SummaCare Certificate of Coverage

HMO
Evidence of Coverage
www.summacare.com
2003

New!
SummaCare Plan Central
On-Line access for claims and referral/authorization
status, eligibility and benefits information.
Go to www.summacare.com and click on
SummaCare Plan Central
Your employer has an agreement with SummaCare, Inc., to provide you with health benefits
coverage. This booklet is your Evidence of Coverage. It explains the group HMO benefits
covered by SummaCare Health Plan. This booklet and the Schedule of Benefits that come with it
help you understand your SummaCare plan.
NOTICE: IF YOU OR YOUR FAMILY MEMBERS ARE COVERED BY MORE THAN ONE
HEALTH CARE PLAN, YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM BOTH
PLANS. EACH PLAN MAY REQUIRE YOU TO FOLLOW ITS RULES OR USE SPECIFIC
PHYSICIANS, PRACTITIONERS OR OTHER PROVIDERS. IT MAY BE IMPOSSIBLE TO
COMPLY WITH BOTH PLANS AT THE SAME TIME. READ ALL OF THE RULES VERY
CAREFULLY, INCLUDING THE COORDINATION OF BENEFITS SECTION. COMPARE
THEM WITH THE RULES OF ANY OTHER PLAN THAT COVERS YOU OR YOUR
FAMILY.
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TABLE OF CONTENTS
I. Your Good Health 5
A. How SummaCare Works 5
B. Understanding Your Plan 5
C. Restrictions on Choice of Providers 5
D. Relationship Between Parties 6
E. When Care Is Managed by Your PCP 7
F. When Care Is Not Managed by Your PCP 8
G. Pre-authorization 8
H. Evaluation of New Technology 9
I. Changing Your Selected PCP 9
J. Services Received Outside of the SummaCare Service Area 10
K. Full-Time Students 10
II. Who Is Eligible for SummaCare 10
A. Employee Eligibility 10
B. Dependent Eligibility 10
C. Qualified Medical Child Support Order 11
III. Enrolling in SummaCare 11
A. Pre-existing Condition Limitation 13
B. Late Enrollment 13
C. Special Enrollment 13
IV. When Coverage Begins 14
A. Initial Group Enrollment 14
B. Newly Eligible Employees or Dependents 14
C. Newborns 14
V. When Coverage Ends 14
A. Your SummaCare Coverage 14
B. Your Dependent’s SummaCare Coverage 15
VI. Reinstatement of Coverage 15
VII. Covered Services 16
A. Outpatient Services Covered 16
B. Inpatient Hospital Services Covered 16
C. Coverage for Emergency/Urgent Care Services 17
D. Other Services Covered 18
1. Ambulance Transportation 18
2. Dental Services 18
3. Durable Medical Equipment/Prosthetic Devices 18
4. Home Health Care Services 18
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5. Hospice Care 19
6. Lab and Other Diagnostic Services 19
7. Infertility Diagnosis and Treatment 19
8. Maternity Services 19
9. Mental Health Services 20
10. Podiatry Services 20
11. Preventative Health Services 20
12. Private Duty Nurses 21
13. Rehabilitation Services 21
14. Re-Constructive Surgery 21
15. Second Surgical Opinions 21
16. Skilled Nursing 21
17. Substance Abuse Detoxification/Rehabilitation 21
18. TMJ 22
19. Transplants 22
18. Vision Care 22
VIII. General Exclusions 22
IX. SummaCare Claims 26
A. The Usual Procedure 26
B. Emergency/Urgent Care 26
C. When Copayments Apply 26
X. Receipt and Release of Information 26
XI. Complaint Procedure 27
XII. Coordination of Benefits (COB) 32
A. Plans that Do Not Coordinate 32
B. How SummaCare Pays as the Primary Plan 32
C. How SummaCare Pays as the Secondary Plan 33
D. Determining Which Plan Is Primary 33
E. Coordination Disputes 34
F. Integration with Medicare 34
G. Subrogation 34
XIII. Continuation of SummaCare Coverage 34
A. Converting to Individual Health Care Coverage Contract 34
B. Continued Coverage for Handicapped Dependent Children 35
C. COBRA Continuation of Coverage 36
D. Ohio Law 38
XIV. Health Insurance Portability and Accountability Act (HIPAA) 39
XV. Definitions 39
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I. Your Good Health
Your good health is the goal of SummaCare. As a licensed Health-Insuring Corporation (HIC)
we believe that the most effective health care is care that is managed by a single doctor. One who
knows you and your medical history. It has become popular for its success in providing the right
care, at the right time, and at a reasonable cost.
A. How SummaCare Works
Your relationship with SummaCare begins when you choose your Primary Care Physician (PCP)
to coordinate your total health care needs. Each covered family member may select a different
SummaCare PCP. A comprehensive list of the PCPs and specialists participating in the
SummaCare network is available in the SummaCare Provider Directory.
Your PCP is the person you will visit first for nearly all illnesses or injuries. If your PCP
determines that you require specialized care, need surgery, should be admitted to a hospital or
other health care facility, he or she will refer you to the appropriate source for care.
B. Understanding Your Plan
SummaCare is simple to use. You need to know how this booklet, your Evidence of Coverage,
relates to your Schedule of Benefits. You should know how your plan works. This will allow you
to maximize the benefits from your plan.
This booklet, combined with your Schedule of Benefits, provides complete information about the
coverage available under your health care plan. To determine your SummaCare benefits for a
specific service, you should refer to this booklet and your Schedule of Benefits. You also should
check this booklet and your Schedule of Benefits when you have a question about coverage
exclusions or other specific areas of your plan. This booklet presents detailed information about
your benefits. Your Schedule of Benefits is a summary of the benefits and costs that you are
responsible for under this plan. If you refer to one without looking at the other, you might
misunderstand your benefits. You can always call Member Services at 330-996-8700 or 800-
996-8701 if you need more information.
You will also be given a Member Handbook. In your Member Handbook you will find a list of
Member’s Rights and Responsibilities. Please read these Rights and Responsibilities. An
understanding of what you may expect from the Plan and what you are required to do is key to
maximizing your benefits and ensuring coverage under SummaCare. This book can be used as a
quick reference guide for questions about your SummaCare plan. Please be aware that your
Member Handbook does not describe your coverage in detail. Always refer to this Evidence of
Coverage and your Schedule of Benefits when you have questions about specific details of your
plan.
There is a SummaCare dictionary in section XV of this booklet. It lists the definitions of terms
that are used in this Evidence of Coverage and your Schedule of Benefits.
C. Restrictions on Choice of Providers
SummaCare limits access to certain health care physicians, practitioners or other providers. Such
physicians, practitioners or other providers include, but are not limited to:
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- Podiatrists (covered only upon referral from your PCP);
- Chiropractors (not covered)
SummaCare does not cover services unless they are provided, arranged or authorized by your PCP.
Exceptions are:
1. Emergency services
2. Routine GYN services
3. Maternity services
4. Mental health services
5. One annual retinal eye exam if you are a diabetic (refer to page 22)
6. Preventive mammograms (refer to page 20)
7. Urgent care services received at an approved urgent care center (refer to page 18)
If the medical care you need is not available from a SummaCare participating physician, practitioner or
other provider, your PCP must get pre-authorization from SummaCare to see a physician who is not on the
SummaCare panel. Your benefits for that physician’s care will be the same as if the care had been
provided by a SummaCare specialist. In order to receive covered services from non-SummaCare
physicians, all of the following must apply:
Services must be medically necessary;
Services must be requested by a SummaCare physician, practitioner or other provider;
Services must be pre-authorized by the SummaCare Health Services Management Program to make
sure those services are covered under your SummaCare plan.
Please consult with your SummaCare physician prior to obtaining service to ensure any necessary preauthorization
was obtained. It is the member’s responsibility to verify that all necessary pre-authorization
is obtained prior to receiving out-of-network care.
D. Relationship Between Parties
The relationship between SummaCare and SummaCare participating physicians, practitioners or other
providers is a contractual relationship. SummaCare participating physicians, practitioners or other
providers are not not agents or employees of SummaCare, nor is SummaCare the agent or employee of any
participating physician, practitioner or other provider.
The relationship between any physician and any covered person is that of physician and patient. The
physician alone is solely responsible for all medical services provided to any covered person. The hospital
alone is responsible for the hospital services provided to any covered person. All other physicians,
practitioners or other providers are only responsible for the particular services they provide to any covered
person.
SummaCare and its employees, officers, trustees or agents shall not be held responsible or otherwise liable
for any negligence or omission or other liability. This applies to any participating or non-participating
physician, practitioner or other provider. This includes, but is not limited to: doctors, hospitals, and
pharmacies. You agree not to seek redress from SummaCare or any of its employees, officers, trustees or
agents, for such negligence, omission or
other liability. Under this SummaCare plan, you must pay for services that are received but not
covered under this plan.
If you would like more information about a SummaCare physician’s, practitioner’s or other provider’s
qualifications, please call SummaCare Member Services at 330-996-8700 or
800-996-8701 or access our Website at www.summacare.com.
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E. When Care Is Managed by Your PCP
Your PCP is available (or has made arrangements for a covering physician) 24 hours a day, 7 days a week.
You will make a minimal copayment at the time of your office visit to your PCP for most types of services.
SummaCare will cover 100% of the costs after you make your copayment. This is true for most types of
outpatient care managed by your PCP. Inpatient hospital services are covered 100% (after any
copayments) when your SummaCare physician, practitioner or other provider coordinates your admission
to the hospital. There is no deductible for you to meet each year. Complete copayment information can be
found in your Schedule of Benefits.
When your PCP manages your medical needs, you pay limited out-of-pocket expenses. Also, you do not
have to submit claim forms. Your SummaCare physician, practitioner or other provider submits the claim
forms for you.
Your SummaCare physician, practitioner or other provider must obtain pre-authorization from
SummaCare’s Health Services Management Program for a hospital admission, outpatient surgery and
certain other services. Please consult with your SummaCare physician, practitioner, or other provider prior
to obtaining services to ensure any necessary pre-authorization was obtained.
Note: You do not need a referral from your PCP in order to receive coverage for the services listed on page
6. For non-emergent services it is the responsibility of the member to ensure that health care providers to
which you are referred to are participating in the SummaCare provider network.
If you require specialized care, your SummaCare physician, practitioner or other provider may refer you to
a specialist who is a SummaCare physician, practitioner or other provider. Standing referrals to specialists
are available if your SummaCare physician, practitioner or other provider determines that you need
continuing care from a particular specialist. In cases extending over prolonged periods of time that are life
threatening, degenerative or disabling illness, your care may be coordinated by a specialist. Please consult
with your SummaCare physician, practitioner, or other provider prior to obtaining services to ensure any
necessary pre-authorization was obtained.
If the medical care you need is not available from a SummaCare participating physician, practitioner or
other provider, your PCP may refer you to an appropriate specialist who is not part of the SummaCare
program, however this must be approved by the SummaCare Health Services Management Program. Your
benefits for that specialist’s care will be the same as if the care had been provided by a SummaCare
participating specialist, including medically necessary transportation costs as determined by SummaCare.
The cost to you will be the same as if you had used a SummaCare physician, practitioner or other provider.
Please consult with your SummaCare physician, practitioner, or other provider prior to obtaining services
to ensure any necessary pre-authorization was obtained. It is the member’s responsibility to ensure any
necessary pre-authorization was obtained prior to receiving out-of network care.
In the event that SummaCare becomes insolvent, you may be responsible for paying for health care
services given by a physician, practitioner or other provider or health care facility that is not
under contract with SummaCare. It does not matter if SummaCare authorized the use of this
physician, practitioner or other provider or health care facility.
Call Member Services at 330-996-8700 or 800-996-8701 when you have a question about
coverage.
