Medical Expense Benefits

All charges allowable under your Medical Expense Benefits are based on usual, reasonable and customary charges as defined in the "Definitions" section. Only charges for medically necessary treatment or diagnosis of an illness or injury are considered allowable.

Your Medical Expenses Benefits Lifetime Maximum is $2,000,000 per person.

Note: Payment for certain types of services is limited. Please refer to the Schedule of Benefits, Limitations and other applicable provisions of the Plan.

RESTORATION OF BENEFITS
When the Plan has paid $2 million for an individual's aggregate medical expenses for services subject to the Plan's $2 million lifetime limit, the Plan shall make no further payments except that:

a) Payments for eligible services not subject to the cap shall continue subject to all other plan limitations, and

b) An annual restoration of $10,000 shall apply for eligible services otherwise subject to the $2 million cap.

THE DEDUCTIBLE
Before the Plan will pay, the Deductible amount shown in the Schedule of Benefits must be met. The Deductible must be satisfied only one time each calendar year regardless of the illness or injury, type of services or treatment provided.

If three or more family members incur covered expenses in any calendar year which causes the total family deductible amounts to reach the Deductible "Per Family" shown in the Schedule of Benefits, the Deductible will be considered to be met for all family members for all other covered expenses incurred in that calendar year.

CO-INSURANCE/CO-PAYMENT
After the deductible is satisfied, the Member is responsible for 20% coinsurance of most expenses. Services of Preferred Providers are subject to the co-payment but not the deductible or coinsurance.

INDEXING
For each calendar year, January through December, the deductibles and maximum out of pocket amounts shall be subject to indexed increases or decreases.

The index shall be determined by the ratio of the prior years per capita aggregate expense as compared to the per capita aggregate expense of two years prior.
The deductibles and out-of-pocket maximums of the Consortium shall not exceed the deductibles and out-of-pocket maximums of the Empire Plan.

MEDICAL EXPENSE BENEFITS
1. a. Private Proprietary Hospitals for the treatment of mental and nervous conditions and chemical dependence:

i. Room and board accommodations. Covered charges for any day on which the patient occupies a private room will not exceed the hospital's most common semi-private room rate; limited to the number of days specified in the Schedule of Benefits.

ii. Special hospital services required for medical care or treatment rendered by the hospital staff or employees to an in-patient and billed by the hospital.

iii. If an in-patient admission would otherwise be necessary for the treatment of a patient’s mental or nervous disorder and the Plan's Managed Benefits Program Administrator, patient and patient’s physician agree that an intensive outpatient day therapy program would provide the appropriate level of treatment, then such treatment may be authorized. Each day of such treatment shall reduce the remaining days available under the in-patient psychiatric benefit by one (1) day.

b. Charges by Other Approved Facilities for the Treatment of Chemical dependence: The term "Approved Facility for the Treatment of Chemical dependence" means a facility or hospital certified by the State of New York or approved by the Joint Commission on Accreditation of Hospitals.

i. Room and board accommodations and services received for the treatment of chemical dependence while confined in an Approved Facility for the Treatment of Chemical dependence as defined above. The maximum duration of coverage while confined in an Approved Facility for the Treatment of Chemical dependence is specified in the Schedule of Benefits.

ii. Out-patient services rendered by the staff of an Approved Facility for the Treatment of Chemical dependence and billed by such facility. Treatment received on an out-patient basis shall be limited as specified in the Schedule of Benefits.

2. Medical or surgical services by a "Physician," including second surgical opinions.

3. The following. medical services and supplies that are recommended by a Physician, and are medically necessary:

a. anesthesia, including the charge for its administration;

b. diagnostic laboratory and X-ray services;

C. oxygen and/or rental of equipment required for its administration;

d. X-ray, radium and radioactive isotope therapy;

e. braces, crutches, casts and splints;

f. blood or other fluids actually injected into the circulatory system;

4. If a Covered Person incurs medically necessary expenses which are recommended and approved by a Physician for private-duty nursing services outside of a hospital, the Plan shall pay for such private-duty nursing charges not exceeding the maximum amount specified in the Schedule of Benefits for such charges. Private-duty nursing services shall be payable only if provided by a Registered Nurse (R.N.). If the services of an R.N. are not available, a Licensed Vocational Nurse (L.V.N.) or a Licensed Practical Nurse (L.P.N.) or a Registered Nurse Midwife acting within the scope of his license.

5. Initial artificial limbs, eyes (including the first pair of contact lenses following cataract surgery, and prescription lenses for Covered Persons lacking organic lenses) and prosthetic appliances (other than dental prosthetics), including the initial purchase only (up to a maximum Plan payment of $250) of a wig to replace natural hair lost as a result of radiation and/or chemotherapy used in the treatment of a covered illness; and replacement of such artificial limbs, eyes or prosthetic appliances, if necessitated due to pathological changes or normal growth.

