This document is a sample only. As the plan administrator, the Company has the obligation to provide participants with the summary plan description and/or plan document. Vitable is not a legal advisor. Vitable recommends that the Company’s counsel reviews and edits this document. Instead of the plan document, you may need an amendment to any existing wrap plan document to include the plan in your consolidated health plan Form 5500.

PLAN DOCUMENT AND

SUMMARY PLAN DESCRIPTION

FOR

Vitable Health Medical Benefit Plan

EFFECTIVE DATE:______________

TABLE OF CONTENTS

Type of Plan: The Plan is a self-funded employee benefit plan.

Type of Administration: The administration of the Plan is provided through a Third-Party Claims Administrator. Plan benefits may be self-funded through a benefit fund, or a trust established by the Plan Sponsor and self-funded with contributions from Employees and/or the Plan Sponsor. The Plan is not insured.

Employer

[Employer to provide employer specific information as detailed in the Vitable contract.]

Claims Administrator

Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7223

The Plan Administrator has retained the services of the Claims Administrator to administer Claims under the Plan.

The Plan Sponsor [to be provided by employer as detailed in the Vitable contract:______________________] sponsors the Plan for its eligible employees and dependents. This document is intended to serve as the Plan Document (PD) and Summary Plan Description (SPD) required by the Employee Retirement Income Security Act (“ERISA”) for Plans subject to ERISA. The Plan Sponsor has contracted with Imagine360 to provide claims processing and other Plan administration services.

It is important that You review this document carefully as it describes Plan benefits and Your rights and responsibilities under the Plan. Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no coverage at all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, such as coordination of benefits, subrogation, exclusions, timeliness of COBRA elections, utilization review or other cost management requirements, lack of Medical Necessity, lack of timely filing of claims, or lack of coverage.

The Plan will pay benefits only for the expenses Incurred while this coverage is in force. No benefits are payable for expenses Incurred before coverage began or after coverage terminated. An expense for a service or supply is Incurred on the date the service or supply is furnished.

All benefits described in this Plan Document are subject to the exclusions and limitations described more fully herein including, but not limited to, the Plan Administrator's determination that: care and treatment is Medically Necessary; charges are reasonable and customary (as defined as an Allowable Charge); and services, supplies and care are not Experimental and/or Investigational. The meanings of these capitalized terms are in the Definitions section of this document.

This document is intended to describe the benefits provided under the Plan but, due to the number and wide variety of different medical procedures and rapid changes in treatment standards, it is impossible to describe all Covered Medical Services and/or exclusions with specificity. Please contact the Claims Administrator regarding questions about specific supplies, treatments or procedures.

Plan Participants may choose to use any appropriate medical care provider and Covered Medical Services will be reimbursed as stated in the Medical Benefits Schedule.

For provider charges subject to the No Surprises Act (NSA) (part of the Consolidated Appropriations Act of 2021), the Plan Participant cost-sharing will be calculated as if the Allowable Charge was the Recognized Amount. The NSA prohibits providers from pursuing payment from the Plan Participant for the difference between the Allowable Charge and the provider’s billed charge for services, except for any applicable cost-sharing.

Provider charges subject to the NSA are those which are submitted for:

Benefit determinations for provider claims subject to the NSA will be made within 30 days of the Claims Administrator’s receipt of the claim and if applicable reimbursement will be submitted directly to the provider.

A deductible is an amount of money that is paid once a Plan Year per Plan Participant. Typically, there is one deductible amount per Plan and it must be paid before any money is paid by the Plan for any Covered Medical Services (except for Covered Medical Services that are not subject to the deductible).

Each Effective Date, a new deductible amount is required.

The deductible will apply toward the maximum out-of-pocket amount.

A copayment is the amount of money that is paid each time a particular service is used. Typically, there may be copayments on some services and other services will not have any copayments.

Copayments, including Prescription Drug copayments, will not apply toward the deductible.

Copayments, including Prescription Drug copayments, will apply to the maximum out-of-pocket amount.

Coinsurance is the percentage amount remaining after the Plan pays the reimbursement rate as shown in the Medical Benefits Schedule and is payable by the Plan Participant until the maximum out-of-pocket amount as shown in the Medical Benefits Schedule is reached. Coinsurance does not apply to the deductible and does not include copayment amounts.

Once the Plan has made the applicable benefit payment as shown in the Medical Benefits Schedule, the remaining percentage owed is the Plan Participant’s “coinsurance” responsibility.

Covered Medical Services are payable by the Plan at the percentages shown each Plan Year until the maximum out-of-pocket amount shown in the Medical Benefits Schedule is reached. Then, Covered Medical Services Incurred by a Plan Participant will be payable at 100% (except for any charges which do not apply to the maximum out-of-pocket amount) for the rest of the Plan Year.

When a Family Unit reaches the maximum out-of-pocket amount, Covered Medical Services for that Family Unit will be payable at 100% (except for any charges which do not apply to the maximum out-of-pocket amount) for the rest of the Plan Year.
​

Administered by Ventegra

The medical deductible does not apply to Prescription Drugs.

Participating Retail Pharmacy – per 30-day supply per prescription

Generic drugs $10 copayment per prescription

Preferred Brand Name drugs Not Covered

Non-Preferred Brand Name drugs Not Covered

Mail Order Pharmacy – Not Covered.

Specialty Drugs – Not Covered

Additional information regarding the Prescription Drug Benefit may be
​found in the separate Prescription Drug Benefits section of this document.

Eligible Classes of Employees.

All Active Employees of the Employer.

Eligibility Requirements for Employee Coverage. A person is eligible for Employee coverage if he or she meets the requirements [to be provided by employer as detailed in the Vitable contract:______________________].

Eligible Classes of Dependents. A “Dependent” is any one of the following persons:

The term “Spouse” shall mean the person to whom the covered Employee is legally married.

This Plan does not allow coverage for common-law marriage.

The Plan Administrator may require documentation proving a legal marriage.

The term “Spouse” will also include “Domestic Partner” which shall mean a covered Employee’s partner with whom a Domestic Partnership has been established, and any Employer required documentation has been received and accepted by the Employer.

A covered Employee's “Dependent child” includes natural child, Stepchild, adopted child, Domestic Partner’s natural child, a child placed with the covered Employee in anticipation of adoption, or children for whom the Employee or covered Spouse is Legal Guardian. A Dependent child will be eligible until reaching the limiting age of 26.

A “Stepchild” means a child of the Spouse who meets the eligibility requirements of this Plan for whom a covered Employee is the stepparent of the child(ren).

“Legal Guardian” means a person recognized by a court of law as having the duty of taking care of and managing the property and rights of a minor child.

The phrase “child placed with a covered Employee in anticipation of adoption” refers to a child whom the Employee intends to adopt, whether or not the adoption has become final, who has not attained the age of 18 as of the date of such placement for adoption. The term “placed” means the assumption and retention by such Employee of a legal obligation for total or partial support of the child in anticipation of adoption of the child. The child must be available for adoption and the legal process has been initiated.

A child of a covered Employee who is an alternate recipient under a Qualified Medical Child Support Order (QMCSO) shall be considered as having a right to Dependent coverage under this Plan. A Participant of this Plan may obtain, without charge, a copy of the procedures governing QMCSO determinations from the Plan Administrator.

Please be advised, the definition of “Dependent” may not be the same definition as established by the Internal Revenue Code (IRC) for individuals that the covered Employee is permitted to pay qualified medical expenses from a Health Savings Account (HSA), or individuals that can be enrolled as an eligible Dependent for tax-free benefits (i.e., non-IRC Section 152 dependent). There may be tax implications for the Employee if he or she enrolls certain eligible Dependent(s). The Employee should consult his or her tax advisor with any questions on the tax consequences of benefits for his or her eligible Dependent(s).

The Plan Administrator may require documentation proving dependency, including birth certificates or initiation of legal proceedings severing parental rights.

After such two-year period, the Plan Administrator may require subsequent proof not more than once each year. The Plan Administrator reserves the right to have such Dependent examined by a Physician of the Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity.

These persons are excluded as Dependents: Other individuals living in the covered Employee’s home, but who are not eligible as defined above; the divorced former Spouse of the Employee, former Domestic Partner of the Employee, grandchild(ren), foster child(ren), or any person who is covered under the Plan as an Employee.

If a Plan Participant covered under this Plan changes status from Employee to Dependent or Dependent to Employee, and the Plan Participant is covered continuously under this Plan before, during and after the change in status, credit will be given for deductibles and all amounts applied to maximums.

If both parents are Employees, their children may be covered as Dependent children of one of the parents, but not of both.

Eligibility Requirements for Dependent Coverage. A family member of an Employee will become eligible for Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family member satisfies the requirements for Dependent coverage.

At any time, the Plan may require proof that a Spouse or a child qualifies or continues to qualify as a Dependent as defined by this Plan.

Please note that the Employee is solely responsible to notify the Plan when their dependent no longer qualifies as an eligible dependent for coverage under the Plan. Failure to timely notify the Plan may result in such Dependent’s coverage being retroactively or prospectively terminated and a loss of Your Dependent’s right to elect COBRA continuation coverage.

ACQUISITIONS

Employees who were enrolled under the health plan of an acquired company or in their eligibility waiting period, if applicable, as of the day before the date of acquisition, will be eligible to enroll themselves and their previously enrolled eligible Dependents for benefits under this Plan as of the date of acquisition, on the date of termination of the acquired company’s benefit plan, or upon satisfaction of the eligibility waiting period, whichever is later. Any deductibles and maximum out-of-pocket amounts previously satisfied under the prior health plan will not be applied toward the coverage under this Plan.

An acquired Employee (and their Dependents) who were not actively enrolled under the health plan offered by the acquired company, will not be eligible to enroll under this Plan until open enrollment or during a Special Enrollment event.

In the event that an acquired company did not have a health plan, all acquired Employees who otherwise meet the eligibility requirements of this Plan (and their eligible Dependents), will be eligible to enroll as of the date of the acquisition, subject to the eligibility waiting period.

Effective Date of Employee Coverage. An Employee will be covered under this Plan [effective date: ] once the Employee satisfies all of the following:

1. The Eligibility Requirement.

2. The Active Employee Requirement.

3. The Enrollment Requirements of the Plan.

Active Employee Requirement. An Employee must be an Active Employee (as defined by this Plan) for this coverage to take effect.

Effective Date of Dependent Coverage. A Dependent's coverage will take effect on the day that the Eligibility Requirements are met; the Employee is covered under the Plan; and all Enrollment Requirements are met.

Enrollment Requirements. An Employee must enroll for coverage by completing an enrollment application along with the appropriate payroll deduction authorization, if applicable. If Dependent coverage is desired, the covered Employee will be required to enroll the Dependent(s).

Enrollment Requirements for Newborn Children.

A newborn child of a covered Employee must be enrolled in the Plan on a timely basis, as defined in the section “Timely Enrollment” following this section, for there to be coverage for the newborn from the date of birth.

TIMELY OR LATE ENROLLMENT AND OPEN ENROLLMENT

If two Employees are covered under the Plan and the Employee who is covering the Dependent children terminates coverage, the Dependent coverage may be continued by the other covered Employee with no waiting period as long as coverage has been continuous.

Unless otherwise required by law, if an individual loses eligibility for coverage as a result of terminating employment, reduction of hours of employment or a general suspension of coverage under the Plan, then upon becoming eligible again due to resumption of employment or due to resumption of Plan coverage, only the most recent period of eligibility will be considered for purposes of determining whether the individual is a Late Enrollee.

The time between the date a Late Enrollee first becomes eligible for enrollment under the Plan and the first day of coverage is not treated as a waiting period. Coverage begins as stated in the Open Enrollment section below.

Plan Participants will receive detailed information regarding open enrollment from their Employer.

SPECIAL ENROLLMENT PERIODS

Federal law provides Special Enrollment provisions under some circumstances. The events described below may create a right to enroll in the Plan under a Special Enrollment Period.

To request Special Enrollment or obtain more detailed information of these portability rules, contact the Plan Administrator.

An Employee or Dependent who is eligible, but not enrolled in this Plan, may enroll if the individual loses eligibility for other coverage and the loss of eligibility for coverage meets all of the following conditions:

a. The Employee or Dependent was covered under a group health plan or had health insurance coverage at the time coverage under this Plan was previously offered to the individual; and

b. If required by the Plan Administrator, the Employee stated in writing at the time that coverage was offered that the other health coverage was the reason for declining enrollment; and

c. Either (i) the other coverage was COBRA coverage and the COBRA coverage was exhausted, or (ii) the other coverage was not COBRA coverage, and the coverage was terminated as the result of loss of eligibility for the coverage or because employer contributions towards the coverage were terminated; and

d. The Employee or Dependent requests enrollment in this Plan after the date of exhaustion of COBRA coverage or the termination of non-COBRA coverage due to loss of eligibility or termination of employer contributions, described above.

