Principal Select Plus Health Insurance Plan

The text presented in this web page is directly from the booklet provided by The Principal Life Insurance Company, which describes the major provisions of the Select Plus Group Health Insurance Policy issued to American Bank. It has been edited only insofar as necessary for it to be viewed on this website.

Topic Guide

Schedule of Benefits	Eligibility	Details of Benefits	Limitations
Deductibles and co-payments	Employee	Covered Expenses	Not-Covered Expenses
Claims	Dependents	Child Health Services	Pre-Existing Conditions
Coverage after Termination	Newborns	Home Health	Coordination of Benefits
Definitions		Hospice

 

This section highlights the benefits provided under Your plan. The purpose is to give you quick access to the information You will most often want to review. Please read the other sections of this booklet for a more detailed explanation of Your benefits and any limitations or restrictions that might apply.

SCHEDULE OF BENEFITS

MEDICAL EXPENSE INSURANCE
If You or one of Your Dependents are sick or injured, the Schedule of Benefits then in force will be payable for Medically Necessary Care.

COMPREHENSIVE MEDICAL

Benefits Payable
Comprehensive Medical benefits payable for confinement, treatment, or service received each Contract Year will be:

70% of each person's Covered Charges in excess of the deductible amount described

below, until Out­of­Pocket Expenses are $2,500 per person or $5,000 per family; and
100% of Covered Charges in excess of the $2,500 per person or $5,000 per family

Out-of-Pocket Expense limits for that Contract Year; except that:
benefits payable for Hospital Confinement Charges will be paid at 80% of the 70% rate shown above, if Preadmission Certification is not obtained within the time limits specified;

and

benefits for Surgery Related Charges will be paid at 50% of the 70% rate shown above, if a second surgical opinion is not obtained as described below; and

benefits for Second Opinion Consultation Charges will be paid at 100% instead of the 70% shown above; and

benefits for allergy testing will be paid at 50% instead of the 70% rate shown above; and

benefits for male or female sterilization will be paid at 50% instead of the 70% rate shown above; and

the benefit reductions/limits determined for Hospital Confinement Charges, Surgery Related Charges, allergy testing and male or female sterilization will not be counted toward satisfaction of the Contract Year Out-of-Pocket Expense limits stated above. Also, these reductions/limits will apply even if the Out-of-Pocket Expense limit has already been satisfied in a Contract Year.

Deductible Amount

Individual. The individual deductible amount for You and for each of Your Dependents each Contract Year will be $500 with respect to all Covered Charges.

Family The maximum combined deductible amount for all persons in the same family (You and Your Dependents) each Contract Year will be $1500 with respect to the combined total of all Covered Charges for You and Your Dependents; but not counting more than $500 of such Covered Charges for each person in the family.

When the family maximum deductible is satisfied, benefits will be payable as if the individual deductible for each person in the family had been satisfied for the Contract Year.

HOW TO BE INSURED - PERSONAL (YOU)

MEDICAL EXPENSE INSURANCE

Eligibility
You will be eligible for coverage if You are the employee of a Participating Employer and insured for benefits provided by the Participating HMO.

Effective Date for Insurance
Your insurance will normally be in effect on the date You are eligible.

Termination

Your insurance will cease on the earliest of:

. the date the Master Group Policy is terminated; or

. the end of the Contract Month for which the last premium payment is made for Your insurance; or

. the date You are no longer eligible for coverage.

HOW TO BE INSURED - DEPENDENTS

MEDICAL EXPENSE INSURANCE

Eligibility
You will be eligible for insurance for Your Dependents on the later of:

· the date You are eligible for personal insurance;

· or the date You first acquire a Dependent.

Effective Date
Insurance for Your Dependents will be in force under the same terms as described earlier for Your insurance, except:

· Insurance will not be effective unless You are covered for personal insurance.

Automatic Coverage for a Newborn Child
If, while Your personal Medical Expense Insurance is in force, You acquire a Dependent child less than 31 days of age, or acquire a newly adopted child of any age, that child will be automatically insured for medical benefits on the date the child becomes a Dependent whether or not You have applied for Dependent insurance. You must apply (and pay any required premium) before the date of the end of a period of 31 days following the event in order to continue the child's insurance beyond that date.

The Period of Limited Activity restrictions and proof of good health requirements will not apply to the newborn child. No premium will be charged for this automatic coverage. However, premium will be charged if insurance is continued beyond the automatic period.

If the newborn child's insurance terminates because You fail to apply (or pay the required premium) within the 31-day period, benefits will be payable only for covered expenses incurred by the child while insurance was in force. The Individual Purchase Rights and the Extended Benefits (after termination of insurance) will not apply to the child

Coverage for a Newborn Child - State Required
Benefits for Newborn Children: A child born to You or one of Your Dependents while this plan is in force, is covered under this plan from the moment of birth for the same benefits and under the same terms and conditions applicable for children. Coverage for such newborn child consists of coverage for injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects, birth abnormalities or premature birth, and usual and customary transportation costs of the newborn child, not to exceed $1,000, to and from the nearest available facility appropriately staffed and equipped to treat the newborn child's condition, when such transportation is certified by the attending Physician as necessary to protect the health and safety of the newborn child.

