C and O Employees' Hospital Association

Plan Name 6

Taxpayer Identification and Plan Numbers 6

Administration of Plan 6

Type of Plan 6

Plan Year 6

Collective Bargaining 6

Contributions and Funding 7

Agent for Service of Legal Process 7

Qualified Medical Child Support Orders (QMCSO) 7

Plan Eligibility 7

Plan Purpose 8

COEHA Board of Directors 10

Active Employees 12

COBRA Members 13

Leave of Absence Members 19

Suspended Members 19

Dismissed Members 19

Furloughed Employees 20

Disabled Members 21

Separated Employees 23

Early Retirement Members 24

60/30 Major Medical Members 24

60/30 Major Medical Spouse Members 25

Medicare Members (Referral to Medicare Supplemental

Handbook) 25

In-Network Services 26

Out-of-Network Services/Major Medical Benefits 27

Selecting a Participating Provider 27

Providers not in the Network 28

Out-of-Network Referrals 28

Plan One 29

Plan Two 29

Plan Three 30

Plan Four 30

Plan Five 31

Plan Five A 32

Plan Six 32

Plan Eight 32

Membership Identification Card 34

Time Limit for Filing Claims & How to File Claims 34

Ambulance Services 35

Durable Medical Equipment 36

Orthotics 36

Prosthethic Devices 37

Chiropractic Services 38

Emergency Room Benefits 38

Hospitalization 39

Skilled Nursing Facility Care 39

Inpatient Rehabilitation in a Hospital or Rehabilitation Center 40

Outpatient Office Visits, Consultations & Diagnostic Testing 40

Home Health Services 41

Kidney Dialysis 41

Podiatry 41

Outpatient Physical, Occupational and Speech Therapy 42

Vasectomy and Tubal Ligation Procedures 42

Maternity 42

Cosmetic and Plastic Surgery 43

Gastric Bypass Surgery/Stomach Stapling/Lap Belt 43

Removal of Excess Skin After Gastric Bypass or

Extreme Weight Loss/Tummy Tuck 43

Reconstructive Surgery Following Mastectomy 43

Dental Work 44

Jaw Joint Disorders 44

Chemo/Radiation Therapy 45

Organ Transplants 45

Ophthalmology 45

Mental Health 46

Substance Abuse 46

Hearing Examinations/Hearing Aids 47

Smoking Deterrents 48

Prescription Drugs 48

Exceptional Cases 52

Be considerate and respectful to all COEHA staff and participating providers

Seek services of COEHA participating providers if applicable

Read all COEHA document materials and ask questions if you do not understand

Know the benefits for your classification of membership

Provide complete health status information as needed to receive appropriate care

Respond to our letters promptly

Always utilize your membership identification card when seeking healthcare services

Notify COEHA when a change in your employment status occurs such as a change from active status to off sick, furloughed, suspended, dismissed, separated, leave of absence or retirement

Forward to COEHA any bills you receive more than once for the same services

Maintain your health and participate in decisions concerning your treatment

The members who support the C and O Employees’ Hospital Association and the dedicated staff of professionals who administer the benefits keep this Organization operating efficiently.

The Year 1997 was the C and O Employees’ Hospital Association’s 100^th anniversary. We would like to recognize one of the Administrators who successfully managed these Offices for forty years from 1946 through 1986:

C and O Employees’ Hospital Association (COEHA)

Employer Identification Number is 23-7082348

Plan Number is 501

The Plan is administered by the C and O Employees’ Hospital Association, 511 Main Street, 2^nd Floor, Clifton Forge, Virginia 24422-1166.

COEHA is a welfare benefit plan providing medical, surgical, and hospital care.

January 1 through December 31

COEHA was established through a collective bargaining agreement that was negotiated through the Cooperating Railway Labor Organizations and National Railway Labor Conference. Members and beneficiaries may obtain a copy of such agreement upon written request to the Plan Administrator. The agreement also is available for examination at the COEHA office.

The Plan is funded by membership contributions through a monthly dues assessment and contributions from Chessie Systems X Transportation (CSXT).

Jack N. Pate

President and Administrator

C and O Employees’ Hospital Association

511 Main Street, 2^nd Floor

Clifton Forge, Virginia 24422-1166

Plan Eligibility:

Generally, all Brotherhood of Locomotive Engineers (BLE) and United Transportation Union (UTU) employees and former employees on the former C and O Railway territory and other individuals, which the Board of Directors may from time to time decide to admit to COEHA, are eligible for membership.

Effective January 1, 2008, coverage through COEHA will commence the first day of the thirteenth (13^th) calendar month from the date a new employee starts the training program at the CSXT REDI Center.

An employee who returns to work after a status of furloughed, separated, suspended, dismissed, leave of absence or disabled will be eligible for coverage on the first day of the month following the month in which they have worked at least seven (7) calendar days. For example, if an employee returns to work in January, and works seven days in January, the employee will be eligible for coverage in February. In the event such employee returns to work at a time during a month when there is not opportunity to render compensated service on at least seven calendar days during that month, such employee will be deemed to have satisfied the seven-day rule, provided that they are available or actually work every available work opportunity.

An eligible active employee who returns to work after completion of service in the armed forces of the United States will be eligible for coverage on the day they first render compensated service upon their return.

Any member of COEHA who fails to submit current membership premiums for his class of membership, shall be notified by certified mail of the delinquency and given thirty (30) days to bring membership status up to date. Failure to comply with this notice will result in forfeiture of membership.

As a cost containment measure, COEHA has instituted an automatic dues deduction program for monthly membership premiums from your checking account. You will be required to participate in the automatic dues deduction program or you may remit your dues directly to COEHA either quarterly, semi-annually, or annually. If you choose to participate in the automatic dues deduction program, your premiums will be deducted on the fifth (5^th) day of each month.

Any request for reinstatement must be submitted to the COEHA Finance Committee in accordance with the guidelines outlined in the Appeal Procedure Section of these Rules and Regulations.

The C and O Employees’ Hospital Association was established in 1897 as a joint effort between the Chesapeake and Ohio Railway Company and its employees to provide certain healthcare benefits for the employees and retirees of the Chesapeake and Ohio Railway Company.

Healthcare benefits will be furnished in accordance with such rules and regulations as may from time to time be approved by the Board of Directors of COEHA, provided, that at all times COEHA shall conduct itself strictly as a non-profit organization pursuant to Section 501 (c) (9) of the Internal Revenue Code of 1986 as same may be amended, or the comparable section of any future Revenue Act.

All benefits are subject to the limitations and exclusions in these Rules and Regulations and are payable when determined by the Plan to be medically necessary. No oral statement of any person can modify or otherwise affect the benefits, limitations, and exclusions of these Rules and Regulations, convey or void any coverage, increase or reduce any benefits under this Plan, or be used in the prosecution or defense of a claim under this Plan.