For purposes of these rules, a loss of eligibility occurs if one of the following occurs:

i. The Employee or Dependent has a loss of eligibility due to the other plan no longer offering any benefits to a class of similarly situated individuals (for example: part-time employees).

ii. The Employee or Dependent has a loss of eligibility under the other plan as a result of legal separation, divorce, termination of domestic partnership, cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the Plan), death, termination of employment, or reduction in the number of hours of employment or contributions towards the coverage were terminated.

iii. The Employee or Dependent has a loss of eligibility when the other coverage is offered through an HMO, or other arrangement, in the individual market that does not provide benefits to individuals who no longer reside, live or work in a service area, (whether or not within the choice of the individual).

iv. The Employee or Dependent has a loss of eligibility when coverage is offered through an HMO, or other arrangement, in the group market that does not provide benefits to individuals who no longer reside, live or work in a service area, (whether or not within the choice of the individual), and no other benefit package is available to the individual.

If the Employee or Dependent lost the other coverage as a result of the individual's failure to pay premiums or required contributions or for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan), that individual does not have a Special Enrollment right.

then the Dependent may be enrolled under this Plan. If the Employee is not enrolled at the time of the event, the Employee must enroll under this Special Enrollment Period in order for their eligible Dependents to enroll.

To be eligible for this Special Enrollment, the Dependent and/or Employee must request enrollment during this period.

In the case of birth, adoption, or placement for adoption, marriage and domestic partnerships, the Spouse/Dependents of the covered Employee may also be enrolled as a Dependent of the covered Employee if the Spouse/Dependent is otherwise eligible for coverage.

Employees and their Dependents who are otherwise eligible for coverage under the Plan, but who are not enrolled, can enroll in the Plan provided they request enrollment in writing within 60 days from the date of the following loss of coverage or gain in eligibility if:

If eligible, the Employee and/or Dependent may enroll under this Plan. If the Employee is not enrolled at the time of the event, he or she must enroll under this Special Enrollment Period in order for their eligible Dependent to enroll.

This Special Enrollment Period is a period of 60 days and begins on the date of the loss of coverage under the Medicaid or CHIP plan or on the date of the determination of eligibility for a premium subsidy under Medicaid or CHIP. To be eligible for this Special Enrollment, the Employee must request enrollment in writing during this 60-day period. The effective date of coverage will be the first day of the first month following the date of loss of coverage or gain in eligibility.

If a State in which the Employee lives offers any type of subsidy, this Plan shall also comply with any other State laws as set forth in statutes enacted by State legislature and amended from time to time, to the extent that the State law is applicable to the Plan, the Employer, and its Employees.

For more information regarding special enrollment periods, contact the Plan Administrator.

The Employer or Plan has the right to rescind any coverage of the Employee and/or Dependents for cause, making a fraudulent claim or an intentional material misrepresentation in applying for or obtaining coverage, or obtaining benefits under the Plan. The Employer or Plan may either void coverage for the Employee and/or covered Dependents for the period of time coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion, or may immediately terminate coverage. If coverage is to be terminated or voided retroactively for fraud or misrepresentation, the Plan will provide at least 30 days' advance written notice of such action. The Employer will refund all contributions paid for any coverage rescinded; however, claims paid will be offset from this amount. The Employer reserves the right to recoup Plan payments by any method allowed by law.

When Employee Coverage Terminates. Employee coverage will terminate on the earliest of these dates:

1. The date the Plan is terminated or amended such that the covered Employee loses coverage;

2. The date the covered Employee ceases to be in one of the Eligible Classes, or, if applicable, the last day of the stability period for which the covered Employee met the required minimum hours of service established by the Employer. This includes death or termination of active employment of the covered Employee. (See the section entitled COBRA Continuation Coverage.) It also includes an Employee on disability or leave of absence, unless the Plan specifically provides for continuation during these periods;

3. The end of the period for which the required contribution has been paid if the charge for the next period is not paid when due; or

4. As otherwise specified in the Eligibility section.

Note: Except in certain circumstances, a covered Employee may be eligible for COBRA Continuation Coverage. For a complete explanation of when COBRA Continuation Coverage is available, what conditions apply and how to select it, see the section entitled COBRA Continuation Coverage.

Continuation During Family and Medical Leave. When applicable, this Plan shall at all times comply with the Family and Medical Leave Act of 1993 (FMLA) as promulgated in regulations issued by the Department of Labor and amended from time to time, if, in fact, FMLA is applicable to the Employer and all of its Employees and locations. This Plan shall also comply with any other State leave laws as set forth in statutes enacted by State legislature and amended from time to time, to the extent that the State leave law is applicable to the Employer and its Employees covered by this Plan. Leave taken pursuant to any other State leave law shall run concurrently with leave taken under FMLA, to the extent consistent with applicable law.

If applicable, during any leave taken under the FMLA and/or other applicable State leave law, the Employer will maintain coverage under this Plan on the same conditions as coverage would have been provided if the covered Employee had been continuously employed during the entire leave period.

If Plan coverage terminates during the FMLA, coverage will be reinstated for the Employee and their covered Dependents if the Employee returns to work in accordance with the terms of the FMLA and/or other State leave law. Coverage will be reinstated only if the person(s) had coverage under this Plan when the FMLA leave started and will be reinstated to the same extent that it was in force when that coverage terminated.

Outside of FMLA, this Plan does not offer a continuation of coverage policy for an Employee and enrolled Dependents if the Employee’s active, full-time work ceases.

Employees on Military Leave. Employees going into or returning from military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act (USERRA) under the following circumstances. These rights apply only to Employees and their Dependents covered under the Plan immediately before leaving for military service.

1. The maximum period of coverage of a person under such an election shall be the lesser of:

a. The 24-month period beginning on the date on which the person's absence begins; or

b. The day after the date on which the person was required to apply for or return to a position of employment and fails to do so.

2. A person who elects to continue group health plan coverage must pay up to 102% of the full contribution under the Plan, except a person on active duty for 30 days or less cannot be required to pay more than the Employee's share, if any, for the coverage.

3. An exclusion or waiting period may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated because of service. However, an exclusion or waiting period may be imposed for coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been Incurred in, or aggravated during, the performance of uniformed service.

If the Employee wishes to elect this coverage or obtain more detailed information, contact the Plan Administrator. The Employee may also have continuation rights under USERRA. In general, the Employee must meet the same requirements for electing USERRA coverage as are required under COBRA Continuation Coverage requirements. Coverage elected under USERRA runs concurrently with COBRA. The Employee may elect USERRA continuation coverage for the Employee and their Dependents. Only the Employee has election rights. Dependents do not have any independent right to elect USERRA health plan continuation.

The Civilian Reservist Emergency Workforce Act of 2021 (“CREW”) provides eligible Employees, who are called to services by the Federal Emergency Management Agency (FEMA), rights under USERRA.

​When Dependent Coverage Terminates. A Dependent's coverage will terminate on the earliest of these dates:

Note: Except in certain circumstances, a covered Dependent may be eligible for COBRA Continuation Coverage. For a complete explanation of when COBRA Continuation Coverage is available, what conditions apply and how to select it, see the section entitled COBRA Continuation Coverage.

Utilization Management performs important functions under this Plan by assisting Plan Participants prior to obtaining medical care to ensure the proposed services are Medically Necessary and appropriate, or if there are alternatives to consider. Utilization Management performs Pre-Service Review, Concurrent Care Review and may offer Case Management to assist Plan Participants who are experiencing more complex long-term health care issues.

A Pre-Service Review does not constitute a claim and is not a benefit determination on a service that has already been performed. All Pre-Service Reviews are subject to the terms and conditions, limitations and exclusions of the Plan in effect at the time services are provided.

A Pre-Service Review may be recommended by the Plan, or it may be required by the Plan as a condition precedent to paying benefits. A Pre-Service Review provides information regarding benefits and coverage prior to the Plan Participant receiving the care. Pre-Service Review is not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician or other health care provider.

The Pre-Service Review process begins by calling the toll free number listed on the Vitable Health Medical Benefit Plan identification card.

Pre-Service Review provides information regarding coverage before the Plan Participant receives treatment, services and/or supplies. All reviews are subject to the terms and conditions, limitations and exclusions of the Plan in effect at the time services are provided. Obtaining a Pre-Service Review is not required as a condition precedent to paying benefits and is not a guarantee that a claims will be paid.

If a Plan Participant has an ongoing medical condition or catastrophic Illness, a Utilization Management Case Manager may be assigned to monitor this Plan Participant, and to work with the attending Physician and Plan Participant to design a treatment plan and coordinate appropriate Medically Necessary care. The Case Manager will consult with the Plan Participant, the family, and the attending Physician in order to assist in coordinating the Plan of Care approved by the Plan Participant’s attending Physician and the Plan Participant.

This Plan of Care may include some or all of the following:

Case Management is not a requirement of the Plan. There are no reductions of benefits or penalties if the Plan Participant and family choose not to participate.

Each treatment plan is individualized to a specific Plan Participant and is not appropriate or recommended for any other patient, even one with the same diagnosis. All treatment and care decisions will be the sole determination of the Plan Participant and the attending Physician.

ALTERNATIVE CARE

Through alternative care, Case Management may help the Plan Participant and the Plan Administrator obtain care/treatment for a serious Illness or Injury that is Medically Necessary and appropriate for the diagnosis. When alternative care and treatment are identified by Case Management as Medically Necessary and approved by the Plan Administrator, and where there is a reasonable expectation of savings to the Plan without sacrificing the quality of care to the Plan Participant, the Plan may approve and pay for all or part of the charges not shown as a Covered Medical Service or as a Covered Prescription Drug in this Plan Document. These expenses will be considered on the same basis as the care and treatment for which they are substituted. Benefits provided under this section are subject to all other limitations and provisions within the Plan. In exercising its authority, this Plan will act in a way so as not to discriminate against any Plan Participant. If the care is not being substituted for other Covered Medical Services, it will be considered on the same basis as a same or similar Covered Medical Service or Covered Prescription Drug shown in this Plan Document, as determined by the Claims Administrator.

Clinical Trials (Routine Patient Costs). Benefits are provided to Qualified Individuals for the Routine Patient Costs of items and services furnished in connection with participation in an Approved Clinical Trial. Routine Patient Costs include all items and services consistent with the coverage provided under this Plan that are typically covered for a Qualified Individual who is not enrolled in a clinical trial. Routine Patient Costs do not include:

If one or more Participating Providers is participating in a clinical trial, the Plan may require that a Qualified Individual participate in the trial through such a Participating Provider if the Provider will accept the individual as a participant in the trial.

Approved Clinical Trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and that is described in any of the following:

A Qualified Individual must meet the following conditions:

Covered Medical Services are Medically Necessary services Incurred for the following items of service and supply. These charges are subject to the benefit limits, exclusions, and other provisions of this Plan. A charge is Incurred on the date that the service or supply is performed or furnished. Covered Medical Services must be received from a licensed health care professional acting within the scope of his/her license.

Breast Pumps and Breast Pump Supplies. Coverage includes:

Note: Breast pumps and breast pump supplies when purchased through a retail store (for example, through Target, Wal-Mart, Walgreens) will be considered payable only for the purposes of this benefit. The Claims Administrator will require the following documentation: claim form with proof of purchase to include purchase price and item description.

Lactation support and counseling. Coverage includes:

Inpatient and outpatient comprehensive antenatal, perinatal and postpartum lactation support and counseling for female Plan Participants for the duration of the breastfeeding.

Refer to the separate Prescription Drug Benefits of this Plan regarding prescription coverage of oral contraceptive medications, devices, transdermals, vaginal contraceptives, implantables and injectables, including Physician-prescribed over the counter (OTC) contraceptives for female Plan Participants.

Facility charges and general anesthesia for dental and oral surgery procedures are considered as Covered Medical Services only if Medically Necessary.

No charge will be covered for dental and oral surgical procedures involving orthodontic care of the teeth, periodontal disease, and preparing the mouth for the fitting, or continued use, of dentures .

Benefit payment for nursing, home health aide, and therapy services is subject to the Home Health Care limit shown in the Medical Benefits Schedule.

This benefit does not include the following:

A home health care visit will be considered a periodic visit by either a nurse or therapist, or four hours of home health aide services.

This Plan will not cover gym memberships, or dues for participation in weight loss programs (e.g., Weight Watchers, etc.), whether or not prescribed by a Physician.