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F. When Care is Not Managed by Your PCP
With the exception of those services listed on page 6, SummaCare will not cover health care
services that have not been pre-authorized or managed by your PCP. You will be financially
responsible for services not managed by your PCP.
G. Pre-Authorization
Your SummaCare physician, practitioner or other provider is responsible for obtaining any
required pre-authorizations from SummaCare. Your SummaCare physician, practitioner or other
provider will request pre-authorization by contacting SummaCare’s Health Services Management
Program. Pre-authorization is required for certain procedures to ensure that the service is
medically necessary and that you will receive all of the benefits to which you are entitled. If your
physician, practitioner or other provider requests pre-authorization and SummaCare determines
that a service is not medically necessary, you and your physician, practitioner or other provider
will receive a letter stating this and directions on how to initiate an appeal if you disagree with
this decision. (NOTE: procedures requiring pre-authorization are listed on your Schedule of
Benefits). In the case of an adverse determination, the health insuring corporation shall notify the
provider or health care facility rendering the health care service by telephone within three
business days after making the adverse determination, and shall provide written or electronic
confirmation of the telephone notification to the enrollee and the provider or health care facility
within one business day after making the telephone notification. The member shall have the right
to request an internal review if a response is not received within these time frames. Your
SummaCare physician, practitioner or other provider will review your treatment plan, expected
length of stay (if a hospital admission is required), and other features of your care with the Health
Services Management Program.
Your SummaCare physician, practitioner or other provider handles all communication with
SummaCare’s Health Services Management Program.
SummaCare supports a comprehensive Utilization Management Program encompassing preauthorization,
concurrent review, retrospective review, case management and pharmaceutical
review.
Pre-authorization review is the process of determining the medical necessity of a proposed
procedure, surgery or treatment (including pharmacological intervention) relative to approved
criteria. Pre-authorization is required for certain procedures and prescriptions to ensure that the
service is medically necessary and that you will receive all of the benefits to which you are
entitled. SummaCare uses nationally accepted criteria when reviewing a service for preauthorization.
Internally developed criteria may supplement industry standard criteria as needed
and approved by SummaCare.
Concurrent review is the process of continual reassessment of the medical necessity and
appropriateness of care in a hospital, medical rehabilitation unit or skilled nursing facility during
the institutional stay.
Retrospective review is the process of determining certification for payment after services have
been rendered.
Case management is a tool for improving outcomes of health care delivery through patient education and
self-care management, nurse/social worker telephone support and resource management.
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Board-certified physician consultants from appropriate specialty areas are available, as needed, to
SummaCare’s Medical Directors in making determinations of medical necessity. Also, SummaCare
continually evaluates new technologies and the application of existing technologies, including procedures,
services, treatments and pharmaceuticals. The SummaCare Pharmacy and Therapeutic Program is
responsible for assuring optimal therapeutic use of pharmaceuticals and for developing policies and
procedures, which guide pharmacy management.
The Health Services Management Program follows nationally accepted criteria. Medically necessary care
is defined as services or supplies provided by a hospital, physician, practitioner or other provider to
identify or treat an illness or injury. This applies when those services or supplies are:
1. Consistent with the symptoms or diagnosis and treatment of the condition, disease, ailment or injury;
2. Appropriate to the standards of good medical practice;
3. Not primarily for the convenience of the patient, the physician, practitioner or other provider; and
4. The most appropriate supplies or services that can be given safely to the patient. If your symptoms or
condition require services or supplies that cannot be given safely on an outpatient basis, you will
receive the services or supplies on an inpatient basis.
H. Evaluation of New Technology
SummaCare periodically reviews and assesses new medical technologies and new applications of existing
technologies for inclusion as covered benefits. This includes medical procedures, drugs and devices. The
SummaCare Chief Medical Officer in collaboration with the Clinical Quality Committee reviews and
investigates new technology in the following manner:
1. Determines if FDA and/or Medical College Board Approval has been obtained.
2. Reviews research data.
3. Requests information directly from the manufacturer.
At least two (2) sources of information must be utilized including such references as Hayes Directory,
scientific literature, abstracts or other data. Regulatory reviews may also be used in review.
Participating physicians, practitioners, and other providers are informed of the implementation of the new
technology and how it relates to each benefits package.
I. Changing Your Selected Primary Care Physician
At SummaCare, we believe that your relationship with your PCP is key to helping you maintain the best of
health. Your relationship with your provider is very personal. If you would like to change your PCP, call
Member Services at 330-996-8700 or 800-996-8701. You may also submit a PCP change on our Website,
www.summacare.com. The new relationship will be effective within 31 days after the date you ask for the
change. SummaCare will send you a new identification card that shows the effective date of the change.
If you visit your new PCP before the effective date of the change, SummaCare will not provide coverage
for those services. If you believe that you need medical attention that cannot wait for this effective date,
call Member Services.
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J. Services Received Outside of the SummaCare Service Area
If you are traveling outside of the SummaCare service area, you must still coordinate your care
through your PCP, except in the case of an emergency or an urgent care situation. (See pages
17/18 for more information on Emergency Services and Urgent Care Situations). Your PCP will
coordinate any services, which may be appropriate for your condition. Except for emergencies or
urgent care situations, care that is received outside of the SummaCare service area that has not
been managed by your PCP will not be covered.
K. Full-Time Students
If your dependent is a full-time student meeting the eligibility requirements and residing outside
of the service area, he/she will be covered for emergency and urgent care services while outside
the service area. Routine care services will not be covered outside of the service area. (See pages
17/18 for more information on Emergency and Urgent Care Services.)
Full-time student status will be verified at least annually.
II.
Who Is Eligible for SummaCare
A. Employee Eligibility
To enroll in the SummaCare plan, you must be:
1. Eligible to participate in your employer’s health benefits program under the employer’s
written requirements; (This may at times for certain employers, include retirees).
2. Considered a legitimate, regularly employed employee. You must work at least 25 hours per
week;
3. Living in the SummaCare service area or employed in the SummaCare service area and living
in a county next to that service area.
You may also be eligible if you used to be employed by the employer currently contracting with
SummaCare. The employer must have elected to continue group coverage under State or Federal
law. Contact your employer’s personnel or employee benefits office for more information about
eligibility.
B. Dependent Eligibility
Dependents eligible for SummaCare must be:
1. Your legal spouse; *
2. You or your spouse’s unmarried dependent child under age 19. An unmarried dependent
child who is under age 25** may qualify if that child is a full-time student at an accredited
school. You must show proof of full-time student status. You can get this from your
dependent’s school.
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The term “dependent child” includes: 1) biological children; 2) stepchildren; 3) legally adopted
children; 4) children for whom you or your spouse is the legal guardian; and 5) children for
whom you are responsible by court decree or qualified medical support order for principal
support or medical care, even if the child lives outside of the SummaCare service area.
(Dependents living outside of the service area must also follow the rules of the plan.)
In the event of a divorce, you must remove your spouse from your SummaCare plan upon the
effective date of the divorce. Failure to do so is considered insurance fraud. Dependents
eligibility ages may vary by employer. Contact your employer’s personnel or employee benefits
office to find out dependent age limits. Your adopted child becomes an eligible dependent on the
same basis as other dependents;
1. In the case of an agency adoption, on the date of adoptive placement as specified in the
adoptive placement agreement; or
2. In the case of an independent adoption, on the later of the date the child is placed in your
physical custody or the date the petition for adoption is filed with the probate court.
Qualified Medical Child Support Orders:
The Plan Administrator shall enroll for immediate coverage under this Plan any Alternate
Recipient who is the subject of a Medical Child Support Order that is a “Qualified Medical Child
Support Order” (“QMCSO”) if such an individual is not already covered by the Plan as an
Eligible Dependent once the Plan Administrator has determined that such order meets the
standards for qualification.
“Alternate Recipient” shall mean any child of a Covered Person who is recognized under a
Medical Child Support Order as having a right to enrollment under this Plan as the Covered
Person’s Eligible Dependent. For purposes of the benefits provided under this Plan, an Alternate
Recipient shall be treated as an Eligible Dependent, but for purposes of the reporting and
disclosure requirements, an Alternate Recipient shall have the same status as a Covered Person.
“Medical Child Support Order” shall mean any judgment, decree or order (including approval of
a domestic relations settlement agreement) issued by a court of competent jurisdiction that:
1. Provides for child support with respect to a Covered Person’s child or directs the
Covered Person to provide coverage under a health benefits plan pursuant to
a state domestic relations law (including a community property law); or
2. Enforces a law relating to medical child support described in Social Security Act 1908 (as
added by Omnibus Reconciliation Act of 1993, 13822 with respect to a group health plan.
III.
Enrolling In SummaCare
To enroll yourself and any eligible dependents in the SummaCare plan, you must complete an
enrollment application (and Health Questionnaire for groups with less than fifty (50) employees).
When completing the application, you must choose a PCP from the SummaCare Provider
Directory for yourself, your spouse and your underage dependents. The PCP names must be
noted in the space indicated on the application. Keep the Provider Directory for future reference,
you may change your PCP in accordance with the information provided on Page 9.
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SummaCare must internally use your protected health information in order to conduct our
business and provide you with the care and services to which you are entitled as a SummaCare
member. SummaCare may use or disclose information about you in order to facilitate your
treatment and/or payment by or to a physician, health care provider, third party administrator,
insurance company, or other appropriate entities, including government and law enforcement
agencies, without your signed authorization. Additional disclosures may include the following:
Individuals involved in arranging for your care or payment of your care.
Business Associates, who are persons or organizations contracted with to
assist us with our health care operation.
As required by law or law enforcement agencies.
Public Health Activities
The Food and Drug Administration
Plan Sponsors
Health Oversight Activities
Lawsuits and Disputes
Coroner, Medical Examiners and Funeral Directors
Organ and Tissue Donations
Research
Military and Veterans
National Security and Intelligence
Workers’ Compensation
SummaCare will use and disclose your protected information as necessary, and as permitted by law, for our
health care operations. Such operations include processing claims, payment, treatment, coordination of
care, business management, accreditation and licensing, quality improvement, enrollment, underwriting,
compliance, auditing and other functions related to your health benefits plan.
Data used for research purposes will not include personal identification information and must be approved
by the HIPAA Compliance Committee. The release of this information does not require member
authorization.
In the event that you are deemed incompetent or cannot provide authorization, SummaCare requires
documented proof of power of attorney or guardianship prior to release of any information. Legal counsel
will review the documentation prior to release of information.
Any protected health information shared with plan sponsors, which may include fully or self-insured
employer groups, will only be disclosed if the plan sponsor agrees to strict confidentiality provisions, or if
you provide written authorization to disclose your protected health information. Aggregate data, which
does not contain protected health information, may be supplied to a plan sponsor without your written
authorization.
Plan Sponsors must agree to all of the following:
Not use or disclose protected health information other than as permitted by the Plan
document or by law
Ensure that their agents and subcontractors agree to the same restrictions and conditions
of protected health information as the employer or plan sponsor.
Not to use the protected health information for employment or other benefit related
decisions.
Notify SummaCare of any use or disclosure of protected health information that is not
consistent with the uses and disclosures listed in the plan document.
Permit you to access and amend your protected health information
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Make necessary information available to SummaCare in order to provide you with an
accounting of disclosures, should you request one.
Establish procedures for the return, destruction and restriction of further use of your
protected health information.
Identify which of their employees have access to protected health information.
Establish procedures for actions if the plan sponsor or its employees inappropriately use
or disclose protected health information.
SummaCare must also provide you with a; Notice of Privacy Practices upon your enrollment.
The Notice of Privacy Practices further defines your rights and remedies concerning the
disclosure of your protected health information.