COEHA is governed by a Board of Directors. The members of the current Board of Directors are:

Director Union Affiliation

Jack N. Pate Local Chairman

President; Administrator, United Transportation Union
COEHA

422 Sullivan Road

Glen Morgan, WV 25847

(304) 252-5227

Norman V. Smith Brotherhood of Locomotive Engineers
Vice President, COEHA
1707 Jones Street
Flatwoods, KY 41139
(606) 834-1766

Kenneth Farley Local Chairman, E Craft
Secretary-Treasurer, COEHA United Transportation Union
271 Township Road 1167
Proctorville, Ohio 45669
(304) 638-2343

Jim Bowling Local Chairman
Director, COEHA United Transportation Union
815 Park Street
Flatwoods, KY 41139
(606) 836-5413

Glenn Hazelwood General Chairman, Yardmasters

Director, COEHA United Transportation Union

2423 Old Geneva Road

Henderson, KY 42420

(270) 826-3740

Phil Henry Local Chairman

Director, COEHA Brotherhood of Locomotive Engineers

308 11^th Avenue, West

Huntington, WV 25701

(304) 697-7611

Donnie Moates General Chairman
Director, COEHA Brotherhood of Locomotive Engineers
274 Highway 310
Etowah, TN 37331
(423) 263-0909

Jim Townsend General Chairman

Director, COEHA United Transportation Union

1319 Chestnut Street

Kenova, WV 25530

(304) 453-1102

Charles E. Whitmer At Large

P. O. Box 443

Clifton Forge, VA 24422

(540) 863-5681

The following classifications of membership are eligible for benefits through COEHA. For members obtaining employment elsewhere and receiving Healthcare benefits from such employment, COEHA will only provide such benefits that are in excess of the other Healthcare Plan benefits and in accordance with the Rules and Regulations governing operation of COEHA. In no instance will COEHA provide a duplication of benefits. For those members relocating more than 100 miles by road from the main line of the former C&O Railway, please refer to the Plan Section for Off-Line Members. Please refer to the COEHA Plan Section of these Rules and Regulations for a summary of your benefits. The Benefits Section provides coverage information regarding specific healthcare services.

BLE and UTU members who are actively employed with CSXT and work within 100 miles by road of the main line of the former Southern Region, Cincinnati-Chicago Division of the former Chesapeake and Ohio Railway Company whose membership premiums are remitted to COEHA. (Refer to Plan One for benefits)

Dependents of actively employed members who are covered by the National Health and Welfare Plan are eligible for supplemental coverage with COEHA upon payment of dues premiums. (Refer to Plan Six for benefits)

An active member of COEHA becoming a full-time employee of the BLE or UTU is eligible for benefits of COEHA upon payment of premiums directly to COEHA as specified for active members. (Refer to Plan One for benefits)

Active employees age 65 or older and eligible for Medicare coverage will still be covered by COEHA as their primary insurer. (Refer to Plan One for benefits)

Active members of COEHA transferred outside of the COEHA territory are eligible to maintain their membership in COEHA. These members would be covered by the National Health and Welfare Plan as their primary insurer, and COEHA would be secondary. (Refer to Plan Eight for benefits)

Right to Continuation Coverage.

Qualifying Events. Under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA) members are entitled to elect to continue participation in COEHA, for a limited period of time, if the member loses his regular coverage under the Plan as a result of either of the following events commonly referred to as "Qualifying Events":

(1) Termination of employment (for reasons other than gross misconduct); or

(2) A reduction in hours of work.

A "loss of Plan coverage" includes an increase in the premiums the member is required to pay.

If a member’s spouse is covered under the COEHA, he or she also has the right to elect Continuation Coverage if he or she loses coverage under the medical option as a result of any of the following events also known as "Qualifying Events":

(1) The end of the member’s employment (for reasons other than gross misconduct);

(2) A reduction in the member’s hours of work;

(3) The death of the member;

(4) Divorce or legal separation from the member; or

(5) The member becomes entitled to Medicare benefits under Title XVIII of the Social Security Act.

A member’s covered dependent child also has the right to elect Continuation Coverage for himself or herself if he or she loses regular coverage under the Plan as a result of any of the following events also known as "Qualifying Events":

(1) The end of the covered parent’s employment relationship (for reasons other than gross misconduct);

(2) A reduction in the covered parent’s hours of work;

(3) The death of a covered parent;

(4) The parents’ divorce or legal separation;

(5) The covered parent becomes entitled to Medicare benefits under Title XVIII of the Social Security Act; or

(6) The child loses dependent status under the terms of the Plan.

A dependent child includes a child born to or placed for adoption with a covered employee during the period of COBRA coverage.

Separate elections. If there is a choice among types of coverage under the Plan, each person who is eligible for Continuation Coverage (known as a "Qualified Beneficiary") is entitled to make a separate election among the types of coverage. Thus, a spouse or dependent child is entitled to elect Continuation Coverage even if the covered employee does not make that election. Similarly, a spouse or dependent child may elect different coverage from the coverage that the covered employee elects.

Duties of Qualified Beneficiaries. A covered employee or family member has the responsibility to inform the Plan Administrator of a divorce, legal separation, or a child’s loss of dependent status under the Plan within 60 days of the event or the date on which regular Plan coverage would be lost because of the event. In addition, the covered employee or a family member must inform the Plan Administrator before the end of the original 18-month Continuation Coverage period and within 60 days of a determination by the Social Security Administration that the individual concerned was disabled at the time of the covered employee’s termination of employment relationship or reduction in hours of employment. The individual may extend Continuation Coverage if they were disabled at any time during the first 60 days of Continuation Coverage. The extension of Continuation Coverage due to disability is also available to the non-disabled spouse and dependent children of the disabled individual.

If, during Continued Coverage, the covered employee or family member is later determined by the Social Security Administration as no longer being disabled, the individual must inform the Plan Administrator within 30 days of the date the re-determination was made. When the Plan Administrator is notified that one of these events has occurred, the member will be notified of his or her Continuation Coverage rights.

Election of Continuation Coverage. Under COBRA, a Qualified Beneficiary is entitled to have an election period of 60 days to decide whether to elect Continuation Coverage. The 60-day election period begins on the later of (1) the date the individual would lose regular Plan coverage because of one of the qualifying events described above or (2) the date the individual is sent a notice of the right to elect Continuation Coverage. If a Qualified Beneficiary informs the COEHA within the 60-day election period that he or she wants Continuation Coverage, Continuation Coverage begins on the date the individual’s regular Plan coverage ends. There is one exception, however. If a Qualified Beneficiary waives Continuation Coverage, he or she may revoke the waiver at any time before the 60-day election period ends. In that case, the Continuation Coverage begins on the date the waiver is revoked. Coverage will not be provided for the period between the date regular Plan coverage ends and the date the waiver is revoked.

If a Qualified Beneficiary dies or become legally incapacitated before the 60-day election period ends, then a personal representative has the right to make an election on the Qualified Beneficiary’s behalf, provided the election is made before the end of the 60-day election period. The period between the date of death or legal incapacity and the date the personal representative is appointed will not be included for purposes of calculating such 60-day period.

If a Qualified Beneficiary does not choose Continuation Coverage within the 60 day election period, the individual’s eligibility for Continuation Coverage will end.

Cost of Continuation Coverage. The cost of regular Continuation Coverage is the full cost of the monthly premium plus a two percent administrative charge. The cost of Continuation Coverage provided after the 18^th month on account of disability under Title II or XVI of the Social Security Act is 150 percent of the full cost of the monthly premium. If you experience a Qualifying Event, you will be notified about the premium rates and the due dates for payments. The premium costs will increase during the Qualified Beneficiary’s period of Continuation Coverage to the extent such premium increases have increased for non-COBRA coverage under the Plan.