Charges for multiple surgical procedures are subject to the following provisions in the absence of a negotiated amount established by a provider network arrangement or other discounting or negotiated arrangement:

Note: Routine prenatal office visits will be payable as shown under the Pregnancy benefit in the Medical Benefits Schedule. The following services will continue to be payable per normal Plan provisions:

Pregnancy-related ultrasounds, lab screenings (not otherwise specified), Complications of Pregnancy (as defined under this Plan), delivery, and post-partum care (and will not apply to the Pregnancy of a Dependent child).

Group health plans generally may not, under Federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Preventive Care/Routine Well Care is care by a Physician that is not for an Injury or Illness and will only apply in the absence of a diagnosis for a medical condition, including a recurring condition or for medication.

The Plan Participant should consult with his/her Physician at the time services are rendered as to whether or not the services provided will be considered Preventive Care/Routine Well Care as mandated under the Affordable Care Act (ACA), U.S. Preventive Services Task Force (USPSTF) grades A and B recommendations or the Women’s Preventive Services as required by the Health Resources, Services Administration (HRSA) and Healthcare.gov.

Otherwise, services rendered which are not considered or billed by the Physician as Preventive Care/Routine Well Care (as stated above) will be subject to the terms and conditions, limitations and exclusions of the Plan in effect at the time services are provided.

Mammoplasty coverage will include reimbursement for:

To contact Recuro Health Telehealth call (844) 715-1724, or access their webpage at www.member.recurohealth.com for additional information.

Telehealth services not Incurred through Recuro Health Telehealth will be a Covered Medical Service subject to the same deductible, copayment, or coinsurance requirements that apply to comparable health services provided in person.

Routine Nursery Care. Routine well newborn nursery care is care while the newborn is Hospital-confined after birth and includes room, board, and other normal well-baby care, including circumcision, for which a Hospital makes a charge.

This coverage is provided in accordance with the Enrollment Requirements for Newborn Children provision if a parent (1) is a Plan Participant who was covered under the Plan at the time of the birth, or (2) enrolls himself or herself (as well as the newborn child if required) in accordance with the Special Enrollment provisions with coverage effective as of the date of birth.

Covered Medical Services for routine nursery care will be applied toward the Plan of the covered mother (if eligible and enrolled).

Group health plans generally may not, under Federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, Plans and issuers may not, under Federal law, require that a provider obtain authorization from the Plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Routine Physician Care. This benefit is for routine well-baby care made by a Physician for pediatric visits to the newborn child, including circumcision, while Hospital confined as a result of the child's birth.

Covered Medical Services for routine Physician care will be applied toward the Plan of the covered mother (if eligible and enrolled).

The following exclusions and limitations apply to expenses Incurred by all Plan Participants:

Abortion. The charges related to an elective abortion, unless the life of the covered mother is endangered or the Pregnancy is the result of rape or incest.

Acupuncture. Charges for acupuncture.

Adoption Fees. Charges for adoption fees.

Air Ambulance.

Alternative Medicine. The charges for care, treatment, services or supplies related to alternative medicine that is not an accepted medical practice as determined by the Plan, except as specifically shown as a Covered Medical Service under this Plan.

Biofeedback. Charges for biofeedback.

Cardiac Rehabilitation. Charges for cardiac rehabilitation services.

Chemotherapy or radiation treatment with Radioactive Substances. Charges for materials and services of technicians.

Coding guidelines. Charges for inappropriate coding in accordance with the industry standard guidelines in effect at the time services were received.

Complications of non-covered treatments. Care, services or treatment required as a result of complications from a treatment not covered under the Plan.

Cosmetic Procedures. Any surgery or procedure, the primary purpose of which is to improve or change the appearance of any portion of the body, but which does not restore bodily function, correct a disease state, or improve a physiological function. Cosmetic procedures include cosmetic surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, cosmetic surgery (including reimplantation). This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. This exclusion does not apply to surgery to restore function if the body area has been altered by Injury, disease, trauma, congenital/developmental anomalies, or previously covered therapeutic processes or as specifically shown as a Covered Medical Service under this Plan.

Counseling. Care and treatment for group therapy, bereavement, marital or pre-marital, relationship, or financial counseling.

Custodial Care. Services or supplies provided mainly as a rest cure, maintenance, Custodial Care or domiciliary care consisting chiefly of room and board, except as specifically shown as a Covered Medical Service under this Plan.

Dental services. Care, treatment, services and supplies including appliances in connection with dental services and oral surgery, except as specifically shown as a Covered Medical Service under this Plan.

Dialysis. Charges for dialysis services including dialysis, Facility services, supplies, and medications.

Durable Medical Equipment Repair. Charges for repair, adjustment or replacement of rented Durable Medical Equipment or components.

Educational or vocational testing. Services for educational or vocational testing or training, except as specifically stated as a Covered Medical Service under this Plan.

Excess charges. The part of an expense for care and treatment of an Injury or Illness that is in excess of the Allowable Charge.

Exercise programs. Exercise programs for treatment of any condition, except for Physician-supervised cardiac rehabilitation, occupational or physical therapy if covered by this Plan.

Experimental or not Medically Necessary. Care and treatment that is either Experimental/ Investigational or not Medically Necessary except as provided consistent with the Affordable Care Act preventive services requirements.

Fees. Charges for completion of form fees, missed appointment fees or late fees.

Foot care (routine). Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions (except open cutting operations), and treatment of corns, calluses or toenails (unless deemed Medically Necessary).

Foot orthotics (other than Medically Necessary foot orthotics immediately following foot surgery), corrective shoes, unless they are an integral part of a lower body brace; arch supports; and special shoe accessories.

Foreign travel. Care, treatment or supplies out of the U.S. if travel is for the sole purpose of obtaining medical services.

Gender Reassignment. The charges for Gender Dysphoria/Transition/Reassignment care and treatment.

Gene Therapy. The charges for Gene Therapy.

Genetic Testing. The charges for genetic testing, except as provided consistent with the Affordable Care Act preventive services requirements.

Government coverage. Care, treatment or supplies furnished by a program or agency funded by any government. This exclusion does not apply to Medicaid or when otherwise prohibited by applicable law.

Hair loss/Wigs. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician.

Hearing Exams and Hearing Aids/Devices. Charges Incurred in connection with routine hearing exams and charges for the purchase or fitting of hearing aids/devices or such similar aid devices including Bone Anchored Hearing Aids (BAHA). This exclusion does not apply to routine hearing screenings as provided by the Affordable Care Act Preventive Services requirements.

Home Infusion Therapy. Charges for intravenous or gastrointestinal (enteral) infusion or intravenous injection of fluids, nutrition or medication furnished in the home setting.

Hospice Care Services and Supplies. Charges for Hospice Care Services and Supplies. Respite care is not eligible for coverage.

Hospital employees. Professional services billed by a Physician or nurse who is an employee of a Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service.

Illegal Acts. Charges for services received as a result of an Illness or Injury occurring directly, or indirectly as a result of a serious criminal act, or a riot or public disturbance, regardless of causation. For this exclusion to apply, it is not necessary that criminal charges be filed, or if filed, that a conviction result, or that a sentence of imprisonment for a term be imposed.

Charges for services, supplies, care or treatment to a Plan Participant for an Injury or Illness which occurred as a result of that Plan Participant while under the influence of alcohol or drugs, or a combination thereof. It is not necessary that criminal charges be filed, or if filed, that a conviction result, or that a sentence of imprisonment for a term be imposed.

This exclusion does not apply if the Injury resulted from an act of domestic violence or a medical (including both physical and mental health) condition.

Impotence. Care, treatment, services, supplies or medication in connection with treatment for impotence or sexual dysfunction.

Incarcerated. Care, treatment, services, and supplies Incurred and/or provided to a Plan Participant by a government entity while housed in a governmental institution.

Infertility. Charges for the diagnosis, treatment of the underlying medical condition associated with Infertility and services to restore or enhance fertility, including, but not limited to, artificial insemination, in vitro fertilization, embryo transfer procedures.

Infusion Therapy. Charges intravenous infusion or injection of fluids, nutrition or medication, and charges for hyperalimentation or total parenteral nutrition (TPN) for Plan Participants recovering from or preparing for surgery.

Learning disabilities, behavioral modifications, or developmental delay services or treatment, except when provided as treatment for an autism spectrum disorder.

Mailing or Sales Tax. Charges for mailing, shipping, handling, postage, conveyance, and sales tax.

Massage Therapy. Charges for massage therapy.

Medical Pharmaceuticals. Charges for pharmaceuticals administered under the medical benefits of this Plan, Incurred in an outpatient, office or home setting.

Medical Services Outside the United States. Charges for medical services Incurred by the Plan Participant traveling outside the United States and its territories.

Mental Disorders. Charges for care, supplies, and treatment of Mental Disorders.

No charge. Care and treatment for which there would not have been a charge if no coverage had been in force.

No obligation to pay. Charges Incurred for which the Plan has no legal obligation to pay.

No Physician recommendation. Care, treatment, services or supplies not recommended and approved by a Physician; or treatment, services or supplies when the Plan Participant is not under the regular care of a Physician. Regular care means ongoing medical supervision or treatment which is appropriate care for the Injury or Illness.

Non-emergency Hospital admissions. Care and treatment billed by a Hospital for non-Medical Emergency admissions on a Friday or a Saturday. This does not apply if surgery is performed within 24 hours of admission.

Obesity. Non-surgical and surgical care and treatment of obesity, including morbid obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Illness, except as provided consistent with the Affordable Care Act preventive services requirements.

Occupational Injury. Care and treatment of an Injury or Illness that is occupational – that is, arises from work for wage or profit including self-employment. This exclusion applies even though the Plan Participant:

Orthotic Appliances. Charge for the initial purchase, fitting, and repair of orthotic appliances such as braces (except dental braces), splints, casts, or other appliances which are required for support of an injured or deformed part of the body as a result of a disabling congenital condition, Injury, or Illness.

Orthotic Insoles. Charges for orthotic insoles for the feet even when prescribed by a Physician for diabetic foot care or patients with peripheral vascular disease only.

Orthognathic Surgery. Charges for orthognathic surgery.

Outpatient Rehabilitation Therapies. Charges for therapies not listed as a Covered Medical Service elsewhere in the Plan.

Prosthetic Devices. The initial purchase, fitting, repair and replacement of fitted prosthetic devices which replace body parts.

Personal comfort items. Personal comfort items, patient convenience items or other equipment, such as, but not limited to, air conditioners, air-purification units, humidifiers, electric heating units, orthopedic mattresses, blood pressure instruments, scales, non-Prescription Drugs and medicines, first-aid supplies, and non-Hospital adjustable beds.

Plan design excludes. Charges excluded by the Plan design as mentioned in this document or that exceed a listed limit under this Plan.

Pregnancy for Dependents other than Spouse. Care and treatment of Pregnancy and Complications of Pregnancy for a covered Dependent other than a covered Spouse, except as specifically stated as a benefit under this Plan.

Private duty nursing. Charges in connection with care, treatment or services by a private duty nurse.

Relative giving services. Professional services performed by a person who ordinarily resides in the Plan Participant's home or is related to the Plan Participant as a Spouse, parent, child, brother or sister, whether the relationship is by blood or exists in law.

Replacement braces. Replacement of braces of the leg, arm, back, neck, or artificial arms or legs, unless there is sufficient change in the Plan Participant's physical condition to make the original device no longer functional.

Routine care. Charges for routine or periodic examinations and evaluation procedures, physical exams and immunizations related to travel, employment, insurance, sports, licensing, etc., or treatment or services not directly related to the diagnosis or treatment of a specific Injury, Illness, or Pregnancy-related condition, which is known or reasonably suspected, except as specifically stated as a benefit under this Plan or required by applicable law.

Services before or after coverage. Care, treatment or supplies for which a charge was Incurred before a person was covered under this Plan or after coverage ceased under this Plan.

Sleep Disorders. Charges related to the diagnosis and treatment of sleep disorders or disturbances, including treatment of sleep apnea.

Substance Abuse. Charges for care, supplies, and treatment of Substance Abuse.

Surgical sterilization reversal. Care and treatment for reversal of surgical sterilization for men or women.

Surrogate Fees. Charges for surrogate fees.

Temporomandibular Joint (TMJ) Disorders. The charges for medical treatment of Temporomandibular Joint (TMJ) Syndrome and related services.

Travel or accommodations. Charges for travel or accommodations, whether or not recommended by a Physician, except as specifically stated as a benefit under this Plan.

War. Any loss that is due to a declared or undeclared act of war.

