20201209Suez to Staff 41-59.pdf

SUEZ WATER’S RESPONSE TO SECOND PRODUCTION REQUEST
OF THE COMMISSION STAFF - 1
15427194_1.DOCX [30-209]
Michael C. Creamer (ISB No. 4030)
Preston N. Carter (ISB No. 8462)
Givens Pursley LLP
601 W. Bannock St.
Boise, ID 83702
Telephone: [phone]
Facsimile: [phone]
[e-mail]
[e-mail]
Attorneys for SUEZ Water Idaho Inc.
BEFORE THE IDAHO PUBLIC UTILITIES COMMISSION
IN THE MATTER OF THE APPLICATION
OF SUEZ WATER IDAHO INC. FOR
AUTHORITY TO INCREASE ITS RATES
AND CHARGES FOR WATER SERVICE
IN THE STATE OF IDAHO
Case No. SUZ-W-20-02
SUEZ WATER IDAHO INC.’S
RESPONSE TO SECOND
PRODUCTION REQUEST OF THE
COMMISSION STAFF
SUEZ Water Idaho Inc., (“SUEZ Water” or “Company”) submits the following
responses to the Second Production Request of the Commission Staff to SUEZ Water,
dated November 18, 2020. Please note that the responses to Requests Nos. 46, 47,
48, 49, 51, and 55 are confidential and will be submitted under separate cover per the
Commission’s rules.
DATED: December 9, 2020
SUEZ WATER IDAHO INC.
By: _______________________
Michael C. Creamer
Preston N. Carter
Attorneys for Applicant
RECEIVED
Wednesday, December 9, 2020 2:18:25 PM
IDAHO PUBLIC
UTILITIES COMMISSION
SUEZ WATER’S RESPONSE TO SECOND PRODUCTION REQUEST
OF THE COMMISSION STAFF - 2
15427194_1.DOCX [30-209]
CERTIFICATE OF SERVICE

I certify that on December 9, 2020, a true and correct copy of the foregoing was
served upon all parties of record in this proceeding via electronic mail as indicated
below:
Commission Staff
Jan Noriyuki, Commission Secretary
Idaho Public Utilities Commission
11331 W. Chinden Blvd., Bldg. 8, Ste. 201-A
Boise, ID 83714
[e-mail]
Electronic Mail

Dayn Hardie
Deputy Attorney General
Idaho Public Utilities Commission
11331 W. Chinden Blvd., Bldg. 8, Ste. 201-A
Boise, ID 83714
[e-mail]
Electronic Mail
Intervening Parties Electronic Mail
Ada County: - Non-Confidential Responses
Only
Lorna K. Jorgensen
John C. Cortabitarte
Ada County Prosecuting Attorney’s Office
Civil Division
200 W. Front Street, Room 3191
Boise, ID 83702
[e-mail]
Boise City: Non-Confidential
Responses Only
Abigail R. Germaine
Deputy City Attorney
Boise City Attorney’s Office
150 N. Capitol Blvd.
P.O. Box 500
Boise, ID 83701-0500
[e-mail]
CAPAI: - Non-Confidential Responses Only
Brad M. Purdy
2019 N. 17th Street
Boise, ID 83702
[e-mail]
Suez Water Customer Group:
Norman M. Semanko
Parsons Behle & Latimer
800 W. Main Street, Suite 1300
Boise, ID 83702
[e-mail]
[e-mail]
Intervenors: - Non-Confidential Responses
Only
Marty Durand
Piotwrowski Durand PLLC
1020 Main Street, Suite 440
P.O. Box 2864
Boise, ID 83701
[e-mail]
Idaho Fair House Council, Inc. -
Non-Confidential Responses
Only
Ken Nagy
Attorney at Law
P.O. Box 164
Lewiston, ID 83501
[e-mail]

SUEZ WATER’S RESPONSE TO SECOND PRODUCTION REQUEST
OF THE COMMISSION STAFF - 3
15427194_1.DOCX [30-209]
Micron Technology, Inc.
Austin Rueschhoff
Thorvald A. Nelson
Holland & Hart
555 17th St., Suite 3200
[e-mail]
[e-mail]
[e-mail]
[e-mail]

Jim Swier
Greg Harwood
Micron Technology, Inc.
8000 S. Federal Way
[e-mail]
[e-mail]

Preston N. Carter
SUZ-W-20-02 IPUC DR 41 Page 1 of 2
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: T. Michaelson
REQUEST NO. 41:
On Pages 3 and 4 of his direct testimony, Company Witness Michaelson describes adjustments made to the average numbers of residential and commercial customers. Please provide all work papers used to calculate these adjustments in EXCEL format with formulas and links intact
RESPONSE NO. 41: Workpapers supporting these adjustments were provided to IPUC Staff on 09/30/2020 – filename “SUZ-W-20-02 Revenues”.
Adjustment R1: For Residential customers, tab “Exhibit 5 Sched 4” provides the total number of customers at the beginning and end of the Test Year (84,819 and 86,102 respectively). These figures were taken from the “Total Customer Count” tab. An average of the total gain of
1,283 (or 642 average new customers) was used to calculate the average number of new
bills as well as pro-forma additional average usage for the Test Period of 91,857 CCF using the Test Year annual average usage per Residential bill of 23.87 CCF. This additional usage revenue was allocated to the Winter, Summer 1 and Summer 2 blocks using the percentages developed on the “Bill Analysis Current & Propose” tab. Additional
fixed revenue was calculated by multiplying the average number of additional bills (3,849)
by the present and proposed 5/8” meter charge of $21.11 and $25.81. For Commercial customers the same computation was made to arrive at the average growth (24). This average growth in customers was used to calculate the number of new
bills as well as pro-forma additional average usage for the Test Period of 16,067 CCF
using the Test Year annual average usage per Commercial bill of 111.58 CCF. This additional usage revenue was allocated to the Winter, Summer 1 and Summer 2 blocks using the percentages developed on the “Bill Analysis Current & Propose” tab. Additional fixed revenue was calculated by allocating the average number of additional bills (144)
and multiplying by the present and proposed ¾”, 1”, 1 ½” and 2” meter charges. Adjustment R2: Adjustment R2 calculates the average pro-forma full-year equivalent Residential
customers (372) from the end of the Test Year through March 31, 2021. The “Total
Customer Count” tab, cells F222 – O222 provides the calculations. For Commercial customers an 8-year average annual growth amount (137) was used as the starting point. The annual average was reduced by 9/12 to account for the period
July 2020 – March 2021 and a simple average was taken to arrive at the 51 full-year
equivalent commercial customer addition. Calculations are provided in cells AH85 – AH87 on the “Total Customer Count” tab.
SUZ-W-20-02 IPUC DR 42
Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: T. Michaelson

REQUEST NO. 42:
On Pages 4 and 5 of his direct testimony, Company Witness Michaelson describes the
regression method used to adjust the consumption of residential and commercial
customers. Please provide all workpapers used to calculate these adjustments in
EXCEL format with formulae and links intact.

RESPONSE NO. 42: Workpapers supporting these adjustments were provided to IPUC Staff on 09/30/2020 –
filename “SUZ-W-20-02 Revenues”.
Tab “Exhibit 5 Sched 4D” shows the output of running the regression analysis. The “Input
Y Range” is E6:E35 (Actual Residential consumption) and the “Input X Range” is C6:D35
(Year and Palmer Z Index). Once the output of the regression is produced, the “Predicted
Residential” column is created using the formulae in Column F. The predicted Residential
annual usage amount for the Test Year (101.94) is compared to the Actual Residential
annual usage amount (107.11), resulting in a 5,171 gallon adjustment (or 6.91CCF).
SUZ-W-20-02 IPUC DR 43
Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: T. Michaelson

REQUEST NO. 43:
On Page 4 of his direct testimony, Company Witness Michaels states that he used
Palmer Z index amounts taken from NOAA National Centers for Environmental
Information, Climate at a Glance ( ). Please provide the Palmer-Z data
used to create the regression model in EXCEL format. Please provide all parameters
that were selected to download the Palmer-Z data, including:
a. Parameter
b. Time Scale
c. Month
d. Start year
e. End Year
f. State
g. Climate Division
RESPONSE NO. 43:
Please refer to Request No. 43 Attachment for the Palmer-Z data used to create the regression model. Parameters used are listed below:
a. Parameter = Palmer Z-Index
b. Time Scale = 7 month c. Month = October d. Start Year = 1915 e. End Year = 2020
f. State = Idaho
g. Climate Division = 5. Southwest Valleys https://www.ncdc.noaa.gov/cag/divisional/time-series/1005/zndx/7/10/1915-2020?base_prd=true&begbaseyear=1901&endbaseyear=2000

CASE NO. SUZ-W-20-02

Response No. 43 Attachment 1

EXCEL Spreadsheet Provided Separately
in Native Format

SUZ-W-20-02 IPUC DR 44
1 of 2
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: M. Thompson

REQUEST NO. 44:
Please provide the data that supports the Customers per Employee 2000-2020 chart on Page 8 of Company Witness Thompson's direct testimony RESPONSE NO. 44:

Please find the supporting data set for the company’s Customers per Employee 2000-2020 chart on Page 8 of Company Witness Thompson's direct testimony.

SUZ-W-20-02 IPUC DR 44 2 of 2

Year Customer Count Employee Count Customer per Employee
2000 68,534 97 710.00
2001 70,562 92 771.00
2002 71,978 91 795.00
2003 74,177 85 869.00
2004 76,388 90 845.00
2005 78,892 90 881.00
2006 81,795 93 883.00
2007 83,235 93 898.00
2008 86,151 96 894.00
2009 84,022 97 868.00
2010 84,604 100 847.00
2011 84,378 98 862.00
2012 85,596 99 865.00
2013 86,849 99 878.00
2014 88,314 98 901.16
2015 90,032 94 957.79
2016 91,732 92 997.09
2017 93,001 102 911.77
2018 95,449 101 945.04
2019 97,029 105 924.09
2020 98,413* 120* 820.11 872.53 Average
*projected 2020 year end totals

SUZ-W-20-02 IPUC DR 45 1 of 2
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: M. Thompson

REQUEST NO. 45:
Please provide the data that supports the Customers per Employee 2000-2020 chart
on Page 8 of Company Witness Thompson's direct testimony Please provide the data
supporting the Customer vs Employee Count 2000-2020 chart on Page 8 of Company Witness Thompson's direct testimony.
RESPONSE NO. 45: Please find the supporting data set for the company’s Customers per Employee 2000-2020 chart and Customer vs Employee Count 2000-2020 chart on Page 8 of Company
Witness Thompson's direct testimony.

SUZ-W-20-02 IPUC DR 45 2 of 2

Year Customer Count Employee Count Customer per Employee
2000 68,534 97 710.00
2001 70,562 92 771.00
2002 71,978 91 795.00
2003 74,177 85 869.00
2004 76,388 90 845.00
2005 78,892 90 881.00
2006 81,795 93 883.00
2007 83,235 93 898.00
2008 86,151 96 894.00
2009 84,022 97 868.00
2010 84,604 100 847.00
2011 84,378 98 862.00
2012 85,596 99 865.00
2013 86,849 99 878.00
2014 88,314 98 901.16
2015 90,032 94 957.79
2016 91,732 92 997.09
2017 93,001 102 911.77
2018 95,449 101 945.04
2019 97,029 105 924.09
2020 98,413* 120* 820.11 872.53 Average
*projected 2020 year end totals

SUZ-W-20-02 IPUC DR 50 Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 50:
With reference to the Wage Adjustments on Page 4 of the testimony, please provide supporting documentation for the test year ratio of 68.10% of the opex payroll to gross payroll.
RESPONSE NO. 50: As noted in Exhibit 10, Schedule 1, on row 20 the opex payroll to gross payroll percentage test year ratio is calculated by taking the June 30, 2020 test year balances for Net Operating Labor expense in accounts 50100 to 50125, and dividing that by the sum of
accounts 50100 to 50115 which represent Gross Labor or Total Payroll expense and
includes all payroll to opex, capital, deferred, etc. 50100 Supervisory labor $3,041,951.78 50105 Direct labor 4,666,978.01
50110 Supervisory labor transferred 12,979.57
50115 Direct Labor transferred in - 0 - Gross Labor $7,721,909.36
50120 Supervisory labor transferred out $(1,350,100.76)
50125 Direct labor transferred out (1,113,029.31) Labor Transferred to capital, etc. $(2,463,130.07)

(Net Labor = sum of accounts 50100 through 50125 or Gross Labor less Transferred) Net Labor $5,258,779.29

Net Labor / Gross Labor = % Opex payroll to Gross payroll
$5,258,779.29 / $7,721,909.36 = 68.10%

SUZ-W-20-02 IPUC DR 52
Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 52:
With reference to the Incentive Programs on Page 4 of the testimony, please provide a description of the Company's Short-Term Incentive Plan, including the goal targets and criteria requirements. Please provide descriptions and amounts of the target awards based upon the job/salary grade, including the personal goals and Company goals
RESPONSE NO. 52: Please see Attachment 1 detailing the Short Term Incentive Plan (STIP), Attachment 2 describing the Long Term Incentive Plan (LTIP), each with the respective
goals/objectives, both Corporate and Personal, and Attachment 3 for the Target awards
based upon job grade.

Short Term Incentive Plan

PLAN DOCUMENT
JANUARY 2008
SUZ-W-20-02 IPUC DR 52
Attachment 1 Page 1 of 5

1
SHORT TERM INCENTIVE PLAN PLAN DOCUMENT

SHORT TERM INCENTIVE PLAN

PURPOSE

The Short Term Incentive Plan (STIP) is an annual compensation plan that supports United Water’s
business objectives by:
 Providing an annual incentive strategy that drives performance towards objectives
critical to creating shareholder value.
 Offering competitive cash compensation opportunities to all eligible employees.
 Awarding outstanding achievement among employees who can directly impact United
Water’s results.
 Providing cash awards for both qualitative and quantitative results.
 Providing cash compensation opportunities for making sound business decisions that
impact the company’s financial performance and the overall success of Suez.

ELIGIBILITY

All active exempt employees including expatriates are eligible to participate in STIP if not covered by
another annual incentive plan. Employees must be hired or promoted into STIP eligible positions by the
first pay period of the fourth quarter of the plan year, in order to be eligible for a STIP award for that
plan year..

AWARD OPPORTUNITIES

Employees are assigned a target award based on their job/salary grade. Target awards for expatriates
will be based on their Suez compensation plan unless otherwise agreed to by Suez. The target award is
established at market competitive levels and is expressed as a percentage of base salary. Target awards
will be prorated for part-time employees. Paid awards may range from 0% to 200% of the target award
based on achievement of financial objectives and personal objectives. Should any events occur during
the performance year that in the opinion of the management of United Water materially affect the
performance targets set, then United Water may recommend to the Compensation Advisory
Committee and Suez that an adjustment be made to any final payment.

PERFORMANCE MEASURES

The STIP program is based on two different measures of performance that are critical to United Water’s
success, financial and personal performance.
SUZ-W-20-02 IPUC DR 52
Attachment 1 Page 2 of 5

2
SHORT TERM INCENTIVE PLAN PLAN DOCUMENT

FINANCIAL
Each year, Suez Environment and United Water’s Compensation Advisory Committee determine
financial measures and target performance levels that will form the basis for measuring success under
STIP. Each objective is assigned a weight based on the employee’s job/salary grade.

PERSONAL
As a part of the Performance and Development Review (PDR) process, employees have specific annual
objectives that support the attainment of departmental or organizational objectives. These objectives
form the basis for the personal objective portion of STIP. Managers have the flexibility to set the weight
of each personal objective in accordance with the plan’s guidelines.

PAYOUT SCALES

Every level of company, business segment/department and individual performance earns a different
STIP payout. As United Water and its employees meet or exceed their objectives the payout will grow as
shown on the below payout scales.

Financial Objectives

% Of Objective Achieved PAYMENT %
< 80% 0% (Threshold)
100% 100% (Target)
> 120% 200% (Maximum)

No incentive will be paid for results at or below 80% (threshold) of an objective. An incentive payment
equal to two times the target can be earned for results equal to or greater than 120% of objective. A
curvilinear progression applies for determining the payout % between threshold and maximum. (See
Appendix A)
Personal Objectives

Scale Performance Definition Payment %
0 Significantly below objective 0 %
1 Close to objective 1%-90%
2 Met objective 91%-110%
3 Above objective 111% -150%
4 Significantly above objective 151% - 200% SUZ-W-20-02 IPUC DR 52
Attachment 1 Page 3 of 5

3
SHORT TERM INCENTIVE PLAN PLAN DOCUMENT

At the end of the performance year, managers will evaluate their employee’s personal objectives and
assign a payment percentage based on the level of performance achieved. Personal objectives that are
financial indicators should be measured using the scale for financial objectives.

PLAN PAYOUTS

Employees who are on the active payroll on December 31st of the performance year will be eligible to
receive an award. Employees who are terminated for cause or gross misconduct or who voluntarily
resign prior to the end of a plan year will not receive a STIP award.

STIP awards will be prorated for eligible new hires based on the number of days on payroll the year of
hire. Employees whose target award may have changed during a plan year due to a job change will
receive a prorated award based on number of days in each job.

Employees who choose to retire prior to the end of any plan year and have worked a minimum of 3
months in the plan year, will receive an award that is prorated to reflect the number of days actually
worked during the plan year. This also applies in the event of death, disability (defined as any
consecutive absence of 60 days or more), leave of absence, inter-company transfers or a reduction in
force. In the event of disability the pro-ration will apply to financial targets only and not personal
objectives. Payments will be made when normally paid in the 1st quarter of the year following the
performance year.

STIP awards are based on year-end salary and are paid in lump sum during the first quarter following the
end of the performance year. STIP award payments can be deferred, under the terms of United
Water’s Deferred Compensation Plan.

STIP awards are treated as ordinary income for tax purposes. Taxes will be withheld and are owed in the
year awards are paid.

ADMINISTRATION

United Water’s Compensation Advisory Committee, Suez Environment and the CEO of United Water
administer the STIP program. The interpretation of the application of the plan document is at the sole
discretion of the company and the CEO’s decision will be binding. United Water’s Compensation group
manages program administration.

Important SUZ-W-20-02 IPUC DR 52
Attachment 1 Page 4 of 5

4
SHORT TERM INCENTIVE PLAN PLAN DOCUMENT

Neither STIP, nor any action taken in conjunction with this plan, shall be construed as giving to any employee the right
to be retained by United Water. The statements in this document do not constitute a contract relative to compensation
treatment and are not intended to create any contractual rights, either expressed or implied, between United Water and
its employees. Certain situations may require compensation treatment different than the practices expressed here. The
policies, practices, and procedures described in this document may be changed, altered, modified, or deleted at any
time, with or without prior notice by United Water. The STIP may be modified or terminated at any time. These actions
may affect present and future eligible employees.

APPENDIX A

Curvilinear Payment Table
Perf.
Score
Payment
%
Perf.
Score
Payment
%
Perf.
Score
Payment
%
≤80% 0.0% 94% 76.9% 108% 132.0%
81% 6.8% 95% 81.1% 109% 136.6%
82% 13.4% 96% 85.1% 110% 141.4%
83% 19.7% 97% 89.0% 111% 146.4%
84% 25.4% 98% 92.8% 112% 151.6%
85% 31.8% 99% 96.5% 113% 156.9%
86% 37.5% 100% 100.0% 114% 162.5%
87% 43.1% 101% 103.5% 115% 168.2%
88% 48.4% 102% 107.2% 116% 174.1%
89% 53.6% 103% 111.0% 117% 180.3%
90% 58.6% 104% 114.9% 118% 186.6%
91% 63.4% 105% 118.9% 119% 193.2%
92% 68.0% 106% 123.1% 120% 200.0%
93% 72.5% 107% 127.5% ≥120% 200.0%

SUZ-W-20-02 IPUC DR 52
Attachment 1 Page 5 of 5

Long Term Incentive Plan
PLAN DOCUMENT
As Amended Effective January 2018

SUZ-W-20-02 IPUC DR 52 Attachment 2
Page 1 of 6
06/21/18 10:21:42 AM Page 2

LONG TERM INCENTIVE PLAN PLAN DOCUMENT

LONG TERM INCENTIVE PLAN
1. OBJECTIVES 1.1. Provide a long-term incentive plan that will instill a strong corporate identity based on teamwork and entrepreneurial spirit among the participants, as well as to drive the achievement of SUEZ NA’S growth and financial objectives.
1.2. Provide a strong financial incentive to aid in retention of Key Management through capital accumulation.
1.3. Provide a balance with other short-term incentive plans though a longer term perspective (three year cycle).
2. DEFINITIONS
2.1. Base Salary: The fixed component of compensation that is in effect as of the end of the Plan Cycle (the salary in effect at the time of a qualifying termination) that is
used to determine an award under the Plan.
2.2. Change of Control: The consummation of any of the following events: a reorganization, merger, or consolidation of the Company with respect to which more
than 50% ownership has been changed.
2.3. Chief Executive Officer or "CEO": The top officer of SUEZ NA
2.4. Code Section 409A: Section 409A of the Internal Revenue Code of 1986, as
amended, and the Treasury regulations and other guidance issued thereunder.
2.5. EBIT: Earnings Before Interest and Taxes.
2.6. Eligible Employee: Any employee of SUEZ NA who is designated to be eligible based on division, salary and reporting level (excluding expatriates).
2.7. Participant: An eligible employee who has been selected to participate in the Plan and who is eligible to receive an award under the Plan.
2.8. Performance Measures: Corporate financial and safety measures as established by the CEO and approved by SUEZ, the attainment of which will be the basis for granting an award under the Plan.
2.9. Performance Score: The total of the weighted Corporate Performance Measures achieved at the end of each Plan Cycle.
2.10. Plan: The SUEZ NA Long-term Incentive Plan or the "Plan" as set forth herein and as it may be amended from time to time.
2.11. Plan Cycle: The three-year performance period that begins on January 1 of the first
year and ends on December 31 of the third year.
2.12. ROCE: Return on Capital Employed.
2.13. Target Award: The value of payment that a Participant qualifies to receive,
assuming that a 100% performance level is achieved on each of the assigned Performance Measures.
2.14. SUEZ NA. or the "Company".
SUZ-W-20-02 IPUC DR 52 Attachment 2
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06/21/18 10:21:42 AM Page 3

LONG TERM INCENTIVE PLAN PLAN DOCUMENT

3. PARTICIPATION
3.1. Participation is limited to Eligible Employees.
3.2. Employees in band 2 must have a minimum annual salary of $165,000 in order to be eligible to participate. This salary level will be adjusted annually by the approved base merit percent.
3.3. Additional Participants or management levels may be added in the future, at the review and approval by the CEO and the SVP Human Resources.
3.4. Eligible Employees who are hired before September 1st of the Plan Cycle may participate in the cycle which began in the year in which they are hired.
4. PERFORMANCE MEASURES
4.1. The CEO along with the CFO, will establish the performance measures for each Plan Cycle.
4.2. Financial Performance Measures will consist of Corporate EBIT, ROCE, and Revenue/Organic Growth. The CEO along with the CFO, may change the Performance Measures on an as-needed basis, consistent with the Company’s
Medium Term Plan.
4.3. Each of the Corporate Financial Performance Measures will be weighted according to the following table:

EBIT ROCE Revenue/Organic Growth
Each of the Safety Performance Measures will be weighted according to the following table:

Frequency Severity

4.5 Threshold performance has been established at 80% of targeted results and equates to a Performance Factor of 30%. Maximum performance has been established at 120% of targeted results and equates to a Performance Factor of
200%.
4.6 In calculating performance for award determination, extraordinary expenses and/or financial gains may be excluded by the CEO.

SUZ-W-20-02 IPUC DR 52 Attachment 2
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LONG TERM INCENTIVE PLAN PLAN DOCUMENT

5. AWARD CALCULATIONS Each Participant will have a target award based on their salary band or for executive management team members, the SUEZ topex designation for their position.

<80% 0.0% 93% 75.5% 107% 135.0%
80% 30.0% 94% 79.0% 108% 140.0%
81% 33.5% 95% 82.5% 109% 145.0%
82% 37.0% 96% 86.0% 110% 150.0%
83% 40.5% 97% 89.5% 111% 155.0%
84% 44.0% 98% 92.0% 112% 160.0%
85% 47.5% 99% 95.5% 113% 165.0%
86% 51.0% 100% 100.0% 114% 170.0%
87% 54.5% 101% 105.0% 115% 175.0%
88% 58.0% 102% 110.0% 116% 180.0%
89% 61.5% 103% 115.0% 117% 185.0%
90% 65.0% 104% 120.0% 118% 190.0%
91% 68.5% 105% 125.0% 119% 195.0%
92% 72.0% 106% 130.0% 120% + 200.0% 5.1 The Payout scale is based on a linear schedule.
5.2 The CEO will determine the final award payment under the Plan for each Plan Cycle.
6. VESTING OF AWARDS 6.1 Three Year Cycles vest on the final day of the third anniversary year of the grant date.
6.2 If a Change of Control results in the termination of the Plan, all unvested Targets immediately vest.
6.3 The CEO along with the SVP Human Resources shall have the right to approve accelerated vesting for an individual Participant in any instances at its sole discretion.

SUZ-W-20-02 IPUC DR 52 Attachment 2
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LONG TERM INCENTIVE PLAN PLAN DOCUMENT

7 AWARD DISTRIBUTIONS
7.1 Distribution will occur following the end of the Plan Cycle once the performance results have been confirmed and the payments approved by the CEO.
7.2 Payment of the value of vested award shall be made in a lump sum by March 15th of the calendar year immediately following the end of the Plan Cycle; provided, however, that in no event shall such payments be made later than the last day of
the calendar year immediately following the end of the Plan Cycle.
7.3 Except as provided in Section 8, Participants must be actively employed by the Company as of the last day of the Plan Cycle to receive a payment under the Plan.
7.4 Payment of awards will not be made in any Plan Cycle that does not meet the threshold level of Corporate financial performance.
8 SPECIAL DISTRIBUTIONS 8.1 Death: In the event of a Participant’s death while actively employed by SUEZ NA, all of the Participant’s targets will automatically vest and a prorated payment, based on the number of completed months of active service in the cycle, will be made to the designate beneficiary(ies). The value of all awards within his/her account shall be paid out in a lump sum by March 15th of the calendar year immediately following the calendar year of the Participant’s death.
8.2 Upon the termination of a Participant as a result of total disability (as determined by the SVP Human Resources) while actively employed by SUEZ NA, or in the event of the Participant's retirement from the Company, all of the Participant’s accrued targets will automatically vest and a prorated payment, based on the number of completed months of active service in the cycle, will be made. The value of all vested within his/her account shall be paid out in a lump sum on the 90th day
following the date of the Participant’s termination or retirement, as applicable or, if earlier, March 15 of the calendar year immediately following the calendar year of such termination or retirement; provided, that , in the case of a Participant who is a
“specified employee” within the meaning of Code Section 409A, payment shall not be made before the first day of the seventh (7th) month following such Participant’s termination or retirement or, if earlier, the date of the Participant’s death..
8.3 Change of Control: If a Change of Control results in the termination of the Plan, all shall immediately vest. If the Change of Control constitutes a “change in control: within the meaning of Code Section 409A, and payment of the value of all unvested cycles within a Participant’s account shall be paid in a lump sum as soon as practicable, subject to the timing and other restrictions set forth in Code Section 409A (including, but not limited to Treas. Reg §1.409A-3(i)(4)(ix)(B)); otherwise, payment shall be made in accordance with the other provisions of the Plan.
SUZ-W-20-02 IPUC DR 52 Attachment 2
Page 5 of 6
06/21/18 10:21:42 AM Page 6

LONG TERM INCENTIVE PLAN PLAN DOCUMENT

8.4 Upon termination of a Participant for any other reason except for death, total disability, or retirement, all awards shall be forfeited, and the Participant will not be
entitled to receive any award under this Plan.
8.5 Termination of the Plan: In the event of termination of the Plan by the CEO, the value of each Participant’s account will be established and payment shall be made in a lump sum as soon as practicable, subject to the timing and other restrictions set forth in Code Section 409A (including but not limited to, Treas. Reg. §1.409SA-3(i)(4)(ix)(A),(C) and (D).
9 GENERAL
9.1 The CEO will consider grants of awards under the Plan annually, and any future awards under the Plan will be at its sole and final discretion.
9.2 The CEO has designated the Senior Vice President - Human Resources to be responsible for the implementation and on-going administration of the Plan.
9.3 Interpretation of all matters related to this Plan, including but not limited to eligibility,
calculation and determination of awards, as well as the resolution of any questions relating to the accounting procedures of the Plan, shall be at the sole and final determination of the CEO.
9.4 The Plan may be amended or discontinued by the CEO at any time. However, no amendment may adversely affect the value of vested awards in a Participant's account on a retroactive basis without the Participant’s consent.
9.5 The Plan may be funded through Company earnings, insurance or other methods as determined from time to time by the CEO.
9.6 Nothing in this Plan shall be interpreted as giving any Participant the right to be retained as an employee of SUEZ NA, or of limiting SUEZ NA's rights to control or terminate the service of any Participant at any time in the course of its business.
9.7 This Plan shall be construed in accordance with all applicable Federal and State securities and regulatory laws. Except to the extent Federal law controls, the Plan shall be governed by and construed and administered in accordance with the laws of the State of Delaware without regard to is laws relation to the conflict of laws. In the event that any section, or portion of a section, of the Plan shall be held invalid, illegal, or unenforceable, that section, or portion of that section, shall not affect any
other section hereof. This Plan shall be construed and enforced as if the invalid, illegal, or unenforceable section, or portion of the section, had never been contained herein. Notwithstanding the foregoing, this Plan is intended to comply with Code
Section 409A and shall be interpreted accordingly. Moreover, and notwithstanding any other provision of the Plan to the contrary, the Company reserves the right to amend or modify the Plan prospectively or retroactively in order to comply with regulations or other guidance promulgated by the Department of Treasury or Internal Revenue Service under Code Section 409A.
9.8 The Company reserves the right to change or end this plan at any time, for any reason, with or without notice.

SUZ-W-20-02 IPUC DR 52 Attachment 2
Page 6 of 6
SUZ-W-20-02
IPUC DR 52
Attachment 3
1 of 1
SUZ-W-20-02
Target Awards
Job Title STIP %LTIP %Dept ID Department
Automated Tech Sys Analyst 5%060RIID100 Idaho Production
Production Mgr 15%060RIID100 Idaho Production
Production Ops Supervisor 10%060RIID100 Idaho Production
Sr Water Quality Specialist 10%060RIID100 Idaho Production
T&D Manager 15%060RIID113 Idaho System Maintenance Dis
T&D Operations Supervisor 10%060RIID113 Idaho System Maintenance Dis
Construction Supervisor 10%060RIID205 Idaho Engineering
Control Systems Specialist 10%060RIID205 Idaho Engineering
Director Engineering 20%060RIID205 Idaho Engineering
GIS Coordinator 5%060RIID205 Idaho Engineering
GIS Idaho Manager 15%060RIID205 Idaho Engineering
Hydrogeologist 15%060RIID205 Idaho Engineering
Project Liaison 5%060RIID205 Idaho Engineering
Project Manager 10%060RIID205 Idaho Engineering
Senior Project Engineer 15%060RIID205 Idaho Engineering
Senior Project Engineer 15%060RIID205 Idaho Engineering
Credit & Collections Superviso 10%060RIID304 Idaho Customer Svc Office
Customer Service Manager 10%060RIID304 Idaho Customer Svc Office
Director Operations 20%060RIID400 Idaho Admin General
Env Health & Safety Manager 15%060RIID400 Idaho Admin General
Inventory Control Specialist 5%060RIID400 Idaho Admin General
Operations Manager 15%060RIID400 Idaho Admin General
Operations Planner 5%060RIID400 Idaho Admin General
Regulatory Compliance Manager 15%060RIID400 Idaho Admin General
Sr. Operations Planner 5%060RIID400 Idaho Admin General
VP & General Manager 20%15%060RIID400 Idaho Admin General
Communications&Comnty Edu Spec 5%060RIID405 Idaho Corp Communications
Communications&Comnty Rela Mgr 15%060RIID405 Idaho Corp Communications
Human Resources Generalist 10%060RIID415 Idaho Human Resources
Dir Finance and Customer Svc 20%060RIID530 Idaho Financial Planning
Fin Plan Rptg & Analysis Supv 10%060RIID530 Idaho Financial Planning
SUZ-W-20-02 IPUC DR 53
Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 53:
With reference to the Incentive Programs on Page 4 of the testimony, please provide a description of the Non-Exempt Incentive Program, including the basis for the incentive payments and the amount or percentage of the incentive payment.
RESPONSE NO. 53: Please see Attachment1 for a description of the Non-Exempt Incentive Program and Attachment 2 for the percentage of the incentive payment target for non-bargaining hourly positions.

2018 NON-EXEMPT NON- UNION
INCENTIVE PROGRAM

SUZ-W-20-02 IPUC DR 53 Attachment 1
Page 1 of 6
Important: The statements in this document do not constitute a contract relative to compensation treatment and are not intended to create any contractual rights, either
expressed or implied, between SUEZ and its employees. The policies, practices, and procedures described in this document may be changed, altered, modified, or deleted
at any time, with or without prior notice by SUEZ. The program may be modified or terminated at any time. These actions may affect present and future eligible

Non- Exempt Non- Union Incentive Program - Policy Document

PURPOSE: The program supports SUEZ’s business ideals by recognizing the efforts of non-
exempt employees in contributing to the success of the Company’s environmental health and
safety performance, corporate social responsibility by helping to strengthen the communities
in which we live, work and serve and our overall corporate objectives.

ELIGIBILITY: All active non-exempt regular employees, part-time (employees who are
regularly scheduled to work less than 37.5 hours per week) and full-time, are eligible to
participate in the Incentive Program. Employees must be hired by the first pay period of the
fourth quarter of the plan year, in order to be eligible for an award for that plan year.

AWARD OPPORTUNITY: The target award for non-exempt/non-union employees is 3% of
productive earnings. Payment is calculated based on percent of target accomplishment
multiplied by the employee’s total productive earnings for the calendar year.

Productive Earnings are defined as: Earnings for all hours an employee is paid for
(including regular time, overtime, rest time, stand-by, emergency, personal time
(paid), holidays (incl. floaters), vacation, bereavement, and jury duty). Productive
earnings exclude sick time (paid/unpaid), STD, LTD, worker’s Compensation, personal
time (unpaid), wash up pay and FML time.

PERFORMANCE MEASURES: Performance Measures are subject to change from one plan
year to the next and are at the discretion of senior management and the plan administrator.
All performance is to be measured against proposed targets on a cumulative YTD basis for
incentive purposes. The program is based on the following measurements for each Business
Unit:

2018* 2019
EHS & SUEZ Sponsored Activities 0.50%** 0.50%
Required Training 0.50% 0.50%
EHS Performance 0.50% 0.50%

1. EHS & SUEZ-NA SPONSORED ACTIVITIES: Each employee must participate in four (4)
EHS or SUEZ NA Sponsored Activities on an annual basis.

o EHS Activities include but are not limited to:
o Participate in or conduct a formal EHS safety inspection
o Submit an actionable and verified unsafe condition or near miss or
environmental improvement idea thru Intelex or on a report form.
o Participate in and/ or conduct a Job Safety Analysis/Safe Work Plan
Session
o Participate in and/ or conduct a formal EHS Risk Assessment
o Participate in or conduct an EHS self-assessment and/or survey
SUZ-W-20-02 IPUC DR 53 Attachment 1
Page 2 of 6
Important: The statements in this document do not constitute a contract relative to compensation treatment and are not intended to create any contractual rights, either
expressed or implied, between SUEZ and its employees. The policies, practices, and procedures described in this document may be changed, altered, modified, or deleted
at any time, with or without prior notice by SUEZ. The program may be modified or terminated at any time. These actions may affect present and future eligible

Non- Exempt Non- Union Incentive Program - Policy Document

o Participate in an EHS activity approved by an EHS Manager and deemed
part of this program
o Participate in or lead the development of an SOP where EHS issues are
identified and mitigation is provided. Attend an EHS conference and then
provide a presentation to management on topics covered.
o Participate in or lead an emergency response drill scenario development.
o Participate in or lead an emergency response drill.
o Become an active participant in a Safety Committee (must attend 10 of
12 annual meeting)
o Identify and work with management to schedule vendors for
presentations on work related safety topics.
o SUEZ NA Sponsored Activities are defined as:
o Employee participation in support of approved community programs,
activities and critical needs areas (environmental, conservation and
other) that enrich the quality of life and opportunities for all citizens.
Such programs must be sponsored by SUEZ NA.
 Employee participation in an activity during scheduled work hours
is subject to advance supervisor approval and must not adversely
impact staffing coverage and operational needs
 Employees should represent SUEZ NA in a professional manner.
Frequency: ** For performance year 2018, the EHS & SUEZ NA Sponsored Activities
performance measure will be included in the bonus calculation based on successful
completion of two (2) activities. SUEZ NA Sponsored activities performed only after
June 30, 2018 will be included for performance year 2018. *For performance year
2019 and forward, the EHS & SUEZ NA Sponsored Activity performance measure will
have a target of four (4) activities. At least two (2) of the four (4) activities must be
completed by the first half of each year.
Verification of activities will be conducted by submission of forms, attendance sheets
or equivalent (as determined by each Business Unit). Corporate EHS will provide a
quarterly summary of status of activities completion to each employee and/or their
supervisor for distribution to the employee.

Measurement: Activities will be measured individually. * For performance year
2018 Employees who complete one (1) activity will receive 50% of the goal; two (2)
activities will equal 100%. *For performance year 2019 and forward, Employees
who complete two (2) activities will receive 50% of the goal; four (4) activities will
equal 100%.

2. REQUIRED TRAINING: Complete and maintain assigned required training according to
specified timeframes. Each employee is expected to review and maintain compliance
with the required training as identified by their position, by the assigned date.

SUZ-W-20-02 IPUC DR 53 Attachment 1
Page 3 of 6
Important: The statements in this document do not constitute a contract relative to compensation treatment and are not intended to create any contractual rights, either
expressed or implied, between SUEZ and its employees. The policies, practices, and procedures described in this document may be changed, altered, modified, or deleted
at any time, with or without prior notice by SUEZ. The program may be modified or terminated at any time. These actions may affect present and future eligible

Non- Exempt Non- Union Incentive Program - Policy Document

Frequency: Ongoing; measured at year-end.

Measurement: Achievement as follows:
o > 15% overdue = 0%
o 1-15% overdue = 75%
o 0% overdue = 100%

Corporate EHS will provide a quarterly summary of required training status completion to
each employee and/or their supervisor for distribution to the employee.

3. EHS PERFORMANCE: Meet or exceed Division/Business Unit’s year end results for EHS
as follows:

o Preventable Automobile Accident Targets*
o Environmental Avoidable incidents

*Preventable Automobile Incident is defined as any incident, involving a fleet vehicle, when
it is determined after incident analysis that the driver failed to exercise every reasonable
precaution. A Preventable incident may include: 1) property damage, regardless of what
property was damaged, to what extent, or where it occurred or, 2) personal injury,
regardless of who was injured.
Frequency: Ongoing; measured at year-end.

Measurement: Achievement as follows:

o 50% for meeting Division/Business Unit’s environmental avoidable incident
targets for Severity 4 avoidable incidents and above (as defined in the
Environmental Compliance Assurance Program (ECAP) manual), or any
missed samples and/or any late reporting irrespective of the severity level*
o 50% for meeting Division/Business Unit’s Preventable Automobile accident
incident targets.

*For performance year 2018, the Preventable Automobile accident targets will
be included in the bonus calculation, effective July 2018. Beginning 2019,
Preventable Automobile accidents incidences will be calculated on a full year.

PAYOUTS: Regular part-time and full-time employees who are on the active payroll on
December 31st of the performance year will be eligible to receive an award. Employees who
are terminated for cause or gross misconduct will not receive an award regardless of when
termination occurs. Employees who voluntarily resign prior to the end of the plan year will
not receive an award. Awards are treated as ordinary income for tax purposes. Taxes will
SUZ-W-20-02 IPUC DR 53 Attachment 1
Page 4 of 6
Important: The statements in this document do not constitute a contract relative to compensation treatment and are not intended to create any contractual rights, either
expressed or implied, between SUEZ and its employees. The policies, practices, and procedures described in this document may be changed, altered, modified, or deleted
at any time, with or without prior notice by SUEZ. The program may be modified or terminated at any time. These actions may affect present and future eligible

Non- Exempt Non- Union Incentive Program - Policy Document

be withheld and are owed in the year awards are paid. Payment decision will be made
annually by the executive management team and if approved will be paid in the 2nd quarter
of the following performance year.

1. AWARD EXAMPLE, Payment for Performance Year 2018

Productive Earnings $50,000
Target 3% $ 1,500

Performance Measure Weight Met % (A) (B) $$
EHS & SUEZ Sponsored
Activities 1.00% 1 of 2 50% 33.33% $250.00
Required Training 1.00% 20%
overdue 0% 33.33% $0
EHS
Performance
0.50% 100% 100% 16.67% $250.00
Preventable
Automobile
Accidents
0.50% 100% 100% 16.67% $250.00
Total 3.00% 100% $750.00

2. AWARD EXAMPLE, Payment for Performance Year 2019

Performance Measure Weight Met % (A) (B) $$
EHS & SUEZ Sponsored
Activities 1.00% 2 of 4 50% 33.33% $250.00
Required Training 1.00% 10%
overdue 75% 33.33% $375.00
EHS
Performance
0.50% 100% 100% 16.67% $250.00
Preventable
Automobile
Accidents
0.50% 100% 100% 16.67% $250.00
Total 3.00% 100% $1,125.00

SUZ-W-20-02 IPUC DR 53 Attachment 1
Page 5 of 6
Important: The statements in this document do not constitute a contract relative to compensation treatment and are not intended to create any contractual rights, either
expressed or implied, between SUEZ and its employees. The policies, practices, and procedures described in this document may be changed, altered, modified, or deleted
at any time, with or without prior notice by SUEZ. The program may be modified or terminated at any time. These actions may affect present and future eligible

Non- Exempt Non- Union Incentive Program - Policy Document

ADMINISTRATION: SUEZ NA Human Resources department will administer this program.
The interpretation of the application of the plan document is at the sole discretion of the
company and the Division President’s decision will be binding. Continuation of the program
will be determined by the Division President and decision will be communicated to plan
participants prior to the commencement of the next performance year. Incentive payments
are not considered eligible earnings for calculation of pension benefit or 401(k) deferrals and
company match as per plans’ provisions.

SUZ-W-20-02 IPUC DR 53 Attachment 1
Page 6 of 6
SUZ-W-20-02
IPUC DR 53
Attachment 2
Page 1 of 1
SUZ-W-20-02
Non-Exempt Bonus
Job Title Dept ID Department
Engineering Design Tech 3%060RIID205 Idaho Engineering
Customer Service Rep 3%060RIID304 Idaho Customer Svc Office
Lead Customer Service Rep 3%060RIID304 Idaho Customer Svc Office
Administrative Coordinator 3%060RIID400 Idaho Admin General
Accounting Clerk (Finance Clerk)3%060RIID530 Idaho Financial Planning
SUZ-W-20-02 IPUC DR 54
Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 54:
With reference to Adjustment No. 2 Workers Compensation on Page 5 of the testimony, please provide the supporting documentation and workpapers for the adjustment, including the inputs for the three-year average of workers compensation.
RESPONSE NO. 54: Please see Exhibit 10 Schedule 1 Adjustment No. 2 for the historical three-year workers compensation expense as reflected in general ledger account 91460 (2017, 2018 and 2019). The 2019 expense is net of a reserve adjustment of ($176,454). The workers
compensation expense for year 2017, 2018 and 2019 is $93,261, $122,150 and $137,043
respectively, resulting in a three-year average expense of $117,484. Total workers compensation expense (account 91460) to Gross Payroll costs (account 50100 & 50105) over three years from 2017 through 2019, equals a sum of $352,454
workers compensation expense divided by $20,305,427 gross payroll expense, and
produces a three year ratio of 1.736% used in the adjustment.
SUZ-W-20-02
IPUC DR 56 Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 56:
With reference to Adjustment No. 4 PBOP on Page 6 of the testimony, please provide supporting documentation and workpapers supporting the Towers Watson actuarial valuation dated March 2020 with a service cost of $207,049 and interest component of ($560,205).
RESPONSE NO. 56: Please see the attachment showing the documentation supporting the pro forma actuarial PBOP valuation of ($353,156), dated March 2020.

On Exhibit No. 10, Schedule 1, J. Cary, Page 4, line 6 and 7, the Company inadvertently labelled the split of the Test Year PBOP expense as “service cost” versus “interest component”. The correct labelling should have been as follows:
6 PEBOP Expense Service Cost*
7 PEBOP Expense All Other PEBOP costs “All Other PEBOP costs” consist of interest cost, expected return on assets, prior service
cost amortization and (gain)/loss amortization.
The Test Year split percentages were then applied to the projected PBOP expense of ($353,156) to arrive as the service cost of $207,049 and all other PBOP costs of ($560,205).

* Please also note the line numbering includes duplicate numbers. The specifically referenced line is the second line 6.
SUEZ Water Postretirement Medical & Life Plan
Actual 2020 ASC 715-60 Net Periodic Postretirement Cost/(Income)
Idaho Public Utility Commission
Non-Bargaining Bargaining Total
Assumptions
Discount rate for 2020 ("DR")3.60%
Expected rate of return on assets for 2020 ("EROA")6.75%
Tax rate for 2020 ("TR")60.00%
Funded status as of December 31, 2019
Accumulated postretirement benefit obligation ("APBO")(3,456,683)$ (5,934,372)$ (9,391,055)$
Market value of assets ("MVA")268,455$ 6,215,661$ 6,484,116$
Funded status (3,188,228)$ 281,289$ (2,906,939)$
Amount recognized in accumulated other comprehensive income
Net (gain)/loss 277,511$ 449,674$ 727,185$
Prior service cost (1,149,151)$ (1,363,519)$ (2,512,670)$
Total (871,640)$ (913,845)$ (1,785,485)$
2020 Net periodic benefit cost/(income)
Service cost 45,007$ 129,013$ 174,020$
Interest cost1 122,154$ 208,897$ 331,051$
Expected return on assets2,3 (8,303)$ (410,736)$ (419,039)$
Prior service cost amortization (200,601)$ (238,587)$ (439,188)$
(Gain)/loss amortization -$ -$-$
Total cost/(income)(41,743)$ (311,413)$ (353,156)$
Expected benefit payments for 2020 ("EBP")128,150$ 265,720$ 393,870$
1 Equal to APBO x DR - EBP x [ (1+DR)^0.5 - 1 ]
2 For non-bargaining: equal to MVA x TR x EROA - EBP x [ (1 + TR x EROA)^0.5 - 1 ]
3 For bargaining: equal to MVA x EROA - EBP x [ (1+EROA)^0.5 - 1 ]
1
http://natct.internal.towerswatson.com/clients/606516/6065162020Valuation-AllPlans/Documents/2020 OPEB Expense Breakdown_Idaho.xlsx
SUZ-W-20-02
IPUC DR 56 Attachment Page 1 of 1
SUZ-W-20-02 IPUC DR 57
Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 57:
With reference to Adjustment No. 5 Employee Healthcare, Group Term Life, and Long-Term Disability on Page 7 of the testimony, please provide documentation and work papers supporting the calculation of the adjustment. Additionally, please provide the policies governing these benefits and the calculation for the 3.36% increase in healthcare
costs.
RESPONSE NO. 57: Please see Attachment 1 through 5 for the current policies governing Employee Heath
care, Group Term Life and Long-Term Disability. In 2021, the Company is changing its
healthcare provider to Cigna and the plan documents will be provided as an update to this response when they become available. The Company’s Health care costs for 2021 have been revised as the medical plan costs
are now known. Please see Attachment 6 for the revised Exhibit 10 Schedule 1
Adjustment 5 for updated Healthcare costs of $746,902 and Adjustment 8 for the updated Fringe Allocation adjustment of ($526,365) as a result of the revised medical costs, along with the work paper used to calculate medical costs. Please note that this revision obviates the portion of the original adjustment which included the 3.36% estimated
medical cost increase adjustment.

Product: BLUECARD PPO
Company Name: SUEZ WATER RESOURCES INC. PLAN
3-HIGH DEDUCTIBLE HEALTH PLAN
(SINGLE CONTRACT TYPES POPULATION)
Group Number: 76026-0059, 0061, 0063, 0066, 0067, 0070, 0071, 0074, 0075
PKG 001
Effective Date: January 1, 2020

SUZ-W-20-02 IPUC DR 57 Attachment 1
Page 1 of 109
Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com
Dear Valued Customer: Thank you for choosing Horizon Blue Cross Blue Shield of New Jersey for your health insurance coverage. You're enrolled in a great plan! We are here to help you understand your benefits and
take charge of your health.
The enclosed information will help you better understand your benefits and the additional programs and resources available to you as a Horizon BCBSNJ member.
It is important to register for Member Online Services at HorizonBlue.com. Through Member
Online Services, you can:
• View your benefits.
• Check your claims status and payments.
• View authorizations and referrals, if applicable.
• Print a duplicate member ID card or display your member ID card.
• Tell us if you have other health insurance coverage.
• Change your doctor or dentist, if applicable.
• Manage your Member Online Services account and preferences.
Important Tips to Follow
• Keep your Horizon BCBSNJ member ID card with your at all times. It is the key to accessing your health care benefits. Please present your member ID card whenever you need medical care or services. You can also sign in to Member Online Services at
HorizonBlue.com to view and print your member ID card.
• Visit HorizonBlue.com/doctorfinder to find in-network doctors, hospitals or health care professionals. If you would like a printed copy of the directory, please call Member Services at 1-800-355-BLUE (2583).
Call our Interactive Voice Response (IVR) system for information at your convenience. Through our IVR system, you can get answers to your questions 24 hours a day (usually including weekends/holidays). Be prepared if a medical emergency arises. If you or a covered dependent experiences a medical
emergency, we suggest you follow these steps: - Call 911 or go directly to the nearest Emergency Room. - Call your Primary Care Physician (PCP) or personal doctor as soon as reasonably possible so that he/she may coordinate your follow up care. You do not need to call Member Services in a medical emergency.
SUZ-W-20-02 IPUC DR 57 Attachment 1
Page 2 of 109
Have a question about your benefits? If you have questions about your Horizon BCBSNJ coverage, you can sign in to Member Online
Services at HorizonBlue.com to chat with a Member Services Representative or send a secure email using My Messages. You can also call 1-800-355-BLUE (2583), Monday through Wednesday and Friday from 8 a.m. to 6 p.m., Eastern Time (ET) and Thursday, from 9 a.m. to 6 p.m., ET, to speak with a representative.

We look forward to continuing to serve your health insurance needs. Sincerely,
Christopher M. Lepre Senior Vice President Market Business Units

SUZ-W-20-02 IPUC DR 57 Attachment 1
Page 3 of 109

SUZ-W-20-02 IPUC DR 57 Attachment 1
Page 4 of 109

SUZ-W-20-02 IPUC DR 57 Attachment 1
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Notice of Nondiscrimination
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and does
not discriminate against nor does it exclude people or treat them differently on the basis of race, color,
gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status
in the administration of the plan, including enrollment and benefit determinations.
Horizon BCBSNJ provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and information written in other languages.
Contacting Member Services
Please call Member Services at 1-800-355-BLUE (2583) or the phone number on the back of your member ID card, if you need the free aids and services noted above and for all other
Member Services issues, including:
• Claim, benefits or enrollment inquiries • Lost/stolen ID cards • Address changes • Any other inquiry related to your benefits or health plan
Filing a Section 1557 Grievance
If you believe that Horizon BCBSNJ has failed to provide the free communication aids and services or
discriminated on the basis of race, color, gender, national origin, age or disability you can file a
discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ’s Civil Rights
Coordinator can be reached by calling the Member Services number on the back of your member ID card or by writing to the following address:
Horizon BCBSNJ – Civil Rights Coordinator PO Box 820 Newark, NJ 07101
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office
for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Office for Civil Rights Headquarters U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 or 1-800-537-7697 (TDD)
OCR Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

An Independent Licensee of the Blue Cross and Blue Shield Association.
SUZ-W-20-02 IPUC DR 57 Attachment 1
Page 6 of 109

The draft booklet contains only the information administered by Horizon Blue Cross Blue Shield of New Jersey and is only a partial description of the benefits, limitations, exclusions and other provisions of your health care plan. The draft booklet is not a Summary Plan Description and
shall be used for general reference only and shall not supersede any terms within your plan document. Horizon disclaims all subsequent liability, accuracy, correctness, and validity of any information should the Plan Administrator alter the document or otherwise modify the
information contained therein. The Group shall indemnify and hold harmless Horizon from and against any claims, judgment, civil penalties, cause of action, liability, damage, cost or expense, including attorneys' fees, arising out of or in connection with the use or tampering of the booklet
provided herein. Please note: This booklet is currently in a draft status. For any updates please contact The
Corporate Major Accounts Contract Issuance Team.