The initial premium for Continuation Coverage will be due 45 days after the date of the initial Continuation Coverage election. There is a 30-day grace period after the due date for each of the subsequent premiums.

Continuation Coverage. The Continuation Coverage is identical to the coverage then being provided under the Plan to similarly situated employees, their spouses, and their dependent children who have not experienced a qualifying event. If their coverage changes, Continuation Coverage will change in the same way. COEHA reserves the right to terminate Continuation Coverage retroactively for an individual determined to be ineligible for such coverage.

Duration of Coverage. If the member or a covered family member loses regular Plan coverage due to a termination of employment or a reduction in hours of work, Continuation Coverage generally may last for only 18 months.

Special rule for disability. If a Qualified Beneficiary loses regular Plan coverage due to a termination of employment or a reduction in hours of employment and is determined to have been disabled under Title II or XVI of the Social Security Act at the time of the termination or reduction in hours or within the first 60 days of COBRA coverage, then Continuation Coverage may last for up to 29 months, provided, however, that COEHA is notified of the disability determination before the end of the regular 18-month period and within 60 days of the date the determination is made. A Qualified Beneficiary must also notify COEHA within 30 days if a final determination is made that the member is no longer disabled under Title II or XVI of the Social Security Act).

Second qualifying event. This 18-month (or 29- month) period of Continuation Coverage may be extended for up to 36 months if a second "qualifying event" (for example, death, divorce or legal separation, or Medicare entitlement) occurs during the 18-month (or 29-month) period, but only for those individuals who were Qualified Beneficiaries in connection with the first qualifying event and are Qualified Beneficiaries at the time of the second qualifying event. For example, if a terminated employee chooses Continuation Coverage for himself and his spouse and the employee dies before the 18-month (or 29-month) period ends, the spouse may elect to receive Continuation Coverage for a total of 36 months. The 36 months would be measured from the date of the employee’s termination of employment. A termination that follows a reduction in hours is not a Qualifying Event that creates a right to Continuation Coverage.

Continuation coverage will be terminated. COBRA provides that Continuation Coverage will be terminated, if any of the following events occurs:

(1) The premium for Continuation Coverage is not paid within 30 days of the due date;

(2) The Qualified Beneficiary first becomes covered, after the date of his or her COBRA election, under another group health plan (as an employee or otherwise) even if such group health plan contains a preexisting condition limitation or exclusion so long as such limitation or exclusion does not apply to you because of the new rules enacted under the Health Insurance Portability and Accountability Act of 1996.

(3) The Qualified Beneficiary becomes entitled to the Medicare benefits under Title XVIII of the Social Security Act;

(4) Coverage has been extended for up to 29 months due to disability and there has been a final determination that the individual is no longer disabled under Title II or XVI of the Social Security Act. In that case, Continuation Coverage will end as of the first day of the month that begins more than 30 days after the date the final determination is made; or

(5) The end of the maximum eligibility period is reached.

Once Continuation Coverage terminates for any reason, it cannot be reinstated.

Leave of Absence Members (Other Than For Health Reasons):

Actively employed members of COEHA who are granted a leave of absence from CSXT pursuant to applicable collective bargaining agreement

Leave of Absence members are classified as active employees and are eligible for coverage through COEHA through the remainder of the month in which they last worked. Membership in COEHA can be continued in a COBRA status upon payment of dues premiums. (Refer to Plan One for benefits) Once COBRA coverage has been exhausted, the member is eligible for continuation of benefits. There will be a change in benefits and premiums. (Refer to Plan Four for benefits)

Actively employed members who are suspended from CSXT

Suspended members are classified as active employees and are eligible for coverage through COEHA through the remainder of the month in which they last worked and the following calendar month without payment of membership premiums. For the second, third and fourth months, the employee is covered by the National Health and Welfare Plan. After the fourth month, coverage with the National Health and Welfare Plan will terminate and membership in COEHA can be continued in a COBRA status upon payment of dues premiums. (Refer to Plan One for benefits) Once COBRA coverage has been exhausted, the member is eligible for continuation of benefits. There will be a change in benefits and premiums. (Refer to Plan Four for benefits)

Actively employed members who are dismissed from CSXT

Dismissed members are covered by the National Health and Welfare Plan effective with the date of dismissal. They will continue to be covered by the National Plan for the next four months following the month in which they last rendered any compensated service or received vacation pay. However, the vacation pay must be received prior to dismissal to be considered vacation pay. After the fourth month, coverage with the National Plan will terminate and membership in COEHA can be continued in a COBRA status upon payment of dues premiums. (Refer to Plan One for benefits) Once COBRA coverage has been exhausted, the member is eligible for continuation of benefits. There will be a change in benefits and premiums. (Refer to Plan Four for benefits)

Active members of COEHA who are furloughed from their employment with CSXT

Active members of COEHA who are furloughed from their employment with CSXT are entitled to benefits of COEHA identical to those as an active member, without payment of membership premiums for four (4) months following the month in which the last compensated service was performed. Vacation payments received subsequent to the month in which furlough occurs will not extend healthcare benefits beyond the four (4) month period. (Refer to Plan One for benefits)

If such furloughed member becomes disabled while covered as a furloughed employee during this four month period, coverage will continue as long as disability is the only reason the employee does not perform work in his regular occupation if recalled, and member will be covered by the provisions for Disabled Members. The Association will require medical certification from the member’s attending physician stating member is under medical care and unable to return to work.

Beginning with the fifth (5th) month, members who continue on furlough are eligible to continue their benefits through COEHA in a COBRA status upon payment of membership premiums. Once COBRA has been exhausted, the member is eligible for continuation of benefits. There will be a change in benefits and premiums. (Refer to Plan Four for benefits)

Members of COEHA who are out of service on account of illness, injury, disability or pregnancy, which continues to prevent their return to service in their CSXT occupations

Disabled members are eligible for coverage with COEHA for the remainder of the year in which they last rendered compensated service or received vacation pay and the following calendar year. They will be entitled to benefits identical to those of an active member without payment of premiums as long as they continue to be out of service on account of illness, injury, disability or pregnancy, which continues to prevent their return to service in their CSXT occupation. They are no longer eligible for coverage with COEHA without payment of premiums should they accept other regular employment or their disability ends. (Refer to Plan One for benefits) Beginning with the next calendar year, the member is given the option to choose between two types of coverage:

Major medical benefits only with no premium (Refer to Plan Two for benefits)

Full coverage, both in and out-of-network, with a premium (Refer to Plan Three for benefits)

If a member does not qualify for at least eighteen (18) months of coverage identical to an active member under the above ruling for Disabled Members, they may be eligible for continuation of this coverage under the COBRA guidelines. Please contact COEHA for more information. (Example: employee was off sick and did not work January through May of 2008—employee returned to work June 2008 and worked through August 2008—effective September 2008 the employee is unable to return to work due to illness—employee would be eligible for coverage as follows: the remainder of 2008 and the entire year of 2009 without payment of membership dues (16 months)—effective January 2010, the employee would be eligible for two (2) months of coverage under COBRA (Refer to Plan One for benefits) upon payment of membership premiums and once the employee has exhausted COBRA coverage (16 plus 2), employee would be eligible for continuation of coverage through COEHA upon payment of membership premiums (Refer to Plan Three for benefits) or employee would be eligible for Major Medical coverage the entire year of 2010 without payment of membership premiums (Refer to Plan Two for benefits))

COEHA will require medical certification from the member’s attending physician, stating that the member is under medical care and is unable to return to work. The medical certification is required every six months or until a member returns to work in their regular occupation with CSXT. In the event an annuity is awarded, a copy of the Railroad Retirement Award Notice Letter is required and, in some instances, medical certification may still be required.