Participating Pharmacies have contracted with the Plan to charge Plan Participants reduced fees for covered Prescription Drugs. Ventegra is the administrator of the Pharmacy drug plan.

Eligible expenses Incurred through the Prescription Drug benefits of this Plan apply to the maximum out-of-pocket amount as shown in the Medical Benefits Schedule.

PARTICIPATING RETAIL PHARMACY

Any one retail participating Pharmacy prescription is available up to a 30-day supply per prescription and includes Generic Drugs only. Preferred Brand name and non-Preferred Brand names are not covered under this Plan.

If a drug is purchased when the Plan Participant's ID card is not used, the Plan Participant will be required to pay 100% of the total cost at the point of sale, no discount will be given, and the Plan Participant will be required to submit the prescription receipt to Ventegra for reimbursement (less applicable copayments as shown in the Prescription Drug Benefits Schedule).

MAIL ORDER PHARMACY

This Plan does not cover mail order Pharmacy.

SPECIALTY PHARMACY

Specialty Drugs are not covered under the Prescription Drug benefit of this Plan.

PREVENTIVE CARE COVERAGE

The following will be covered at 100%, no copayment required for formulary drugs:

See VPC drugs as stated on https://app.vitablehealth.com/care-nav/medications?distance=50&zipcode=90290&additionalPlan=MEC&plan=Vitable+Primary+Care+-+Enhanced

Limits To This Benefit

The covered drug charge for any one prescription will be limited to:

1. Refills only up to the number of times specified by a Physician.

2. Refills up to one year from the date of order by a Physician.

A “Claim” means a request for a Plan benefit made by a Claimant (the Plan Participant or an authorized representative) after medical treatment has occurred. When services are received from a health care provider, a Plan Participant should show their Group Health identification card to the provider. Providers may submit Claims on a Plan Participant’s behalf.

If it is necessary for a Plan Participant to submit a Claim, they should request an itemized bill from their health care provider which will include procedure (CPT) and diagnostic (ICD) codes.

The following information must be provided when submitting a Claim for processing:

Claims should be received by the Claims Administrator within 90 days from the date charges for the services were Incurred. Benefits are based on the Plan's provisions in effect at the time the charges were Incurred. Claims received later than that date will be denied.

The Plan Participant must provide sufficient documentation (as determined by the Claims Administrator) to support a Claim for benefits. The Plan reserves the right to have a Plan Participant seek a second medical opinion.

Claims for expenses should be submitted to the applicable address below:

Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7332

A “Claim” means a request for a Plan benefit made by a Claimant (the Plan Participant or an authorized representative) after medical treatment has occurred. A Claim is not a request to determine a Claimant’s eligibility for benefits, nor is it a request for a Pre-Service Review prior to receiving medical treatment to determine Medical Necessity.

A Claimant may appoint an authorized representative to act upon his or her behalf with respect to a Claim. Only those individuals who satisfy the Plan’s requirements to be an authorized representative will be considered an authorized representative. A healthcare provider is not an authorized representative simply by virtue of an assignment of benefits. Contact the Claims Administrator for information on the Plan’s procedures for authorized representatives.

A Pre-Service Review may be requested as explained in the Utilization Management section of this Plan. A Pre-Service Review may be recommended by the Plan, or it may be required by the Plan as a condition precedent to paying benefits. A Pre-Service Review resulting in an adverse determination cannot be appealed under the Plan’s Internal and External Review Procedures

A Pre-Service Review may also include a reconsideration of an adverse determination for Concurrent Care if the service has not been Incurred and the Plan Participant has been given ample time in which to request a reconsideration prior to the reduction or termination of the Concurrent Care.

Adverse determinations related to “Concurrent Care” may arise when the Plan has approved an on-going course of treatment to be provided over a period of time or for a specific number of treatments. If the Plan determines that the previously approved course of treatment should be reduced or terminated, the Plan must allow the Claimant sufficient notice in advance of further treatment to allow the Claimant to request reconsideration of the adverse determination prior to the reduction or termination of the Concurrent Care.

Adverse determinations related to “Concurrent Care” may also occur during a Plan Participant’s inpatient Facility stay. If the inpatient Facility stay continues beyond the number of days approved as part of the Concurrent Care review, the Plan must allow the Claimant sufficient notice in advance of further treatment to allow the Claimant to request reconsideration of the adverse determination prior to the reduction or termination of the Concurrent Care.

The Claimant must indicate when requesting a reconsideration of the adverse determination for Concurrent Care if the request is of an urgent nature. When an urgent care request exists, the Plan is required to respond in an expedited manner, but the request must be received at least 24 hours prior to the expiration or reduction of the existing Concurrent Care approval.

A Post-Service Claim is a Claim for medical care, treatment, or services that a Claimant has already received.

All questions regarding Claims should be directed to the Claims Administrator. All Claims will be considered for payment according to the Plan’s terms and conditions, limitations and exclusions, and industry standard guidelines in effect at the time charges were Incurred. The Plan may, when appropriate or when required by law, consult with relevant health care professionals and access professional industry resources in making decisions about Claims involving specialized medical knowledge or judgment.

Initial Benefit Determination

A Claim will not be deemed submitted until it is received by the Claims Administrator. The initial benefit determination on a Claim will be made within 30 days of the Claim Administrator’s receipt of the Claim (or 15 days if the Claim is a Concurrent Care Determination). If additional information is necessary to process the Claim, the Claims Administrator will make a written request to the Claimant for the additional information within this initial period. The Claimant must submit the requested information within 45 days of receipt of the request from the Claims Administrator. Failure to submit the requested information within the 45-day period may result in a denial of the Claim or a reduction in benefits. If additional information is requested, the Plan’s time period for making a determination is suspended until such time as the Claimant provides the information, or the end of the 45-day period, whichever occurs earlier. A benefit determination on the Claim will be made within 15 days of the Plan’s receipt of the additional information. Under the No Surprises Act, the Plan will have up to 30 calendar days to send a notice of denial of payment or an initial payment to the Provider from the time the Claim is resubmitted with additional information.

Notice of Adverse Benefit Determination

If a Claim is denied in whole or in part, the Plan shall provide the Claimant with an Explanation of Benefits (EOB), and/or provide written or electronic notice of the determination to providers, that will include the following:

If applicable:

If the Claimant has questions about the denial, the Claimant may contact the Claims Administrator at the address or telephone number printed on the Explanation of Benefits/Explanation of Payment.

An Adverse Benefit Determination also includes a rescission of coverage when applied as a retroactive cancellation or discontinuance of coverage due to fraud or intentional misrepresentation. A rescission of coverage does not include a cancellation or discontinuance of coverage that takes effect prospectively, nor is it a retroactive cancellation or discontinuance due to the Plan Participant’s failure to pay the required premium in a timely manner.

How to Appeal an Adverse Benefit Determination

A Claimant may appeal an Adverse Benefit Determination. The Plan offers two-levels of review; an Internal Review procedure and an External Review procedure that will allow the Claimant with a full and fair review of the Adverse Benefit Determination.

The Plan will provide for a review that does not give deference to the previous Adverse Benefit Determination and that is conducted by an individual who is neither the person who made the determination on a prior level of review, nor a subordinate of that person. Additionally, if an External Review is requested, that review will be conducted by an Independent Review Organization that was not involved in any of the prior determinations.

In addition, the Plan Administrator may:

Note: When the dispute of a Claim payment or Claim denial only involves payment amounts due from the Plan to the Provider, and the provider has no recourse against the Plan Participant under the No Surprises Act, the payment dispute may only be resolved through open negotiation, or the Independent Dispute Resolution (IDR) process as outlined in the NSA. There may be instances when a Plan Participant may appeal a Claim through this section concurrently with a Provider’s payment dispute through the IDR process.

First Level of Internal Review

The written request for a First Level Internal Review must be submitted within 180 days of the Claimant’s receipt of an Explanation of Benefits/Explanation of Payment that includes the adverse benefit determination.

The Claimant should include the following information in their request for review:

The First Level of Internal Review request should be addressed to:

Plan Administrator

c/o Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7332

An appeal will not be deemed submitted until it is received by the Claims Administrator. The Claimant cannot proceed to the next level of internal or external review if the Claimant fails to submit a timely request for a First Level Internal Review.

The First Level of Internal Review will be performed by the Claims Administrator on the Plan’s behalf. The Claims Administrator will review the information initially received and any additional information provided by the Claimant and determine if the Initial Benefit Determination was appropriate based upon the terms and conditions of the Plan and other relevant information. The Claims Administrator will send a written or electronic Notice of Determination to the Claimant within 30 days of the receipt of the appeal. The Notice of Determination resulting from a First Level Internal Review shall meet the requirements as stated above.

Second Level of Internal Review

If the Claimant does not agree with the determination from the First Level of Internal Review, the Claimant may submit a Second Level Internal Review request in writing within 60 days of the Claimant’s receipt of the Notice of Determination from the First Level of Internal Review, along with any additional supporting information.

The Second Level of Internal Review request should be addressed to:

Plan Administrator

c/o Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7332

An appeal will not be deemed submitted until it is received by the Plan Administrator or the Claims Administrator on the Plan Administrator’s behalf. The Claimant cannot proceed with an External Review or file suit if the Claimant fails to submit a timely appeal.

The Second Level of Internal Review will be completed by the Plan Administrator and/or its designee. The Plan Administrator/designee will review the information initially received and any additional information provided by the Claimant and make a determination on the appeal based upon the terms and conditions of the Plan and other relevant information. The Plan Administrator/designee will send a written or electronic Notice of Determination for the Second Level of Internal Review to the Claimant within 30 days of receipt of the appeal (or 15 days for an appeal of a Concurrent Care Claim Determination). The Second Level of Internal Review Notice of Determination shall meet the requirements as stated above.

If the Claimant is not satisfied with the outcome of the final determination on the Second Level of Internal Review, the Claimant may request an External Review. The Claimant must exhaust the First and Second Levels of Internal Review before requesting an External Review unless the Plan Administrator did not comply fully with the Plan’s Internal Review Procedure for the First Level of Internal Review.

This Plan has an External Review Procedure that provides for a review conducted by a qualified Independent Review Organization (IRO) that shall be assigned on a random basis.

A Claimant may, by written request made to the Plan within four months from the date of receipt of the notice of the Final Internal Review Adverse Benefit Determination or the first day of the fifth month following receipt of such notice, whichever occurs later, request a review by an IRO of a final Adverse Benefit Determination of a Claim, except where such request is limited by applicable law.

A request for External Review may be granted only for Adverse Benefit Determinations that involve a:

For an Adverse Benefit Determination to be eligible for External Review, the Claimant must complete the required forms to process an External Review. The Claimant may contact the Claims Administrator for additional information.

The Claimant will be notified in writing within six business days as to whether Claimant’s request is eligible for external review and if additional information is necessary to process Claimant’s request. If Claimant’s request is determined ineligible for External Review, notice will include the reasons for ineligibility and contact information for the appropriate oversight agency. If additional information is required to process Claimant’s request, Claimant may submit the additional information within the four-month filing period, or 48 hours, whichever occurs later.

Claimant should receive written notice from the assigned IRO of Claimant’s right to submit additional information to the IRO and the time periods and procedures to submit this additional information. The IRO will make a final determination and provide written notice to the Claimant and the Plan no later than 45 days from the date the IRO receives Claimant’s request for External Review. The notice from the IRO should contain a discussion of its reason(s) and rationale for the decision, including any applicable evidence-based standards used, and references to evidence or documentation considered in reaching its decision.

The decision of the IRO is binding upon the Plan and the Claimant, except to the extent other remedies may be available under applicable law. Before filing a lawsuit, the Claimant must exhaust all available levels of review as described in this section, unless an exception under applicable law applies. A legal action to obtain benefits must be commenced within one year of the date of the Notice of Determination on the Final Level of Internal or External Review, whichever is applicable.

Occasionally, benefits are paid more than once, are paid based upon improper billing or a misstatement in a proof of loss or enrollment information, are not paid according to the Plan’s terms, conditions, limitations, or exclusions, or should otherwise not have been paid by the Plan. As such, this Plan may pay benefits that are later found to be greater than the Allowable Charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid, primary payers, or from the party on whose behalf the charge(s) were paid. As such, whenever the Plan pays benefits exceeding the amount of benefits payable under the terms of the Plan, the Plan Administrator has the right to recover any such erroneous payment directly from the person or entity who received such payment and/or from other payers and/or the Plan Participant on whose behalf such payment was made, using any recovery method permitted by law.