SummaCare maintains physical, electronic, and procedural safeguards that comply with
applicable regulatory standards to guard your personal health information. In addition,
SummaCare requires all affiliated parties who maintain your health records to enforce
confidentiality policies and procedures within their facilities.
In addition, you may review your personal health information within SummaCare’s control by
contacting Member Services at 330-996-8700 or 800-996-8701 to schedule an appointment with
the appropriate department representative. You may schedule appointments with physicians,
practitioners, or other health care providers, from whom you are receiving health care, to review
personal health information within their control. To maintain confidentiality in accordance with
Federal Regulations, access to your spouse’s health information will be denied unless your
spouse provides a written signed document authorizing the release of the information to you.
SummaCare warrants that any other person and/or entity receiving information from SummaCare
signs a confidentiality agreement which requires them to abide by and release information in
accordance with SummaCare’s confidentiality policies and procedures.
You may receive a copy of the confidentiality policies by calling the Member Services
Department at 330-996-8700 or 800-996-8701.
A. Pre-Existing Condition Limitation
There are no pre-existing condition limitations for enrolling in the SummaCare plan. Also,
enrollment or re-enrollment in SummaCare cannot be based upon or subject to results of genetic
screening or testing. When you become eligible, you can apply to enroll in SummaCare during
your employer’s annual open enrollment period or within 31 days after the date you become
eligible. At that time, you will choose whether you want coverage for only yourself, or for
yourself and your eligible dependents.
B. Late Enrollment
If you turn down “first opportunity” enrollment for yourself and/or your dependents because of other group
health insurance coverage, you may still be able to enroll in the future. You must request enrollment
within 31 days after your other coverage ends.
C. Special Enrollment
If you have a change in family status due to marriage, birth, adoption or placement for adoption,
you may enroll the affected person. This is provided you request enrollment within 31 days of
the change.
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IV.
When Coverage Begins
Coverage begins as of the date specified by your employer, except as provided in Section III.
A. Initial Group Enrollment
Coverage for the group begins on the effective date of the contract between your employer and
SummaCare.
B. Newly Eligible Employees or Dependents
If the enrollment form is received after the effective date of the contract, and:
1. You are hired during your employer’s Open Enrollment period; coverage will become effective when
you have met your employer’s eligibility requirements (waiting period).
2. Within 31 days of first becoming eligible, then coverage is effective on the date of eligibility.
C. Newborns
1. If you have Family Coverage, your newborn child is automatically enrolled in SummaCare at birth.
After the birth, you must complete paperwork and submit it to your employer’s personnel or employee
benefits office within 90 days of the date of birth or your newborn will not remain covered under your
SummaCare plan after these 90 days.
2. If you have coverage other than Family Coverage, your newborn is automatically enrolled in
SummaCare at birth. After the birth, you must complete paperwork and submit it to your employer’s
personnel or employee benefits office within 31 days of the date of birth or your newborn will not
remain covered under your SummaCare plan after 31 days. You will be notified of any increase in
premium.
V. When Coverage Ends
A. Your SummaCare Coverage Ends on the Earliest of:
1. The date the contract between your employer and SummaCare ends (see exception below);
2. The date you stop being an eligible employee under Section II. A;
3. The end of the month in which you inform your employer that you no longer want coverage under the
SummaCare plan;
4. The date on which your SummaCare coverage began if it is later determined that you made a material
misrepresentation on an enrollment form;
5. The date on which you commit fraud or forgery with respect to the plan;
6. The date on which you allowed a person not eligible for benefits to use a SummaCare identification
card;
7. The date you enter into active duty in the Armed Forces of any country; or
8. The date on which you limited, interfered with, or prejudiced SummaCare’s right to recover benefits
paid which you recovered or had a legal right to recover from another person or organization.
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When you become eligible, you can apply to enroll in SummaCare during your employer’s annual open
enrollment period or within thirty-one days after the date you become eligible. At that time, you will
choose whether you want coverage for only yourself, or for yourself and your eligible dependents.
However, if you or any of your dependents are confined to a hospital on the effective date of coverage with
SummaCare, SummaCare will not duplicate any benefits or services related to this stay by any other
insurance coverage.
In the event your coverage under this plan terminates while you or your covered dependent is an inpatient
in a hospital, the continuation of your SummaCare coverage shall terminate at the earliest occurrence of
any of the following:
a. The covered individual’s discharge from that facility; or
b. The determination by the covered person’s attending physician that inpatient care is no
longer medically indicated; or
c. The covered individual has reached the limit for contracted benefits.
d. The effective date of any new coverage.
B. Coverage for Your Dependent Will End on the Earliest of:
1. The date your own coverage ends;
2. The date a dependent is no longer eligible for coverage. This is according to the eligibility
requirements of your employer and of SummaCare under Section II.B;
3. The end of the month for which the required Subscription Rate for SummaCare coverage has been
paid;
4. The end of the month in which you inform your employer that you no longer want coverage for your
dependent under your SummaCare plan;
5. The date your dependent enters into active duty in the Armed Forces of any country;
6. The end of the month in which your dependent reaches the dependent limiting age.
7. If your dependent is an inpatient in the hospital his/her coverage will end on the effective date of any
new coverage.
For exceptions regarding the above, see “Continuation of SummaCare Coverage” or call Member Services
at 330-996-8700 or 800-996-8701.
VI.
Reinstatement of Coverage
If your coverage ends and you want to re-enroll in SummaCare through a different employer and a
different plan (group number), your benefits will be effective as though you are enrolling in SummaCare
for the first time. If you are re-enrolling in SummaCare through the same employer and plan (group
number) any benefit payments and copayments that have been made for that benefit year will be carried
forward. Any employer eligibility-waiting period will apply to this reinstatement. Those payments will be
applied towards lifetime or annual benefit maximums.
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VII.
Covered Services
The following services are covered by SummaCare when provided, authorized or managed by your PCP.
If you receive services that have not been pre-authorized by your SummaCare physician, practitioner or
other provider - except for those services listed on page 6 - you will be responsible for paying for these
services. Coverage is provided subject to copayments, limitations and exclusions that are specified in this
booklet and your Schedule of Benefits.
A. Outpatient Services Covered
1. Office visits to your physician, practitioner or other provider, including physical exams, well child
care, immunizations and other preventive health care services that are base on the recommendations of
the United States Preventive Services Task Force. Copies of these recommendations are available
from Member Services.
2. Office visits to a SummaCare participating OB/GYN for obstetrical/gynecological services (a referral
from your PCP is not necessary).
3. Diagnostic services.
4. Medically necessary surgical procedures and anesthesia that are covered benefits.
5. Office visits to medical or surgical specialists.
6. Urgent care services. Urgent care services apply to health problems that require immediate attention
but are not emergencies. For conditions that are emergencies, refer to page 17 “Emergency
Services/Urgent Care Situations”.
7. Emergency services (refer to page 17 for more information)
8. Services for mental health and substance abuse detoxification/rehabilitation.
9. Allergy testing and treatment. Allergy shot only do not need individual pre-authorization.
10. Physical, occupational, speech and cardio/pulmonary therapies.
B. Inpatient Hospital Services Covered
1. Semi-private room and board; private room and special care units if medically necessary and
authorized by the SummaCare Health Services Management Program.
2. Physician, practitioner or other provider services related to medical treatment or surgery.
3. General nursing services.
4. Diagnostic services.
5. Operating room, anesthesia and supplies.
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6. Medically necessary supplies and services, such as oxygen, including equipment required for its
administration, blood and blood plasma (if not replaced) and other fluids to be injected into the
circulatory system; braces, crutches, casts, splints, trusses, surgical dressings and ostomy supplies used
while in the hospital.
7. Prescribed drugs consumed while in the hospital.
8. Physical, occupational, speech and cardio/pulmonary therapies (see Schedule of Benefits for
limitation).
9. Services for nonexperimental human organ and tissue transplants. These must be pre-authorized and
approved by the SummaCare Health Services Management Program and performed at an approved
facility. Ohio Major Solid Organ Transplants (including heart, heart-lung, kidney, liver and pancreas)
must also be pre-authorized and approved using the Major Solid Organ Transplant Consortium
criteria. Covered transplants include: heart, lung, heart-lung, liver, pancreas, kidney, bowel, cornea
and nonexperimental bone marrow (in some cases).
10. Mental health and substance detoxification/rehabilitation.
C. Coverage for Emergency Services/Urgent Care Situations
Emergency services are available 24 hours a day, seven days a week. In an emergency, go to the nearest
hospital. An emergency is defined as a medical condition that manifests itself by such acute symptoms of
sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health
and medicine could reasonably expect the absence of immediate medical attention to result in any of the
following: placing the health of the individual or the health of a pregnant woman or her baby in serious
jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Some
examples of emergencies are:
1. Unusual and severe chest pain;
2. Unusual or excessive bleeding;
3. Poisoning;
4. Inability to breathe; or
5. Obvious limb fractures.
If you experience symptoms that meet the definition of an emergency, call 911 for emergency assistance.
Emergency treatment for a condition that meets the definition does not have to be pre-authorized
by your PCP. You do not have to use a SummaCare network hospital in the following instances:
1. You are not able to physically go to a network hospital due to circumstances beyond your
control.
2. The time required to travel to a network hospital would impair your health.
3. An ambulance takes you to a non-network hospital without your direction.
4. You are unconscious.
5. A natural disaster prevents you from using a network hospital.
6. A hospital that was a network hospital has become a non-network hospital and you were
unaware of this fact.
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However, you need to tell your PCP about your emergency treatment within 48 hours after
receiving care, or as soon thereafter as medically possible so that your PCP can coordinate any
follow-up care that is necessary.
An urgent care situation occurs when you require care as soon as possible, but it is not life-or
limb-threatening. Some examples of urgent care situations are:
1. Minor cuts and abrasions;
2. Minor burns;
3. Sprains;
4. Earaches or stomachaches; and
5. Other minor injuries.
If you require urgent care and you are inside the SummaCare service area, you may go to an
approved urgent care center without a referral from your PCP. If you are outside of the
SummaCare service area, you may go to the nearest urgent care center for treatment without a
referral from your PCP. If you cannot locate an urgent care center, call your PCP or the
SummaCare 24 Hour Nurse Line for instructions. Refer to your Schedule of Benefits for
information on copayment amounts for urgent care.
D. Other Services Covered
1. Ambulance transportation
SummaCare covers charges for medically necessary emergency transportation to the nearest
hospital. In situations that are not an emergency, ambulance transportation must be preauthorized
by SummaCare’s Health Services Management Program. Ambulance
transportation must be provided by a professional ambulance service.
2. Dental services
SummaCare covers initial treatment for damage to sound, natural teeth resulting from
accidental injury. Initial treatment includes treatment that is necessary to stabilize the injury
after trauma. Those injuries resulting from biting, chewing or eating are not covered to the
extent that dental services would be required.
3. Durable medical equipment and prosthetic devices
The rental or purchase of durable medical equipment is covered if the needed equipment meets
coverage and medical necessity guidelines. Most equipment must be pre-authorized by your
physician through the SummaCare Health Services Management Program.
SummaCare covers the first prosthesis. A replacement prosthesis will be covered if medically
necessary and authorized by the Health Services Management Program. To be covered by
SummaCare, prosthetic devices must be on SummaCare’s list of approved prosthetic
appliances. Deluxe versions will not be covered.
4. Home health care services
The following home health care services are covered if the need for services meets medical
necessity guidelines. These services must be pre-authorized by your physician through the
SummaCare’s Health Services Management Program. Also, these services must be based on a
written treatment plan.
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a. Skilled Nursing services provided by a registered or licensed practical nurse;
b. Physical, occupational, speech therapies when your condition
limits your ability to go to a facility to receive these services; and
c. Medical social services.
