquisition) ........................................................................................... 41 Special Enrollment Period (Children's Health Insurance Program (CHIP) Reauthorization Act of 2009) ............ 42 Open Enrollment..................................................................................................................................................42

TERMINATION OF COVERAGE .................................................................................. 44

Termination of Employee Coverage .................................................................................................................... 44 Termination of Dependent(s) Coverage...............................................................................................................44 Leave of Absence ................................................................................................................................................ 44 Layoff .................................................................................................................................................................. 44 Family and Medical Leave Act (FMLA) ............................................................................................................. 44 Extension of Benefits For Inpatient or During Total Disability .......................................................................... 45

CONTINUATION OF COVERAGE ............................................................................... 46

Qualifying Events ................................................................................................................................................ 46 Notification Requirements...................................................................................................................................46 Cost of Coverage ................................................................................................................................................. 47 When Continuation Coverage Begins..................................................................................................................47 Family Members Acquired During Continuation ................................................................................................ 47 Extension of Continuation Coverage ................................................................................................................... 48 End of Continuation.............................................................................................................................................49 Special Rules Regarding Notices.........................................................................................................................49 Military Mobilization .......................................................................................................................................... 50 Plan Contact Information.....................................................................................................................................50 Address Changes ................................................................................................................................................. 50

MEDICAL CLAIM FILING PROCEDURE ..................................................................... 51

POST-SERVICE CLAIM PROCEDURE ................................................................................51

Filing a Claim ...................................................................................................................................................... 51 Notice of Authorized Representative...................................................................................................................51 Notice of Claim ................................................................................................................................................... 51 Time Frame for Benefit Determination ............................................................................................................... 52 Notice of Benefit Denial ...................................................................................................................................... 52 Appealing a Denied Post-Service Claim.............................................................................................................. 52 Notice of Benefit Determination on Appeal ........................................................................................................53 Foreign Claims .................................................................................................................................................... 54

PRE-SERVICE CLAIM PROCEDURE...................................................................................54

Health Care Management .................................................................................................................................... 54 Filing a Pre-Certification Claim .......................................................................................................................... 54 Notice of Authorized Representative...................................................................................................................55 Time Frame for Pre-Service Claim Determination..............................................................................................55 Concurrent Care Claims ...................................................................................................................................... 56 Notice of Pre-Service Claim Denial .................................................................................................................... 56 Appealing a Denied Pre-Service Claim ............................................................................................................... 57 Notice of Pre-Service Determination on Appeal .................................................................................................58 Case Management................................................................................................................................................58 Special Delivery Program....................................................................................................................................58

POST-SERVICE AND PRE-SERVICE CLAIM EXTERNAL APPEALS PROCEDURE ........59

External Appeal ................................................................................................................................................... 59 Right to External Appeal ..................................................................................................................................... 59 Notice of Right to External Appeal ..................................................................................................................... 59 Independent Review Organization.......................................................................................................................60 Notice of External Review Determination...........................................................................................................60 Expedited External Review ................................................................................................................................. 60

COORDINATION OF BENEFITS ................................................................................. 61

Definitions Applicable to this Provision..............................................................................................................61 Effect on Benefits ................................................................................................................................................ 62 Order of Benefit Determination ........................................................................................................................... 62 Coordination With Medicare ............................................................................................................................... 62 Limitations on Payments ..................................................................................................................................... 63 Right to Receive and Release Necessary Information ......................................................................................... 63 Facility of Benefit Payment ................................................................................................................................. 63 Automobile Accident Benefits............................................................................................................................. 63

SUBROGATION/REIMBURSEMENT........................................................................... 65

GENERAL PROVISIONS ............................................................................................. 67

Administration of the Plan...................................................................................................................................67 Applicable Law....................................................................................................................................................67 Assignment .......................................................................................................................................................... 67 Benefits Not Transferable....................................................................................................................................67 Clerical Error ....................................................................................................................................................... 67 Conformity With Statute(s) ................................................................................................................................. 67 Effective Date of the Plan .................................................................................................................................... 68 Fraud or Intentional Misrepresentation................................................................................................................68 Free Choice of Hospital and Physician ................................................................................................................ 68 Incapacity ............................................................................................................................................................ 68 Incontestability .................................................................................................................................................... 68 Legal Actions.......................................................................................................................................................68 Limits on Liability ............................................................................................................................................... 68 Lost Distributees..................................................................................................................................................69 Medicaid Eligibility and Assignment of Rights...................................................................................................69 Physical Examinations Required by the Plan ...................................................................................................... 69 Plan is Not a Contract .......................................................................................................................................... 69 Plan Modification and Amendment ..................................................................................................................... 69 Plan Termination ................................................................................................................................................. 69 Pronouns .............................................................................................................................................................. 70 Recovery for Overpayment..................................................................................................................................70 Status Change ...................................................................................................................................................... 70 Time Effective ..................................................................................................................................................... 70 Workers' Compensation Not Affected ................................................................................................................. 70

HIPAA PRIVACY .......................................................................................................... 71

Disclosure by Plan to Plan Sponsor ..................................................................................................................... 71 Use and Disclosure by Plan Sponsor ................................................................................................................... 71 Obligations of Plan Sponsor ................................................................................................................................ 71 Exceptions ........................................................................................................................................................... 72

DEFINITIONS ............................................................................................................... 73

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