A Plan Participant, provider, another benefit plan, insurer, or any other person or entity who receives a payment exceeding the amount of benefits payable under the terms of the Plan or on whose behalf such payment was made, shall return or refund the amount of such erroneous payment to the Plan within 30 days of discovery or demand. The Plan Administrator shall have no obligation to secure payment for the expense for which the erroneous payment was made or to which it was applied.

The person or entity receiving an erroneous payment may not apply such payment to another expense. The Plan Administrator shall have the sole discretion to choose who will repay the Plan for an erroneous payment and whether such payment shall be reimbursed in a lump sum. When a Plan Participant or other entity does not comply with the provisions of this section, the Plan Administrator shall have the authority, in its sole discretion, to deny payment of any Claims for benefits by the Plan Participant and to deny or reduce future benefits payable (including payment of future benefits for other Injuries or Illnesses) under the Plan by the amount due as reimbursement to the Plan. The Plan Administrator may also, in its sole discretion, deny or reduce future benefits (including future benefits for other Injuries or Illnesses) under any other group benefits plan maintained by the Plan Sponsor, to the extent allowed by law. The reductions will equal the amount of the required reimbursement.

Providers and any other person or entity accepting payment from the Plan or to whom a right to benefits has been assigned, in consideration of services rendered, payments and/or rights, agree to be bound by the terms of this Plan and agree to submit Claims for reimbursement in strict accordance with their State’s health care practice acts, ICD-10 or CPT standards, Medicare guidelines, HCPCS standards, or other standards approved by the Plan Administrator. Any payments made on Claims for reimbursement not in accordance with the above provisions shall be repaid to the Plan within 30 days of discovery or demand or incur prejudgment interest of 1.5% per month. If the Plan must bring an action against a Plan Participant, Provider or other person or entity to enforce the provisions of this section, then that Plan Participant, Provider or other person or entity agrees to pay the Plan’s attorneys’ fees and costs, regardless of the action’s outcome.

Further, Plan Participants, beneficiaries, estate, heirs, guardian, personal representative, or assignees (Plan Participants) shall assign, or be deemed to have assigned, to the Plan their right to recover said payments made by the Plan, from any other party and/or recovery for which the Plan Participant(s) are entitled, for or in relation to Facility-acquired condition(s), Provider error(s), or damages arising from another party’s act or omission for which the Plan has not already been refunded.

The Plan reserves the right to deduct from any benefits properly payable under this Plan the amount of any payment which has been made:

The deduction may be made against any Claim for benefits under this Plan by an Employee or by any of his covered Dependents if such payment is made with respect to the Employee or any person covered or asserting coverage as a Dependent of the Plan Participant.

If the Plan seeks to recoup funds from a Provider due to a Claim being made in error, a Claim being fraudulent on the part of the Provider, and/or the Claim is the result of the Provider’s misstatement, said Provider shall, as part of its Assignment of Benefits from the Plan, abstain from billing the Plan Participant for any outstanding amount(s).

Coordination of the benefit plans. The Plan’s Coordination of Benefits provision sets forth rules for the order of payment of Covered Medical Services when two or more plans – including Medicare – are paying. The Plan has adopted the order of benefits as set forth in the National Association of Insurance Commissioners (NAIC) Model COB Regulations, as amended. When a Plan Participant is covered by this Plan and another plan, or the Plan Participant’s Spouse (which is defined to include Domestic Partner, if applicable, in this section) is covered by this Plan and by another plan, or the couple’s covered children are covered under two or more plans the plans will coordinate benefits when a claim is received.

The plan that pays first according to the rules will pay as if there were no other plans involved. The secondary and subsequent plans will pay the balance due up to 100% of the total Allowable Charges.

Benefit plan. This provision will coordinate the medical and prescription drug and dental benefits of a benefit plan. The term benefit plan means this Plan or any one of the following plans:

The term benefit plan does not include hospital indemnity, accident only, specified disease, school accident or non-medical long-term care coverage.

Allowable Charge(s). For a charge to be allowable, it must be a usual, customary, and reasonable charge and at least part of it must be covered under this Plan. (See “Allowable Charge” in the Definitions section.)

In the case of Health Maintenance Organization (HMO) or other in-network only plans: This Plan will not consider any charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an HMO or network plan is primary and the Plan Participant does not use an HMO or network provider, this Plan will not consider as an Allowable Charge any charge that would have been covered by the HMO or network plan had the Plan Participant used the services of an HMO or network provider.

In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the Allowable Charge.

Benefit plan payment order. When two or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules:

The first rule that describes which plan is primary is the rule that applies:

Special rule. If: (i) the person covered directly is a Medicare beneficiary, and (ii) Medicare is secondary to Plan B, and (iii) Medicare is primary to Plan A (for example, if the person is Retired), THEN Plan B will pay first.

When a child is covered as a Dependent and the parents are married or living together, these rules will apply:

When a child’s parents are divorced, legally separated or not living together, whether or not they have ever been married, these rules will apply:

If there is no Medical Child Support Order allocating responsibility for the Dependent child’s health care expenses, the order of benefits are as follows:

1st The plan covering the custodial parent,

2nd The plan covering the spouse of the custodial parent,

3rd The plan covering the non-custodial parent, and

4th The plan covering the spouse of the non-custodial parent.

When a child is covered as a Dependent under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined as if those individuals were parents of the child.

Unless specifically stated otherwise, Medical Child Support Order and custody provisions apply up to age 19 for any Dependent child.

For a Dependent child who has coverage under either or both parents’ plans and also has his or her own coverage as a dependent under a spouse’s plan, Rule (e) applies. If the Dependent child’s coverage under the spouse’s plan began on the same date as the Dependent child’s coverage under either or both parents’ plans, the birthday rule shall apply to the Dependent child’s parents and the Dependent child’s spouse.

COORDINATION WITH MEDICARE

Notwithstanding all other provisions of this Plan, Plan Participants who are eligible for Medicare benefits may be entitled to benefits under this Plan which will be coordinated with Medicare in accordance with the Coordination of Benefits provision of this Plan and subject to the rules and regulations as specified by the Tax Equity and Fiscal Responsibility Act of 1982 as may be amended from time to time. This Plan is primary to Medicare coverage for all Active Employees and Dependents (regardless of age) unless Medicare states otherwise or for certain medical conditions. In the event that this Plan is secondary to Medicare and the Plan Participant is enrolled under Part A, Part B, or both, benefits payable under this Plan will be reduced by benefits that would be payable for the same services under Medicare Parts A and B.

Medicare Secondary Payer Rules

Medicare is the primary payor (and the Plan is the secondary payor) for:

If Medicare is the primary payor (and the Plan is the secondary payor), the benefits under the Plan are not intended to duplicate any benefits to which Plan Participants are, or would be, entitled under Medicare. Plan Participants must complete any documents or authorizations as may be requested by the Plan in order to obtain reimbursement by Medicare. The Plan will not reduce the benefits due to that Plan Participant's eligibility for Medicare where federal law requires that the Plan determine the benefits for that Plan Participant without regard to the benefits available under Medicare. This section will apply to the maximum extent permitted by federal or state law.

COORDINATION WITH AUTOMOBILE INSURANCE COVERAGE

The Plan’s liability for expenses arising out of an automobile Accident is based on the type of automobile insurance law enacted by the Plan Participant’s State. Nationally, there are three types of State automobile insurance laws:

Coordination With Automobile No-fault Coverage. Except as required by law, the Plan is secondary to any No-Fault Automobile coverage. It is not intended to reduce the level of coverage that would otherwise be available through a No-Fault Automobile Insurance policy nor does it intend to be primary in order to reduce the premiums or cost of No-Fault Automobile coverage.

If the Plan Participant incurs Covered Medical Services as a result of an automobile Accident (either as driver, passenger or pedestrian), the amount of Covered Medical Services that the Plan will pay is limited to:

An individual is considered to be covered under an automobile insurance policy if he/she is either:

Coordination With Financial Responsibility Law. The Plan is secondary to automobile coverage or to any other party who may be liable for the Plan Participant’s medical expenses resulting from the automobile Accident. If the Plan Participant’s State has a “financial responsibility” law which does not allow the Plan to pay benefits as secondary or which does not allow the Plan to advance payments with the intent of subrogating or recovering the payment, the Plan will not pay any benefits related to an automobile Accident for the Plan Participant.

Coordination With Other Automobile Liability Insurance. If the Plan Participant’s State does not have a No-Fault Automobile Insurance law or a “financial responsibility” law, this Plan is secondary to their automobile insurance coverage or to any other party who may be liable for the Plan Participant’s medical expenses resulting from the automobile Accident.

Coordination With Underinsured/Uninsured Motorist Coverage. If the Plan Participant is involved in an automobile Accident and, as a result of the Accident, the Plan pays benefits, and if the Plan Participant receives a settlement from their underinsured or uninsured motorist policy, the Plan is entitled to receive from the proceeds of the settlement with the underinsured or uninsured motorist coverage, the expenses of the Plan. The Plan is not entitled to receive any recovery that is in excess of its expenses. The Plan agrees to payment of benefits prior to the receipt by the Plan Participant of any recovery from their underinsured or uninsured motorist policy. The Plan Participant agrees to notify the Plan of the existence of a recovery from an underinsured or uninsured motorist policy and further agrees to remit to the Plan the proceeds of any recovery received from an underinsured or uninsured motorist policy up to the expenditures made by the Plan. Any expenses by the Plan which are in excess of the proceeds received by the underinsured/uninsured motorist policy will be the responsibility of the Plan pursuant to the terms and conditions of the Plan.

Claims determination period. Benefits will be coordinated on a Calendar Year or Plan Year basis, as shown in the Medical Benefits Schedule. This is called the claims determination period.

Right to receive or release necessary information. To make this provision work, this Plan may give or obtain needed information from another insurer or any other organization or person. This information may be given or obtained without the consent of or notice to any other person. A Plan Participant will give this Plan the information it asks for about other plans and their payment of Allowable Charges.

Facility of payment. This Plan may repay other plans for benefits paid that the Claims Administrator determines the Plan should have paid. That repayment will count as a valid payment under this Plan.

Right of recovery. This Plan may pay benefits that should be paid by another benefit plan. In this case this Plan may recover the amount paid from the other benefit plan or the Plan Participant. That repayment will count as a valid payment under the other benefit plan.

Further, this Plan may pay benefits that are later found to be greater than the Allowable Charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid.

Exception to Medicaid. In accordance with ERISA (if applicable), the Plan shall not take into consideration the fact that an individual is eligible for or is provided medical assistance through Medicaid when enrolling an individual in the Plan or making a determination about the payments for benefits received by a Plan Participant under the Plan.

then the Plan Participant(s) authorizes the Plan to pursue, sue, compromise and/or settle any such Claims in the Plan Participant(s) and/or the Plan’s name and agrees to fully cooperate with the Plan in the prosecution of any such Claims. The Plan Participant(s) assigns all rights to the Plan or its assignee to pursue a Claim and the recovery of all expenses from any and all sources listed above.

The Plan’s right to reimbursement extends to any incident related care that is received by the Plan Participant(s) (“Incurred”) prior to the liable party being released from liability. The Plan Participant’s/Plan Participants’ obligation to reimburse the Plan is therefore tethered to the date upon which the Claims were Incurred, not the date upon which the payment is made by the Plan. In the case of a settlement, the Plan Participant has an obligation to review the “lien” provided by the Plan and reflecting Claims paid by the Plan for which it seeks reimbursement, prior to settlement and/or executing a release of any liable or potentially liable third party, and is also obligated to advise the Plan of any incident related care Incurred prior to the proposed date of settlement and/or release, which is not listed but has been or will be Incurred, and for which the Plan will be asked to pay.

If at the time of Injury, Illness, or disability there is available, or potentially available, any Coverage (including but not limited to Coverage resulting from a judgment at law or settlements), the benefits under this Plan shall apply only as an excess over such other sources of Coverage, except as otherwise provided for under the Plan’s Coordination of Benefits section. The Plan’s benefits shall be excess to:

Benefits paid by the Plan, funds recovered by the Plan Participant(s), and funds held in trust over which the Plan has an equitable lien exist separately from the property and estate of the Plan Participant(s), such that the death of the Plan Participant(s), or filing of bankruptcy by the Plan Participant(s), will not affect the Plan’s equitable lien, the funds over which the Plan has a lien, or the Plan’s right to subrogation and reimbursement.

In the event that the Plan Participant(s) dies as a result of his/her injuries and a wrongful death or survivor Claim is asserted against a third party or any Coverage, the Plan’s subrogation and reimbursement rights shall still apply.