5. Hospice care
The following hospice services are covered if the need for services meets medical necessity
guidelines. Services must be pre-authorized by your physician through the SummaCare
Health Services Management Program:
a. All covered home health care services listed above, except nursing services, which may be
authorized for up to eight (8) hours in any twenty four (24) hour period;
b. Room and board while in a hospice facility;
Services and supplies furnished by the hospice facility during the admission,
including part-time nursing care by or under the supervision of a registered nurse;
c. Dietary guidance;
d. Durable medical equipment;
e. Bereavement counseling for family members who are enrolled members, up to
two visits, and;
f. Home health aide visits.
Homemaker, volunteer and spiritual counseling services, food or home-delivered meals; and
custodial care, rest care or care for someone’s convenience are not covered. Chemotherapy
or radiation therapy if other than palliative treatment is not covered.
6. Lab and other diagnostic services
SummaCare will cover the cost of medically necessary lab work and other diagnostic services
such but not limited to MRI’s and mammograms.
7. Infertility diagnosis
SummaCare will cover the costs for medically necessary infertility diagnosis and treatment
when services are provided by a SummaCare physician, practitioner or other provider.
Coverage does not include infertility drug therapy or monitoring or procedures used to induce
pregnancy. (Please refer to the “Exclusions” section of this booklet for more information.)
8. Maternity services
Maternity services provided by SummaCare physicians, practitioners or other providers to you or your
covered dependent are covered. Your physician, practitioner or other provider must notify
SummaCare Health Services Management of the anticipated delivery date. You do not need a referral
by your PCP for the following services to be covered:
a. Hospital charges related to your pregnancy;
b. Pre- and post-natal care; and
c. Treatment for complications of pregnancy, childbirth and any obstetrical disorder,
injury or condition arising from childbirth
SummaCare covers up to a 48-hour hospital admission for routine vaginal delivery and up to a 96-hour
admission for cesarean section delivery, unless authorization for an extended hospital stay has been
obtained from SummaCare’s Health Services Management Program.
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If mother or newborn are discharged prior to 48 hours (vaginal) or 96 hours (cesarean), home
follow-up care that is provided within 72 hours of the time of discharge will be covered.
SummaCare also covers physician-directed follow up care, which includes:
a. Physical assessment of the mother and newborn;
b. Parent education;
c. Assistance and training in breast or bottle-feeding;
d. Assessment of the home support system;
Performance of any medically necessary and appropriate clinical tests; and any other services that
are consistent with the follow up care recommended in the protocols and guidelines developed by
national organizations that represent pediatric, obstetric and nursing professionals. This coverage
applies to services provided in a medical facility and/or through home health care visits. These
providers must be knowledgeable and experienced in newborn care.
Emergency deliveries are covered, regardless of physician, practitioner or other provider. Your
OB/GYN physician, practitioner or other provider must notify SummaCare’s Health Services
Management Program or your PCP within forty eight (48) hours after the delivery or as soon
thereafter as medically possible.
9. Mental health services
SummaCare will cover mental health services received from a participating physician,
practitioner or other provider. A referral from your PCP is not necessary.
Contact Member Services at 330-996-8700 or 800-996-8701 for more information.
Your behavioral health physician, practitioner or other provider may need to request
authorization for continued care.
10. Podiatry services
SummaCare covers pre-authorized medically necessary treatment by a plan podiatrist.
Routine foot care and orthotics are not covered.
11. Preventive health services
SummaCare covers a variety of periodic health examinations that conform to national
guidelines. Examples of preventive health services include, but are not limited to:
a. Well child care, including immunizations;
b. Cholesterol screening;
c. Blood pressure checks;
d. Annual screening mammograms beginning at age 40 (Covered at physician's discretion for
women with higher than average risk below age 40)*; and
e. PAP smears.
f. Cytologic screening to detect cervical cancer
*Mammogram benefit includes examinations that are performed in a health care facility or a
mobile mammography-screening unit that is accredited under the American College of
Radiology Mammography Accreditation Program and included in the SummaCare
network. If you have any questions about which preventive health services are covered, please call
Member Services at 330-996-8700 or 800-996-8701.
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12. Private-duty nurses
Services provided by private-duty nurses to you or your covered dependent while in the hospital will
be covered only if these services are medically necessary. Your physician must pre-authorize these
services through SummaCare’s Health Services Management Program.
13. Rehabilitation Service
Rehabilitative services, including physical, occupational, speech and cardio/pulmonary therapies, will
be covered only if they are determined to be medically necessary by the SummaCare Health Services
Management Program and functional improvement can be demonstrated.
Speech therapy is designed to provide treatment following acute conditions, congenital hearing loss
and congenital conditions for which corrective surgery has been performed (e.g. cleft palates).
Conditions such as behavioral speech disorders, learning disorders, stuttering, slow speech
development, chronic muscle imbalance, and language therapy are excluded.
Cardio/pulmonary rehabilitative services to provide treatment following acute conditions are covered.
14. Re-constructive breast surgery
Re-construction of the breast on which the mastectomy has been performed; Surgery and
re-construction of the other breast to produce a symmetrical appearance; and prostheses
and physical complications at all stages of the mastectomy, including lymphedemas.
15. Second surgical opinions
SummaCare covers second opinions to a SummaCare physician, practitioner or other provider upon
referral from your PCP and/or SummaCare’s Health Services Management Program.
16. Skilled nursing
Skilled nursing facility services are covered if the need for services meets medical necessity criteria.
Services must be pre-authorized by your physician, practitioner or other provider through
SummaCare’s Health Services Management Program.
SummaCare will provide reimbursement for skilled nursing care received in a non-network facility if
all of the following conditions apply to you, your spouse or dependent:
a. You lived or had a contract to live in the facility on or before September 1
1997
b. You, immediately before being hospitalized, lived or had a contract to live in the facility.
After hospitalization you reside in a part of the facility that is a skilled nursing facility,
regardless of whether you resided in a different part of the facility before hospitalization;
c. The facility provides the level of skilled nursing care that you require; and
d. The facility is willing to accept from SummaCare the same terms and conditions that
apply to an in-network facility, including rates.
17. Substance abuse detoxification and rehabilitation
SummaCare covers pre-approved admissions to a facility for intensive chemical dependency
detoxification and rehabilitation services in an inpatient setting or through a structured outpatient
program. A diagnosis of abuse or addiction to alcohol and/or drugs must be established and
approved for treatment by the SummaCare Health Services Management Program. Individual or
group therapy sessions are covered when required for the treatment of abuse or addiction to alcohol
or drugs and authorized for treatment by the SummaCare Health Services Management Program.
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18. Temporomandibular joint (TMJ) disorder
SummaCare covers medical treatment for TMJ disorders, which have been pre-authorized. Dental
services such as oral appliances and braces are not covered.
19. Transplants
Non-experimental organ transplants are covered for the insured recipient if the recommended
treatment program is pre-authorized and approved by SummaCare’s Health Services Management
program and performed at an approved facility. In addition, major solid organ transplants (including
heart, kidney, heart-lung, liver and pancreas) must be pre-authorized using guidelines including those
set by the Ohio Major Solid Organ Transplant Consortium. Covered transplants include: heart, lung,
heart-lung, liver, pancreas, cornea, kidney, bowel and non-experimental bone marrow. Reasonable
travel and lodging expenses are covered for the insured recipient if the transplant is received out of
area and approved by the SummaCare Health Services Management Program.
20. Vision care
One routine eye exam is covered every twenty four (24) months when performed by a plan
physician or practitioner. SummaCare also covers one retinal eye exam for diabetics every 12
months when performed by a plan physician.
VIII.
General Exclusions
A. SummaCare Will Not Provide Coverage For:
1. Abortions (Elective)
Elective Abortions, whether surgically or pharmaceutically induced, except when continuation of
pregnancy poses a serious healthy hazard to the mother or the fetus has a congenital malformation
incompatible with life.
2. Acupuncture, Alternative Medicine
Acupuncture or other treatment classified as “alternative medicine” unless specifically listed as
covered in the Schedule of Benefits.
3. Autistic Disease
Treatment of conditions related to autistic disease or mental retardation.
4. Chiropractic Services
Chiropractic services, including spinal manipulation or skeletal adjustments.
5. Contraceptive Devices, Vitamins, Food Supplements
Contraceptive drugs and devices, vitamins, minerals or food supplements.
6. Convenience Items
Personal convenience items such as vacuum cleaners, air conditioners, humidifiers, elevators,
chair lifts, physical fitness equipment and other such devices even though prescribed by a
physician, practitioner, or other provider.
7. Cosmetic Surgery
Treatment or surgery to improve appearance (such as liposuction, breast augmentation, hair
transplants, hair growth stimulants, sclerotherapy, etc.) except when it is needed to correct
congenital defects of your covered newborn. Conditions, which result from accidental injury,
are covered by SummaCare, as is reconstructive surgery after a mastectomy.
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8. Custodial Care
Custodial care includes but is not limited to sitters, homemakers’ services or care in a place
that services you primarily as a resident when you do not require skilled nursing.
9. Court Ordered Treatment
Testing or treatment ordered by a court or agreed to through a plea bargain.
10. Dental Care
Any care or treatment of teeth, gums, alveolar process or gingival tissues, except as specified
on page 18 or where such a condition requires medical attention classified as basic health
care. Dental services and appliances such as braces are also not covered.
11. Donor Related Transplant Cost
Donor-related costs for organ transplants, including but not limited to harvesting costs,
transportation costs, organ storage costs and any other expenses not directly associated with
the surgical transplant procedure performed on you or your dependent.
12. Educational Training
Services and supplies for training or education, except diabetes education classes that are
covered if approved by SummaCare’s Health Services Management Program.
13. Effective Date
Services provided or charges incurred before the effective date of coverage under the plan or
after coverage ends, subject to the specific exception noted in Section IV.
14. Experimental Treatment
Services and supplies that are experimental or of a research nature.
15. Eye Services and Hardware
Expenses incurred for eyeglass lenses or frames; fitting of eyeglass lenses or frames;
orthoptic or vision training; bio microscopy; field charting or aniseikonia investigation;
devices to correct vision; radial keratotomy or other refractive surgery; eye examinations
required by an employer as a condition of employment or by virtue of a labor agreement, or
required by a government body or agent.
16. Foot Care
Foot care that is not medically necessary, including diagnostic treatment for weak strained,
unstable or flat feet.
Foot orthotics.
The treatment of corns, calluses or toenails, unless the charge was for the removal of nail
roots, or in conjunction with the treatment of a metabolic or peripheral vascular disease.
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17. Government Provided Treatment
Treatment provided or furnished by any agency of the United States Government, the
government of any other country or any state or political subdivision.
18. Growth Hormones
Growth hormone therapy.
19. Hearing Aids
Expenses incurred for hearing aids, the examination for prescribing and fitting them. Hearing
therapy and any related diagnostic hearing tests.
20. Illegal Charges
Charges for services for which you or your covered dependents are not legally required to
pay, or that would not have been made if no coverage existed.
21. IQ Testing
Testing for intelligence, aptitude or interest.
22. Jaw Joint Disorder
Care or treatment of jaw-joint problems including orthognathic or osteotomy surgery that
relates to malposition of the jaw, cranial mandibulare disorders, nerves and other tissues
related to the joint or associated myofascial pain except as specified on page 21 or where
such a condition requires medical attention classified as basic health care, such as
temporomandibular joint (TMJ) disorder.
23. Marital Therapy
Marital counseling or therapy.
24. Maximum Limit Levels
Services or charges that exceed a maximum limit as specified in this booklet or your
Schedule of Benefits.
25. Nicotine Dependency
The treatment of nicotine dependency including smoking cessation programs or clinics and
prescribed medications.
26. Not Medically Necessary
Services and supplies that are not considered medically necessary for your diagnosis and
treatment.