Disabled members who have exhausted their one year "waiver of premium" coverage or their one year full benefits "with premium" coverage and have not been awarded a disability annuity are eligible for continuation of coverage in the COEHA. There will be a change in premiums and benefits. (Refer to Plan Four for benefits)

Disabled members who have exhausted their one year "waiver of premium" coverage or their one year full benefits "with premium" coverage and have been awarded a disability annuity are eligible for continuation of coverage in COEHA. There will be a change in premiums and benefits. (Refer to Plan Four for benefits)

Members who are awarded a disability annuity will continue to be eligible for benefits of COEHA without payment of premiums for the same period of time the eligibility would have continued had the member not been awarded an annuity; however, those members qualifying for Medicare must become a member of Parts A and B of Medicare (both Parts A & B should be effective with the same date), paying premiums as prescribed in accordance with the effective date of your Medicare coverage. (Refer to Plans Seven and Ten of the COEHA Medicare Supplemental Handbook for benefits)

In the event a disabled member is furloughed during a period of disability of four or more months, the member would be required to begin payment of premiums to COEHA in a COBRA status as provided in the section of the Rules and Regulations for Furloughed Members, immediately upon termination of disability status.

Separated Employees:

Members 55 years of age or more, or with fifteen (15) years or more of membership accepting lump sum separation allowance and deferring or ineligible for retirement pension whose premiums are remitted to COEHA

Separated employees are classified as active employees and are entitled to such benefits as active employees through the remainder of the month in which the employees last worked. (Refer to Plan Four for benefits after the first month) Membership under COBRA is also available. (Refer to Plan One for benefits)

Members who retire between the ages of 60 and 65 that do not meet the requirements for the 60/30 Major Medical membership

Members are entitled to the in-network benefits upon payment of membership premiums. Premiums are due according to the effective date of your Railroad Retirement or Social Security Annuity. (Refer to Plan Four for benefits) Membership under COBRA is also available. (Refer to Plan One for benefits)

Those members retiring at 60 years of age or older, with 30 or more years of service with the Railroad Retirement Board, but not yet 65 years of age

Members who retire effective January 1, 2002 or later, are entitled to one of two different plans of benefits. One plan entitles the members to both in-network benefits and major medical benefits, with the in-network benefits being paid in full less the deductible and office visits copays upon payment of premium, while the other plan pays a percentage less the deductible and office visits copays and has a lifetime maximum of $100,000 with no premium. If you choose the plan with no premium, you have four months (the month you are eligible to retire, plus three months) to change to the other 60/30 plan. (Refer to Plans Five & Five A for benefits) Membership under COBRA is also available. (Refer to Plan One for benefits)

Certain employees who retire on disability may be eligible for these same benefits upon attaining age 60. These members must have continued their membership in COEHA until age 60.

Such member should contact the COEHA Offices for eligibility information.

Once a member becomes eligible for Medicare benefits, COEHA membership must be converted to the Medicare Supplement Plan. (See the COEHA Medicare Supplemental Handbook)

A spouse of a 60/30 Major Medical COEHA member is eligible for our supplemental coverage to the National Health and Welfare Plan upon payment of membership premiums. (Refer to Plan Six for benefits)

To give you the highest quality medical care available, we have created an extensive network of healthcare providers by partnering with Anthem Blue Cross Blue Shield. Anthem offers COEHA and its members access to the BlueCard program. This program electronically links all Blue Cross and Blue Shield Plans and their providers—creating one large, national network. The network includes more than 80 percent of the hospitals and nearly 90 percent of the physicians in the United States and, COEHA and its members have access to all of them.

COEHA has an open network, which means you can use the services of providers who belong to our network without first getting a referral from another physician.

COEHA’s designation of a physician or other provider as a participating provider is not an endorsement of that provider. Except as to the payment of benefits for covered services, COEHA has no responsibility for the care or services rendered by a participating provider or for the manner in which that care or service was rendered.

You can easily find a participating provider online at www.anthem.com or call 1-800-810-BLUE (2583). The Anthem web site address and the phone number are located on the back of your ID card. You can also call your provider directly and ask if they participate in the BlueCard PPO network. As always, COEHA is available if additional assistance is required.

Whenever possible, you should seek medical care from participating providers in the COEHA network.

Full benefit payment is made for medically necessary treatment from COEHA participating providers for covered services, less applicable co-pays and/or deductibles.

Some categories of our membership are eligible for out of network coverage. If you choose to utilize this option, your services are paid at a reduced level of benefits as outlined below:

Also, some benefits are only covered under your Major Medical level of benefits as outlined below: (Please refer to the Benefits Section for those services only covered under Major Medical)

Annual deductible must be satisfied (please see the COEHA Plans Section for your appropriate deductible

Payment is made at 80% of our fee schedule for covered charges (provider may bill you for charges in excess of our fee schedule)

Out-of-pocket expense in the amount of $1500 must be satisfied before our payment percentage reverts to 100% of our fee schedule for covered charges (provider may bill you for charges in excess of our fee schedule)

Lifetime maximum of $1,000,000

(Non-covered services, deductibles, $15 co-payments, and charges in excess of our fee schedule are not included in the $1500 out-of-pocket expense—example: member with a $650 deductible would pay $2150 out of pocket before expenses would be covered at 100%--$650 deductible + $1500 out-of-pocket=$2150)

COEHA members may select any participating provider in our network without a referral. Some members live in towns or cities where no participating providers are available. If this is the case for you, locate the nearest town or city where COEHA providers are available. If the closest COEHA provider is within 30 miles by road, you must utilize those providers, unless you are eligible for the out-of-network coverage outlined above and you prefer to utilize your out-of-network benefits at a reduced rate.

There are some areas where network providers have not yet been contracted and the nearest COEHA provider is more than 30 miles away. Members in these areas are permitted to use providers of their choice. However, if you choose a physician more than 30 miles away in an area where we have the specialty available in network, you should seek the services of our network physician unless you are eligible for the out-of-network coverage outlined above and you prefer to utilize your out-of-network benefits at a reduced rate.

Out-of-network referrals are covered if the required specialty is not participating in your area within 30 miles by road and if the referral comes from a participating physician. Referrals must be approved prior to treatment in order to receive full benefit payment.

Requests made by a patient to see a different physician who is not a COEHA provider are not considered approved referrals and are not covered unless you are eligible for out-of-network coverage at a reduced rate.

Plan benefits are highlighted below. For specific benefits, please refer to the Benefits Section.