1. It is the Plan Participant(s) obligation at all times, both prior to and after payment of benefits by the Plan to:

If timely repayment is not made, or the Plan Participant(s) and/or his or her attorney fails to comply with any of the requirements of the Plan, the Plan has the right, in addition to any other lawful means of recovery, to deduct the value of the Plan Participant’s amount owed to the Plan. To do this, the Plan may refuse payment of any future benefits and any funds or payments due under this Plan on behalf of the Plan Participant(s) in an amount equivalent to any outstanding amounts owed by the Plan Participant to the Plan. This provision applies even if the Plan Participant has disbursed settlement funds.

2. If the minor’s parents or court-appointed guardian fail to take such action, the Plan shall have no obligation to advance payment of benefits on behalf of the minor. Any court costs or legal fees associated with obtaining such approval shall be paid by the minor’s parents or court-appointed guardian.

The Plan Administrator retains sole, full, and final discretionary authority to construe and interpret the language of this provision, to determine all questions of fact and law arising under this provision, and to administer the Plan’s subrogation and reimbursement rights. The Plan Sponsor may amend the Plan at any time without notice.

In the event that any section of this provision is considered invalid or illegal for any reason, said invalidity or illegality shall not affect the remaining sections of this provision and Plan. The section shall be fully severable. The Plan shall be construed and enforced as if such invalid or illegal sections had never been inserted in the Plan.

The Plan has the right to recover any benefits the Plan paid in error to the Plan Participant or on behalf of a Plan Participant to which the Plan Participant is not entitled, for services which were not covered under the Plan, or for benefits paid in excess of the Plan’s Allowable Charges. The Plan may recover benefits paid in error from the Plan Participant, the provider who received a payment from the Plan on the Plan Participant’s behalf, or from any person who may have benefited. The Plan may also offset any future benefits otherwise payable to or on the Plan Participant’s behalf, or from any other Plan Participant enrolled through the same covered Employee (or Retiree, if applicable).

Introduction

The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”). COBRA Continuation Coverage can become available to You and other members of Your family when group health coverage would otherwise end. You should check with Your Employer to see if COBRA applies to You and Your Dependents.

You may have other options available to You when You lose group health coverage. For example, You may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, You may qualify for lower costs on Your monthly premiums and lower out-of-pocket costs. Additionally, You may qualify for a 30-day special enrollment period for another group health plan for which You are eligible (such as a Spouse’s plan), even if that plan generally doesn’t accept Late Enrollees.

What is COBRA Continuation Coverage?

“COBRA Continuation Coverage” is a continuation of Plan coverage when coverage otherwise would end because of a life event known as a “Qualifying Event.” After a Qualifying Event, COBRA Continuation Coverage must be offered to each person who is a “Qualified Beneficiary.” You, Your Spouse, and Your Dependent children could become Qualified Beneficiaries if coverage under the Plan is lost because of the Qualifying Event. Under the Plan, Qualified Beneficiaries who elect COBRA Continuation Coverage must pay for COBRA Continuation Coverage.

Note: “Qualified Beneficiary” is a term defined under IRS COBRA regulations to mean a covered Employee, the spouse of a covered Employee, or the Dependent Child of a covered Employee. Continuation coverage for Domestic Partners and their Dependents is offered voluntarily by the Employer and is not required by or subject to COBRA. As this is COBRA-equivalent coverage, a Domestic Partner will be treated as a Qualified Beneficiary to the same extent as if the Domestic Partner were the Employee's spouse and will have independent election rights, including in the event of the covered Employee’s death. In addition, the Dependent Children of a covered Domestic Partner will be treated as “Qualified Beneficiaries” for these purposes to the same extent that Dependents of a spouse would be so treated and will have independent election rights, including in the event of the covered Employee’s death. Although the Plan will treat a Domestic Partner as a “Qualified Beneficiary,” this treatment does not qualify a Domestic Partner as a “Qualified Beneficiary” under IRS COBRA final regulations.

When is COBRA Continuation Coverage available?

The Plan will offer COBRA Continuation Coverage to Qualified Beneficiaries only after the Plan Administrator has been notified that a Qualifying Event has occurred.

If You are a covered Employee, You will become a Qualified Beneficiary if You lose Your coverage under the Plan due to one of the following Qualifying Events:

If You are the Spouse of a covered Employee, You will become a Qualified Beneficiary if You lose Your coverage under the Plan due to one of the following Qualifying Events:

Your Dependent children will become Qualified Beneficiaries if they lose coverage under the Plan due to one of the following Qualifying Events:

If this Plan provides Retiree health coverage, sometimes, filing a proceeding in bankruptcy under Title 11 of the United States Code can be a Qualifying Event. If a proceeding in bankruptcy is filed with respect to the Employer, and that bankruptcy results in the loss of coverage of any Retired Employee covered under the Plan, the Retired Employee will become a Qualified Beneficiary with respect to the bankruptcy. The Retired Employee’s Spouse, surviving Spouse, and Dependent children also will become Qualified Beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

The Plan Administrator must be notified within 60 days after the Qualifying Event occurs. You must provide this notice in writing to the Plan Administrator [to be provided by employer as detailed in the Vitable contract:______________________].

Notice must be postmarked, if mailed, or dated, if emailed or hand-delivered, on or before the 60th day following the Qualifying Event.

How is COBRA Continuation Coverage provided?

Once the Plan Administrator receives notice that a Qualifying Event has occurred, COBRA Continuation Coverage will be offered to each of the Qualified Beneficiaries. Each Qualified Beneficiary will have an independent right to elect COBRA Continuation Coverage. Covered Employees may elect COBRA Continuation Coverage on behalf of their Spouses, and parents may elect COBRA Continuation Coverage on behalf of their Dependent children.

In the event that the COBRA Administrator determines that the individual is not entitled to COBRA Continuation Coverage, the COBRA Administrator will provide to the individual an explanation as to why he or she is not entitled to COBRA Continuation Coverage.

How long does COBRA Continuation Coverage last?

COBRA Continuation Coverage is a temporary continuation of coverage that generally last for 18 months due to the employment termination or reduction of hours of work. Certain Qualifying Events, or a second Qualifying Event during the initial period of coverage, may permit a Qualified Beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA Continuation Coverage can be extended, discussed below.

If the Qualifying Event is the death of the covered Employee (or former Employee), the covered Employee’s (or former Employee’s) becoming entitled to Medicare benefits (under Part A, Part B, or both), Your divorce or legal separation, or a Dependent child’s losing eligibility as a Dependent child, COBRA Continuation Coverage can last for up to a total of 36 months.

Medicare extension of COBRA Continuation Coverage

Entitlement to Medicare is not considered a traditional secondary Qualifying Event for a covered Dependent; however, Medicare entitlement does provide potentially longer periods of continuation coverage to certain Qualified Beneficiaries based on the sequence of events. If a covered Employee becomes entitled to Medicare, but the Employee is still a full-time active Employee, this event is not a COBRA Qualifying Event since Medicare entitlement alone does not cause a loss of coverage. If the covered Employee voluntarily terminates employment after the Medicare entitlement date, the loss of coverage triggers a potential 18-month COBRA continuation period for all Qualified Beneficiaries. While the covered Employee is only entitled to 18 months of COBRA Continuation Coverage, the other Qualified Beneficiaries (spouse and/or Dependent children) are entitled to 18 months or 36 months, measured from the date of the Employee's Medicare entitlement, whichever is greater.

Note: Medicare entitlement means that You are eligible for and enrolled in Medicare.

Disability extension of 18-month period of COBRA Continuation Coverage

If You or anyone in Your family covered under the Plan is determined by the Social Security Administration (SSA) to be disabled and You notify the Plan Administrator as set forth herein, You and Your entire family may be entitled to receive up to an additional 11 months of COBRA Continuation Coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA Continuation Coverage and must last at least until the end of the 18-month period of COBRA Continuation Coverage. An extra fee will be charged for this extended COBRA Continuation Coverage.

Notice of the disability determination must be provided in writing to the Plan Administrator by the date that is 60 days after the latest of:

In any event, this notice must be furnished before the end of the first 18 months of Continuation Coverage.

The notice must include the name of the Qualified Beneficiary determined to be disabled by the SSA and the date of the determination. A copy of SSA’s Notice of Award Letter must be provided within 30 days after the deadline to provide the notice. You must provide this notice to the Plan Administrator by [to be provided by employer as detailed in the Vitable contract:______________________]

Second Qualifying Event extension of 18-month period of COBRA Continuation Coverage

If Your family experiences another Qualifying Event while receiving 18 months of COBRA Continuation Coverage, the Spouse and Dependent children in Your family can get up to 18 additional months of COBRA Continuation Coverage, for a maximum of 36 months, if the Plan Administrator is properly notified about the second Qualifying Event. This extension may be available to the Spouse and any Dependent children receiving COBRA Continuation Coverage if the covered Employee or former Employee dies, becomes entitled to Medicare benefits (in certain circumstances), or gets divorced or legally separated, or if the Dependent child stops being eligible under the Plan as a Dependent child. This extension is only available if the second Qualifying Event would have caused the Spouse or Dependent child to lose coverage under the Plan had the first Qualifying Event not occurred.

Notice of a second Qualifying Event must be provided in writing to the Plan Administrator by the date that is 60 days after the latest of:

The notice must include the name of the Qualified Beneficiary experiencing the second Qualifying Event, a description of the event and the date of the event. If the extension of coverage is due to a divorce or legal separation, a copy of the decree of divorce or legal separation must be provided within 30 days after the deadline to provide the notice.

You must provide this notice to the Plan Administrator [to be provided by employer as detailed in the Vitable contract:______________________]

Does COBRA Continuation Coverage ever end earlier than the maximum periods above?

COBRA Continuation Coverage will end before the end of the maximum period on the earliest of the following dates:

How Do I Pay for COBRA Continuation Coverage?

Once COBRA Continuation Coverage is elected, You must pay for the cost of the initial period of coverage within 45 days. Payments are then due on the first day of each month to continue coverage for that month. If a payment is not received and/or post-marked within 30 days of the due date, COBRA Continuation Coverage will be canceled and will not be reinstated.

Are There Other Coverage Options Besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA Continuation Coverage, there may be other coverage options for You and Your family through the Health Insurance Marketplace, Medicaid, Children’s Health Insurance Program (CHIP) or other group health plan coverage options (such as a Spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA Continuation Coverage. You can learn more about many of these options at www.HealthCare.gov.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if You don’t enroll in Medicare Part A or B when You are first eligible because You are still employed, after the Medicare initial enrollment period, You have an 8-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of:

If You don’t enroll in Medicare and elect COBRA continuation coverage instead, You may have to pay a Part B late enrollment penalty and You may have a gap in coverage if You decide You want Part B later. If You elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate Your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if You enroll in the other part of Medicare after the date of the election of COBRA coverage.

If You are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if You are not enrolled in Medicare.

For more information visit https://www.medicare.gov/medicare-and-You.

Additional Information

Additional information about the Plan and COBRA Continuation Coverage is available from the Plan Administrator [to be provided by employer as detailed in the Vitable contract:______________________]or the COBRA Administrator:

For more information about Your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in Your area or visit www.dol.gov/agencies/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Current Addresses

To protect Your family’s rights, let the Plan Administrator (who is identified above) know about any changes in the addresses of family members. You should also keep a copy, for Your records, of any notices You send to the Plan Administrator.

As a Plan Participant in the Plan, 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:

RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS

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 Employee Benefits Security 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 Plan Administrator may make a reasonable charge for the copies.

To the extent required by ERISA to be prepared by the Plan, receive a summary of the Plan's annual financial report. Plan Administrators are required by law to furnish Participants in certain plans with a copy of this summary annual report.

CONTINUE GROUP HEALTH PLAN COVERAGE

Continue health care coverage for Yourself, Your spouse and/or Your 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.

PRUDENT ACTIONS BY PLAN FIDUCIARIES

In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the operation of the Employee Welfare Benefit Plan. The people who operate the 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 welfare benefit under the Plan or exercising Your rights under ERISA.

ENFORCE YOUR RIGHTS

If Your Claim for a 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 Document 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 Plan 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 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 or suit is frivolous.

ASSISTANCE WITH YOUR QUESTIONS

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 Employee Benefits Security Administration, U.S. Department of Labor, listed in Your telephone directory or the Office of Outreach, Education, and Assistance, Employee Benefits Security 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 Employee Benefits Security Administration.