27. Obesity
Treatment or products for obesity, food addiction or weight reduction.
28. Personal Service Items
Personal services such as haircuts, shampoos and sets, guest meals and radio/television
rentals.
29. Physician Non-Approved
Services that are not performed, prescribed or pre-authorized through your SummaCare
physician, practitioner or other provider except for those services listed on page 6.
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30. Prenatal Classes
Prenatal classes.
31. Pregnancy Inducement/Surrogate Parenting
Any medically unnecessary treatment to bring about pregnancy, including drug therapy and
monitoring, embryo transplants, in-vitro fertilization (IVF), gamete intrafallopian transfer
(GIFT), zygote intrafallopian transfer (ZIFT) and any other test tube baby production
procedures. Surrogate parenting procedures are also not covered.
32. Prescription Drugs
Prescription drugs except those drugs administered during a visit to a physician or during a
covered hospital inpatient stay.
33. Remedial Education
Charges in connection with any treatment, therapy, teaching technique or program for
remedial education, rehabilitation or training that is mainly intended to overcome, improve or
compensate for any learning impairment, regardless of whether such impairment is diagnosed
as functional or organic.
34. Rest Cures, Recreational Therapy
Rest cures, travel, recreation or diversional therapy, even though prescribed by a physician,
practitioner or other provider.
35. Sex Therapy
Sex therapy.
37. Services Provider by Household Residents
Services provided by people who ordinarily reside in your household or the household of
your covered dependent, or who are related by blood or marriage or legal adoption to you or
your covered dependent.
38. Sports and Special Employee Related Exams
Sports, premarital examinations, physical, or psychological examinations required by: a) a
school for sports exams b) an employer in order to begin or continue working c). an insurance
company in order to obtain insurance; or d) a government agency.
39. Sterilization Reversals
Reversal of elective sterilization procedures.
40. Telephone Consultations, Forms, Missed Appointments
Charges for telephone consultations, missed appointments or the completion of claim forms,
medical reports or certifications.
41. Transsexual Surgery
Transsexual surgery or any services leading to or in connection with transsexual surgery
including disturbances of gender identification or any complications thereof. Complications
may be covered only if they reach the threshold of medically necessary to basic health care.
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42. Travel and Lodging
Travel and lodging, even though a physician prescribes care, except reasonable lodging and travel
costs needed for out-of-area transplant expenses for insured recipient only as approved by the
SummaCare Health Services Management Program.
43. War
Charges incurred as a result of war or any act of war, whether declared or undeclared, or any act of
aggression, when the Covered Person is a member of the armed forces of any country, or during
service by a Covered Person in the armed forces of any country. This exclusion does not apply to any
covered Person who is not a member of the armed forces.
44. Workers’ Compensation
Care or treatment of work or occupational-related injury or illness covered by Workers’
Compensation.
IX. SummaCare Claims
A. The Usual Procedure
You usually do not have to complete and submit claim forms. Your SummaCare physician, practitioner or
other provider to whom you were referred, will submit a claim for covered services to SummaCare for you.
All you have to do is make your required copayment while at your physician’s, practitioner’s or other
provider’s office. (Services that require copayments, and the amount of those copayments, are listed in
your Schedule of Benefits). Except as otherwise described in this section, if you get a bill for services
from your PCP or from a physician, practitioner or other provider to whom your PCP referred you, send
the bill to SummaCare. You do not have to complete a claim form. SummaCare will always pay the
physician, practitioner or other provider of care directly. You will not receive any checks. You may
receive an explanation of benefits (EOB) detailing how much SummaCare has paid for the care you
received. For contracted providers there is a one-year filing period to submit your claims.
B. Emergency/Urgent Care
In the event of an emergency or urgent care situation, if you receive services from a physician other than a
SummaCare physician, practitioner or other provider, you may have to pay for those services at the time of
service and submit a claim to SummaCare. You can obtain claim forms from your employer or
SummaCare. You must attach the doctor and hospital bills from the non-SummaCare Physician,
practitioner or other provider to your claim form. Refer to pages 17/18 for more information on
Emergency/Urgent Care.
C. When Copayments Apply
Your SummaCare plan includes certain services that involve copayments. These services and their
copayment amounts are listed in your Schedule of Benefits. For example, a copayment for an office visit
to your PCP, say $10 per visit, will be paid at the time you are at your PCP’s office.
X. Receipt and Release of Information
SummaCare must internally use your protected health information in order to conduct our business and
provide you with the care and services to which you are entitled as a SummaCare member. SummaCare
may use or disclose information about you in order to facilitate your treatment and/or payment by or to a
physician, health care provider, third party administrator, insurance copay, or other appropriate entities,
including government and law enforcement agencies, without your signed authorization. Members
understand that such information may be used to provide appropriate treatment, coordination of care,
quality measurement and other appropriate uses related to quality treatment and care. Members further
understand that medical information may be obtained from the review of medical records and claims
26

information, which may contain information regarding behavioral health, HIV, aids and substance abuse
information. SummaCare warrants that any other entity receiving information from SummaCare must
agree to SummaCare’s confidentiality policies when using member’s medical information.
XI. Complaint Procedure
If you remain dissatisfied with a decision about a claim, or have another complaint, you can call Member
Services at 330-996-8700 or 1-800-996-8701. A Member Services representative will ask you questions
about your complaint and, if required, investigate the facts. You will receive a verbal response to your
complaint within five business days.
If you are still not satisfied, you can pursue your complaint further through one of SummaCare’s two
formal complaint processes. They are the Grievance and the Appeal Process. The Appeal Process should
be used whenever you disagree with SummaCare’s decision to deny, reduce, or terminate a service or a
claim. The Grievance Process should be used for all other complaints, regarding such things as service,
quality of care, or timely access to doctors and other providers. Each process is explained in detail on the
following pages.
A. Grievances
If you are dissatisfied with the care or service you receive from SummaCare or any of our contracted health
care providers, you may address those concerns through our formal grievance process. Some examples of
complaints that would be handled as a grievance are:
Excessive time on hold when calling Member Services;
Rude treatment by a physician or his office staff;
You believe that the medical care you received from a SummaCare provider was inappropriate;
You believe a SummaCare employee has violated your privacy rights.
To file a grievance, send your request to:
SummaCare Health Plan
Appeals/Grievance Department
P.O. Box 3620
Akron, Ohio 44309-3620
You may also fax your grievance to 330-996-8545, or submit it electronically to info@summacare.com. If
you wish, you may submit your grievance in person by visiting the SummaCare offices located at 10 North
Main Street, Akron, Ohio. Please be as clear as possible when describing your grievance. If you need help
with your grievance, please call Member Services for assistance. A Member Services representative will
help you document the substance of your grievance over the phone. If your complaint is about the quality
or appropriateness of care, you must file your grievance within 180 days from the date services were
received.
SummaCare will investigate your grievance and respond to you in writing within 30 calendar days. Our
response will inform you of our findings and any action that SummaCare has or will take as a result of your
grievance.
If you are not satisfied with SummaCare’s response, you may file a second level grievance at the same
address listed above. Your second level grievance will be reviewed by individuals who were not
previously involved in investigating your complaint. A written response will be issued within 40 calendar
days. The response will inform you of any further action SummaCare will take.
If you still are not satisfied, you may file a complaint with the Ohio Department of Insurance,
Consumer Services Division, 2100 Stella Court, Columbus, Ohio 43215-1067. You may also call
the Ohio Department of Insurance at 1-800-686-1526 or 614-644-2673.
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B. Internal SummaCare Appeals:
As a member of SummaCare, you have the right to appeal decisions that deny or limit your health
care benefits. If a service is denied, reduced, or terminated, or if payment of a claim is fully or
partially denied, you may appeal that denial. To file an appeal, send a written request to:
SummaCare Health Plan
Appeals/Grievance Department
P.O. Box 3620
Akron, Ohio 44309-3620
You may also fax your appeal to 330-996-8545, or submit it electronically to
info@summacare.com. If you wish, you may submit your appeal in person by visiting the
SummaCare offices located at 10 North Main Street, Akron, Ohio. Please be as clear as possible
when describing your appeal. Any additional documentation that supports your request should be
submitted with your appeal. If you need help with your appeal, please call Member Services for
assistance. A Member Services representative will help you document the substance of your
appeal over the phone. However, you will still need to follow-up with a signed, written appeal.
You must file your appeal within 180 days from the date you first received notice of the denial
you wish to appeal. SummaCare may accept an appeal from you after 180 days for just cause, but
we are under no obligation to do so. An authorized individual, which may be a friend, family
member, doctor, or anyone you choose may appeal for you, provided SummaCare receives a
signed and dated statement from you or other legal authority authorizing that person to act on
your behalf.
After SummaCare investigates the facts, your appeal will be reviewed by individuals who had no
previous involvement with the decision. If your appeal is in any way related to the medical
appropriateness of the care or services in question, the appeal would be reviewed by a boardcertified
physician. The exact time frame for resolving your appeal depends upon a number of
factors that are explained below. However, in every case SummaCare will resolve both levels of
internal appeal within 60 days from the date we received your first level appeal letter, or as fast as
is medically necessary.
C. First Level Post-Service Appeals:
If your appeal is about a service that you have already received, it will be handled as a postservice
appeal. SummaCare will notify you in writing of the outcome to your first level postservice
appeal within 30 calendar days from the date we received your appeal.
D. First Level Pre-service Appeals:
If your appeal is asking that SummaCare cover a service or medical item that you have not yet
received, SummaCare will notify you in writing of the outcome within 15 calendar days. Our
response will explain the basis of the decision and inform you of any action that SummaCare has
or will take as a result of your appeal.
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E. Expedited or Fast Appeals:
SummaCare may choose to expedite your appeal if you believe that waiting 15 days for a preservice
decision could result in any of the following:
Place you or your unborn child in serious jeopardy;
Cause serious impairment to bodily functions or serious dysfunction of any bodily organ
or
part;
Place you in severe pain that cannot be adequately managed without the care or treatment
in
question.
Expedited appeals are only granted in medically urgent situations. SummaCare does not have to
expedite your appeal if we believe that it does not meet any of the three reasons listed above. If
we determine that your appeal does not qualify for a fast/expedited review, we will still process it
as a standard pre-service appeal. If you disagree with SummaCare’s decision not to expedite an
appeal, you may file a grievance. If a licensed physician indicates that expedition is necessary for
medical reasons, SummaCare will automatically expedite your appeal.
If SummaCare does expedite your appeal, it will be completed within 72 hours from the time it is
received or as fast as the medical necessity dictates. To request that your appeal be expedited,
you must call Member Services at (330) 996-8700 or 1-800-996-8701. If your expedited appeal
is denied in whole or in part, you may skip the second level of internal appeal and proceed
immediately with an expedited independent review (see N below).
F. Second Level Appeals:
Ohio law requires SummaCare to complete the entire appeals process within 60 calendar days from receipt
of your first level appeal request. In order to meet this requirement, SummaCare will automatically begin
reviewing your appeal at the second level of review if your first level appeal is not wholly approved. For
post-service appeals you will have seven days after SummaCare issues our first level decision to contact
us and let us know that you wish us to complete the second level appeal process. For pre-service appeals
you will have 45 days from the date we received your first level appeal letter to contact us and let us
know that you wish us to complete the second level appeal process described below. You may contact us
over the phone, by fax, mail or email. If SummaCare does not hear from you within these time frames,
we will assume that you agree with the first level decision and do not wish to have your appeal considered
at the second level. Your second level appeal may then be dismissed. If you contact us after these time
frames and ask to proceed with the second level of appeal, SummaCare may not be able to complete both
levels of appeal within 60 calendar days as required by state law. For this reason, SummaCare may not be
able to consider your request at the second level. However, even if you have missed the time frame for
filing a second level appeal, you may still have the right to appeal further via one of the additional external
appeal processes described below.