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Table of Contents
Introduction ......................................................................................................................................2
Definitions........................................................................................................................................3
Schedule of Covered Services and Supplies ..................................................................................22 Eligible Basic Services and Supplies .................................................................................24 Eligible Supplemental Services and Supplies ....................................................................33
General Information .......................................................................................................................35 How To Enroll ...................................................................................................................35 Your Identification Card ....................................................................................................35 Types of Coverage Available.............................................................................................35 Special Enrollment Periods ................................................................................................35 Individual Losing Other Coverage.....................................................................................35 Multiple Employment ........................................................................................................36 When Your Coverage Ends ...............................................................................................36 Benefits After Termination ................................................................................................36 Continuing Coverage Under the Federal Family and Medical Leave Act .........................36 Continuation of Coverage Under COBRA ........................................................................37 Continuation of Coverage under the USERRA .................................................................38 Continuation of Care ..........................................................................................................39 Medical Necessity And Appropriateness ...........................................................................40 Cost Containment...............................................................................................................40 Managed Care Provisions ..................................................................................................40
Your Preferred Provider Organization (PPO) Program .................................................................42 The Deductible ...................................................................................................................42 Single Coverage (Applies When Only the Employee Is Covered) ....................................42 Out-of-Pocket Maximum ...................................................................................................43 Single Coverage (Applies when only the Employee is covered) .......................................43 Payment Limits ..................................................................................................................43 Benefits From Other Plans ................................................................................................43
Summary of Covered Services and Supplies .................................................................................44 Eligible Basic Services and Supplies .................................................................................44 Allergy Testing and Treatment ............................................................................. 44 Ambulatory Surgery.............................................................................................. 44 Anesthesia ............................................................................................................. 44 Audiology Services ............................................................................................... 44 Birthing Centers .................................................................................................... 44 Dental Care and Treatment ................................................................................... 45 Diagnosis and Treatment of Autism ..................................................................... 45 Diagnostic X-rays and Laboratory Tests .............................................................. 46 Emergency Room.................................................................................................. 46 Facility Charges .................................................................................................... 46
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Fertility Services ................................................................................................... 47 Home Health Agency Care ................................................................................... 47 Hospice Care ......................................................................................................... 47 Inpatient Physician Services ................................................................................. 49 Mastectomy Benefits ............................................................................................ 49 Maternity/Obstetrical Care.................................................................................... 49 Medical Emergency .............................................................................................. 50 Mental or Nervous Disorders (including Group Therapy) and Substance Abuse 50 Nutritional Counseling .......................................................................................... 50 Physical Rehabilitation ......................................................................................... 50 Practitioner’s Charges for Non-Surgical Care and Treatment .............................. 50 Practitioner’s Charges for Surgery........................................................................ 51 Pre-Admission Testing Charges ........................................................................... 51 Preventive Care ..................................................................................................... 51 Second Opinion Charges....................................................................................... 53 Skilled Nursing Facility Charges .......................................................................... 54 Speech Language Pathology Services .................................................................. 54 Surgical Services ................................................................................................... 54 Telemedicine Services, provided by Horizon CareOnline ................................... 55 Therapeutic Manipulation ..................................................................................... 55 Therapy Services ................................................................................................... 55 Transplant Benefits ............................................................................................... 55 Urgent Care ........................................................................................................... 57 Eligible Supplemental Services and Supplies ....................................................................58 Ambulance Services.............................................................................................. 58 Blood 58 Diabetes Benefits .................................................................................................. 58 Durable Medical Equipment ................................................................................. 60 Home Infusion Therapy ........................................................................................ 60 Foot Orthotics ....................................................................................................... 60 Oxygen and its Administration ............................................................................. 60 Private Duty Nursing Care .................................................................................... 61 Prosthetic Devices ................................................................................................. 61 Wigs Benefit ......................................................................................................... 61
Utilization Management.................................................................................................................62 Required Hospital Stay Review .........................................................................................63 Notice of Hospital Admission Required ............................................................................63 Continued Stay Review......................................................................................................63 Alternate Treatment Features/Individual Case Management ............................................63 Definitions..........................................................................................................................63 Alternate Treatment/Individual Case Management Plan ...................................................64 Exclusion............................................................................................................................65
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Schedule of Procedures Requiring Prior Authorization .................................................................66
Claims Procedures .........................................................................................................................67
Exclusions Under The Blue Card PPO Program ...........................................................................74
Benefits Payable for Automobile Related Injuries ........................................................................81
Subrogation and Reimbursement ...................................................................................................83
The Effect of Medicare on Benefits ...............................................................................................86 Important Notice ................................................................................................................86 Medicare Eligibility by Reason of Age .............................................................................86 Medicare by Reason of Disability ......................................................................................87 Medicare Eligibility by Reason of End Stage Renal Disease ............................................87 Dual Medicare Eligibility ..................................................................................................88 How To File A Claim If You Are Eligible For Medicare ..................................................88
Appeals Process .............................................................................................................................90
Non-Duplication of Benefits ..........................................................................................................93
Service Centers ..............................................................................................................................95
Statement of ERISA Rights ...........................................................................................................98
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Introduction
Your Blue Card PPO benefit program gives you broad protection to help meet the costs of Illnesses and Accidental Injuries. This benefit program offers the highest level of benefits when services are obtained from any physician or hospital designated as a PPO Network provider either in New Jersey or in another Blue Cross and Blue Shield service area.
In this booklet you’ll find the important features of your group’s Blue Card PPO benefits provided by the Plan administered by Horizon Blue Cross Blue Shield of New Jersey.
Your benefits are self-insured through your Employer. Therefore, while Horizon BCBSNJ will initially review claims, all final claims decisions will be made by the Plan Administrator named by your Employer.
This booklet replaces any booklets or certificates you may previously have received.
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Definitions
This section defines certain important words used in this booklet. The meaning of each defined word, whenever it appears in this booklet, is governed by its definition as listed in this section.
Act of War: Any act peculiar to military, naval or air operations in time of War.
Active: Performing, doing, participating or similarly functioning in a manner usual for the task for full pay, at the Employer's place of business, or at any other place that the Employer's business requires the Employee to go.
Admission: Days of Inpatient services provided to a Covered Person.
Adverse Benefit Determination – an adverse benefit determination is any denial, reduction or termination of, or failure to provide or make payment for (in whole or in part), a benefit, including one based on a determination of eligibility, as well as one based on the application of any utilization review criteria, including determinations that an item or service for which benefits are otherwise provided are not covered because they are deemed to be experimental/investigational or not medically necessary or appropriate.
Affiliated Company: A corporation or other business entity affiliated with the Employer through common ownership of stock or assets; or as otherwise defined by the Employer.
Allowance: Subject to the exceptions below, an amount determined by the Plan as the east of the following amounts:
(a) the actual charge made by the Provider for the service or supply;
(b) in the case of In-Network Providers, the amount that the Provider has agreed to accept for the service or supply; or
(c) in the case of Out-of-Network Providers, the following:
(i) For Practitioners’ services, 300% of the amount determined for the service based on the Resource Based Relative Value System (RBRVS) promulgated by the Centers for Medicare and Medicaid Services.
(ii) For the services of Ambulatory Surgical Centers, 300% of the amount determined for the services based on the RBRVS.
(iii) For all other Covered Services and Supplies, the amount determined for the Covered Service or Supply in accordance with: (a) profiles compiled by Horizon BCBSNJ based on usual and prevailing payments made to Providers for similar services or supplies in specific geographical areas; or (b) similar profiles compiled by outside vendors.

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Exceptions:
(1) With respect to (i) a Medical Emergency; or (ii) Covered Services and Supplies provided in an In-Network Hospital, the Allowance determined in accordance with part (c), above, for any Covered Services and Supplies provided by Out-of-Network Providers shall be increased as needed to ensure that the Covered Person has no greater liability than he/she would have if they were provided by In-Network Providers. But this (ii) shall not apply if the Covered Person: (a) had or was given the opportunity to select In-Network Providers to provide the Covered Services or Supplies; and (b) elected the services of Out-of-Network Providers.
(2) With respect to parts (c)(i) and (c)(ii), above, if Medicare does not prescribe a reimbursement rate for the Covered Service or Supply, the Allowance for it will be determined in accordance with: (a) profiles compiled by Horizon BCBSNJ based on usual and prevailing payments made to Providers for similar services or supplies in specific geographical areas; or (b) similar profiles compiled by outside vendors.
Ambulance: A certified transportation vehicle that: (a) transports ill or injured people; and (b) contains all life-saving equipment and staff as required by state and local law.
Ambulatory Surgical Center: A Facility mainly engaged in performing Outpatient Surgery.
a. It must:
1. be staffed by Practitioners and Nurses under the supervision of a physician;
2. have permanent operating and recovery rooms;
3. be staffed and equipped to give Medical Emergency care; and
4. have written back-up arrangements with a local Hospital for Medical Emergency care.
b. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
1. accredited for its stated purpose by either the Joint Commission or the Accreditation Association for Ambulatory Care; or
2. approved for its stated purpose by Medicare.
The Plan does not recognize a Facility as an Ambulatory Surgical Center if it is part of a Hospital.
Approved Hemophilia Treatment Center – A health care facility licensed by the State of New Jersey for the treatment of hemophilia or one which meets the same standards if located in another state.
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Behavioral Interventions Based on Applied Behavioral Analysis (ABA): Interventions or strategies, based on learning theory, that are intended to improve a person’s socially important behavior. This is achieved by using instructional and environmental modifications that have been evaluated through scientific research using reliable and objective measurements. These include the empirical identification of functional relations between behavior and environmental factors.
Such intervention strategies include, but are not limited to: chaining; functional analysis; functional assessment; functional communication training; modeling (including video modeling); procedures designed to reduce challenging and dangerous behaviors; prompting; reinforcement systems, including differential reinforcement, shaping and strategies to promote generalization.
Benefit Day: Each of the following:
a. Each midnight the Covered Person is registered as an Inpatient; or
b. Each day when Inpatient Admission and discharge occur on the same calendar day.
Benefit Month – The monthly period starting with the date shown on your identification card.
Benefit Period – the twelve-month period starting on January 1st and ending on December 31st. The first and/or last Benefit Period may be less than a calendar year. The first Benefit Period begins on your coverage date. The last Benefit Period ends when you are no longer covered.
Birthing Center – a Facility which mainly provides care and treatment for women during uncomplicated pregnancy, routine full-term delivery, and the immediate post-partum period.
a. It must:
1. provide full-time Skilled Nursing Care by or under the supervision of Nurses; 2. be staffed and equipped to give Medical Emergency care; and 3. have written back-up arrangements with a local Hospital for Medical Emergency care.
b. The Plan will recognize it if:
1. it carries out its stated purpose under all relevant state and local laws; or 2. it is approved for its stated purpose by the Accreditation Association for Ambulatory Care; or 3. it is approved for its stated purpose by Medicare.
The Plan does not recognize a Facility as a Birthing Center if it is part of a Hospital.
BlueCard PPO Provider: A Provider, not in New Jersey, which has a written agreement with another Blue Cross and/or Blue Shield plan to provide care to both that plan’s subscribers and other Blue Cross and/or Blue Shield plans’ subscribers. For purposes of this Plan, a BlueCard PPO Provider is an In-Network Provider.
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Booklet: A detailed summary of benefits covered.
Certified Registered Nurse Anesthetist (C.R.N.A.) – A Registered Nurse, certified to administer anesthesia, who is employed by and under the supervision of a Physician anesthesiologist.
Coinsurance: The percent applied to Covered Charges (not including Deductibles) for certain Covered Services or Supplies in order to calculate benefits under the Plan. These are shown in the Schedule of Covered Services and Supplies. The term does not include Copayments. For example, if the Plan's Coinsurance for an item of expense is 60%, then the Covered Person's Coinsurance for that item is 40%. Unless the context indicates otherwise, the Coinsurance percents shown in this Booklet are the percents that the Plan will pay.
Complex Imaging Services: Includes the following services-
a) Computed Tomography (CT);
b) Computed Tomography Angiography (CTA);
c) Magnetic Resonance Imaging (MRI);
d) Magnetic Resonance Spectroscopy (MRS);
e) Positron Emission Tomography (PET);
f) Nuclear Medicine including Nuclear Cardiology.
Cosmetic Services: Services (including Surgery) rendered to refine or reshape body structures or surfaces that are not functionally impaired. They are: (a) to improve appearance or self-esteem; or (b) for other psychological, psychiatric or emotional reasons. The following are not considered "cosmetic":
a. Surgery to correct the result of an Injury;
b. Surgery to treat a condition, including a birth defect, which impairs the function of a body organ;
c. Surgery to reconstruct a breast after a mastectomy is performed.
d. Treatment of newborns to correct congenital defects and abnormalities.
e. Treatment of cleft lip.
The following are some procedures that are always considered "cosmetic":
a. Surgery to correct gynecomastia;
b. Breast augmentation procedures, including their reversal for women who are asymptomatic;
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c. Reversal of breast augmentation procedures for asymptomatic women who had reconstructive Surgery or who previously had breast implants for cosmetic purposes;
d. Rhinoplasty, except when performed to treat an Injury;
e. Lipectomy;
f. Ear or other body piercing.
Coverage Date: The date on which coverage under this Plan begins for the Covered Person.
Covered Charges: The authorized charges, up to the Allowance, for Covered Services and Supplies. A Covered Charge is Incurred on the date the Covered Service or Supply is furnished. Subject to all of the terms of this Plan, the Plan provides coverage for Covered Services or Supplies Incurred by a Covered Person while the person is covered by this Plan.
Covered Person – you who is enrolled under the Plan.
Covered Services and Supplies – the types of services and supplies described in the Covered Services and Supplies section of this booklet. The services and supplies must be:
a. furnished or ordered by a Provider; and
b. For Preventive Care, or Medically Necessary and Appropriate to diagnose or treat an Illness (including Mental or Nervous Disorders) or Injury.
Current Procedural Terminology (C.P.T.): The most recent edition of an annually revised listing published by the American Medical Association, which assigns numerical codes to procedures and categories of medical care.
Custodial Care: Care that provides a level of routine maintenance for the purpose of meeting personal needs. This is care that can be provided by a layperson who does not have professional qualifications or skills.
Custodial Care includes, but is not limited to: help in walking or getting into or out of bed; help in bathing, dressing and eating; help in other functions of daily living of a similar nature; administration of or help in using or applying creams and ointments; routine administration of medical gasses after a regimen of therapy has been set up; routine care of a patient, including functions such as changes of dressings, diapers and protective sheets and periodic turning and positioning in bed; routine care and maintenance in connection with casts, braces and other similar devices, or other equipment and supplies used in treatment of a patient, such as colostomy and ileostomy bags and indwelling catheters; routine tracheostomy care; general supervision of exercise programs, including carrying out of maintenance programs of repetitive exercises that do not need the skills of a therapist and are not skilled services.
Even if a Covered Person is in a Hospital or other recognized Facility, the Plan does not cover care if it is custodial in nature.
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Day Programs: Outpatient personalized or packaged programs that: (a) are designed primarily for patients who are medically stable enough to live at home, but who may require certain therapies; (b) offer multiple therapies in a day setting; and (c) are usually scheduled for three to five days a week and five to nine and a half hours per day. Some examples of the therapies offered are: cognitive therapy; recreation therapy; work hardening programs; vocational therapy; group cognitive/interpersonal therapy; remedial treatments; and treatments to improve interpersonal communication and social skills. “Day Programs” do not include outpatient programs for the treatment of mental illnesses.
Deductible: The amount of Covered Charges that a Covered Person must pay before this Plan provides any benefits for such charges. The term does not include Coinsurance, Copayments and Non-Covered Charges. See the Schedule of Covered Services and Supplies section of this Booklet for details.
Developmental Disability(ies): A person’s severe chronic disability which:
(a) is attributable to a mental or physical impairment, or a combination of them;
(b) for the purposes solely of the provision of this Program entitled “Diagnosis and Treatment of Autism and Other Developmental Disabilities”, is manifest before age 22;
(c) is likely to continue indefinitely;
(d) results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; the capacity for independent living or economic self-sufficiency; and
(e) reflects the need for a combination and sequence of special inter-disciplinary or generic care, treatment or other services which are: (i) of lifelong or extended duration; and (ii) individually planned or coordinated.
Developmental Disability includes, but is not limited to, severe disabilities attributable to: mental retardation; autism; cerebral palsy; epilepsy; spina-bifida; and other neurological impairments where the above criteria are met.

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Diagnostic Services: Procedures ordered by a recognized Provider because of specific
symptoms to diagnose a specific condition or disease. Some examples are:
a. Radiology and ultrasound;
b. Lab and pathology; and
c. EKG’s, EEG’s and other electronic diagnostic tests
Except as allowed under covered charges for Preventive Care, Diagnostic Services are not covered under the Plan if the procedures are ordered as part of a routine or periodic physical examination or screening.
Durable Medical Equipment – equipment which the Plan determines to be:
a. designed and able to withstand repeated use;
b. primarily and customarily used to serve a medical purpose;
c. generally not useful to you in the absence of an Illness or injury; and
d. suitable for use in the home.
Some examples are walkers, wheelchairs, hospital-type beds, breathing equipment and apnea monitors.
Durable Medical Equipment does not include adjustments made to vehicles, air conditioners, air purifiers, humidifiers, dehumidifiers, elevators, ramps, stair glides, Emergency Alert equipment, handrails, heat appliances, improvements made to the home or place of business, waterbeds, whirlpool baths and exercise and massage equipment.
Elective Surgical Procedure: Non-emergency Surgery that may be scheduled for a day of the patient's choice without risking the patient's life or causing serious harm to the patient's bodily functions.
Employee: A person employed by the Employer; a proprietor or partner of the Employer.
Employer: Collectively, all employers included under the Plan.
Enrollment Date – the effective date of your coverage or, if earlier, the first day of any applicable waiting period.
Essential Health Benefits: This has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act, and as further defined by the Secretary of the U.S. Department of Health and Human Services. The term includes: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services (including behavioral health treatment); Prescription Drugs; rehabilitative and habilitative services
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and devices; lab services; preventive and wellness services and chronic disease management; and pediatric services (including oral and vision care).
Experimental or Investigational: Any: treatment; procedure; Facility; equipment; drug; device; or supply (collectively, "Technology") which, as determined by The Plan, fails to meet any one of these tests:
a. The Technology must either be: (a) approved by the appropriate federal regulatory agency and have been in use for the purpose defined in that approval; or (b) proven to The Plan's satisfaction to be the standard of care.
This applies to drugs, biological products, devices and any other product or procedure that must have final approval to market from: (i) the FDA; or (ii) any other federal government body with authority to regulate the Technology. But, such approval does not imply that the Technology will automatically be deemed by The Plan as Medically Necessary and Appropriate and the accepted standard of care.
b. There must be sufficient proof, published in peer-reviewed scientific literature, that confirms the effectiveness of the Technology. That proof must consist of well-designed and well-documented investigations. But, if such proof is not sufficient or is questionable, The Plan may consider opinions about and evaluations of the Technology from appropriate specialty advisory committees and/or specialty consultants.
c. The Technology must result in measurable improvement in health outcomes, and the therapeutic benefits must outweigh the risks, as shown in scientific studies. "Improvement" means progress toward a normal or functional state of health.
d. The Technology must be as safe and effective as any established modality. (If an alternative to the Technology is not available, The Plan may, to determine the safety and effectiveness of a Technology, consider opinions about and evaluations of the Technology from appropriate specialty advisory committees and/or specialty consultants.)
e. The Technology must demonstrate effectiveness when applied outside of the investigative research setting.
Services and supplies that are furnished for or in connection with an Experimental or Investigational Technology are not Covered Services and Supplies under this Program, even if they would otherwise be deemed Covered Services and Supplies. But, this does not apply to: (a) services and supplies needed to treat a patient suffering from complications secondary to the Experimental or Investigational Technology; or (b) Medically Necessary and Appropriate services and supplies that are needed by the patient apart from such a Technology.
Regarding a., above, The Plan will evaluate a Prescription Drug for uses other than those approved by the FDA. For this to happen, the drug must be recognized to be Medically Necessary and Appropriate for the condition for which it has been prescribed in one of these:
 The American Hospital Formulary Service Drug Information.
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 The United States Pharmacopeia Drug Information.
Even if such an "off-label" use of a drug is not supported in one or more of the above compendia, The Plan will still deem it to be Medically Necessary and Appropriate if supportive clinical evidence for the particular use of the drug is given in a clinical study or published in a major peer-reviewed medical journal. But, in no event will this Program cover any drug that the FDA has determined to be Experimental, Investigational or contraindicated for the treatment for which it is prescribed.
Also, regardless of anything above, this Plan will provide benefits for services and supplies furnished to a Covered Person for medical care and treatment associated with: (i) an approved cancer clinical trial (Phase I, II, III and/or IV); or (ii) an approved Phase I, II, III and/or IV clinical trial for another life threatening condition. This coverage will be provided if: (a) the Covered Person’s Practitioner is involved in the clinical trial; and (b) he/she has concluded that the Covered Person’s participation would be appropriate. It can also be provided if the Covered Person gives medical or scientific information proving that such participation would be appropriate.
This coverage for clinical trials includes, to the extent coverage would be provided other than for the clinical trial: (a) Practitioners' fees; (b) lab fees; (c) Hospital charges; (d) treating and evaluating the Covered Person during the course of treatment or regarding a complication of the underlying Illness; and (e) other routine costs related to the patient's care and treatment, to the extent that these services are consistent with usual and customary patterns and standards of care furnished whenever a Covered Person receives medical care associated with an approved clinical trial.
This coverage for clinical trials does not include: (a) the cost of Experimental or Investigational drugs or devices themselves; (b) non-health services that the patient needs to receive the care and treatment; (c) the costs of managing the research; or (d) any other services, supplies or charges that this Program would not cover for treatment that is not Experimental or Investigational.
With respect to coverage for clinical trials, The Plan will not:
• Deny a qualified Covered Person participation in an approved clinical trial;
• Deny or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with an approved clinical trial; or
• Discriminate against the Covered Person on the basis of his/her participation in such a trial.
Eye Examination - a comprehensive medical examination of the eye performed by a Practitioner, including a diagnostic ophthalmic examination, with or without definitive refraction as medically indicated, with medical diagnosis and initiation of diagnostic and treatment programs, prescription of medication and lenses, post cycloplegic Visit if required and verification of lenses if prescribed.
Facility: An entity or institution: (a) which provides health care services within the scope of its license, as defined by applicable law; and (b) which the Plan either: (i) is required by law to recognize; or (ii) determines in its sole discretion to be eligible under the Plan.
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Family or Medical Leave of Absence – a period of time of predetermined length, approved by the Employer, during which the Employee does not work, but after which the Employee is expected to return to Active service. Any Employee who has been granted an approved Leave of Absence in accordance with the Family and Medical Leave Act of 1993 shall be considered to be Active for purposes of eligibility for Covered Services and Supplies under your Plan.
FDA: The Food and Drug Administration.
Foot Orthotics – custom-made supportive devices designed to restrict, immobilize, strengthen or protect the foot.
Government Hospital – A Hospital which is operated by a government or any of its subdivisions or agencies. This includes any federal, military, state, county or city Hospital.
Group Health Plan – an Employee welfare benefit plan, as defined in Title I of section 3 of P.L. 93-406 (ERISA) to the extent that the Plan provides medical care and includes items and services paid for as medical care to Employees or their dependents directly or through insurance, reimbursement or otherwise.
Home Area: The 50 states of the United States of America, the District of Columbia and Canada.
Home Health Agency – a Provider which mainly provides Skilled Nursing Care for an Ill or Injured person in his home under a home health care program designed to eliminate Hospital stays. The Plan will recognize it if it is licensed by the state in which it operates, or it is certified to participate in Medicare as a Home Health Agency.
Home Health Care: Nursing and other Home Health Care services rendered to a Covered Person in his/her home. For Home Health Care to be covered, these rules apply:
a. The care must be given on a part-time or intermittent basis, except if full-time or 24-hour services are Medically Necessary and Appropriate on a short-term basis.
b. Continuing Inpatient stay in a Hospital would be needed in the absence of Home Health Care.
c. The care is furnished under a physician's order and under a plan of care that: (a) is established by that physician and the Home Health Care Provider; (b) is established within 14 days after Home Health Care starts; and (c) is periodically reviewed and approved by the physician.
Home Health Care Services: Any of these services needed for the Home Health Care plan: nursing care; physical therapy; occupational therapy; medical social work; nutrition services; speech therapy; home health aide services; medical appliances and equipment, drugs and medicines, lab services and special meals, to the extent these would have been Covered Services and Supplies if the Covered Person was a Hospital Inpatient; diagnostic and therapeutic services (including Surgical services) performed in a Hospital Outpatient department, a physician's office, or any other licensed health care Facility, to the extent these would have been Covered Services
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and Supplies under this Plan if furnished during a Hospital Inpatient stay.
Horizon BCBSNJ: Horizon Blue Cross Blue Shield of New Jersey.
Hospice – a Provider which mainly provides palliative and supportive care for terminally Ill or terminally Injured people under a hospice care program. The Plan will recognize a Hospice if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. approved for its stated purpose by Medicare; or
b. it is accredited for its stated purpose by either the Joint Commission or the National Hospice Organization.
Hospice Care Program: A health care program which provides an integrated set of services designed to provide Hospice care. Hospice services are centrally coordinated through an interdisciplinary team directed by a Practitioner.
Hospital – a Facility which mainly provides inpatient care for Ill or Injured people. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited as a Hospital by the Joint Commission or
b. approved as a Hospital by Medicare.
Among other things, a Hospital is not a convalescent home, rest or nursing Facility, infirmary, Hospice, Substance Abuse Center or a Facility, or part of it, which mainly provides domiciliary or Custodial Care, educational care, non-medical or rehabilitative care. A Facility for the aged is also not a Hospital.
The Plan will pay benefits for covered medical expenses incurred at hospitals operated by the United States government only if services are for treatment on an emergency basis; or services are provided in a hospital located outside of the United States and Puerto Rico.
The above limitations do not apply to military retirees, their dependents, and the dependents of active-duty military personnel who: (i) have both military health coverage and the Plan coverage; and (ii) receive care in facilities run by the Department of Defense or Veteran’s Administration.

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Illness – a sickness or disease suffered by a Covered Person.
Incidental Surgical Procedure: One that: (a) is performed at the same time as a more complex primary procedure; and (b) is clinically integral to the successful outcome of the primary procedure.
Incurred: A charge is Incurred on the date a Covered Person receives a service or supply for which a charge is made.
Injury: All damage to a person's body due to accident, and all complications arising from that damage.
In-Network – a Provider, or the Covered Services and Supplies provided by a Provider, who has an agreement with the Plan to furnish Covered Services or Supplies.
In-Network Coverage: The level of coverage, shown in the Schedule of Covered Services and Supplies, which is provided if an In-Network Provider provides the service or supply.
Inpatient: A Covered Person who is physically confined as a registered bed patient in a Hospital or other Facility, or the services or supplies provided to such Covered Person, depending on the context in which the term is used.
Joint Commission: The Joint Commission on the Accreditation of Health Care Organizations.
Late Enrollee – a Covered Person who requests enrollment under the Plan more than 31 days after first becoming eligible. However, you will not be considered a Late Enrollee under certain circumstances. See the General Information section of this booklet for additional information.
Maintenance Therapy: That point in the therapeutic process at which no further improvement in the gaining or restoration of a function, reduction in disability or relief of pain is expected. Continuation of therapy at this point would be for the purpose of holding at a steady state or preventing deterioration.
Medical Emergency: A medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to: severe pain; psychiatric disturbances; and/or symptoms of Substance Abuse) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate attention to result in: (a) placing the health of the person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of a bodily organ or part.
With respect to a pregnant woman who is having contractions, a Medical Emergency exists where: (a) there is not enough time to make a safe transfer to another Hospital before delivery; or (b) the transfer may pose a threat to the health or safety of the woman or the unborn child.
Examples of a Medical Emergency include, but are not limited to: heart attacks; strokes; convulsions; severe burns; obvious bone fractures; wounds requiring sutures; poisoning; and loss
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of consciousness.
Medically Necessary and Appropriate: This means or describes a health care service that a health care Provider, exercising his/her prudent clinical judgment, would provide to a Covered Person for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that is: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Person’s illness, injury or disease; not primarily for the convenience of the Covered Person or the health care Provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Person’s illness, injury or disease.
“Generally accepted standards of medical practice”, as used above, means standards that are based on:
a. credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;
b. physician and health care Provider specialty society recommendations;
c. the views of physicians and health care Providers practicing in relevant clinical areas; and
d. any other relevant factor as determined by the New Jersey Commissioner of Banking and Insurance by regulation.
Mental Health Center: A Facility which mainly provides treatment for people with mental health problems. The Plan will recognize such a place if: (1) it carries out its stated purpose under all relevant state and local laws; and (2) it is:
a. accredited for its stated purpose by the Joint Commission;
b. approved for its stated purpose by Medicare; or
c. accredited or licensed by the state in which it is located to provide mental health services.
Mental or Nervous Disorders: Conditions which manifest symptoms that are primarily mental or nervous (whether organic or non-organic, biological or non-biological, chemical or non-chemical in origin and irrespective of cause, basis or inducement) for which the primary treatment is psychotherapy or psychotherapeutic methods or psychotropic medication. Mental or Nervous Disorders include, but are not limited to: psychoses; neurotic and anxiety disorders; schizophrenic disorders; affective disorders; personality disorders; and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems.
In determining whether or not a particular condition is a Mental or Nervous Disorder, the Plan may refer to the current edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (the “Manual”). But in no event shall the following be considered Mental or Nervous Disorders:
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(1) Conditions classified as V-codes in the most current edition of the Manual. These include relational problems such as: parent-child conflicts; problems related to abuse or neglect when intervention is focused on the perpetrator; situations not attributable to a diagnostic disorder, including: bereavement, academic, occupational, religious, and spiritual problems.
(2) Conditions related to behavior problems or learning disabilities, except with respect to the treatment of Mental or Nervous Disorders or Developmental Disabilities.
(3) Conditions that the Plan determines to be due to developmental disorders. These include, but are not limited to: mental retardation; academic skills disorders; or motor skills disorders. But, this does not apply to the extent required by law for the treatment of Mental or Nervous Disorders or Developmental Disabilities.
(4) Conditions that the Plan determines to lack a recognizable III-R classification in the most current edition of the Manual. This includes, but is not limited to, treatment for: adult children of alcoholic families; or co-dependency.
Mutually Exclusive Surgical Procedures: Surgical procedures that:
a. differ in technique or approach, but lead to the same outcome;
b. represent overlapping services or accomplish the same result;
c. in combination, may be anatomically impossible.
Negotiation Arrangement (a.k.a., Negotiated National Account Arrangement): An agreement negotiated between a control/home licensee and one or more par/host licensees for any national account that is not delivered through the BlueCard Program.
Non-Covered Charges: Charges for services and supplies which: (a) do not meet this Plan's definition of Covered Charges; (b) exceed any of the coverage limits shown in this Booklet; or (c) are specifically identified in this Booklet as Non-Covered Charges.
Nurse: A Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.), or a nursing specialist such as a nurse mid-wife or nurse anesthetist, who:
a. is properly licensed or certified to provide medical care under the laws of the state where he/she practices; and
b. provides medical services which are: (a) within the scope of his/her license or certificate; and (b) are covered by this Plan.
Out-of-Hospital: Services or supplies provided to a Covered Person other than as an Inpatient or Outpatient.
Out-of-Network: A Provider, or the services and supplies furnished by a Provider, who does not
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have an agreement with Horizon BCBSNJ to provide Covered Services or Supplies, depending on the context in which the term is used.
Out-of-Network Benefits: The coverage shown in the Schedule of Covered Services and Supplies which is provided if an Out-of-Network Provider provides the service or supply.
Out-of-Pocket Maximum: The maximum dollar amount that a Covered person must pay as Deductible, and Coinsurance for Covered Services and Supplies during any Benefit Period. Once that dollar amount is reached, no further such payments are required for the remainder of that Benefit Period.
Outpatient: Either: (a) a Covered Person at a Hospital who is other than an Inpatient; or (b) the services and supplies provided to such a Covered Person, depending on the context in which the term is used.
Partial Hospitalization: Intensive short-term non-residential day treatment services that are: (a) for Mental or Nervous Disorders; chemical dependency; and (b) rendered for any part of a day for a minimum of four consecutive hours per day.
Pharmacy: A Facility: (a) which is registered as a Pharmacy with the appropriate state licensing agency; and (b) in which Prescription Drugs are dispensed by a pharmacist.
Physical Rehabilitation Center: A Facility which mainly provides therapeutic and restorative services to ill or injured people. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by either the Joint Commission or the Commission on Accreditation for Rehabilitation Facilities; or
b. approved for its stated purpose by Medicare.
Plan: The SUEZ Water Resources Inc. Medical Plan
Plan Year: The twelve-month period starting on January 1st and ending on December 31st.
Post-Service Claim – is any claim for a benefit under a group health Plan that is not a Pre-Service claim.
Practitioner: A person that the Plan is required by law to recognize who:
a. is properly licensed or certified to provide medical care under the laws of the state where he/she practices; and
b. provides medical services which are: (a) within the scope of the license or certificate; and (b) are covered by this Plan.
Practitioners include, but are not limited to, the following; physicians; chiropractors; dentists; optometrists; pharmacists; chiropodists; psychologists; physical therapists; audiologists; speech
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language pathologists; certified nurse mid-wives; registered professional nurses; nurse practitioners; and clinical nurse specialists.
Prescription Drug Cost Share Amount: The sum total of the following In-Network expenses Incurred by a Covered Person or covered family during a Calendar Year under a self-insured stand-alone group prescription drug plan or an insured stand-alone group prescription drug plan provided by Horizon BCBSNJ or another carrier:
(a) Expenses that are applied toward the prescription drug plan’s deductible, if any (excluding any such expenses, including any fourth quarter deductible carry over as defined in the prescription drug plan, that were carried over from the preceding Calendar Year).
(b) Amounts paid or payable by the Covered Person as copayments and/or coinsurance under the prescription drug plan.
Pre-Service Claim – is any claim for a benefit under a group health plan with respect to which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.
Preventive Care: Services or supplies that are not provided for the treatment of an Injury or Illness. It includes, but is not limited to: routine physical exams, including: related X-rays and lab tests; immunizations and vaccines; screening tests; well-baby care; and well adult care.
Prior Authorization: Authorization by Horizon BCBSNJ for a Practitioner to provide specified treatment to Covered Persons. After Horizon BCBSNJ gives this approval, Horizon BCBSNJ gives the Practitioner a certification number. Benefits for services that are required to be, but are not, given Prior Authorization are subject to reduction as described in the “Utilization Review and Management” section of this Booklet.
Program: The plan of group health benefits described in this Booklet.
Provider: A Facility or Practitioner of health care in accordance with the terms of this Plan.
Related Structured Behavioral Programs: Services given by a qualified Practitioner that are comprised of multiple intervention strategies, i.e., behavioral intervention packages, based on the principles of ABA. These include, but are not limited to: activity schedules; discrete trial instruction; incidental teaching; natural environment training; picture exchange communication system; pivotal response treatment; script and script-fading procedures; and self-management.
Routine Foot Care: The cutting, debridement, trimming, reduction, removal or other care of: corns; calluses; flat feet; fallen arches; weak feet; chronic foot strain; dystrophic nails; excrescences; helomas; hyperkeratosis; hypertrophic nails; non-infected ingrown nails; dermatomes; keratosis; onychauxis; onychocryptosis; tylomas; or symptomatic complaints of the feet.
Routine Nursing Care: The appropriate nursing care customarily furnished by a recognized Facility for the benefit of its Inpatients.
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Skilled Nursing Care: Services which: (a) are more intensive than Custodial Care; (b) are provided by an R.N. or L.P.N.; and (c) require the technical skills and professional training of an R.N. or L.P.N.
Skilled Nursing Facility: A Facility which mainly provides full-time Skilled Nursing Care for ill or injured people who do not need to be in a Hospital. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by the Joint Commission; or
b. approved for its stated purpose by Medicare. In some places, a Skilled Nursing Facility may be called an "Extended Care Center" or a "Skilled Nursing Center."
Special Care Unit: A part of a Hospital set up for very ill patients who must be observed constantly. The unit must have a specially trained staff and special equipment and supplies on hand at all times. Some types of Special Care Units are:
a. intensive care units;
b. cardiac care units;
c. neonatal care units; and
d. burn units.
Special Enrollment Period – A period as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), during which you may enroll yourself and your Dependents for coverage under the Plan.
Specialist: A health care Practitioner who provides medical care in any generally accepted medical or surgical specialty or sub-specialty.
Substance Abuse – the abuse or addiction to drugs or controlled substances, including alcohol.
Substance Abuse Centers – Facilities that mainly provide treatment for people with Substance Abuse problems. The Plan will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by the Joint Commission; or
b. approved for its stated purpose by Medicare.
Surgery/Surgical:
a. The performance of generally accepted operative and cutting procedures, including: surgical diagnostic procedures; specialized instrumentations; endoscopic exams; and other invasive procedures;
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b. The correction of fractures and dislocations;
c. Pre-operative and post-operative care; or
d. Any of the procedures designated by C.P.T. codes as Surgery.
Therapeutic Manipulation – the treatment of the articulations of the spine and musculoskeletal structures for the purpose of relieving certain abnormal clinical conditions resulting from the impingement upon associated nerves causing discomfort. Some examples are manipulation or adjustment of the spine, hot or cold packs, electrical muscle stimulation, diathermy, skeletal adjustments, massage, adjunctive therapy, ultra-sound, doppler, whirlpool or hydro-therapy or other treatment of a similar nature.
Therapy Services: The following services and supplies when they are:
a. ordered by a Practitioner;
b. performed by a Provider;
c. Medically Necessary and Appropriate for the treatment of a Covered Person's Illness or Accidental Injury.
Chelation Therapy: The administration of drugs or chemicals to remove toxic concentrations of metals from the body.
Chemotherapy: The treatment of malignant disease by chemical or biological antineoplastic agents.
Cognitive Rehabilitation Therapy: Retraining the brain to perform intellectual skills that it was able to perform prior to disease, trauma, Surgery, congenital anomaly or previous therapeutic process.
Dialysis Treatment: The treatment of an acute renal failure or chronic irreversible renal insufficiency by removing waste products from the body. This includes hemodialysis and peritoneal dialysis.
Infusion Therapy: The administration of antibiotic, nutrient, or other therapeutic agents by direct infusion.
Occupational Therapy: The treatment to develop or restore a physically disabled person's ability to perform the ordinary tasks of daily living.
Physical Therapy: The treatment by physical means to: relieve pain; develop or restore normal function; and prevent disability following Illness, Injury or loss of limb.
Radiation Therapy: The treatment of disease by X-ray, radium, cobalt, or high energy particle sources. Radiation Therapy includes the rental or cost of radioactive materials. Diagnostic Services requiring the use of radioactive materials are not Radiation Therapy.
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Respiration Therapy: The introduction of dry or moist gases into the lungs.
Speech Therapy: Therapy that is by a qualified speech therapist and is described in a., b. or c:
a. Speech therapy to restore speech after a loss or impairment of a demonstrated, previous ability to speak. Two examples of speech therapy that will not be covered are: (a) therapy to correct pre-speech deficiencies; and (b) therapy to improve speech skills that have not fully developed.
b. Speech therapy to develop or improve speech to correct a defect that both: (a) existed at birth; and (b) impaired or would have impaired the ability to speak.
c. Regardless of anything in a. or b. above to the contrary, speech therapy needed to treat a speech impairment of a Covered Person diagnosed with a Developmental Disability.
Urgent Care: Outpatient and Out-of-Hospital medical care which, as determined by the Plan or an entity designated by the Plan, is needed due to an unexpected Illness, Injury or other condition that is not life threatening, but that needs to be treated by a Provider within 24 hours.
Urgent Care Claim: An Urgent Care Claim is any claim for medical care which, if denied, in the opinion of the Covered Person or his/her Provider, will cause serious medical consequences in the near future, or subject the Covered Person to severe pain that cannot be managed without the medical services that have been denied.
Value-Based Program: An outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment.
Visit: An occasion during which treatment or consultation services are rendered in a Provider's office, in the Outpatient department of an eligible Facility, or by a Provider on the staff of (or under contract or arrangement with) a Home Health Agency to provide covered Home Health Care services or supplies.
Waiting Period – the period of time between enrollment in the program and the date when you become eligible for benefits. We, Us and Our: The Plan.
You, Your: An Employee.

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Schedule of Covered Services and Supplies
BENEFITS FOR COVERED SERVICES OR SUPPLIES UNDER THIS PLAN ARE SUBJECT TO ALL DEDUCTIBLE(S), COPAYMENT(S), COINSURANCE(S) AND MAXIMUM(S) STATED IN THIS SCHEDULE AND ARE DETERMINED PER BENEFIT PERIOD BASED ON ALLOWANCE, UNLESS OTHERWISE STATED.
NOTE: BENEFITS WILL BE REDUCED OR ELIMINATED FOR NONCOMPLIANCE
WITH THE UTILIZATION REVIEW PROVISIONS CONTAINED IN THIS PLAN.
REFER TO THE SECTION OF THIS PLAN CALLED “EXCLUSIONS” TO SEE WHAT SERVICES AND SUPPLIES ARE NOT COVERED.
The Plan will provide the coverage listed in this Schedule of Covered Services and Supplies,
subject to the terms, conditions, limitations and exclusions stated within this Plan.
Services and supplies provided by an In-Network Provider are covered at the In-Network level.
Services and supplies provided by an Out-of-Network Provider are covered at the
Out-of-Network level. However, this does not apply to services and supplies provided by an Out-
of-Network Provider in a case where: (a) the Covered Person is an Inpatient in a Hospital; (b) the
admitting physician was a Network Practitioner; and (c) the Covered Person and/or the Covered
Persons Practitioner complied with this Plans rules with res pect to Prior Authorization or
notification. In this case, the Covered Services and Supplies provided by Out-of-Network
Providers during the Inpatient stay will be covered at the In-Network level.
Please note that you may be responsible for paying charges, which exceed allowance when services
are rendered by an Out-of-Network Provider.
Coinsurance 85% of Covered Basic Charges.
In-Network
85% of Covered Supplemental Charges.
Coinsurance 60% of Covered Basic Charges.
Out-of-Network 60% of Covered Supplemental Charges.
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Out-of-Pocket Maximum In-Network After $5,000/Covered Person, We provide 100% of Covered Allowance.
Out-of-Pocket Maximum
Out-of-Network After $10,000/Covered Person, We provide 100% of
Covered Allowance.
Note: The Out-Pocket Maximum cannot be met with:
• Non-Covered Charges
Deductible
In-Network
Applies to $2,000/Covered Person.
Basic/Supplemental Services
Deductible Out-of-Network
Applies to $4,000/Covered Person.
Basic/Supplemental Services
Medicare Alternate Deductible – For a Covered Person who is eligible for Medicare by reason
of a disability, but is not insured by both Parts A and B, the Medicare Alternate Deductible is equal to the Deductible plus what Parts A and B of Medicare would have paid had the Covered Person been covered as such by Medicare.
After the 30-month period ends described in the section Medicare and Your Benefits, with respect to a Covered Person who is eligible for Medicare solely on the basis of End Stage Renal Disease, but is not insured by both Parts A and B, the Medicare Alternate Deductible is equal to the
Deductible plus what Parts A and B of Medicare would have paid had the Covered Person been covered as such by Medicare.
BENEFIT PERIOD MAXIMUM
In-Network Unlimited. Applies to all Covered Services and Supplies.
Out-of-Network Unlimited. Applies to all Covered Services and Supplies.
PER LIFETIME MAXIMUMS
In-Network Unlimited. Applies to all Covered Services and Supplies.
Out-of-Network Unlimited. Applies to all Covered Services and Supplies.
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A. ELIGIBLE BASIC SERVICES AND SUPPLIES
ALLERGY TESTING AND TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
AMBULATORY SURGERY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
ANESTHESIA
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
COMPLEX IMAGING SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DENTAL CARE AND TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIAGNOSTIC X-RAY AND LABORATORY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIALYSIS CENTER CHARGES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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EMERGENCY ROOM (EMERGENT)
In-Network Outpatient
Facility Subject to Deductible and 85% Coinsurance.
Outpatient
Professional Subject to Deductible and 85% Coinsurance.
Out-of-Network Outpatient Facility Subject to Deductible and 85% Coinsurance.
Outpatient Professional Subject to Deductible and 85% Coinsurance. EMERGENCY ROOM (NON-EMERGENT)
In-Network Outpatient Facility Subject to Deductible and 85% Coinsurance.
Outpatient Professional Subject to Deductible and 85% Coinsurance.
Out-of-Network
Outpatient
Facility Subject to Deductible and 60% Coinsurance.
Outpatient Professional Subject to Deductible, and 60% Coinsurance.
FACILITY CHARGES 365 days Inpatient Hospital care.
In-Network Subject to Preapproval, Deductible, and 85% Coinsurance.
Out-of-Network Subject to Preapproval, Deductible, and 60% Coinsurance.
FERTILITY SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to 4 attempts per Lifetime.

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HOME HEALTH AGENCY CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 120 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
HOSPICE CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 210 day Benefit Period maximum.
INPATIENT PHYSICIAN SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
MATERNITY/OBSTETRICAL CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
MENTAL OR NERVOUS DISORDERS (INCLUDING GROUP THERAPY) AND SUBSTANCE ABUSE
Inpatient
In-Network Subject to Prior Authorization, Deductible, and 85% Coinsurance.
Inpatient
Out-of-Network Subject to Prior Authorization, Deductible and 60% Coinsurance.

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In-Network
Outpatient and
Out-Of-Hospital Subject to Deductible, and 85% Coinsurance.
Out-of-Network
Outpatient and
Out-Of-Hospital Subject to Deductible, and 60% Coinsurance.
NUTRITIONAL COUNSELING
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 3 Visit Benefit Period maximum.
PHYSICAL REHABILITATION
Inpatient In-Network Subject to Deductible, and 85% Coinsurance.
Inpatient Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 120 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
PRACTITIONER’S CHARGES FOR NON-SURGICAL CARE AND TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PRACTITIONER’S CHARGES FOR SURGERY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PREADMISSION TESTING
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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PREVENTIVE CARE
In-Network Subject to 100% Coinsurance. Applies to all Preventive Care except as noted below.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Applies to all Preventive Care except as noted below.
a. GYNECOLOGICAL CARE AND EXAMINATIONS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 exam per year.
b. MAMMOGRAPHY
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
c. PAP SMEARS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
d. ROUTINE PHYSICALS AND IMMUNIZATIONS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
e. PROSTATE CANCER SCREENING
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.

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f. COLORECTAL CANCER SCREENING
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
g. VISION EXAM - ANNUAL/ROUTINE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 exam per year.
h. HEARING EXAM - ROUTINE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 routine hearing exam or audiology function test per year for adults.
SECOND OPINION CHARGES
In-Network Subject to Deductible, and 85% Coinsurance
Out-of-Network Subject to Deductible, and 60% Coinsurance.
SKILLED NURSING FACILITY CHARGES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to 120 day Benefit Period maximum, combined In-Network and Out-of-Network.
SURGICAL SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.

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TELEMEDICINE BEHAVIORAL HEALTH SERVICES, PROVIDED BY HORIZON CAREONLINE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network No Benefit.
TELEMEDICINE MEDICAL SERVICES, PROVIDED BY HORIZON CAREONLINE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network No Benefit.
THERAPEUTIC MANIPULATIONS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-
Network.
THERAPY SERVICES
In-Network Subject to Deductible and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
a. CHELATION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
b. CHEMOTHERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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c. COGNITIVE REHABILITATION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. d. DIALYSIS TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
e. INFUSION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
f. OCCUPATIONAL THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. g. PHYSICAL THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. h. RADIATION TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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i. RESPIRATION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
j. SPEECH THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. Note: Speech Therapy is eligible for restorative purposes only; it is not covered for developmental delay. TRANSPLANT BENEFITS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.