The Plan will not use or disclose Protected Health Information (“PHI”) except as permitted by this section or as otherwise permitted or required by law, including but not limited to the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (the “HIPAA Privacy Rule”), as may be amended from time to time. Nothing in this section shall be construed to prohibit the Plan Sponsor’s receipt of “summary health information,” as described in the HIPAA Privacy Rule, for certain Plan Sponsor-related purposes, including obtaining premium bids for health insurance, making Plan design and funding decisions, and modifying, amending, or terminating the Plan.

The Plan will disclose PHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor to the Plan that the Plan has been amended to provide for the Plan Sponsor’s receipt of PHI and that the Plan Sponsor agrees to comply with the following provisions:

The Plan will not use or disclose ePHI except as permitted by this section or as otherwise permitted or required by law, including but not limited to the requirements of 45 C.F.R. Sections 164.314(b)(1) and (2) and its implementing regulations, 45 C.F.R. parts 160, 162, and 164 of the Security Standards of the Health Insurance Portability and Accountability Act of 1996 (the “HIPAA Security Standards”), as they may be amended from time to time. Nothing in this section shall be construed to prohibit the Plan Sponsor’s receipt of “summary health information,” as described in the HIPAA Security Standards, for certain Plan Sponsor-related purposes, including obtaining premium bids for health insurance, making Plan design and funding decisions, and modifying, amending, or terminating the Plan.

The Plan will disclose ePHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that the Plan has been amended to provide for the Plan Sponsor’s receipt of ePHI and that the Plan Sponsor agrees to comply with the following provisions:

The Health Information Technology for Economic and Clinical Health Act (HITECH) of the American Recovery and Reinvestment Act of 2009 (ARRA) imposes notification in the event of a Breach of unsecured PHI.

The Plan Sponsor will report to the Privacy Official of the Plan any use or disclosure of PHI not permitted by HIPAA, along with any Breach of unsecured PHI. The Plan Sponsor will treat the Breach as being discovered in accordance with HIPAA’s requirements. The Plan Sponsor will make the report to the Privacy Official not more than 30 calendar days after the Plan Sponsor learns of such non-permitted use or disclosure. If a delay is requested by a law enforcement official in accordance with 45 C.F.R. § 164.412, the Plan Sponsor may delay notifying the Privacy Official for the time period specified by such regulation. The Plan Sponsor’s report will at least:

The Plan Sponsor will report to the Privacy Official within 30 calendar days any attempted or successful: a) unauthorized access, use, disclosure, modification, or destruction of ePHI; and b) interference with the Plan Sponsor’s system operations in the Plan Sponsor’s information systems, of which the Plan Sponsor becomes aware. The Plan Sponsor will make this report upon the Privacy Official’s request, except if any such Security Incident resulted in a disclosure or Breach of PHI or ePHI not permitted by the HITECH Act, the Plan Sponsor will make the report in accordance with the above.

PLAN ADMINISTRATOR. Vitable Health Medical Benefit Plan is the benefit plan of Vitable Health, the Plan Administrator, also called the Plan Sponsor. It is to be administered by the Plan Administrator in accordance with the provisions of ERISA, if applicable. An individual or committee may be appointed by Vitable Health to be Plan Administrator and serve at the convenience of the Employer. If the Plan Administrator or a committee member resigns, dies or is otherwise removed from the position, Vitable Health shall appoint a new Plan Administrator as soon as reasonably possible.

The Plan Administrator has the authority to, and does so allocate limited fiduciary duties to American Health Holdings, Inc. Those duties are limited to a review of and determination on a Plan Participant’s request (or a request by the Plan Participant’s treating provider) for a pre-determination of benefits prior to the occurrence of treatment or services. As part of those limited duties, American Health Holdings shall have the discretionary authority and ultimate decision-making authority to review the request and any submitted documentation, make a decision, respond to an appeal if the decision is to deny the request, and to maintain records related to its activities related to this decision. See the Utilization Management section for additional information.

The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies, interpretations, practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan, to make determinations regarding issues which relate to eligibility for benefits, to decide disputes which may arise relative to a Plan Participant's rights, and to decide questions of Plan interpretation and those of fact relating to the Plan. The decisions of the Plan Administrator will be final and binding on all interested parties.

Service of legal process may be made upon the Plan Administrator.

DUTIES OF THE PLAN ADMINISTRATOR

PLAN ADMINISTRATOR COMPENSATION. The Plan Administrator serves without compensation; however, all expenses for plan administration, including compensation for hired services, will be paid by the Plan.

If age is a factor in determining eligibility or amount of coverage and there has been a misstatement of age, the coverages or amounts of benefits, or both, for which the person is covered shall be adjusted in accordance with the Plan Participant's true age. Any such misstatement of age shall neither continue coverage otherwise validly terminated, nor terminate coverage otherwise validly in force. Benefits will be adjusted following the date of the discovery of such misstatement.

FUNDING

For Employee Coverage: The Employer shares the cost of Employee coverage under this Plan with the covered Employee.

For Dependent Coverage: The Employee shares the cost of Dependent coverage under the Plan with the covered Employee.

The level of any Employee contributions is set by the Plan Administrator. The Plan Administrator reserves the right to change the level of Employee contributions.

No term, condition or provision of the Plan shall be waived, and there shall be no estoppel against the enforcement of any provision of the Plan, except by written direction of the Plan Administrator. No such waiver shall be deemed a continuing waiver unless specifically stated. Each waiver shall operate only as to the specific term or condition waived and shall not constitute a waiver of such term or condition for the future or as to any act other than that specifically waived.

This Plan is not in lieu of and does not affect any requirement for coverage by Workers' Compensation Insurance or, where permitted and applicable, any other alternative form of Workers’ Compensation benefits.

A benefit payment made via check must be cashed or deposited within one year after the date the check was issued or it will be treated as a forfeiture and may be used by the Plan Administrator to pay Plan benefits or offset Plan administrative expenses.

This Plan shall be deemed to automatically be amended to conform as required by any applicable law, regulation or the order or judgment of a court of competent jurisdiction governing provisions of this Plan, including, but not limited to, stated maximums, exclusions, or limitations. In the event that any law, regulation or the order or judgment of a court of competent jurisdiction causes the Plan Administrator to pay Claims which are otherwise limited or excluded under this Plan, such payments will be considered as being in accordance with the terms of this Plan Document.

The following actions by a Plan Participant or a Plan Participant’s knowledge of such actions being taken by another, constitute fraud and will result in termination of all coverage under this Plan for the entire Family Unit of which the Plan Participant is a member:

In addition to being considered fraud on the Plan and an intentional misrepresentation, enrolling ineligible dependents or maintaining coverage for a person who no longer satisfies the dependent eligibility rules violates company policy. If the company determines that an ineligible dependent has been enrolled, coverage may be canceled retroactively. The company reserves the right to recover any and all benefit payments made for services received by ineligible dependents and to terminate a Plan Participant’s employment, if applicable.

A Plan Participant may not assign or transfer any benefits or rights that arise under the Plan or applicable law to any other person, including a healthcare provider, and any purported assignment or transfer is void. This includes (but is not limited to) an attempted assignment or transfer of claims for payment of benefits, breach of fiduciary duty, penalties or any other claim or remedy. For convenience, the Plan may pay any undisputed benefit directly to the healthcare provider, but this is not a waiver of this anti-assignment provision and does not make the healthcare provider an assignee or confer any other rights on the provider. Similarly, the Plan recognizes an authorized representative for purposes of the Plan’s claims and appeal procedures, but the authorized representative is not an assignee and has no derivative rights with respect to the claim. However, this anti-assignment provision will not apply (1) to an assignment of a Plan Participant’s rights to the Plan or the Plan Administrator, or (2) to the extent required under Medicaid laws.

The Plan reserves the right to allocate the deductible amount to any Covered Medical Services and to apportion the benefits to the Plan Participant and any assignees. Such allocation and apportionment shall be conclusive and shall be binding upon the Plan Participant and all assignees.

If a Claimant is a minor or is physically or mentally incapable of giving a valid release for payment, the Claims Administrator, at its option, may make payment to a party who has assumed responsibility for the care of such person. Such payments will be made until Claim is made by a guardian. If a Claimant dies while benefits remain unpaid, benefits will be paid at the Claim Administrator’s option to:

Such payment will release the Plan Administrator and Claims Administrator of all further liability to the extent of payment.

A Claims Administrator is not a fiduciary under the Plan by virtue of paying claims in accordance with the Plan's rules as established by the Plan Administrator.

The Plan is not to be construed as a contract for or of employment.

Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly terminated. An equitable adjustment of contributions will be made when the error or delay is discovered.

If an overpayment occurs in a Plan reimbursement amount, the Plan retains a contractual right to the overpayment. The person or institution receiving the overpayment will be required to return the incorrect amount of money. In the case of a Plan Participant, the amount of overpayment may be deducted from future benefits payable.

The Plan Sponsor reserves the right, at any time, to amend, suspend or terminate the Plan in whole or in part at any time and for any reason. This includes amending the benefits under the Plan or the Trust agreement (if any). Subject to the requirements of ERISA §402 (if applicable), in the event of a termination or partial termination of the Plan or Trust (if applicable), the Plan by action of the Plan Administrator, the Board of Directors, or other authorized committee thereof, shall direct the disposition of Plan assets, including assets held in a Trust, if any, which may include transfer of such assets to another employee benefit plan or trust maintained by the Employer.

The following terms have special meanings and when used in this Plan will be capitalized.

Accident means a sudden and unforeseen event, or a deliberate act resulting in unforeseen consequences.

Active Employee is an Employee who is on the regular payroll of the Employer and who has begun to perform the duties of his or her job with the Employer.

Allowable Charge means the amount for a treatment, service or supply that is the negotiated amount established by a provider network arrangement or other discounting or negotiated arrangement.

For Covered Medical Services rendered by a Physician, Hospital or ancillary provider in a geographic area where applicable law or a governmental authority directs the amount to be paid, the Allowable Charge will mean the amount established by applicable law or governmental authority for the Covered Medical Service.

In the absence of such network arrangement, negotiated arrangement, controlling law or governmental directive that establishes the amount to be paid, the Allowable Charge will mean 90% of UCR.

In the event the Non-Network Provider disputes the Plan’s Allowable Charge for any claim subject to the No Surprises Act (NSA) through the Independent Dispute Resolution (IDR) process, the Allowable Charge may be determined by a Certified IDR Entity.

Ancillary Services mean incidental services that assist a medical procedure, but are not essential to the accomplishment of the medical procedure (i.e., laboratory testing).

Applied Behavior Analysis (ABA) Therapy is a scientific approach that applies the understanding of how behavior works to real situations with the goal of increasing behaviors that are helpful, and decreasing behaviors that are harmful or that affect learning. ABA Therapy involves many techniques for understanding and changing behavior. ABA Therapy programs can help to increase language and communication skills; improve attention, social skills, and academics; and decrease problem behaviors.

Approved Clinical Trial means a phase I, II, III or IV trial that is federally funded by specified Agencies (National Institutes of Health, CDCP, Agency for Health Care Research, CMS, Dept. of Defense or Veterans Affairs, or a non-governmental entity identified by NIH guidelines) or is conducted under an Investigational new Drug application reviewed by the FDA (if such application is required).

Birthing Center means any freestanding health Facility, place, professional office or institution which is not a Hospital or in a Hospital, where births occur in a home-like atmosphere. This Facility must be licensed and operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the Facility is located.

The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse-midwife; and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post-delivery confinement.

Calendar Year means January 1st through December 31st of the same year.

Certified Independent Dispute Resolution (IDR) Entity means an entity responsible for conducting determinations under the No Surprises Act (NSA) that has been properly certified by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury.

COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Complications of Pregnancy are determined as follows:

These conditions are included before the Pregnancy ends: acute nephritis; ectopic Pregnancy; miscarriage; nephrosis; cardiac decompensation; missed abortion; hyperemesis gravidarum; and eclampsia of Pregnancy.

Other Pregnancy related conditions will be covered that are as medically severe as those listed.

These conditions are not considered a Complication of Pregnancy: false labor; occasional spotting; rest during Pregnancy even if prescribed by a Physician; morning sickness; or like conditions that are not medically termed as Complications of Pregnancy.

Congenital Anomaly means a physical, metabolic or anatomic deviation from the normal pattern of development that is apparent at birth or detected during the first year of life.

Covered Medical Service(s) means those Medically Necessary services or supplies that are covered under this Plan, Preventive Care Services as determined by the current U.S. Preventive Services Task Force (USPSTF) grades A and B recommendations, and other routine care services specifically stated as an eligible expense under this Plan.

Custodial Care is care (including Room and Board needed to provide that care) that is given principally for personal hygiene or for assistance in daily activities and can, according to generally accepted medical standards, be performed by persons who have no medical training. Examples of Custodial Care are help in walking and getting out of bed; assistance in bathing, dressing, feeding; or supervision over medication which could normally be self-administered.