A newborn child is covered from the moment of birth until We notify You as to the amount of any additional premium for such child's coverage. All liability with respect to such child terminates at the end of 31 days

after notice has been furnished to You, unless on or before the 31st day, the additional premium, if any, has been paid to Us. Your adopted child shall also be automatically insured as stated provided:

· a written agreement to adopt the child was entered into prior to the child's birth; and

· the child is ultimately placed in Your home.

Child Health Care Supervision Services -State Required
Child Health Care Supervision Services are Physician delivered or Physician­supervised services which include as a minimum benefits, coverage for services delivered at the intervals and scope stated below.

Benefits for children will include coverage for Child Health Care Supervision Services from the moment of birth to age 16. Benefits will be paid the same as for any other sickness, except that no deductible will be applied to these charges. Coverage will be limited to one visit to one provider for any or all of the services provided at each visit.

Covered Services: For the purposes of these state­required benefits, Child Health Care Supervision Services will include 18 lifetime visits for each insured Dependent child at approximately the following intervals: birth, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years, 8 years, 10 years, 12 years, 14 years, and 16 years. Services covered at each visit include a history, Physician examination, developmental assessment, anticipatory guidance and appropriate immunizations and laboratory tests, in keeping with prevailing medical standards.

Upon exhaustion of these state-required benefits, benefits will be provided the same as for any other Dependent.

Termination
Insurance for all of Your Dependents will terminate on the date Your personal insurance ceases.

Insurance for any one Dependent will terminate on the last day of the Premium Period in which he or she ceases to be Your Dependent.

However, Medical Expense Insurance will be continued beyond the maximum age for a Dependent child who is incapable of self-support because of Developmental Disability or physical handicap. You must apply for this continuation within 31 days after the child reaches the maximum age.

DESCRIPTION OF BENEFITS - MEDICAL EXPENSE INSURANCE

PAYMENT PROVISIONS

Benefit Qualification
To qualify for payment of the benefits provided by Your plan, You and Your Dependents must:

· be insured under the plan on the date medical treatment or service is received; and

· satisfy the requirements listed in the CLAIM PROCEDURES Section.

Benefits Payable
Benefits payable will be as described in this section, subject to:

· all listed limitations; and

· the terms and conditions of COORDINATION WITH OTHER BENEFITS.

MEDICAL EXPENSE INSURANCE

COMPREHENSIVE MEDICAL

Payment Conditions
If You or one of Your Dependents receives treatment or service for a sickness or injury, We will pay Comprehensive Medical benefits for Covered Charges:

· in excess of the deductible amount; and

· at the payment percentage(s) indicated; and

· to the Maximum Payment Limit: as described in the SCHEDULE OF BENEFITS Section.

Covered Charges Carried Forward

To determine deductible satisfaction, treatment or service received by You or by a Dependent during the last three months of a Contract Year may be counted as if received in either:

· the Contract Year in which actually received; or the next following Contract Year; whichever would result in greater benefit payment

Covered Charges
Covered Charges will be the actual cost charged to You or Your Dependent for:

· Hospital room and board (but not more than the Hospital Room Maximum for each day of confinement in a private room) if the charges are not Weekend Admission Charges;

· Hospital services other than room and board;

· the services of a Physician;

· the services of a graduate registered nurse; the services of certified nurse midwives and midwives licensed pursuant to Florida statutes;

· The services of birth centers licensed pursuant to Florida statutes; the services of licensed physiotherapists;

· surgical dressings, casts, splints, braces, crutches, artificial limbs, and artificial eyes;

· rental of a wheelchair, hospital­type bed, or an artificial respirator;

· anesthesia, and oxygen (including rental of equipment for its administration);

· x­ray and laboratory examinations;

· x­ray, radium, and radioactive isotope therapy;

· transportation by ambulance provided by a Hospital or a licensed service to and from a local Hospital (or to and from the nearest Hospital equipped to furnish needed treatment not available in a local Hospital);

· Dental Services to repair damage to the jaw and natural teeth, if the damage is the direct result of an accident (but did not result from chewing) and if the Dental Services are completed within six months after the accident;

· Home Health Care as described below;

· convalescent care in a Nursing Facility as described Hospice Care as described below; but only to the extent that the actual charges do not exceed Prevailing Charges.

Home Health Care
Comprehensive Medical Covered Charges will include charges by a Home Health Care Agency for:

· part­time or intermittent home nursing care by or under the supervision of a registered nurse;

· part­time or intermittent home care by a Home Health Aide;

· physical, occupational, or speech therapy;

· drugs and medicines requiring a Physician's prescription and other supplies prescribed by the attending Physician, if the cost of these items would have been Covered Charges had You or Your Dependent remained Hospital confined; but only to the extent that such services and supplies are provided under the terms of a Home Health Care Plan, and then only if a Physician certifies that confinement in a Hospital or Nursing Facility would be necessary in the absence of Home Health Care

The general Comprehensive Medical limitations listed in this section will apply to Home Health Care. In addition, Comprehensive Medical Covered Charges will not include charges for:

· services or supplies not included in the Home Health Care Plan; or
· the services of any person who normally lives in Your home or Your Dependent's home; or
· custodial care (services or supplies provided to assist a person in daily living­­e.g., meals and personal grooming); or
· transportation services; or

· more than 20 Home Health Care visits in a Contract Year. For this purpose, one visit will be counted for up to four hours of service (in a 24­hour period) by a Home Health Aide and one visit will be counted for each visit by any other person. In addition, if other Home Health Care is included under the terms described in the HMO Membership Services Contract and Membership Handbook, the 20 visit limit listed above will be reduced by the number of visits provided by that other Home Health Care each Contract Year.