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B. ELIGIBLE SUPPLEMENTAL SERVICES AND SUPPLIES
AMBULANCE SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 85% Coinsurance.
BLOOD
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIABETES BENEFITS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DURABLE MEDICAL EQUIPMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. FOOT ORTHOTICS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Subject to $1,000 maximum per Benefit Period. HOME INFUSION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
OXYGEN AND ADMINISTRATION
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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PROSTHETIC DEVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
NON-ROUTINE VISION CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
WIGS BENEFIT
In-Network Subject to 85% Coinsurance.
Out-of-Network Subject to 85% Coinsurance.
Subject to $750.00 Benefit Period Maximum.
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General Information
How To Enroll
If you meet your Employers eligibility rules, including any Waiting Period established by the Employer, you may enroll by completing an enrollment form.
Your Identification Card
You will receive an ID card to show to the Hospital, physician or other Provider when you receive services or supplies. Your ID card shows: (a) the group through which you are enrolled; (b) your type of coverage; and (c) your ID number.
Always carry this card and use your identification number when you receive covered services or supplies. If you lose your card, you can still use your coverage if you know your identification number. The inside back cover of this booklet has space to record your identification number along with other information you will need when making inquiries about your benefits. You should, however, contact your enrollment official immediately to replace the lost card.
You cannot let anyone not named in your coverage use your card or your coverage.
Types of Coverage Available
You may enroll under one of the following types of coverage:
• Single – provides coverage for you only.
Special Enrollment Periods
If you enroll during a Special Enrollment Period, you are not considered a Late Enrollee.
Individual Losing Other Coverage
If you are eligible for coverage, but not enrolled, you must be permitted to enroll if each of the following conditions is met:
a. the individual was covered under a group health plan or had health insurance coverage at the time coverage was previously offered;
b. the Employee stated in writing that coverage under a group health plan or health insurance coverage was the reason for declining enrollment when it was first offered;
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c. the Employee coverage described in the first bullet above:
(i) Was under a COBRA “(or other state mandated)” continuation provision and the COBRA coverage was exhausted; or
(ii) Was not under such a provision and either coverage was terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or Employer contributions toward such coverage were terminated;
d. the Employee requests enrollment not later than 31 days after the date of exhaustion of coverage described in (i) above or termination of coverage or Employer contribution described in (ii) above.
Coverage must be effective not later than the first day of the first calendar month beginning after the date the completed request for enrollment is received.
Multiple Employment
If you work for both the Employer and an Affiliated Company, or for more than one Affiliated Company, the Plan will treat you as if employed only by one Employer; and you will not have multiple coverage. But, if your group’s plan uses the amount of an Employee’s earnings to set the rates, determine class, figure benefit amounts, or for any other reason, your earnings will be calculated as the sum of your earnings from the Employer and its Affiliated Companies.
When Your Coverage Ends
Your coverage ends on the last day of the benefit month in which your enrollment in the Plan ends, or on the last day of the benefit month for which premiums have been paid by your group.
Benefits After Termination
If you are confined as an inpatient in an eligible facility on the date your coverage ends, benefits will be available for eligible services provided during the uninterrupted continuation of that stay, but only to the extent they would otherwise be available.
Continuing Coverage Under the Federal Family and Medical Leave Act
If you take a leave that qualifies under the Federal Family and Medical Leave Act (FMLA) (e. g., to care for a sick family member, or after the birth or adoption of a Child Dependent), you may continue coverage under this Plan. You may also continue coverage for your Dependents.
You will be subject to the same Plan rules as an Active Employee. But, your legal right to have your Employer pay its share of the required contribution, as it does for Active Employees, is subject to your eventual return to Active work.
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Coverage that continues under this law ends at the first to occur of the following:
• The date you again become Active.
• The end of a total leave period of 12 weeks in any 12 month period.
• The date coverage for you or a Dependent would have ended had you not been on leave.
• Your failure to make any required contribution.
Consult your benefits representative for application forms and further details.
Continuation of Coverage Under COBRA
Under a federal law called the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), you may have the opportunity to continue group health care coverage which would otherwise end, if any of these events occur:
• Your death;
• Your work hours are reduced;
• Your employment ends for a reason other than gross misconduct.
You must notify your benefits representative of a divorce or legal separation. This notice must be given within 60 days of the date the event occurred. If notice is not given within this time, the Dependent will not be allowed to continue coverage.
You will receive a written election notice of the right to continue the insurance. In general, this notice must be returned within 60 days of the later of: (a) the date the coverage would otherwise have ended; or (b) the date of the notice. You or the other person asking for coverage must pay the required amount to maintain it. The first payment must be made by the 45th day after the date the election notice is completed.
If you elect to continue coverage, it will be identical to the health care coverage for other members of your class. It will continue as follows:
• Up to 18 months in the event of the end of your employment or a reduction in your hours. Further, if you or a covered Dependent are determined to be disabled, according to the Social Security Act, at the time you became eligible for COBRA coverage, or during the first 60 days of the continued coverage, that person and any other person then entitled to the continued coverage may elect to extend this 18-month period for up to an extra 11 months. To elect this extra 11 months, the person must give the Employer written proof of Social Security's determination before the first to occur of: (a) the end of the 18 month continuation period; or (b) 60 days after the date the person is determined to be disabled.
Continuation coverage for a person will cease before the end of a maximum period just described if one of these events occurs:
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• This Plan ends for the class you belong to.
• The person fails to make required payments for the coverage.
• The person becomes covered under any other group health plan. But, coverage will not end due to this rule until the end of any period for which benefits for them are limited, under the other plan.
• The person becomes entitled to Medicare benefits.
If a person's COBRA coverage was extended past 18 months due to total disability; and there is a final determination (under the Social Security Act) that the person, before the end of the additional continuation period of 11 months, is no longer disabled, the coverage will end on the first of the month that starts more than 30 days after that determination.
The above is a general description of COBRA's requirements. If coverage for you ends for any reason, you should immediately contact your benefits representative to find out if coverage can be continued. Your Employer is responsible for providing all notices required under COBRA.
Continuation of Coverage under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
If the Employee is absent from work due to performing service in the uniformed services, this federal law gives the Employee the right to elect to continue the health coverage under this Plan (for himself/herself and the Employee’s Dependents, if any). If the Employee so elects, the coverage can be continued, subject to the payment of any required contributions, until the first to occur of the following:
 The end of the 24-month period starting on the date the Employee was first absent from work due to the service.
 The date on which the Employee fails to return to work after completing service in the uniformed services, or fails to apply for reemployment after completing service in the uniformed services.
 The date on which this Plan ends.
If the Employee elects to continue the coverage, the Employee’s contributions for it are determined as follows:
a) If the Employee’s service in the uniformed services is less than 31 days, his/her contribution for the coverage will be the same as if there were no absence from work.
b) If the service extends for 31 or more days, the Employee’s contribution for the coverage can be up to 102% of total cost of coverage.
For the purposes of this provision, the terms “uniformed services” and “service in the uniformed services” have the following meanings:
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Uniformed services: The following:
1. The Armed Services.
2. The Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty.
3. The commissioned corps of the Public Health Service.
4. Any other category of persons designated by the President in time of war or national emergency.
Service in the uniformed services: The performance of duty on a voluntary or involuntary basis in a uniformed service under competent authority. This includes:
1. Active duty.
2. Active and inactive duty for training.
3. National Guard duty under federal statute.
4. A period for which a person is absent from employment: (a) for an exam to determine the fitness of the person to perform any such duty; or (b) to perform funeral honors duty authorized by law.
5. Service as: (a) an intermittent disaster-response appointee upon activation of the National Disaster Medical System (NDMS); or (b) a participant in an authorized training program in support of the mission of the NDMS.
Continuation of Care
Horizon BCBSNJ will provide written notice to each Covered Person at least 30 business days prior to the termination or withdrawal from Horizon BCBSNJ’s Network of a Covered Person’s Provider currently treating the Covered Person, as reported to Horizon BCBSNJ. The 30 day prior notice may be waived in cases of immediate termination of a Provider based on: breach of contract by the Provider; a determination of fraud; or Horizon BCBSNJ medical director's opinion that the Provider is an imminent danger to the patient or the public health, safety or welfare.
The Plan shall assure continued coverage of Covered Services and Supplies by a terminated Provider for up to four months in cases where it is Medically Necessary and Appropriate for the Covered Person to continue treatment with that Provider. In the case of pregnancy of a Covered Person: (a) the Medical Necessity and Appropriateness of continued coverage by that Provider shall be deemed to be shown; and (b) such coverage can continue to the postpartum evaluation of the Covered Person, up to six weeks after the delivery.
In the event that a Covered Person is receiving post-operative follow-up care, the Plan shall continue to cover services rendered by the Provider for the duration of the treatment, up to six months. In the event that a Covered Person is receiving oncological or psychiatric treatment, the
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Plan shall continue to cover services rendered by the Provider for the duration of the treatment, up to one year. If the services are provided in an acute care Facility, the Plan will continue to cover them regardless of whether the Facility is under contract or agreement with Horizon BCBSNJ.
Covered Services and Supplies shall be covered to the same extent as when the Provider was employed by or under contract with Horizon BCBSNJ. Payment for Covered Services and Supplies shall be made based on the same methodology used to reimburse the Provider while the Provider was employed by or under contract with Horizon BCBSNJ.
The Plan shall not allow continued services in cases where the Provider was terminated due to: (a) Horizon BCBSNJ Medical Director's opinion that the Provider is an imminent danger to a patient or to the public health, safety and welfare, (b) a determination of fraud; or (c) a breach of contract.
Medical Necessity And Appropriateness
We will make payment for benefits under this Plan only when:
• Services are performed or prescribed by your attending physician;
• Services, in our judgment, are provided at the proper level of care (Inpatient; Outpatient; Out-of-Hospital; etc.);
• Services or supplies are Medically Necessary and Appropriate for the diagnosis and treatment of an Illness or Injury.
THE FACT THAT YOUR ATTENDING PHYSICIAN MAY PRESCRIBE, ORDER, RECOMMEND OR APPROVE A SERVICE OR SUPPLY DOES NOT, IN ITSELF, MAKE IT MEDICALLY NECESSARY FOR THE TREATMENT AND DIAGNOSIS OF AN ILLNESS OR ACCIDENTAL INJURY OR MAKE IT AN ELIGIBLE MEDICAL EXPENSE.
Cost Containment
If the Plan determines that an eligible service can be provided in a medically acceptable, cost-effective alternative setting, the Plan reserves the right to provide benefits for such service when performed in that setting.
Managed Care Provisions
Member Services
The Member Services Representatives who staff Horizon BCBSNJ Member Services Departments are there to answer Covered Persons' questions about the Plan and to assist in managing their care. To contact Member Services, a Covered Person should call the number on his/her Identification (ID) Card.

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Miscellaneous Provisions
a. This Plan is intended to pay for Covered Services and Supplies as described in this Booklet. The Plan does not provide the services or supplies themselves, which may, or may not, be available.
b. The Plan is only required to provide its Allowance for Covered Services and Supplies, to the extent stated in the Plan. The Plan has no other liability.
c. Benefits are to be provided in the most cost-effective manner practicable. If the Plan determines that a more cost-effective manner exists, the Plan reserves the right to require that care be rendered in an alternate setting as a condition of providing payment for benefits.

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YOUR PREFERRED PROVIDER ORGANIZATION (PPO) PROGRAM

Your PPO Program provides you with the freedom to choose any Provider; however, your choice of Providers will determine how your benefits are paid. Benefits provided by In-Network Providers will be paid at a higher benefit level than benefits provided for an Out-of-Network Provider. You will be responsible for any Deductible, Coinsurance and Copayments that apply; however, if you use In-Network Providers, you will not have to file claims. In-Network Providers will accept our payment as payment in full. Out-of-Network Providers may balance bill to charges, and you will generally need to file claims to receive benefits.
Your Plan shares the cost of your health care expenses with you. This section explains what you pay, and how Deductibles, Coinsurance and Copayments work together.
Note: Coverage will be reduced if a Covered Person does not comply with the Utilization Review and Management and Prior Authorization requirements contained in this Plan.
BENEFIT PROVISIONS
The Deductible
The services and supplies covered under the Plan (except Preventive Care services) are subject to a Deductible (as described below) which must be met during a Calendar Year before any benefits are payable. There are separate Deductibles for In-Network Coverage and for Out-of-Network Coverage. After an applicable Deductible is met, the Covered Services and Supplies are further subject to any applicable Coinsurance described in the Schedule of Covered Services and Supplies.
Single Coverage (Applies When Only the Employee Is Covered)
Each Calendar Year, each Covered Person covered for Single Coverage must have Covered Charges that exceed the Deductible for Single Coverage before Plan pays any benefits to that person. There are separate Single Coverage Deductibles for In-Network and Out-of-Network coverage. The Deductibles are shown in the Schedule of Covered Services and Supplies. The applicable Deductible cannot be met with Non-Covered Charges. And only Covered Charges Incurred by the Covered Person while covered by the Plan can be used to meet the applicable Deductible.
A Covered Charge, whether Incurred In-Network or Out-of-Network, can be used to meet each of the Single Coverage Deductibles, until the In-Network Single Coverage Deductible is met. Once that occurs, the difference between the In-Network Single Coverage Deductible and the Out-of-Network Single Coverage Deductible must still be met for the Employee to be eligible for Out-of-Network benefits, and only Covered Charges Incurred Out-of-Network can be used to meet this difference.
Once the applicable Deductible is met, Plan pays benefits for other Covered Charges above the Deductible (In-Network or Out-of-Network, as the case may be) Incurred by that Covered Person,
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less any applicable Coinsurance, for the rest of that Calendar Year. But all charges must be Incurred while that person is covered by the Plan. And what Plan pays is based on all of the Plan’s terms.
Out-of-Pocket Maximum
Single Coverage (Applies when only the Employee is covered)
This Program limits the amount that an Employee has to pay “out-of-pocket” during a Calendar Year Covered Services and Supplies. This “Out-of-Pocket Maximum” is described in the “Schedule of Covered Services and Supplies” (the Schedule). There are separate maximums for In-Network and Out-of-Network expenses.
Once the Employee has Incurred, during a Calendar Year, an amount of Covered Charges for which no benefits have been paid or are payable equal to a Single Coverage Out-of-Pocket Maximum, Horizon BCBSNJ will pay 100% of any additional Covered Charges (In-Network or Out-of-Network, as the case may be) Incurred by the Employee for the rest of that year.
Any Covered Charge used to meet either or both of the Single Coverage Deductibles can also be used to meet both the In-Network and Out-of-Network Out-of-Pocket Maximums. Otherwise, however, only unpaid In-Network Covered Charges can be used to meet the In-Network maximum, and only unpaid Out-of-Network Covered Charges can be used to meet the Out-of-Network maximum.
An Out-of-Pocket Maximum cannot be met with Non-Covered Charges. But solely for the purposes of this subsection, a Covered Person’s Prescription Drug Cost Share Amount shall be applied towards the applicable In-Network Out-of-Pocket Expense Maximum under this Program.
Payment Limits
The Plan limits what it will pay for certain types of charges. See the Schedule of Covered Services and Supplies for these limits.
Benefits From Other Plans
The benefits the Plan will provide may also be affected by benefits from Medicare and other health benefit plans. Read The Effect of Medicare on Benefits and Coordination of Benefits and Services sections of this Booklet for an explanation of how this works.

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Summary of Covered Services and Supplies
This section lists the types of charges the Plan will consider as Covered Services or Supplies up to its Allowance subject to all the terms of your group’s program including, but not limited to, Medical Necessity and Appropriateness, Utilization Management features, Schedule of Covered Services and Supplies, benefit limitations and exclusions.
A. ELIGIBLE BASIC SERVICES AND SUPPLIES
Allergy Testing and Treatment
This Plan covers allergy testing and treatment, including routine allergy injections.
Ambulatory Surgery
The Plan covers charges for Ambulatory Surgery performed in a Hospital Outpatient department
or Out-of-Hospital, a Practitioner’s office or an Ambulatory Surgical Center in connection with
covered Surgery.
Anesthesia
The Plan covers anesthetics and their administration.
Audiology Services
The Plan covers audiology services rendered by a physician or a licensed audiologist, where such
services are determined to be Medically Necessary and Appropriate and when performed within
the scope of practice.
Birthing Centers
Deliveries in Birthing Centers, in many cases, are deemed an effective cost-saving alternative to
Inpatient Hospital care. At a Birthing Center, deliveries take place in “birthing rooms,” where
decor and furnishings are designed to provide a more natural, home-like atmosphere.
All care is coordinated by a team of certified nurse-midwives and pediatric nurse-practitioners.
Obstetricians, pediatricians and a nearby Hospital are available in case of complications.
Prospective Birthing Center patients are carefully screened. Only low-risk pregnancies are
accepted. High-risk patients are referred to a Hospital maternity program.
The Birthing Center's services, including pre-natal, delivery and post-natal care, will be covered
in full. If complications occur during labor, delivery may take place in a Hospital because of the
need for emergency and/or Inpatient care. If, for any reason, the pregnancy does not go to term,
the Plan will not provide payment to the Birthing Center.
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Dental Care and Treatment
The Plan covers:
a. the diagnosis and treatment of oral tumors and cysts; and
b. the surgical removal of bony impacted teeth; and
c. charges for Surgical treatment of temporo-mandibular joint dysfunction syndrome (TMJ) in a Covered Person. However, the Plan does not cover any charges for orthodontia, crowns or bridgework.
Treatment of an Accidental Injury to natural teeth or the jaw is covered, but only if:
a. the Accidental Injury occurs while the Covered Person is covered under your group’s Plan.
b. the Accidental Injury was not caused, directly or indirectly, by biting or chewing.
c. treatment is performed within 18 months from the date of injury.
Treatment includes replacing natural teeth lost due to such Accidental Injury, in no event does it include orthodontic treatment.
Diagnosis and Treatment of Autism
This Plan provides coverage for charges for the screening and diagnosis of autism.
If a Covered Person’s primary diagnosis is autism, and regardless of anything in the Plan to the contrary, the Plan provides coverage when: (i) the services are given Prior Authorization; and (ii) the services are for the following Medically Necessary and Appropriate Therapy Services, as prescribed in a treatment plan:
(a) Occupational Therapy needed to develop the Covered Person’s ability to perform the ordinary tasks of daily living;
(b) Physical Therapy needed to develop the Covered Person’s physical functions; and
(c) Speech Therapy needed to treat the Covered Person’s speech impairment.
Notwithstanding anything in the Plan to the contrary, the foregoing Therapy Services as prescribed in a treatment plan will not be subject to benefit Visit maximums.
Also, if a Covered Person’s primary diagnosis is autism, in addition to coverage for certain Therapy Services, as described above, the Plan also covers Medically Necessary and Appropriate: (a) Behavioral Interventions Based on Applied Behavioral Analysis (ABA); and (b) Related Structured Behavioral Plans. Such interventions and programs must be prescribed in a treatment plan.
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Benefits for these services are payable on the same basis as for other conditions, and they are available under this provision whether or not the services are restorative. Benefits for the above Therapy Services available pursuant to this provision are payable separately from those payable for other conditions and will not operate to reduce the Therapy Services benefits available under the Plan for those other conditions.
Any treatment plan referred to above must: (a) be in writing; (b) be signed by the treating Practitioner; and (c) include: (i) a diagnosis; (ii) proposed treatment by type, frequency and duration; (iii) the anticipated outcomes stated as goals; and (iv) the frequency by which the treatment plan will be updated.
With respect to the covered behavioral interventions and programs mentioned above, the term “Practitioner” shall also include a person who is credentialed by the national Analyst Certification Board as either: (a) a Board Certified Behavior Analyst-Doctoral; or (b) a Board Certified Behavior Analyst.
The Plan may request more information if it is needed to determine the coverage under the Plan. The Plan may also require the submission of an updated treatment plan once every six months, unless the Plan and the treating physician agree to more frequent updates.
Diagnostic X-rays and Laboratory Tests
The Plan covers charges for diagnostic x-rays and laboratory tests.
Emergency Room
This Plan covers services provided by a Hospital emergency room to treat a Medical Emergency or provide a Medical Screening Examination.
Facility Charges
This Plan covers Hospital semi-private room and board and Routine Nursing Care provided by a Hospital on an Inpatient basis. The Plan limits what it covers each day to the room and board limit shown in the Schedule of Covered Services and Supplies.
If a Covered Person Incurs charges as an Inpatient in a Special Care Unit, this Plan covers the charges the same way it covers charges for any Illness.
This Plan also covers: (a) Outpatient Hospital services, including services furnished by a Hospital Outpatient clinic; and (b) emergency room care, as described above.
If a Covered Person is an Inpatient in a Facility at the time this Plan ends, this Plan will continue to cover that Facility stay, subject to all other terms of this Plan.
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Fertility Services
This Plan covers charges for procedures designed to enhance fertility, including, artificial insemination. However, fertility enhancement treatments, such as in-vitro fertilization, in-vivo fertilization, gamete-intra-fallopian-transfer (GIFT), Zygote Intra-fallopian-transfer (ZIFT), sperm, egg, and/or inseminated eggs procurement and processing and freezing, and storage and thawing of sperm and/or embryos are specifically excluded.
Home Health Agency Care
This Plan covers Home Health Care services furnished by Home Health Agency.
In order for Home Health Agency charges to be considered Covered Charges, the Covered Persons Admission to Home Health Agency care may be direct to Home Health Agency care with no prior Inpatient Admission.
This Plan does not cover:
a. services furnished to family members, other than the patient; or
b. services and supplies not included in the Home Health Care plan; or
c. services that are mainly Custodial Care.
Hospice Care
Hospice Care benefits will be provided for:
1. part-time professional nursing services of an R.N., L.P.N. or Licensed Viatical Nurse (L.V.N.);
2. home health aide services provided under the supervision of an R.N.;
3. medical care rendered by a Hospice Care Program Practitioner;
4. therapy services;
5. Diagnostic Services;
6. medical and Surgical supplies and Durable Medical Equipment if given Prior Authorization by Horizon BCBSNJ;
7. Prescription Drugs;
8. oxygen and its administration;
9. medical social services;
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10. respite care;
11. psychological support services to the Terminally Ill or Injured patient;
12. family counseling related to the patient's terminal condition;
13. dietician services;
14. Inpatient room, board and general nursing services; and
15. Bereavement counseling.
No Hospice Care benefits will be provided for:
1. medical care rendered by the patient's private Practitioner;
2. volunteer services or services provided by others without charge;
3. pastoral services;
4. homemaker services;
5. food or home-delivered meals;
6. Private-Duty Nursing services;
7. dialysis treatment;
8. treatment not included in the Hospice Care Program;
9. services and supplies provided by volunteers or others who do not normally charge for their services;
10. funeral services and arrangements;
11. legal or financial counseling or services; or
12. any Hospice Care services that are not given Prior Authorization by Horizon BCBSNJ.
Respite care benefits are limited to a maximum of 15 days per Covered Person per Benefit Period;
Bereavement counseling is covered for a maximum of 15 visits;
“Terminally Ill or Injured” means that the Covered Person’s Practitioner has certified in writing that the Covered Person’s life expectancy is six months or less.
Hospice care must be furnished according to a written “Hospice Care Program”.
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Inpatient Physician Services
This Plan provides benefits for Covered Services and Supplies furnished by a physician to a Covered Person who is a registered Inpatient in a Facility.
Mastectomy Benefits
This Plan covers a Hospital stay of at least 72 hours following a modified radical mastectomy and
a Hospital stay of at least 48 hours following a simple mastectomy. A shorter length of stay may
be covered if the patient, in consultation with her physician, determines that it is Medically Necessary and Appropriate. The patient’s Provider does not need to obtain Prior Authorization for prescribing 72 or 48 hours, as appropriate, of Inpatient care. But, any rule of this Plan that that the patient or her Provider notify Horizon BSBSNJ about the stay remains in force.
Benefits for these services shall be subject to the same Deductible, Copayments and/or Coinsurance as for other Hospital services covered under this Plan.
Maternity/Obstetrical Care
Pursuant to both federal and state law, covered medical care related to pregnancy; childbirth; abortion; or miscarriage, includes: (a) the Hospital delivery; and (b) a Hospital Inpatient stay for at least 48 hours after a vaginal delivery or 96 hours after a cesarean section. This applies if: (a)
the attending physician determines that Inpatient care is Medically Necessary and Appropriate; or (b) if it is requested by the mother (regardless of Medical Necessity and Appropriateness). For the purposes of this subsection and as required by state law, “attending physician” shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child. For the purposes of this provision and as required by federal law, a Hospital Inpatient stay is
deemed to start:
(a) at the time of delivery; or
(b) in the case of multiple births, at the time of the last delivery; or
(c) if the delivery occurs out of the Hospital, at the time the mother or newborn is admitted to the Hospital.
Services and supplies provided by a Hospital to a newborn child during the initial Hospital stay of
the mother and child are covered as part of the obstetrical care benefits. But, if the child's care is given by a different physician from the one who provided the mother's obstetrical care, the child's care will be covered separately.
If they are given Prior Authorization by Horizon BCBSNJ, this Plan also covers Birthing Center charges (see above) made by a Practitioner for: (a) pre-natal care; (b) delivery; and (c) post-partum care for a Covered Person's pregnancy.
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Medical Emergency
This Plan covers charges relating to a Medical Emergency. This includes diagnostic X-ray and lab charges Incurred due to the Medical Emergency.
Benefits include coverage of trauma at any designated level I or II trauma center, as Medically Necessary and Appropriate. The coverage continues at least until, in the judgment of the attending physician, the Covered Person: (a) is medically stable; (b) no longer requires critical care; and (c) can be safely transferred to another Facility, if needed. The Plan will also cover a medical screening exam that is: (a) rendered upon a Covered Person’s arrival at a Hospital; (b) required under federal law to be performed by the Hospital; and (c) needed to determine whether a Medical Emergency situation exists.
In the event of a potentially life-threatening condition, the Covered Person should use the 911 emergency response system. Further 911 information is available on the Identification Card.
Mental or Nervous Disorders (including Group Therapy) and Substance Abuse
The Plan covers treatment for Mental or Nervous Disorders and Substance Abuse.
A Covered Person may receive covered treatment as an Inpatient in a Hospital or a Substance Abuse Center. He/she may also receive covered treatment at a Hospital Outpatient Substance Abuse Center, or from any Practitioner (including a psychologist or social worker). The benefits for the covered treatment of Mental or Nervous Disorders or Substance Abuse are provided on the same basis and subject to the same terms and conditions as for other Illnesses.
Nutritional Counseling
This Plan covers charges for nutritional counseling for the management of a medical condition that has a specific diagnostic criteria that can be verified. The nutritional counseling must be prescribed by a Practitioner. This section does not apply to nutritional counseling related to "Diabetes Benefits".
Physical Rehabilitation
This Plan covers Inpatient treatment in a Physical Rehabilitation Center. Inpatient treatment will include the same services and supplies available to any other Facility Inpatient.
Practitioner’s Charges for Non-Surgical Care and Treatment
This Plan covers Practitioner's charges for the non-Surgical care and treatment of an Illness, Injury, Mental or Nervous Disorder or Substance Abuse. This includes Medically Necessary pharmaceuticals which in the usual course of medical practice are administered by a Practitioner, if the pharmaceuticals are billed by the Practitioner or by a Specialty Pharmaceutical Provider.
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Practitioner’s Charges for Surgery
This Plan covers Practitioners' charges for Surgery. This Plan does not cover Cosmetic Surgery. Surgical procedures include: (a) those after a mastectomy on one or both breasts; (b) reconstructive breast Surgery; and (c) Surgery to achieve symmetry between both breasts.
Pre-Admission Testing Charges
This Plan covers Pre-Admission diagnostic X-ray and lab tests needed for a planned Hospital Admission or Surgery. To be covered, these tests must be done on an Outpatient or Out-of-Hospital basis within seven days of the planned Admission or Surgery.
This Plan does not cover tests that are repeated after Admission or before Surgery. But, this does not apply if the Admission or Surgery is deferred solely due to a change in the Covered Person's health.
Preventive Care
This program provides benefits for certain Covered Services and Supplies relating to Preventive Care including related diagnostic x-rays and laboratory tests. Coverage is limited each Benefit Period as described in the Schedule of Covered Services and Supplies. The covered Preventive Care benefits are as follows: a. Gynecological Care and Examinations
This program covers routine gynecological care and examinations including 1 pap smear per Benefit Period as designated in the Schedule of Covered Services and Supplies.
b. Mammography
This program covers charges made for mammograms provided to a female Covered Person according to the schedule below. Coverage will be provided, subject to all the terms of your Plan, and the following limitations:
The Plan will cover charges for: a. one baseline mammogram for female Covered Persons who are at least 35 but less than 40 years of age. (However, if the woman is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, the Plan will cover a mammogram at such age and intervals as deemed needed by the woman’s Practitioner.) b. one mammogram each year for female Covered Persons age 40 and older.
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c. Pap Smears
This program provides benefits for charges Incurred in conducting a Pap smear. This benefit, except as may be Medically Necessary and Appropriate for diagnostic purposes, shall be limited to one pap smear per Benefit Period. d. Routine Physicals and Immunizations
This program covers routine physical examination(s) and immunizations for you as designated in the Schedule of Covered Services and Supplies. e. Prostate Cancer Screening
This program covers 1 routine office visit per Benefit Period for adult Covered Persons, including a digital rectal examination and a prostate-specific antigen test for adult male Covered Persons.
f. Colorectal Cancer Screening
Coverage is provided for colorectal cancer screening rendered at regular intervals for Covered Persons 50 years of age or older and forCovered Persons of any age who are deemed to be at high risk for this type of cancer.
Covered test include: a screening fecal occult blood test; flexible sigmoidoscopy; colonoscopy; barium enema; any combination of these tests; or the most reliable, medically recognized screening test available.
For the purposes of this part, “high risk for colorectal cancer” means that a Covered Person has: (a) a family history of: familial adenomatous polyposis; hereditary non-polyposis colon cancer; or breast, ovarian, endometrial or colon cancer or polyps; (b) chronic inflammatory bowel disease, or (c) a background, ethnicity or lifestyle that the Covered Person’s physician believes puts the Covered Person at elevated risk for colorectal cancer.
The method and frequency of screening shall be: (a) in accordance with the most recent published guidelines of the American Cancer Society; and (b) as deemed to be medically necessary by the Covered Person’s physician, in consultation with the Covered Person.
g. Routine vision exam.
Routine vision screening (one per year) as part of wellness exam.
h. Hearing Exam.
One routine hearing exam or audiology function test per year for adults.

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i. Additional Preventive Services
In addition to any other Preventive Care benefits described above, the Plan shall cover the following preventive services and shall not impose any cost-sharing requirements, such as Deductibles, Copayments or Coinsurance, on any Covered Person receiving them:
1. Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force;
2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person;
3. For infants and children (if coverage under the Plan are provided for them) and adolescents who are Covered Persons, evidence-informed Preventive Care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
4. With respect to female Covered Persons, such additional preventive care and screenings, not described in part 1, above, as are provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
New recommendations to the preventive services listed above at the schedule established by the Secretary of Health and Human Services shall administratively updated.
Second Opinion Charges
If a covered Person is scheduled for an Elective Surgical Procedure, this Plan covers a Practitioner's charges for a second opinion and charges for related diagnostic X-ray and lab tests. If the second opinion does not confirm the need for the Surgery, this Plan will cover a Practitioner's charges for a third opinion regarding the need for the Surgery. This Plan will cover charges if the Practitioner(s) who gives the opinion:
a. are board certified and qualified, by reason of his/her specialty, to give an opinion on the proposed Surgery or Hospital Admission;
b. are not a business associate of the Practitioner who recommended the Surgery; and
c. do not perform or assist in the Surgery if it is needed.

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Skilled Nursing Facility Charges
This Plan covers bed and board (including diets, drugs, medicines and dressings and general nursing service) in a Skilled Nursing Facility. The Covered Person must be admitted to the Skilled Nursing Facility within 14 days of discharge from a Hospital, for continuing medical care and treatment prescribed by a Practitioner.
Speech Language Pathology Services
The Plan covers speech-language pathology services rendered by a physician or a licensed speech-language pathologist, where such services are determined to be Medically Necessary and Appropriate and when performed within the scope of practice.
Surgical Services
Subject to all of the Plan’s other terms and conditions, the Plan covers Surgery, subject also to the following requirements:
a. The Plan will not make separate payment for pre- and post-operative care.
b. Subject to the following exception, if more than one surgical procedure is performed: (i) on the same patient; (ii) by the same physician; and (iii) on the same day, the following rules apply:
1 The Plan will cover the primary procedure, plus 50% of what the Plan would have paid for each of the other procedures, up to five, had those procedures been performed alone.
2. If more than five surgical procedures are performed, each of the procedures beyond the fifth will be reviewed. The amount that the Plan will pay for each such procedure will then be based on the circumstances of the particular case.
Exception: The Plan will not cover or make payment for any secondary procedure that, after review, is deemed to be a Mutually Exclusive Surgical Procedure or an Incidental Surgical Procedure.
As part of the coverage for Surgery, if a Covered Person is receiving benefits for a mastectomy, the Plan will also cover the following, as determined after consultation between the attending physician and the Covered Person:
• Reconstruction of the breast on which the mastectomy was performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
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• Prostheses and the treatment of physical complications at all stages of the mastectomy, including lymphodemas.
Also, see “Transplant Benefits”.
Telemedicine Services, provided by Horizon CareOnline
SUEZ Water Resources Inc. has selected an innovative Telemedicine Program, Horizon
CareOnline, for its members through Horizon BCBSNJ, currently powered by American Well. This additional Program allows you to visit with an American Well general practitioner via telecommunication using a computer, tablet or smart phone. This Program also allows you to visit with American Well psychiatrists, psychologists, or social workers for treatment of Mental or Nervous Disorders via telecommunication using a computer, tablet or smart phone. The
Program does not provide additional covered services (or benefits) under your health benefit plan. Telemedicine is a covered benefit only when provided through Horizon BCBSNJ’s designated telemedicine vendor. The Telemedicine Program is not available to Covered Persons who are eligible for Medicare when Medicare is primary to this Plan.
Therapeutic Manipulation
The Plan covers charges for Therapeutic Manipulations.
Therapy Services
The Plan covers charges for all Therapy Services.
Please refer to the Schedule of Covered Services and Supplies for additional information.
Transplant Benefits
This Plan covers services and supplies for the following types of transplants:
a. Cornea;
b. Kidney;
c. Lung;
d. Liver;
e. Heart;
f. Heart valve;
g. Pancreas;
h. Small bowel;
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i. Chondrocycte (for knee);
j. Heart/Lung;
k. Kidney/Pancreas;
l. Liver/Pancreas;
m. Double lung;
n. Heart/Kidney;
o. Kidney/Liver;
p. Liver/Small Bowel;
q. Multi-visceral transplant (small bowel and liver with one or more of the following: stomach; duodenum; jejunum; ileum; pancreas; colon);
r. Allogeneic bone marrow;
s. Allogeneic stem cell;
t. Non-myeloblative stem cell;
u. Tandem stem cell.
This Plan also provides benefits for the treatment of cancer by dose-intensive Chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants. This applies only to transplants that are performed:
a by institutions approved by the National Cancer Institute; or
b. pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Such treatment will be covered to the same extent as for any other Illness.
When organs/tissues are harvested from a cadaver, this Plan will also cover those charges for Surgical, storage and transportation services that: (a) are directly related to donation of the organs/tissues; and (b) are billed for by the Hospital where the transplant is performed.
Eligible expenses include transportation of the patient and one companion who is traveling on the same days to and or from the site of the transplant of the purpose of an evaluation, the transplant procedure or necessary post- discharge follow up, reasonable and necessary expense for lodging and meals for the patient (while not confined) and one companion, benefits are paid at a per diem rate of up to $50 for one person or up to $100 for two people, travel and lodging expense are only available if the transplant recipient resides more than 50 miles from the facility performing the transplant, if the patient is a dependant minor child- then the transportation expenses of two companions will be covered and lodging and meal expenses will be reimbursed up to the $100 per
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diem rate, there is a combined overall LIFETIME MAX OF $10,000.00 per covered person for ALL transportation, lodging and meal expenses incurred by the transplant recipient and companions) and reimbursed under this plan in connection with all transplant procedures
Urgent Care
This Plan provides benefits for Covered Services and Supplies furnished for Urgent Care of a Covered Person.

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B. ELIGIBLE SUPPLEMENTAL SERVICES AND SUPPLIES
Ambulance Services
The Plan covers charges for transporting a Covered Person to:
a. a local Hospital, if needed care and treatment can be provided by a local Hospital;
b. the nearest Hospital where needed care and treatment can be given, if a local Hospital cannot provide it. It must be connected with an inpatient admission; or
c. another inpatient Facility when Medically Necessary and Appropriate.
Coverage can be by professional ambulance service, ground or air. Your group’s plan does not cover chartered air flights. The Plan will also not cover other travel or communication expenses of patients, Practitioners, Nurses or family members.
Blood
This Plan covers: (a) blood; (b) blood products; (c) blood transfusions; and (d) the cost of testing and processing blood. This Plan does not pay for blood that has been donated or replaced on behalf of the Covered Person.
This Plan also covers expenses Incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia. The home treatment program must be under the supervision of a State approved hemophilia treatment center. A home treatment program will not preclude further or additional treatment or care at an eligible Facility. But, the number of home treatments, according to a ratio of home treatments to Benefit Days, cannot exceed the total number of benefit days allowed for any other Illness under this Plan.
As used above: (a) “blood product” includes but is not limited to Factor VIII, Factor IX and cryoprecipitate; and (b) “blood infusion equipment” includes but is not limited to syringes and needles.
Diabetes Benefits
This Plan also provides benefits for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist;
a. blood glucose monitors and blood glucose monitors for the legally blind;
b. test strips for glucose monitors and visual reading and urine testing strips;
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c. insulin;
d. injection aids;
e. cartridges for the legally blind;
f. syringes;
g. insulin pumps and appurtenances to them;
h. insulin infusion devices; and
i. oral agents for controlling blood sugar.
Subject to the terms below, this Plan also covers diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of the Illness. This includes information on proper diet.
a. Benefits for self-management education and education relating to diet shall be limited to Visits that are to a professional described in b., below and that are Medically Necessary and Appropriate upon:
1. the diagnosis of diabetes;
2. the diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the Covered Person's symptoms or conditions which requires changes in the Covered Person's self-management; and
3. determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is needed.
b. Diabetes self-management education is covered when rendered by:
1. a dietician registered by a nationally recognized professional association of dieticians;
2. a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators; or
3. a registered pharmacist in New Jersey qualified with regard to management education for diabetes by any institution recognized by the Board of Pharmacy of the State of New Jersey.
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Durable Medical Equipment
Your plan covers charges for the rental of Durable Medical Equipment needed for therapeutic use. The Plan may Determine to cover the purchase of such items when it is less costly and more practical than to rent such items. The Plan does not cover:
a. replacements or repairs; or
b. the rental or purchase of any items (such as air conditioners, exercise equipment, saunas and air humidifiers) which do not fully meet the definition of Durable Medical Equipment.
Home Infusion Therapy
Home Infusion Therapy is a method of administering intravenous (IV) medications or nutrients via pump or gravity in the home. These services and supplies are eligible when rendered or used in connection with Home Infusion Therapy:
• Solutions and pharmaceutical additives,
• Pharmacy compounding and dispensing services,
• Ancillary medical supplies, and
• Nursing services associated with patient and/or alternative caregiver training, visits necessary to monitor intravenous therapy regimen and medical emergency care, but not for administration of home infusion therapy.
Home Infusion Therapy includes chemotherapy, intravenous antibiotic therapy, total parenteral nutrition, enteral nutrition (when sole source of nutrition) hydration therapy, intravenous pain management, gammaglobulin infusion therapy (IVIG), and prolastin therapy.
Note: Home Infusion Therapy must be authorized by the Plan.
Foot Orthotics
The Plan covers foot orthotics. Custom inserts prescribed by a MD are covered.
Oxygen and its Administration
The Plan covers oxygen and its administration.

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Private Duty Nursing Care
This Plan covers the services of a Nurse for Private Duty Nursing care. These conditions apply:
a. The care must be ordered by a physician.
b. The care must be furnished while: (i) intensive skilled nursing care is required in the treatment of an acute Illness or during the acute period after an Injury; and (ii) the patient is not in a Facility that provides nursing care.
Requirement (b)(i), above, will not be deemed to be met if the care actually furnished is mainly Custodial Care or maintenance. Also, no benefits will be provided for the services of a Nurse who: (a) ordinarily resides in the patient's home; or (b) is a member of the patient's immediate family.
Prosthetic Devices
The Plan limits coverage for prosthetic devices. The Plan covers the fitting and purchase of artificial limbs and eyes, and other prosthetic devices. To be covered, such devices must take the place of a natural part of a Covered Person’s body, or be needed due to a functional birth defect in a covered Child Dependent, or as needed for reconstructive breast Surgery. The Plan does not cover dental prosthetics or devices. Wigs Benefit
Wigs are covered as a result of hair loss due to radiation therapy, chemotherapy, and second degree burns.
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Utilization Management
IMPORTANT NOTICE – THIS NOTICE APPLIES TO ALL FEATURES UNDER THIS UTILIZATION REVIEW SECTION.
BENEFITS WILL BE REDUCED FOR NON-COMPLIANCE WITH THE PROVISIONS OF THIS UTILIZATION MANAGEMENT SECTION. YOUR PLAN DOES NOT COVER ANY INPATIENT ADMISSION, OR ANY OTHER SERVICE OR SUPPLIES, THAT IS NOT MEDICALLY NECESSARY AND APPROPRIATE. HORIZON BCBSNJ DETERMINES WHAT IS MEDICALLY NECESSARY AND APPROPRIATE UNDER YOUR PLAN.
Your plan has utilization review features under which Horizon BCBSNJ or its designee reviews Hospital Admissions and listed procedures. These features must be complied with if you:
a. are admitted as an inpatient or outpatient to a Hospital or other Facility or on an out-of-hospital basis; or
b. are advised to enter a Hospital or other Facility; or
c. plan to have a listed procedure performed. If you or your Provider do not comply with this Utilization Management section, you will not be eligible for full benefits under your plan. Your Plan has Medical Appropriateness Review features. Under these features, Horizon BCBSNJ reviews the medical appropriateness of the care that is expected to be rendered.
In addition, what Horizon BCBSNJ covers is subject to all of the terms and conditions of your group’s plan.
With respect to Covered Charges incurred in connection with Mental or Nervous Disorders, all notices required to be given in accordance with this Utilization Management section must be given to the Care Manager.
Your Plan has Individual Case Management features. Under these features, a case coordinator reviews your medical needs in clinical situations with the potential for catastrophic claims to Determine whether alternative treatment may be available and appropriate. See the Alternative Treatment Features description for details.
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REQUIRED HOSPITAL STAY REVIEW
Notice of Hospital Admission Required
If you plan to use a Hospital in the Select Hospital Network, the Hospital will make all necessary arrangements for Pre Admission Review. If you plan to use a Out-of-Network Hospital, you must notify Horizon BCBSNJ of the Hospital Admission. The time and manner in which the notice must be given is described below. When you or your Provider do not comply with the requirements of this section, Horizon BCBSNJ reduces coverage for those Covered Charges.
Continued Stay Review
Horizon BCBSNJ has the right to initiate a continued stay review of any inpatient admission; and Horizon BCBSNJ may contact your Practitioner or Facility by phone or in writing.
You or your Provider must initiate a continued stay review whenever it is Medically Necessary and Appropriate to change the authorized length of an inpatient stay. This must be done before the end of the previously authorized length of stay.
In the case of an Admission, the continued stay review Determines:
a. the Medical Necessity and Appropriateness of Admission;
b. the anticipated length of stay and extended length of stay; and
c. the appropriateness of health care alternatives.
Horizon BCBSNJ notifies the Practitioner and Facility by phone of the outcome of the review. Horizon BCBSNJ confirms in writing the outcome of a review that results in a denial. The notice always includes any newly authorized length of stay.
NOTE: YOUR PLAN DOES NOT COVER ANY CHARGES THAT ARE INCURRED WITH RESPECT TO INPATIENT SERVICES OR SUPPLIES THAT ARE NOT AUTHORIZED IN ACCORDANCE WITH THIS CONTINUED STAY REVIEW.
ALTERNATE TREATMENT FEATURES/INDIVIDUAL CASE MANAGEMENT
Definitions
“Alternate Treatment” means those services and supplies which meet both of the following tests:
a. They are Determined, in advance, by Horizon BCBSNJ to be Medically Necessary and Appropriate and cost effective in meeting your long-term or intensive care needs in connection with a Catastrophic Illness, Accidental Injury; or in completing a course of care
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outside of the acute Hospital setting, for example, completing a course of IV antibiotics at home.
b. Benefits for charges incurred for the services and supplies would not otherwise be payable under the Plan.
“Catastrophic Illness or Injury” means one of the following:
a. head injury requiring an inpatient stay;
b. spinal cord injury;
c. severe burn over 20% or more of the body;
d. multiple injuries due to an accident;
e. premature birth;
f. CVA or stroke;
g. congenital defect which severely impairs a bodily function;
h. brain damage due to either an accident or cardiac arrest or resulting from a Surgical procedure;
i. terminal Illness, with a prognosis of death within 6 months;
j. Acquired Immune Deficiency Syndrome (AIDS);
k. Substance Abuse;
l. a Mental or Nervous Disorder; or
m. any other Illness or injury determined by Horizon BCBSNJ to be catastrophic.
Alternate Treatment/Individual Case Management Plan
Horizon BCBSNJ will identify cases of Catastrophic Illness or Accidental Injury. The appropriateness of the level of patient care given to you as well as the setting in which it is received will be evaluated. In order to maintain or enhance the quality of patient care for you, Horizon BCBSNJ will develop an Alternate Treatment/Individual Case Management Plan.
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a. An Alternate Treatment/Individual Case Management Plan is a specific written document, developed by Horizon BCBSNJ through discussion and agreement with:
1. you, or your legal guardian if necessary;
2. your attending Practitioner; and
3. Horizon BCBSNJ or its designee.
b. The Alternate Treatment/Individual Case Management Plan includes:
1. treatment plan objectives;
2. course of treatment to accomplish the stated objectives;
3. the responsibility of each of the following parties in implementing the Plan:
(a) Horizon BCBSNJ (b) attending Practitioner (c) you (d) your family, if any; and
4. estimated cost and savings.
If Horizon BCBSNJ, the attending Practitioner, and you agree in writing on an Alternate Treatment/Individual Case Management Plan, the services and supplies required in connection with such Alternate treatment plan/Individual Case Management will be considered as Covered Charges under the terms of your Plan.
The agreed upon alternate treatment must be ordered by your Practitioner.
Benefits payable under the Alternate Treatment/Individual Case Management Plan will be considered in the accumulation of any Benefit Period and Per Lifetime maximums.
Exclusion
Alternate Treatment/Individual Case Management does not include services and supplies that Horizon BCBSNJ Determines to be Experimental or Investigational.
Important Notice: You are not required, in any way, to accept an Alternate Treatment/Individual Case Management Plan recommended by Horizon BCBSNJ.
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SCHEDULE OF PROCEDURES,TREATMENT AND SUPPLIES REQUIRING PRIOR AUTHORIZATION
• All Admissions to a Skilled Nursing Facility.
• Hospice Care.
• Inpatient Hospital Care for Medical or Mental Health/Substance Abuse care.
• Private Duty Nursing.
Note: Network providers will handle all pre-certifications. In the event any portion of a facility day is determined not medically necessary, it will be the facility and not the patient's liability.
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CLAIMS PROCEDURES
Claim forms and instructions for filing claims will be provided to Covered Persons. Completed claim forms and any other required materials must be submitted to Horizon BCBSNJ or its designees for processing. Covered Persons do not need to file claims for In-Network Covered Services and Supplies. For Out-of-Network Covered Services and Supplies, Covered Persons will generally have to file a claim for benefits, unless a state law requires Providers to file claims on behalf of Covered Persons. In this case, however, a Covered Person still has the option to file claims on his/her own behalf.
Submission of Claims
These procedures apply to the filing of claims. All notices will be in writing.
a. Claim forms must be filed no later than 18 months after the date the services were Incurred.
b. Itemized bills must accompany each claim form. A separate claim form is needed for each claim filed. In general, the bills must contain enough data to identify: the patient; the Provider; the type of service and the charge for each service and the Provider's license number.
Bills for Private Duty Nursing must state that the Nurse is a Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.) and must contain the Nurse's license number.
c If a claim is denied or disputed, in whole or in part, Horizon BCBSNJ will notify the claimant (or his/her agent or designee) of it within 30 calendar days after receipt of the claim.
The denial notice will set forth:
1. the reason(s) the claim is denied;
2. specific references to the main Plan provision(s) on which the denial is based;
3. a specific description of any further material or information needed to complete the claim, and why it is needed;
4. a statement that the claim is disputed, if this is so. If the dispute is about the amount of the claim, Horizon BCBSNJ will explain why and also explain why any coding changes were made.
5. a statement of the special needs to which the claim is subject, if this is the case;
6. an explanation of the Plan's claim review procedure, including any rights to pursue civil action;
7. if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the decision, either the specific rule or a statement that such a rule was
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relied upon in making the decision, and that a copy of such rule will be provided free of charge upon request;
8. if the decision is based on Medical Necessity and Appropriateness or an Experimental or Investigational (or similar) exclusion or limitation, either an explanation of the scientific or clinical judgment for the decision, applying the terms of the Plan to the medical circumstances, or a statement that such explanation will be provided free of charge upon request;
9. if the decision involves a Medical Emergency or Urgent Care, a description of the expedited review process applicable to such claims; and
10. the toll free number that the Covered Person or his/her Provider can call to discuss the claim.
To Whom Payment Will Be Made
a. Payment for services of an In-Network Provider or a BlueCard Provider will be made directly to that Provider if the Provider bills Horizon BCBSNJ, as Horizon BCBSNJ determines. To receive In-Network coverage, a Covered Person must show his/her ID card when requesting Covered Services and Supplies from a Provider that has such an agreement.
b. Payment for services of Out-of-Network Providers will be made to you.
c. Except as stated above, in the event of a Covered Person's death or total incapacity, any payment or refund due will be made to his/her heirs, beneficiaries, trustees or estate.
If Horizon BCBSNJ pays anyone who is not entitled to benefits under this Plan, Horizon BCBSNJ has the right to recover those payments on behalf of the Plan.

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BLUECARD
Overview
Horizon BCBSNJ has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Arrangements.” These Inter- Plan Arrangements operate under rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever Covered Persons access healthcare services outside the geographic area we serve, the claims for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described generally below.
Typically, when accessing care outside the geographic area we serve, Covered Persons obtain care from healthcare providers that have a contractual agreement (“BlueCard Providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, Covered Persons may obtain care from healthcare providers in the Host Blue geographic area that do not have a contractual agreement (“nonparticipating providers”) with the Host Blue. Horizon BCBSNJ remains responsible for fulfilling our contractual obligations to the Covered Person. Horizon BCBSNJ's payment practices in both instances are described below.
This disclosure describes how claims are administered for Inter-Plan Arrangements and the fees that are charged in connection with Inter-Plan Arrangements.
Note that Dental Care Benefits that are not paid as medical claims/benefits, and those Prescription Drug Benefits or Vision Care Benefits that may be administered by a third party contracted by Horizon BCBSNJ to provide the specific service or services, are not processed through Inter-Plan Arrangements.
BlueCard® Program
The BlueCard Program is an Inter-Plan Arrangement. Under this Inter-Plan Arrangement, when Covered Persons access Covered Services and Supplies within the geographic area served by a Host Blue, the Host Blue will be responsible for contracting and handling all interactions with its BlueCard Providers. The financial terms of the Inter-Plan Arrangements are described generally below.
Liability Calculation Method Per Claim – In General
Covered Person's Liability Calculation
Unless subject to a fixed dollar copayment, the calculation of the Covered Person’s liability on claims for Covered Services and Supplies will be based on the lower of the BlueCard Provider's billed Covered Charges or the negotiated price made available to Horizon BCBSNJ by the Host Blue.
Claims Pricing
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Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to us by the Host Blue may be represented by one of the following:
(i) An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or
(ii) An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements and performance-related bonuses or incentives; or
(iii) An average price. An average price is a percentage of billed Covered Charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other claim- and non-claim-related transactions. Such transactions may include the same ones as noted above for an estimated price.
The Host Blue determines whether it will use an actual, estimated or average price. Host Blues using either an estimated price or an average price may prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid or anticipated to be paid to providers or refunds received or anticipated to be received from providers). However, the BlueCard Program requires that the amount paid by the Covered Person is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. The method of claims payment by Host Blues is taken into account by Horizon BCBSNJ in determining the group’s premiums.
Negotiated (non-BlueCard Program) National Account Arrangements
With respect to one or more Host Plans, instead of using the BlueCard Program, Horizon BCBSNJ may process the Covered Person’s claims for Covered Services and Supplies through Negotiated National Account Arrangements.
In addition, if Horizon BCBSNJ and the group have agreed that (a) Host Blue(s) shall make available (a) custom healthcare provider network(s) in connection with this agreement, then the terms and conditions set forth in Horizon BCBSNJ's Negotiated National Account Arrangement(s) with such Host Blue(s) shall apply. These include the provisions governing the processing and payment of claims when Covered Persons access such network(s). In negotiating such Negotiated National Account Arrangements, Horizon BCBSNJ is not acting on behalf of or as an agent for the group or the group health plan.
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Covered Person's Liability Calculation.
Covered Person liability calculation will be based on the lower of either billed Covered Charges or negotiated price (refer to the description of negotiated price under "Claims Pricing" in the "Liability Calculation Method Per Claim – In General" provision above) made available to Horizon BCBSNJ by the Host Blue that allows the Covered Person access to negotiated participation agreement networks of specified participating healthcare providers outside of Horizon BCBSNJ's service area.
Special Cases: Value-Based Programs
Value-Based Programs Overview
The Covered Person may access Covered Services and Supplies from providers that participate in a Host Blue’s Value-Based Program. Value-Based Programs may be delivered either through the BlueCard Program or a Negotiated National Account Arrangement(s).
Value-Based Programs under the BlueCard Program
Horizon BCBSNJ has included a factor for bulk distributions from Host Blues in a group's premium for Value-Based Programs when applicable under this Booklet.
Value-Based Programs under Negotiated National Account Arrangements
If Horizon BCBSNJ has entered into a Negotiated National Account Arrangement with a Host Blue to provide Value-Based Programs to Covered Persons, Horizon BCBSNJ will follow the same procedures for Value-Based Programs as noted above in the Liability Calculation Method Per Claim – In General section.
Return of Overpayments
Recoveries of overpayments from a Host Blue or its BlueCard Providers and nonparticipating providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, audits, utilization review refunds and unsolicited refunds. Recoveries will be applied so that corrections will be made, in general, on either a claim-by-claim or prospective basis.
Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees
In some instances federal or state laws or regulations may impose a surcharge, tax or other fee that applies to insured accounts. If applicable, Horizon BCBSNJ will include any such surcharge, tax or other fee in determining a group's premium.
Non-Participating Healthcare Providers Outside Horizon BCBSNJ's Service Area
Covered Person's Liability Calculation
In General
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When Covered Services and Supplies are provided outside of Horizon BCBSNJ's service area by nonparticipating providers, the amount(s) a Covered Person pays for such services will be based on either the Host Blue’s nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law. In these situations, the Covered Person may be responsible for the difference between the amount that the nonparticipating provider bills and the payment Horizon BCBSNJ will make for the Covered Services and Supplies as set forth in this paragraph. Payments for out-of-network emergency services will be provided as if the care was provided by a participating healthcare provider with respect to application of the Covered Person's copayment, deductible or coinsurance.
Exceptions
In some exception cases, at the group's direction Horizon BCBSNJ may pay claims from nonparticipating healthcare providers outside of Horizon BCBSNJ's service area based on the provider’s billed charge. This may occur in situations where a Covered Person did not have reasonable access to a BlueCard Provider, as Determined by Horizon BCBSNJ in Horizon BCBSNJ's sole and absolute discretion in accordance with this Booklet or by state and/or federal law, as applicable. Adverse Determinations can be reviewed by an independent utilization review agency (IURO), court of law, arbitrator or any administrative agency having the appropriate jurisdiction.
In other exception cases, at the group's direction, Horizon BCBSNJ may pay such claims based on the payment Horizon BCBSNJ would make if Horizon BCBSNJ were paying a nonparticipating provider inside of Horizon BCBSNJ's service area, as described elsewhere in this Booklet. This may occur where the Host Blue’s corresponding payment would be more than Horizon BCBSNJ's in-service area nonparticipating provider payment. Horizon BCBSNJ may choose to negotiate a payment with such a provider on an exception basis.
Unless otherwise stated, in any of these exception situations, the Covered Person may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and the payment Horizon BCBSNJ will make for the Covered Services and Supplies as set forth in this paragraph.
BCBS Global Core Coverage TM
General Information. If Covered Persons are outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands (hereinafter: “BlueCard service area”), they may be able to take advantage of BCBS Global Core when accessing Covered Services and Supplies. The BCBS Global Core Coverage is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although BCBS Global Core assists Covered Persons with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when Covered Persons receive care from providers outside the BlueCard service area, the Covered Persons will typically have to pay the providers and submit the claims themselves to obtain reimbursement for these services.
Inpatient Services
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In most cases, if Covered Persons contacts the BCBS Global Core Service Center for assistance, hospitals will not require Covered Persons to pay for covered inpatient services, except for their cost-share amounts. In such cases, the hospital will submit Covered Persons' claims to the BCBS Global Core Service Center to initiate claims processing.
However, if Covered Persons paid in full at the time of service, the Covered Persons must submit a claim to obtain reimbursement for Covered Services and Supplies. Covered Persons must contact Horizon BCBSNJ to obtain precertification for non-emergency inpatient services.
Outpatient Services
Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require Covered Persons to pay in full at the time of service. Covered Persons must submit a claim to obtain reimbursement for Covered Services and Supplies.
Submitting a BCBS Global Core Claim
When Covered Persons pay for Covered Services and Supplies outside the BlueCard service area, they must submit a claim to obtain reimbursement. For institutional and professional claims, Covered Persons should complete a BCBS Global Core claim form and send the claim form with the provider’s itemized bill(s) to the BCBS Global Core Service Center address on the form to initiate claims processing. The claim form is available from Horizon BCBSNJ, BCBS Global Core Service Center, or online at www.bcbsglobalcore.com. If Covered Persons need assistance with their claim submissions, they should call BCBS Global Core at 1.800.810.BLUE (2583) or call collect at 1.804.673.1177, 24 hours a day, seven days a week.