Your second level appeal will be reviewed by a fresh set of individuals who were not involved in either the
initial denial or the first level appeal decision. If your second level appeal is in any way related to the
medical appropriateness of the care or services in question, the appeal will be reviewed by a board -
certified physician or other appropriately licensed healthcare professional in the same or similar specialty
that typically treats the medical condition or provides the procedure or treatment in question. If your second
level appeal is purely a benefit issue, it will be heard by the SummaCare Appeals Committee.
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G. Second Level Post-Service Appeals:
SummaCare will send you a written response to your second level post-service appeal within 30
calendar days from the date we received your second level request and within 60 calendar days
from the date we received your first level appeal letter (whichever comes first).
H. Second Level Pre-Service Appeals:
SummaCare will send you a written response to your second level pre-service appeal within 15
calendar days from the date we received your second level request and within 60 calendar days
from the date we received your first level appeal letter (whichever comes first).
Please Note: The time frame for resolving any of your internal appeals described above may be
shortened if the seriousness of your condition requires a faster review. In certain situations,
SummaCare may, with your permission, choose to skip the internal appeal process and proceed
directly with one of the additional external appeal processes described below. SummaCare may
choose to skip the second level of internal appeal without your permission.
I. Additional External Appeals:
If you are still not happy with SummaCare’s decision, you may request a review from another
source. You may appeal denials for any of the reasons listed below:
a. They are not covered services;
b. They are not medically necessary; or
c. They are experimental and you have a terminal illness
These additional appeals are available only after you complete SummaCare’s internal appeal
process. The procedures for appealing denials beyond SummaCare are explained below.
J. Denial Because Services Are Not Covered
If SummaCare denies a service because it is not a covered service, you may request a review from
the Ohio Department of Insurance. You can write the Department of Insurance at 2100 Stella
Court, Columbus, Ohio 43215 or call the Department at 1-800-686-1526.
The Department will review your contract and the type of service requested. If the Department
determines that the service is not a covered benefit, SummaCare does not have to pay for the
service. If the Department determines that the service is a covered benefit, the plan must either
pay for the service or give you an opportunity for review by an Independent Review Organization
(IRO).
K. Denial Because Services Are Not Medically Necessary
If SummaCare denies a service because it is not medically necessary and the service and related
expenses will cost you more than $500 if it is not covered by SummaCare (the $500 does not
apply to expedited cases), you may request an external review from an Independent Review
Organization (IRO). The IRO is not affiliated with SummaCare.
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You must request this review within (60) days of receiving notice that your appeal was denied by
SummaCare. Your request must be in writing and include certification from the provider that the
service will cost you more than $500.
The IRO will review your medical records and determine if the recommended service is
medically necessary. If the IRO determines that the service is medically necessary, SummaCare
must pay for the service according to the terms of the contract. If the IRO determines that the
service is not medically necessary, the plan does not have to pay for the service.
L. Denial Because Services Are Experimental
If you have a terminal illness you may also request an external review when services are denied
because they are experimental or investigative. To qualify for this review you must meet all of
the following criteria:
1. You have a terminal condition that, according to the current diagnosis, has a high probability
of causing death within (2) two years.
2. You request an external review not later than (60) days after receiving the decision of
SummaCare denying the requested service because it is experimental.
3. Your physician certifies that one of the following situations applies to your condition:
a. Standard Therapies have not been effective in improving your condition;
b. Standard Therapies are not medically appropriate for you;
c. There is no standard therapy covered by the health plan that will benefit you more than the
therapy requested by either you or your physician.
4. Your physician has recommended a drug, device, procedure or other therapy that he or she
certifies in writing is likely to benefit you more than standard therapies, or you have
requested a therapy that has been found in a preponderance of peer-reviewed published
studies to be associated with effective clinical outcomes for the same condition.
5. You have exhausted all internal levels of appeal.
6. The drug, device, procedure, or other therapy would be covered if it were not considered to be
experimental.
M. Instructions for Requesting an Independent Review
You must request an external review in writing within 60 days of receiving notice from SummaCare that
your request for coverage is denied. You (the member), an authorized person, the provider, or the health
care facility representative may request the review. The provider and health care facility must have the
member’s signed authorization to request a review. You do not need the authorization of the provider.
You cannot be required to pay for the review. The review is paid for by SummaCare.
The Independent Review Organization must provide you with a response within 30 days. The decision of
the IRO must include:
a. A description of the patient’s condition;
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. The principal reason for the decision; and
c. An explanation of the clinical rationale for the decision.
N. Expedited Review
When the independent review must be completed quickly because of your medical condition, you may
request an external review by phone, fax or email. However, you must follow-up this request with a
written request within five days. The independent review organization must provide you with a response
to an expedited review within seven (7) days of your initial request.
You may request an expedited independent review if delaying the review will do any of the following:
a. Place the health of the patient or unborn child in serious jeopardy;
b. Cause serious impairment to bodily functions; or
c. Cause serious dysfunction of any body organ or part.
No suit or claim for benefits may be brought unless all the requirements of this section have been followed.
O. Provider Reconsiderations
SummaCare offers your provider the right to request in writing, on your behalf, a review of a decision you
disagree with. SummaCare may require that your provider obtain a signed statement from you authorizing
him or her to request reconsideration. SummaCare will work with your provider to get the information
needed to review the decision. SummaCare will reply to your provider’s request within three business
days.
XII. Coordination of Benefits (COB)
“Coordination of Benefits” is the procedure used to pay health care expenses when a person is covered by
more than one plan. SummaCare follows rules established by Ohio law to decide which plan pays first and
how much the other plan must pay. In accordance with non-duplication rules of insurance, combined
payments of all plans should not exceed what SummaCare would pay in the absence of another plan.
When you or your family members are covered by another plan along with this one, SummaCare will
follow Ohio Coordination of Benefits rules to determine which plan is primary and which is secondary.
You must submit all bills first to the primary plan. The primary plan must pay its full benefits as if you had
no other coverage. If the primary plan denies the claim or does not pay the full bill, you may then send the
balance to the secondary plan. SummaCare will follow non-duplication rules of insurance when paying as
a secondary plan.
A. Plans that Do Not Coordinate
SummaCare pays for health care only when you follow SummaCare’s rules and procedures as stated in this
Evidence of Coverage. If SummaCare’s rules conflict with those of another plan, it may be impossible to
receive benefits from both plans.
B. How SummaCare Pays as the Primary Plan
SummaCare will pay as the primary plan when coordinating with the following kinds of individual policies
or contracts:
1. Medicaid;
2. Group hospital indemnity plans which pay less than $100 per day;
3. School accident coverage;
4. Some supplemental sickness and accident policies.
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When SummaCare is primary, SummaCare will pay the full benefit allowed by SummaCare’s
allowable expense as if you had no other coverage.
C. How SummaCare Pays as the Secondary Plan
1. When SummaCare is secondary, SummaCare’s payments will be based on the balance left
after the primary plan has paid. SummaCare will pay no more than the balance of
SummaCare’s Allowable Expense. In no event will SummaCare pay more than it would have
paid had it been primary. It is your responsibility to make sure that the secondary plan has all
of the information that it needs from the primary insurer.
2. SummaCare will pay only for health care expenses that are covered by this plan.
3. SummaCare will pay only if you have followed all of SummaCare’s procedural requirements
including obtaining care from or arranged by your SummaCare provider and obtaining any
required pre-authorizations.
4. SummaCare will pay no more than the Allowable Expense for the health care involved. If
SummaCare’s Allowable Expense is lower than the primary plan’s, we will use the primary
plan’s Allowable Expense that may be less than the actual bill.
D. Determining Which Plan Is Primary
To decide which plan is primary, SummaCare must consider both the Coordination of Benefits
provisions of the other plan and which member of your family is involved in a claim. The
primary plan will be determined by the first of the following that applies:
1. Non-coordinating Plan. If you have another plan that does not coordinate benefits, it will
always be primary.
2. Employee. The plan that covers you as an employee (neither laid off nor retired), member,
(insured or subscriber) other than a dependent is always primary.
3. Children (Parents Divorced or Separated). If the court decree makes one parent responsible
for health care expenses, that parent’s plan is primary. If the court decree gives joint custody
and does not mention health care, we follow the birthday rule (see Part 4 below). If neither of
those rules applies, the order will be determined in accordance with the Ohio Department of
Insurance rule on Coordination of Benefits.
4. Children and the Birthday Rule. When your children’s health care expenses are involved, we
follow the “birthday rule”. The plan of the parent with the first birthday in a calendar year is
always primary for the children. If your birthday is in January and your spouse’s birthday is
in March, your plan will be primary for all of your children. However, if your spouse’s plan
has some other coordination rule (for example, a “gender rule” that says the father’s plan is
always primary), SummaCare will follow the rules of that plan.
5. Other Situations. For all other situations not described above, the order of benefit will be
determined in accordance with the Ohio Department of Insurance rule on Coordination of
Benefits.
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E. Coordination Disputes
If you believe that we have not paid a claim properly, you should first attempt to resolve the
problem by following the complaint procedure detailed in this Evidence of Coverage. Contact
SummaCare Member Services at 330-996-8700 or 800-996-8701 for information. If you are still
not satisfied, you may call the Ohio Department of Insurance at 614-644-2673 or 800-686-1526
for instructions on filing a consumer complaint.
F. Integration With Medicare
Under Federal law, if you or your covered dependents are both covered by SummaCare and
eligible for Medicare benefits, usually SummaCare is the primary plan and Medicare is the
secondary plan. But when permitted by law, SummaCare is the secondary plan.
G. Subrogation
This provision applies if the Plan pays benefits to or on behalf of a covered person for care for an
injury or illness for which the covered person or the covered person’s representative or
beneficiary has a right to recover, including, but not limited to, when such injury or illness is
sustained in any situation covered by workers compensation, automobile insurance, homeowners
insurance, liability insurance, uninsured/underinsured motorist insurance or any other first-party
or third-party benefits of insurance. The Plan will have the right to recover the value of benefits
paid from the covered person or the covered person’s representative or beneficiary through
reimbursement. Further, the Plan will have the right to recover the actual amount of benefits paid
from any responsible person or responsible entity (“responsible” being defined ad any person or
entity who may be called upon to pay damages to the covered person or the covered person’s
representative or beneficiary, whether through first-party or third-party insurance benefits),
through assignment and/or subrogation.
The plan will not bear any costs of suit or attorney’s fees incurred by the covered person, or the
covered person’s representative or beneficiary.
The covered person, or the covered person’s representative or beneficiary, will execute
documents and do whatever is necessary for the plan to exercise its subrogation and assignment
rights and will do nothing to limit, interfere or prejudice SummaCare’s rights. If the covered
person, or the covered person’s representative or beneficiary, limits, interferes with or prejudices
the plan’s right of recovery, it may result in termination of coverage.
XIII. Continuation of SummaCare Coverage
A. Converting to an Individual Health Care Coverage Contract
When your or your dependents’ SummaCare coverage ends under your employer’s group health
care coverage contract with SummaCare, you may be eligible to obtain an individual standard or
basic conversion health care contract by making direct payments to SummaCare. However,
benefits under the individual health care conversion contract may differ from the coverage you
now have through your group coverage.
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1. An individual health care conversion coverage contract is available to you if you terminate
employment unless:
2.
a. Your termination of coverage was based on non-payment of Subscription Rates after
reasonable notice in writing; or
b. You are, or are eligible to be, covered for benefits that are at least comparable to your
former employer’s group contract with SummaCare under:
Medicare;
Any state or federal law; or
Any policy or insurance or hospitalization plan providing comparable
benefits.