Hospice Care
Comprehensive Medical Covered Charges will include charges for Hospice Care Services provided by a Hospice, Hospice Care Team, Hospital, Home Health Care Agency, or Nursing Facility for:
· any sick or injured individual (You or Your Dependent) who, in the opinion of the attending Physician, has no reasonable prospect of cure and is expected to live no longer than six months; and

· the family (You or Your Dependents) of any such individual; but only to the extent that such Hospice Care Services are provided under the terms of a Hospice Care Program and are billed through the Hospice that manages that program

Hospice Care Services consist of:
· inpatient and outpatient care, home care, nursing care, counseling, and other supportive services and supplies provided to meet the physical, psychological, spiritual, and social needs of the dying individual; and
· drugs and medicines requiring a Physician's prescription and other supplies prescribed for the dying individual by any Physician who is a part of the Hospice Care Team; and
· instructions for care of the patient, counseling, and other supportive services for the family of the dying individual.

The general Comprehensive Medical limitations listed in this section will apply to Hospice Care. In addition, Comprehensive Medical Covered Charges will not include Hospice Care charges that:
· are for Hospice Care Services not included in the attending Physician's recommended plan of treatment and not approved by Us; or
· are for transportation services; or
· are for custodial care (services or supplies provided to assist a person in daily living­­e.g., meals and personal grooming); or
· are for Hospice Care Services provided at a time other than during an Episode of Hospice Care; or
· are for Hospice Care Services in Your or Your Dependent's home outside the Service Area; or are for financial and legal counseling or

· are for any service for which the Hospice does not customarily charge the dying individual or his or her family; or
· are for volunteer or spiritual counseling.

Nursing Facility Confinement
Comprehensive Medical Covered Charges will include charges by a Nursing Facility for room, board, and other services required for treatment, provided that:
· a Physician certifies hospitalization would be necessary in the absence of Nursing Facility Confinement; and
· charges for more than 100 days of confinement in a Contract Year will not be Covered Charges; and
· if other Nursing Facility Confinement coverage is included under the terms described in the HMO Membership Services Contract and Membership Handbook, and Schedule of Benefits issued to You, the 100 day limit listed above will be reduced by the number of days of such other coverage provided in a Contract Year; and
· charges for confinement after the date the attending Physician stops treatment or withdraws certification will not be Covered Charges

Limitations

Comprehensive Medical benefits will not be paid for:

· confinement, treatment, or service that is not for Medically Necessary Care; or

· any part of a charge for confinement, treatment, or service that exceeds Prevailing Charges;

or
· the services of any person in Your Immediate Family or any person in Your Dependent's Immediate Family; or
· Dental Services and materials (except as described under Covered Charges); or

· eye examinations for the correction of vision or the fitting of glasses; or

· vision materials, (frames or lenses), except as necessary for the first pair of corrective lenses following cataract surgery performed while You or Your Dependent is insured under this plan; or
· hearing aids; or

· acupuncture treatment; or
drugs or medicines (whether or not they require a Physician's prescription); or

· nutritional supplements, or special diets (whether or not they require a Physician's prescription); or

· comfort or convenience services and supplies; or

· crowns, bridges, dentures, or other dental prosthetic devices, dental restorative care, periodontal care, treatment for temporomandibular joint dysfunction (TMJ) unless Medically

· orthognathic surgery, including Hospital and professional services and supplies associated with such care; preventive dental services; or

· confinement, treatment, or service for Cosmetic Surgery; or

· confinement, treatment, or service for educational or training problems, learning disorders, marital counseling, or social counseling (except as described under Hospice Care); or confinement, treatment, or service for which You or Your Dependent has no financial liability or that would be provided at no charge in the absence of insurance; or

· confinement, treatment, or service that is paid for or furnished by the United States Government or one of its agencies, or state and other laws (except as required under Medicaid provisions or Federal law); or

· confinement, treatment, or service that results from war or act of war; or

· confinement, treatment, or service to which a contributing cause was the commission of a felony or misdemeanor of which You or Your Dependent is convicted or to which a contributing cause was You or Your Dependent's engagement in an illegal activity or if the condition was self-inflicted; or

· confinement, treatment, or service required due to accidents when You or Your Dependent is convicted of driving while impaired; or

· organ transplants not approved by the Food and Drug Administration or within the definition

of clinically accepted medical practice; services relating to an excluded transplant, which would not be performed but for the transplant; and medical and surgical complications resulting from non­covered transplants; the cost of any care arising from an organ donation by You or Your Dependent when the recipient is not You or Your Dependent; donor and recipient transportation costs, whether or not You or Your Dependent is the donor; or