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Exclusions Under The Blue Card PPO Program
The following are not Covered Services and Supplies under the plan. The Plan will not pay for any charges incurred for, or in connection, with:
Acupuncture.
Administration of oxygen, except as otherwise stated in this booklet.
Ambulance, in the case of a non-Medical Emergency.
Anesthesia and consultation services when they are given in connection with Non-Covered Charges.
An inpatient admission or any part of an inpatient admission primarily for:
• Physical Therapy, except as otherwise specified in this booklet; and/or • rehabilitation therapy, except as otherwise specified in this booklet.
Any charge to the extent it exceeds the Allowance.
Any therapy not included in the definition of Therapy Services.
Balances for services and supplies after payment has been made under the plan.
Blood or blood plasma or other blood derivatives or components which is replaced by a Covered Person.
Broken appointments.
Charges incurred during a person’s temporary absence from an eligible Provider’s grounds before discharge.
Claims that are not submitted within eighteen months in which the eligible expenses were incurred.
Completion of claim forms.
Copayments, Deductibles, and the individual’s part of any Coinsurance; expenses incurred after any Payment maximum is or would be reached.
Cosmetic Services, including cosmetic Surgery, procedures, treatment, drugs or biological products, unless required as a result of an accidental Injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly; complications of cosmetic Surgery; drugs prescribed for cosmetic purposes.
Court ordered treatment which is not Medically Necessary.
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Custodial Care or domiciliary care, including respite care except as specifically covered under your Plan.
Dental care or treatment, including appliances, except as otherwise stated in this booklet.
Diversional/recreational therapy or activity.
Drugs dispensed to a Covered Person while a patient in a Facility.
Drugs, obtained from a State or local public health agency, for the treatment of venereal disease or mental disease.
Drugs dispensed by other than a Pharmacist or a Pharmacy or for services rendered by a Pharmacist which are beyond the scope of his license. Benefits are not provided for drugs given by a physician or other practitioner.
Education or training while a Covered Person is confined in an institution that is primarily an institution for learning or training.
Employment/career counseling.
Experimental or Investigational treatments, procedures, Hospitalizations, drugs, biological products or medical devices.
Eye Examinations, eyeglasses, contact lenses, and all fittings, except as specified in this booklet; surgical treatment for the correction of a refractive error including, but not limited to, radial keratotomy.
Facility charges (e.g., operating room, recovery room, use of equipment) when billed for by a Provider that is not an eligible Facility.
Hearing aids or fitting of hearing aids.
Herbal medicine.
Home Health Care Visits connected with administration of dialysis.
Housekeeping services except as an incidental part of the Eligible services of a Home Health Care Agency.
Hypnotism.
Illness or Injury, including a condition which is the result of an Illness or Injury, which: (a) occurred on the job; and (b) is covered or could have been covered for benefits provided under a workers' compensation, employer's liability, occupational disease or similar law. However, this exclusion does not apply to the following persons for whom coverage under workers’
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compensation is optional, unless such persons are actually covered for workers’ compensation: a self-employed person or a partner of a limited liability partnership; members of a limited liability company or partners of a partnership who actively perform services on behalf of the self-employed business, the limited liability partnership, limited liability company or the partnership.
Immunizations, except as otherwise specified in this booklet.
Infertility enhancement treatments, except as otherwise stated in this booklet.
Local anesthesia charges billed separately by a Practitioner for Surgery he performed on an Outpatient basis.
Maintenance therapy for:
• Physical Therapy; • Manipulative Therapy; • Occupational Therapy; and • Speech Therapy.
Marriage, career or financial counseling; sex therapy.
Medical Emergency services, or supplies, when not rendered by a Practitioner.
Membership costs for health clubs, weight loss clinics and similar programs.
Methadone maintenance.
Milieu Therapy:
Inpatient services and supplies which are primarily for milieu therapy even though eligible treatment may also be provided.
This means that the Plan has Determined:
1. the purpose of an entire or portion of an inpatient stay is chiefly to change or control a patient’s environment; and
2. an inpatient setting is not Medically Necessary for the treatment provided, if any.
Non-medical equipment which may be used primarily for personal hygiene or for comfort or convenience of a Covered Person rather than for a medical purpose, including air conditioners, dehumidifiers, purifiers, saunas, hot tubs, televisions, telephones, first aid kits, exercise equipment, heating pads and similar supplies which are useful to a person in the absence of Illness or injury.
Non-Prescription Drugs or supplies, except as may be Medically Necessary and Appropriate for the treatment of certain illness or Injury, except as otherwise stated in this Plan.
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Pastoral counseling.
Personal comfort and convenience items.
Prescription Drugs that in the usual course of medical practice are self-administered or dispensed by a retail or mail-order Pharmacy.
Psychoanalysis to complete the requirements of an educational degree or residency program.
Psychological testing for educational purposes.
Removal of abnormal skin outgrowths and other growths including, but not limited to, paring or chemical treatments to remove corns, callouses, warts, hornified nails and all other growths, unless it involves cutting through all layers of the skin.
Rest or convalescent cures.
Room and board charges for any period of time during which the Covered Person was not physically present in the room.
Routine exams (including related diagnostic X-rays and lab tests) and other services connected with activities such as the following: pre-marital or similar exams or tests; research studies; education or experimentation; mandatory consultations required by Hospital regulations.
Routine foot care, except as may be Medically Necessary and Appropriate for the treatment of certain Illness or Accidental Injury, including treatment for corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, symptomatic complaints of the feet.
Self-administered services such as: biofeedback, patient-controlled analgesia, related diagnostic testing, self-care and self-help training.
Services involving equipment or Facilities used when the purchase, rental or construction has not been approved in compliance with applicable state laws or regulations.
Services performed by any of the following:
a. A Hospital resident, intern or other Practitioner who is paid by a Facility or other source, who is not permitted to charge for services covered under the Plan, whether or not the Practitioner is in training. However, Hospital-employed Physician specialists may bill separately for their services.
b. Anyone who does not qualify as a physician.
Services provided during a stay at a Facility which in whole or in part was for diagnostic studies. This exclusion applies when the services were provided for any of the following reasons:
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diagnosis, evaluation, confirmation (or to rule out), or to check the current status of a condition which was treated in the past.
Services required by the group as a condition of employment or rendered through a medical department, clinic, or other similar service provided or maintained by the group.
Services or supplies:
- eligible for payment under either federal or state programs (except Medicaid). This provision applies whether or not the Covered Person asserts his rights to obtain this coverage or payment for these services;
- for which a charge is not usually made, such as a Practitioner treating a professional or business associate, or services at a public health fair;
- for which the Provider has not received a certificate of need or such other approvals as are required by law;
- for which the Covered Person would not have been charged if he did not have health care coverage;
- furnished by one of the following members of the Covered Person’s family, unless otherwise stated in this booklet: Spouse, Child, parent, in-law, brother or sister;
- in connection with any procedure or examination not necessary for the diagnosis or treatment of injury or sickness for which a bonafide diagnosis has been made because of existing symptoms.
- needed because the Covered Person engaged, or tried to engage, in an illegal occupation or committed, or tried to commit, a felony;
- not specifically covered under your plan;
- provided by a Practitioner if the Practitioner bills the Covered Person directly for the services or supplies, regardless of the existence of any financial or contractual arrangement between the Practitioner and the Provider;
- provided by or in a Government Hospital unless the services are for treatment:
a. of a non-service Medical Emergency;
b. by a Veterans’ Administration Hospital of a non-service related Illness or Accidental Injury; or the Hospital is located outside of the United States and Puerto Rico; or unless otherwise required by law;
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NOTE: The above limitations do not apply to military retirees, their dependents, and the dependents of active duty military personnel who have both military health coverage and coverage under your Plan, and receive care in Facilities run by the Department of Defense or Veteran’s Administration;
- provided by a licensed pastoral counselor in the course of his normal duties as a pastor or minister;
- provided by a social worker, except as otherwise stated in this booklet;
- provided during any part of a stay at a Facility, or during Home Health Care chiefly for bed rest, rest cure, convalescence, custodial or sanatorium care, diet therapy or occupational therapy;
- received as a result of: war, declared or undeclared; police actions; service in the armed forces or units auxiliary thereto; or riots or insurrection;
- rendered prior to the Covered Person’s Effective Date or after his termination date of coverage under the program, unless specified otherwise;
- which are specifically limited or excluded elsewhere in this booklet;
- which are not Medically Necessary and Appropriate; or
- which a Covered Person is not legally obligated to pay for.
Special medical reports not directly related to treatment of the Covered Person (e.g. employment physicals, reports prepared in connection with litigation.)
Stand-by services required by a Practitioner; services performed by Surgical assistants not employed by a Facility.
Sterilization reversal.
Sunglasses even if by Prescription.
Surrogate Motherhood
Telemedicine services to Covered Persons who are eligible for Medicare when Medicare is primary to this Plan.
Telephone consultations, except as the Plan may request.
TMJ syndrome treatment, except as otherwise stated in this booklet.
Transplants, except as otherwise stated in this booklet.
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Transportation; travel.
Vision therapy, vision or visual acuity training, orthoptics and pleoptics.
Vitamins and dietary supplements, except prenatal and children’s vitamins requiring a Prescription.
Weight reduction or control, unless there is a diagnosis of morbid obesity; special foods, food supplements, liquid diets, diet plans or any related products, except as specifically covered under the Plan. Wigs, toupees, hair transplants, hair weaving, or any drug used to eliminate baldness unless deemed Medically Necessary and Appropriate.
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BENEFITS PAYABLE FOR AUTOMOBILE RELATED INJURIES
This section applies when expenses are Incurred by a Covered Person due to an Automobile Related Injury.
Definitions
"Automobile Related Injury": Bodily injury of a Covered Person due to an accident while occupying, entering into, alighting from or using an auto; or if the Covered Person was a pedestrian, caused by an auto or by an object propelled by or from an auto.
"Allowable Expense": A Medically Necessary and Appropriate, reasonable and customary item of expense that is at least in part a Covered Charge under this Plan or PIP.
"Eligible Expense": That portion of expense Incurred for treatment of an Injury which is covered under this Plan without application of Deductibles or Copayments, if any.
"Out-of-State Automobile Insurance Coverage" or "OSAIC": Any coverage for medical expenses under an auto insurance contract other than PIP. This includes auto insurance contracts issued in another state or jurisdiction.
"PIP": Personal injury protection coverage (i.e., medical expense coverage) that is part of an auto insurance contract issued in New Jersey.
Application of this Provision
When expenses are Incurred as a result of an Automobile Related Injury, and the injured person has coverage under PIP or OSAIC, this provision will be used to determine whether this Plan provides coverage that is primary to such coverage or secondary to such coverage. It will also be used to determine the amount payable if this Plan provides primary or secondary coverage.
Determination of Primary or Secondary Coverage
This Plan provides secondary coverage to PIP unless this Plan's health coverage has been elected as primary by or for the Covered Person. This election is made by the named insured under a PIP contract. It applies to that person's family members who are not themselves named insured under other auto contracts. This Plan may be primary for one Covered Person, but not for another if the persons have separate auto contracts and have made different selections regarding the primary of health coverage.
This Plan is secondary to OSAIC. But, this does not apply if the OSAIC contains provisions that make it secondary or excess to the Covered Person's other health benefits. In that case, this Plan is primary.
If the above rules do not determine which health coverage is primary, or if there is a dispute as to whether this Plan will provide benefits for Covered Charges as if it were primary.
Benefits This Plan Will Pay if it is Primary to PIP or OSAIC
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If this Plan is primary to PIP or OSAIC, it will pay benefits for Covered Charges in accordance with its terms. If there are other plans that: (a) provide benefits to the Covered Person; and (b) are primary to auto insurance coverage, then this Plan's rules regarding the coordination of benefits will apply.
Benefits This Plan Will Pay if it is Secondary to PIP
If this Plan is secondary to PIP, the actual coverage will be the lesser of:
a. the Allowable Expenses left uncovered after PIP has provided coverage (minus this Plan's Deductibles, and/or Coinsurance); or
b. the actual benefits that this Plan would have paid if it provided its coverage primary to PIP.
Medicare
To the extent that this Plan provides coverage that supplements Medicare's, then this Plan can be primary to automobile insurance only insofar as Medicare is primary to auto insurance.

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Subrogation and Reimbursement
If another person or entity, through an act or omission, causes any participant, beneficiary, or any other covered person receiving benefits under this Plan, hereinafter individually and collectively referred to as “Covered Person”, to suffer an injury or illness, and in the event benefits were paid under the Plan for that injury or illness, a Covered Person must agree to the provisions listed below. Additionally, if a Covered Person is injured and no other person or entity is responsible but a Covered Person receives (or is entitled to) a recovery from another source, and if the Plan paid benefits for that injury, a Covered Person must also agree to the provisions listed below.
This Plan provides benefits to or on behalf of said Covered Person only on the following terms and conditions:
1. In the event that benefits are provided under this Plan, the Plan shall be subrogated to all of the Covered Person’s or the Covered Person’s representative’s (representative for this purpose includes, if applicable, heirs, administrators, legal representatives, parents (if a minor), successors, or assignees) rights of recovery against any person or organization to the extent of the benefits provided to the Covered Person. The Covered Person shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Covered Person shall do nothing after loss to prejudice such rights. The Covered Person hereby agrees to cooperate with the Plan and/or any representatives of the Plan in completing such forms and in giving such information surrounding any injury, illness, or accident as the Plan or the Plan representatives deem necessary to fully investigate the incident.
2. The Plan is also granted a right of reimbursement from the proceeds of any recovery whether by settlement, judgment, or otherwise. This right of reimbursement is cumulative with and not exclusive of the subrogation right granted in paragraph 1, but only to the extent of the benefits provided by the Plan. The Plan is entitled under its right of recovery to be reimbursed for the Plan’s benefit payments even if the Covered Person is not “made whole” for all of his or her damages in the recoveries the he or she receives.
3. By accepting benefits hereunder, the Covered Person hereby grants an automatic lien against and assigns to the Plan, in an amount equal to the benefits paid by the Plan, any recovery, whether by settlement, judgment, or other payment intended for, payable to, or received by the Covered Person, or on behalf of the Covered Person. The Covered Person hereby consents to said lien and/or assignment and agrees to take whatever steps are necessary to help the Plan secure said lien and/or assignment. The Covered Person agrees that said lien and/or assignment shall constitute a charge upon the proceeds of any recovery and the Plan shall be entitled to assert security interest thereon. By the acceptance of benefits under the Plan, the Covered Person and his or her representatives agree to hold the proceeds of any settlement, judgment and/or other payment in trust for the benefit of the Plan to the extent of 100% of all benefits paid on behalf of the Covered Person.
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4. The subrogation and reimbursement rights and liens apply to any recoveries made by the Covered Person as a result of the injuries sustained, including but not limited to the following:
a. Payments made directly by the third party tortfeasor, or any insurance company on behalf of the third party tortfeasor, or any other payments on behalf of the third party tortfeasor.
b. Any payments or settlements or judgment or arbitration awards paid by any insurance company under an uninsured or underinsured motorist coverage, whether on behalf of a Covered Person or other person.
c. Any other payments from any source designed or intended to compensate a Covered Person for injuries sustained.
d. Any worker’s compensation award or settlement.
e. Any recovery made pursuant to no-fault insurance.
f. Any medical payments made as a result of such coverage in any automobile or homeowners insurance policy.
5. The Covered Person shall not take action that may prejudice the Plan’s right of recovery, including but not limited to the assignment of any rights of recovery from any tortfeasor or other person or entity. No Covered Person shall make any settlement which specifically reduces or excludes, or attempts to reduce or exclude the benefits provided by the Plan. The Plan will not reduce its share of any recovery unless, in the exercise of its discretion, the Plan agrees in writing.
6. The Plan’s right of recovery shall be a prior lien against any proceeds recovered by the Covered Person, which right shall not be defeated nor reduced by the application of any doctrine purporting to defeat the Plan’s recovery rights by allocating the proceeds exclusively to non-medical expense damages. Accordingly, the Plan is entitled under its right of recovery to be reimbursed for its benefit payments even if the Covered Person is not “made whole” for all of his or her damages in the recoveries he or she receives; there shall be no application of the “made whole” doctrine, “rimes doctrine” or any such doctrine defeating the Plan’s right of recovery.
7. No Covered Person hereunder shall incur any expenses on behalf of the Plan in pursuit of the Plan’s rights hereunder. Specifically, no court costs or attorney’s fees may be deducted from the Plan’s recovery without the prior express written consent of the Plan and the Plan’s right of recovery is not subject to reduction of attorney’s fees and costs under the “common fund” or any other doctrine.
8. In the event that a Covered Person shall fail or refuse to honor its obligations hereunder, then the Plan shall be entitled to recover any costs incurred in enforcing the terms hereof including but not limited to attorney’s fees, litigation, court costs, and other expenses. The
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Plan shall also be entitled to offset the reimbursement obligation against any entitlement to future Plan benefits hereunder until the Covered Person has fully complied with his or her reimbursement obligations hereunder, regardless of how those future Plan benefits are incurred.
9. Any reference to state law in any other provision of this policy shall not be applicable to this provision, if the Plan is governed by ERISA. By acceptance of benefits under the Plan, the Covered Person agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, the Plan shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the Plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief.

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THE EFFECT OF MEDICARE ON BENEFITS
IMPORTANT NOTICE
For the purposes of this Booklet’s “Coordination of Benefits and Services” provision, the benefits for a Covered Person may be affected by whether he/she is eligible for Medicare and whether the "Medicare as Secondary Payer" rules apply to the Plan. This section, on "Medicare as Secondary Payer", or parts of it, may not apply to this Plan. The Employee must contact the Employer to find out if the Employer is subject to Medicare as Secondary Payer rules.
For the purpose of this section:
a. "Medicare" means Part A and B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time.
b. A Covered Person is deemed to be eligible for Medicare by reason of age from the first day of the month during which he/she reaches age 65. But, if the Covered Person is born on the first day of a month, he/she is deemed to be eligible for Medicare from the first day of the month that is immediately prior to his/her 65th birthday. A Covered Person may also be eligible for Medicare by reason of disability or End-Stage Renal Disease (ESRD).
c. Under the rules for coordination of benefits and services described earlier, a "Primary Plan" pays benefits for a Covered Person's Covered Charges first, ignoring what the Covered Person's "Secondary Plan(s)" pays. The "Secondary Plan(s)" then pays the remaining unpaid Allowable Expenses in accordance with the provisions of the Covered Person's secondary health plan.
The following rules explain how this Plan's group health benefits interact with the benefits available under Medicare as Secondary Payer rules. A Covered Person may be eligible for Medicare by reason of age, disability or ESRD. Different rules apply to each type of Medicare eligibility as explained below:
In all cases where a person is eligible for Medicare and this Plan is the secondary plan, the Allowable Expenses under this Plan and for the purposes of the Coordination of Benefits and Services rules, will be reduced by what Medicare would have paid if the Covered Person had enrolled for full Medicare coverage. But this will not apply, however, if; (a) the Covered Person is eligible for, but not covered, under Part A of Medicare; and (b) he/she could become covered under Part A only by enrolling and paying the required premium for it.
Medicare Eligibility by Reason of Age
This section applies to a Covered Person who is:
a. The Employee or covered spouse;
b. eligible for Medicare by reason of age; and
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c. has coverage under this program due to the current employment status of the Employee.
Under this section, such a covered person is referred to as a "Medicare eligible".
This section does not apply to:
a. a Covered Person, other than an Employee or covered Spouse;
b. a Covered Person who is under age 65; or
c. a Covered Person who is eligible for Medicare solely on the basis of End Stage Renal Disease
When a Covered Person becomes eligible for Medicare by reason of age, this Plan permits the Covered Person to make a prospective election change that cancels coverage under this Plan and elect Medicare as the primary health plan.
If a Covered Person cancels coverage under this Plan, the Covered Person will no longer be covered by this Plan. Medicare will be the primary payer. Coverage under this plan will end on the last day of the month in which the Covered Person elects Medicare the primary health plan.
If a Covered Person does not make an election upon becoming eligible for Medicare by reason of age, this Plan will continue to be the primary health plan. This plan pays first, ignoring Medicare. Medicare will be considered the secondary health plan.
Medicare Eligibility by Reason of Disability
This part applies to a Covered Person who:
a. is under age 65;
b. is eligible for Medicare by reason of disability; and
c. has coverage under this Plan due to the current employment status of the Employee.
This part does not apply to:
a. a Covered Person who is eligible for Medicare by reason of age; or
b. a Covered Person who is eligible for Medicare solely on the basis of ESRD.
When a Covered Person becomes eligible for Medicare by reason of disability, this Plan is the primary plan; Medicare is the secondary plan.
Medicare Eligibility by Reason of End Stage Renal Disease
This part applies to a Covered Person who is eligible for Medicare solely on the basis of ESRD.
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This part does not apply to a Covered Person who is:
a. eligible for Medicare by reason of age ; or
b. eligible for Medicare by reason of disability.
When (a) a Covered Person becomes eligible for Medicare solely on the basis of ESRD; and (b) Incurs a charge for the treatment of ESRD for which benefits are payable under both this Plan and Medicare, this Plan is deemed the Primary Plan for a specified time, referred to as the “coordination period”. This Plan pays first, ignoring Medicare. Medicare is the Secondary Plan. The coordination period is up to 30 consecutive months.
The coordination period starts on the earlier of:
a. the first month of a Covered Person’s Medicare Part A entitlement based on ESRD; or
b. the first month in which he/she could become entitled to Medicare if he/she filed a timely application.
After the 30-month period described above ends, if an ESRD Medicare eligible person Incurs a charge for which benefits are payable under both this Plan and Medicare, Medicare is the Primary Plan and this Plan is the Secondary Plan.
Dual Medicare Eligibility
This part applies to a Covered Person who is eligible for Medicare on the basis of ESRD and either age or disability.
When a Covered Person who is eligible for Medicare due to either age or disability (other than ESRD) has this Plan as the primary payer, then becomes eligible for Medicare based on ESRD, this Plan continues to be the primary payer for the first 30 months of dual eligibility. After the 30-month period, Medicare becomes the primary payer (as long as Medicare dual eligibility still exists).
When a Covered Person who is eligible for Medicare due to either age or disability (other than ESRD) has this Plan as the secondary payer, then becomes eligible for Medicare based on ESRD, this Plan continues to be the secondary payer.
When a Covered Person who is eligible for Medicare based on ESRD also becomes eligible for Medicare based on age or disability (other than ESRD), this Plan continues to be the primary payer for 30 months after the date of Medicare eligibility based on ESRD.
How To File A Claim If You Are Eligible For Medicare
Follow the procedure that applies to you or the Covered Person from the categories listed below when filing a claim.
New Jersey Providers:
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• The Covered Person should give the Practitioner or other Provider his/her identification number. This number is shown on the Medicare Request for Payment (claim form) under “Other Health Insurance”;
• The Provider will then submit the Medicare Request for Payment to the Medicare Part B carrier;
• After Medicare has taken action, the Covered Person will receive an Explanation of Benefits form from Medicare;
• If the remarks section of the Explanation of Benefits contains this statement, no further action is needed: “This information has been forwarded to Horizon Blue Cross Blue Shield of New Jersey for their consideration in processing supplementary coverage benefits;”
• If the above statement does not appear on the Explanation of Benefits, the Covered Person should include his/her Identification number and the name and address of the Provider in the remarks section of the Explanation of Benefits and send it to Horizon BCBSNJ.
Out-of-State Providers:
• The request for Medicare payment should be submitted to the Medicare Part B carrier in the area where services were performed. Call your local Social Security office for information;
• Upon receipt of the Explanation of Benefits, show the Identification Card number and the name and address of the Provider in the remarks section and send the Explanation of Benefits to Horizon BCBSNJ for processing.

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APPEALS PROCESS
A Covered Person (or a Provider or authorized representative acting on behalf of the Covered Person and with his/her consent) may appeal Adverse Benefit Determinations. There are two types of Adverse Benefit Determinations, administrative and utilization management. “Administrative” determinations involve issues such as eligibility for coverage, benefit decisions, etc. “Utilization management” determinations are decisions that involve the use of medical judgment and/or deny or limit an admission, service, procedure or extension of stay based on the Plan's clinical and medical necessity criteria. The appeal processes for the two types differ and are described briefly below.
No Covered Person or Provider who files an appeal will be subject to disenrollment, discrimination or penalty. If there is a claim denial for either type of decision, you will receive information that includes the reason for the denial, a reference to the Plan provision on which it is based, and a description of any internal rule or protocol that affected the decision.
Appeals Process for Adverse Administrative Decisions
For this type of adverse claim decisions, you will be notified of a denial as quickly as possible, but not later than the following:
• For Urgent Care Claims, 72 hours from receipt of the claim;
• For Pre-Service Claims, 15 calendar days from receipt of the claim;
• For Post-Service Claims, 30 calendar days from receipt of the claim.
If you wish to appeal the decision, you have 180 days to do so. Your written request for a review of the decision should include the reason(s) why you feel the claim should not have been denied. It should also include any additional information (e.g., medical records) that you feel support your appeal.
The decision regarding your appeal will be reached as soon as possible, but not later than the following:
• For Urgent Care Claims, 72 hours from receipt of your appeal;
• For Pre-Service Claims, 30 calendar days from receipt of your appeal;
• For Post-Service Claims, 60 calendar days from receipt of your appeal.
If the initial decision on your claim is upheld upon review, you will also be informed of any additional appeal rights that you may have.
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Appeals Process for Adverse Utilization Management Decisions
The process for this type of adverse decision is briefly described below. A denial notification will include a brochure that fully describes your appeal rights and how you go about exercising them.
If such a claim is denied, your treating Provider can discuss your case with a Horizon BCBSNJ Medical Director, who can be reached by telephone at the number provided in the brochure. If the initial denial is upheld, you or the Provider can further appeal the decision within one year after receiving the denial letter. The appeal can be in writing or can be initiated by telephone. The applicable address and telephone number will be provided in the brochure.
Your appeal must include the following information:
• The name(s) and address(es) of the Covered Person and/or the Provider(s);
• The Covered Person's identification number;
• The date(s) of service;
• The nature of and reason behind your appeal;
• The remedy sought; and
• Any documentation that supports your appeal.
Your appeal will be decided as soon as possible, but not later than the following:
• For Urgent Care Claims, within 72 hours from receipt of your appeal;
• For other claims, within 30 calendar days from receipt of your appeal.
External Appeal Rights
If (a) the initial denial relates to an adverse utilization management decision or a rescission of coverage under the plan, (b) it is upheld pursuant to the internal appeal process, and (c) you are still dissatisfied, you have the additional right to pursue an external appeal with an Independent Review Organization (IRO). To exercise this right, you must request an external appeal in writing within four months after receiving our final internal appeal decision. The brochure accompanying our initial denial and final internal appeal decision will provide full details regarding the process that must be followed to request and obtain an external review. Generally, you must complete the internal appeal process before your claim will be eligible for external review. A small filing fee may be required. If so, it will be noted in the brochure.
If the process for obtaining this review is successfully completed, and your claim is deemed eligible, you will be notified and your appeal will be assigned to an IRO. Once it is assigned, the IRO will notify you about any additional steps that must be taken to complete your appeal. Once
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all of these additional steps are completed, the IRO will review all of the information in your case as if it were new. The IRO is not bound by any decisions or conclusions that were reached during the internal appeals process.
The IROs decision will be communicated to you in writing within 45 calendar days after its receipt of the appeal, or, if your external appeal request was handled on an expedited basis due to your medical circumstances, within 72 hours. The written decision issued by the IRO will include complete information regarding your appeal and the rationale for the decision. The decision will also include a statement that the IROs decision is binding except to the extent that other remedies may be available to you or the Plan pursuant to state or federal law. If the decision is favorable to you, the Plan must pay benefits without delay even if it intends to seek other judicial remedies. The decision will also advise you about other resources that may be available to you for additional assistance.

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Non-Duplication of Benefits
As with most group health care programs, this program contains a type of coordination of benefits provision called “non-duplication of benefits.” This provision is used when you and your covered dependents (spouse or child) receive services which are eligible for payment under more than one group health program. The main objective is to assure that your covered expenses will be paid, but that the combined payments do not amount to more than the amount this program would pay if it were the only program. Under this arrangement, the benefits of one program are reduced to the extent they are payable by another program. Here is how the order of benefits works: • When the other group coverage does not have a “coordination of benefits” provision then that coverage pays first. • When the person who received care is covered as an employee under one group coverage, and as a dependent under another, then the employee coverage pays first. • When a dependent child is covered under two group coverages and his parents are not separated or divorced, the coverage of the parent whose birthday (according to month and day) falls earlier in the year first; if both parents have the same birthday, the Plan covering the parent for the longer time pays first. • If the dependent child’s parents are separated or divorced, the following applies: 1. The coverage of the parent with custody of the child pays first; 2. Then, the coverage of the spouse (if any) of the parent with custody of the child pays; and 3. Finally, the coverage of the parent without custody of the child pays. 4. Regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child’s health care expenses, the coverage of that parent pays first. • The Plan which covers a person as an active employee or his dependent will pay before the plan which covers such person as a laid off or retired employee or his dependent. If the other plan does not have a coordination of benefits provision concerning laid off or retired employees, then this rule does not apply. • When none of the above circumstances applies, the coverage you have had for the longest time pays first. If you receive more than you should have when your benefits are coordinated, you will be expected to repay any overpayment.
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This program will provide its regular benefits in full when it is primarily liable (the program which pays first). When this program is secondary liable (pays second), it will provide a reduced amount. This reduced amount is determined as follows: 1. The benefits that would be payable for allowable expenses under this program (without considering other programs’ benefits) are calculated; 2. The benefits payable under all other programs (for the same allowable expenses) are subtracted from (1); and 3. The difference, if any, is payable by this program. In no event will this program’s liability as a secondary program exceed its liability as a primary program.
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Service Centers
If you have any questions about the Plan, call your nearest Service Center.
Telephone personnel are available:
Monday, Tuesday, Wednesday and Friday from 8:00 a.m. to 8:00 p.m.
Thursday from 9:00 a.m. to 8:00 p.m. (E.T.) Eastern Time
For questions and assistance with your Blue Card PPO benefits and services, please call:
1-800-355-BLUE (2583)
When you are outside of New Jersey and need to locate a nationwide Network PPO Provider, please call:
1-800-810-BLUE (2583)
For Mental Health and Substance Abuse, please call:
1-800-626-2212
Always have your identification card handy when calling. Your ID number helps get prompt answers to your questions about enrollment, benefits or claims.
Use this space for information you will need when asking about your coverage.
The company office or enrollment official to contact about coverage:
__________________________________________________________________
The identification number shown on my identification card:
__________________________________________________________________
The effective date when my coverage begins:
__________________________________________________________________
My group number is:
__________________________________________________________________
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ERISA INFORMATION The following information, together with the information contained in the rest of this Booklet, comprise the Summary Plan Description required by the Employee Retirement Income Security Act of 1974, as amended (ERISA).
Name of Plan: The SUEZ Water Resources Inc. Medical Plan
Plan Sponsor: SUEZ Water Resources Inc.
461 From Rd., Suite 400
Paramus, New Jersey 07652
Plan Administrator: SUEZ Water Resources Inc. 461 From Rd., Suite 400
Paramus, New Jersey 07652
Employer Identification Number: 22-2441477
Plan Number: 501
Classification and Funding:
The Plan described in this Booklet is classified as a welfare benefits plan by the Department of
Labor. It is funded by both the company and Employee contributions.
Type of Administration: Contract Administration. Benefits are provided in accordance with the provisions of the Plan Sponsor. Horizon Blue Cross Blue Shield of New Jersey provides
administrative services only.
Claims Administrator: Horizon Blue Cross Blue Shield of New Jersey, Inc.
Agent for Service of Legal Process: Plan Administrator
The Plan Year begins on January 1 and ends on December 31.
Plan Administrator Authority and Powers:
The Plan Administrator shall have exclusive discretionary authority and power to determine
eligibility for benefits and to construe the terms and provisions of this Plan, to determine questions of fact and law arising under this Plan, and to exercise all of the powers necessary for the operation of this Plan. However, the Plan has delegated to the Claims Administrator the authority to make
final claims determinations and to decide initial and final claims appeals on the Plan's behalf.
Plan Modification and Termination Information
Notwithstanding anything to the contrary in this Summary Plan Description, the Plan
Sponsor/Administrator expressly reserves the right, at any time, for any reason and without limitation to terminate, modify or otherwise amend this Plan and any or all of the benefits provided
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there under, either in whole or in part, whether to all persons covered thereby or one or more groups thereof. These rights include specifically, but are not limited to, (1) the right to terminate benefits under the Plan with respect to any participant therein; (2) the right to modify benefits under this Plan to all or any group of participants therein; (3) the right to require or increase contributions by any participants therein towards the cost of this Plan; and (4) the right to amend this Plan or any term or condition thereof; in each case, whether or not such rights are exercised with respect to any other participant or group of participants in this plan.
Not a Contract of Employment
No provision of the Plan described in this Booklet is to be considered a contract of employment. The Employer’s rights with respect to disciplinary actions and termination of Employees are in no way changed by the provisions of the Plan.
If you have any questions about the Plan, contact the Plan Administrator.
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STATEMENT OF ERISA RIGHTS
As a participant in SUEZ Water Resources Inc. Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
• Receive information about your plan and benefits.
• Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
• Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.
• Receive a summary of the plan's annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report.
• Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110.00 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the
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administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plans' decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your fights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example if it finds your claim is frivolous.
Assistance with Your Questions
If your have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquires, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

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Product: BLUECARD PPO
Company Name: SUEZ WATER RESOURCES INC. PLAN
3-HIGH DEDUCTIBLE HEALTH PLAN
(NON-SINGLE CONTRACT TYPES POPULATION)
Group Number: 76026-0059, 0061, 0063, 0066, 0067, 0070, 0071, 0074, 0075; PKG 002, 003, 004
Effective Date: January 1, 2020

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Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com Dear Valued Customer: Thank you for choosing Horizon Blue Cross Blue Shield of New Jersey for your health insurance
coverage. You're enrolled in a great plan! We are here to help you understand your benefits and
take charge of your health. The enclosed information will help you better understand your benefits and the additional programs and resources available to you as a Horizon BCBSNJ member.

It is important to register for Member Online Services at HorizonBlue.com. Through Member Online Services, you can:
• View your benefits.
• Check your claims status and payments.
• View authorizations and referrals, if applicable.
• Print a duplicate member ID card or display your member ID card.
• Tell us if you have other health insurance coverage.
• Change your doctor or dentist, if applicable.
• Manage your Member Online Services account and preferences.

Important Tips to Follow
• Keep your Horizon BCBSNJ member ID card with your at all times. It is the key to accessing your health care benefits. Please present your member ID card whenever you
need medical care or services. You can also sign in to Member Online Services at HorizonBlue.com to view and print your member ID card.
• Visit HorizonBlue.com/doctorfinder to find in-network doctors, hospitals or health care professionals. If you would like a printed copy of the directory, please call Member
Services at 1-800-355-BLUE (2583).
Call our Interactive Voice Response (IVR) system for information at your convenience. Through our IVR system, you can get answers to your questions 24 hours a day (usually including weekends/holidays).
Be prepared if a medical emergency arises. If you or a covered dependent experiences a medical emergency, we suggest you follow these steps: - Call 911 or go directly to the nearest Emergency Room. - Call your Primary Care Physician (PCP) or personal doctor as soon as reasonably possible so
that he/she may coordinate your follow up care. You do not need to call Member Services in a
medical emergency.
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Have a question about your benefits? If you have questions about your Horizon BCBSNJ coverage, you can sign in to Member Online
Services at HorizonBlue.com to chat with a Member Services Representative or send a secure email using My Messages. You can also call 1-800-355-BLUE (2583), Monday through Wednesday and Friday from 8 a.m. to 6 p.m., Eastern Time (ET) and Thursday, from 9 a.m. to 6 p.m., ET, to speak with a representative.

We look forward to continuing to serve your health insurance needs. Sincerely,
Christopher M. Lepre
Executive Vice President Commercial Business
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Notice of Nondiscrimination
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and
does not discriminate against nor does it exclude people or treat them differently on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.
Horizon BCBSNJ provides free aids and services to people with disabilities to communicate effectively
with us, such as qualified sign language interpreters and information written in other languages.
Contacting Member Services
Please call Member Services at 1-800-355-BLUE (2583) or the phone number on the back of
your member ID card, if you need the free aids and services noted above and for all other
Member Services issues, including:
• Claim, benefits or enrollment inquiries
• Lost/stolen ID cards
• Address changes
• Any other inquiry related to your benefits or health plan
Filing a Section 1557 Grievance
If you believe that Horizon BCBSNJ has failed to provide the free communication aids and services or discriminated on the basis of race, color, gender, national origin, age or disability you can file a discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ’s Civil Rights Coordinator can be reached by calling the Member Services number on the back of your member ID card
or by writing to the following address:
Horizon BCBSNJ – Civil Rights Coordinator
PO Box 820 Newark, NJ 07101
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Office for Civil Rights Headquarters U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 or 1-800-537-7697 (TDD)
OCR Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