3. Each of your covered dependents has the right to obtain an individual health care conversion
coverage contract if the dependent’s group coverage ends for one of the following reasons:
a. Your death;
b. Your spouse ceases to be an eligible dependent, due to divorce or annulment of your
marriage;
c. Your covered dependent child reaches the limiting age; or
d. Your covered dependent child reaches the limiting age, or ceases to be an eligible
dependent for another reason, and you do not have the right to get an individual health
care conversion contract at that time.
A dependent child does not have the right to get an individual health care conversion coverage contract
while your spouse has the right to cover that child under the spouse’s individual health care conversion
coverage contract.
The person who has the right to get the individual health care conversion coverage contract must apply for
it and pay the required Subscription Rate to SummaCare within 31 days after the group health care
coverage for that person ends. Evidence of good health is not required. For more information on a
conversion contract, please call SummaCare Member Services at 330-996-8700 or 800-996-8701.
When a valid application and payment are received by SummaCare as set forth above, the individual health
care conversion contract will take effect on the day after the group health care coverage ends.
B. Continued Coverage for Handicapped Dependent Children
As long as your coverage is effective, coverage of an unmarried dependent child who is incapable of selfsupport
because of mental disability or physical handicap will be continued beyond the specified limiting
age if certain conditions are met:
1. The child became incapacitated before reaching the limiting age, and has been continuously
incapacitated since then;
2. The child is and continuously has been primarily dependent upon you for support and maintenance;
3. and SummaCare receives satisfactory proof of such incapacity and dependency within 31 days of the child
reaching the limiting age. Payment of the required Subscription Rates for the child must be continued
by or through your employer. SummaCare may require satisfactory proof of the child’s continued
incapacity and dependency, including medical examinations at SummaCare’s expense. However, such
proof will be required at the time the child reaches the limiting age and no more frequently than
annually thereafter.
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C. COBRA Continuation of Coverage
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that certain
employers provide employees and their dependents with the opportunity to continue SummaCare
coverage under the employer’s group contract for a period of months after it would otherwise
terminate, provided that the employee pays the full cost of such coverage. Contact your
employer’s personnel or employee benefits office to determine if your employer offers
continuation coverage.
If you or any of your dependents elect coverage under COBRA, each individual making the
election will receive the medical coverage in effect for such individual when the coverage was
otherwise scheduled to terminate. If you have any questions about COBRA continuation
coverage, do not hesitate to contact your employer.
The length of time COBRA coverage lasts depends on the reason coverage ended. You and your
covered dependents have a right to choose COBRA continuation coverage for up to eighteen (18)
months if you lose your group health coverage because of any of the following qualifying events:
1. A reduction in your hours of employment; or
2. The termination of your employment, for reasons other than gross misconduct on your part.
If you or a dependent are disabled (as set forth in Title II or XVI of the Social Security Act) when
coverage ends for any of these reasons, coverage may be continued for the disabled person for an
additional 11 months, but only if the disabled person has notified the employer within 60 days
after the determination of disability was made and prior to the end of the initial 18 month
coverage period. This means a possible total continuation period of up to 29 months for the
disabled person. When the additional 11 months of coverage begins, the cost of coverage for the
disabled person increases to the amount permitted by law.
COBRA regulations may change from time to time. The continuation of coverage will be
provided in accordance with current law.
In addition, your covered eligible dependent has the right to choose COBRA continuation
coverage for up to 36 months if such dependent loses coverage under SummaCare because of any
of the following qualifying events:
1. Your death;
2. Your divorce, legal separation or annulment of your marriage;
3. You become covered under Medicare; or
4. Your dependent ceases to meet SummaCare’s eligibility requirements.
Generally, losing coverage under SummaCare as a result of a qualifying event entitles you and/or
your spouse or dependent child to become a qualified beneficiary under COBRA.
Under the law, a qualified beneficiary must notify the employer of the following qualifying
events within 60 days of the qualifying event:
1. Divorce or legal separation of employee and spouse; or
2. A dependent child’s loss of eligibility.
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Also, a qualified beneficiary must notify the employer within 60 days of the Social Security
determination that the qualified beneficiary was disabled at the time of the employee’s
termination or reduction in hours.
The employer must notify:
1. Each covered employee and his or her spouse (if any) of their right to continue coverage
when the SummaCare plan becomes subject to COBRA;
2. Each new employee and his or her spouse (if any) of their COBRA rights when they become
covered under the SummaCare plan; and
3. Each qualified beneficiary of his or her COBRA rights within fourteen (14) days of having
been informed of or having a record of a qualifying event.
Each person who elects to continue coverage also must receive notice of any conversion privilege
during the 180 days just prior to the end of the continuation period, allowing them to convert to
an individual health care coverage contract.
A qualified beneficiary may elect to continue coverage under the SummaCare plan up to 60 days
after the later of:
1. The date coverage under SummaCare would otherwise end; or
2. The date notice of continuation rights is provided by the employer.
Each qualified beneficiary may elect to continue any or all of the benefits for which they were
enrolled at the time of the qualifying event. An employee or spouse may elect to cover all
eligible qualified beneficiaries under one continuation enrollment.
Contact your employer’s personnel or employee benefits office to determine the cost for your
continuation of coverage and to elect continuation of coverage. A qualified beneficiary is
required to make the payment in monthly installments (normally due on the first day of each
month). Your employer may not require any payment that is retroactive to the date of the
qualifying event until 45 days after the qualified beneficiary timely elects COBRA coverage.
The amount of the payment may be adjusted once every 12 months. The cost will be determined
in advance of the 12-month period.
The law provides that the continuing coverage will end on the earliest date of the following
events:
1. 18 months after the date of the employee’s termination of employment or reduction in hours
(an additional 18 months if another qualifying event occurs during such 18 month period),
unless the Social Security Administration determines that a qualified beneficiary was disabled
at the time of termination or reduction of hours and the qualified beneficiary so informs
his/her employer (as described previously) before the end of the 18 month period. In this
case, coverage may be extended (at an additional cost) until the month that begins more than
30 days after the final determination by the Social Security Administration that the disability
has ended, to a maximum of 29 months;
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2. 36 months after any other qualifying event, even in the event of multiple qualifying events;
3. The employer no longer provides group health coverage to any of its employees;
4. The qualified beneficiary does not pay for continuation coverage in a timely fashion;
5. The qualified beneficiary becomes covered under another group health plan unless a preexisting
condition clause in such plan affects the qualified beneficiary’s coverage; or
6. The qualified beneficiary becomes covered under Medicare.
D. Ohio Law
1. Section 1751.53 of the Ohio Revised Code requires Ohio employers to provide involuntarily
terminated employees the option to continue their group medical coverage for up to six
months. Therefore, if you are affected by this law, you are eligible to continue SummaCare
coverage for you and your covered dependents for up to six months after termination,
provided the Subscription Rates for such coverage are paid. You are eligible for this
continuation of coverage if you meet all of the following requirements:
a. You have been continuously covered by this SummaCare plan or any prior similar
group coverage replaced by this SummaCare plan during the three month period before
termination of your employment;
b. You are entitled to unemployment benefits under Ohio law at the time of your
employment termination;
c. You are neither eligible for nor covered by Medicare; and
d. You are neither eligible for nor covered by any other insured or uninsured arrangement
that provides hospital, surgical, or medical coverage for individuals in a group.
2. Section 1751.54 of the Ohio Revised Code requires Ohio employers to provide employees
who are reservists called or ordered to active duty, and the covered dependents of any such
reservists, the option to continue their group medical coverage for up to 18 months after the
date on which the coverage would otherwise terminate because the reservist is called or
ordered to active duty. Therefore, all covered persons who would be affected by this law are
eligible to continue their group coverage under this SummaCare plan for up to 18 months,
provided the Subscription Rates for such coverage are paid. Coverage may be continued for
up to 36 months if any of the following events occur during the 18 month period:
The death, divorce, or separation of the reservist; or
The reservist’s covered dependent child ceases to meet the eligibility criteria set forth
in Section II.B.
You, your spouse and/or dependent child must file a written election of continuation of coverage
with your employer and pay the first contribution required for the extension of coverage. The
written election and payment must be received no later than 31 days after the date on which the
coverage would otherwise terminate.
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You, your spouse and/or dependent child must pay to the employer, on a monthly basis and in
advance, the amount of contribution required by the employer.
XIV.
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA imposes portability requirements on group health plan to ensure that employees remain
insurable when moving from one health plan to another.
Portability relates directly to pre-existing condition exclusionary periods (PCE) that benefit plans
may impose on enrollees. The PCE periods are limited to a maximum of 12 months. An
individual will receive credit for any time served under a previous pre-existing exclusionary
period as he/she moves from plan to plan as long as there is not a lapse in coverage for more than
63 days.
A pre-existing condition is an ailment that has been treated or diagnosed within six months
immediately preceding the start of coverage. Insurers may not consider pregnancy or the use of
genetic testing for imposing a PCE exclusionary period.
Individuals who lose coverage under employer-provided health plans receive a certificate of
creditable coverage. This certificate will be provided either by your employer or SummaCare
depending upon arrangements agreed upon by your employer and SummaCare. Consult with
your Human Resources Representative to determine where this responsibility lies. The
Certificate will be automatically provided when normal coverage terminates under the plan and
again when COBRA coverage terminates.
XV.
Definitions
When used in this booklet or your Schedule of Benefits, the terms listed below will have these
meanings:
Accident
A sudden, unforeseen event that causes trauma to the body.
Annual Open Enrollment
The annual period during which an eligible employee may enroll himself or herself and his or her
eligible dependents in the SummaCare plan.
Authorization
A physician’s written order or referral for the provision of covered services obtained through
SummaCare’s Health Services Management Program.
Calendar Year
A period of one year beginning January 1 and ending December 31.
Contract Year
The 12-month period beginning on the effective date or any renewal date of the contract between
SummaCare and your employer.
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Coordination of Benefits
The provision that applies when a person is covered under more than one group medical program. It
requires that payment of benefits will be coordinated by all programs to eliminate over insurance or
duplication of benefits.
Copayment/Coinsurance
The dollar amount and/or percentage of costs shown in the Schedule of Benefits that a covered person must
pay directly to the physician, practitioner or other provider for certain covered services (in addition to
Subscription Rates). Note: Copayments for services that are basic health care services will not exceed
thirty percent of the total cost of the service, except for physician office visits, emergency health services
and urgent care services. Also, copayments paid in a contract year will not exceed two hundred percent of
the total annual premium that is charged to the member.
Covered Person
An eligible person, who enrolls, becomes covered and remains covered under this plan, and continues to
meet the plan’s eligibility requirements.
Covered Services
The healthcare services and items described in this booklet and updated in the Schedule of Benefits, for
which SummaCare provides benefits to covered persons.
Creditable Coverage
Coverage of the individual from a wide range of specified sources including group health plans, health
insurance coverage, Medicare, Medicaid and COBRA.
Custodial Care
Care comprised of services and supplies, including room and board and other institutional services, that is
provided to an individual, whether disabled or not, primarily to assist in the activities of daily living.
Eligible Person
The employee or the employee’s spouse or child who meets the eligibility requirements specified in
Section II of this booklet.
Emergency
A medical condition that manifests itself by such acute symptoms of sufficient severity, including severe
pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect
the absence of immediate medical attention to result in any of the following: placing the health of the
individual or the health of a pregnant women or her baby in serious jeopardy; serious impairment to bodily
functions; or serious dysfunction of any bodily organ or part.
Emergency Services
Healthcare services which are available seven days per week, 24 hours per day in order to prevent jeopardy
to a covered person’s health status (as defined under “Emergency”) which would occur if such services
were not received as soon as possible including, where appropriate, ambulance transportation and
indemnity payments for out of area coverage.