· confinement, treatment, service or materials for Kerato­Refractive Eye Surgery (surgery to improve nearsightedness, farsightedness, and/or astigmatism by changing the shape of the cornea, including but not limited to radial keratotomy and keratomileusis surgery), unless corrected vision in the operated eye is worse than 20/70 prior to surgery and can be corrected to 20/70 or better only by such surgery; or

· eye exercises; or

· confinement, treatment, or service covered by medical expense insurance issued under the Individual Purchase Rights: or

· confinement, treatment, or service that results from a sickness or an injury arising out of or in the course of any employment for wage or profit; or

· confinement, treatment, or service that is subject to the Pre­Existing Conditions Restrictions Section; or

· preventative health services such as well baby care, routine immunizations and inoculations given as preventive measures against disease, routine physical examinations, and

check­ups; gynecological examinations; physical examinations for employment, school, camp, sports, licensing, insurance, adoption or marriage, or other examinations ordered by a third party; or

· confinement, treatment, or service due to a mental or nervous disorder, alcoholism, or drug abuse; or

· confinement, treatment, or service for foot care with respect to: corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet, clipping of the nails, casting for orthotics, or any appliance (including orthotics); or

· services provided in an emergency facility for nonmedical emergencies; or

· health education services; or

· unless mandated by state law, treatment or service provided by a chiropractor; or

· treatment or service provided by a podiatrist; or

· housekeeping, homemaker services, and room and board as part of home health services;

or

· except as provided under Covered Charges: ambulance transportation due to the absence

of other transportation on the part of You or Your Dependent; nonmedical emergency ambulance services; charges for transportation by air or sea ambulance in excess of ground ambulance transportation costs, except for newborn Dependent children; travel other than ground ambulance travel for a Medical Emergency (whether or not prescribed by a Physician); or

· custodial care, nursing home care, rest cures and domiciliary care. Care is considered custodial when it is primarily for the purpose of meeting personal needs. For example, custodial care includes help in walking, getting in and out of bed, bathing, dressing, shopping, eating and meal preparation, general household services, taking medicine, or other home services furnished mainly to assist people in meeting personal, family or domestic needs to include extraordinary personal needs created by the illness of a family Dependent. Custodial care is excluded regardless of location or setting; or

· unless mandated by state law, the following prosthetic devices and services: dentures, hearing aids, contact lenses) non rigid appliances and supplies such as elastic stocking, garter belts, arch supports, corsets and corrective orthopedic shoes; orthotic devices; sunglasses; clothing; breast pumps; orthodontic braces; needles and syringes; contraceptive devices; items deemed to be experimental or research devices in Our opinion and based upon standards developed by the AMA and or FDA; devices designed exclusively to remedy sexual dysfunction except when authorized by a Physician to repair the physical functioning of a body part as a result of a functional disorder or an accidental injury occurring while the individual is insured under this plan; repair replacement, orroutine periodic maintenance of prosthetic medical appliances; and all other devices deemed not to be Medically Necessary Care by Us, are excluded; or

· durable medical equipment that does not serve a medical purpose, cannot withstand repeated use, and is inappropriate for use in You or Your Dependent's home; equipment that is generally not useful to a person in the absence of illness, injury or disease; deluxe equipment such as motor driven wheelchairs and beds, except when such deluxe features are necessary for the effective treatment of You or Your Dependent's condition in order for the individual to operate the equipment himself or herself; items not primarily medical in nature or for Your or Your Dependent's comfort and convenience such as bedboards, bathtub lifts, overbed tables, adjust-a-bed, telephone arms, air conditioners, air purifiers; replacement, repair, or routine periodic maintenance of purchased durable medical equipment; Physician's equipment such as stethoscope, disposable bags and elastic stockings; exercise and hygienic equipment such as exercise cycle, Moore wheel, Bidet toilet seats and bath tub seats; self-help devices (not primarily medical in nature) such as sauna baths and elevators; corrective orthopedic or orthotic shoes and arch supports; and research equipment or items deemed to be experimental by Us; or

· whole blood, blood products or packed cells, if replaced by donor and if replaced by an agency or organization without charge; blood storage; or

· prescription drugs, medicines, supplies or devices directly or indirectly related to birth control; any medical service, prescription drugs, medicine, supplies or procedure directly or indirectly related to the following: childbirth classes, reversal of voluntarily induced sterilization, services related to sex transformation, artificial insemination with donor semen,

in-vitro fertilization and embryo transplant procedure, drug therapy for infertility, and home delivery for childbirth; Pergonal, Clomid and other drugs meant to serve the same purpose as Pergonal and Clomid; infertility services, maternity services provided outside the Service Area within three weeks of the estimated date of delivery unless prior authorization has been given in writing by the medical director or designee; or

· acupuncture, biofeedback, hypnotherapy, sleep therapy, weight reduction therapy, vocational therapy, marriage and sex counseling, behavior training, conduct disorders and related family counseling; and remedial education, including treatment of learning disabilities, attention deficit disorders or minimal

· brain dysfunction; therapy through behavior modifications; other therapy considered long-term (long-term therapy is defined as being more than 60 days in duration from the onset of therapy); educational and other non-medical treatments for mental retardation; or

· surgical procedures and associated care for the treatment of obesity, such as intestinal bypass surgery, stomach stapling, balloon dilation, wiring of the jaw, procedures or similar nature, as well as the complications of such procedures; surgery or hospitalization for the purpose of weight reduction; diet programs such as Optifast, Nutri­System and other similar diet programs; or

· genetic counseling and genetic studies which are not needed for diagnosis or treatment of genetic abnormalities; growth hormones which are not for Medically Necessary Care; or

· care for military service­connected conditions or disabilities to which You or Your Dependent is legally entitled and for which facilities are reasonably available; or

· charges incurred by You or Your Dependent for not keeping or canceling an appointment.