An Independent Licensee of the Blue Cross and Blue Shield Association.
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The draft booklet contains only the information administered by Horizon Blue Cross Blue Shield
of New Jersey and is only a partial description of the benefits, limitations, exclusions and other
provisions of your health care plan. The draft booklet is not a Summary Plan Description and
shall be used for general reference only and shall not supersede any terms within your plan document. Horizon disclaims all subsequent liability, accuracy, correctness, and validity of any information should the Plan Administrator alter the document or otherwise modify the
information contained therein. The Group shall indemnify and hold harmless Horizon from and
against any claims, judgment, civil penalties, cause of action, liability, damage, cost or expense,
including attorneys' fees, arising out of or in connection with the use or tampering of the booklet
Please note: This booklet is currently in a draft status. For any updates please contact The
Corporate Major Accounts Contract Issuance Team.
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Table of Contents
Introduction .................................................................................................................................................... 1
Definitions...................................................................................................................................................... 2
Schedule of Covered Services and Supplies ................................................................................................ 23 Eligible Basic Services and Supplies ............................................................................................... 26 Eligible Supplemental Services and Supplies .................................................................................. 35
General Information ..................................................................................................................................... 37 How To Enroll ................................................................................................................................. 37 Your Identification Card .................................................................................................................. 37 Types of Coverage Available........................................................................................................... 37 Change In Type Of Coverage .......................................................................................................... 37 Enrollment of Dependents ............................................................................................................... 38 Special Enrollment Periods .............................................................................................................. 39 Individual Losing Other Coverage................................................................................................... 39 New Dependents .............................................................................................................................. 39 Special Enrollment Due to Marriage ............................................................................................... 40 Special Enrollment Due to Newborn/Adopted Children ................................................................. 40 Multiple Employment ...................................................................................................................... 40 Eligible Dependents ......................................................................................................................... 40 When Coverage Ends ....................................................................................................................... 41 Benefits After Termination .............................................................................................................. 42 Continuing Coverage Under the Federal Family and Medical Leave Act ....................................... 42 Continuation of Coverage Under COBRA ...................................................................................... 42 Continuation of Coverage under the USERRA ............................................................................... 44 Continuation of Care ........................................................................................................................ 45 Medical Necessity and Appropriateness .......................................................................................... 46 Cost Containment............................................................................................................................. 46 Managed Care Provisions ................................................................................................................ 46
Your Preferred Provider Organization (PPO) Program ............................................................................... 48 The Deductible ................................................................................................................................. 48 For Other than Single Coverage ...................................................................................................... 48 Out-of-Pocket Maximum ................................................................................................................. 49 Multiple Coverage ........................................................................................................................... 49 Payment Limits ................................................................................................................................ 49 Benefits From Other Plans .............................................................................................................. 49
Summary of Covered Services and Supplies ............................................................................................... 50 Eligible Basic Services and Supplies ............................................................................................... 50 Allergy Testing and Treatment ............................................................................. 50 Ambulatory Surgery.............................................................................................. 50 Anesthesia ............................................................................................................. 50 Audiology Services ............................................................................................... 50
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Birthing Centers .................................................................................................... 50 Dental Care and Treatment ................................................................................... 51 Diagnosis and Treatment of Autism ..................................................................... 51 Diagnostic X-rays and Laboratory Tests .............................................................. 52 Emergency Room.................................................................................................. 52 Facility Charges .................................................................................................... 53 Fertility Services ................................................................................................... 53 Home Health Agency Care ................................................................................... 53 Hospice Care ......................................................................................................... 53 Inpatient Physician Services ................................................................................. 55 Mastectomy Benefits ............................................................................................ 55 Maternity/Obstetrical Care.................................................................................... 55 Maternity/Obstetrical Care for Child Dependents ................................................ 56 Medical Emergency .............................................................................................. 56 Mental or Nervous Disorders (including Group Therapy) and Substance Abuse 56 Nutritional Counseling .......................................................................................... 57 Physical Rehabilitation ......................................................................................... 57 Practitioner’s Charges for Non-Surgical Care and Treatment .............................. 57 Practitioner’s Charges for Surgery........................................................................ 57 Pre-Admission Testing Charges ........................................................................... 57 Preventive Care ..................................................................................................... 57 Second Opinion Charges....................................................................................... 60 Skilled Nursing Facility Charges .......................................................................... 61 Surgical Services ................................................................................................... 61 Telemedicine Services, provided by Horizon CareOnline ................................... 62 Therapeutic Manipulation ..................................................................................... 62 Therapy Services ................................................................................................... 62 Transplant Benefits ............................................................................................... 62 Urgent Care ........................................................................................................... 64 Eligible Supplemental Services and Supplies .................................................................................. 65 Ambulance Services.............................................................................................. 65 Blood 65 Diabetes Benefits .................................................................................................. 65 Durable Medical Equipment ................................................................................. 67 Home Infusion Therapy ........................................................................................ 67 Foot Orthotics ....................................................................................................... 67 Oxygen and its Administration ............................................................................. 67 Prosthetic Devices ................................................................................................. 67 Specialized Non-Standard Infant Formulas .......................................................... 68 Wigs Benefit ......................................................................................................... 68
Utilization Management............................................................................................................................... 69 Required Hospital Stay Review ....................................................................................................... 70 Notice of Hospital Admission Required .......................................................................................... 70 Continued Stay Review.................................................................................................................... 70 Alternate Treatment Features/Individual Case Management .......................................................... 71
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Definitions........................................................................................................................................ 71 Alternate Treatment/Individual Case Management Plan ................................................................. 72 Exclusion.......................................................................................................................................... 73
Schedule of Procedures Requiring Prior Authorization ............................................................................... 74
Claims Procedures ....................................................................................................................................... 75
Exclusions Under The Blue Card PPO Program ......................................................................................... 82
Benefits Payable for Automobile Related Injuries ...................................................................................... 89
Subrogation and Reimbursement ................................................................................................................. 91
The Effect of Medicare on Benefits ............................................................................................................. 94 Important Notice .............................................................................................................................. 94 Medicare Eligibility by Reason of Age ........................................................................................... 94 Medicare by Reason of Disability .................................................................................................... 95 Medicare Eligibility by Reason of End Stage Renal Disease .......................................................... 96 Dual Medicare Eligibility ................................................................................................................ 96 How To File A Claim If You Are Eligible For Medicare ................................................................ 97
APPEALS PROCESS .................................................................................................................................. 98
Non-Duplication of Benefits ...................................................................................................................... 101
Service Centers .......................................................................................................................................... 103
Statement of ERISA Rights ....................................................................................................................... 106
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Introduction
Your Blue Card PPO benefit program gives you broad protection to help meet the costs of
Illnesses and Accidental Injuries. This benefit program offers the highest level of benefits when
services are obtained from any physician or hospital designated as a PPO Network provider
either in New Jersey or in another Blue Cross and Blue Shield service area.
In this booklet you’ll find the important features of your group’s Blue Card PPO benefits
provided by the Plan administered by Horizon Blue Cross Blue Shield of New Jersey.
Your benefits are self-insured through your Employer. Therefore, while Horizon BCBSNJ will
initially review claims, all final claims decisions will be made by the Plan Administrator named
by your Employer.
This booklet replaces any booklets or certificates you may previously have received.
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Definitions
This section defines certain important words used in this booklet. The meaning of each defined word, whenever it appears in this booklet, is governed by its definition as listed in this section.
Accidental Injury – Medical care for the treatment of traumatic bodily injuries resulting from an accident.
Act of War: Any act peculiar to military, naval or air operations in time of War.
Active: Performing, doing, participating or similarly functioning in a manner usual for the task for full pay, at the Employer's place of business, or at any other place that the Employer's business requires the Employee to go.
Admission: Days of Inpatient services provided to a Covered Person.
Adverse Benefit Determination – an adverse benefit determination is any denial, reduction or termination of, or failure to provide or make payment for (in whole or in part), a benefit, including one based on a determination of eligibility, as well as one based on the application of any utilization review criteria, including determinations that an item or service for which benefits are otherwise provided are not covered because they are deemed to be experimental/investigational or not medically necessary or appropriate.
Affiliated Company: A corporation or other business entity affiliated with the Employer through common ownership of stock or assets; or as otherwise defined by the Employer.
Allowance: Subject to the exceptions below, an amount determined by the Plan as the east of the following amounts:
(a) the actual charge made by the Provider for the service or supply;
(b) in the case of In-Network Providers, the amount that the Provider has agreed to accept for the service or supply; or
(c) in the case of Out-of-Network Providers, the following:
(i) For Practitioners’ services, 300% of the amount determined for the service based on the Resource Based Relative Value System (RBRVS) promulgated by the Centers for Medicare and Medicaid Services.
(ii) For the services of Ambulatory Surgical Centers, 300% of the amount determined for the services based on the RBRVS.
(iii) For all other Covered Services and Supplies, the amount determined for the Covered Service or Supply in accordance with: (a) profiles compiled by Horizon BCBSNJ based on usual and prevailing payments made to Providers for similar
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services or supplies in specific geographical areas; or (b) similar profiles compiled by outside vendors.
Exceptions:
(1) With respect to (i) a Medical Emergency; or (ii) Covered Services and Supplies provided in an In-Network Hospital, the Allowance determined in accordance with part (c), above, for any Covered Services and Supplies provided by Out-of-Network Providers shall be increased as needed to ensure that the Covered Person has no greater liability than he/she would have if they were provided by In-Network Providers. But this (ii) shall not apply if the Covered Person: (a) had or was given the opportunity to select In-Network Providers to provide the Covered Services or Supplies; and (b) elected the services of Out-of-Network Providers.
(2) With respect to parts (c)(i) and (c)(ii), above, if Medicare does not prescribe a reimbursement rate for the Covered Service or Supply, the Allowance for it will be determined in accordance with: (a) profiles compiled by Horizon BCBSNJ based on usual and prevailing payments made to Providers for similar services or supplies in specific geographical areas; or (b) similar profiles compiled by outside vendors.
Alternate Payee:
a. A custodial parent, who is not an Employee under the terms of the Plan, of a Child Dependent; or
b. The Division of Medical Assistance and Health Services in the New Jersey Department of Human Services which administers the State Medicaid Program.
Ambulance: A certified transportation vehicle that: (a) transports ill or injured people; and (b) contains all life-saving equipment and staff as required by state and local law.
Ambulatory Surgical Center: A Facility mainly engaged in performing Outpatient Surgery.
a. It must:
1. be staffed by Practitioners and Nurses under the supervision of a physician;
2. have permanent operating and recovery rooms;
3. be staffed and equipped to give Medical Emergency care; and
4. have written back-up arrangements with a local Hospital for Medical Emergency care.
b. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
1. accredited for its stated purpose by either the Joint Commission or the
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Accreditation Association for Ambulatory Care; or
2. approved for its stated purpose by Medicare.
The Plan does not recognize a Facility as an Ambulatory Surgical Center if it is part of a Hospital.
Approved Hemophilia Treatment Center – A health care facility licensed by the State of New Jersey for the treatment of hemophilia or one which meets the same standards if located in another state.
Behavioral Interventions Based on Applied Behavioral Analysis (ABA): Interventions or strategies, based on learning theory, that are intended to improve a person’s socially important behavior. This is achieved by using instructional and environmental modifications that have been evaluated through scientific research using reliable and objective measurements. These include the empirical identification of functional relations between behavior and environmental factors.
Such intervention strategies include, but are not limited to: chaining; functional analysis; functional assessment; functional communication training; modeling (including video modeling); procedures designed to reduce challenging and dangerous behaviors; prompting; reinforcement systems, including differential reinforcement, shaping and strategies to promote generalization.
Benefit Day: Each of the following:
a. Each midnight the Covered Person is registered as an Inpatient; or
b. Each day when Inpatient Admission and discharge occur on the same calendar day.
Benefit Month: The one-month period beginning on the Effective Date of the Plan and each succeeding monthly period.
Benefit Period – the twelve-month period starting on January 1st and ending on December 31st. The first and/or last Benefit Period may be less than a calendar year. The first Benefit Period begins on your coverage date. The last Benefit Period ends when you are no longer covered.
Birthing Center – a Facility which mainly provides care and treatment for women during uncomplicated pregnancy, routine full-term delivery, and the immediate post-partum period.
a. It must:
1. provide full-time Skilled Nursing Care by or under the supervision of Nurses; 2. be staffed and equipped to give Medical Emergency care; and 3. have written back-up arrangements with a local Hospital for Medical Emergency care.
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b. The Plan will recognize it if:
1. it carries out its stated purpose under all relevant state and local laws; or 2. it is approved for its stated purpose by the Accreditation Association for Ambulatory Care; or 3. it is approved for its stated purpose by Medicare.
The Plan does not recognize a Facility as a Birthing Center if it is part of a Hospital.
BlueCard PPO Provider: A Provider, not in New Jersey, which has a written agreement with another Blue Cross and/or Blue Shield plan to provide care to both that plan’s subscribers and other Blue Cross and/or Blue Shield plans’ subscribers. For purposes of this Plan, a BlueCard PPO Provider is an In-Network Provider.
Booklet: A detailed summary of benefits covered.
Calendar Year: A year starting January 1.
Certified Registered Nurse Anesthetist (C.R.N.A.) – A Registered Nurse, certified to administer anesthesia, who is employed by and under the supervision of a Physician anesthesiologist.
Child Dependent: A person who: has not attained the age of 26; and is:
• The natural born child or stepchild of you, your Spouse, or Domestic Partner regardless of where or with whom the child lives;
• A child who is: (a) legally adopted by you, your Spouse, or Domestic Partner, regardless of where or with whom such child lives; or (b) placed with you for adoption. But, proof of such adoption or placement satisfactory to the Plan must be furnished to us when we ask;
• You, your Spouse's or Domestic Partner's legal ward. But, proof of guardianship satisfactory to the Plan must be furnished to us when we ask.
Coinsurance: The percent applied to Covered Charges (not including Deductibles) for certain Covered Services or Supplies in order to calculate benefits under the Plan. These are shown in the Schedule of Covered Services and Supplies. The term does not include Copayments. For example, if the Plan's Coinsurance for an item of expense is 60%, then the Covered Person's Coinsurance for that item is 40%. Unless the context indicates otherwise, the Coinsurance percents shown in this Booklet are the percents that the Plan will pay.
Complex Imaging Services: Includes the following services-
a) Computed Tomography (CT);
b) Computed Tomography Angiography (CTA);
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c) Magnetic Resonance Imaging (MRI);
d) Magnetic Resonance Spectroscopy (MRS);
e) Positron Emission Tomography (PET);
f) Nuclear Medicine including Nuclear Cardiology.
Cosmetic Services: Services (including Surgery) rendered to refine or reshape body structures or surfaces that are not functionally impaired. They are: (a) to improve appearance or self-esteem; or (b) for other psychological, psychiatric or emotional reasons. The following are not considered "cosmetic":
a. Surgery to correct the result of an Injury;
b. Surgery to treat a condition, including a birth defect, which impairs the function of a body organ;
c. Surgery to reconstruct a breast after a mastectomy is performed.
d. Treatment of newborns to correct congenital defects and abnormalities.
e. Treatment of cleft lip.
The following are some procedures that are always considered "cosmetic":
a. Surgery to correct gynecomastia;
b. Breast augmentation procedures, including their reversal for women who are asymptomatic;
c. Reversal of breast augmentation procedures for asymptomatic women who had reconstructive Surgery or who previously had breast implants for cosmetic purposes;
d. Rhinoplasty, except when performed to treat an Injury;
e. Lipectomy;
f. Ear or other body piercing.
Coverage Date: The date on which coverage under this Plan begins for the Covered Person.
Covered Charges: The authorized charges, up to the Allowance, for Covered Services and Supplies. A Covered Charge is Incurred on the date the Covered Service or Supply is furnished. Subject to all of the terms of this Plan, the Plan provides coverage for Covered Services or Supplies Incurred by a Covered Person while the person is covered by this Plan.
Covered Person – you and your dependents who are enrolled under the Plan.
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Covered Services and Supplies – the types of services and supplies described in the Covered Services and Supplies section of this booklet. The services and supplies must be:
a. furnished or ordered by a Provider; and
b. For Preventive Care, or Medically Necessary and Appropriate to diagnose or treat an Illness (including Mental or Nervous Disorders) or Injury.
Current Procedural Terminology (C.P.T.): The most recent edition of an annually revised listing published by the American Medical Association, which assigns numerical codes to procedures and categories of medical care.
Custodial Care: Care that provides a level of routine maintenance for the purpose of meeting personal needs. This is care that can be provided by a layperson who does not have professional qualifications or skills.
Custodial Care includes, but is not limited to: help in walking or getting into or out of bed; help in bathing, dressing and eating; help in other functions of daily living of a similar nature; administration of or help in using or applying creams and ointments; routine administration of medical gasses after a regimen of therapy has been set up; routine care of a patient, including functions such as changes of dressings, diapers and protective sheets and periodic turning and positioning in bed; routine care and maintenance in connection with casts, braces and other similar devices, or other equipment and supplies used in treatment of a patient, such as colostomy and ileostomy bags and indwelling catheters; routine tracheostomy care; general supervision of exercise programs, including carrying out of maintenance programs of repetitive exercises that do not need the skills of a therapist and are not skilled services.
Even if a Covered Person is in a Hospital or other recognized Facility, the Plan does not cover care if it is custodial in nature.
Day Programs: Outpatient personalized or packaged programs that: (a) are designed primarily for patients who are medically stable enough to live at home, but who may require certain therapies; (b) offer multiple therapies in a day setting; and (c) are usually scheduled for three to five days a week and five to nine and a half hours per day. Some examples of the therapies offered are: cognitive therapy; recreation therapy; work hardening programs; vocational therapy; group cognitive/interpersonal therapy; remedial treatments; and treatments to improve interpersonal communication and social skills. “Day Programs” do not include outpatient programs for the treatment of mental illnesses.
Deductible: The amount of Covered Charges that a Covered Person must pay before this Plan provides any benefits for such charges. The term does not include Coinsurance, Copayments and Non-Covered Charges. See the Schedule of Covered Services and Supplies section of this Booklet for details.
Dependent: A Spouse, Domestic Partner, or Child Dependent whom the Employee enrolls for coverage under this Plan, as described in the General Information section of this Booklet.
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Developmental Disability(ies): A person’s severe chronic disability which:
(a) is attributable to a mental or physical impairment, or a combination of them;
(b) for the purposes solely of the provision of this Program entitled “Diagnosis and Treatment of Autism and Other Developmental Disabilities”, is manifest before age 22;
(c) is likely to continue indefinitely;
(d) results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; the capacity for independent living or economic self-sufficiency; and
(e) reflects the need for a combination and sequence of special inter-disciplinary or generic care, treatment or other services which are: (i) of lifelong or extended duration; and (ii) individually planned or coordinated.
Developmental Disability includes, but is not limited to, severe disabilities attributable to: mental retardation; autism; cerebral palsy; epilepsy; spina-bifida; and other neurological impairments where the above criteria are met.
Diagnostic Services: Procedures ordered by a recognized Provider because of specific
symptoms to diagnose a specific condition or disease. Some examples are:
a. Radiology and ultrasound;
b. Lab and pathology; and
c. EKG’s, EEG’s and other electronic diagnostic tests
Except as allowed under covered charges for Preventive Care, Diagnostic Services are not covered under the Plan if the procedures are ordered as part of a routine or periodic physical examination or screening.
Domestic Partners: Persons who meet these criteria:
(1) Both persons have a common residence and are otherwise jointly responsible for each other's common welfare, as evidenced by joint financial arrangements or joint ownership of real property, which shall be demonstrated by at least one of the following:
(a) A joint deed, mortgage agreement or lease;
(b) A joint bank account;
(c) Designation of one of the persons as a primary beneficiary in the other's will;
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(d) Designation of one of the persons as a primary beneficiary in the other person's life insurance policy or retirement plan; or
(e) joint ownership of a motor vehicle;
(2) Both persons agree to be jointly responsible for each other's basic living expenses during the Domestic Partnership;
(3) Neither person is in a marriage recognized by the State in which he or she resides or a member of another Domestic Partnership;
(4) Neither person is related to the other by blood or affinity up to and including the fourth degree of consanguinity;
(5) Both persons have chosen to share each other's lives in a committed relationship of mutual caring;
(6) Both persons are at least 18 years of age;
Domestic Partnership: A relationship between the Employee and another person as the Employee that meets the requirements set forth under this Plan. Proof that such a relationship exists, as determined by the Plan, must be given to the Plan when requested. The Plan has the right to determine eligibility for coverage under this Plan.
Durable Medical Equipment – equipment which the Plan determines to be:
a. designed and able to withstand repeated use;
b. primarily and customarily used to serve a medical purpose;
c. generally not useful to you in the absence of an Illness or injury; and
d. suitable for use in the home.
Some examples are walkers, wheelchairs, hospital-type beds, breathing equipment and apnea monitors.
Durable Medical Equipment does not include adjustments made to vehicles, air conditioners, air purifiers, humidifiers, dehumidifiers, elevators, ramps, stair glides, Emergency Alert equipment, handrails, heat appliances, improvements made to the home or place of business, waterbeds, whirlpool baths and exercise and massage equipment.
Elective Surgical Procedure: Non-emergency Surgery that may be scheduled for a day of the patient's choice without risking the patient's life or causing serious harm to the patient's bodily functions.
Employee: A person employed by the Employer; a proprietor or partner of the Employer.
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Employer: Collectively, all employers included under the Plan.
Enrollment Date: A person's Coverage Date or, if earlier, the first day of any applicable Waiting Period.
Essential Health Benefits: This has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act, and as further defined by the Secretary of the U.S. Department of Health and Human Services. The term includes: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services (including behavioral health treatment); Prescription Drugs; rehabilitative and habilitative services and devices; lab services; preventive and wellness services and chronic disease management; and pediatric services (including oral and vision care).
Elective Surgical Procedure: Non-emergency Surgery that may be scheduled for a day of the patient's choice without risking the patient's life or causing serious harm to the patient's bodily functions.
Experimental or Investigational: Any: treatment; procedure; Facility; equipment; drug; device; or supply (collectively, "Technology") which, as determined by The Plan, fails to meet any one of these tests:
a. The Technology must either be: (a) approved by the appropriate federal regulatory agency and have been in use for the purpose defined in that approval; or (b) proven to The Plan's satisfaction to be the standard of care.
This applies to drugs, biological products, devices and any other product or procedure that must have final approval to market from: (i) the FDA; or (ii) any other federal government body with authority to regulate the Technology. But, such approval does not imply that the Technology will automatically be deemed by The Plan as Medically Necessary and Appropriate and the accepted standard of care.
b. There must be sufficient proof, published in peer-reviewed scientific literature, that confirms the effectiveness of the Technology. That proof must consist of well-designed and well-documented investigations. But, if such proof is not sufficient or is questionable, The Plan may consider opinions about and evaluations of the Technology from appropriate specialty advisory committees and/or specialty consultants.
c. The Technology must result in measurable improvement in health outcomes, and the therapeutic benefits must outweigh the risks, as shown in scientific studies. "Improvement" means progress toward a normal or functional state of health.
d. The Technology must be as safe and effective as any established modality. (If an alternative to the Technology is not available, The Plan may, to determine the safety and effectiveness of a Technology, consider opinions about and evaluations of the Technology from appropriate specialty advisory committees and/or specialty consultants.)
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e. The Technology must demonstrate effectiveness when applied outside of the investigative research setting.
Services and supplies that are furnished for or in connection with an Experimental or Investigational Technology are not Covered Services and Supplies under this Program, even if they would otherwise be deemed Covered Services and Supplies. But, this does not apply to: (a) services and supplies needed to treat a patient suffering from complications secondary to the Experimental or Investigational Technology; or (b) Medically Necessary and Appropriate services and supplies that are needed by the patient apart from such a Technology.
Regarding a., above, The Plan will evaluate a Prescription Drug for uses other than those approved by the FDA. For this to happen, the drug must be recognized to be Medically Necessary and Appropriate for the condition for which it has been prescribed in one of these:
• The American Hospital Formulary Service Drug Information.
• The United States Pharmacopeia Drug Information.
Even if such an "off-label" use of a drug is not supported in one or more of the above compendia, The Plan will still deem it to be Medically Necessary and Appropriate if supportive clinical evidence for the particular use of the drug is given in a clinical study or published in a major peer-reviewed medical journal. But, in no event will this Program cover any drug that the FDA has determined to be Experimental, Investigational or contraindicated for the treatment for which it is prescribed.
Also, regardless of anything above, this Plan will provide benefits for services and supplies furnished to a Covered Person for medical care and treatment associated with: (i) an approved cancer clinical trial (Phase I, II, III and/or IV); or (ii) an approved Phase I, II, III and/or IV clinical trial for another life threatening condition. This coverage will be provided if: (a) the Covered Person’s Practitioner is involved in the clinical trial; and (b) he/she has concluded that the Covered Person’s participation would be appropriate. It can also be provided if the Covered Person gives medical or scientific information proving that such participation would be appropriate.
This coverage for clinical trials includes, to the extent coverage would be provided other than for the clinical trial: (a) Practitioners' fees; (b) lab fees; (c) Hospital charges; (d) treating and evaluating the Covered Person during the course of treatment or regarding a complication of the underlying Illness; and (e) other routine costs related to the patient's care and treatment, to the extent that these services are consistent with usual and customary patterns and standards of care furnished whenever a Covered Person receives medical care associated with an approved clinical trial.
This coverage for clinical trials does not include: (a) the cost of Experimental or Investigational drugs or devices themselves; (b) non-health services that the patient needs to receive the care and treatment; (c) the costs of managing the research; or (d) any other services, supplies or charges that this Program would not cover for treatment that is not Experimental or Investigational.
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With respect to coverage for clinical trials, The Plan will not:
• Deny a qualified Covered Person participation in an approved clinical trial;
• Deny or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with an approved clinical trial; or
• Discriminate against the Covered Person on the basis of his/her participation in such a trial.
Eye Examination - a comprehensive medical examination of the eye performed by a Practitioner, including a diagnostic ophthalmic examination, with or without definitive refraction as medically indicated, with medical diagnosis and initiation of diagnostic and treatment programs, prescription of medication and lenses, post cycloplegic Visit if required and verification of lenses if prescribed.
Facility: An entity or institution: (a) which provides health care services within the scope of its license, as defined by applicable law; and (b) which the Plan either: (i) is required by law to recognize; or (ii) determines in its sole discretion to be eligible under the Plan.
Family or Medical Leave of Absence: A period of time of predetermined length, approved by the Employer, during which the Employee does not work, but after which the Employee is expected to return to Active service. Any Employee who has been granted an approved leave of absence in accordance with the Family and Medical Leave Act of 1993 shall be deemed to be Active for purposes of eligibility for coverage under this Plan.
FDA: The Food and Drug Administration.
Foot Orthotics – custom-made supportive devices designed to restrict, immobilize, strengthen or protect the foot.
Government Hospital – A Hospital which is operated by a government or any of its subdivisions or agencies. This includes any federal, military, state, county or city Hospital.
Group Health Plan – an Employee welfare benefit plan, as defined in Title I of section 3 of P.L. 93-406 (ERISA) to the extent that the Plan provides medical care and includes items and services paid for as medical care to Employees or their dependents directly or through insurance, reimbursement or otherwise.
Home Area: The 50 states of the United States of America, the District of Columbia and Canada.
Home Health Agency: A Provider which mainly provides care for an ill or injured person in the person's home under a home health care program designed to eliminate Hospital stays. The Plan will recognize it if it: (a) is licensed by the state in which it operates; or (b) is certified to take part in Medicare as a Home Health Agency.
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Home Health Care: Nursing and other Home Health Care services rendered to a Covered Person in his/her home. For Home Health Care to be covered, these rules apply:
a. The care must be given on a part-time or intermittent basis, except if full-time or 24-hour services are Medically Necessary and Appropriate on a short-term basis.
b. Continuing Inpatient stay in a Hospital would be needed in the absence of Home Health Care.
c. The care is furnished under a physician's order and under a plan of care that: (a) is established by that physician and the Home Health Care Provider; (b) is established within 14 days after Home Health Care starts; and (c) is periodically reviewed and approved by the physician.
Home Health Care Services: Any of these services needed for the Home Health Care plan: nursing care; physical therapy; occupational therapy; medical social work; nutrition services; speech therapy; home health aide services; medical appliances and equipment, drugs and medicines, lab services and special meals, to the extent these would have been Covered Services and Supplies if the Covered Person was a Hospital Inpatient; diagnostic and therapeutic services (including Surgical services) performed in a Hospital Outpatient department, a physician's office, or any other licensed health care Facility, to the extent these would have been Covered Services and Supplies under this Plan if furnished during a Hospital Inpatient stay.
Horizon BCBSNJ: Horizon Blue Cross Blue Shield of New Jersey.
Hospice – a Provider which mainly provides palliative and supportive care for terminally Ill or terminally Injured people under a hospice care program. The Plan will recognize a Hospice if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. approved for its stated purpose by Medicare; or
b. it is accredited for its stated purpose by either the Joint Commission or the National Hospice Organization.
Hospice Care Program: A health care program which provides an integrated set of services designed to provide Hospice care. Hospice services are centrally coordinated through an interdisciplinary team directed by a Practitioner.
Hospital: A Facility which mainly provides Inpatient care for ill or injured people. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited as a hospital by the Joint Commission: or
b. approved as a hospital by Medicare.
Among other things, a Hospital is not any of these: a convalescent home; a rest or nursing
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Facility; an infirmary; a Hospice; a Substance Abuse Center; or a Facility (or part of it) which mainly provides: domiciliary or Custodial Care; educational care; non-medical or ineligible services or supplies; or rehabilitative care. A facility for the aged is also not a Hospital. "Hospital" shall also not include a satellite facility of a Hospital for which a separate facility license is required by law, unless the satellite also meets this definition in its own right.
The Plan will pay benefits for Covered Services and Supplies Incurred at Hospitals operated by the United States government only if: (a) the services or supplies are for treatment on an emergency basis; or (b) the services or supplies are provided in a hospital located outside of the United States or Puerto Rico.
The above limitations do not apply to military Retirees, their dependents, and the dependents of active-duty military personnel who: (a) have both military health coverage and the Plan coverage; and (b) receive care in facilities run by the Department of Defense or Veteran's Administration.
Illness – a sickness or disease suffered by a Covered Person.
Incidental Surgical Procedure: One that: (a) is performed at the same time as a more complex primary procedure; and (b) is clinically integral to the successful outcome of the primary procedure.
Incurred: A charge is Incurred on the date a Covered Person receives a service or supply for which a charge is made.
Injury: All damage to a person's body due to accident, and all complications arising from that damage.
In-Network: A Provider, or the Covered Services and Supplies provided by a Provider, who has an agreement to furnish Covered Services or Supplies under this Plan.
In-Network Coverage: The level of coverage, shown in the Schedule of Covered Services and Supplies, which is provided if an In-Network Provider provides the service or supply.
Inpatient: A Covered Person who is physically confined as a registered bed patient in a Hospital or other Facility, or the services or supplies provided to such Covered Person, depending on the context in which the term is used.
Joint Commission: The Joint Commission on the Accreditation of Health Care Organizations.
Late Enrollee: A person who requests enrollment under this Plan more than 31 days after first becoming eligible. However, a person will not be deemed a Late Enrollee under certain conditions. See the General Information section of this Booklet for more details.
Late Enrollee – a Covered Person who requests enrollment under the Plan more than 31 days after first becoming eligible. However, you will not be considered a Late Enrollee under certain circumstances. See the General Information section of this booklet for additional information.
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Maintenance Therapy: That point in the therapeutic process at which no further improvement in the gaining or restoration of a function, reduction in disability or relief of pain is expected. Continuation of therapy at this point would be for the purpose of holding at a steady state or preventing deterioration.
Medical Emergency: A medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to: severe pain; psychiatric disturbances; and/or symptoms of Substance Abuse) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate attention to result in: (a) placing the health of the person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of a bodily organ or part.
With respect to a pregnant woman who is having contractions, a Medical Emergency exists where: (a) there is not enough time to make a safe transfer to another Hospital before delivery; or (b) the transfer may pose a threat to the health or safety of the woman or the unborn child.
Examples of a Medical Emergency include, but are not limited to: heart attacks; strokes; convulsions; severe burns; obvious bone fractures; wounds requiring sutures; poisoning; and loss of consciousness.
Medically Necessary and Appropriate: This means or describes a health care service that a health care Provider, exercising his/her prudent clinical judgment, would provide to a Covered Person for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that is: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Person’s illness, injury or disease; not primarily for the convenience of the Covered Person or the health care Provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Person’s illness, injury or disease.
“Generally accepted standards of medical practice”, as used above, means standards that are based on:
a. credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;
b. physician and health care Provider specialty society recommendations;
c. the views of physicians and health care Providers practicing in relevant clinical areas; and
d. any other relevant factor as determined by the New Jersey Commissioner of Banking and Insurance by regulation.
Medicaid: The health care program for the needy provided by Title XIX of the United States Social Security Act, as amended from time to time.
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Medicare: Part A and Part B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time.
Mental Health Center: A Facility which mainly provides treatment for people with mental health problems. The Plan will recognize such a place if: (1) it carries out its stated purpose under all relevant state and local laws; and (2) it is:
a. accredited for its stated purpose by the Joint Commission;
b. approved for its stated purpose by Medicare; or
c. accredited or licensed by the state in which it is located to provide mental health services.
Mental or Nervous Disorders: Conditions which manifest symptoms that are primarily mental or nervous (whether organic or non-organic, biological or non-biological, chemical or non-chemical in origin and irrespective of cause, basis or inducement) for which the primary treatment is psychotherapy or psychotherapeutic methods or psychotropic medication. Mental or Nervous Disorders include, but are not limited to: psychoses; neurotic and anxiety disorders; schizophrenic disorders; affective disorders; personality disorders; and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems.
In determining whether or not a particular condition is a Mental or Nervous Disorder, the Plan may refer to the current edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (the “Manual”). But in no event shall the following be considered Mental or Nervous Disorders:
(1) Conditions classified as V-codes in the most current edition of the Manual. These include relational problems such as: parent-child conflicts; problems related to abuse or neglect when intervention is focused on the perpetrator; situations not attributable to a diagnostic disorder, including: bereavement, academic, occupational, religious, and spiritual problems.
(2) Conditions related to behavior problems or learning disabilities, except with respect to the treatment of Mental or Nervous Disorders or Developmental Disabilities.
(3) Conditions that the Plan determines to be due to developmental disorders. These include, but are not limited to: mental retardation; academic skills disorders; or motor skills disorders. But, this does not apply to the extent required by law for the treatment of Mental or Nervous Disorders or Developmental Disabilities.
(4) Conditions that the Plan determines to lack a recognizable III-R classification in the most current edition of the Manual. This includes, but is not limited to, treatment for: adult children of alcoholic families; or co-dependency.
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Mutually Exclusive Surgical Procedures: Surgical procedures that:
a. differ in technique or approach, but lead to the same outcome;
b. represent overlapping services or accomplish the same result;
c. in combination, may be anatomically impossible.
Negotiation Arrangement (a.k.a., Negotiated National Account Arrangement): An agreement negotiated between a control/home licensee and one or more par/host licensees for any national account that is not delivered through the BlueCard Program.
Network – the Blue Card Preferred Provider Organization Provider Network. Network means the Plan Prescription Drug Network. Non-Covered Charges: Charges for services and supplies which: (a) do not meet this Plan's definition of Covered Charges; (b) exceed any of the coverage limits shown in this Booklet; or (c) are specifically identified in this Booklet as Non-Covered Charges.
Nurse: A Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.), or a nursing specialist such as a nurse mid-wife or nurse anesthetist, who:
a. is properly licensed or certified to provide medical care under the laws of the state where he/she practices; and
b. provides medical services which are: (a) within the scope of his/her license or certificate; and (b) are covered by this Plan.
Out-of-Hospital: Services or supplies provided to a Covered Person other than as an Inpatient or Outpatient.
Out-of-Network: A Provider, or the services and supplies furnished by a Provider, who does not have an agreement with Horizon BCBSNJ to provide Covered Services or Supplies, depending on the context in which the term is used.
Out-of-Network Benefits: The coverage shown in the Schedule of Covered Services and Supplies which is provided if an Out-of-Network Provider provides the service or supply.
Out-of-Pocket Maximum: The maximum dollar amount that a Covered person must pay as Deductible or Coinsurance for Covered Services and Supplies during any Benefit Period. Once that dollar amount is reached, no further such payments are required for the remainder of that Benefit Period.
Outpatient: Either: (a) a Covered Person at a Hospital who is other than an Inpatient; or (b) the services and supplies provided to such a Covered Person, depending on the context in which the term is used.
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Partial Hospitalization: Intensive short-term non-residential day treatment services that are: (a) for Mental or Nervous Disorders; or chemical dependency; and (b) rendered for any part of a day for a minimum of four consecutive hours per day.
Per Lifetime: During the lifetime of a person.
Pharmacy: A Facility: (a) which is registered as a Pharmacy with the appropriate state licensing agency; and (b) in which Prescription Drugs are dispensed by a pharmacist.
Physical Rehabilitation Center: A Facility which mainly provides therapeutic and restorative services to ill or injured people. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by either the Joint Commission or the Commission on Accreditation for Rehabilitation Facilities; or
b. approved for its stated purpose by Medicare.
Plan: The SUEZ Water Resources Inc. Medical Plan
Plan Year: The twelve-month period starting on January 1st and ending on December 31st.
Post-Service Claim – is any claim for a benefit under a group health Plan that is not a Pre-Service claim.
Practitioner: A person that the Plan is required by law to recognize who:
a. is properly licensed or certified to provide medical care under the laws of the state where he/she practices; and
b. provides medical services which are: (a) within the scope of the license or certificate; and (b) are covered by this Plan.
Practitioners include, but are not limited to, the following; physicians; chiropractors; dentists; optometrists; pharmacists; chiropodists; psychologists; physical therapists; audiologists; speech language pathologists; certified nurse mid-wives; registered professional nurses; nurse practitioners; and clinical nurse specialists.
Prescription Drug Cost Share Amount: The sum total of the following In-Network expenses Incurred by a Covered Person or covered family during a Calendar Year under a self-insured stand-alone group prescription drug plan or an insured stand-alone group prescription drug plan provided by Horizon BCBSNJ or another carrier:
(a) Expenses that are applied toward the prescription drug plan’s deductible, if any (excluding any such expenses, including any fourth quarter deductible carry over as defined in the prescription drug plan, that were carried over from the preceding Calendar Year).
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(b) Amounts paid or payable by the Covered Person as copayments and/or coinsurance under the prescription drug plan.
Pre-Service Claim – is any claim for a benefit under a group health plan with respect to which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.
Preventive Care: Services or supplies that are not provided for the treatment of an Injury or Illness. It includes, but is not limited to: routine physical exams, including: related X-rays and lab tests; immunizations and vaccines; screening tests; well-baby care; and well adult care.
Prior Authorization: Authorization by Horizon BCBSNJ for a Practitioner to provide specified treatment to Covered Persons. After Horizon BCBSNJ gives this approval, Horizon BCBSNJ gives the Practitioner a certification number. Benefits for services that are required to be, but are not, given Prior Authorization are subject to reduction as described in the “Utilization Review and Management” section of this Booklet.
Program: The plan of group health benefits described in this Booklet.
Provider: A Facility or Practitioner of health care in accordance with the terms of this Plan.
Related Structured Behavioral Programs: Services given by a qualified Practitioner that are comprised of multiple intervention strategies, i.e., behavioral intervention packages, based on the principles of ABA. These include, but are not limited to: activity schedules; discrete trial instruction; incidental teaching; natural environment training; picture exchange communication system; pivotal response treatment; script and script-fading procedures; and self-management.
Routine Foot Care: The cutting, debridement, trimming, reduction, removal or other care of: corns; calluses; flat feet; fallen arches; weak feet; chronic foot strain; dystrophic nails; excrescences; helomas; hyperkeratosis; hypertrophic nails; non-infected ingrown nails; dermatomes; keratosis; onychauxis; onychocryptosis; tylomas; or symptomatic complaints of the feet.
Routine Nursing Care: The appropriate nursing care customarily furnished by a recognized Facility for the benefit of its Inpatients.
Skilled Nursing Care: Services which: (a) are more intensive than Custodial Care; (b) are provided by an R.N. or L.P.N.; and (c) require the technical skills and professional training of an R.N. or L.P.N.
Skilled Nursing Facility: A Facility which mainly provides full-time Skilled Nursing Care for ill or injured people who do not need to be in a Hospital. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by the Joint Commission; or
b. approved for its stated purpose by Medicare. In some places, a Skilled Nursing Facility
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may be called an "Extended Care Center" or a "Skilled Nursing Center."
Special Care Unit: A part of a Hospital set up for very ill patients who must be observed constantly. The unit must have a specially trained staff and special equipment and supplies on hand at all times. Some types of Special Care Units are:
a. intensive care units;
b. cardiac care units;
c. neonatal care units; and
d. burn units.
Special Enrollment Period – A period as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), during which you may enroll yourself and your Dependents for coverage under the Plan.
Specialist: A health care Practitioner who provides medical care in any generally accepted medical or surgical specialty or sub-specialty.
Spouse: The person who is legally married to the Employee. Proof of legal marriage must be submitted to the Plan when requested.
Substance Abuse: The abuse or addiction to drugs or controlled substances, including alcohol.
Substance Abuse Centers: Facilities that mainly provide treatment for people with Substance Abuse problems. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by the Joint Commission; or
b. approved for its stated purpose by Medicare.
Surgery/Surgical:
a. The performance of generally accepted operative and cutting procedures, including: surgical diagnostic procedures; specialized instrumentations; endoscopic exams; and other invasive procedures;
b. The correction of fractures and dislocations;
c. Pre-operative and post-operative care; or
d. Any of the procedures designated by C.P.T. codes as Surgery.
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Therapeutic Manipulation – the treatment of the articulations of the spine and musculoskeletal structures for the purpose of relieving certain abnormal clinical conditions resulting from the impingement upon associated nerves causing discomfort. Some examples are manipulation or adjustment of the spine, hot or cold packs, electrical muscle stimulation, diathermy, skeletal adjustments, massage, adjunctive therapy, ultra-sound, doppler, whirlpool or hydro-therapy or other treatment of a similar nature.
Therapy Services: The following services and supplies when they are:
a. ordered by a Practitioner;
b. performed by a Provider;
c. Medically Necessary and Appropriate for the treatment of a Covered Person's Illness or Accidental Injury.
Chelation Therapy: The administration of drugs or chemicals to remove toxic concentrations of metals from the body.
Chemotherapy: The treatment of malignant disease by chemical or biological antineoplastic agents.
Cognitive Rehabilitation Therapy: Retraining the brain to perform intellectual skills that it was able to perform prior to disease, trauma, Surgery, congenital anomaly or previous therapeutic process.
Dialysis Treatment: The treatment of an acute renal failure or chronic irreversible renal insufficiency by removing waste products from the body. This includes hemodialysis and peritoneal dialysis.
Infusion Therapy: The administration of antibiotic, nutrient, or other therapeutic agents by direct infusion.
Occupational Therapy: The treatment to develop or restore a physically disabled person's ability to perform the ordinary tasks of daily living.
Physical Therapy: The treatment by physical means to: relieve pain; develop or restore normal function; and prevent disability following Illness, Injury or loss of limb.
Radiation Therapy: The treatment of disease by X-ray, radium, cobalt, or high energy particle sources. Radiation Therapy includes the rental or cost of radioactive materials. Diagnostic Services requiring the use of radioactive materials are not Radiation Therapy.
Respiration Therapy: The introduction of dry or moist gases into the lungs.
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Speech Therapy: Therapy that is by a qualified speech therapist and is described in a., b. or c:
a. Speech therapy to restore speech after a loss or impairment of a demonstrated, previous ability to speak. Two examples of speech therapy that will not be covered are: (a) therapy to correct pre-speech deficiencies; and (b) therapy to improve speech skills that have not fully developed.
b. Speech therapy to develop or improve speech to correct a defect that both: (a) existed at birth; and (b) impaired or would have impaired the ability to speak.
c. Regardless of anything in a. or b. above to the contrary, speech therapy needed to treat a speech impairment of a Covered Person diagnosed with a Developmental Disability.
Urgent Care: Outpatient and Out-of-Hospital medical care which, as determined by the Plan or an entity designated by the Plan, is needed due to an unexpected Illness, Injury or other condition that is not life threatening, but that needs to be treated by a Provider within 24 hours.
Urgent Care Claim: An Urgent Care Claim is any claim for medical care which, if denied, in the opinion of the Covered Person or his/her Provider, will cause serious medical consequences in the near future, or subject the Covered Person to severe pain that cannot be managed without the medical services that have been denied.
Value-Based Program: An outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment.
Visit: An occasion during which treatment or consultation services are rendered in a Provider's office, in the Outpatient department of an eligible Facility, or by a Provider on the staff of (or under contract or arrangement with) a Home Health Agency to provide covered Home Health Care services or supplies.
Waiting Period – the period of time between enrollment in the program and the date when you become eligible for benefits. We, Us and Our: The Plan.
You, Your: An Employee.

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Schedule of Covered Services and Supplies
BENEFITS FOR COVERED SERVICES OR SUPPLIES UNDER THIS PLAN ARE SUBJECT TO ALL DEDUCTIBLE(S), COPAYMENT(S), COINSURANCE(S) AND MAXIMUM(S) STATED IN THIS SCHEDULE AND ARE DETERMINED PER BENEFIT PERIOD BASED ON ALLOWANCE, UNLESS OTHERWISE STATED.
NOTE: BENEFITS WILL BE REDUCED OR ELIMINATED FOR NONCOMPLIANCE
WITH THE UTILIZATION REVIEW PROVISIONS CONTAINED IN THIS PLAN.
REFER TO THE SECTION OF THIS PLAN CALLED “EXCLUSIONS” TO SEE WHAT SERVICES AND SUPPLIES ARE NOT COVERED.
The Plan will provide the coverage listed in this Schedule of Covered Services and Supplies,
subject to the terms, conditions, limitations and exclusions stated within this Plan.
Services and supplies provided by an In-Network Provider are covered at the In-Network level.
Services and supplies provided by an Out-of-Network Provider are covered at the
Out-of-Network level. However, this does not apply to services and supplies provided by an
Out-of-Network Provider in a case where: (a) the Covered Person is an Inpatient in a Hospital;
(b) the admitting physician was a Network Practitioner; and (c) the Covered Person and/or the
Covered Person's Practitioner complied with this Plan's rules with respect to Prior Authorization
or notification. In this case, the Covered Services and Supplies provided by Out-of-Network
Providers during the Inpatient stay will be covered at the In-Network level.
Please note that you may be responsible for paying charges, which exceed allowance when
services are rendered by an Out-of-Network Provider.
Coinsurance 85% of Covered Basic Charges.
In-Network
85% of Covered Supplemental Charges.
Coinsurance 60% of Covered Basic Charges.
Out-of-Network 60% of Covered Supplemental Charges.
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Out-of-Pocket Maximum In-Network After $5,000/Individual, $10,000/family, We provide 100% of Covered Allowance.
Note: The Out-of-Pocket Maximum of $5,000 applies to Husband/Wife and Parent/Child contracts. The Out-of-Pocket Maximum of $10,000 applies to family contracts.
Out-of-Pocket Maximum
Out-of-Network After $10,000/Individual, $20,000/family, We
provide 100% of Covered Allowance.
Note: The Out-of-Pocket Maximum of $10,000 applies to Husband/Wife and Parent/Child
contracts. The Out-of-Pocket Maximum of $20,000 applies to family contracts.

Note: The Out-Pocket Maximum cannot be met with:
• Non-Covered Charges Deductible In-Network Applies to $2,800/Individual.
Basic/Supplemental Services $4,500/family.
Note: If a family member reaches the $2,800 IRS minimum Deductible, benefits will begin to pay for that member. The minimum family deductible of $2,800 applies to Husband/Wife, Parent/Child and Family contracts. The true family aggregate Deductible is $4,500.
Deductible Out-of-Network Applies to $4,000/Individual. Basic/Supplemental Services $6,200/family.
Note: If a family member reaches the $4,000 Deductible, benefits will begin to pay for that member. The minimum family deductible of $4,000 applies to Husband/Wife and Parent/Child contracts. The true family aggregate Deductible is $6,200.
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BENEFIT PERIOD MAXIMUM
In-Network Unlimited. Applies to all Covered Services and Supplies.
Out-of-Network Unlimited. Applies to all Covered Services and Supplies.
PER LIFETIME MAXIMUMS
In-Network Unlimited. Applies to all Covered Services and Supplies.
Out-of-Network Unlimited. Applies to all Covered Services and Supplies.
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A. ELIGIBLE BASIC SERVICES AND SUPPLIES
ALLERGY TESTING AND TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
AMBULATORY SURGERY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
ANESTHESIA
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
COMPLEX IMAGING SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DENTAL CARE AND TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIAGNOSTIC X-RAY AND LABORATORY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIALYSIS CENTER CHARGES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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EMERGENCY ROOM (EMERGENT)
In-Network Outpatient
Facility Subject to Deductible and 85% Coinsurance.
Outpatient
Professional Subject to Deductible and 85% Coinsurance.
Out-of-Network Outpatient Facility Subject to Deductible and 85% Coinsurance.
Outpatient Professional Subject to Deductible and 85% Coinsurance. EMERGENCY ROOM (NON-EMERGENT)
In-Network Outpatient Facility Subject to Deductible and 85% Coinsurance.
Outpatient Professional Subject to Deductible and 85% Coinsurance.
Out-of-Network
Outpatient
Facility Subject to Deductible and 60% Coinsurance.
Outpatient Professional Subject to Deductible, and 60% Coinsurance.
FACILITY CHARGES 365 days Inpatient Hospital care.
In-Network Subject to Preapproval, Deductible, and 85% Coinsurance.
Out-of-Network Subject to Preapproval, Deductible, and 60% Coinsurance.
FERTILITY SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to 4 attempts per Lifetime.
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HOME HEALTH AGENCY CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 120 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
HOSPICE CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 210 day Benefit Period maximum.
INPATIENT PHYSICIAN SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
MATERNITY/OBSTETRICAL CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
MENTAL OR NERVOUS DISORDERS (INCLUDING GROUP THERAPY) AND SUBSTANCE ABUSE
Inpatient In-Network Subject to Prior Authorization, Deductible, and 85% Coinsurance.
Inpatient Out-of-Network Subject to Prior Authorization, Deductible and 60% Coinsurance.
In-Network Outpatient and Out-Of-Hospital Subject to Deductible, and 85% Coinsurance.
Out-of-Network Outpatient and Out-Of-Hospital Subject to Deductible, and 60% Coinsurance.
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NUTRITIONAL COUNSELING
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 3 Visit Benefit Period maximum.
PHYSICAL REHABILITATION
Inpatient In-Network Subject to Deductible, and 85% Coinsurance.
Inpatient Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 120 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
PRACTITIONER’S CHARGES FOR NON-SURGICAL CARE AND TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PRACTITIONER’S CHARGES FOR SURGERY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PREADMISSION TESTING
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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PREVENTIVE CARE
In-Network Subject to 100% Coinsurance. Applies to all Preventive Care except as noted below.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Applies to all Preventive Care except as noted below.
a. GYNECOLOGICAL CARE AND EXAMINATIONS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 exam per year.
b. MAMMOGRAPHY
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
c. PAP SMEARS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
d. ROUTINE PHYSICALS AND IMMUNIZATIONS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
e. WELL-CHILD CARE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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f. WELL-CHILD IMMUNIZATIONS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
g. PROSTATE CANCER SCREENING
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
h. COLORECTAL CANCER SCREENING
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
i. VISION EXAM - ANNUAL/ROUTINE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 exam per year.
j. HEARING EXAM - ROUTINE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 routine hearing exam or audiology function test per year for adults and children.
SECOND OPINION CHARGES
In-Network Subject to Deductible, and 85% Coinsurance
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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SKILLED NURSING FACILITY CHARGES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to 120 day Benefit Period maximum, combined In-Network and Out-of-Network.
SURGICAL SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
TELEMEDICINE BEHAVIORAL HEALTH SERVICES, PROVIDED BY HORIZON CAREONLINE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network No Benefit.
TELEMEDICINE MEDICAL SERVICES, PROVIDED BY HORIZON CAREONLINE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network No Benefit.
THERAPEUTIC MANIPULATIONS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
THERAPY SERVICES
In-Network Subject to Deductible and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
a. CHELATION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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b. CHEMOTHERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
c. COGNITIVE REHABILITATION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. d. DIALYSIS TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
e. INFUSION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
f. OCCUPATIONAL THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. g. PHYSICAL THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism.
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h. RADIATION TREATMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
i. RESPIRATION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
j. SPEECH THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. Note: Speech Therapy is eligible for restorative purposes only; it is not covered for developmental delay. TRANSPLANT BENEFITS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
URGENT CARE SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.

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B. ELIGIBLE SUPPLEMENTAL SERVICES AND SUPPLIES
AMBULANCE SERVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 85% Coinsurance.
BLOOD
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIABETES BENEFITS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DURABLE MEDICAL EQUIPMENT
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. FOOT ORTHOTICS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Subject to $1,000 maximum per Benefit Period. HOME INFUSION THERAPY
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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OXYGEN AND ADMINISTRATION
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PROSTHETIC DEVICES
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
SPECIALIZED NON-STANDARD INFANT FORMULAS
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
NON-ROUTINE VISION CARE
In-Network Subject to Deductible, and 85% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
WIGS BENEFIT
In-Network Subject to 85% Coinsurance.
Out-of-Network Subject to 85% Coinsurance.
Subject to $750.00 Benefit Period Maximum.
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General Information
How To Enroll
If you meet your Employer's eligibility rules, including any Waiting Period established by the Employer, you may enroll by completing an enrollment form. If you enroll your eligible Dependents at the same time, their coverage will become effective on the same date as your own. Except as otherwise provided below, if you or an eligible Dependent is not enrolled within 31 days after becoming eligible for the coverage under this Plan, that person is deemed a Late Enrollee.
Your Identification Card
You will receive an ID card to show to the Hospital, physician or other Provider when you receive services or supplies. Your ID card shows: (a) the group through which you are enrolled; (b) your type of coverage; and (c) your ID number. All of your covered Dependents share your identification number as well.
Always carry this card and use your ID number when you or a Dependent receive Covered Services or Supplies. If you lose your card, you can still use your coverage if you know your ID number. The inside back cover of this Booklet has space to record your ID number, along with other information you will need when asking about your benefits. You should, however, contact your benefits representative quickly to replace the lost card.
You cannot let anyone other than you or a Dependent use your card or your coverage.
Types of Coverage Available
You may enroll under one of the following types of coverage:
• Family – provides coverage for you, your Spouse or Domestic Partner and your Child Dependents.
• Husband and Wife/Two Adults – provides coverage for you and your Spouse or Domestic Partner only.
• Parent and Child(ren) – provides coverage for you and your Child Dependents, but not your Spouse or Domestic Partner.
Change In Type Of Coverage
If you want to change your type of coverage, see your benefits representative. If you marry, you should arrange for enrollment changes within 31 days before or after your marriage.
If: (a) you gain or lose a member of your family; or (b) someone covered under this Plan changes family status, you should check this Booklet to see if coverage should be changed. This can happen in many ways, e.g., due to the birth or adoption of a child, divorce, or death of a Spouse.
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You must enroll a newly born or newly adopted Child Dependent within 31 days of the date or birth or adoption in order to have coverage for your Child Dependent. If you are enrolled for Family or Parent and Child(ren) coverage, you must submit an enrollment form within 31 days from the date of birth or adoption to notify the Plan of the addition.
Except as provided below, anyone who does not enroll within a required time will be considered
a Late Enrollee. Late Enrollees may enroll only during the next open-enrollment month.
Coverage will be effective as of the open-enrollment date.
Enrollment of Dependents
The Plan cannot deny coverage for your Child Dependent on the grounds that:
• The Child Dependent was born out of wedlock;
• The Child Dependent is not claimed as a dependent on your federal tax return; or
• The Child Dependent does not reside with you or in the Service Area.
If you are the non-custodial parent of a Child Dependent, the Plan will:
• Provide such information to the custodial parent as may be needed for the Child
Dependent to obtain benefits through this Plan;
• Permit the custodial parent, or the Provider, with the authorization of the custodial parent,
to submit claims for the Child Dependent for Covered Services and Supplies, without
your approval; and
• Make payments on such claims directly to: (a) the custodial parent; (b) the Provider; or
(c) the Division of Medical Assistance and Health Services in the Department of Human
Services, which administers Medicaid, as appropriate.
If you are a parent who is required by a court or administrative order to provide health coverage
for your Child Dependent, the Plan will:
• Permit you to enroll your Child Dependent, without any enrollment restrictions;
• Permit: (a) the Child Dependent’s other parent; (b) the Division of Medical Assistance
and Health Services; or (c) the Division of Family Development as the State IV-D
agency, in the Department of Human Services, to enroll the Child Dependent in this Plan,
if the parent who is the Covered Person fails to enroll the Child Dependent; and
• Not terminate coverage of the Child Dependent unless the parent who is the Covered
Person provides Horizon BCBSNJ or the Plan with satisfactory written proof that:
• the court or administrative order is no longer in effect: or
• the Child Dependent is or will be enrolled in a comparable health benefits plan
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which will be effective on the date coverage under this Plan ends.
Special Enrollment Periods
Persons who enroll during a Special Enrollment Period described below are not considered Late Enrollees.
Individual Losing Other Coverage
If you and/or an eligible Dependent, are eligible for coverage, but not enrolled, you and/or your Dependent must be allowed to enroll if each of the following conditions is met:
a. The person was covered under a group or other health plan at the time coverage under this Plan was previously offered.
b. You stated in writing that coverage under the other plan was the reason for declining enrollment when it was offered.
c. The other health coverage:
(i) was under a COBRA (or other state mandated) continuation provision and the COBRA or other coverage is exhausted; or
(ii) was not under such a provision and either: (a) coverage was terminated as a result of: loss of eligibility for the coverage (including as a result of legal separation; divorce; death; termination of employment; or reduction in the number of hours of employment); or (b) employer contributions toward such coverage ended.
d. Enrollment is requested within 31 days after: (a) the date of exhaustion of the coverage described in item (c)(i) above; or (b) termination of the coverage or employer contributions as described in item (c)(ii) above.
In this case, coverage under this Plan will be effective as of the date that the prior health coverage ended.
New Dependents
If the following conditions are met, the Plan will provide a Dependent Special Enrollment Period during which the Dependent (or, if not otherwise enrolled, you) may enroll or be enrolled:
a. You are covered under the Plan (or have met any Waiting Period and are eligible to enroll but for a failure to enroll during a previous enrollment period).
b. The person becomes your dependent through marriage, birth, or adoption (or placement for adoption).
The Dependent Special Enrollment Period is a period of no less than 31 days starting on the later of: (a) the date dependent coverage is made available pursuant to this section; or (b) the date of
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the marriage, birth, or adoption/placement.
Special Enrollment Due to Marriage or Acquiring a Domestic Partner
You may enroll a new Spouse or Domestic Partner under this Plan. If you are eligible, but previously declined coverage, you are also eligible to enroll at the same time that your Spouse or Domestic Partner is enrolled.
You must request enrollment of your Spouse or Domestic Partner within 31 days after the marriage or acquiring the Domestic Partner.
The coverage becomes effective not later than the first day of the month next following the date of the completed request.
Special Enrollment Due to Newborn/Adopted Children
You may enroll a newly born or newly adopted Dependent Child.
If you do not make the request for enrollment and the contribution is not paid within such 31-day period, the newborn child will be a Late Enrollee.
Multiple Employment
If you work for both the Employer and an Affiliated Company, or for more than one Affiliated Company, the Plan will treat you as if employed only by one Employer. You will not have multiple coverage.
Eligible Dependents
Your eligible Dependents are your Spouse or Domestic Partner, your Child Dependents.
To enroll a Domestic Partner, you must provide proof that a Domestic Partnership exists by providing us with acceptable proof of the Domestic Partnership.
Coverage for your Spouse will end: (a) at the end of the month in which you divorce; or (b) at the end of the month in which you tell us to delete your Spouse from coverage following marital separation.
Coverage for a Child Dependent ends the last day of the Calendar Year in which the Child Dependent reaches age 26.
Coverage will continue for a child dependent beyond the age of 26 provided that prior to age 26 he or she was enrolled under the Plan and is incapable of self-sustaining employment by reason of mental retardation or physical handicap. For your handicapped child to remain covered, you must submit proof of the child’s inability to engage in self-sustaining employment by reason of mental retardation or physical handicap within 31 days of the child’s attainment of age 26. The
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proof must be in a form which meets the Plan’s approval. Such proof must be resubmitted every two (2) years within 31 days before or after the child’s birth date.
Coverage for a handicapped child dependent will end on the last day of the benefit month in which the earliest of the following occurs: the termination of your coverage, the failure of your child dependent to satisfy the definition of child dependent for any reason other than age and the termination of your child dependent’s inability to engage in self-sustaining employment by reason of mental retardation or physical handicap.
If your child was enrolled as a handicapped dependent under previous coverage with the Horizon BCBSNJ and there has been no interruption in coverage, the child may be covered as an eligible dependent under this program, regardless of age.
When Coverage Ends
Your coverage under this Plan ends when the first of these occurs:
• The end of the Benefit Month which you cease to be eligible due to termination of your employment or any other reason.
• The date on which the Plan ends for the class of which you are a member.
• You fail to make, when due, any required contribution for the coverage.
Coverage for a Dependent ends:
• When your coverage ends.
• When coverage for Dependents under this Plan ends.
• When you fail to make, when due, any required contribution for the Dependent coverage.
• As otherwise described under "Eligible Dependents", above.
In addition to the above reasons for the termination of coverage under the Plan, if a Covered Person,
(1) performs an act, practice or omission that constitutes fraud; or
(2) makes an intentional misrepresentation of material fact,
then the Plan has the right to rescind that Covered Person’s coverage under the Plan. The Plan will provide a notice of rescission to the Covered Person at least 30 days in advance of the termination date.
The Plan retains the right to recoup from any involved person all payments made and/or benefits paid on his/her behalf.
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Benefits After Termination
If you or a Dependent are confined as an Inpatient in a Facility on the date coverage ends, the Plan's benefits will be paid, subject to the Plan's terms, for Covered Services and Supplies furnished during the uninterrupted continuation of that stay.
Continuing Coverage Under the Federal Family and Medical Leave Act
If you take a leave that qualifies under the Federal Family and Medical Leave Act (FMLA) (e. g., to care for a sick family member, or after the birth or adoption of a Child Dependent), you may continue coverage under this Plan. You may also continue coverage for your Dependents.
You will be subject to the same Plan rules as an Active Employee. But, your legal right to have your Employer pay its share of the required contribution, as it does for Active Employees, is subject to your eventual return to Active work.
Coverage that continues under this law ends at the first to occur of the following:
• The date you again become Active.
• The end of a total leave period of 12 weeks in any 12 month period.
• The date coverage for you or a Dependent would have ended had you not been on leave.
• Your failure to make any required contribution.
Consult your benefits representative for application forms and further details.
Continuation of Coverage Under COBRA
Under a federal law called the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), you and your enrolled Dependents, not including a Dependent who is your Domestic Partner and any newborn or newly adopted child may have the opportunity to continue group health care coverage which would otherwise end, if any of these events occur:
• Your death;
• Your work hours are reduced;
• Your employment ends for a reason other than gross misconduct.
Each of your enrolled Dependents has the right to continue coverage if it would otherwise end due to any of these events:
• Your death;
• Your work hours are reduced;
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• Your employment ends for reason other than gross misconduct;
• You became entitled to Medicare benefits;
• In the case of your Spouse, the Spouse ceased to be eligible due to divorce or legal separation; or
• In the case of a Child Dependent, he/she ceased to be a Child Dependent under this Plan's rules.
You or your Dependent must notify your benefits representative of a divorce or legal separation, or when a child no longer qualifies as a Child Dependent. This notice must be given within 60 days of the date the event occurred. If notice is not given within this time, the Dependent will not be allowed to continue coverage.
You will receive a written election notice of the right to continue the insurance. In general, this notice must be returned within 60 days of the later of: (a) the date the coverage would otherwise have ended; or (b) the date of the notice. You or the other person asking for coverage must pay the required amount to maintain it. The first payment must be made by the 45th day after the date the election notice is completed.
If you and/or your Dependents elect to continue coverage, it will be identical to the health care coverage for other members of your class. It will continue as follows:
• Up to 18 months in the event of the end of your employment or a reduction in your hours. Further, if you or a covered Dependent are determined to be disabled, according to the Social Security Act, at the time you became eligible for COBRA coverage, or during the first 60 days of the continued coverage, that person and any other person then entitled to the continued coverage may elect to extend this 18-month period for up to an extra 11 months. To elect this extra 11 months, the person must give the Employer written proof of Social Security's determination before the first to occur of: (a) the end of the 18 month continuation period; or (b) 60 days after the date the person is determined to be disabled.
• Up to 36 months for your Dependent(s) in the event of: your death; your divorce or legal separation; your entitlement to Medicare; or your child ceasing to qualify as a Child Dependent.
Continuation coverage for a person will cease before the end of a maximum period just described if one of these events occurs:
• This Plan ends for the class you belong to.
• The person fails to make required payments for the coverage.
• The person becomes covered under any other group health plan. But, coverage will not end due to this rule until the end of any period for which benefits for them are limited, under the other plan.
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• The person becomes entitled to Medicare benefits.
If a person's COBRA coverage was extended past 18 months due to total disability; and there is a final determination (under the Social Security Act) that the person, before the end of the additional continuation period of 11 months, is no longer disabled, the coverage will end on the first of the month that starts more than 30 days after that determination.
NOTE: Any right to continue the Plan’s coverage that is granted to an Employee’s Spouse pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, shall not apply with respect to an Employee’s Domestic Partner.
The above is a general description of COBRA's requirements. If coverage for you or a Dependent ends for any reason, you should immediately contact your benefits representative to find out if coverage can be continued. Your Employer is responsible for providing all notices required under COBRA.
Continuation of Coverage under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
If the Employee is absent from work due to performing service in the uniformed services, this federal law gives the Employee the right to elect to continue the health coverage under this Plan (for himself/herself and the Employee’s Dependents, if any). If the Employee so elects, the coverage can be continued, subject to the payment of any required contributions, until the first to occur of the following:
 The end of the 24-month period starting on the date the Employee was first absent from work due to the service.
 The date on which the Employee fails to return to work after completing service in the uniformed services, or fails to apply for reemployment after completing service in the uniformed services.
 The date on which this Plan ends.
If the Employee elects to continue the coverage, the Employee’s contributions for it are determined as follows:
a) If the Employee’s service in the uniformed services is less than 31 days, his/her contribution for the coverage will be the same as if there were no absence from work.
b) If the service extends for 31 or more days, the Employee’s contribution for the coverage can be up to 102% of total cost of coverage.
For the purposes of this provision, the terms “uniformed services” and “service in the uniformed services” have the following meanings:
Uniformed services: The following:
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1. The Armed Services.
2. The Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty.
3. The commissioned corps of the Public Health Service.
4. Any other category of persons designated by the President in time of war or national emergency.
Service in the uniformed services: The performance of duty on a voluntary or involuntary basis in a uniformed service under competent authority. This includes:
1. Active duty.
2. Active and inactive duty for training.
3. National Guard duty under federal statute.
4. A period for which a person is absent from employment: (a) for an exam to determine the fitness of the person to perform any such duty; or (b) to perform funeral honors duty authorized by law.
5. Service as: (a) an intermittent disaster-response appointee upon activation of the National Disaster Medical System (NDMS); or (b) a participant in an authorized training program in support of the mission of the NDMS.
Continuation of Care
Horizon BCBSNJ will provide written notice to each Covered Person at least 30 business days prior to the termination or withdrawal from Horizon BCBSNJ’s Network of a Covered Person’s Provider currently treating the Covered Person, as reported to Horizon BCBSNJ. The 30 day prior notice may be waived in cases of immediate termination of a Provider based on: breach of contract by the Provider; a determination of fraud; or Horizon BCBSNJ medical director's opinion that the Provider is an imminent danger to the patient or the public health, safety or welfare.
The Plan shall assure continued coverage of Covered Services and Supplies by a terminated Provider for up to four months in cases where it is Medically Necessary and Appropriate for the Covered Person to continue treatment with that Provider. In the case of pregnancy of a Covered Person: (a) the Medical Necessity and Appropriateness of continued coverage by that Provider shall be deemed to be shown; and (b) such coverage can continue to the postpartum evaluation of the Covered Person, up to six weeks after the delivery.
In the event that a Covered Person is receiving post-operative follow-up care, the Plan shall continue to cover services rendered by the Provider for the duration of the treatment, up to six months. In the event that a Covered Person is receiving oncological or psychiatric treatment, the Plan shall continue to cover services rendered by the Provider for the duration of the treatment,
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up to one year. If the services are provided in an acute care Facility, the Plan will continue to cover them regardless of whether the Facility is under contract or agreement with Horizon BCBSNJ.
Covered Services and Supplies shall be covered to the same extent as when the Provider was employed by or under contract with Horizon BCBSNJ. Payment for Covered Services and Supplies shall be made based on the same methodology used to reimburse the Provider while the Provider was employed by or under contract with Horizon BCBSNJ.
The Plan shall not allow continued services in cases where the Provider was terminated due to: (a) Horizon BCBSNJ Medical Director's opinion that the Provider is an imminent danger to a patient or to the public health, safety and welfare, (b) a determination of fraud; or (c) a breach of contract.
Medical Necessity And Appropriateness
We will make payment for benefits under this Plan only when:
• Services are performed or prescribed by your attending physician;
• Services, in our judgment, are provided at the proper level of care (Inpatient; Outpatient; Out-of-Hospital; etc.);
• Services or supplies are Medically Necessary and Appropriate for the diagnosis and treatment of an Illness or Injury.
THE FACT THAT YOUR ATTENDING PHYSICIAN MAY PRESCRIBE, ORDER, RECOMMEND OR APPROVE A SERVICE OR SUPPLY DOES NOT, IN ITSELF, MAKE IT MEDICALLY NECESSARY AND APPROPRIATE FOR THE DIAGNOSIS AND TREATMENT OF AN ILLNESS OR INJURY OR MAKE IT AN ELIGIBLE MEDICAL EXPENSE.
Cost Containment
If it has been determined that an eligible service can be provided in a medically acceptable, cost-effective alternative setting, we reserve the right to provide benefits for such a service when it is performed in that setting.
Managed Care Provisions
Member Services
The Member Services Representatives who staff Horizon BCBSNJ Member Services Departments are there to answer Covered Persons' questions about the Plan and to assist in managing their care. To contact Member Services, a Covered Person should call the number on his/her Identification (ID) Card.
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Miscellaneous Provisions
a. This Plan is intended to pay for Covered Services and Supplies as described in this Booklet. The Plan does not provide the services or supplies themselves, which may, or may not, be available.
b. The Plan is only required to provide its Allowance for Covered Services and Supplies, to the extent stated in the Plan. The Plan has no other liability.
c. Benefits are to be provided in the most cost-effective manner practicable. If the Plan determines that a more cost-effective manner exists, the Plan reserves the right to require that care be rendered in an alternate setting as a condition of providing payment for benefits.
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YOUR PREFERRED PROVIDER ORGANIZATION (PPO) PROGRAM
Your PPO Program provides you with the freedom to choose any Provider; however, your choice of Providers will determine how your benefits are paid. Benefits provided by In-Network Providers will be paid at a higher benefit level than benefits provided for an Out-of-Network Provider. You will be responsible for any Deductible, Coinsurance and Copayments that apply; however, if you use In-Network Providers, you will not have to file claims. In-Network Providers will accept our payment as payment in full. Out-of-Network Providers may balance bill to charges, and you will generally need to file claims to receive benefits.
Your Plan shares the cost of your health care expenses with you. This section explains what you pay, and how Deductibles, Coinsurance and Copayments work together.
Note: Coverage will be reduced if a Covered Person does not comply with the Utilization Review and Management and Prior Authorization requirements contained in this Plan.
BENEFIT PROVISIONS
The Deductible
The services and supplies covered under the Plan (except Preventive Care services) are subject to a Deductible (as described below) which must be met during a Calendar Year before any benefits are payable. There are separate Deductibles for In-Network Coverage and for Out-of-Network Coverage. After an applicable Deductible is met, the Covered Services and Supplies are further subject to any applicable Coinsurance described in the Schedule of Covered Services and Supplies.
For Other than Single Coverage (applies when the Employee and at least one other family member (collectively, the “Covered Family”) are covered.
Each Calendar Year, each Covered Family must have Covered Charges that exceed the Deductible before Plan pays any benefits to or for any member of that family. There are separate Other than Single Coverage Deductibles for In-Network and Out-of-Network coverage. The Deductibles are shown in the Schedule of Covered Services and Supplies. The applicable Deductible cannot be met with Non-Covered Charges. And only Covered Charges Incurred by the Covered Family while covered by the Policy can be used to meet the applicable Deductible.
A Covered Charge, whether Incurred In-Network or Out-of-Network, can be used to meet each of the Multiple Coverage Deductibles, until the In-Network Multiple Coverage Deductible is met. Once that occurs, the difference between the In-Network Multiple Coverage Deductible and the Out-of-Network Multiple Coverage Deductible must still be met for the family members to be eligible for Out-of-Network benefits, and only Covered Charges Incurred Out-of-Network can be used to meet this difference.
Once one or more members of a Covered Family have Incurred a combined total of Covered Charges toward the applicable Deductible equal to the Other than Single Coverage Deductible, Plan pays benefits for other Covered Charges Incurred by those members (In-Network or Out-of-
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Network, as the case may be), less any applicable Coinsurance, for the rest of that Calendar Year. But all charges must be Incurred while those members are covered by the Plan. And what Plan pays is based on all of the Plan’s terms.
Out-of-Pocket Maximum
Multiple Coverage (Applies when the Employee and at least one other family member are covered)
This Program limits the amount that the covered members of a family have to pay “out-of-pocket” during a Calendar Year for Covered Services and Supplies. This “Out-of-Pocket Maximum” is described in the “Schedule of Covered Services and Supplies” (the Schedule). There are separate maximums for In-Network and Out-of-Network expenses.
Once the covered members of a family individually or collectively have Incurred, during a Calendar Year, an amount of Covered Charges for which no benefits have been paid or are payable equal to a Multiple Coverage Out-of-Pocket Maximum, the Plan will pay 100% of any additional Covered Charges (In-Network or Out-of-Network, as the case may be) Incurred by those members for the rest of the year.
An Out-of-Pocket Maximum cannot be met with Non-Covered Charges. But solely for the purposes of this subsection, a Covered Person’s or covered family’s Prescription Drug Cost Share Amount shall be applied towards the applicable In-Network Out-of-Pocket Expense Maximum under this Program.
Payment Limits
The Plan limits what it will pay for certain types of charges. We may also limit what we will pay for all Illnesses and Injuries. See the Schedule of Covered Services and Supplies for these limits.
Benefits From Other Plans
The benefits the Plan will provide may also be affected by benefits from Medicare and other health benefit plans. Read The Effect of Medicare on Benefits and Coordination of Benefits and Services sections of this Booklet for an explanation of how this works.