Donor means one who furnishes blood, tissue, or an organ to be used in the Plan Participant.

Durable Medical Equipment means equipment which (a) can withstand repeated use, (b) is primarily and customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of an Illness or Injury and (d) is appropriate for use in the home.

Emergency Services means the following:

When furnished with respect to a Medical Emergency, Emergency Services shall also include an item or service provided by a Non-Network provider (regardless of the department of the Hospital in which items or services are furnished) after the Plan Participant is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the Emergency Services are furnished, until such time as the provider determines that the Plan Participant is able to travel using non-medical transportation or non-emergency medical transportation, and the Plan Participant is in a condition to, and in fact does, give informed consent to the provider to be treated as a Non-Network Provider.

Employee means a person who is classified by his Employer as an Active, common law Employee.

Employer is [to be provided by employer as detailed in the Vitable contract:______________________]

ERISA is the Employee Retirement Income Security Act of 1974, as amended.

Experimental and/or Investigational means services, supplies, care and treatment which does not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical community or government oversight agencies at the time services were rendered.

The Plan Administrator must make an independent evaluation of the Experimental/nonexperimental standings of specific technologies. The Plan Administrator shall be guided by a reasonable interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim and the proposed treatment. The decision of the Plan Administrator will be final and binding on the Plan. The Plan Administrator will be guided by the following principles:

Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating Facility or the protocol(s) of another Facility studying substantially the same drug, service, medical treatment or procedure; or the written informed consent used by the treating Facility or by another Facility studying substantially the same drug, device, medical treatment or procedure.

Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved by the Food and Drug Administration for general use.

Facility means a healthcare institution which meets all applicable state or local licensure requirements. For the purposes of the Claim Review and Audit Program, Facility includes, but is not limited to, Hospitals, emergency, rehabilitation and Skilled Nursing Facilities, Outpatient Surgical Centers, laboratories, x-ray, MRI or other CT facilities, and any other health care Facility.

Family Unit is the covered Employee and the family members who are covered as Dependents under the Plan.

Fiduciary is the entity that exercises discretionary authority or control over management of the Plan or the disposition of its assets, renders investment advice to the Plan or has discretionary authority or responsibility in the administration of the Plan.

Formulary means a list of prescription medications compiled by the third party payor of safe, effective therapeutic drugs specifically covered by this Plan.

Generic drug means a Prescription Drug which has the equivalency of the brand name drug with the same use and metabolic disintegration. This Plan will consider as a Generic drug any Food and Drug Administration approved Generic pharmaceutical dispensed according to the professional standards of a licensed pharmacist and clearly designated by the pharmacist as being Generic.

Habilitation Services mean a service designed to assist individuals in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community based settings.

Home Health Care Agency is an organization that meets all of these tests: its main function is to provide Home Health Care Services and Supplies; it is federally certified as a Home Health Care Agency; and it is licensed by the state in which it is located, if licensing is required.

Home Health Care Plan must meet these tests: it must be a formal written plan made by the patient's attending Physician which is reviewed at least every 30 days; it must state the diagnosis; and it must specify the type and extent of Home Health Care required for the treatment of the patient.

Home Health Care Services and Supplies include: part-time or intermittent nursing care by or under the supervision of a registered nurse (R.N.); part-time or intermittent home health aide services provided through a Home Health Care Agency (this does not include general housekeeping services); physical, occupational and speech therapy; medical supplies; and laboratory services by or on behalf of the Hospital.

Hospice Agency is an organization where its main function is to provide Hospice Care Services and Supplies and it is licensed by the state in which it is located, if licensing is required.

Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice Agency and supervised by a Physician.

Hospice Care Services and Supplies are those provided through a Hospice Agency and under a Hospice Care Plan and include inpatient care in a Hospice Unit or other licensed Facility, home care, and family counseling during the bereavement period.

Hospice Unit is a Facility or separate Hospital Unit that provides treatment under a Hospice Care Plan and admits at least two unrelated persons who are expected to die within six months.

Hospital is an institution that is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense and that fully meets these tests: it is approved by Medicare as a Hospital; it maintains diagnostic and therapeutic facilities on the premises for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of Physicians; it continuously provides on the premises 24-hour nursing services by or under the supervision of registered nurses (R.N.s); and it is operated continuously with organized facilities for operative surgery on the premises.

Illness means:

For a covered Employee and covered Spouse, Illness means a bodily disorder, disease, or physical sickness. Illness includes Pregnancy, childbirth, miscarriage or Complications of Pregnancy.

For a covered Dependent other than Spouse, Illness means a bodily disorder, disease, or physical sickness, but does not include Pregnancy or its complications.

Incurred means the date the service is rendered or the supply is obtained. With respect to a course of treatment or procedure which includes several steps or phases of treatment, expenses are Incurred for the various steps or phases as the services related to each step are rendered and not when services relating to the initial step or phase are rendered.

Independent Freestanding Emergency Department means a health care facility that is geographically separate and distinct, and licensed separately, from a Hospital under applicable state law, and which provides any Emergency Services. Independent Freestanding Emergency Departments do not include Urgent Care Centers or Clinics.

Infertility means incapable of producing offspring.

Injury means an accidental physical Injury to the body caused by unexpected external means.

Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within a Hospital solely for the care and treatment of patients who are critically ill. This also includes what is referred to as a "coronary care unit" or an "acute care unit." It has: facilities for special nursing care not available in regular rooms and wards of the Hospital; special lifesaving equipment which is immediately available at all times; at least two beds for the accommodation of the critically ill; and at least one registered nurse (R.N.) in continuous and constant attendance 24 hours a day.

Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations. Lifetime is understood to mean while covered under this Plan. Under no circumstances does Lifetime mean during the Lifetime of the Plan Participant.

Medical Child Support Order means any judgment, decree or order (including approval of a domestic relations settlement agreement) issued by a court of competent jurisdiction that:

Medical Emergency means a medical condition manifesting itself by acute symptoms of sufficient severity including severe pain such that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy to the health of an individual (or, in the case of a pregnant woman, the health of the woman or her unborn child), (2) serious impairment to body functions, or (3) serious dysfunction of any body organ or part. A Medical Emergency includes such conditions as heart attacks, cardiovascular accidents, poisonings, loss of consciousness or respiration, convulsions or other such acute medical conditions.

Medically Necessary or Medical Necessity care and treatment is recommended or approved by a Physician; is consistent with the patient's condition or accepted standards of good medical practice; is medically proven to be effective treatment of the condition; is not performed mainly for the convenience of the patient or provider of medical services; and is the most appropriate level of services which can be safely provided to the patient.

All of these criteria must be met; merely because a Physician recommends or approves certain care does not mean that it is Medically Necessary.

The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary.

Medicare is the Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act, as amended.

Network Provider/Network Facility means a healthcare institution or healthcare provider who have by contract agreed to provide services at discounted reimbursement rates. A single direct contract or case agreement between a health care Facility or healthcare provider and a Plan constitutes a contractual relationship for purposes of this definition with respect to the parties to the agreement and particular individual(s) involved.

No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.

Non-Network Provider/Non-Network Facility means a healthcare institution or healthcare provider who do not have a contractual relationship with the Plan or issuer, respectively, regarding reimbursement of items or services they provide.

Outpatient Care and/or Services is treatment including services, supplies and medicines provided and used at a Hospital under the direction of a Physician to a person not admitted as a registered bed patient; or services rendered in a Physician's office, laboratory or X-ray Facility, an Outpatient Surgical Center, or the Plan Participant’s home.

Outpatient Surgical Center is a licensed Facility that is used mainly for performing outpatient surgery, has a staff of Physicians, has continuous Physician and nursing care by registered nurses (R.N.s) and does not provide for overnight stays.

Pharmacy means a licensed establishment where covered Prescription Drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices.

Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Optometrist (O.D.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor, Licensed Professional Physical Therapist, Master of Social Work (M.S.W.), Certified Nurse Midwife (CNM) or Certified Midwife (CM), Occupational Therapist, Doctor of Dental Surgery (D.D.S.), Physiotherapist, Psychiatrist, Psychologist (Ph.D.), Speech Language Pathologist, and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license.

Plan means Vitable Health Medical Benefit Plan, which is a benefits plan for certain Employees of the Employer [to be provided by employer as detailed in the Vitable contract:______________________] and as described in this document.

Plan Amendment means a formal document that changes the provisions of the Plan Document, duly signed by the authorized person or persons as designated by the Plan Sponsor.

Plan of Care is a written plan that describes the services being provided and any applicable short term and long term goals, specific treatment techniques, anticipated frequency and duration of treatment, and/or treatment protocol for the Plan Participant’s specific condition. The Plan of Care must be written or approved by a Physician and updated as the Plan Participant’s condition changes.

Plan Participant is any Employee or Dependent who is covered under this Plan.

Plan Year is the 12-month period beginning on the effective date [to be provided by employer as detailed in the Vitable contract:______________________] through the following consecutive 12 months.

Pregnancy is childbirth and conditions associated with Pregnancy, including complications.

Prescription Drug means any of the following: a Food and Drug Administration-approved drug or medicine which, under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription"; injectable insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed Physician.

Qualified Individual means someone who is eligible to participate in an “Approved Clinical Trial” and either the individual’s doctor has concluded that participation is appropriate or the participant provides medical and scientific information establishing that their participation is appropriate.

Qualifying Payment Amount (QPA) means the median of the contracted rates recognized by the Plan or recognized by all Plans serviced by the Plan’s Third-Party Administrator (if calculated by the Third-Party Administrator), for the same or a similar item or service provided by a provider in the same or similar specialty in the same geographic region. If there are insufficient (meaning at least three) contracted rates available to determine a QPA, said amount will be determined by referencing an applicable state all-payer claims database or any eligible third-party database in accordance with applicable law.

Recognized Amount, except for Non-Network Provider air ambulance services, means an amount determined under an applicable all-payer model agreement, or if unavailable, an amount determined by applicable state law. If no such amounts are available or applicable, and for Non-Network Provider air ambulance services, the Recognized Amount shall mean the lesser of a provider’s billed charge or the Qualifying Payment Amount.

Room and Board means all charges, by whatever name called, which are made by a Hospital, Hospice, Skilled Nursing Facility, Rehabilitation Facility or other covered Facilities as a condition of inpatient confinement as a bed patient.

Routine Patient Cost(s) means all items and services consistent with the coverage provided in the Plan that is typically covered for a Qualified Individual who is not enrolled in a clinical trial. Routine Patient Costs do not include: 1) the Investigational item, device or service itself; 2) items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; and 3) a service that is clearly inconsistent with the widely accepted and established standards of care for a particular diagnosis. Plans are not required to provide benefits for routine patient care services provided outside of the Plan’s network area unless out-of-network benefits are otherwise provided under the Plan.

Skilled Nursing Facility is a Facility that fully meets all of the following:

1. It is licensed to provide professional nursing services on an inpatient basis to persons convalescing from Injury or Illness. The service must be rendered by a registered nurse (R.N.) or by a licensed practical nurse (L.P.N.) under the direction of a registered nurse. Services to help restore patients to self-care in essential daily living activities must be provided.

2. Its services are provided for compensation and under the full-time supervision of a Physician.

3. It provides 24-hour nursing services by licensed nurses, under the direction of a full-time registered nurse.

4. It maintains a complete medical record on each patient.

5. It has an effective utilization review plan.

6. It is not, other than incidentally, a place for rest, the aged, Custodial or educational care.

7. It is approved and licensed by Medicare.

This term also applies to charges Incurred in a Facility referring to itself as an extended care Facility, convalescent nursing home, rehabilitation Hospital, long-term acute care Facility or any other similar nomenclature.

Sleep Disorder means medical/psychological condition that disrupts the patient’s sleep on a chronic basis.

Usual and Customary Rate (UCR). “Usual” means the amount of a charge made for medical services, care, or supplies, to the extent that the charge does not exceed the common level of charges made by other medical professionals with similar credentials, or Facilities, pharmacies, or equipment suppliers of similar standing, which are located in the same geographic locale in which the charge was incurred. “Customary” means to the form and substance of a service, supply, or treatment provided in accordance with generally accepted standards of medical practice to one individual, which is appropriate for the care or treatment of an individual of the same sex, comparable age and who has received such services or supplies within the same geographic locale. Usual and Customary does not necessarily mean the actual charge made nor the specific service or supply furnished to a Plan Participant by a Provider of services or supplies.

You / Your means the Employee and, when applicable, covered Dependents.