6. Rental (or purchase at the Plan's option) of Durable Medical Equipment prescribed by a Physician and required for therapeutic use in the treatment of an active illness or injury. Local transportation by a professional ambulance service, or organized voluntary ambulance service, to the nearest hospital or other medical institution for covered medical treatment.

7. Charges for expenses by an ambulatory care center, to the extent such expenses would have been covered if provided by a hospital as part of an in-patent confinement.

8. Dental care or treatment due to accidental injury to sound natural teeth within 12 months of the accident or necessary due to congenital disease or anomaly

9. Care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column.

10. Services by duly licensed podiatrists or licensed Physicians for treatment of diseases, injuries, and malformations of the foot. There are two general exceptions: treatment of weak, strained or flat foot, of any instability or imbalance of the foot, or of any metatarsalgia or bunion is not covered, however, if a cutting operation is used, such treatment will be covered; and treatment of corns, calluses or toenails, including cutting or removal thereof is not covered, however, if such treatment is prescribed by a Doctor of Medicine (M.D.) who is providing treatment for a metabolic disease (such as diabetes mellitus) or a peripheral vascular disease (such as atherosclerosis), it will be covered.

11. Charges related to voluntary sterilization, including Physician and hospital or other facility charges.

12. Maternity care including inpatient hospital coverage for mother and newborn for at least 48 hours after childbirth (96 hours following a cesarean section). If the mother is discharged earlier than the recommended time frames described above, coverage of one home health care visit rendered by a home health agency that is:

(a) an agency or hospital that has been issued a certificate as a certified home health agency (CHHA) by the New York State Department of Health to provide home health services; or

(b) if outside of New York State, a home health agency that meets the same criteria required to obtain the certificate in New York State.

A home health maternity care visit must be requested within 48 hours of the delivery (96 hours in the case of a cesarean delivery). The visit must be rendered within 24 hours after discharge or of the time of the request, whichever is later.

The home health maternity care visit is not subject to deductible, coinsurance or co-payment if billed separately from the hospital's charges for maternity care services.
Maternity care also includes parent education, assistance and training in breast or bottle-feeding, the performance of any necessary maternal and newborn clinical assessments and the services of a midwife.

13. Charges for a second medical opinion by an appropriate specialist, including but not limited to a specialist affiliated with a specialty care center for the treatment of cancer, in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer. For non-preferred providers, the patient's financial responsibility shall be limited to the amount he would have paid had the provider been a preferred provider.

14. Charges for breast reconstruction after a mastectomy in the manner determined by the attending physician and the patient to be appropriate. This includes (a) all stages of
reconstruction of the breast on which the mastectomy has been performed; and (b) surgery and reconstruction of the other breast to produce a symmetrical appearance

15. For diabetic patients, the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or other licensed health care provider legally authorized to prescribe under title eight of the education law: blood glucose monitors and blood glucose monitors for the legally blind, data management systems, test strips for glucose monitors and visual reading and urine testing strips, insulin, injection aids, cartridges for the legally blind, syringes, insulin pumps and appurtenances thereto, insulin diffusion devices and oral agents for controlling blood sugar.

Coverage shall also include diabetes self-management education to ensure that persons with diabetes are educated to the proper self-management and treatment of their diabetic condition including information on proper diets. Such coverage for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes, where a physician diagnosis a significant change in the patient's symptoms or conditions which necessitate changes in a patient's self management or where reeducation or refresher education is necessary. Such education may be provided by the physician or other licensed health care provider legally authorized to prescribe under title eight of the education law or their staff, as part of an office visit for diabetes diagnosis or treatment or by a certified diabetes nurse educator, certified nutritionists, certified dietician or registered dietician upon the referral of a physician or other licensed health care provider legally authorized to prescribe under title eight of the education law. Coverage for self-management education and education relating to diet shall also include home visits when medically necessary.

16. Charges for pre-hospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section 3005 of the Public Health law. Deductibles, coinsurance and/ or copayments shall apply.

17. Charges for surgical or medical procedures which would correct malformation, disease or dysfunction resulting in infertility; diagnostic tests and procedures necessary to determine infertility or that are necessary in connection with surgical or medical procedures to correct malformation, disease or dysfunction resulting in infertility, including hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy, sonohysterogram, post coital tests, testis biopsy, semen analysis, blood tests and ultrasound. Coverage shall not include diagnosis or treatment in connection with in vitro fertilization, gamete intrafallopian tube transfers or zygote intrafallopian tube transfers, the reversal of sterilization, sex change procedures, cloning or procedures or services that are experimental. Coverage is limited to individuals whose ages range from twenty-one (21) through forty-four (44) years.