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Summary of Covered Services and Supplies
This section lists the types of charges the Plan will consider as Covered Services or Supplies up to its Allowance subject to all the terms of your group’s program including, but not limited to, Medical Necessity and Appropriateness, Utilization Management features, Schedule of Covered Services and Supplies, benefit limitations and exclusions.
A. ELIGIBLE BASIC SERVICES AND SUPPLIES
Allergy Testing and Treatment
This Plan covers allergy testing and treatment, including routine allergy injections.
Ambulatory Surgery
The Plan covers charges for Ambulatory Surgery performed in a Hospital Outpatient department
or Out-of-Hospital, a Practitioner’s office or an Ambulatory Surgical Center in connection with
covered Surgery.
Anesthesia
The Plan covers anesthetics and their administration.
Audiology Services
This Plan covers audiology services rendered by a physician or licensed audiologist or licensed
speech-language pathologist. The services must be: (a) determined to be Medically Necessary
and Appropriate; and (b) performed within the scope of the Practitioner's practice.
Birthing Centers
Deliveries in Birthing Centers, in many cases, are deemed an effective cost-saving alternative to
Inpatient Hospital care. At a Birthing Center, deliveries take place in “birthing rooms,” where
decor and furnishings are designed to provide a more natural, home-like atmosphere.
All care is coordinated by a team of certified nurse-midwives and pediatric nurse-practitioners.
Obstetricians, pediatricians and a nearby Hospital are available in case of complications.
Prospective Birthing Center patients are carefully screened. Only low-risk pregnancies are
accepted. High-risk patients are referred to a Hospital maternity program.
The Birthing Center's services, including pre-natal, delivery and post-natal care, will be covered
in full. If complications occur during labor, delivery may take place in a Hospital because of the
need for emergency and/or Inpatient care. If, for any reason, the pregnancy does not go to term,
the Plan will not provide payment to the Birthing Center.
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Dental Care and Treatment
The Plan covers:
a. the diagnosis and treatment of oral tumors and cysts; and
b. the surgical removal of bony impacted teeth; and
c. charges for Surgical treatment of temporo-mandibular joint dysfunction syndrome (TMJ) in a Covered Person. However, the Plan does not cover any charges for orthodontia, crowns or bridgework.
Treatment of an Accidental Injury to natural teeth or the jaw is covered, but only if:
a. the Accidental Injury occurs while the Covered Person is covered under your group’s Plan.
b. the Accidental Injury was not caused, directly or indirectly, by biting or chewing.
c. treatment is performed within 18 months from the date of injury.
Treatment includes replacing natural teeth lost due to such Accidental Injury, in no event does it include orthodontic treatment.
For a Covered Person who is severely disabled or who is a Child Dependent under age 6, coverage shall be provided for the following:
a. General anesthesia and Hospitalization for dental services; or
b. Dental services rendered by a dentist regardless of where the dental services are provided for medical conditions covered by this Plan which require Hospitalization for general anesthesia.
This coverage shall be subject to the same utilization requirements imposed upon all inpatient stays.
Diagnosis and Treatment of Autism
This Plan provides coverage for charges for the screening and diagnosis of autism.
If a Covered Person’s primary diagnosis is autism, and regardless of anything in the Plan to the contrary, the Plan provides coverage when: (i) the services are given Prior Authorization; and (ii) the services are for the following Medically Necessary and Appropriate Therapy Services, as prescribed in a treatment plan:
(a) Occupational Therapy needed to develop the Covered Person’s ability to perform the
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ordinary tasks of daily living;
(b) Physical Therapy needed to develop the Covered Person’s physical functions; and
(c) Speech Therapy needed to treat the Covered Person’s speech impairment.
Notwithstanding anything in the Plan to the contrary, the foregoing Therapy Services as prescribed in a treatment plan will not be subject to benefit Visit maximums.
Also, if a Covered Person’s primary diagnosis is autism, in addition to coverage for certain Therapy Services, as described above, the Plan also covers Medically Necessary and Appropriate: (a) Behavioral Interventions Based on Applied Behavioral Analysis (ABA); and (b) Related Structured Behavioral Plans. Such interventions and programs must be prescribed in a treatment plan.
Benefits for these services are payable on the same basis as for other conditions, and they are available under this provision whether or not the services are restorative. Benefits for the above Therapy Services available pursuant to this provision are payable separately from those payable for other conditions and will not operate to reduce the Therapy Services benefits available under the Plan for those other conditions.
Any treatment plan referred to above must: (a) be in writing; (b) be signed by the treating Practitioner; and (c) include: (i) a diagnosis; (ii) proposed treatment by type, frequency and duration; (iii) the anticipated outcomes stated as goals; and (iv) the frequency by which the treatment plan will be updated.
With respect to the covered behavioral interventions and programs mentioned above, the term “Practitioner” shall also include a person who is credentialed by the national Analyst Certification Board as either: (a) a Board Certified Behavior Analyst-Doctoral; or (b) a Board Certified Behavior Analyst.
The Plan may request more information if it is needed to determine the coverage under the Plan. The Plan may also require the submission of an updated treatment plan once every six months, unless the Plan and the treating physician agree to more frequent updates.
Diagnostic X-rays and Laboratory Tests
The Plan covers charges for diagnostic x-rays and laboratory tests.
Emergency Room
This Plan covers services provided by a Hospital emergency room to treat a Medical Emergency or provide a Medical Screening Examination.
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Facility Charges
The Plan covers charges for Hospital semi-private room and board and routine nursing care when it is provided to you by a Hospital on an inpatient basis.
If a Covered Person incurs charges as an inpatient in a special care unit, the Plan covers the charges the same way it covers charges for any Illness.
The Plan will also cover Outpatient Hospital services including services provided by a Hospital Outpatient clinic. The Plan covers emergency room treatment
If a Covered Person is an inpatient in a Facility at the time your group’s program ends, the Plan will continue to cover that Facility stay in accordance with all other terms of your group’s program.
Fertility Services
This Plan covers charges for procedures designed to enhance fertility, including, artificial insemination. However, fertility enhancement treatments, such as in-vitro fertilization, in-vivo fertilization, gamete-intra-fallopian-transfer (GIFT), Zygote Intra-fallopian-transfer (ZIFT), sperm, egg, and/or inseminated eggs procurement and processing and freezing, and storage and thawing of sperm and/or embryos are specifically excluded.
Home Health Agency Care
This Plan covers Home Health Care services furnished by Home Health Agency.
In order for Home Health Agency charges to be considered Covered Charges, the Covered Person's Admission to Home Health Agency care may be direct to Home Health Agency care with no prior Inpatient Admission.
This Plan does not cover:
a. services furnished to family members, other than the patient; or
b. services and supplies not included in the Home Health Care plan; or
c. services that are mainly Custodial Care.
Hospice Care
Hospice Care benefits will be provided for:
1. part-time professional nursing services of an R.N., L.P.N. or Licensed Viatical Nurse (L.V.N.);
2. home health aide services provided under the supervision of an R.N.;
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3. medical care rendered by a Hospice Care Program Practitioner;
4. therapy services;
5. Diagnostic Services;
6. medical and Surgical supplies and Durable Medical Equipment if given Prior Authorization by Horizon BCBSNJ;
7. Prescription Drugs;
8. oxygen and its administration;
9. medical social services;
10. respite care;
11. psychological support services to the Terminally Ill or Injured patient;
12. family counseling related to the patient's terminal condition;
13. dietician services;
14. Inpatient room, board and general nursing services; and
15. Bereavement counseling.
No Hospice Care benefits will be provided for:
1. medical care rendered by the patient's private Practitioner;
2. volunteer services or services provided by others without charge;
3. pastoral services;
4. homemaker services;
5. food or home-delivered meals;
6. Private-Duty Nursing services;
7. dialysis treatment;
8. treatment not included in the Hospice Care Program;
9. services and supplies provided by volunteers or others who do not normally charge for their services;
10. funeral services and arrangements;
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11. legal or financial counseling or services; or
12. any Hospice Care services that are not given Prior Authorization by Horizon BCBSNJ.
Respite care benefits are limited to a maximum of 15 days per Covered Person per Benefit Period;
Bereavement counseling is covered for a maximum of 15 visits;
“Terminally Ill or Injured” means that the Covered Person’s Practitioner has certified in writing that the Covered Person’s life expectancy is six months or less.
Hospice care must be furnished according to a written “Hospice Care Program”.
Inpatient Physician Services
This Plan provides benefits for Covered Services and Supplies furnished by a physician to a Covered Person who is a registered Inpatient in a Facility.
Mastectomy Benefits
This Plan covers a Hospital stay of at least 72 hours following a modified radical mastectomy
and a Hospital stay of at least 48 hours following a simple mastectomy. A shorter length of stay
may be covered if the patient, in consultation with her physician, determines that it is Medically Necessary and Appropriate. The patient’s Provider does not need to obtain Prior Authorization for prescribing 72 or 48 hours, as appropriate, of Inpatient care. But, any rule of this Plan that that the patient or her Provider notify Horizon BSBSNJ about the stay remains in force.
Benefits for these services shall be subject to the same Deductible, Copayments and/or
Coinsurance as for other Hospital services covered under this Plan.
Maternity/Obstetrical Care
Pursuant to both federal and state law, covered medical care related to pregnancy; childbirth; abortion; or miscarriage, includes: (a) the Hospital delivery; and (b) a Hospital Inpatient stay for at least 48 hours after a vaginal delivery or 96 hours after a cesarean section. This applies if: (a)
the attending physician determines that Inpatient care is Medically Necessary and Appropriate;
or (b) if it is requested by the mother (regardless of Medical Necessity and Appropriateness). For the purposes of this subsection and as required by state law, “attending physician” shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child. For the purposes of this provision and as required by federal law, a Hospital
Inpatient stay is deemed to start:
(a) at the time of delivery; or
(b) in the case of multiple births, at the time of the last delivery; or
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(c) if the delivery occurs out of the Hospital, at the time the mother or newborn is admitted to
the Hospital.
Services and supplies provided by a Hospital to a newborn child during the initial Hospital stay of the mother and child are covered as part of the obstetrical care benefits. But, if the child's care is given by a different physician from the one who provided the mother's obstetrical care, the child's care will be covered separately.
If they are given Prior Authorization by Horizon BCBSNJ, this Plan also covers Birthing Center charges (see above) made by a Practitioner for: (a) pre-natal care; (b) delivery; and (c) post-partum care for a Covered Person's pregnancy.
Maternity/Obstetrical Care for Child Dependents
The Plan covers Obstetrical Benefits for a Child Dependent. A female Child Dependent is
covered under the Plan for any services incident to or resulting from her pregnancy. However, the plan does not provide coverage to a child of a Child Dependent.
Medical Emergency
This Plan covers charges relating to a Medical Emergency. This includes diagnostic X-ray and
lab charges Incurred due to the Medical Emergency.
Benefits include coverage of trauma at any designated level I or II trauma center, as Medically Necessary and Appropriate. The coverage continues at least until, in the judgment of the
attending physician, the Covered Person: (a) is medically stable; (b) no longer requires critical care; and (c) can be safely transferred to another Facility, if needed. The Plan will also cover a medical screening exam that is: (a) rendered upon a Covered Person’s arrival at a Hospital; (b)
required under federal law to be performed by the Hospital; and (c) needed to determine whether a Medical Emergency situation exists.
In the event of a potentially life-threatening condition, the Covered Person should use the 911
emergency response system. Further 911 information is available on the Identification Card.
Mental or Nervous Disorders (including Group Therapy) and Substance Abuse
The Plan covers treatment for Mental or Nervous Disorders and Substance Abuse.
A Covered Person may receive covered treatment as an Inpatient in a Hospital or a Substance
Abuse Center. He/she may also receive covered treatment at a Hospital Outpatient Substance Abuse Center, or from any Practitioner (including a psychologist or social worker). The benefits for the covered treatment of Mental or Nervous Disorders or Substance Abuse are provided on
the same basis and subject to the same terms and conditions as for other Illnesses.
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Nutritional Counseling
This Plan covers charges for nutritional counseling for the management of a medical condition that has a specific diagnostic criteria that can be verified. The nutritional counseling must be prescribed by a Practitioner. This section does not apply to nutritional counseling related to "Diabetes Benefits".
Physical Rehabilitation
This Plan covers Inpatient treatment in a Physical Rehabilitation Center. Inpatient treatment will include the same services and supplies available to any other Facility Inpatient.
Practitioner’s Charges for Non-Surgical Care and Treatment
This Plan covers Practitioner's charges for the non-Surgical care and treatment of an Illness, Injury, Mental or Nervous Disorder or Substance Abuse. This includes Medically Necessary pharmaceuticals which in the usual course of medical practice are administered by a Practitioner, if the pharmaceuticals are billed by the Practitioner or by a Specialty Pharmaceutical Provider.
Practitioner’s Charges for Surgery
This Plan covers Practitioners' charges for Surgery. This Plan does not cover Cosmetic Surgery. Surgical procedures include: (a) those after a mastectomy on one or both breasts; (b) reconstructive breast Surgery; and (c) Surgery to achieve symmetry between both breasts.
Pre-Admission Testing Charges
The Plan covers Pre-Admission diagnostic x-ray and laboratory tests needed for a planned Hospital Admission or Surgery. The Plan only covers these tests if the tests are done on an Outpatient or Out-of-Hospital basis within 7 days of the planned Admission or Surgery.
However, the Plan does not cover tests that are repeated after Admission or before Surgery, unless the Admission or Surgery is deferred solely due to a change in the Covered Person’s health.
Preventive Care
This program provides benefits for certain Covered Services and Supplies relating to Preventive Care including related diagnostic x-rays and laboratory tests. Coverage is limited each Benefit Period as described in the Schedule of Covered Services and Supplies. The covered Preventive Care benefits are as follows: a. Gynecological Care and Examinations
This program covers routine gynecological care and examinations including 1 pap smear per Benefit Period as designated in the Schedule of Covered Services and Supplies.
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b. Mammography
This program covers charges made for mammograms provided to a female Covered Person according to the schedule below. Coverage will be provided, subject to all the terms of your Plan, and the following limitations:
The Plan will cover charges for: a. one baseline mammogram for female Covered Persons who are at least 35 but less than 40 years of age. (However, if the woman is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, the Plan will cover a mammogram at such age and intervals as deemed needed by the woman’s Practitioner.) b. one mammogram each year for female Covered Persons age 40 and older.
c. Pap Smears
This program provides benefits for charges Incurred in conducting a Pap smear. This benefit, except as may be Medically Necessary and Appropriate for diagnostic purposes, shall be limited to one pap smear per Benefit Period. d. Routine Physicals and Immunizations
This program covers routine physical examination(s) and immunizations for you and your Spouse and Dependent Children over the age of 19 as designated in the Schedule of Covered Services and Supplies. e. Well-Child Care Benefits
Benefit are provided for well-child care for your enrolled child dependents through the end of the day before the child attains age nineteen. Well-child care services according to the following schedule:
• 7 visits up to age 1;
• 3 visits age 1 up to age 2;
• 1 visit each year ages 2 up to age 18.
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f. Well-Child Immunizations
Well-Child immunizations and lead poisoning screening and treatment are covered without age restriction. In order to be covered under this section, childhood immunizations must be as recommended by the Advisory Committee on Immunization Practices of the United States Public Health Service and the Department of Health pursuant to Section 7. of P.L. 1995, Ch 316.
g. Prostate Cancer Screening
This program covers 1 routine office visit per Benefit Period for adult Covered Persons, including a digital rectal examination and a prostate-specific antigen test for adult male Covered Persons.
h. Colorectal Cancer Screening
Coverage is provided for colorectal cancer screening rendered at regular intervals for Covered Persons 50 years of age or older and forCovered Persons of any age who are deemed to be at high risk for this type of cancer.
Covered test include: a screening fecal occult blood test; flexible sigmoidoscopy; colonoscopy; barium enema; any combination of these tests; or the most reliable, medically recognized screening test available.
For the purposes of this part, “high risk for colorectal cancer” means that a Covered Person has: (a) a family history of: familial adenomatous polyposis; hereditary non-polyposis colon cancer; or breast, ovarian, endometrial or colon cancer or polyps; (b) chronic inflammatory bowel disease, or (c) a background, ethnicity or lifestyle that the Covered Person’s physician believes puts the Covered Person at elevated risk for colorectal cancer.
The method and frequency of screening shall be: (a) in accordance with the most recent published guidelines of the American Cancer Society; and (b) as deemed to be medically necessary by the Covered Person’s physician, in consultation with the Covered Person.
i. Routine vision exam.
Routine vision screening (one per year) as part of wellness exam.
j. Hearing Exam.
One routine hearing exam or audiology function test per year for adults and children.
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k. Additional Preventive Services
In addition to any other Preventive Care benefits described above, the Plan shall cover the following preventive services and shall not impose any cost-sharing requirements, such as Deductibles, Copayments or Coinsurance, on any Covered Person receiving them:
1. Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force;
2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person;
3. For infants and children (if coverage under the Plan are provided for them) and adolescents who are Covered Persons, evidence-informed Preventive Care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
4. With respect to female Covered Persons, such additional preventive care and screenings, not described in part 1, above, as are provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
New recommendations to the preventive services listed above at the schedule established by the Secretary of Health and Human Services shall administratively updated.
Second Opinion Charges
If a covered Person is scheduled for an Elective Surgical Procedure, this Plan covers a Practitioner's charges for a second opinion and charges for related diagnostic X-ray and lab tests. If the second opinion does not confirm the need for the Surgery, this Plan will cover a Practitioner's charges for a third opinion regarding the need for the Surgery. This Plan will cover charges if the Practitioner(s) who gives the opinion:
a. are board certified and qualified, by reason of his/her specialty, to give an opinion on the proposed Surgery or Hospital Admission;
b. are not a business associate of the Practitioner who recommended the Surgery; and
c. do not perform or assist in the Surgery if it is needed.
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Skilled Nursing Facility Charges
This Plan covers bed and board (including diets, drugs, medicines and dressings and general nursing service) in a Skilled Nursing Facility. The Covered Person must be admitted to the Skilled Nursing Facility within 14 days of discharge from a Hospital, for continuing medical care and treatment prescribed by a Practitioner.
Surgical Services
Subject to all of the Plan’s other terms and conditions, the Plan covers Surgery, subject also to the following requirements:
a. The Plan will not make separate payment for pre- and post-operative care.
b. Subject to the following exception, if more than one surgical procedure is performed: (i) on the same patient; (ii) by the same physician; and (iii) on the same day, the following rules apply:
1 The Plan will cover the primary procedure, plus 50% of what the Plan would have paid for each of the other procedures, up to five, had those procedures been performed alone.
2. If more than five surgical procedures are performed, each of the procedures beyond the fifth will be reviewed. The amount that the Plan will pay for each such procedure will then be based on the circumstances of the particular case.
Exception: The Plan will not cover or make payment for any secondary procedure that, after review, is deemed to be a Mutually Exclusive Surgical Procedure or an Incidental Surgical Procedure.
As part of the coverage for Surgery, if a Covered Person is receiving benefits for a mastectomy, the Plan will also cover the following, as determined after consultation between the attending physician and the Covered Person:
• Reconstruction of the breast on which the mastectomy was performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Prostheses and the treatment of physical complications at all stages of the mastectomy, including lymphodemas.
Also, see “Transplant Benefits”.
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Telemedicine Services, provided by Horizon CareOnline
SUEZ Water Resources Inc. has selected an innovative Telemedicine Program, Horizon CareOnline, for its members through Horizon BCBSNJ, currently powered by American Well. This additional Program allows you to visit with an American Well general practitioner via telecommunication using a computer, tablet or smart phone. This Program also allows you to visit with American Well psychiatrists, psychologists, or social workers for treatment of Mental or Nervous Disorders via telecommunication using a computer, tablet or smart phone. The Program does not provide additional covered services (or benefits) under your health benefit plan. Telemedicine is a covered benefit only when provided through Horizon BCBSNJ’s designated telemedicine vendor. The Telemedicine Program is not available to Covered Persons who are eligible for Medicare when Medicare is primary to this Plan.
Therapeutic Manipulation
The Plan covers charges for Therapeutic Manipulations.
Therapy Services
The Plan covers charges for all Therapy Services.
Transplant Benefits
This Plan covers services and supplies for the following types of transplants:
a. Cornea;
b. Kidney;
c. Lung;
d. Liver;
e. Heart;
f. Heart valve;
g. Pancreas;
h. Small bowel;
i. Chondrocycte (for knee);
j. Heart/Lung;
k. Kidney/Pancreas;
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l. Liver/Pancreas;
m. Double lung;
n. Heart/Kidney;
o. Kidney/Liver;
p. Liver/Small Bowel;
q. Multi-visceral transplant (small bowel and liver with one or more of the following: stomach; duodenum; jejunum; ileum; pancreas; colon);
r. Allogeneic bone marrow;
s. Allogeneic stem cell;
t. Non-myeloblative stem cell;
u. Tandem stem cell.
This Plan also provides benefits for the treatment of cancer by dose-intensive Chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants. This applies only to transplants that are performed:
a by institutions approved by the National Cancer Institute; or
b. pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Such treatment will be covered to the same extent as for any other Illness.
When organs/tissues are harvested from a cadaver, this Plan will also cover those charges for Surgical, storage and transportation services that: (a) are directly related to donation of the organs/tissues; and (b) are billed for by the Hospital where the transplant is performed.
Eligible expenses include transportation of the patient and one companion who is traveling on the same days to and or from the site of the transplant of the purpose of an evaluation, the transplant procedure or necessary post- discharge follow up, reasonable and necessary expense for lodging and meals for the patient (while not confined) and one companion, benefits are paid at a per diem rate of up to $50 for one person or up to $100 for two people, travel and lodging expense are only available if the transplant recipient resides more than 50 miles from the facility performing the transplant, if the patient is a dependant minor child- then the transportation expenses of two companions will be covered and lodging and meal expenses will be reimbursed up to the $100 per diem rate, there is a combined overall LIFETIME MAX OF $10,000.00 per covered person for ALL transportation, lodging and meal expenses incurred by the transplant recipient and companion's) and reimbursed under this plan in connection with all transplant procedures
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Urgent Care
This Plan provides benefits for Covered Services and Supplies furnished for Urgent Care of a Covered Person.
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B. ELIGIBLE SUPPLEMENTAL SERVICES AND SUPPLIES
Ambulance Services
The Plan covers charges for transporting a Covered Person to:
a. a local Hospital, if needed care and treatment can be provided by a local Hospital;
b. the nearest Hospital where needed care and treatment can be given, if a local Hospital cannot provide it. It must be connected with an inpatient admission; or
c. another inpatient Facility when Medically Necessary and Appropriate.
Coverage can be by professional ambulance service, ground or air. Your group’s plan does not cover chartered air flights. The Plan will also not cover other travel or communication expenses of patients, Practitioners, Nurses or family members.
Blood
This Plan covers: (a) blood; (b) blood products; (c) blood transfusions; and (d) the cost of testing and processing blood. This Plan does not pay for blood that has been donated or replaced on behalf of the Covered Person.
This Plan also covers expenses Incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia. The home treatment program must be under the supervision of a State approved hemophilia treatment center. A home treatment program will not preclude further or additional treatment or care at an eligible Facility. But, the number of home treatments, according to a ratio of home treatments to Benefit Days, cannot exceed the total number of benefit days allowed for any other Illness under this Plan.
As used above: (a) “blood product” includes but is not limited to Factor VIII, Factor IX and cryoprecipitate; and (b) “blood infusion equipment” includes but is not limited to syringes and needles.
Diabetes Benefits
This Plan also provides benefits for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist;
a. blood glucose monitors and blood glucose monitors for the legally blind;
b. test strips for glucose monitors and visual reading and urine testing strips;
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c. insulin;
d. injection aids;
e. cartridges for the legally blind;
f. syringes;
g. insulin pumps and appurtenances to them;
h. insulin infusion devices; and
i. oral agents for controlling blood sugar.
Subject to the terms below, this Plan also covers diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of the Illness. This includes information on proper diet.
a. Benefits for self-management education and education relating to diet shall be limited to Visits that are to a professional described in b., below and that are Medically Necessary and Appropriate upon:
1. the diagnosis of diabetes;
2. the diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the Covered Person's symptoms or conditions which requires changes in the Covered Person's self-management; and
3. determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is needed.
b. Diabetes self-management education is covered when rendered by:
1. a dietician registered by a nationally recognized professional association of dieticians;
2. a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators; or
3. a registered pharmacist in New Jersey qualified with regard to management education for diabetes by any institution recognized by the Board of Pharmacy of the State of New Jersey.
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Durable Medical Equipment
Your plan covers charges for the rental of Durable Medical Equipment needed for therapeutic use. The Plan may Determine to cover the purchase of such items when it is less costly and more practical than to rent such items. The Plan does not cover:
a. replacements or repairs; or
b. the rental or purchase of any items (such as air conditioners, exercise equipment, saunas and air humidifiers) which do not fully meet the definition of Durable Medical Equipment.
Home Infusion Therapy
Home Infusion Therapy is a method of administering intravenous (IV) medications or nutrients via pump or gravity in the home. These services and supplies are eligible when rendered or used in connection with Home Infusion Therapy:
• Solutions and pharmaceutical additives,
• Pharmacy compounding and dispensing services,
• Ancillary medical supplies, and
• Nursing services associated with patient and/or alternative caregiver training, visits necessary to monitor intravenous therapy regimen and medical emergency care, but not for administration of home infusion therapy.
Home Infusion Therapy includes chemotherapy, intravenous antibiotic therapy, total parenteral nutrition, enteral nutrition (when sole source of nutrition) hydration therapy, intravenous pain management, gammaglobulin infusion therapy (IVIG), and prolastin therapy.
Note: Home Infusion Therapy must be authorized by the Plan.
Foot Orthotics
The Plan covers foot orthotics. Benefits are only payable following bone surgery of the foot to maintain post-surgical bone alignment.
Oxygen and its Administration
The Plan covers oxygen and its administration.
Prosthetic Devices
This Plan limits coverage for prosthetic devices. This Plan covers only the initial fitting and purchase of artificial limbs and eyes, and other prosthetic devices. To be covered, such devices
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must: (a) take the place of a natural part of a Covered Person's body; or (b) be needed due to a functional birth defect in a covered Child Dependent; or (c) be needed for reconstructive breast Surgery. This Plan does not cover: repairs of prosthetic devices or dental prosthetics or devices.
Specialized Non-Standard Infant Formulas
This Plan covers specialized non-standard infant formulas, if these conditions are met:
a. The covered infant's physician has diagnosed him/her as having multiple food protein intolerance;
b. The physician has determined that the formula is Medically Necessary and Appropriate; and
c. The infant has not responded to trials of standard non-cow milk-based formulas, including soybean and goat milk.
Wigs Benefit
Wigs are covered as a result of hair loss due to radiation therapy, chemotherapy, and second degree burns.
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Utilization Management
IMPORTANT NOTICE – THIS NOTICE APPLIES TO ALL FEATURES UNDER THIS UTILIZATION REVIEW SECTION.
BENEFITS WILL BE REDUCED FOR NON-COMPLIANCE WITH THE PROVISIONS OF THIS UTILIZATION MANAGEMENT SECTION. YOUR PLAN DOES NOT COVER ANY INPATIENT ADMISSION, OR ANY OTHER SERVICE OR SUPPLIES, THAT IS NOT MEDICALLY NECESSARY AND APPROPRIATE. HORIZON BCBSNJ DETERMINES WHAT IS MEDICALLY NECESSARY AND APPROPRIATE UNDER YOUR PLAN.
Your plan has utilization review features under which Horizon BCBSNJ or its designee reviews Hospital Admissions and listed procedures. These features must be complied with if you:
a. are admitted as an inpatient or outpatient to a Hospital or other Facility or on an out-of-hospital basis; or
b. are advised to enter a Hospital or other Facility; or
c. plan to have a listed procedure performed. If you or your Provider do not comply with this Utilization Management section, you will not be eligible for full benefits under your plan. Your Plan has Medical Appropriateness Review features. Under these features, Horizon BCBSNJ reviews the medical appropriateness of the care that is expected to be rendered.
In addition, what Horizon BCBSNJ covers is subject to all of the terms and conditions of your group’s plan.
With respect to Covered Charges incurred in connection with Mental or Nervous Disorders, all notices required to be given in accordance with this Utilization Management section must be given to the Care Manager.
Your Plan has Individual Case Management features. Under these features, a case coordinator reviews your medical needs in clinical situations with the potential for catastrophic claims to Determine whether alternative treatment may be available and appropriate. See the Alternative Treatment Features description for details.
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REQUIRED HOSPITAL STAY REVIEW
Notice of Hospital Admission Required
If you plan to use a Hospital in the Select Hospital Network, the Hospital will make all necessary arrangements for Pre Admission Review. If you plan to use a Out-of-Network Hospital, you must notify Horizon BCBSNJ of the Hospital Admission. The time and manner in which the notice must be given is described below. When you or your Provider do not comply with the requirements of this section, Horizon BCBSNJ reduces coverage for those Covered Charges.
Continued Stay Review
Horizon BCBSNJ has the right to initiate a continued stay review of any inpatient admission; and Horizon BCBSNJ may contact your Practitioner or Facility by phone or in writing.
You or your Provider must initiate a continued stay review whenever it is Medically Necessary and Appropriate to change the authorized length of an inpatient stay. This must be done before the end of the previously authorized length of stay.
In the case of an Admission, the continued stay review Determines:
a. the Medical Necessity and Appropriateness of Admission;
b. the anticipated length of stay and extended length of stay; and
c. the appropriateness of health care alternatives.
Horizon BCBSNJ notifies the Practitioner and Facility by phone of the outcome of the review. Horizon BCBSNJ confirms in writing the outcome of a review that results in a denial. The notice always includes any newly authorized length of stay.
NOTE: YOUR PLAN DOES NOT COVER ANY CHARGES THAT ARE INCURRED WITH RESPECT TO INPATIENT SERVICES OR SUPPLIES THAT ARE NOT AUTHORIZED IN ACCORDANCE WITH THIS CONTINUED STAY REVIEW.
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ALTERNATE TREATMENT FEATURES/INDIVIDUAL CASE MANAGEMENT
Definitions
“Alternate Treatment” means those services and supplies which meet both of the following tests:
a. They are Determined, in advance, by Horizon BCBSNJ to be Medically Necessary and Appropriate and cost effective in meeting your long-term or intensive care needs in connection with a Catastrophic Illness, Accidental Injury; or in completing a course of care outside of the acute Hospital setting, for example, completing a course of IV antibiotics at home.
b. Benefits for charges incurred for the services and supplies would not otherwise be payable under the Plan.
“Catastrophic Illness or Injury” means one of the following:
a. head injury requiring an inpatient stay;
b. spinal cord injury;
c. severe burn over 20% or more of the body;
d. multiple injuries due to an accident;
e. premature birth;
f. CVA or stroke;
g. congenital defect which severely impairs a bodily function;
h. brain damage due to either an accident or cardiac arrest or resulting from a Surgical procedure;
i. terminal Illness, with a prognosis of death within 6 months;
j. Acquired Immune Deficiency Syndrome (AIDS);
k. Substance Abuse;
l. a Mental or Nervous Disorder; or
m. any other Illness or injury determined by Horizon BCBSNJ to be catastrophic.
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Alternate Treatment/Individual Case Management Plan
Horizon BCBSNJ will identify cases of Catastrophic Illness or Accidental Injury. The appropriateness of the level of patient care given to you as well as the setting in which it is received will be evaluated. In order to maintain or enhance the quality of patient care for you, Horizon BCBSNJ will develop an Alternate Treatment/Individual Case Management Plan.
a. An Alternate Treatment/Individual Case Management Plan is a specific written document, developed by Horizon BCBSNJ through discussion and agreement with:
1. you, or your legal guardian if necessary;
2. your attending Practitioner; and
3. Horizon BCBSNJ or its designee.
b. The Alternate Treatment/Individual Case Management Plan includes:
1. treatment plan objectives;
2. course of treatment to accomplish the stated objectives;
3. the responsibility of each of the following parties in implementing the Plan:
(a) Horizon BCBSNJ (b) attending Practitioner (c) you (d) your family, if any; and
4. estimated cost and savings.
If Horizon BCBSNJ, the attending Practitioner, and you agree in writing on an Alternate Treatment/Individual Case Management Plan, the services and supplies required in connection with such Alternate treatment plan/Individual Case Management will be considered as Covered Charges under the terms of your Plan.
The agreed upon alternate treatment must be ordered by your Practitioner.
Benefits payable under the Alternate Treatment/Individual Case Management Plan will be considered in the accumulation of any Benefit Period and Per Lifetime maximums.
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Exclusion
Alternate Treatment/Individual Case Management does not include services and supplies that Horizon BCBSNJ Determines to be Experimental or Investigational.
Important Notice: You are not required, in any way, to accept an Alternate Treatment/Individual Case Management Plan recommended by Horizon BCBSNJ.
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SCHEDULE OF PROCEDURES,TREATMENT AND SUPPLIES REQUIRING PRIOR AUTHORIZATION
• All Admissions to a Skilled Nursing Facility.
• Hospice Care.
• Inpatient Hospital Care for Medical or Mental Health/Substance Abuse care.
• Private Duty Nursing.
Note: Network providers will handle all pre-certifications. In the event any portion of a facility day is determined not medically necessary, it will be the facility and not the patient's liability.

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CLAIMS PROCEDURES
Claim forms and instructions for filing claims will be provided to Covered Persons. Completed claim forms and any other required materials must be submitted to Horizon BCBSNJ or its designees for processing. Covered Persons do not need to file claims for In-Network Covered Services and Supplies. For Out-of-Network Covered Services and Supplies, Covered Persons will generally have to file a claim for benefits, unless a state law requires Providers to file claims on behalf of Covered Persons. In this case, however, a Covered Person still has the option to file claims on his/her own behalf.
Submission of Claims
These procedures apply to the filing of claims. All notices will be in writing.
a. Claim forms must be filed no later than 18 months after the date the services were Incurred.
b. Itemized bills must accompany each claim form. A separate claim form is needed for each claim filed. In general, the bills must contain enough data to identify: the patient; the Provider; the type of service and the charge for each service and the Provider's license number.
Bills for Private Duty Nursing must state that the Nurse is a Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.) and must contain the Nurse's license number.
c If a claim is denied or disputed, in whole or in part, Horizon BCBSNJ will notify the claimant (or his/her agent or designee) of it within 30 calendar days after receipt of the claim.
The denial notice will set forth:
1. the reason(s) the claim is denied;
2. specific references to the main Plan provision(s) on which the denial is based;
3. a specific description of any further material or information needed to complete the claim, and why it is needed;
4. a statement that the claim is disputed, if this is so. If the dispute is about the amount of the claim, Horizon BCBSNJ will explain why and also explain why any coding changes were made;
5. a statement of the special needs to which the claim is subject, if this is the case;
6. an explanation of the Plan's claim review procedure, including any rights to pursue civil action;
7. if an internal rule, guideline, protocol, or other similar criterion was relied upon in
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making the decision, either the specific rule or a statement that such a rule was relied upon in making the decision, and that a copy of such rule will be provided free of charge upon request;
8. if the decision is based on Medical Necessity and Appropriateness or an Experimental or Investigational (or similar) exclusion or limitation, either an explanation of the scientific or clinical judgment for the decision, applying the terms of the Plan to the medical circumstances, or a statement that such explanation will be provided free of charge upon request;
9. if the decision involves a Medical Emergency or Urgent Care, a description of the expedited review process applicable to such claims; and
10. the toll free number that the Covered Person or his/her Provider can call to discuss the claim.
d. This applies if you are the non-custodial parent of a Child Dependent. In this case, Horizon BCBSNJ will give the custodial parent the information needed for the Child Dependent to obtain benefits under the Plan. Horizon BCBSNJ will also permit the custodial parent, or the Provider with the authorization of the custodial parent, to submit claims for Covered Services and Supplies without your approval.
To Whom Payment Will Be Made
a. Payment for services of an In-Network Provider or a BlueCard Provider will be made directly to that Provider if the Provider bills Horizon BCBSNJ, as Horizon BCBSNJ determines. To receive In-Network coverage, a Covered Person must show his/her ID card when requesting Covered Services and Supplies from a Provider that has such an agreement.
b. Payment for services of Out-of-Network Providers will be made to you.
c. Except as stated above, in the event of a Covered Person's death or total incapacity, any payment or refund due will be made to his/her heirs, beneficiaries, trustees or estate.
d. If you are the non-custodial parent of a Child Dependent, Horizon BCBSNJ will pay claims filed as described above under "Submission of Claims" directly to: the Provider or Custodial parent; or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.
If Horizon BCBSNJ pays anyone who is not entitled to benefits under this Plan, Horizon BCBSNJ has the right to recover those payments on behalf of the Plan.
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BLUECARD
Overview
Horizon BCBSNJ has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Arrangements.” These Inter- Plan Arrangements operate under rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever Covered Persons access healthcare services outside the geographic area we serve, the claims for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described generally below.
Typically, when accessing care outside the geographic area we serve, Covered Persons obtain care from healthcare providers that have a contractual agreement (“BlueCard Providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, Covered Persons may obtain care from healthcare providers in the Host Blue geographic area that do not have a contractual agreement (“nonparticipating providers”) with the Host Blue. Horizon BCBSNJ remains responsible for fulfilling our contractual obligations to the Covered Person. Horizon BCBSNJ's payment practices in both instances are described below.
This disclosure describes how claims are administered for Inter-Plan Arrangements and the fees that are charged in connection with Inter-Plan Arrangements.
Note that Dental Care Benefits that are not paid as medical claims/benefits, and those Prescription Drug Benefits or Vision Care Benefits that may be administered by a third party contracted by Horizon BCBSNJ to provide the specific service or services, are not processed through Inter-Plan Arrangements.
BlueCard® Program
The BlueCard Program is an Inter-Plan Arrangement. Under this Inter-Plan Arrangement, when Covered Persons access Covered Services and Supplies within the geographic area served by a Host Blue, the Host Blue will be responsible for contracting and handling all interactions with its BlueCard Providers. The financial terms of the Inter-Plan Arrangements are described generally below.
Liability Calculation Method Per Claim – In General
Covered Person's Liability Calculation
Unless subject to a fixed dollar copayment, the calculation of the Covered Person’s liability on claims for Covered Services and Supplies will be based on the lower of the BlueCard Provider's billed Covered Charges or the negotiated price made available to Horizon BCBSNJ by the Host Blue.
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Claims Pricing
Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to us by the Host Blue may be represented by one of the following:
(i) An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or
(ii) An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements and performance-related bonuses or incentives; or
(iii) An average price. An average price is a percentage of billed Covered Charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other claim- and non-claim-related transactions. Such transactions may include the same ones as noted above for an estimated price.
The Host Blue determines whether it will use an actual, estimated or average price. Host Blues using either an estimated price or an average price may prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid or anticipated to be paid to providers or refunds received or anticipated to be received from providers). However, the BlueCard Program requires that the amount paid by the Covered Person is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. The method of claims payment by Host Blues is taken into account by Horizon BCBSNJ in determining the group’s premiums.
Negotiated (non-BlueCard Program) National Account Arrangements
With respect to one or more Host Plans, instead of using the BlueCard Program, Horizon BCBSNJ may process the Covered Person’s claims for Covered Services and Supplies through Negotiated National Account Arrangements.
In addition, if Horizon BCBSNJ and the group have agreed that (a) Host Blue(s) shall make available (a) custom healthcare provider network(s) in connection with this agreement, then the terms and conditions set forth in Horizon BCBSNJ's Negotiated National Account Arrangement(s) with such Host Blue(s) shall apply. These include the provisions governing the processing and payment of claims when Covered Persons access such network(s). In negotiating such Negotiated National Account Arrangements, Horizon BCBSNJ is not acting on behalf of or as an agent for the group or the group health plan.
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Covered Person's Liability Calculation.
Covered Person liability calculation will be based on the lower of either billed Covered Charges or negotiated price (refer to the description of negotiated price under "Claims Pricing" in the "Liability Calculation Method Per Claim – In General" provision above) made available to Horizon BCBSNJ by the Host Blue that allows the Covered Person access to negotiated participation agreement networks of specified participating healthcare providers outside of Horizon BCBSNJ's service area.
Special Cases: Value-Based Programs
Value-Based Programs Overview
The Covered Person may access Covered Services and Supplies from providers that participate in a Host Blue’s Value-Based Program. Value-Based Programs may be delivered either through the BlueCard Program or a Negotiated National Account Arrangement(s).
Value-Based Programs under the BlueCard Program
Horizon BCBSNJ has included a factor for bulk distributions from Host Blues in a group's premium for Value-Based Programs when applicable under this Booklet.
Value-Based Programs under Negotiated National Account Arrangements
If Horizon BCBSNJ has entered into a Negotiated National Account Arrangement with a Host Blue to provide Value-Based Programs to Covered Persons, Horizon BCBSNJ will follow the same procedures for Value-Based Programs as noted above in the Liability Calculation Method Per Claim – In General section.
Return of Overpayments
Recoveries of overpayments from a Host Blue or its BlueCard Providers and nonparticipating providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, audits, utilization review refunds and unsolicited refunds. Recoveries will be applied so that corrections will be made, in general, on either a claim-by-claim or prospective basis.
Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees
In some instances federal or state laws or regulations may impose a surcharge, tax or other fee that applies to insured accounts. If applicable, Horizon BCBSNJ will include any such surcharge, tax or other fee in determining a group's premium.
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Non-Participating Healthcare Providers Outside Horizon BCBSNJ's Service Area
Covered Person's Liability Calculation
In General
When Covered Services and Supplies are provided outside of Horizon BCBSNJ's service area by nonparticipating providers, the amount(s) a Covered Person pays for such services will be based on either the Host Blue’s nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law. In these situations, the Covered Person may be responsible for the difference between the amount that the nonparticipating provider bills and the payment Horizon BCBSNJ will make for the Covered Services and Supplies as set forth in this paragraph. Payments for out-of-network emergency services will be provided as if the care was provided by a participating healthcare provider with respect to application of the Covered Person's copayment, deductible or coinsurance.
Exceptions
In some exception cases, at the group's direction Horizon BCBSNJ may pay claims from nonparticipating healthcare providers outside of Horizon BCBSNJ's service area based on the provider’s billed charge. This may occur in situations where a Covered Person did not have reasonable access to a BlueCard Provider, as Determined by Horizon BCBSNJ in Horizon BCBSNJ's sole and absolute discretion in accordance with this Booklet or by state and/or federal law, as applicable. Adverse Determinations can be reviewed by an independent utilization review agency (IURO), court of law, arbitrator or any administrative agency having the appropriate jurisdiction.
In other exception cases, at the group's direction, Horizon BCBSNJ may pay such claims based on the payment Horizon BCBSNJ would make if Horizon BCBSNJ were paying a nonparticipating provider inside of Horizon BCBSNJ's service area, as described elsewhere in this Booklet. This may occur where the Host Blue’s corresponding payment would be more than Horizon BCBSNJ's in-service area nonparticipating provider payment. Horizon BCBSNJ may choose to negotiate a payment with such a provider on an exception basis.
Unless otherwise stated, in any of these exception situations, the Covered Person may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and the payment Horizon BCBSNJ will make for the Covered Services and Supplies as set forth in this paragraph.
BCBS Global Core Coverage TM
General Information. If Covered Persons are outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands (hereinafter: “BlueCard service area”), they may be able to take advantage of BCBS Global Core when accessing Covered Services and Supplies. The BCBS Global Core Coverage is unlike the BlueCard Program available in the
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BlueCard service area in certain ways. For instance, although BCBS Global Core assists Covered Persons with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when Covered Persons receive care from providers outside the BlueCard service area, the Covered Persons will typically have to pay the providers and submit the claims themselves to obtain reimbursement for these services.
Inpatient Services
In most cases, if Covered Persons contacts the BCBS Global Core Service Center for assistance, hospitals will not require Covered Persons to pay for covered inpatient services, except for their cost-share amounts. In such cases, the hospital will submit Covered Persons' claims to the BCBS Global Core Service Center to initiate claims processing.
However, if Covered Persons paid in full at the time of service, the Covered Persons must submit a claim to obtain reimbursement for Covered Services and Supplies. Covered Persons must contact Horizon BCBSNJ to obtain precertification for non-emergency inpatient services.
Outpatient Services
Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require Covered Persons to pay in full at the time of service. Covered Persons must submit a claim to obtain reimbursement for Covered Services and Supplies.
Submitting a BCBS Global Core Claim
When Covered Persons pay for Covered Services and Supplies outside the BlueCard service area, they must submit a claim to obtain reimbursement. For institutional and professional claims, Covered Persons should complete a BCBS Global Core claim form and send the claim form with the provider’s itemized bill(s) to the BCBS Global Core Service Center address on the form to initiate claims processing. The claim form is available from Horizon BCBSNJ, BCBS Global Core Service Center, or online at www.bcbsglobalcore.com. If Covered Persons need assistance with their claim submissions, they should call BCBS Global Core at 1.800.810.BLUE (2583) or call collect at 1.804.673.1177, 24 hours a day, seven days a week.