Episode of Illness or Injury
A period of consecutive days beginning with the first day (not included in a previous Episode of
Illness or Injury on which a member is furnished health care services for a single diagnosis and
any conditions directly related to the diagnosis, and ending with the last day in which the member
is furnished healthcare services related to that diagnosis and any condition directly related to that
diagnosis.
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Expense Incurred
An expense is incurred when the service or the supply for which it is charged is actually
provided.
Family Coverage
Coverage for you and one or more of your eligible dependents.
Federally Eligible Individual
An individual who has 18 months of creditable coverage; the most recent coverage under an
employer, church or government plan; the individual is not eligible for Medicare/Medicaid; the
individual has accepted and exhausted all continuation of benefits options and new coverage was
put into place within 63 days from the loss of coverage.
Home Health Aid
A person who provides care of a medical or therapeutic nature and reports to and is under the
direct supervision of a Home Health Care Agency.
Home Health Care Agency
A public or private agency or organization, or part of one, that mainly provides skilled nursing
and other therapeutic services. It must be legally qualified in the state or locality in which it
operates. It must keep clinical records on all patients. The services must be supervised by a
physician or registered nurse, and they must be based on policies set by associated professionals,
which include at least one physician and one registered nurse.
Home Health Care Plan
A plan for continued care and treatment of a covered person in his or her home. To qualify, the
Plan must be established in writing by a participating physician who certifies that the covered
person would require confinement in a hospital if he or she did not have the care and treatment
stated in the plan. The Home Health Care Plan is subject to review and prior approval by the
SummaCare Health Services Management Program.
Hospice Care Agency
An agency or organization that is properly licensed in the state in which it operates, has hospice
care available 24 hours a day, 7 days a week and provides or arranges for hospice care services or
supplies.
Hospice Care Plan
A plan that is supervised by a participating physician and involves a team consisting of:
1. A participating physician who provides hospice care;
2. Licensed nurses;
3. A licensed mental health specialist; and
4. A licensed social worker.
The Hospice Care Plan must:
1. Provide the patient’s plan of care;
2. Provide regular reviews of the patient’s care;
3. Inform the proper persons of any change in the patient’s condition; and
4. Comply with governmental regulations.
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Hospice Facility
A facility that is properly licensed in the state in which it operates and is engaged mainly in providing
palliative care to terminally ill patients.
Hospital
An institution that:
1. Provides medical care and treatment of sick and injured persons on an inpatient basis;
2. Is properly licensed or permitted legally to operate as such;
3. Has a physician on call at all times;
4. Has licensed graduate registered nurses on duty twenty-four (24) hours a day;
5. Maintains facilities for the diagnosis and treatment of illness and for major surgery; and
6. Meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO).
In no event will the definition of hospital include an institution or any part of one that is a
convalescent/extended care facility, or any institution, which is used primarily as:
1. A rest facility;
2. A nursing facility;
3. A facility for the aged; or
4. A place for custodial care.
Health Delivery Organization
An:
1. Alcoholism or drug addiction treatment facility;
2. Psychiatric hospital;
3. Ambulatory surgical facility;
4. Freestanding birth center; or
5. Hospice facility - - provided that the facility is licensed in the state in which the facility operates and is
operating within the scope of its license.
Illness
Any physical or mental sickness or disease that manifests treatable symptoms and that requires treatment of
a physician. This definition also includes pregnancy.
Injury
Any accidental bodily damage or harm sustained while the person is covered under the plan and that
requires treatment by a physician.
Maximum Allowable Charge
The amount billed for covered services for which benefits are available under the contract.
Medically Necessary
A service or supply must be necessary and appropriate for the diagnosis and treatment of an illness or
injury as determined by SummaCare based on generally accepted current medical practice.
The fact that any particular physician, practitioner or other provider may prescribe, order, recommend or
approve a service or supply does not, of itself, makes that service medically necessary.
A service or supply will not be considered as medically necessary if:
1. It is provided only as a convenience to the covered person;
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2. It is not appropriate treatment for the covered person’s diagnosis or symptoms;
3. It exceeds (in scope, duration or intensity) that level of care that is needed to provide safe, adequate
and appropriate diagnosis or treatment.
Medicare
Title VIII (Health Insurance of the Aged) of the United States Social Security Act, as amended.
Outpatient
A covered person will be considered to be an outpatient if treated on a basis other than as an inpatient in a
hospital or other covered facility. Outpatient care includes services, supplies and medicines provided and
used at a hospital or other covered facility under the direction of a physician to a person not admitted as an
inpatient.
Participating Physician, Practitioner or Other Provider
Any physician, hospital, or other health services physician, practitioner or other provider who has a
contract with SummaCare to provide covered services to covered persons.
Physician
A legally qualified person acting within the scope of his or her license and holding the degree of Doctor of
Medicine (M.D.) or Doctor of Osteopathy (D.O.).
Plan
The SummaCare plan of health benefits described in this booklet and the Schedule of Benefits.
Practitioner
Doctor of Dental Surgery (D.D.S.); Doctor of Podiatry (D.P.M.); Licensed Clinical Psychologist (Ph.D.);
Certified Nurse Midwife (C.N.M.) acting within the scope of his or her license, under the direction and
supervision of a licensed physician; Physician Assistant (P.A.); Licensed Social Worker (L.S.W.); or
Licensed Physical Therapist (L.P.T.) or Licensed Speech Therapist (L.S.T.) acting within the scope of his
or her license, and performing services ordered by a Doctor of Medicine or a Doctor of Osteopathy.
Primary Care Physician
The SummaCare participating family practice, internal medicine or pediatric physician you choose to be
your personal physician or your dependent’s personal physician.
Provider
A person or organization responsible for furnishing health care services, including a hospital, skilled
nursing facility, rehabilitation facility, ambulatory surgery center or physician.
Reasonable and Customary Charges (R&C)
Charges made for medical services or supplies will be considered reasonable and customary if they are the
amount normally charged by the physician, practitioner or other provider for similar services and supplies,
and do not exceed the amount ordinarily charged by most physician, practitioner or other providers of
comparable services and supplies in the locality where the services or supplies are received.
Determination of whether or not a charge is reasonable and customary will be made by
SummaCare based on nationally obtained and recognized survey data.
Room and Board
Charges made by a hospital or other covered institution for the cost of the room, general duty
nursing care, and other services routinely provided to all inpatients, not including special care
units.
Semi-private Charge
The charge made by a hospital for a room containing two or more beds not including the charge made by
the hospital for special care units.
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Service Area
The geographic area within which SummaCare arranges for the provision of covered services by
participating physician, practitioner or other providers. The service area includes several counties located
in northeastern Ohio.
Schedule of Benefits
A Schedule of Benefits insert included with this booklet provides information on the limits and maximums
of the plan and copayment amounts that you must pay.
Skilled Nursing Facility
Any an institution, other than a hospital, which meets all of the following requirements:
1. Maintains permanent and full-time facilities for bed care of ten or more resident patients;
2. Has available at all times the services of a physician;
3. Has a registered nurse (R.N.) or physician on full-time duty in charge of patient care, and one or more
registered nurses (R.N.s) or licensed vocational nurses (LVNs), or licensed practical nurses (LPNs) on
duty at all times;
4. Maintains a daily medical record for each patient;
5. Is primarily engaged in providing continuous skilled nursing care for sick or injured persons during
the convalescent stage of their illness or injury;
6. Is operating lawfully as a convalescent/extended care facility in the jurisdiction where it is located or
meets the required standards of the Joint Commission on Accreditation of Healthcare Organizations;
and
7. Has a written agreement with at least one other hospital providing for the transfer of patients and
medical information between the hospital and convalescent/extended care facility.
In no event, however, will a convalescent/extended care facility include an institution, which is primarily:
(a) a place for rest; (b) a place for the aged; (c) a place for drug addicts, alcoholics, the blind or deaf; (d) a
place for the mentally ill or retarded; or (e) a hotel or similar place.
Special Care Units
A specific hospital unit that provides concentrated special equipment and highly skilled personnel for the
care of critically ill patients requiring immediate, constant and continuous attention.
This term will include charges for intensive care, coronary care and acute care units of a hospital but does
not include care in a surgical recovery or post-operative room. The unit must meet the required standards
of the Joint Commission on Accreditation on Healthcare Organizations (JCAHO) for special care units.
Subrogation
The procedure that an insurance company can recover from a third party full or part of benefits
paid to an insured.
Subscription Rate
The monthly charge for the coverage provided by SummaCare.
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Waiting Period
The period of time, if any, for which you must be continuously employed with the employer in an
eligible employee class before you become eligible for coverage under the plan.
You, Your
A covered employee, or relating to a covered employee.
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OBLIGATIONS OF SUMMACARE AND PARTICIPATING PHYSICIAN, PRACTITIONER
OR OTHER PROVIDERS
In accordance with the agreement between SummaCare and its participating physicians,
practitioners or other providers will not seek compensation from you for any of the covered
services and supplies described in this booklet or your Schedule of Benefits except for approved
copayments and/or coinsurance. SummaCare is not a member of a guaranty fund, and you are
protected from physicians, practitioners or other providers seeking redress from you to the extent
of the Hold Harmless Agreement below. You will be notified if a participating hospital’s or your
PCP’s agreement with SummaCare ends. Notification will be mailed within 30 days of the
termination if you have selected that PCP within the previous 12 months. A quarterly notice also
will be mailed to you. You will continue to receive covered services and supplies as outlined in
this booklet and the Schedule of Benefits between the date the hospital’s or your PCP’s
agreement ends and 5 business days after notification is mailed to you at your last known address.
You will also be notified by mail within 30 days if a SummaCare agreement with a hospital ends
if you or a dependent have used the hospital directly within the 12 months preceding termination
of the agreement. SummaCare will pay for covered services received between the date the
hospital agreement ends and five business days after notification is mailed to you at your last
known address.
In the event that SummaCare is discontinued, we have arranged for all covered services and
supplies described in this booklet and your Schedule of Benefits to be provided to you until the
coverage would otherwise have ended under your employer’s group health contract. Such health
care coverage may be provided through any one or more of the following methods: (a) insolvency
insurance; (b) provisions in participating physician, practitioner or other provider agreements; (c)
agreements with other organizations or insurers providing automatic conversion rights upon
discontinuation of the plan; and/or (d) other arrangements approved by the Superintendent of
Insurance. For more information, call Member Services at 330-996-8700 or 800-996-8701.
Hold Harmless Agreement
SummaCare Health Plan agrees that in no event, including but not limited to, nonpayment by
SummaCare, insolvency of SummaCare, or breach of this agreement, shall SummaCare bill,
charge, collect a deposit from, seek remuneration or reimbursement from, or have any recourse
against a subscriber, enrollee, person to whom health care services have been provided, or
persons acting on behalf of the covered enrollee, for health care services provided pursuant to this
agreement. This does not prohibit SummaCare from collecting co-insurance, deductibles or
copayments as specifically provided in the Evidence of Coverage, or fees for uncovered health
care services delivered on a fee-for-service basis to persons referenced above, nor from any
recourse against SummaCare or its successor.
FRAUD WARNING
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing false or deceptive statements is guilty
of insurance fraud. If you are found guilty of insurance fraud, you will be terminated from the
plan.
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Important Phone Numbers
SummaCare Member Services 330-996-8700
800-996-8701
SummaCare 24 Hour Nurse Line 800-379-5001
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www.summacare.com
Akron Office
P.O. Box 3620
Akron, Ohio 44309-3620
Phone: (330)996-8410
Toll Free: (800)996-8411
Fax: (330)996-8415
Cleveland Office
Genesis Building
6000 Lombardo Center, Ste 130
Cleveland, Ohio 44131
Phone: (216)524-1400
Toll Free: (888)246-2314
Fax: (216)524-4300