WELLNESS BENEFITS

1 . ROUTINE (in the absence of symptoms) PHYSICAL EXAMINATIONS

a) For members between the ages of 30 and 49, the health benefits plan will contribute toward the cost of one routine physical examination Per every two calendar years per person, subject to the following limitations:

$100 maximum per biennial physical examination when performed by an Aetna Open-Choice PPO physician.

$50 maximum per biennial physical examination when NOT performed by an Aetna Open-Choice PPO physician.

These routine services will not be subject to deductibles, co-payments or coinsurance, however, charges in excess of the above limits will be disallowed.

For members, age 50 or over, the health benefits plan will contribute toward the cost of one routine physical examination per calendar year per person, subject to the following limitations:

$100 maximum per annual physical examination when performed
by an Aetna Open-Choice PPO physician.

$50 maximum per annual physical examination when NOT performed by an Aetna

Open-Choice PPO physician.

These routine services will not be subject to deductibles, co-payments or coinsurance, however, charges in excess of the above limits will be disallowed.

2. ROUTINE (in the absence of symptoms) MAMMOGRAMS

The health benefits plan will contribute toward the cost of routine mammograms as an outpatient or in a physician's office subject to the following conditions and limitations:

a) upon the recommendation of a physician, a mammogram at any age for covered persons having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer,

(b) a single baseline mammogram for covered persons aged thirty-five through thirty-nine inclusive; an annual mammogram for covered persons aged forty and older.

The benefits noted above will be subject to deductible and coinsurance or co-payment.

3. WELL CHILD VISITS
The Consortium will cover well child visits in accordance with the following schedule, as recommended by the American Academy of Pediatrics (Note, the following schedule may change in accordance with AAP guidelines):

CHILD'S AGE

• at birth
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months to 18 years - 1 visit per every 12-months

Services may include a medical history, complete physical exam, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests.

WELL CHILD VISITS AND IMMUNIZATIONS WILL NOT BE SUBJECT TO DEDUCTIBLES, COINSURANCE OR CO-PAYMENTS.

4. IMMUNIZATIONS
The Consortium will cover immunizations . . as recommended by the American Academy of Pediatrics (Note, the following list may change in accordance with AAP guidelines):

• DPT (Diphtheria, Pertussis, Tetanus).
• MMR (Mumps, Measles and Rubella)
• Polio
• Varicella
• Hepatitis B
• Hepatitis A in selected geographic areas
• Hemophilus Influenza
• Pneumoccal Conjugate Vaccine (Prevnar)

WELL CHILD VISITS AND IMMUNIZATIONS WILL NOT BE SUBJECT TO DEDUCTIBLES, COINSURANCE OR CO-PAYMENTS.

5. ROUTINE (in the absence of symptoms) CERVICAL CYTOLOGY SCREENING
The Consortium will cover one cervical cytology screening per calendar year, for women aged eighteen and older as an outpatient or in a physician's office. This includes an annual pelvic examination, collection and preparation of a PAP smear, and laboratory and diagnostic services provided in connection with examining and evaluating the PAP smear. The benefit will be subject to deductibles and coinsurance.

6. ROUTINE (in the absence of symptoms) DIAGNOSTIC SCREENING FOR PROSTATE CANCER

The Health Benefits Plan will contribute towards the cost of routine screenings for prostate cancer as an outpatient or in a physician's office subject to the following conditions and limitations:

*standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer, and

*an annual standard diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific antigen test for men age fifty and over who are asymptomatic and for men age forty and over with a family history of prostate cancer or other prostate cancer risk factors.

The benefits noted above will be subject to deductible and coinsurance or co-payment.

Bone Mineral Density Measurements, Tests, Drugs or Devices

The Plan will cover bone mineral density measurements or tests if allowed under the criteria set forth by the federal Medicare program or the National Institutes of Health (NIH) for the detection of osteoporosis.

Coverage shall apply for individuals meeting the criteria for coverage under the federal Medicare program or the criteria for coverage under the NIH, and include individuals (a) previously diagnosed as having osteoporosis or having a family history of osteoporosis, (b) with symptoms or conditions indicative of the presence or the significant risk of osteoporosis, (c) on a prescribed drug regimen, (d) with lifestyle factors to such a degree posing a significant risk of osteoporosis, or (e) with such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis.

The benefits noted above will be subject to deductible and coinsurance or co-payment.

MANAGED BENEFITS PROGRAM
The Managed Benefits Program, as described in the Managed Benefits Program chapter of this Plan Document, shall be equally applicable to Medical Expense Benefits portion of the Plan to the extent that the specific types of services to which the Program applies are also considered covered Medical Expense Benefits. The penalties specified for non-compliance with the Admission Review Program shall also be applicable to Medical Expense Benefits.