In-Network: 100% payment for covered services less the $15 copay for office visits and consultations

 

Out-of-Network: 80% payment of our fee schedule for covered services less the $15 co-pay for office visits and consultations after the annual $100 deductible has been satisfied

Unlimited lifetime and annual maximum on most in-network benefits

Use of any COEHA network provider with no referral required

Prescription drug coverage at local pharmacy and mail order pharmacy through our prescription drug program

Annual deductible of $650 on all covered services (in or out-of-network, including inpatient and outpatient services)

All services (in or out-of-network) covered at 80% of our fee schedule for covered services less the $15 co-pay for office visits and consultations after annual deductible has been satisfied

Lifetime maximum of $1,000,000

After $1500 out-of-pocket and $650 deductible have been satisfied, payment will revert to 100% of our fee schedule for covered services

Prescription drug coverage at local pharmacy and mail order pharmacy through our prescription drug program

Annual deductible of $650 for all covered services (in and out-of-network, including inpatient and outpatient services)

In-Network - 100% payment for covered services less $15 co-pay for office visits and consultations after $650 deductible has been satisfied

Out-of-Network – 80% payment of our fee schedule for covered services less $15 co-pay for office visits and consultations after $650 deductible has been satisfied

Unlimited lifetime and annual maximum on most in-network benefits

Use of any COEHA network provider with no referral required

Prescription drug coverage at local pharmacy and mail order pharmacy through our prescription drug program

Annual deductible of $650 for all covered services

 

In-Network benefits paid at 100% for covered services less $15 co-pay for office visits and consultations after annual deductible has been satisfied

Emergency benefits paid at 100% after annual deductible has been satisfied when such services are provided at the nearest treatment facility

Unlimited lifetime and annual maximum on most in-network benefits

Use of any COEHA network provider with no referral required

Eligible for consumer prescription card through our pre-scription drug program which entitles the member to group discounts on prescription drugs

Annual deductible of $750 for all covered services (in or out-of-network, including inpatient and outpatient services)

In-Network: 100% payment for covered services less the $15 co-pay for office visits and consultations after the annual deductible has been satisfied

Out-of-Network: 80% payment of our fee schedule for covered services less the $15 co-pay for office visits and consultations after the annual deductible has been satisfied

Unlimited lifetime and annual maximum on most in-network benefits

Use of any COEHA network provider with no referral required

Prescription drug coverage at local pharmacy and mail order pharmacy through our prescription drug program

 

Annual deductible of $100 for all covered services (in or out-of-network, including inpatient and outpatient services)

All covered services (in or out-of-network) covered at 80% of our fee schedule less the $15 copay for office visits and consultations after annual deductible has been satisfied (Please keep in mind that not all physicians will accept our fee schedule—you could be responsible for the amount above the fee schedule—for instance, your surgery costs $6,000—our fee schedule determines $3,000 to be reasonable—the provider can bill you the $3,000 not covered by us, plus your 20%)

Lifetime maximum of $100,000 (if you retire at age 60, this lifetime maximum would have to last you for ages 60-64—once you have exhausted the maximum, you have no coverage)

Prescription drug coverage at local pharmacy and mail order pharmacy through our prescription drug program

Covers the annual deductible not paid under the National Health and Welfare Plan

 

Covers up to 85% of the amount approved, but not paid by the National Health and Welfare Plan

 

Covers the annual deductible not paid under the National Health and Welfare Plan

 

Covers the balance of covered services not paid by the National Health and Welfare Plan

 

 

 

Your membership identification card identifies you as a member of COEHA. It contains a unique member identification number which helps COEHA protect you against possible identity theft. To ensure your provider has the proper insurance information, have the provider copy the front and back of your card. Please have this number available when you call COEHA. Also, please list this number on any correspondence sent to COEHA.

Your membership card does not guarantee coverage of all services or current eligibility. You or your provider can verify your eligibility by contacting COEHA. Should your membership card become lost, stolen or damaged, you can call COEHA with a replacement request at 1-800-679-9135 or locally at 1-540-862-5728.

All claims for services provided our members must be received within one year from the date the services were rendered to be eligible for payment by COEHA. All corrected rebills should be received within one year from the original denial date to be eligible for payment by COEHA.

Your network provider will file your claims for you to the local Blue Cross and Blue Shield Plan. Many healthcare providers will file your claims with the local Blue Cross and Blue Shield Plan even if they are not participating in the network. If a non-participating provider will not file the claim for you, you will be responsible for filing the claim. Assistance with filing the claim will be provided by COEHA.

Claims should contain the following information:

Patient’s full name and COEHA ID Number

ICD-9 Codes (diagnosis codes)

CPT-4 Codes (procedure codes)

Date(s) of service

Name, address, and Tax Identification Number of provider

National Provider Identifier Number (NPI)

Referring physician if applicable

If you are eligible for Major Medical coverage, your annual deductible must be satisfied before any services are covered under the Major Medical or Out-of-Network coverage with the exception of the prescription drug benefit through our prescription drug program.

AMBULANCE SERVICES

COEHA will provide medically necessary service to the nearest treatment facility under emergency circumstances. In the event necessary specialty service is not available at this facility, COEHA will provide medically necessary ambulance service to the nearest designated facility where specialty service is available.

This is equipment needed for medical reasons which is sturdy enough to be used many times without wearing out. COEHA covers certain durable equipment items such as oxygen, oxygen equipment, wheelchairs, hospital beds, etc. Only one of each article is covered. COEHA does not cover maintenance, repair, or replacement of such items.

A certificate of medical necessity must accompany the bill for these services or a copy of the physician’s orders showing length of time equipment is needed.

For durable medical equipment, purchase vs. rental is based on length of time for which this equipment is prescribed. COEHA will not pay more than the purchase price for rentals.

Not all durable medical equipment is covered. This benefit is administered on a case by case basis.

These items will be covered under your Major Medical level of benefits.

Coverage for these items is limited to $2,000 per calendar year, not to exceed a lifetime limitation of $4,000.

These are items serving to protect, restore or improve function. COEHA covers certain orthotic devices such as braces and supports when these items are prescribed by a COEHA network provider. Only one of each article is covered. Repair, replacement or maintenance of such item is not covered.

Not all orthotic devices are covered. This benefit is administered on a case by case basis.

This includes artificial substitutes that replace missing body parts. COEHA covers certain prosthetic devices such as artificial limbs, eyes, etc. A copy of the physician’s orders must accompany the bill for these services. Only one of each article is covered. COEHA does not cover maintenance, repair, or replacement of such items.

Prosthetic devices also include items used to replace an internal body part or function such as ostomy supplies.

Not all prosthetic devices are covered. This benefit is administered on a case by case basis.

For coverage of breast prosthetics, see Section on Reconstructive Surgery following Mastectomy.

These items will be covered under your Major Medical level of benefits.

Coverage for these items is limited to $2,000 per calendar year, not to exceed a lifetime limitation of $4,000.

Plan Six is eligible for appliance benefits under the guidelines summarized in the Plan Section for such members.

CHIROPRACTIC SERVICES

Only those members entitled to our Major Medical coverage (Plans One, Two, Three, Five & Five A) are eligible for chiropractic benefits under the Major Medical Benefits. Plan Six is eligible for chiropractic benefits under the guidelines summarized in the Plan Section for such members. Major Medical chiropractic benefits are outlined below:

Applicable annual deductible must be satisfied before any payment is made

Limit of 40 visits per calendar year—one chiropractic visit per day

All other covered charges will be paid at 80% of our fee schedule

Copay of $15 for office visits or consultations

In case of life-threatening or physically impairing emergencies, members are expected to get care immediately regardless of the provider’s network affiliation. Please notify our Offices within 24 hours if these emergency services are obtained from providers not participating in the COEHA network.

Member is responsible for a $30 copay for services rendered in the emergency room. In cases where the member is admitted to the hospital through the emergency room, the copay will be waived.