MEDICAL EXPENSE INSURANCE

PRE-EXISTING CONDITIONS RESTRICTIONS

A Pre-Existing Condition is a sickness or injury for which a person was confined or received treatment or service in the 90 day period before becoming covered for Comprehensive Medical Expense Insurance.

No benefits will be payable for a Pre­Existing Condition until the earliest of:
· the date ending 90 consecutive days during which no confinement has existed or no treatment or service has been received for the Pre­Existing Condition; or
· the date that a person has been insured for Comprehensive Medical Expense Insurance for at least 12 consecutive months and You are Actively at Work, or a Dependent is not in a Period of Limited Activity;
· and then benefits will be payable only with respect to confinement occurring after that date or to treatment or service received after that date.

However, for persons insured on the date they become a Subscriber, the Pre­Existing Conditions Restrictions will not apply to the first $2,000 of Covered Charges in the first 12 months that insurance is in force.

When insurance under this plan replaces coverage under a Prior Plan, continuous coverage under this plan and/or under the Prior Plan may be applied to satisfy any required time period described in this provision.

MEDICAL EXPENSE INSURANCE

EXTENDED BENEFITS

(after termination of Insurance)

If Medical Expense Insurance under Your plan ceases and If You or Your Dependents qualify, We will pay Comprehensive Medical benefits for confinements, treatment, or services received within 3 months after termination of insurance to the extent that these benefits would have been paid had insurance remained in force.

You will qualify if You are Disabled from the date insurance ceases to the date of confinement, treatment or service. A Dependent (or You, if You are retired) will qualify K in a Period of Limited Activity from the date insurance ceases to the date of confinement, treatment, or service. However, extended benefits will be payable only for treatment or service received for the disabling sickness or injury that was diagnosed by a Physician before the date coverage terminated.

If termination of insurance is due to termination of the group policy, these extended benefits provisions will be payable for up to 12 months, subject to the extended benefits provisions specified above. These extended benefits are payable whether Or not the group plan is replaced.

Exception: Extended Benefits are payable without the Disability and Period of Limited Activity requirements described above, if:
· insurance ceases due to termination of Your plan; and You or Your Dependent is pregnant on the date the plan terminates; and
· the pregnancy began while You or Your Dependent was insured under the plans; and benefits would have been payable for the pregnancy had insurance remained in force.
The extension of benefits under this exception is for the period of the pregnancy.

These extended benefits will not apply to insurance which terminates because You or Your Dependent transfer to an HMO.

MEDICAL EXPENSE INSURANCE

INDIVIDUAL PURCHASE RIGHTS

You may buy other insurance from Us when Your insurance under this plan terminates if You qualify and make timely application. Proof of good health will not be required. The other insurance will be on one of the forms We then issue to persons who apply for individual purchase.

Normal pregnancy benefits are provided under the medical insurance purchased under these individual purchase rights. This will also include benefits for complications of pregnancy. Benefits are paid the same as benefits for any other sickness.

To qualify for the individual purchase:
· Your medical insurance terminates prior to the date the Group Policy is terminated; and

· You move out of the Service Area.

The persons to be covered under any medical expense insurance purchased will be You and all of Your Dependents who are covered under the Group Policy on the date insurance is terminated.

You will not be eligible for individual purchase if the purchased insurance, together with any similar benefits for which the person is covered under another plan or program, will result in over insurance or duplication of benefits based on Our standards for over insurance.

Notice of the individual purchase right must be given to You before insurance under the group policy terminates, or as soon as reasonably possible thereafter.

You must apply for individual purchase and pay the first premium to Us within 31 days after Your insurance under the group plan is terminated. The premium you pay will be at Our normal rate for Your age and for the risk class to which You belong. The other medical expense insurance will then be in force on the day after that termination date.

Your spouse or child may buy other medical expense insurance in the same manner described above, if insurance ceases for Your Dependent solely because he/or she ceases to eligible as a Dependent.

COORDINATION WITH OTHER BENEFITS

MEDICAL EXPENSE INSURANCE

Intent
The intent of Coordination with Other Benefits is to provide that the sum of benefits paid under This Plan plus benefits paid under all other Plans will not exceed the actual cost charged for a treatment or service.

Definitions

As used in this section, the term This Plan will mean the medical expense benefits described in this booklet policy.