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Exclusions Under The Blue Card PPO Program
The following are not Covered Services and Supplies under the plan. The Plan will not pay for any charges incurred for, or in connection, with:
Acupuncture.
Administration of oxygen, except as otherwise stated in this booklet.
Ambulance, in the case of a non-Medical Emergency.
Anesthesia and consultation services when they are given in connection with Non-Covered Charges.
An inpatient admission or any part of an inpatient admission primarily for:
• Physical Therapy, except as otherwise specified in this booklet; and/or • rehabilitation therapy, except as otherwise specified in this booklet.
Any charge to the extent it exceeds the Allowance.
Any therapy not included in the definition of Therapy Services.
Balances for services and supplies after payment has been made under the plan.
Blood or blood plasma or other blood derivatives or components which is replaced by a Covered Person.
Broken appointments.
Charges incurred during a person’s temporary absence from an eligible Provider’s grounds before discharge.
Completion of claim forms.
Copayments, Deductibles, and the individual’s part of any Coinsurance; expenses incurred after any Payment maximum is or would be reached.
Cosmetic Services, including cosmetic Surgery, procedures, treatment, drugs or biological products, unless required as a result of an accidental Injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly; complications of cosmetic Surgery; drugs prescribed for cosmetic purposes.
Court ordered treatment which is not Medically Necessary.
Custodial Care or domiciliary care, including respite care except as specifically covered under your Plan.
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Dental care or treatment, including appliances, except as otherwise stated in this booklet.
Diversional/recreational therapy or activity.
Drugs dispensed to a Covered Person while a patient in a Facility.
Drugs, obtained from a State or local public health agency, for the treatment of venereal disease or mental disease.
Drugs dispensed by other than a Pharmacist or a Pharmacy or for services rendered by a Pharmacist which are beyond the scope of his license. Benefits are not provided for drugs given by a physician or other practitioner.
Education or training while a Covered Person is confined in an institution that is primarily an institution for learning or training.
Employment/career counseling.
Experimental or Investigational treatments, procedures, Hospitalizations, drugs, biological products or medical devices.
Eye Examinations, eyeglasses, contact lenses, and all fittings, except as specified in this booklet; surgical treatment for the correction of a refractive error including, but not limited to, radial keratotomy.
Facility charges (e.g., operating room, recovery room, use of equipment) when billed for by a Provider that is not an eligible Facility.
Hearing aids or fitting of hearing aids.
Herbal medicine.
Home Health Care Visits connected with administration of dialysis.
Housekeeping services except as an incidental part of the Eligible services of a Home Health Care Agency.
Hypnotism.
Illness or Injury, including a condition which is the result of an Illness or Injury, which: (a) occurred on the job; and (b) is covered or could have been covered for benefits provided under a workers' compensation, employer's liability, occupational disease or similar law. However, this exclusion does not apply to the following persons for whom coverage under workers’ compensation is optional, unless such persons are actually covered for workers’ compensation: a self-employed person or a partner of a limited liability partnership; members of a limited liability company or partners of a partnership who actively perform services on behalf of the self-
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employed business, the limited liability partnership, limited liability company or the partnership.
Immunizations, except as otherwise specified in this booklet.
Infertility enhancement treatments, except as otherwise stated in this booklet.
Local anesthesia charges billed separately by a Practitioner for Surgery he performed on an Outpatient basis.
Maintenance therapy for:
• Physical Therapy; • Manipulative Therapy; • Occupational Therapy; and • Speech Therapy.
Marriage, career or financial counseling; sex therapy.
Medical Emergency services, or supplies, when not rendered by a Practitioner.
Membership costs for health clubs, weight loss clinics and similar programs.
Methadone maintenance.
Milieu Therapy:
Inpatient services and supplies which are primarily for milieu therapy even though eligible treatment may also be provided.
This means that the Plan has Determined:
1. the purpose of an entire or portion of an inpatient stay is chiefly to change or control a patient’s environment; and
2. an inpatient setting is not Medically Necessary for the treatment provided, if any.
Non-medical equipment which may be used primarily for personal hygiene or for comfort or convenience of a Covered Person rather than for a medical purpose, including air conditioners, dehumidifiers, purifiers, saunas, hot tubs, televisions, telephones, first aid kits, exercise equipment, heating pads and similar supplies which are useful to a person in the absence of Illness or injury.
Non-Prescription Drugs or supplies, except as may be Medically Necessary and Appropriate for the treatment of certain illness or Injury, except as otherwise stated in this Plan.
Pastoral counseling.
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Personal comfort and convenience items.
Prescription Drugs that in the usual course of medical practice are self-administered or dispensed by a retail or mail-order Pharmacy.
Psychoanalysis to complete the requirements of an educational degree or residency program.
Psychological testing for educational purposes.
Removal of abnormal skin outgrowths and other growths including, but not limited to, paring or chemical treatments to remove corns, callouses, warts, hornified nails and all other growths, unless it involves cutting through all layers of the skin.
Rest or convalescent cures.
Room and board charges for any period of time during which the Covered Person was not physically present in the room.
Routine exams (including related diagnostic X-rays and lab tests) and other services connected with activities such as the following: pre-marital or similar exams or tests; research studies; education or experimentation; mandatory consultations required by Hospital regulations.
Routine foot care, except as may be Medically Necessary and Appropriate for the treatment of certain Illness or Accidental Injury, including treatment for corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, symptomatic complaints of the feet.
Self-administered services such as: biofeedback, patient-controlled analgesia, related diagnostic testing, self-care and self-help training.
Services involving equipment or Facilities used when the purchase, rental or construction has not been approved in compliance with applicable state laws or regulations.
Services performed by any of the following:
a. A Hospital resident, intern or other Practitioner who is paid by a Facility or other source, who is not permitted to charge for services covered under the Plan, whether or not the Practitioner is in training. However, Hospital-employed Physician specialists may bill separately for their services.
b. Anyone who does not qualify as a physician.
Services provided during a stay at a Facility which in whole or in part was for diagnostic studies. This exclusion applies when the services were provided for any of the following reasons: diagnosis, evaluation, confirmation (or to rule out), or to check the current status of a condition which was treated in the past.
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Services required by the group as a condition of employment or rendered through a medical department, clinic, or other similar service provided or maintained by the group.
Services or supplies:
- eligible for payment under either federal or state programs (except Medicaid). This provision applies whether or not the Covered Person asserts his rights to obtain this coverage or payment for these services;
- for which a charge is not usually made, such as a Practitioner treating a professional or business associate, or services at a public health fair;
- for which the Provider has not received a certificate of need or such other approvals as are required by law;
- for which the Covered Person would not have been charged if he did not have health care coverage;
- furnished by one of the following members of the Covered Person’s family, unless otherwise stated in this booklet: Spouse, Child, parent, in-law, brother or sister;
- in connection with any procedure or examination not necessary for the diagnosis or treatment of injury or sickness for which a bonafide diagnosis has been made because of existing symptoms.
- needed because the Covered Person engaged, or tried to engage, in an illegal occupation or committed, or tried to commit, a felony;
- not specifically covered under your plan;
- provided by a Practitioner if the Practitioner bills the Covered Person directly for the services or supplies, regardless of the existence of any financial or contractual arrangement between the Practitioner and the Provider;
- provided by or in a Government Hospital unless the services are for treatment:
a. of a non-service Medical Emergency;
b. by a Veterans’ Administration Hospital of a non-service related Illness or Accidental Injury; or the Hospital is located outside of the United States and Puerto Rico; or unless otherwise required by law;
NOTE: The above limitations do not apply to military retirees, their dependents, and the dependents of active duty military personnel who have both military health coverage and coverage under your Plan, and receive care in Facilities run by the Department of Defense or Veteran’s Administration;
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- provided by a licensed pastoral counselor in the course of his normal duties as a pastor or minister;
- provided by a social worker, except as otherwise stated in this booklet;
- provided during any part of a stay at a Facility, or during Home Health Care chiefly for bed rest, rest cure, convalescence, custodial or sanatorium care, diet therapy or occupational therapy;
- received as a result of: war, declared or undeclared; police actions; service in the armed forces or units auxiliary thereto; or riots or insurrection;
- rendered prior to the Covered Person’s Effective Date or after his termination date of coverage under the program, unless specified otherwise;
- which are specifically limited or excluded elsewhere in this booklet;
- which are not Medically Necessary and Appropriate; or
- which a Covered Person is not legally obligated to pay for.
Special medical reports not directly related to treatment of the Covered Person (e.g. employment physicals, reports prepared in connection with litigation.)
Stand-by services required by a Practitioner; services performed by Surgical assistants not employed by a Facility.
Sterilization reversal.
Sunglasses even if by Prescription.
Surrogate Motherhood
Telemedicine services to Covered Persons who are eligible for Medicare when Medicare is primary to this Plan.
Telephone consultations, except as the Plan may request.
TMJ syndrome treatment, except as otherwise stated in this booklet.
Transplants, except as otherwise stated in this booklet.
Transportation; travel.
Vision therapy, vision or visual acuity training, orthoptics and pleoptics.
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Vitamins and dietary supplements, except prenatal and children’s vitamins requiring a Prescription.
Weight reduction or control, unless there is a diagnosis of morbid obesity; special foods, food supplements, liquid diets, diet plans or any related products, except as specifically covered under the Plan. Wigs, toupees, hair transplants, hair weaving, or any drug used to eliminate baldness unless deemed Medically Necessary and Appropriate.
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BENEFITS PAYABLE FOR AUTOMOBILE RELATED INJURIES
This section applies when expenses are Incurred by a Covered Person due to an Automobile Related Injury.
Definitions
"Automobile Related Injury": Bodily injury of a Covered Person due to an accident while occupying, entering into, alighting from or using an auto; or if the Covered Person was a pedestrian, caused by an auto or by an object propelled by or from an auto.
"Allowable Expense": A Medically Necessary and Appropriate, reasonable and customary item of expense that is at least in part a Covered Charge under this Plan or PIP.
"Eligible Expense": That portion of expense Incurred for treatment of an Injury which is covered under this Plan without application of Deductibles or Copayments, if any.
"Out-of-State Automobile Insurance Coverage" or "OSAIC": Any coverage for medical expenses under an auto insurance contract other than PIP. This includes auto insurance contracts issued in another state or jurisdiction.
"PIP": Personal injury protection coverage (i.e., medical expense coverage) that is part of an auto insurance contract issued in New Jersey.
Application of this Provision
When expenses are Incurred as a result of an Automobile Related Injury, and the injured person has coverage under PIP or OSAIC, this provision will be used to determine whether this Plan provides coverage that is primary to such coverage or secondary to such coverage. It will also be used to determine the amount payable if this Plan provides primary or secondary coverage.
Determination of Primary or Secondary Coverage
This Plan provides secondary coverage to PIP unless this Plan's health coverage has been elected as primary by or for the Covered Person. This election is made by the named insured under a PIP contract. It applies to that person's family members who are not themselves named insured under other auto contracts. This Plan may be primary for one Covered Person, but not for another if the persons have separate auto contracts and have made different selections regarding the primary of health coverage.
This Plan is secondary to OSAIC. But, this does not apply if the OSAIC contains provisions that make it secondary or excess to the Covered Person's other health benefits. In that case, this Plan is primary.
If the above rules do not determine which health coverage is primary, or if there is a dispute as to whether this Plan will provide benefits for Covered Charges as if it were primary.
Benefits This Plan Will Pay if it is Primary to PIP or OSAIC
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If this Plan is primary to PIP or OSAIC, it will pay benefits for Covered Charges in accordance with its terms. If there are other plans that: (a) provide benefits to the Covered Person; and (b) are primary to auto insurance coverage, then this Plan's rules regarding the coordination of benefits will apply.
Benefits This Plan Will Pay if it is Secondary to PIP
If this Plan is secondary to PIP, the actual coverage will be the lesser of:
a. the Allowable Expenses left uncovered after PIP has provided coverage (minus this Plan's Deductibles, and/or Coinsurance); or
b. the actual benefits that this Plan would have paid if it provided its coverage primary to PIP.
Medicare
To the extent that this Plan provides coverage that supplements Medicare's, then this Plan can be primary to automobile insurance only insofar as Medicare is primary to auto insurance.

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Subrogation and Reimbursement
If another person or entity, through an act or omission, causes any participant, beneficiary, or any other covered person receiving benefits under this Plan, hereinafter individually and collectively referred to as “Covered Person”, to suffer an injury or illness, and in the event benefits were paid under the Plan for that injury or illness, a Covered Person must agree to the provisions listed below. Additionally, if a Covered Person is injured and no other person or entity is responsible but a Covered Person receives (or is entitled to) a recovery from another source, and if the Plan paid benefits for that injury, a Covered Person must refund the Plan all benefits paid and must also agree to the provisions listed below.
This Plan provides benefits to or on behalf of said Covered Person only on the following terms and conditions:
1. In the event that benefits are provided under this Plan, the Plan shall be subrogated to all of the Covered Person’s or the Covered Person’s representative’s (representative for this purpose includes, if applicable, heirs, administrators, legal representatives, parents (if a minor), successors, or assignees) rights of recovery against any person or organization to the extent of the benefits provided to the Covered Person. The Covered Person shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Covered Person shall do nothing after loss to prejudice such rights. The Covered Person hereby agrees to cooperate with the Plan and/or any representatives of the Plan in completing such forms and in giving such information surrounding any injury, illness, or accident as the Plan or the Plan representatives deem necessary to fully investigate the incident.
2. The Plan is also granted a right of reimbursement from the proceeds of any recovery whether by settlement, judgment, or otherwise. This right of reimbursement is cumulative with and not exclusive of the subrogation right granted in paragraph 1, but only to the extent of the benefits provided by the Plan. The Plan is entitled under its right of recovery to be reimbursed for the full amount of the Plan’s benefit payments even if the Covered Person is not “made whole” for all of his or her damages in the recoveries that he or she receives.
3. The Plan’s right to reimbursement is, and shall be, prior and superior to the right of any other person or entity, including the Covered Person.
4. By accepting benefits hereunder, the Covered Person hereby grants an automatic lien against and assigns to the Plan, in an amount equal to the benefits paid by the Plan, any recovery, whether by settlement, judgment, or other payment intended for, payable to, or received by the Covered Person, or on behalf of the Covered Person. The Covered Person hereby consents to said lien and/or assignment and agrees to take whatever steps are necessary to help the Plan secure said lien and/or assignment. The Covered Person agrees that said lien and/or assignment shall constitute a charge upon the proceeds of any recovery and the Plan shall be entitled to assert security interest thereon.
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5. By the acceptance of benefits under the Plan, the Covered Person and his or her representatives agree to serve as a constructive trustee and to hold the proceeds of any settlement, judgment and/or other payment in constructive trust for the benefit of the Plan to the extent of 100% of all benefits paid on behalf of the Covered Person.
6. The subrogation and reimbursement rights and liens apply to any recoveries made by the Covered Person as a result of the injuries sustained, including but not limited to the following:
a. Payments made directly by the third party tortfeasor, or any insurance company on behalf of the third party tortfeasor, or any other payments on behalf of the third party tortfeasor.
b. Any payments or settlements or judgment or arbitration awards paid by any insurance company under an uninsured or underinsured motorist coverage, whether on behalf of a Covered Person or other person.
c. Any other payments from any source designed or intended to compensate a Covered Person for injuries sustained.
d. Any worker’s compensation award or settlement.
e. Any recovery made pursuant to no-fault insurance.
f. Any medical payments made as a result of such coverage in any automobile or homeowners insurance policy.
7. The Covered Person shall not take action that may prejudice the Plan’s right of recovery, including but not limited to the assignment of any rights of recovery from any tortfeasor or other person or entity. No Covered Person shall make any settlement which specifically reduces or excludes, or attempts to reduce or exclude the benefits provided by the Plan. The Plan will not reduce its share of any recovery unless, in the exercise of its discretion, the Plan agrees in writing.
8. The Plan’s right of recovery shall be a prior lien against any proceeds recovered by the Covered Person, which right shall not be defeated nor reduced by the application of any doctrine purporting to defeat the Plan’s recovery rights by allocating the proceeds exclusively to non-medical expense damages. Accordingly, the Plan is entitled under its right of recovery to be reimbursed for its benefit payments even if the Covered Person is not “made whole” for all of his or her damages in the recoveries he or she receives; there shall be no application of the “made whole” doctrine, “rimes doctrine” or any such doctrine defeating the Plan’s right of recovery.
9. No Covered Person hereunder shall incur any expenses on behalf of the Plan in pursuit of the Plan’s rights hereunder. Specifically, no court costs or attorney’s fees may be deducted from the Plan’s recovery without the prior express written consent of the Plan and the Plan’s right of recovery is not subject to reduction of attorney’s fees and costs
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under the “common fund” or any other doctrine.
10. In the event that a Covered Person shall fail or refuse to honor its obligations hereunder, then the Plan shall be entitled to recover any costs incurred in enforcing the terms hereof including but not limited to attorney’s fees, litigation, court costs, and other expenses. The Plan shall also be entitled to offset the reimbursement obligation against any entitlement to future Plan benefits hereunder until the Covered Person has fully complied with his or her reimbursement obligations hereunder, regardless of how those future Plan benefits are incurred.
11. Any reference to state law in any other provision of this policy shall not be applicable to this provision, if the Plan is governed by ERISA. By acceptance of benefits under the Plan, the Covered Person agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, the Plan shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the Plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief.

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THE EFFECT OF MEDICARE ON BENEFITS
IMPORTANT NOTICE
For the purposes of this Booklet’s “Coordination of Benefits and Services” provision, the benefits for a Covered Person may be affected by whether he/she is eligible for Medicare and whether the "Medicare as Secondary Payer" rules apply to the Plan. This section, on "Medicare as Secondary Payer", or parts of it, may not apply to this Plan. The Employee must contact the Employer to find out if the Employer is subject to Medicare as Secondary Payer rules.
For the purpose of this section:
a. "Medicare" means Part A and B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time.
b. A Covered Person is deemed to be eligible for Medicare by reason of age from the first day of the month during which he/she reaches age 65. But, if the Covered Person is born on the first day of a month, he/she is deemed to be eligible for Medicare from the first day of the month that is immediately prior to his/her 65th birthday. A Covered Person may also be eligible for Medicare by reason of disability or End-Stage Renal Disease (ESRD).
c. Under the rules for coordination of benefits and services described earlier, a "Primary Plan" pays benefits for a Covered Person's Covered Charges first, ignoring what the Covered Person's "Secondary Plan(s)" pays. The "Secondary Plan(s)" then pays the remaining unpaid Allowable Expenses in accordance with the provisions of the Covered Person's secondary health plan.
The following rules explain how this Plan's group health benefits interact with the benefits available under Medicare as Secondary Payer rules. A Covered Person may be eligible for Medicare by reason of age, disability or ESRD. Different rules apply to each type of Medicare eligibility as explained below:
In all cases where a person is eligible for Medicare and this Plan is the secondary plan, the Allowable Expenses under this Plan and for the purposes of the Coordination of Benefits and Services rules, will be reduced by what Medicare would have paid if the Covered Person had enrolled for full Medicare coverage. But this will not apply, however, if; (a) the Covered Person is eligible for, but not covered, under Part A of Medicare; and (b) he/she could become covered under Part A only by enrolling and paying the required premium for it.
Medicare Eligibility by Reason of Age
This section applies to a Covered Person who is:
a. The Employee or covered spouse;
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b. eligible for Medicare by reason of age; and
c. has coverage under this program due to the current employment status of the Employee.
Under this section, such a covered person is referred to as a "Medicare eligible".
This section does not apply to:
a. a Covered Person, other than an Employee or covered Spouse;
b. a Covered Person who is under age 65; or
c. a Covered Person who is eligible for Medicare solely on the basis of End Stage Renal Disease
When a Covered Person becomes eligible for Medicare by reason of age, this Plan permits the Covered Person to make a prospective election change that cancels coverage under this Plan and elect Medicare as the primary health plan.
If a Covered Person cancels coverage under this Plan, the Covered Person will no longer be covered by this Plan. Medicare will be the primary payer. Coverage under this plan will end on the last day of the month in which the Covered Person elects Medicare the primary health plan.
If a Covered Person does not make an election upon becoming eligible for Medicare by reason of age, this Plan will continue to be the primary health plan. This plan pays first, ignoring Medicare. Medicare will be considered the secondary health plan.
Medicare Eligibility by Reason of Disability
This part applies to a Covered Person who:
a. is under age 65;
b. is eligible for Medicare by reason of disability; and
c. has coverage under this Plan due to the current employment status of the Employee.
This part does not apply to:
a. a Covered Person who is eligible for Medicare by reason of age; or
b. a Covered Person who is eligible for Medicare solely on the basis of ESRD.
When a Covered Person becomes eligible for Medicare by reason of disability, this Plan is the primary plan; Medicare is the secondary plan.
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Medicare Eligibility by Reason of End Stage Renal Disease
This part applies to a Covered Person who is eligible for Medicare solely on the basis of ESRD.
This part does not apply to a Covered Person who is:
a. eligible for Medicare by reason of age ; or
b. eligible for Medicare by reason of disability.
When (a) a Covered Person becomes eligible for Medicare solely on the basis of ESRD; and (b) Incurs a charge for the treatment of ESRD for which benefits are payable under both this Plan and Medicare, this Plan is deemed the Primary Plan for a specified time, referred to as the “coordination period”. This Plan pays first, ignoring Medicare. Medicare is the Secondary Plan. The coordination period is up to 30 consecutive months.
The coordination period starts on the earlier of:
a. the first month of a Covered Person’s Medicare Part A entitlement based on ESRD; or
b. the first month in which he/she could become entitled to Medicare if he/she filed a timely application.
After the 30-month period described above ends, if an ESRD Medicare eligible person Incurs a charge for which benefits are payable under both this Plan and Medicare, Medicare is the Primary Plan and this Plan is the Secondary Plan.
Dual Medicare Eligibility
This part applies to a Covered Person who is eligible for Medicare on the basis of ESRD and either age or disability.
When a Covered Person who is eligible for Medicare due to either age or disability (other than ESRD) has this Plan as the primary payer, then becomes eligible for Medicare based on ESRD, this Plan continues to be the primary payer for the first 30 months of dual eligibility. After the 30-month period, Medicare becomes the primary payer (as long as Medicare dual eligibility still exists).
When a Covered Person who is eligible for Medicare due to either age or disability (other than ESRD) has this Plan as the secondary payer, then becomes eligible for Medicare based on ESRD, this Plan continues to be the secondary payer.
When a Covered Person who is eligible for Medicare based on ESRD also becomes eligible for Medicare based on age or disability (other than ESRD), this Plan continues to be the primary payer for 30 months after the date of Medicare eligibility based on ESRD.
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How To File A Claim If You Are Eligible For Medicare
Follow the procedure that applies to you or the Covered Person from the categories listed below when filing a claim.
New Jersey Providers:
• The Covered Person should give the Practitioner or other Provider his/her identification number. This number is shown on the Medicare Request for Payment (claim form) under “Other Health Insurance”;
• The Provider will then submit the Medicare Request for Payment to the Medicare Part B carrier;
• After Medicare has taken action, the Covered Person will receive an Explanation of Benefits form from Medicare;
• If the remarks section of the Explanation of Benefits contains this statement, no further action is needed: “This information has been forwarded to Horizon Blue Cross Blue Shield of New Jersey for their consideration in processing supplementary coverage benefits;”
• If the above statement does not appear on the Explanation of Benefits, the Covered Person should include his/her Identification number and the name and address of the Provider in the remarks section of the Explanation of Benefits and send it to Horizon BCBSNJ.
Out-of-State Providers:
• The request for Medicare payment should be submitted to the Medicare Part B carrier in the area where services were performed. Call your local Social Security office for information;
• Upon receipt of the Explanation of Benefits, show the Identification Card number and the name and address of the Provider in the remarks section and send the Explanation of Benefits to Horizon BCBSNJ for processing.

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APPEALS PROCESS
A Covered Person (or a Provider or authorized representative acting on behalf of the Covered Person and with his/her consent) may appeal Adverse Benefit Determinations. There are two types of Adverse Benefit Determinations, administrative and utilization management. “Administrative” determinations involve issues such as eligibility for coverage, benefit decisions, etc. “Utilization management” determinations are decisions that involve the use of medical judgment and/or deny or limit an admission, service, procedure or extension of stay based on the Plan's clinical and medical necessity criteria. The appeal processes for the two types differ and are described briefly below.
No Covered Person or Provider who files an appeal will be subject to disenrollment, discrimination or penalty. If there is a claim denial for either type of decision, you will receive information that includes the reason for the denial, a reference to the Plan provision on which it is based, and a description of any internal rule or protocol that affected the decision.
Appeals Process for Adverse Administrative Decisions
For this type of adverse claim decisions, you will be notified of a denial as quickly as possible, but not later than the following:
• For Urgent Care Claims, 72 hours from receipt of the claim;
• For Pre-Service Claims, 15 calendar days from receipt of the claim;
• For Post-Service Claims, 30 calendar days from receipt of the claim.
If you wish to appeal the decision, you have 180 days to do so. Your written request for a review of the decision should include the reason(s) why you feel the claim should not have been denied. It should also include any additional information (e.g., medical records) that you feel support your appeal.
The decision regarding your appeal will be reached as soon as possible, but not later than the following:
• For Urgent Care Claims, 72 hours from receipt of your appeal;
• For Pre-Service Claims, 30 calendar days from receipt of your appeal;
• For Post-Service Claims, 60 calendar days from receipt of your appeal.
If the initial decision on your claim is upheld upon review, you will also be informed of any additional appeal rights that you may have.
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Appeals Process for Adverse Utilization Management Decisions
The process for this type of adverse decision is briefly described below. A denial notification will include a brochure that fully describes your appeal rights and how you go about exercising them.
If such a claim is denied, your treating Provider can discuss your case with a Horizon BCBSNJ Medical Director, who can be reached by telephone at the number provided in the brochure. If the initial denial is upheld, you or the Provider can further appeal the decision within one year after receiving the denial letter. The appeal can be in writing or can be initiated by telephone. The applicable address and telephone number will be provided in the brochure.
Your appeal must include the following information:
• The name(s) and address(es) of the Covered Person and/or the Provider(s);
• The Covered Person's identification number;
• The date(s) of service;
• The nature of and reason behind your appeal;
• The remedy sought; and
• Any documentation that supports your appeal.
Your appeal will be decided as soon as possible, but not later than the following:
• For Urgent Care Claims, within 72 hours from receipt of your appeal;
• For other claims, within 30 calendar days from receipt of your appeal.
External Appeal Rights
If (a) the initial denial relates to an adverse utilization management decision or a rescission of coverage under the plan, (b) it is upheld pursuant to the internal appeal process, and (c) you are still dissatisfied, you have the additional right to pursue an external appeal with an Independent Review Organization (IRO). To exercise this right, you must request an external appeal in writing within four months after receiving our final internal appeal decision. The brochure accompanying our initial denial and final internal appeal decision will provide full details regarding the process that must be followed to request and obtain an external review. Generally, you must complete the internal appeal process before your claim will be eligible for external review. A small filing fee may be required. If so, it will be noted in the brochure.
If the process for obtaining this review is successfully completed, and your claim is deemed eligible, you will be notified and your appeal will be assigned to an IRO. Once it is assigned, the
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IRO will notify you about any additional steps that must be taken to complete your appeal. Once all of these additional steps are completed, the IRO will review all of the information in your case as if it were new. The IRO is not bound by any decisions or conclusions that were reached during the internal appeals process.
The IRO's decision will be communicated to you in writing within 45 calendar days after its receipt of the appeal, or, if your external appeal request was handled on an expedited basis due to your medical circumstances, within 72 hours. The written decision issued by the IRO will include complete information regarding your appeal and the rationale for the decision. The decision will also include a statement that the IRO's decision is binding except to the extent that other remedies may be available to you or the Plan pursuant to state or federal law. If the decision is favorable to you, the Plan must pay benefits without delay even if it intends to seek other judicial remedies. The decision will also advise you about other resources that may be available to you for additional assistance.
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Non-Duplication of Benefits
As with most group health care programs, this program contains a type of coordination of benefits provision called “non-duplication of benefits.” This provision is used when you and your covered dependents (spouse or child) receive services which are eligible for payment under more than one group health program. The main objective is to assure that your covered expenses will be paid, but that the combined payments do not amount to more than the amount this program would pay if it were the only program. Under this arrangement, the benefits of one program are reduced to the extent they are payable by another program. Here is how the order of benefits works: • When the other group coverage does not have a “coordination of benefits” provision then that coverage pays first. • When the person who received care is covered as an employee under one group coverage, and as a dependent under another, then the employee coverage pays first. • When a dependent child is covered under two group coverages and his parents are not separated or divorced, the coverage of the parent whose birthday (according to month and day) falls earlier in the year first; if both parents have the same birthday, the Plan covering the parent for the longer time pays first. • If the dependent child’s parents are separated or divorced, the following applies: 1. The coverage of the parent with custody of the child pays first; 2. Then, the coverage of the spouse (if any) of the parent with custody of the child pays; and 3. Finally, the coverage of the parent without custody of the child pays. 4. Regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child’s health care expenses, the coverage of that parent pays first. • The Plan which covers a person as an active employee or his dependent will pay before the plan which covers such person as a laid off or retired employee or his dependent. If the other plan does not have a coordination of benefits provision concerning laid off or retired employees, then this rule does not apply. • When none of the above circumstances applies, the coverage you have had for the longest time pays first. If you receive more than you should have when your benefits are coordinated, you will be expected to repay any overpayment.
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This program will provide its regular benefits in full when it is primarily liable (the program which pays first). When this program is secondary liable (pays second), it will provide a reduced amount. This reduced amount is determined as follows: 1. The benefits that would be payable for allowable expenses under this program (without considering other programs’ benefits) are calculated; 2. The benefits payable under all other programs (for the same allowable expenses) are subtracted from (1); and 3. The difference, if any, is payable by this program. In no event will this program’s liability as a secondary program exceed its liability as a primary program.
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Service Centers
If you have any questions about the Plan, call your nearest Service Center.
Telephone personnel are available:
Monday, Tuesday, Wednesday and Friday from 8:00 a.m. to 8:00 p.m.
Thursday from 9:00 a.m. to 8:00 p.m. (E.T.) Eastern Time
For questions and assistance with your Blue Card PPO benefits and services, please call:
1-800-355-BLUE (2583)
When you are outside of New Jersey and need to locate a nationwide Network PPO Provider, please call:
1-800-810-BLUE (2583)
For Mental Health and Substance Abuse, please call:
1-800-626-2212
Always have your identification card handy when calling. Your ID number helps get prompt answers to your questions about enrollment, benefits or claims.
Use this space for information you will need when asking about your coverage.
The company office or enrollment official to contact about coverage:
__________________________________________________________________
The identification number shown on my identification card:
__________________________________________________________________
The effective date when my coverage begins:
__________________________________________________________________
My group number is:
__________________________________________________________________
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ERISA INFORMATION The following information, together with the information contained in the rest of this Booklet, comprise the Summary Plan Description required by the Employee Retirement Income Security Act of 1974, as amended (ERISA).
Name of Plan: The SUEZ Water Resources Inc. Medical Plan
Plan Sponsor: SUEZ Water Resources Inc.
461 From Rd., Suite 400
Paramus, New Jersey 07652
Plan Administrator: SUEZ Water Resources Inc. 461 From Rd., Suite 400
Paramus, New Jersey 07652
Employer Identification Number: 22-2441477
Plan Number: 501
Classification and Funding:
The Plan described in this Booklet is classified as a welfare benefits plan by the Department of
Labor. It is funded by both the company and Employee contributions.
Type of Administration: Contract Administration. Benefits are provided in accordance with the provisions of the Plan Sponsor. Horizon Blue Cross Blue Shield of New Jersey provides
administrative services only.
Claims Administrator: Horizon Blue Cross Blue Shield of New Jersey, Inc.
Agent for Service of Legal Process: Plan Administrator
The Plan Year begins on January 1 and ends on December 31.
Plan Administrator Authority and Powers:
The Plan Administrator shall have exclusive discretionary authority and power to determine
eligibility for benefits and to construe the terms and provisions of this Plan, to determine questions of fact and law arising under this Plan, and to exercise all of the powers necessary for the operation of this Plan. However, the Plan has delegated to the Claims Administrator the
authority to make final claims determinations and to decide initial and final claims appeals on the
Plan's behalf.
Plan Modification and Termination Information
Notwithstanding anything to the contrary in this Summary Plan Description, the Plan Sponsor/Administrator expressly reserves the right, at any time, for any reason and without
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limitation to terminate, modify or otherwise amend this Plan and any or all of the benefits provided there under, either in whole or in part, whether to all persons covered thereby or one or more groups thereof. These rights include specifically, but are not limited to, (1) the right to terminate benefits under the Plan with respect to any participant therein; (2) the right to modify benefits under this Plan to all or any group of participants therein; (3) the right to require or increase contributions by any participants therein towards the cost of this Plan; and (4) the right to amend this Plan or any term or condition thereof; in each case, whether or not such rights are exercised with respect to any other participant or group of participants in this plan.
Not a Contract of Employment
No provision of the Plan described in this Booklet is to be considered a contract of employment. The Employer’s rights with respect to disciplinary actions and termination of Employees are in no way changed by the provisions of the Plan.
If you have any questions about the Plan, contact the Plan Administrator.
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STATEMENT OF ERISA RIGHTS
As a participant in SUEZ Water Resources Inc. Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
• Receive information about your plan and benefits.
• Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
• Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.
• Receive a summary of the plan's annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report.
• Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110.00 a day until you receive
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the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plans' decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your fights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example if it finds your claim is frivolous.
Assistance with Your Questions
If your have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquires, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

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Covered Product: BLUE CARD PPO
Company Name: SUEZ WATER RESOURCES INC.
Group Number: 76026-0064, 0065, 0068, 0069, 0072, 0073
Effective Date: January 1, 2020

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Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com Dear Valued Customer:
Thank you for choosing Horizon Blue Cross Blue Shield of New Jersey for your health insurance
coverage. You're enrolled in a great plan! We are here to help you understand your benefits and take charge of your health. The enclosed information will help you better understand your benefits and the additional
programs and resources available to you as a Horizon BCBSNJ member.
It is important to register for Member Online Services at HorizonBlue.com. Through Member Online Services, you can:
• View your benefits.
• Check your claims status and payments.
• View authorizations and referrals, if applicable.
• Print a duplicate member ID card or display your member ID card.
• Tell us if you have other health insurance coverage.
• Change your doctor or dentist, if applicable.
• Manage your Member Online Services account and preferences.
Important Tips to Follow
• Keep your Horizon BCBSNJ member ID card with your at all times. It is the key to
accessing your health care benefits. Please present your member ID card whenever you
need medical care or services. You can also sign in to Member Online Services at HorizonBlue.com to view and print your member ID card.
• Visit HorizonBlue.com/doctorfinder to find in-network doctors, hospitals or health care
professionals. If you would like a printed copy of the directory, please call Member
Services at 1-800-355-BLUE (2583). Call our Interactive Voice Response (IVR) system for information at your convenience. Through our IVR system, you can get answers to your questions 24 hours a day (usually
including weekends/holidays).
Be prepared if a medical emergency arises. If you or a covered dependent experiences a medical emergency, we suggest you follow these steps: - Call 911 or go directly to the nearest Emergency Room.
- Call your Primary Care Physician (PCP) or personal doctor as soon as reasonably possible so
that he/she may coordinate your follow up care. You do not need to call Member Services in a medical emergency.
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Have a question about your benefits? If you have questions about your Horizon BCBSNJ coverage, you can sign in to Member Online
Services at HorizonBlue.com to chat with a Member Services Representative or send a secure email using My Messages. You can also call 1-800-355-BLUE (2583), Monday through Wednesday and Friday from 8 a.m. to 6 p.m., Eastern Time (ET) and Thursday, from 9 a.m. to 6 p.m., ET, to speak with a representative.

We look forward to continuing to serve your health insurance needs. Sincerely,
Christopher M. Lepre
Senior Vice President Market Business Units
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Notice of Nondiscrimination
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws and
does not discriminate against nor does it exclude people or treat them differently on the basis of race,
color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health
status in the administration of the plan, including enrollment and benefit determinations.
Horizon BCBSNJ provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and information written in other languages.
Contacting Member Services
Please call Member Services at 1-800-355-BLUE (2583) or the phone number on the back of
your member ID card, if you need the free aids and services noted above and for all other
Member Services issues, including:
• Claim, benefits or enrollment inquiries • Lost/stolen ID cards • Address changes • Any other inquiry related to your benefits or health plan
Filing a Section 1557 Grievance
If you believe that Horizon BCBSNJ has failed to provide the free communication aids and services or
discriminated on the basis of race, color, gender, national origin, age or disability you can file a discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ’s Civil Rights Coordinator can be reached by calling the Member Services number on the back of your member ID card or by writing to the following address:
Horizon BCBSNJ – Civil Rights Coordinator PO Box 820 Newark, NJ 07101
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office
for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
Office for Civil Rights Headquarters U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 or 1-800-537-7697 (TDD)
OCR Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

An Independent Licensee of the Blue Cross and Blue Shield Association.

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The draft booklet contains only the information administered by Horizon Blue Cross Blue Shield of New Jersey and is only a partial description of the benefits, limitations, exclusions and other provisions of your health care plan. The draft booklet is not a Summary Plan Description and
shall be used for general reference only and shall not supersede any terms within your plan document. Horizon disclaims all subsequent liability, accuracy, correctness, and validity of any information should the Plan Administrator alter the document or otherwise modify the
information contained therein. The Group shall indemnify and hold harmless Horizon from and against any claims, judgment, civil penalties, cause of action, liability, damage, cost or expense, including attorneys' fees, arising out of or in connection with the use or tampering of the booklet
provided herein. Please note: This booklet is currently in a draft status. For any updates please contact The
Corporate Major Accounts Contract Issuance Team.
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Table of Contents
Introduction .................................................................................................................................................... 1
Definitions...................................................................................................................................................... 2
Schedule of Covered Services and Supplies ................................................................................................ 23 Eligible Basic Services and Supplies ............................................................................................... 25 Eligible Supplemental Services and Supplies .................................................................................. 35
General Information ..................................................................................................................................... 37 How To Enroll ................................................................................................................................. 37 Your Identification Card .................................................................................................................. 37 Types of Coverage Available........................................................................................................... 37 Change In Type Of Coverage .......................................................................................................... 38 Enrollment of Dependents ............................................................................................................... 38 Special Enrollment Periods .............................................................................................................. 39 Individual Losing Other Coverage................................................................................................... 39 New Dependents .............................................................................................................................. 40 Special Enrollment Due to Marriage or Acquiring a Domestic Partner .......................................... 40 Special Enrollment Due to Newborn/Adopted Children ................................................................. 40 Multiple Employment ...................................................................................................................... 40 Eligible Dependents ......................................................................................................................... 41 When Your Coverage Ends ............................................................................................................. 41 Benefits After Termination .............................................................................................................. 42 Continuing Coverage Under the Federal Family and Medical Leave Act ....................................... 42 Continuation of Coverage under COBRA ....................................................................................... 43 Continuation of Coverage under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) ........................................................................ 44 Continuation of Care ........................................................................................................................ 46 Medical Necessity And Appropriateness ......................................................................................... 46 Cost Containment............................................................................................................................. 47 Managed Care Provisions ................................................................................................................ 47
Your Preferred Provider Organization (PPO) Program ............................................................................... 48 The Deductible ................................................................................................................................. 48 Family Aggregate Deductible .......................................................................................................... 48 Out-of-Pocket Maximum ................................................................................................................. 48 Payment Limits ................................................................................................................................ 49 Benefits From Other Plans ............................................................................................................... 49
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Summary of Covered Services and Supplies ............................................................................................... 50 Eligible Basic Services and Supplies ............................................................................................... 50 Allergy Testing and Treatment ........................................................................................................ 50 Ambulatory Surgery......................................................................................................................... 50 Anesthesia ........................................................................................................................................ 50 Audiology Services .......................................................................................................................... 50 Birthing Centers ............................................................................................................................... 50 Dental Care and Treatment .............................................................................................................. 51 Diagnosis and Treatment of Autism ................................................................................................ 51 Diagnostic X-rays and Laboratory Tests ......................................................................................... 52 Emergency Room............................................................................................................................. 52 Facility Charges ............................................................................................................................... 52 Fertility Services .............................................................................................................................. 53 Home Health Care............................................................................................................................ 53 Hospice Care .................................................................................................................................... 53 Inpatient Physician Services ............................................................................................................ 55 Mastectomy Benefits ....................................................................................................................... 55 Maternity/Obstetrical Care............................................................................................................... 55 Maternity/Obstetrical Care for Child Dependents ........................................................................... 56 Medical Emergency ......................................................................................................................... 56 Mental or Nervous Disorders (including Group Therapy) and Substance Abuse ........................... 56 Nutritional Counseling ..................................................................................................................... 56 Physical Rehabilitation .................................................................................................................... 57 Practitioner’s Charges for Non-Surgical Care and Treatment ......................................................... 57 Practitioner’s Charges for Surgery................................................................................................... 57 Pre-Admission Testing Charges ...................................................................................................... 57 Preventive Care ................................................................................................................................ 57 Second Opinion Charges.................................................................................................................. 60 Skilled Nursing Facility Charges ..................................................................................................... 60 Surgical Services .............................................................................................................................. 60 Telemedicine Services, provided by Horizon CareOnline .............................................................. 61 Therapeutic Manipulation ................................................................................................................ 61 Therapy Services .............................................................................................................................. 62 Transplant Benefits .......................................................................................................................... 62 Urgent Care ...................................................................................................................................... 63 Eligible Supplemental Services and Supplies .................................................................................. 63 Ambulance Services......................................................................................................................... 63 Blood ................................................................................................................................................ 64 Diabetes Benefits ............................................................................................................................. 64 Durable Medical Equipment ............................................................................................................ 65 Home Infusion Therapy ................................................................................................................... 65 Foot Orthotics .................................................................................................................................. 66 Oxygen and its Administration ........................................................................................................ 66 Private Duty Nursing Care ............................................................................................................... 66 Prosthetic Devices ............................................................................................................................ 66 Specialized Non-Standard Infant Formulas ..................................................................................... 67
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Wigs Benefit .................................................................................................................................... 67
Utilization Management............................................................................................................................... 68 Required Hospital Stay Review ....................................................................................................... 69 Notice of Hospital Admission Required .......................................................................................... 69 Continued Stay Review.................................................................................................................... 69 Alternate Treatment Features/Individual Case Management .......................................................... 70 Definitions........................................................................................................................................ 70 Alternate Treatment/Individual Case Management Plan ................................................................. 71 Exclusion.......................................................................................................................................... 72
Schedule of Procedures Requiring Prior Authorization ............................................................................... 73
Claims Procedures ....................................................................................................................................... 74
Exclusions Under The Blue Card PPO Program ......................................................................................... 81
Benefits Payable for Automobile Related Injuries ...................................................................................... 88
Subrogation and Reimbursement ................................................................................................................. 90
The Effect of Medicare on Benefits ............................................................................................................. 93 IMPORTANT NOTICE................................................................................................................... 93 Medicare Eligibility by Reason of Age ........................................................................................... 93 Medicare Eligibility by Reason of Disability .................................................................................. 94 Medicare Eligibility by Reason of End Stage Renal Disease .......................................................... 95 Dual Medicare Eligibility ................................................................................................................ 95 How To File A Claim If You Are Eligible For Medicare ................................................................ 96
Appeals Process ........................................................................................................................................... 97
Non-Duplication of Benefits ...................................................................................................................... 100
Service Centers .......................................................................................................................................... 102
Statement of ERISA Rights ....................................................................................................................... 105
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Introduction
Your Blue Card PPO benefit program gives you broad protection to help meet the costs of
Illnesses and Accidental Injuries. This benefit program offers the highest level of benefits when
services are obtained from any physician or hospital designated as a PPO Network provider
either in New Jersey or in another Blue Cross and Blue Shield service area.
In this booklet you’ll find the important features of your group’s Blue Card PPO benefits
provided by the Plan administered by Horizon Blue Cross Blue Shield of New Jersey.
Your benefits are self-insured through your Employer.
This booklet replaces any booklets or certificates you may previously have received.