Payment for services rendered in hospital emergency rooms is limited to treatment of emergency problems only. Although a particular hospital may be a COEHA network facility, this does not mean that the members will have access to the emergency room as a responsibility of COEHA for treatment of non-emergency problems that can be handled in the offices of COEHA network providers.

Charges determined to be of a non-emergency nature will be handled at a reduced rate under the Major Medical level of benefits for those eligible for this coverage, and denied for members not eligible for Major Medical benefits.

Semi-private room accommodations and ancillary charges (e.g., supplies) provided in COEHA network facilities are covered.

Private rooms are covered when it has been determined by the attending physician that it is medically necessary.

COEHA will provide private duty nursing care only to the extent such services are certified as medically necessary and prescribed by the attending physician. Services beyond such certified period will not be covered. Private duty nursing is limited to fifteen (15) shifts during any one spell of illness. A spell of illness is defined as successive periods of hospital confinement separated by less than sixty (60) days and due to the same or related causes. Special duty nursing is also limited to services provided by a registered nurse or licensed practical nurse.

Skilled Nursing Facility (SNF) care is health care given when you need skilled nursing or rehabilitation staff to manage, observe, and evaluate your care. These skilled care services are needed daily on a short-term basis.

Our benefits for SNF care are similar to what the Medicare Plan covers for a Medicare member. COEHA will cover the first 20 days in a SNF—preauthorization by COEHA is required. If SNF care is required beyond the first 20 days, COEHA will pay the equivalent to what Medicare would pay up to 100 days. The percentage that Medicare does not cover from the 21^st to the 100^th day changes each calendar year. That percentage would be due by the patient. COEHA will not cover SNF care beyond 100 days for the same spell of illness or injury.

Effective January 1, 2008, COEHA will cover certain medical services provided a member while a resident in a long-term care facility, such as physician visits and physical therapy.

Inpatient rehabilitation in a hospital or rehabilitation center is limited to 30 days per spell of illness or injury.

Member is responsible for a $15 co-payment per office visit or office consultation. COEHA covers the remaining charge when services are provided by COEHA network physicians. (The $15 co-payment is not due for an office visit or office consultation when only laboratory and/or radiology procedures are performed and there is no charge by the physician for the office visit.)

COEHA covers the charge for medically necessary diagnostic testing such as laboratory and x-rays when such services are provided by COEHA network providers.

Only those members entitled to Major Medical benefits are eligible for home health services as follows under the Major Medical Benefit. (Plans One, Two, Three, Five & Five A)

Part-time nursing care rendered by or supervised by a registered nurse or licensed practical nurse and prescribed by the attending physician.

This benefit is limited to thirty (30) months during which time it will be member’s responsibility to enroll in Medicare (both Parts A & B) benefits for end-stage renal disease (ESRD). Medicare will assume responsibility for a portion of the charges for the dialysis treatments and COEHA will be responsible for the deductible and/or coinsurance.

The services of a Podiatrist are covered only when such services are not provided by a COEHA network orthopedist.

General foot care is not covered.

Foot orthotics, such as inserts, are only covered for those members eligible for Major Medical coverage (Plans One, Two, Three, Five & Five A). Arch supports are not covered for any plan of membership.

Outpatient therapy is limited to $5,000 per calendar year which is paid at 80% of our fee schedule to the extent such therapy is certified as necessary and prescribed by an authorized physician.

These procedures are covered when performed solely for the purpose of voluntary sterilization and only when performed by COEHA network physicians. COEHA will only cover this type of surgery once.

Costs associated with subsequent surgery for the purpose of restoring virility or fertility after previous elective sterilization has been carried out are not covered.

Effective January 1, 2006, COEHA is the primary insurer for any pregnancy related claims for active female members for both inpatient and outpatient services.

Members in a furlough, leave of absence, disabled, suspended, or separated status will be provided obstetrical benefits (both inpatient and outpatient services) for as long as their coverage in applicable category is defined. (See appropriate category under the Section entitled "COEHA MEMBERS".)

For those eligible members, COEHA shall provide benefits for a hospital stay in connection with childbirth for the mother and newborn child for (i) 48 hours following a vaginal delivery and (ii) 96 hours following a cesarean section, except to the extent the attending provider, in consultation with the mother, discharged the mother or newborn child prior to the expiration of the applicable minimum length of stay.

Coverage for hospital and/or professional services in connection with cosmetic surgery shall be limited to the repair or alleviation of damage to the member’s person caused solely by bodily injury sustained while the member is covered. Repairs shall be made within one (1) year of the injury unless special extension is requested by the attending surgeon.

Prior authorization by COEHA is required. This surgery is limited to $25,000 and is defined by all services included during the visit for the actual procedure. This surgery will only be covered once.

Prior authorization by COEHA is required. This surgery is limited to $7,500 and is defined by all services included during the visit for the actual procedure. The surgery will only be covered once.

COEHA provides coverage, in the case of a Member who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, (i) all stages of reconstruction of the breast on which the mastectomy has been performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and physical complications of mastectomy, including lymphedemas in a manner determined in consultation with the attending physician and the patient. Such coverage is subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the Plan.

Elective or routine dental work, not associated with injury, is provided through the National Dental Plan for active employees of CSXT, and is not a responsibility of COEHA.

COEHA coverage is limited to the expense of necessary dental repair to natural teeth due to accidental injuries resulting from a direct blow to the mouth. This expense must have prior approval from the COEHA Offices. Repairs shall be made within six (6) months of the injury unless special extension is requested by the attending physician.

Emergency services involving acute dental problems and requiring the services of a medical doctor rather than a dentist, and which do not involve direct repair to natural teeth, are considered the responsibility of COEHA.

Neither the cost for dentures nor implants are covered under any circumstances.

Payment for treatment in connection with the temporomandibular joint (jaw joint) and the complex of muscles, nerves and other tissues related to this joint is limited to a lifetime maximum of $1250.

COEHA covers these services when they are prescribed by a COEHA network provider.

Oral chemotherapy will be classified as prescription drugs and handled accordingly. Please refer to your Benefit Section for prescription drug coverage.

There is a one-time limit of $100,000 for each organ per lifetime for all Plans, with the exception of Plan Six, for human kidney, cornea, bone marrow, liver or heart transplants. Transplant services must be preauthorized by COEHA. COEHA does not cover transplant cases which are considered experimental. The $100,000 limit includes the actual hospital stay for the organ transplant and all services incident to the hospital stay, including charge for procurement of the organ from a living donor.

Bone marrow harvesting which may be done as an outpatient prior to the hospital stay for the actual transplant of the marrow, will also count towards the $100,000 limit.

Routine eye examinations are covered through the National Vision Plan for active employees of CSXT. Ophthalmological services which are other than routine are covered through COEHA. Please keep in mind that although your routine eye care may be covered by a National Vision Plan provider, this provider may not be in the COEHA network. If you utilize the services of a National Vision Plan provider for a routine eye exam, and, during the examination, other medical services are indicated to be necessary, please keep in mind that you should seek those services from a COEHA network provider in order for your expense to be handled at your highest level of benefits.

For other members, coverage for ophthalmological services is provided by COEHA.

Mental health services are limited to care by a Psychiatrist, a Licensed Clinical Psychologist, a Licensed or Certified Clinical Psychiatric Social Worker, a Licensed Professional Counselor (LPC) or a Certified Psychiatric Nurse Specialist.