The term Plan will mean This Plan and any medical expense benefits provided under:
· any insured or noninsured group, service, prepayment, or other program arranged through an employer, trustee, union, or association; and
· any program required or established by state or Federal law (including Medicare Parts A and B); and
· any program sponsored by or arranged through a school or other educational agency;
· the first party medical expense provisions of any automobile policy issued under a no-fault insurance statute, including the self­insured equivalent of any minimum benefits required by law;
except that the term Plan will not include benefits provided under a student accident policy for grade school through high school students, nor will the term Plan include benefits provided under a state medical assistance program where eligibility is based on financial need.

Also, the term Plan will apply separately to those parts of any program that contain provisions for coordination of benefits with other Plans and separately to those parts of any program which do not contain such provisions.

The term Allowable Expense will mean all Prevailing Charges for Medically Necessary Care for treatment or service when at least a part of those charges are covered under at least one of the Plans then in force for the person for whom benefits are claimed. However, the difference between the cost of a private room and the cost of a semiprivate room will be an Allowable Expense only when confinement in a private room is Medically Necessary Care. If a Plan provides benefits in a form other than cash payments, the cash value of those benefits will be both an Allowable Expense and a benefit paid.

An Allowable Expense to a secondary Plan (a Plan which determines its benefits after another Plan has determined its benefits) will include the value or amount of any deductible amount or coinsurance percentage or amount of otherwise Allowable Expense which was not paid by the primary or first paying plan.

The term Claim Determination Period will mean the part of a calendar year during which You or a Dependent would receive benefit payments under this policy if this section were not in force.

Effect on Benefits

Benefits otherwise payable under This Plan for Allowable Expenses during a Claim Determination Period may be reduced H:

· benefits are payable under any other Plan for the same Allowable Expenses; and

· the rules listed below provide that benefits payable under the other Plan are to be determined before the benefits payable under this Plan.

The reduction will be the amount needed to provide that the sum of payments under This Plan plus benefits payable under the other Plan(s) is not more than the total of Allowable Expenses. Each benefit that would be payable in the absence of this section will be reduced proportionately; such reduced amount will be charged against any applicable benefit limit of This Plan.

For this purpose, benefits payable under other Plans will include the benefits that would have been paid had claim been made for them. Also, for any person covered by Medicare Part A, benefits payable will include benefits provided by Medicare Part B. whether or not the Person is covered under that Part B.

Order of Benefit Determination

Except as described under Medicare Exception. below, the benefits payable of a Plan that does not have a coordination of benefits provision similar to the provision described in this section will be determined before the benefits payable of a Plan that does have such a provision. In all other instances, the order of determination will be:

Nondependent/Dependent. The benefits of a Plan which covers the person for whom benefits are claimed as a member or subscriber (that is, other than as a Dependent) are determined before the benefits of a Plan which covers the person as a Dependent.

Dependent Child -Parents Not Separated or Divorced. When This Plan and another Plan cover the same child as a Dependent of deferent persons called parents, the benefits of the Plan of the parent whose birthday falls earlier in a calendar year are determined before those of the Plan of the parent whose birthday falls later in that year; but if both parents have the same birthday, the benefits of the Plan which covered

the parent longer are determined before those of the Plan which covered the other parent for a shorter period of time.

However, if another Plan does not have the rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the

Dependent Child - Separated or Divorced Parents. If two or more Plans cover a Dependent child of divorced or separated parents, benefits for the child are determined in this order:

· first, the Plan of the parent with custody of the child;

· then, the Plan of the spouse of the parent with custody of the child; and

· finally, the Plan of the parent not having custody of the child

However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Determination Period or Plan year during which any benefits are actually paid or provided before the entity has that actual knowledge.

Active/lnactive Employee. The benefits of a Plan which covers a person as an employee who is neither laidoff nor retired, or as that employee's Dependent, are determined before the benefits of a Plan which covers that person as a laid-off or retired employee or as that employee's Dependent. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule will not apply.

Longer/Shorter Length of Coverage. If none of the above rules determine the order of benefits, the benefits of the Plan which covered an employee, member or subscriber longer are determined before those of the Plan which covered that person for the shorter time.

Medicare Exception
Unless otherwise required by Federal law, benefits payable under Medicare will be determined before the benefits payable under This Plan.

Exchange of Information
Any person who claims benefits under This Plan must, upon request, provide all information We believe is needed to coordinate benefits.

In addition, all information We believe is needed to coordinate benefits may be exchanged with other companies, organizations, or persons.

Facility of Payment
We may reimburse any other Plan if:

· benefits were paid by that other Plan; but
· should have been paid under This Plan in accordance with this section.

In such instances, the reimbursement amounts will be considered benefits paid under This Plan and, to the extent of those amounts, will discharge Us from liability.

Right of Recovery
If it is determined that benefits paid under This Plan should have been paid by any other Plan, We will have the right to recover those payments from:
* the person to or for whom the benefits were paid; and/or the other companies or organizations liable for the benefit payments.

CLAIM PROCEDURES

Proof of Loss
Completed claim forms and other information needed to prove loss should be filed promptly. Proof of loss should be sent to Us within 90 days after the date of loss. Proof of loss sent later will be accepted only if there is reasonable cause for the delay. Benefits will not be reduced or denied due to a delay in filing proof of loss K it was filed as soon as reasonably possible. We will not accept a filing of proof of loss more than a year after it is due as described above. An exception will be made only if you were not competent to make claim.

Facility of Payment
We will normally pay all benefits to You. However, if the claimed benefits result from a Dependent's sickness or injury. We may make payment to the Dependent. Also, in the special instances listed below, payment will be as indicated. All payments so made will discharge Us to the full extent of those payments:

* If payment amounts remain due upon Your death, those amount may, at Our option, be paid to Your estate, spouse, child, or parent.

* If We believe a person is not legally able to give a valid receipt for a benefit payment, and no guardian has been appointed, We may pay whoever has assumed the care and support of the person.

Payment, Denial, and Review
Most claims will be processed and paid within a few days after We receive completed proof of loss. Further, if a claim cannot be paid, We will promptly explain why.

If a claimant disagrees with a claim denial, a review may be requested. The request and all added facts should be given to Your local claim office. We will then conduct the review. The claimant will be advised of the final decision and the reasons.

Legal Action
Legal action with respect to a claim may not be started earlier than 60 days after proof of loss is filed. Further, no legal action may be started later than three years after proof is required to be filed.

Time Limits
All time limits in this section will be extended to meet any minimums required by law.

 

DEFINITIONS

Several words and phrases used to describe your plan are capitalized whenever they are used in this booklet-policy. These words and phrases have special meanings as explained in this section.

Active Work; Actively at Work means the active performance of all of a Subscriber's normal job duties at the Participating Employer's usual place or places of business.

Company means Principal Mutual Life Insurance Company.

Contract Month means calendar month.

Contract Year means calendar year.

Cosmetic Surgery means surgery to change:
· the texture or appearance of the skin; or

· the relative size or position of any part of the body; when such surgery is performed primarily for psychological purposes and is not needed to correct or improve a bodily function.

Dental Services mean any confinement, treatment, or service, including periodontal and osseous surgery, provided to diagnose, prevent, or correct:
· malocclusion (abnormal positioning of the teeth and/or relationship of the teeth); and
· craniomandibular or temporomandibular joint disorders; and all other ailments or defects of the teeth and supporting tissue.

Dependent means: your spouse, if that spouse is not in the Armed Forces of any country; and is not insured as a Subscriber under this plan; and is insured for benefits provided directly by a Participating HMO; and your natural or adopted child, if that child:

· is not married; and

· is not in the Armed Forces of any country; and

· is not insured as a Subscriber under this plan; and

is less than 19 years of age; and

· is insured for benefits provided directly by a Participating HMO; and

resides in the Service Area; and

· your stepchild, if that child:

· meets all of the requirements listed above for a natural or adopted child; and lives with you; and

· receives principal support from you; and

· an unmarried child who is not an Immediate Family member of yours, but is residing in your home in an ongoing parent/child relationship which is intended to continue to adulthood whereby you are the legal guardian; and your child age 19 but less than 24 years of age who otherwise qualifies as a natural or legally adopted child, a stepchild, or unmarried child as described above, if that child receives principal support from you and attends school on a full-time basis. For this purpose, school vacation will be considered a part of full­time attendance; and

· your child age 19 but less than 24 years of age who otherwise qualifies as a natural or legally adopted child, a stepchild, or unmarried child as described above, if that child receives principal support from you, is physically or Developmentally Disabled and has been covered continuously since his/her 19th birthday for benefits provided directly by a Participating HMO.

A Dependent shall also include the child of Your insured Dependent son or daughter, if the child meets the requirements described for a natural or legally adopted child.

Developmental Disability means a child's substantial handicap which:
· results from mental retardation, cerebral palsy, epilepsy, or other neurological disorder; and

· is diagnosed by a Physician as a permanent or long term continuing condition.

Home Health Aide means a person, other than a registered nurse, who provides therapeutic care under the direction of a registered nurse and the supervision of a Home Health Care Agency.

Home Health Care Agency means a Hospital, agency, or other service that is certified by the proper authority of the state in which it is located to provide Home Health Care.

Home Health Care Plan means a program of home care that:

· is required as a result of a sickness or injury; and

· follows a period of Hospital confinement; and

· is the result of the sickness or injury that was the cause of the Hospital confinement; and

· is established in writing by the attending Physician within seven days after Hospital confinement ends; and

· is certified by the attending Physician as a replacement for Hospital confinement that would otherwise be necessary.

Hospice means a facility, agency, or service that:

· is licensed, accredited, or approved by the proper regulatory authority to establish and manage Hospice Care Programs; and

· arranges, coordinates, and/or provides Hospice Care Services for dying individuals and their families; and

· maintains records of Hospice Care Services provided and bills for such services on a consolidated basis.

Hospice Care Program means a program:
· managed by a Hospice; and

· established jointly by a Hospice, a Hospice Care Team, and an attending Physician; to meet the special physical, psychological, and spiritual needs of terminally ill individuals and their families.

Hospice Care Team means a group that provides coordinated Hospice Care Services and normally includes:

· a Physician;

· a patient care coordinator (Physician or nurse who serves as an intermediary between the program and the attending Physician);

· a nurse

a mental health specialist;

a social worker;

· a chaplain; and

· lay volunteers.