Limit of fifty (50) days per lifetime, payable at 75% of our fee schedule for covered charges

There is a $15 copay for psychotherapy office/outpatient visits

 

Limit of sixty (60) days per lifetime, with no more than thirty (30) days per period of confinement per calendar year, payable at 75% of our fee schedule for covered charges

Inpatient services include a hospital environment, non-hospital unit, partial hospitalization or intensive day treatment program

 

Limit of fifty (50) days per lifetime, payable at 75% of our fee schedule for covered charges

There is a $15 copay for psychotherapy office/outpatient visits

Limit of sixty (60) days per lifetime, with no more than thirty (30) days per period of confinement per calendar year, payable at 75% of our fee schedule for covered charges

Inpatient services include a hospital environment, non-hospital unit, partial hospitalization or intensive day treatment program

 

Inpatient and outpatient services share a lifetime limitation of $30,000. These services are limited to care by a Psychiatrist, a Licensed Clinical Psychologist, a Licensed or Certified Clinical Psychiatric Social Worker, a Licensed Professional Counselor (LPC) or a Certified Psychiatric Nurse Specialist.

COEHA does not cover the cost for services associated with a rehabilitative program when the patient voluntarily discharges himself from such program against medical advice except in cases where the patient re-enters the rehabilitation program within seven (7) days following such voluntary discharge.

Up to a maximum of $600 each calendar year for:

Tests and examinations, including those by an audiologist or a hearing aid dispenser, to diagnose and determine the cause of a hearing loss, and

Charges for a hearing aid necessary to restore lost or help impaired hearing.

Active members must enroll and participate in the CSX Nicotine Cessation Program to be eligible for COEHA coverage. For more information call (904) 359-7500 or email at Smoking_Cessation@CSX.com.

The following will be covered:

Initial and follow-up physician cessation visits less $15 copay

Prescription therapy less drug copay

Prescription drug coverage is provided through our prescription drug program. Under this program you have a prescription drug card for use in local participating pharmacies (retail) for up to a thirty (30) day supply of generic and brand name medications. For a ninety (90) day supply of generic and brand name medications, you may use the mail order program. Generally, it takes 14 days to process your order and ship it to you.

You are not required to use the mail order program to get a 90 day supply of medication. You can also get a 90 day supply through some retail network pharmacies. Some retail pharmacies may agree to accept the mail order copay for a 90 day supply of medication. (All Walmart and Kroger Pharmacies will handle 90 day fills for mail order copays.)

You are responsible for copays on both the retail pharmacy and the mail order pharmacy medications. These copays are not refundable. The copay on name brand medications is higher than the copay on generic medications. If you prefer a brand name medication when a generic is available, you will only be able to purchase a thirty (30) day supply and you will be responsible for the difference between the cost of brand name and the generic medication.

Utilization Management: For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Listed below are the management tools for the utilization management:

Step Therapy: If your drug is classified as a step therapy drug (see left column of table on next page) that means you have to first try another drug (see right column of table on next page). This only applies to members receiving prescriptions for the following drugs for the first time. Step therapy will not apply to members who are currently taking the following drugs, unless you have not had these drugs filled within 120 days. If your physician determines that you are not able to meet the step therapy requirement due to medical necessity reasons, you should have your physician send us a letter outlining the reasons.

Prior Authorization: This means that you have to get approval in advance from us before your drug can be filled.

Quantity Limitations: This means that there is a limit on the amount of the drug that we cover per prescription or a limit on the period of time we cover the drug for quality, safety or utilization reasons.

Diabetic testing supplies (lancets, lancing devices, test strips and control solution) are also covered through our prescription drug program.

You are eligible for a consumer drug card through our prescription drug program which entitles you to group discounts when purchasing drugs through this drug program.

Drugs used for non-FDA approved indications

Prescriptions used for cosmetic purposes

Drugs used for experimental or investigational use

Fertility drugs

Replacement for drugs lost, stolen or destroyed

Any drug item or medication obtainable without a prescription (except Prilosec OTC and Claritin OTC—for which you must have a written prescription from your physician and purchase through the prescription drug program)

Ostomy supplies

Retin-A

Smoking deterrents (except as defined for Active employees)

Injectables other than insulin and Imitrex

Drugs used for the treatment of Opoid dependence

Nutrients and supplements

 

Cases may arise involving medical care that is not specified in these Rules and Regulations. In these cases, contact COEHA for instructions.

Fertility drugs

Fertility procedures

Prescribed drugs or items which can be purchased over-the-counter (with the exception of Prilosec OTC and Claritin OTC— for which you must have a written prescription from your physician and purchase through the prescription drug program)

Retin-A

Custodial or long-term care (except as defined in the Skilled Nursing Facility Care Section)

Half-way house

Glasses or other visual aids

Hearing aids, batteries (except as defined for active members)

Arch supports

Special lift chairs, or separate chair lift for patient owned furniture, geriatric chairs

Water beds

Membership to YMCA or other fitness organization

Special shoes, unless they are attached to braces

Cosmetic/Reconstructive surgery, except for repair or alleviation of damage to the member caused solely by bodily injury while the member is covered and except for breast reconstruction following a mastectomy covered by the Plan

A dependent child’s pregnancy or the resulting childbirth, abortion or miscarriage

Acupuncture

Treatment rendered by a family member (spouse, mother, father, children, sister, brother, in-laws, grandparents, grandchildren, etc.)

In vitro fertilization, embryo transfer procedures, artificial insemination, immunotherapy for treatment of infertility or any other infertility procedures

Sex change surgery

Reversal of sterilization

Vaccines (except for flu and tetanus when medically necessary)

Work hardening

Experimental procedures

Food supplements

Supplemental feeding

Personal convenience items (television, radios, telephone calls, guest trays, private room differential, etc.)

Hospital admissions for diagnostic testing only

Charge for completion of insurance papers, reports, etc.

Evaluation and studies performed in connection with litigation

Instructional booklets or videos

General foot care

Marriage counseling

Sales tax, shipping and handling for medical supplies

Medical services or testing provided a member incident to treatment of a spouse and/or dependent

On-duty injuries that occur while working and receiving compensation for a person, firm, company, or organization other than the CSXT and/or subsidiaries and affiliated companies

Radial Keratotomy; Lasik Surgery, etc.