Hospital means an institution that is:
· licensed as a hospital by the proper authority of the state in which it is located; and is recognized as a Hospitals by the Joint Commission on Accreditation of Hospitals;but not including any institution, or part thereof, that is used primarily as a clinic, convalescent home, rest home, home for the aged, nursing home, custodial care facility, or training center.

Hospital Confinement Charges mean Covered Charges by a Hospital for room, board, and other usual services and by a Physician for pathology, radiology, or the administration of anesthesia while a person is confined in a Hospital. The charges must be incurred while the person is confined for a period of at least 15 consecutive hours ( for any cause)

Hospital Room Maximum means Covered Charges by a Hospital for room and board while confined in a private room up to:

* the Hospital's most frequent semiprivate room rate, if the Hospital has semiprivate rooms; or the Hospital's most frequent private room rate, if the Hospital has no semiprivate rooms.

Immediate Family means an insured person's mother, father, sister, brother, spouse, or children).

Medical Emergency means the sudden and acute onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in:
* permanently placing you or your Dependent's life in jeopardy; and/or

* serious impairment to bodily function; and/or

* serious and permanent dysfunction to any bodily organ or part; and/or

* other serious medical consequences.

Medically Necessary Care means any service or supply for prevention, diagnosis, or treatment that is prescribed by a Physician and considered by Us to be:
· necessary and appropriate; and

· nonexperimental or non-investigational and not in conflict with accepted medical or surgical practices prevailing in the geographic locality where, and at the time when, the service or supply is ordered.

Nursing Facility means an institution (including an intermediate care facility as defined in the lowa Code)or distinct part thereof, that is licensed to provide skilled nursing care for persons recovering from sickness or injury and:

· is supervised on a full-time basis by a Physician or a graduate registered nurse; and has transfer arrangements with one or more Hospitals, a utilization review plan, and operating policies developed and monitored by a professional group that includes at least one Physician; and

· has an existing contract for the services of a Physician, maintains daily records on each patient and is equipped to dispense and administer drugs; and provides 24-hour nursing care and other medical treatment.

Not included are rest homes, homes for the aged, or places for treatment of mental disease, drug addiction, or alcoholism.

Participating Employer means any employer who, upon subscription to this trust, is accepted as a Participating Employer under this plan.

Participating HMO means any Health Maintenance Organization that:

· is licensed or certified to provide prepaid health care services by the proper authority of the state in which it is located; and

· is listed below:

Period of Limited Activity means any period of time during which a person:
· is confined in a Hospital or Nursing Facility; or

· whether confined or not, s unable to carry on the regular and usual activities of a healthy person of the same age and sex.

Physician means a licensed Doctor of Medicine or Osteopathy; and any other licensed health care practitioner that state law requires be recognized as a physician under Your benefit plan.

Policyholder means the Trustees to whom the master policy is issued (First interstate Bank of Des Moines, N.A. Trustee of the Principal Health Care Group Trust).

Preadmission Certification means approval by Us of a Physician's report of:
· a Hospital admission for a Medical Emergency; or

· for any other Hospital admission, a proposed Hospital admission.

The report may be either verbal or written, It must include:

· the reason for the Hospital admission and confinement; and

· the significantly symptoms, physical finding, and treatment plan; and

· the procedures performed or to be performed during the Hospital confinement; and

. the estimated length of Hospital confinement.

If must be provided to Us:

· prior to a proposed Hospital admission (for other than a Medical Emergency); or

· within 48 hours following a Hospital admission for a Medical Emergency or as soon as reasonably possible.

In addition, a Preadmission Certification may be extended if additional Hospital confinement is necessary. An additional Physician's report must be furnished to and approved by Us.

The additional report must include:

· the reasons for requesting additional Hospital confinement; and

· the procedures to be performed during the confinement; and

· the estimated length of the additional Hospital confinement.

It must be provided to Us prior to the expiration of the Preadmission Certification currently in force.

Prevailing Charge means the amounts, as determined by Us, that most Physicians or other health care providers charge for the same or a similar treatment or service in the cost area (or comparable cost area) where the treatment or service is provided.

Prior Plan means any group medical expense plan of the Participating Employer that is terminated on the day before the date the employer becomes a Participating Employer under this plan.

Second Opinion Consultation Charges mean Covered Charges for:

· consultation with a Second Opinion Physician to obtain a second (and third, if necessary) opinion prior to the performance of surgery for which a second opinion is recommended; and

· necessary diagnostic x­ray and laboratory examinations performed in connection with such consultation.

Second Opinion Physician means a Physician who:
· is an appropriate specialist for the particular surgery recommended; and is not a partner or associate of the Physician who recommended surgery.

Service Area means the geographic area within which a Participating HMO is licensed or certified to provide the prepaid health care services.

Surgery Related Charges mean Covered Charges by:
a Physician for performing a surgical operation (including charges for a surgical suite, if any) ; and

· a Physician for administration of anesthesia required for the purpose of surgery; and

· a Hospital or other licensed health care provider for room and board and other services related to a surgical operation.

We, Us, and Our mean Principal Mutual Life Insurance Company, Des Moines, Iowa.

You, Your means the person who is an employee of a Participating Employer, insured for benefits provided directly by the Participating HMO and named as the Subscriber on the Enrollment Form.

 

GH 101 (PHC)