Physician visits in the home

Pharmacy consultations

Massage by a massage therapist

Treatment outside the United States

 

SUBROGATION OF BENEFITS

By accepting or continuing membership, the member or the member’s legal representative agrees that payment by COEHA for treatment, hospitalization, or any other benefit to or on behalf of the member because of injuries for which some other person, firm, corporation, association, company or government is liable to the member shall entitle COEHA to full rights of subrogation with respect to any claim, suit or cause of action that the member has against such third party, and that any such payment by COEHA is advanced to the member subject to and conditional upon COEHA’s subrogation right. This subrogation right applies to any form of payment to the member by such third party who is liable to the member, whether the payment be received through an insurance policy or contract, or by settlement, judgment or otherwise, and regardless of whether the payment is classified as payment for medical expenses. COEHA has the right to recover from any such third party the full amount of all medical, hospital, drug or other services or benefits paid for or furnished by COEHA to or for the benefit of the member and the member hereby assigns to COEHA such portion of his claim as may be necessary to fully protect the subrogation rights of COEHA. Furthermore, any member who settles with or collects from such third party has an affirmative duty to notify COEHA immediately of the settlement or collection, and of the identity of any person or entity with custody of any portion of the settlement or collection, and has the duty to segregate out and pay to COEHA its full subrogation claim. COEHA is entitled to 100 percent of its subrogation claim, regardless of whether the member obtains full or partial recovery and regardless of any legal fees or other expenses incurred in obtaining the recovery. Any member who settles with or collects from any such third party without protecting the subrogation rights of COEHA and without paying over to COEHA the full amount of such subrogation claim, shall be directly liable to COEHA for the full amount of such subrogation claim, and all such payments shall be made to COEHA, in Clifton Forge, Virginia. If COEHA deems it necessary, the member must execute and deliver to COEHA any written authority or assignment that COEHA may require to assist COEHA in its recovery, but no such written authority or assignment is essential to the full and vested subrogation rights of COEHA nor to the liability of the third party or the member with respect thereto. This subrogation right is automatic, and does not require that COEHA give any notice to the member or the third party in order to protect or preserve its subrogation right. Furthermore, the member is obligated to advise COEHA immediately anytime the member has a claim in which there may be third party liability for the member’s injuries. If COEHA is deprived of its subrogation rights by any act, default, acceptance of payment or release of claims by the member, or by the failure of the member to advise COEHA of the existence of such third party claim, then COEHA may, at its sole option, recover its subrogation claims from the member by suit, or may withhold any further benefits, whether for the injury in question or any other illness or injury that the member would otherwise be entitled to receive, until such member makes good the subrogation claim of COEHA by full payment thereof, including COEHA’s expenses and legal fees if any. This subrogation right shall not apply against any sum received by the member under any policy of hospital or surgical insurance carried by the member. For purposes of this Section, the term "member" includes any person entitled to benefits under COEHA.

Even though some other person, firm, corporation, company, association or government may be at fault, causing injury to the member, payments made by COEHA will still be limited to the member’s available benefits, since this is a limited benefit plan. When COEHA makes recovery of its benefits and expenses paid out, pursuant to its subrogation rights herein set forth, the member’s benefits will be restored to the extent allowed by the net subrogation recovery made by COEHA. It is the express duty and responsibility of the injured member to advise the COEHA in writing at the outset of any injury the member receives under circumstances whereby a third party may be responsible to the member because of the injury and to cooperate fully with COEHA to effect it’s subrogation recovery. When the member settles a third party claim, the settlement with the third party shall automatically terminate and release any claims of the member to further or future benefits under COEHA until the subrogation right of COEHA is satisfied in full. The member must take this fact into consideration in making any settlement with any third party. For purposes of this Section, a final judgment shall be regarded, also, as a settlement of the member’s claim.

The claims procedures described below are effective January 1, 2003 and supercede any conflicting language in these Rules and Regulations.

If a member’s claim under the Plan is wholly or partially denied, he or she will be notified of the decision, after the Plan’s receipt of the claim, within:

(i) 72 hours for an urgent care claim,

(ii) 15 days for a pre-service claim,

(iii) 30 days for a post-service claim, or

(iv) 45 days for a disability claim, as applicable.

 

A determination regarding a request for the Plan to approve an on-going course of treatment will be made in sufficient advance of the proposed reduction or termination of treatment to allow the member to appeal before the benefit is reduced or terminated.

Under special circumstances, the notice period may be extended for an additional:

(i) 48 hours for urgent care claims,

(ii) 24 hours for concurrent care decisions,

(iii) 15 days for pre-service claims,

(iv) 15 days for post-service claims, or

(v) 30 days for disability claims.

 

If an extension is required, the member will be notified of the special circumstances involved and the date by which the Plan Administrator expects to render a final decision.

If the member’s claim is denied, the Plan Administrator will provide the member with a written or electronic notification of an adverse benefit determination. The notice will:

(i) provide the specific reason(s) for the denial,

(ii) refer the member to the pertinent Rules and Regulations provisions on which the denial is based,

(iii) describe any additional information necessary for the member to perfect his or her claim and explain why such information is necessary,

(iv) describe the Plan’s review procedure and time limits applicable to the member’s right to bring a civil action under ERISA section 502(a) following an adverse benefit determination on review,

(v) (A) in the case of an adverse benefit determination, refer the member to the criteria that was relied upon in making the adverse determination, or a statement that certain criteria was relied upon and that a copy of such rule(s) will be provided to the member free of charge upon request, or (B) if the adverse determination is based on a medical necessity, experimental treatment or similar exclusion or limit, provide either an explanation of the clinical judgment for the determination or a statement that such an explanation will be provided free of charge, upon request, and

(vi) in the case of an adverse determination for urgent care, describe the expedited review process applicable to such claims.

 

In the case of an adverse benefit determination involving a claim for urgent care, the information described above may be provided to the member orally within the permitted time frame provided that written or electronic notification is furnished to the member no later than three days after such oral notification.

Appeal of Denied Claims. If the member’s claim is denied, the member will be provided:

(i) a full and fair review with at least 180 days to appeal an adverse benefit determination,

(ii) a review that does not defer to the initial adverse benefit determination, and is conducted by an appropriate named fiduciary who is not involved with the adverse appeal,

(iii) a determination which is based on a medical judgment and for which the named fiduciary has consulted with a health care professional with suitable expertise related to the area of medicine required, and

(iv) the identity of the experts whose advice was solicited on behalf of the Plan, without regard to whether the advice was relied upon in making the benefit determination.

Further, the review must provide that the consulted health care provider was not consulted upon for the adverse determination which is subject to the appeal (nor his or her subordinate) and provide, in the case of an urgent care claim, an expedited review process, to which the member’s request may be submitted orally or in writing. All necessary information may be transmitted between the Plan and the member by telephone, facsimile, or other available method.

The Plan Administrator will notify the member of the Plan’s benefit determination upon review of a denied claim within:

(i) for an urgent care claim, within 72 hours;

(ii) for pre-service claims, within a reasonable period of time appropriate to the medical circumstances. The notification shall be provided no later than 30 days after the Plan’s receipt of the member’s request of a review of an adverse benefit determination;

(iii) for post-service claims, within a reasonable period of time. The notification shall be provided no later than 60 days after the Plan’s receipt of the member’s request of a review of an adverse benefit determination.

The Plan’s decision on review may be either a written or electronic notification. The notification will set forth for the member:

(i) the specific reason for the adverse determination,

(ii) reference the specific Plan provisions on which the benefit determination is based,

(iii) a statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits,

(iv) a statement describing any voluntary appeal procedures offered by the Plan and the member’s right to obtain the information about such procedures, and a statement regarding the member’s right to bring an action under ERISA section 502(a); and

(v) if an internal rule or protocol was relied upon in making the adverse determination, a copy of such rule or protocol shall be provided free of charge to the member upon request,

(vi) if the adverse determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the member’s medical circumstances, or a statement that such explanation will be provided free of charge upon request; and the following statement: "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Dept. of Labor Office and your State insurance regulatory agency."

As a COEHA member, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:

Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.

Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

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.

Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights.

Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage.

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 other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a (pension, welfare) benefit or exercising your rights under ERISA.

If your claim for a (pension, welfare) benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report 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 you up to $110 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. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in 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 any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.