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Definitions
This section defines certain important words used in this booklet. The meaning of each defined word, whenever it appears in this booklet, is governed by its definition as listed in this section.
Act of War: Any act peculiar to military, naval or air operations in time of War.
Active: Performing, doing, participating or similarly functioning in a manner usual for the task for full pay, at the Employer's place of business, or at any other place that the Employer's business requires the Employee to go.
Adverse Benefit Determination – an adverse benefit determination is any denial, reduction or termination of, or failure to provide or make payment for (in whole or in part), a benefit, including one based on a determination of eligibility, as well as one based on the application of any utilization review criteria, including determinations that an item or service for which benefits are otherwise provided are not covered because they are deemed to be experimental/investigational or not medically necessary or appropriate.
Affiliated Company: A corporation or other business entity affiliated with the Employer through common ownership of stock or assets; or as otherwise defined by the Employer.
Allowance: Subject to the exceptions below, an amount determined by the Plan as the east of the following amounts:
(a) the actual charge made by the Provider for the service or supply;
(b) in the case of In-Network Providers, the amount that the Provider has agreed to accept for the service or supply; or
(c) in the case of Out-of-Network Providers, the following:
(i) For Practitioners’ services, 300% of the amount determined for the service based on the Resource Based Relative Value System (RBRVS) promulgated by the Centers for Medicare and Medicaid Services.
(ii) For the services of Ambulatory Surgical Centers, 300% of the amount determined for the services based on the RBRVS.
(iii) For all other Covered Services and Supplies, the amount determined for the Covered Service or Supply in accordance with: (a) profiles compiled by Horizon BCBSNJ based on usual and prevailing payments made to Providers for similar services or supplies in specific geographical areas; or (b) similar profiles compiled by outside vendors.
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Exceptions:
(1) With respect to (i) a Medical Emergency; or (ii) Covered Services and Supplies provided in an In-Network Hospital, the Allowance determined in accordance with part (c), above, for any Covered Services and Supplies provided by Out-of-Network Providers shall be increased as needed to ensure that the Covered Person has no greater liability than he/she would have if they were provided by In-Network Providers. But this (ii) shall not apply if the Covered Person: (a) had or was given the opportunity to select In-Network Providers to provide the Covered Services or Supplies; and (b) elected the services of Out-of-Network Providers.
(2) With respect to parts (c)(i) and (c)(ii), above, if Medicare does not prescribe a reimbursement rate for the Covered Service or Supply, the Allowance for it will be determined in accordance with: (a) profiles compiled by Horizon BCBSNJ based on usual and prevailing payments made to Providers for similar services or supplies in specific geographical areas; or (b) similar profiles compiled by outside vendors.
Alternate Payee:
a. A custodial parent, who is not an Employee under the terms of the Plan, of a Child Dependent; or
b. The Division of Medical Assistance and Health Services in the New Jersey Department of Human Services which administers the State Medicaid Program.
Ambulance: A certified transportation vehicle that: (a) transports ill or injured people; and (b) contains all life-saving equipment and staff as required by state and local law.
Ambulatory Surgical Center: A Facility mainly engaged in performing Outpatient Surgery.
a. It must:
1. be staffed by Practitioners and Nurses under the supervision of a physician;
2. have permanent operating and recovery rooms;
3. be staffed and equipped to give Medical Emergency care; and
4. have written back-up arrangements with a local Hospital for Medical Emergency care.
b. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
1. accredited for its stated purpose by either the Joint Commission or the
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Accreditation Association for Ambulatory Care; or
2. approved for its stated purpose by Medicare.
The Plan does not recognize a Facility as an Ambulatory Surgical Center if it is part of a Hospital.
Approved Hemophilia Treatment Center – A health care facility licensed by the State of New Jersey for the treatment of hemophilia or one which meets the same standards if located in another state.
Behavioral Interventions Based on Applied Behavioral Analysis (ABA): Interventions or strategies, based on learning theory, that are intended to improve a person’s socially important behavior. This is achieved by using instructional and environmental modifications that have been evaluated through scientific research using reliable and objective measurements. These include the empirical identification of functional relations between behavior and environmental factors.
Such intervention strategies include, but are not limited to: chaining; functional analysis; functional assessment; functional communication training; modeling (including video modeling); procedures designed to reduce challenging and dangerous behaviors; prompting; reinforcement systems, including differential reinforcement, shaping and strategies to promote generalization.
Benefit Day: Each of the following:
a. Each midnight the Covered Person is registered as an Inpatient; or
b. Each day when Inpatient Admission and discharge occur on the same calendar day.
Benefit Month: The one-month period beginning on the Effective Date of the Plan and each succeeding monthly period.
Benefit Period – the twelve-month period starting on January 1st and ending on December 31st. The first and/or last Benefit Period may be less than a calendar year. The first Benefit Period begins on your coverage date. The last Benefit Period ends when you are no longer covered.
Birthing Center – a Facility which mainly provides care and treatment for women during uncomplicated pregnancy, routine full-term delivery, and the immediate post-partum period.
a. It must:
1. provide full-time Skilled Nursing Care by or under the supervision of Nurses; 2. be staffed and equipped to give Medical Emergency care; and 3. have written back-up arrangements with a local Hospital for Medical Emergency care.
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b. The Plan will recognize it if:
1. it carries out its stated purpose under all relevant state and local laws; or 2. it is approved for its stated purpose by the Accreditation Association for Ambulatory Care; or 3. it is approved for its stated purpose by Medicare.
The Plan does not recognize a Facility as a Birthing Center if it is part of a Hospital.
BlueCard PPO Provider: A Provider, not in New Jersey, which has a written agreement with another Blue Cross and/or Blue Shield plan to provide care to both that plan’s subscribers and other Blue Cross and/or Blue Shield plans’ subscribers. For purposes of this Plan, a BlueCard PPO Provider is an In-Network Provider.
Booklet: A detailed summary of benefits covered.
Calendar Year: A year starting January 1.
Care Manager – a person or entity designated by the Plan to manage, assess, coordinate, direct and authorize the appropriate level of health care treatment.
Certified Registered Nurse Anesthetist (C.R.N.A.) – A Registered Nurse, certified to administer anesthesia, who is employed by and under the supervision of a Physician anesthesiologist.
Child Dependent: A person who: has not attained the age of 26; and is:
• The natural born child or stepchild of you, your Spouse, or Domestic Partner regardless of where or with whom the child lives;
• A child who is: (a) legally adopted by you, your Spouse, or Domestic Partner, regardless of where or with whom such child lives; or (b) placed with you for adoption. But, proof of such adoption or placement satisfactory to the Plan must be furnished to us when we ask;
• You, your Spouse's or Domestic Partner's legal ward. But, proof of guardianship satisfactory to the Plan must be furnished to us when we ask.
Coinsurance: The percent applied to Covered Charges (not including Deductibles) for certain Covered Services or Supplies in order to calculate benefits under the Plan. These are shown in the Schedule of Covered Services and Supplies. The term does not include Copayments. For example, if the Plan's Coinsurance for an item of expense is 60%, then the Covered Person's Coinsurance for that item is 40%. Unless the context indicates otherwise, the Coinsurance percents shown in this Booklet are the percents that the Plan will pay.
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Complex Imaging Services: Includes the following services-
a) Computed Tomography (CT)
b) Computed Tomography Angiography (CTA)
c) Magnetic Resonance Imaging (MRI)
d) Magnetic Resonance Spectroscopy (MRS)
e) Positron Emission Tomography (PET)
f) Nuclear Medicine including Nuclear Cardiology
Cosmetic Services: Services (including Surgery) rendered to refine or reshape body structures or surfaces that are not functionally impaired. They are: (a) to improve appearance or self-esteem; or (b) for other psychological, psychiatric or emotional reasons. The following are not considered "cosmetic":
a. Surgery to correct the result of an Injury;
b. Surgery to treat a condition, including a birth defect, which impairs the function of a body organ;
c. Surgery to reconstruct a breast after a mastectomy is performed.
d. Treatment of newborns to correct congenital defects and abnormalities.
e. Treatment of cleft lip.
The following are some procedures that are always considered "cosmetic":
a. Surgery to correct gynecomastia;
b. Breast augmentation procedures, including their reversal for women who are asymptomatic;
c. Reversal of breast augmentation procedures for asymptomatic women who had reconstructive Surgery or who previously had breast implants for cosmetic purposes;
d. Rhinoplasty, except when performed to treat an Injury;
e. Lipectomy;
f. Ear or other body piercing.
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Coverage Date: The date on which coverage under this Plan begins for the Covered Person.
Covered Charges: The authorized charges, up to the Allowance, for Covered Services and Supplies. A Covered Charge is Incurred on the date the Covered Service or Supply is furnished. Subject to all of the terms of this Plan, the Plan provides coverage for Covered Services or Supplies Incurred by a Covered Person while the person is covered by this Plan.
Covered Person – you and your dependents who are enrolled under the Plan.
Covered Services and Supplies – the types of services and supplies described in the Covered Services and Supplies section of this booklet. The services and supplies must be:
a. furnished or ordered by a Provider; and
b. For Preventive Care, or Medically Necessary and Appropriate to diagnose or treat an Illness (including Mental or Nervous Disorders) or Injury.
Current Procedural Terminology (C.P.T.): The most recent edition of an annually revised listing published by the American Medical Association, which assigns numerical codes to procedures and categories of medical care.
Custodial Care: Care that provides a level of routine maintenance for the purpose of meeting personal needs. This is care that can be provided by a layperson who does not have professional qualifications or skills.
Custodial Care includes, but is not limited to: help in walking or getting into or out of bed; help in bathing, dressing and eating; help in other functions of daily living of a similar nature; administration of or help in using or applying creams and ointments; routine administration of medical gasses after a regimen of therapy has been set up; routine care of a patient, including functions such as changes of dressings, diapers and protective sheets and periodic turning and positioning in bed; routine care and maintenance in connection with casts, braces and other similar devices, or other equipment and supplies used in treatment of a patient, such as colostomy and ileostomy bags and indwelling catheters; routine tracheostomy care; general supervision of exercise programs, including carrying out of maintenance programs of repetitive exercises that do not need the skills of a therapist and are not skilled services.
Even if a Covered Person is in a Hospital or other recognized Facility, the Plan does not cover care if it is custodial in nature.
Day Programs: Outpatient personalized or packaged programs that: (a) are designed primarily for patients who are medically stable enough to live at home, but who may require certain therapies; (b) offer multiple therapies in a day setting; and (c) are usually scheduled for three to five days a week and five to nine and a half hours per day. Some examples of the therapies offered are: cognitive therapy; recreation therapy; work hardening programs; vocational therapy; group cognitive/interpersonal therapy; remedial treatments; and treatments to improve interpersonal communication and social skills. “Day Programs” do not include outpatient programs for the treatment of mental illnesses.
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Deductible: The amount of Covered Charges that a Covered Person must pay before this Plan provides any benefits for such charges. The term does not include Coinsurance, Copayments and Non-Covered Charges. See the Schedule of Covered Services and Supplies section of this Booklet for details.
Dependent: A Spouse, Domestic Partner, or Child Dependent whom the Employee enrolls for coverage under this Plan, as described in the General Information section of this Booklet.
Developmental Disability(ies): A person’s severe chronic disability which:
(a) is attributable to a mental or physical impairment, or a combination of them;
(b) for the purposes solely of the provision of this Program entitled “Diagnosis and Treatment of Autism and Other Developmental Disabilities”, is manifest before age 22;
(c) is likely to continue indefinitely;
(d) results in substantial functional limitations in three or more of the following areas of major life activity: self-care; receptive and expressive language; learning; mobility; self-direction; the capacity for independent living or economic self-sufficiency; and
(e) reflects the need for a combination and sequence of special inter-disciplinary or generic care, treatment or other services which are: (i) of lifelong or extended duration; and (ii) individually planned or coordinated.
Developmental Disability includes, but is not limited to, severe disabilities attributable to: mental retardation; autism; cerebral palsy; epilepsy; spina-bifida; and other neurological impairments where the above criteria are met.
Diagnostic Services: Procedures ordered by a recognized Provider because of specific symptoms to diagnose a specific condition or disease. Some examples are:
a. Radiology and ultrasound;
b. Lab and pathology; and
c. EKG’s, EEG’s and other electronic diagnostic tests
Except as allowed under covered charges for Preventive Care, Diagnostic Services are not covered under the Plan if the procedures are ordered as part of a routine or periodic physical examination or screening.
Domestic Partners: Persons who meet these criteria:
(1) Both persons have a common residence and are otherwise jointly responsible for each other's common welfare, as evidenced by joint financial arrangements or joint ownership
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of real property, which shall be demonstrated by at least one of the following:
(a) A joint deed, mortgage agreement or lease;
(b) A joint bank account;
(c) Designation of one of the persons as a primary beneficiary in the other's will;
(d) Designation of one of the persons as a primary beneficiary in the other person's life insurance policy or retirement plan; or
(e) joint ownership of a motor vehicle;
(2) Both persons agree to be jointly responsible for each other's basic living expenses during the Domestic Partnership;
(3) Neither person is in a marriage recognized by the State in which he or she resides or a member of another Domestic Partnership;
(4) Neither person is related to the other by blood or affinity up to and including the fourth degree of consanguinity;
(5) Both persons have chosen to share each other's lives in a committed relationship of mutual caring;
(6) Both persons are at least 18 years of age.
Domestic Partnership: A relationship between the Employee and another person as the Employee that meets the requirements set forth under this Plan. Proof that such a relationship exists, as determined by the Plan, must be given to the Plan when requested. The Plan has the right to determine eligibility for coverage under this Plan.
Durable Medical Equipment: Medically Necessary and Appropriate equipment which the Plan determines to fully meet these requirements:
a. It is designed for and able to withstand repeated use;
b. It is primarily and customarily used to serve a medical purpose;
c. It is generally not useful to a person in the absence of an Illness or Injury; and
d. It is suitable for use in the home.
Some examples are: walkers; wheelchairs (manual or electric); hospital-type beds; breathing equipment; and apnea monitors.
Some examples of services and supplies that are not considered to be Durable Medical Equipment are: adjustments made to vehicles; furniture; scooters; all terrain vehicles (ATVs);
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non-hospital-type beds; air conditioners; air purifiers; humidifiers; dehumidifiers; elevators; ramps; stair glides; emergency alert equipment; handrails; heat appliances; improvements made to the home or place of business; waterbeds; whirlpool baths; and exercise and massage equipment.
Elective Surgical Procedure: Non-emergency Surgery that may be scheduled for a day of the patient's choice without risking the patient's life or causing serious harm to the patient's bodily functions.
Employee: A person employed by the Employer; a proprietor or partner of the Employer.
Employer: Collectively, all employers included under the Plan.
Enrollment Date: A person's Coverage Date or, if earlier, the first day of any applicable Waiting Period.
Essential Health Benefits: This has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act, and as further defined by the Secretary of the U.S. Department of Health and Human Services. The term includes: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services (including behavioral health treatment); rehabilitative and habilitative services and devices; lab services; preventive and wellness services and chronic disease management; and pediatric services (including oral and vision care).
Experimental or Investigational: Any: treatment; procedure; Facility; equipment; drug; device; or supply (collectively, "Technology") which, as determined by The Plan, fails to meet any one of these tests:
a. The Technology must either be: (a) approved by the appropriate federal regulatory agency and have been in use for the purpose defined in that approval; or (b) proven to The Plan's satisfaction to be the standard of care.
This applies to drugs, biological products, devices and any other product or procedure that must have final approval to market from: (i) the FDA; or (ii) any other federal government body with authority to regulate the Technology. But, such approval does not imply that the Technology will automatically be deemed by The Plan as Medically Necessary and Appropriate and the accepted standard of care.
b. There must be sufficient proof, published in peer-reviewed scientific literature, that confirms the effectiveness of the Technology. That proof must consist of well-designed and well-documented investigations. But, if such proof is not sufficient or is questionable, The Plan may consider opinions about and evaluations of the Technology from appropriate specialty advisory committees and/or specialty consultants.
c. The Technology must result in measurable improvement in health outcomes, and the therapeutic benefits must outweigh the risks, as shown in scientific studies. "Improvement" means progress toward a normal or functional state of health.
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d. The Technology must be as safe and effective as any established modality. (If an alternative to the Technology is not available, The Plan may, to determine the safety and effectiveness of a Technology, consider opinions about and evaluations of the Technology from appropriate specialty advisory committees and/or specialty consultants.)
e. The Technology must demonstrate effectiveness when applied outside of the investigative research setting.
Services and supplies that are furnished for or in connection with an Experimental or Investigational Technology are not Covered Services and Supplies under this Program, even if they would otherwise be deemed Covered Services and Supplies. But, this does not apply to: (a) services and supplies needed to treat a patient suffering from complications secondary to the Experimental or Investigational Technology; or (b) Medically Necessary and Appropriate services and supplies that are needed by the patient apart from such a Technology.
Regarding a., above, The Plan will evaluate a Prescription Drug for uses other than those approved by the FDA. For this to happen, the drug must be recognized to be Medically Necessary and Appropriate for the condition for which it has been prescribed in one of these:
 The American Hospital Formulary Service Drug Information.
 The United States Pharmacopeia Drug Information.
Even if such an "off-label" use of a drug is not supported in one or more of the above compendia, The Plan will still deem it to be Medically Necessary and Appropriate if supportive clinical evidence for the particular use of the drug is given in a clinical study or published in a major peer-reviewed medical journal. But, in no event will this Program cover any drug that the FDA has determined to be Experimental, Investigational or contraindicated for the treatment for which it is prescribed.
Also, regardless of anything above, this Plan will provide benefits for services and supplies furnished to a Covered Person for medical care and treatment associated with: (i) an approved cancer clinical trial (Phase I, II, III and/or IV); or (ii) an approved Phase I, II, III and/or IV clinical trial for another life threatening condition. This coverage will be provided if: (a) the Covered Person’s Practitioner is involved in the clinical trial; and (b) he/she has concluded that the Covered Person’s participation would be appropriate. It can also be provided if the Covered Person gives medical or scientific information proving that such participation would be appropriate.
This coverage for clinical trials includes, to the extent coverage would be provided other than for the clinical trial: (a) Practitioners' fees; (b) lab fees; (c) Hospital charges; (d) treating and evaluating the Covered Person during the course of treatment or regarding a complication of the underlying Illness; and (e) other routine costs related to the patient's care and treatment, to the extent that these services are consistent with usual and customary patterns and standards of care furnished whenever a Covered Person receives medical care associated with an approved clinical trial.
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This coverage for clinical trials does not include: (a) the cost of Experimental or Investigational drugs or devices themselves; (b) non-health services that the patient needs to receive the care and treatment; (c) the costs of managing the research; or (d) any other services, supplies or charges that this Program would not cover for treatment that is not Experimental or Investigational.
With respect to coverage for clinical trials, The Plan will not:
• Deny a qualified Covered Person participation in an approved clinical trial;
• Deny or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with an approved clinical trial; or
• Discriminate against the Covered Person on the basis of his/her participation in such a trial.
Eye Examination - a comprehensive medical examination of the eye performed by a Practitioner, including a diagnostic ophthalmic examination, with or without definitive refraction as medically indicated, with medical diagnosis and initiation of diagnostic and treatment programs, prescription of medication and lenses, post cycloplegic Visit if required and verification of lenses if prescribed.
Facility: An entity or institution: (a) which provides health care services within the scope of its license, as defined by applicable law; and (b) which the Plan either: (i) is required by law to recognize; or (ii) determines in its sole discretion to be eligible under the Plan.
Family or Medical Leave of Absence – a period of time of predetermined length, approved by the Employer, during which the Employee does not work, but after which the Employee is expected to return to Active service. Any Employee who has been granted an approved Leave of Absence in accordance with the Family and Medical Leave Act of 1993 shall be considered to be Active for purposes of eligibility for Covered Services and Supplies under your Plan.
FDA: The Food and Drug Administration.
Foot Orthotics – custom-made supportive devices designed to restrict, immobilize, strengthen or protect the foot.
Government Hospital – A Hospital which is operated by a government or any of its subdivisions or agencies. This includes any federal, military, state, county or city Hospital.
Group Health Plan – an Employee welfare benefit plan, as defined in Title I of section 3 of P.L. 93-406 (ERISA) to the extent that the Plan provides medical care and includes items and services paid for as medical care to Employees or their dependents directly or through insurance, reimbursement or otherwise.
Home Area: The 50 states of the United States of America, the District of Columbia and Canada.
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Home Health Agency: A Provider which mainly provides care for an ill or injured person in the person's home under a home health care program designed to eliminate Hospital stays. The Plan will recognize it if it: (a) is licensed by the state in which it operates; or (b) is certified to take part in Medicare as a Home Health Agency.
Home Health Care: Nursing and other Home Health Care services rendered to a Covered Person in his/her home. For Home Health Care to be covered, these rules apply:
a. The care must be given on a part-time or intermittent basis, except if full-time or 24-hour services are Medically Necessary and Appropriate on a short-term basis.
b. Continuing Inpatient stay in a Hospital would be needed in the absence of Home Health Care.
c. The care is furnished under a physician's order and under a plan of care that: (a) is established by that physician and the Home Health Care Provider; (b) is established within 14 days after Home Health Care starts; and (c) is periodically reviewed and approved by the physician.
Home Health Care Services: Any of these services needed for the Home Health Care plan: nursing care; physical therapy; occupational therapy; medical social work; nutrition services; speech therapy; home health aide services; medical appliances and equipment, drugs and medicines, lab services and special meals, to the extent these would have been Covered Services and Supplies if the Covered Person was a Hospital Inpatient; diagnostic and therapeutic services (including Surgical services) performed in a Hospital Outpatient department, a physician's office, or any other licensed health care Facility, to the extent these would have been Covered Services and Supplies under this Plan if furnished during a Hospital Inpatient stay.
Horizon BCBSNJ: Horizon Blue Cross Blue Shield of New Jersey.
Hospice – a Provider which mainly provides palliative and supportive care for terminally Ill or terminally Injured people under a hospice care program. The Plan will recognize a Hospice if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. approved for its stated purpose by Medicare; or
b. it is accredited for its stated purpose by either the Joint Commission or the National Hospice Organization.
Hospice Care Program: A health care program which provides an integrated set of services designed to provide Hospice care. Hospice services are centrally coordinated through an interdisciplinary team directed by a Practitioner.
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Hospital: A Facility which mainly provides Inpatient care for ill or injured people. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited as a hospital by the Joint Commission: or
b. approved as a hospital by Medicare.
Among other things, a Hospital is not any of these: a convalescent home; a rest or nursing Facility; an infirmary; a Hospice; a Substance Abuse Center; or a Facility (or part of it) which mainly provides: domiciliary or Custodial Care; educational care; non-medical or ineligible services or supplies; or rehabilitative care. A facility for the aged is also not a Hospital. "Hospital" shall also not include a satellite facility of a Hospital for which a separate facility license is required by law, unless the satellite also meets this definition in its own right.
The Plan will pay benefits for Covered Services and Supplies Incurred at Hospitals operated by the United States government only if: (a) the services or supplies are for treatment on an emergency basis; or (b) the services or supplies are provided in a hospital located outside of the United States or Puerto Rico.
The above limitations do not apply to military Retirees, their dependents, and the dependents of active-duty military personnel who: (a) have both military health coverage and the Plan coverage; and (b) receive care in facilities run by the Department of Defense or Veteran's Administration.
Illness – a sickness or disease suffered by a Covered Person.
Incurred: A charge is Incurred on the date a Covered Person receives a service or supply for which a charge is made.
Injury: All damage to a person's body due to accident, and all complications arising from that damage.
In-Network – a Provider, or the Covered Services and Supplies provided by a Provider, who has an agreement with the Plan to furnish Covered Services or Supplies.
In-Network Coverage: The level of coverage, shown in the Schedule of Covered Services and Supplies, which is provided if an In-Network Provider provides the service or supply.
Inpatient: A Covered Person who is physically confined as a registered bed patient in a Hospital or other Facility, or the services or supplies provided to such Covered Person, depending on the context in which the term is used.
Joint Commission: The Joint Commission on the Accreditation of Health Care Organizations.
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Late Enrollee – a Covered Person who requests enrollment under the Plan more than 31 days after first becoming eligible. However, you will not be considered a Late Enrollee under certain circumstances. See the General Information section of this booklet for additional information.
Maintenance Therapy: That point in the therapeutic process at which no further improvement in the gaining or restoration of a function, reduction in disability or relief of pain is expected. Continuation of therapy at this point would be for the purpose of holding at a steady state or preventing deterioration.
Medical Emergency: A medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to: severe pain; psychiatric disturbances; and/or symptoms of Substance Abuse) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate attention to result in: (a) placing the health of the person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of a bodily organ or part.
With respect to a pregnant woman who is having contractions, a Medical Emergency exists where: (a) there is not enough time to make a safe transfer to another Hospital before delivery; or (b) the transfer may pose a threat to the health or safety of the woman or the unborn child.
Examples of a Medical Emergency include, but are not limited to: heart attacks; strokes; convulsions; severe burns; obvious bone fractures; wounds requiring sutures; poisoning; and loss of consciousness.
Medically Necessary and Appropriate: This means or describes a health care service that a health care Provider, exercising his/her prudent clinical judgment, would provide to a Covered Person for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that is: in accordance with the generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Covered Person’s illness, injury or disease; not primarily for the convenience of the Covered Person or the health care Provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Covered Person’s illness, injury or disease.
“Generally accepted standards of medical practice”, as used above, means standards that are based on:
a. credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;
b. physician and health care Provider specialty society recommendations;
c. the views of physicians and health care Providers practicing in relevant clinical areas; and
d. any other relevant factor as determined by the New Jersey Commissioner of Banking and Insurance by regulation.
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Medicaid: The health care program for the needy provided by Title XIX of the United States Social Security Act, as amended from time to time.
Medicare: Part A and Part B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time.
Mental Health Center: A Facility which mainly provides treatment for people with mental health problems. The Plan will recognize such a place if: (1) it carries out its stated purpose under all relevant state and local laws; and (2) it is:
a. accredited for its stated purpose by the Joint Commission;
b. approved for its stated purpose by Medicare; or
c. accredited or licensed by the state in which it is located to provide mental health services.
Mental or Nervous Disorders: Conditions which manifest symptoms that are primarily mental or nervous (whether organic or non-organic, biological or non-biological, chemical or non-chemical in origin and irrespective of cause, basis or inducement) for which the primary treatment is psychotherapy or psychotherapeutic methods or psychotropic medication. Mental or Nervous Disorders include, but are not limited to: psychoses; neurotic and anxiety disorders; schizophrenic disorders; affective disorders; personality disorders; and psychological or behavioral abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems.
In determining whether or not a particular condition is a Mental or Nervous Disorder, the Plan may refer to the current edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (the “Manual”). But in no event shall the following be considered Mental or Nervous Disorders:
(1) Conditions classified as V-codes in the most current edition of the Manual. These include relational problems such as: parent-child conflicts; problems related to abuse or neglect when intervention is focused on the perpetrator; situations not attributable to a diagnostic disorder, including: bereavement, academic, occupational, religious, and spiritual problems.
(2) Conditions related to behavior problems or learning disabilities, except with respect to the treatment of Mental or Nervous Disorders or Developmental Disabilities.
(3) Conditions that the Plan determines to be due to developmental disorders. These include, but are not limited to: mental retardation; academic skills disorders; or motor skills disorders. But, this does not apply to the extent required by law for the treatment of Mental or Nervous Disorders or Developmental Disabilities;
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(4) Conditions that the Plan determines to lack a recognizable III-R classification in the most current edition of the Manual. This includes, but is not limited to, treatment for: adult children of alcoholic families; or co-dependency.
Mutually Exclusive Surgical Procedures: Surgical procedures that:
(a) differ in technique or approach, but lead to the same outcome;
(b) represent overlapping services or accomplish the same result;
(c) in combination, may be anatomically impossible.
Negotiation Arrangement (a.k.a., Negotiated National Account Arrangement): An agreement negotiated between a control/home licensee and one or more par/host licensees for any national account that is not delivered through the BlueCard Program.
Non-Covered Charges: Charges for services and supplies which: (a) do not meet this Plan's definition of Covered Charges; (b) exceed any of the coverage limits shown in this Booklet; or (c) are specifically identified in this Booklet as Non-Covered Charges.
Nurse: A Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.), or a nursing specialist such as a nurse mid-wife or nurse anesthetist, who:
a. is properly licensed or certified to provide medical care under the laws of the state where he/she practices; and
b. provides medical services which are: (a) within the scope of his/her license or certificate; and (b) are covered by this Plan.
Out-of-Hospital: Services or supplies provided to a Covered Person other than as an Inpatient or Outpatient.
Out-of-Network: A Provider, or the services and supplies furnished by a Provider, who does not have an agreement with Horizon BCBSNJ to provide Covered Services or Supplies, depending on the context in which the term is used.
Out-of-Network Benefits: The coverage shown in the Schedule of Covered Services and Supplies which is provided if an Out-of-Network Provider provides the service or supply.
Out-of-Pocket Maximum: The maximum dollar amount that a Covered person must pay as Deductible, or Coinsurance for Covered Services and Supplies during any Benefit Period. Once that dollar amount is reached, no further such payments are required for the remainder of that Benefit Period.
Outpatient: Either: (a) a Covered Person at a Hospital who is other than an Inpatient; or (b) the services and supplies provided to such a Covered Person, depending on the context in which the term is used.
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Partial Hospitalization: Intensive short-term non-residential day treatment services that are: (a) for Mental or Nervous Disorders; chemical dependency; and (b) rendered for any part of a day for a minimum of four consecutive hours per day.
Per Lifetime: During the lifetime of a person.
Period of Confinement: Consecutive days of Inpatient services or successive Inpatient stays due to the same or related causes, when discharge and re-admission to a Facility occurs within 90 days or less. The Plan determines if the cause(s) of the stays are the same or related.
Pharmacy: A Facility: (a) which is registered as a Pharmacy with the appropriate state licensing agency; and (b) in which Prescription Drugs are dispensed by a pharmacist.
Physical Rehabilitation Center: A Facility which mainly provides therapeutic and restorative services to ill or injured people. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by either the Joint Commission or the Commission on Accreditation for Rehabilitation Facilities; or
b. approved for its stated purpose by Medicare.
Plan: The SUEZ Water Resources Inc. Medical Plan
Plan Year: The twelve-month period starting on January 1st and ending on December 31st.
Post-Service Claim – is any claim for a benefit under a group health Plan that is not a Pre-Service claim.
Practitioner: A person that the Plan is required by law to recognize who:
a. is properly licensed or certified to provide medical care under the laws of the state where he/she practices; and
b. provides medical services which are: (a) within the scope of the license or certificate; and (b) are covered by this Plan.
Practitioners include, but are not limited to, the following; physicians; chiropractors; dentists; optometrists; pharmacists; chiropodists; psychologists; physical therapists; audiologists; speech language pathologists; certified nurse mid-wives; registered professional nurses; nurse practitioners; and clinical nurse specialists.
Pre-Service Claim – is any claim for a benefit under a group health plan with respect to which the terms of the Plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care.
Preventive Care: Services or supplies that are not provided for the treatment of an Injury or Illness. It includes, but is not limited to: routine physical exams, including: related X-rays and
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lab tests; immunizations and vaccines; screening tests; well-baby care; and well adult care.
Prior Authorization: Authorization by Horizon BCBSNJ for a Practitioner to provide specified treatment to Covered Persons. After Horizon BCBSNJ gives this approval, Horizon BCBSNJ gives the Practitioner a certification number. Benefits for services that are required to be, but are not, given Prior Authorization are subject to reduction as described in the “Utilization Review and Management” section of this Booklet.
Program: The plan of group health benefits described in this Booklet.
Provider: A Facility or Practitioner of health care in accordance with the terms of this Plan.
Related Structured Behavioral Programs: Services given by a qualified Practitioner that are comprised of multiple intervention strategies, i.e., behavioral intervention packages, based on the principles of ABA. These include, but are not limited to: activity schedules; discrete trial instruction; incidental teaching; natural environment training; picture exchange communication system; pivotal response treatment; script and script-fading procedures; and self-management.
Routine Foot Care: The cutting, debridement, trimming, reduction, removal or other care of: corns; calluses; flat feet; fallen arches; weak feet; chronic foot strain; dystrophic nails; excrescences; helomas; hyperkeratosis; hypertrophic nails; non-infected ingrown nails; dermatomes; keratosis; onychauxis; onychocryptosis; tylomas; or symptomatic complaints of the feet.
Routine Nursing Care: The appropriate nursing care customarily furnished by a recognized Facility for the benefit of its Inpatients.
Skilled Nursing Care: Services which: (a) are more intensive than Custodial Care; (b) are provided by an R.N. or L.P.N.; and (c) require the technical skills and professional training of an R.N. or L.P.N.
Skilled Nursing Facility: A Facility which mainly provides full-time Skilled Nursing Care for ill or injured people who do not need to be in a Hospital. The Plan will recognize it if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by the Joint Commission; or
b. approved for its stated purpose by Medicare. In some places, a Skilled Nursing Facility may be called an "Extended Care Center" or a "Skilled Nursing Center."
Special Care Unit: A part of a Hospital set up for very ill patients who must be observed constantly. The unit must have a specially trained staff and special equipment and supplies on hand at all times. Some types of Special Care Units are:
a. intensive care units;
b. cardiac care units;
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c. neonatal care units; and
d. burn units.
Special Enrollment Period: A period, as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), during which you may enroll yourself and your Dependents for the coverage under this Plan.
Specialist: A health care Practitioner who provides medical care in any generally accepted medical or surgical specialty or sub-specialty.
Spouse: The person who is legally married to the Employee. Proof of legal marriage must be submitted to the Plan when requested.
Substance Abuse – the abuse or addiction to drugs or controlled substances, including alcohol.
Substance Abuse Centers – Facilities that mainly provide treatment for people with Substance Abuse problems. The Plan will recognize such a place if it carries out its stated purpose under all relevant state and local laws, and it is either:
a. accredited for its stated purpose by the Joint Commission; or
b. approved for its stated purpose by Medicare.
Surgery/Surgical:
a. The performance of generally accepted operative and cutting procedures, including: surgical diagnostic procedures; specialized instrumentations; endoscopic exams; and other invasive procedures;
b. The correction of fractures and dislocations;
c. Pre-operative and post-operative care; or
d. Any of the procedures designated by C.P.T. codes as Surgery.
Therapeutic Manipulation – the treatment of the articulations of the spine and musculoskeletal structures for the purpose of relieving certain abnormal clinical conditions resulting from the impingement upon associated nerves causing discomfort. Some examples are manipulation or adjustment of the spine, hot or cold packs, electrical muscle stimulation, diathermy, skeletal adjustments, massage, adjunctive therapy, ultra-sound, doppler, whirlpool or hydro-therapy or other treatment of a similar nature.
Therapy Services: The following services and supplies when they are:
a. ordered by a Practitioner;
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b. performed by a Provider;
c. Medically Necessary and Appropriate for the treatment of a Covered Person's Illness or Accidental Injury.
Chelation Therapy: The administration of drugs or chemicals to remove toxic concentrations of metals from the body.
Chemotherapy: The treatment of malignant disease by chemical or biological antineoplastic agents.
Cognitive Rehabilitation Therapy: Retraining the brain to perform intellectual skills that it was able to perform prior to disease, trauma, Surgery, congenital anomaly or previous therapeutic process.
Dialysis Treatment: The treatment of an acute renal failure or chronic irreversible renal insufficiency by removing waste products from the body. This includes hemodialysis and peritoneal dialysis.
Infusion Therapy: The administration of antibiotic, nutrient, or other therapeutic agents by direct infusion.
Occupational Therapy: The treatment to develop or restore a physically disabled person's ability to perform the ordinary tasks of daily living.
Physical Therapy: The treatment by physical means to: relieve pain; develop or restore normal function; and prevent disability following Illness, Injury or loss of limb.
Radiation Therapy: The treatment of disease by X-ray, radium, cobalt, or high energy particle sources. Radiation Therapy includes the rental or cost of radioactive materials. Diagnostic Services requiring the use of radioactive materials are not Radiation Therapy.
Respiration Therapy: The introduction of dry or moist gases into the lungs.
Speech Therapy: Therapy that is by a qualified speech therapist and is described in a., b. or c:
a. Speech therapy to restore speech after a loss or impairment of a demonstrated, previous ability to speak. Two examples of speech therapy that will not be covered are: (a) therapy to correct pre-speech deficiencies; and (b) therapy to improve speech skills that have not fully developed.
b. Speech therapy to develop or improve speech to correct a defect that both: (a) existed at birth; and (b) impaired or would have impaired the ability to speak.
c. Regardless of anything in a. or b. above to the contrary, speech therapy needed to treat a speech impairment of a Covered Person diagnosed with a Developmental Disability.
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Urgent Care: Outpatient and Out-of-Hospital medical care which, as determined by the Plan or an entity designated by the Plan, is needed due to an unexpected Illness, Injury or other condition that is not life threatening, but that needs to be treated by a Provider within 24 hours.
Urgent Care Claim: An Urgent Care Claim is any claim for medical care which, if denied, in the opinion of the Covered Person or his/her Provider, will cause serious medical consequences in the near future, or subject the Covered Person to severe pain that cannot be managed without the medical services that have been denied.
Value-Based Program: An outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment.
Visit: An occasion during which treatment or consultation services are rendered in a Provider's office, in the Outpatient department of an eligible Facility, or by a Provider on the staff of (or under contract or arrangement with) a Home Health Agency to provide covered Home Health Care services or supplies.
Waiting Period – the period of time between enrollment in the program and the date when you become eligible for benefits. We, Us and Our: The Plan.
You, Your: An Employee.
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Schedule of Covered Services and Supplies
BENEFITS FOR COVERED SERVICES OR SUPPLIES UNDER THIS PLAN ARE SUBJECT TO ALL DEDUCTIBLE(S), COPAYMENT(S), COINSURANCE(S) AND MAXIMUM(S) STATED IN THIS SCHEDULE AND ARE DETERMINED PER BENEFIT PERIOD BASED ON ALLOWANCE, UNLESS OTHERWISE STATED.
NOTE: BENEFITS WILL BE REDUCED OR ELIMINATED FOR NONCOMPLIANCE
WITH THE UTILIZATION REVIEW PROVISIONS CONTAINED IN THIS PLAN.
REFER TO THE SECTION OF THIS PLAN CALLED “EXCLUSIONS” TO SEE WHAT SERVICES AND SUPPLIES ARE NOT COVERED.
The Plan will provide the coverage listed in this Schedule of Covered Services and Supplies,
subject to the terms, conditions, limitations and exclusions stated within this Plan.
Services and supplies provided by an In-Network Provider are covered at the In-Network level.
Services and supplies provided by an Out-of-Network Provider are covered at the
Out-of-Network level. However, this does not apply to services and supplies provided by an
Out-of-Network Provider in a case where: (a) the Covered Person is an Inpatient in a Hospital;
(b) the admitting physician was a Network Practitioner; and (c) the Covered Person and/or the
Covered Person's Practitioner complied with this Plan's rules with respect to Prior Authorization
or notification. In this case, the Covered Services and Supplies provided by Out-of-Network
Providers during the Inpatient stay will be covered at the In-Network level.
Please note that you may be responsible for paying charges, which exceed allowance when
services are rendered by an Out-of-Network Provider.
Coinsurance 80% of Covered Basic Charges.
In-Network
80% of Covered Supplemental Charges.
Coinsurance 60% of Covered Basic Charges.
Out-of-Network 60% of Covered Supplemental Charges.
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Out-of-Pocket Maximum In-Network After $2,500/Covered Person, $7,500/family, the plan provide
100% of Covered Allowance. Out-of-Pocket Maximum Out-of-Network After $4,000/Covered Person, $12,000/family, the plan provide
100% of Covered Allowance. Note: The Out-Pocket Maximum cannot be met with:
• Non-Covered Charges Deductible
In-Network
Applies to Basic/ $200/Covered Person.
Supplemental Services $600/family. Must be aggregately satisfied by two or more
separate Covered Persons.
Out-of-Network
Applies to $750/Covered Person.
Basic/Supplemental Services $2,250/family. Must be aggregately satisfied by two or
more separate Covered Persons.
Period of Confinement $250 Per Period of Confinement Deductible Applies to In-Network and Out-of-Network Services
BENEFIT PERIOD MAXIMUM
In-Network Unlimited. Applies to all Covered Services and Supplies.
Out-of-Network Unlimited. Applies to all Covered Services and Supplies.
PER LIFETIME MAXIMUMS
In-Network Unlimited. Applies to all Covered Services and Supplies.
Out-of-Network Unlimited. Applies to all Covered Services and Supplies.
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A. ELIGIBLE BASIC SERVICES AND SUPPLIES
ALLERGY TESTING AND TREATMENT
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
AMBULATORY SURGERY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
ANESTHESIA
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
COMPLEX IMAGING SERVICES
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DENTAL CARE AND TREATMENT
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIAGNOSTIC X-RAY AND LABORATORY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIALYSIS CENTER CHARGES
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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EMERGENCY ROOM (EMERGENT)
In-Network Outpatient
Facility Subject to $150 Copayment and 100% Coinsurance.
Outpatient
Professional Subject to Deductible, and 80% Coinsurance.
Out-of-Network Outpatient Facility Subject to $150 Copayment and 100% Coinsurance.
Outpatient Professional Subject to Deductible, and 80% Coinsurance. EMERGENCY ROOM (NON-EMERGENT)
In-Network Outpatient Facility Subject to $150 Copayment and 100% Coinsurance.
Outpatient Professional Subject to Deductible, and 80% Coinsurance.
Out-of-Network
Outpatient
Facility Subject to $150 Copayment and 100% Coinsurance.
Outpatient Professional Subject to Deductible, and 60% Coinsurance.
FACILITY CHARGES 365 days Inpatient Hospital care.
In-Network Subject to Preapproval, $250.00 Per Period of Confinement Deductible, Deductible, and 80% Coinsurance.
Out-of-Network Subject to Preapproval, $250.00 Per Period of Confinement Deductible, Deductible, and 60% Coinsurance.
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FERTILITY SERVICES
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to 4 attempts per Lifetime.
HOME HEALTH AGENCY CARE
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 120 Visit Benefit Period maximum, combined In-Network and Out-of-Network. Includes Durable Medical Equipment used by a Home Health Professional.
HOSPICE CARE
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 210 day Benefit Period maximum, combined In-Network and Out-of-Network.
INPATIENT PHYSICIAN SERVICES
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
MATERNITY/OBSTETRICAL CARE
In-Network Subject to $25.00 Copayment for the initial Visit, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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MENTAL OR NERVOUS DISORDERS (INCLUDING GROUP THERAPY) AND SUBSTANCE ABUSE
Inpatient In-Network Subject to Prior Authorization, $250.00 Per Period of Confinement
Deductible, Deductible and 80% Coinsurance.
Inpatient
Out-of-Network Subject to Prior Authorization, $250.00 Per Period of Confinement
Deductible, Deductible and 60% Coinsurance.
In-Network Outpatient Subject to Deductible, and 80% Coinsurance.
Out-Of-Hospital Subject to $25.00 Copayment and 100% Coinsurance.
Out-of-Network Outpatient and Out-Of-Hospital Subject to Deductible, and 60% Coinsurance.
NUTRITIONAL COUNSELING
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 3 Visit Benefit Period maximum.
PHYSICAL REHABILITATION
Inpatient In-Network Subject to Deductible, and 80% Coinsurance.
Inpatient Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to a 120 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
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PRACTITIONER’S CHARGES FOR NON-SURGICAL CARE AND TREATMENT
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PRACTITIONER’S CHARGES FOR SURGERY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PREADMISSION TESTING
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PREVENTIVE CARE
In-Network Subject to 100% Coinsurance. Applies to all Preventive Care except as noted below.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Applies to all Preventive Care except as noted below.
a. GYNECOLOGICAL CARE AND EXAMINATIONS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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b. MAMMOGRAPHY
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
c. PAP SMEARS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
d. ROUTINE PHYSICALS AND IMMUNIZATIONS
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
e. WELL-CHILD CARE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
f. WELL-CHILD IMMUNIZATIONS, AND LEAD POISONING SCREENING AND TREATMENT
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
g. PROSTATE CANCER SCREENING
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
h. COLORECTAL CANCER SCREENING
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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i. VISION EXAM - ANNUAL/ROUTINE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 exam per year.
j. HEARING EXAM - ROUTINE
In-Network Subject to 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Limited to 1 routine hearing exam or audiology function test per year for adults and children.
PRIMARY CARE PHYSICIAN
In-Network Subject to $25.00 Copayment and 100% Coinsurance.
Out-of-Network Subject to Deductible and 60% Coinsurance.
SECOND OPINION CHARGES
In-Network Subject to $35.00 Copayment and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
SKILLED NURSING FACILITY CHARGES
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Subject to 120 day Benefit Period maximum, combined In-Network and Out-of-Network.
SPECIALIST SERVICES
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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SURGICAL SERVICES
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
TELEMEDICINE BEHAVIORAL HEALTH SERVICES, PROVIDED BY HORIZON CAREONLINE
In-Network Subject to $10.00 Copayment, and 100% Coinsurance.
Out-of-Network No Benefit.
TELEMEDICINE MEDICAL SERVICES, PROVIDED BY HORIZON CAREONLINE
In-Network Subject to $10.00 Copayment, and 100% Coinsurance.
Out-of-Network No Benefit.
THERAPEUTIC MANIPULATIONS
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
THERAPY SERVICES
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
a. CHELATION THERAPY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
b. CHEMOTHERAPY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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c. COGNITIVE REHABILITATION THERAPY
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. d. DIALYSIS TREATMENT
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
e. INFUSION THERAPY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
f. OCCUPATIONAL THERAPY
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. g. PHYSICAL THERAPY
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. h. RADIATION TREATMENT
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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i. RESPIRATION THERAPY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network.
j. SPEECH THERAPY
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Benefits subject to a 60 Visit Benefit Period maximum, combined In-Network and Out-of-Network. The 60 Visit maximum does not apply to the treatment of autism. Note: Speech Therapy is eligible for restorative purposes only; it is not covered for developmental delay. TRANSPLANT BENEFITS
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
URGENT CARE SERVICES
In-Network Subject to $50.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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B. ELIGIBLE SUPPLEMENTAL SERVICES AND SUPPLIES
AMBULANCE SERVICES
In-Network Subject to 80% Coinsurance.
Out-of-Network Subject to 80% Coinsurance.
BLOOD
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DIABETES BENEFITS
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
DURABLE MEDICAL EQUIPMENT
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. FOOT ORTHOTICS
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance. Subject to $1,000 maximum per Benefit Period. HOME INFUSION THERAPY
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
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OXYGEN AND ADMINISTRATION
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
PRIVATE DUTY NURSING
In-Network Subject to Prior Authorization, Deductible and 80% Coinsurance.
Out-of-Network Subject to Prior Authorization, Deductible, and 60% Coinsurance.
PROSTHETIC DEVICES
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
SPECIALIZED NON-STANDARD INFANT FORMULAS
In-Network Subject to Deductible, and 80% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
NON-ROUTINE VISION CARE
In-Network Subject to $35.00 Copayment, and 100% Coinsurance.
Out-of-Network Subject to Deductible, and 60% Coinsurance.
WIGS BENEFIT
In-Network Subject to 80% Coinsurance.
Out-of-Network Subject to 80% Coinsurance.
Subject to $750.00 Benefit Period Maximum.
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General Information
How To Enroll
If you meet your Employer's eligibility rules, including any Waiting Period established by the Employer, you may enroll by completing an enrollment form. If you enroll your eligible Dependents at the same time, their coverage will become effective on the same date as your own. Except as otherwise provided below, if you or an eligible Dependent is not enrolled within 31 days after becoming eligible for the coverage under this Plan, that person is deemed a Late Enrollee.
Your Identification Card
You will receive an identification card to show to the Hospital, Physician or provider when you receive services or supplies. Your identification card shows the group through which you are enrolled, your type of coverage, your identification number and the effective date when you can start to use your benefits. All of your eligible dependents share your identification number as well.
Always carry this card and use your identification number when you receive covered services or supplies. If you lose your card, you can still use your coverage if you know your identification number. The inside back cover of this booklet has space to record your identification number along with other information you will need when making inquiries about your benefits. You should, however, contact your enrollment official immediately to replace the lost card.
You cannot let anyone not named in your coverage use your card or your coverage.
Types of Coverage Available
You may enroll under one of the following types of coverage:
• Single – provides coverage for you only.
• Family – provides coverage for you, your Spouse or Domestic Partner and your Child Dependents.
• Husband and Wife/Two Adults – provides coverage for you and your Spouse or Domestic Partner only.
• Parent and Child(ren) – provides coverage for you and your Child Dependents, but not your Spouse or Domestic Partner.
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Change In Type Of Coverage
If you want to change your type of coverage, see your benefits representative. If you marry, you should arrange for enrollment changes within 31 days before or after your marriage.
If: (a) you gain or lose a member of your family; or (b) someone covered under this Plan changes family status, you should check this Booklet to see if coverage should be changed. This can happen in many ways, e.g., due to the birth or adoption of a child, divorce, or death of a Spouse.
For example:
• You must enroll a newly born or newly adopted Child Dependent within 31 days of the date or birth or adoption in order to have coverage for your Child Dependent. If you are enrolled for Family or Parent and Child(ren) coverage, you must submit an enrollment form within 31 days from the date of birth or adoption to notify the Plan of the addition. If you are enrolled for Single coverage, you must enroll your child and pay any required additional contributions within 31 days from the date of birth or adoption.
• If you have Single coverage and marry, or acquire a Domestic Partner, your new Spouse or Domestic Partner will be covered from the date you marry or meet the rules for covering Domestic Partners if you apply for Husband and Wife or Family coverage within 31 days.
Except as provided below, anyone who does not enroll within a required time will be considered a Late Enrollee. Late Enrollees may enroll only during the next open-enrollment month. Coverage will be effective as of the open-enrollment date.
Enrollment of Dependents
The Plan cannot deny coverage for your Child Dependent on the grounds that:
• The Child Dependent was born out of wedlock;
• The Child Dependent is not claimed as a dependent on your federal tax return; or
• The Child Dependent does not reside with you or in the Service Area.
If you are the non-custodial parent of a Child Dependent, the Plan will:
• Provide such information to the custodial parent as may be needed for the Child Dependent to obtain benefits through this Plan;
• Permit the custodial parent, or the Provider, with the authorization of the custodial parent, to submit claims for the Child Dependent for Covered Services and Supplies, without your approval; and
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• Make payments on such claims directly to: (a) the custodial parent; (b) the Provider; or (c) the Division of Medical Assistance and Health Services in the Department of Human Services, which administers Medicaid, as appropriate.
If you are a parent who is required by a court or administrative order to provide health coverage for your Child Dependent, the Plan will:
• Permit you to enroll your Child Dependent, without any enrollment restrictions;
• Permit: (a) the Child Dependent’s other parent; (b) the Division of Medical Assistance and Health Services; or (c) the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the Child Dependent in this Plan, if the parent who is the Covered Person fails to enroll the Child Dependent; and
• Not terminate coverage of the Child Dependent unless the parent who is the Covered Person provides Horizon BCBSNJ or the Plan with satisfactory written proof that:
• the court or administrative order is no longer in effect: or
• the Child Dependent is or will be enrolled in a comparable health benefits plan which will be effective on the date coverage under this Plan ends.
Special Enrollment Periods
Persons who enroll during a Special Enrollment Period described below are not considered Late Enrollees.
Individual Losing Other Coverage
If you and/or an eligible Dependent, are eligible for coverage, but not enrolled, you and/or your Dependent must be allowed to enroll if each of the following conditions is met:
a. The person was covered under a group or other health plan at the time coverage under this Plan was previously offered.
b. You stated in writing that coverage under the other plan was the reason for declining enrollment when it was offered.
c. The other health coverage:
(i) was under a COBRA (or other state mandated) continuation provision and the COBRA or other coverage is exhausted; or
(ii) was not under such a provision and either: (a) coverage was terminated as a result of: loss of eligibility for the coverage (including as a result of legal separation; divorce; death; termination of employment; or reduction in the number of hours of employment); or (b) employer contributions toward such coverage ended.
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d. Enrollment is requested within 31 days after: (a) the date of exhaustion of the coverage described in item (c)(i) above; or (b) termination of the coverage or employer contributions as described in item (c)(ii) above.
In this case, coverage under this Plan will be effective as of the date that the prior health coverage ended.
New Dependents
If the following conditions are met, the Plan will provide a Dependent Special Enrollment Period during which the Dependent (or, if not otherwise enrolled, you) may enroll or be enrolled:
a. You are covered under the Plan (or have met any Waiting Period and are eligible to enroll but for a failure to enroll during a previous enrollment period).
b. The person becomes your dependent through marriage, birth, or adoption (or placement for adoption).
The Dependent Special Enrollment Period is a period of no less than 31 days starting on the later of: (a) the date dependent coverage is made available pursuant to this section; or (b) the date of the marriage, birth, or adoption/placement.
Special Enrollment Due to Marriage or Acquiring a Domestic Partner
You may enroll a new Spouse or Domestic Partner under this Plan. If you are eligible, but previously declined coverage, you are also eligible to enroll at the same time that your Spouse or Domestic Partner is enrolled.
You must request enrollment of your Spouse or Domestic Partner within 31 days after the marriage or acquiring the Domestic Partner.
The coverage becomes effective not later than the first day of the month next following the date of the completed request.
Special Enrollment Due to Newborn/Adopted Children
You may enroll a newly born or newly adopted Child Dependent.
If you do not make the request for enrollment and the contribution is not paid within such 31-day period, the newborn child will be a Late Enrollee.
Multiple Employment
If you work for both the Employer and an Affiliated Company, or for more than one Affiliated Company, the Plan will treat you as if employed only by one Employer. You will not have multiple coverage.
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Eligible Dependents
Your eligible Dependents are your Spouse or Domestic Partner, your Child Dependents.
To enroll a Domestic Partner, you must provide proof that a Domestic Partnership exists by providing us with acceptable proof of the Domestic Partnership.
Coverage for your Spouse will end: (a) at the end of the month in which you divorce; or (b) at the end of the month in which you tell us to delete your Spouse from coverage following marital separation.
Coverage for a Domestic Partner will end when the Domestic Partnership ends.
Coverage for a Child Dependent ends the last day of the Calendar Year in which the Child Dependent reaches age 26.
Coverage will continue for a child dependent beyond the age of 26 provided that prior to age 26 he or she was enrolled under the Plan and is incapable of self-sustaining employment by reason of mental retardation or physical handicap. For your handicapped child to remain covered, you must submit proof of the child’s inability to engage in self-sustaining employment by reason of mental retardation or physical handicap within 31 days of the child’s attainment of age 26. The proof must be in a form which meets the Plan’s approval. Such proof must be resubmitted every two (2) years within 31 days before or after the child’s birth date.
Coverage for a handicapped child dependent will end on the last day of the benefit month in which the earliest of the following occurs: the termination of your coverage, the failure of your child dependent to satisfy the definition of child dependent for any reason other than age and the termination of your child dependent’s inability to engage in self-sustaining employment by reason of mental retardation or physical handicap.
If your child was enrolled as a handicapped dependent under previous coverage with the Horizon BCBSNJ and there has been no interruption in coverage, the child may be covered as an eligible dependent under this program, regardless of age.
When Your Coverage Ends
Your coverage under this Plan ends when the first of these occurs:
• The end of the Benefit Month which you cease to be eligible due to termination of your employment or any other reason.
• The date on which the Plan ends for the class of which you are a member.
• You fail to make, when due, any required contribution for the coverage.
Coverage for a Dependent ends:
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• When your coverage ends.
• When coverage for Dependents under this Plan ends.
• When you fail to make, when due, any required contribution for the Dependent coverage.
• As otherwise described under "Eligible Dependents", above.
In addition to the above reasons for the termination of coverage under the Plan, if a Covered Person,
(1) performs an act, practice or omission that constitutes fraud; or
(2) makes an intentional misrepresentation of material fact,
then the Plan has the right to rescind that Covered Person’s coverage under the Plan. The Plan will provide a notice of rescission to the Covered Person at least 30 days in advance of the termination date.
The Plan retains the right to recoup from any involved person all payments made and/or benefits paid on his/her behalf.
Benefits After Termination
If you or a Dependent are confined as an Inpatient in a Facility on the date coverage ends, the Plan's benefits will be paid, subject to the Plan's terms, for Covered Services and Supplies furnished during the uninterrupted continuation of that stay.
Continuing Coverage Under the Federal Family and Medical Leave Act
If you take a leave that qualifies under the Federal Family and Medical Leave Act (FMLA) (e. g., to care for a sick family member, or after the birth or adoption of a Child Dependent), you may continue coverage under this Plan. You may also continue coverage for your Dependents.
You will be subject to the same Plan rules as an Active Employee. But, your legal right to have your Employer pay its share of the required contribution, as it does for Active Employees, is subject to your eventual return to Active work.
Coverage that continues under this law ends at the first to occur of the following:
• The date you again become Active.
• The end of a total leave period of 12 weeks in any 12 month period.
• The date coverage for you or a Dependent would have ended had you not been on leave.
• Your failure to make any required contribution.
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Consult your benefits representative for application forms and further details.
Continuation of Coverage under COBRA
Under a federal law called the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA), you and your enrolled Dependents, not including a Dependent who is your or Domestic Partner and any newborn or newly adopted child may have the opportunity to continue group health care coverage which would otherwise end, if any of these events occur:
• Your death;
• Your work hours are reduced;
• Your employment ends for a reason other than gross misconduct.
Each of your enrolled Dependents has the right to continue coverage if it would otherwise end due to any of these events:
• Your death;
• Your work hours are reduced;
• Your employment ends for reason other than gross misconduct;
• You became entitled to Medicare benefits;
• In the case of your Spouse, the Spouse ceased to be eligible due to divorce or legal separation; or
• In the case of a Child Dependent, he/she ceased to be a Child Dependent under this Plan's rules.
You or your Dependent must notify your benefits representative of a divorce or legal separation, or when a child no longer qualifies as a Child Dependent. This notice must be given within 60 days of the date the event occurred. If notice is not given within this time, the Dependent will not be allowed to continue coverage.
You will receive a written election notice of the right to continue the insurance. In general, this notice must be returned within 60 days of the later of: (a) the date the coverage would otherwise have ended; or (b) the date of the notice. You or the other person asking for coverage must pay the required amount to maintain it. The first payment must be made by the 45th day after the date the election notice is completed.
If you and/or your Dependents elect to continue coverage, it will be identical to the health care coverage for other members of your class. It will continue as follows:
• Up to 18 months in the event of the end of your employment or a reduction in your hours. Further, if you or a covered Dependent are determined to be disabled, according to the
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Social Security Act, at the time you became eligible for COBRA coverage, or during the first 60 days of the continued coverage, that person and any other person then entitled to the continued coverage may elect to extend this 18-month period for up to an extra 11 months. To elect this extra 11 months, the person must give the Employer written proof of Social Security's determination before the first to occur of: (a) the end of the 18 month continuation period; or (b) 60 days after the date the person is determined to be disabled.
• Up to 36 months for your Dependent(s) in the event of: your death; your divorce or legal separation; your entitlement to Medicare; or your child ceasing to qualify as a Child Dependent.
Continuation coverage for a person will cease before the end of a maximum period just described if one of these events occurs:
• This Plan ends for the class you belong to.
• The person fails to make required payments for the coverage.
• The person becomes covered under any other group health plan. But, coverage will not end due to this rule until the end of any period for which benefits for them are limited, under the other plan.
• The person becomes entitled to Medicare benefits.
If a person's COBRA coverage was extended past 18 months due to total disability; and there is a final determination (under the Social Security Act) that the person, before the end of the additional continuation period of 11 months, is no longer disabled, the coverage will end on the first of the month that starts more than 30 days after that determination.
NOTE: Any right to continue the Plan’s coverage that is granted to an Employee’s Spouse pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, shall not apply with respect to an Employee’s or Domestic Partner.
The above is a general description of COBRA's requirements. If coverage for you or a Dependent ends for any reason, you should immediately contact your benefits representative to find out if coverage can be continued. Your Employer is responsible for providing all notices required under COBRA.
Continuation of Coverage under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
If the Employee is absent from work due to performing service in the uniformed services, this federal law gives the Employee the right to elect to continue the health coverage under this Plan (for himself/herself and the Employee’s Dependents, if any). If the Employee so elects, the coverage can be continued, subject to the payment of any required contributions, until the first to occur of the following:
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 The end of the 24-month period starting on the date the Employee was first absent from work due to the service.
 The date on which the Employee fails to return to work after completing service in the uniformed services, or fails to apply for reemployment after completing service in the uniformed services.
 The date on which this Plan ends.
If the Employee elects to continue the coverage, the Employee’s contributions for it are determined as follows:
a) If the Employee’s service in the uniformed services is less than 31 days, his/her contribution for the coverage will be the same as if there were no absence from work.
b) If the service extends for 31 or more days, the Employee’s contribution for the coverage can be up to 102% of total cost of coverage.
For the purposes of this provision, the terms “uniformed services” and “service in the uniformed services” have the following meanings:
Uniformed services: The following:
1. The Armed Services.
2. The Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty.
3. The commissioned corps of the Public Health Service.
4. Any other category of persons designated by the President in time of war or national emergency.
Service in the uniformed services: The performance of duty on a voluntary or involuntary basis in a uniformed service under competent authority. This includes:
1. Active duty.
2. Active and inactive duty for training.
3. National Guard duty under federal statute.
4. A period for which a person is absent from employment: (a) for an exam to determine the fitness of the person to perform any such duty; or (b) to perform funeral honors duty authorized by law.
5. Service as: (a) an intermittent disaster-response appointee upon activation of the National Disaster Medical System (NDMS); or (b) a participant in an authorized training program
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in support of the mission of the NDMS.
Continuation of Care
Horizon BCBSNJ will provide written notice to each Covered Person at least 30 business days prior to the termination or withdrawal from Horizon BCBSNJ’s Network of a Covered Person’s Provider currently treating the Covered Person, as reported to Horizon BCBSNJ. The 30 day prior notice may be waived in cases of immediate termination of a Provider based on: breach of contract by the Provider; a determination of fraud; or Horizon BCBSNJ medical director's opinion that the Provider is an imminent danger to the patient or the public health, safety or welfare.
The Plan shall assure continued coverage of Covered Services and Supplies by a terminated Provider for up to four months in cases where it is Medically Necessary and Appropriate for the Covered Person to continue treatment with that Provider. In the case of pregnancy of a Covered Person: (a) the Medical Necessity and Appropriateness of continued coverage by that Provider shall be deemed to be shown; and (b) such coverage can continue to the postpartum evaluation of the Covered Person, up to six weeks after the delivery.
In the event that a Covered Person is receiving post-operative follow-up care, the Plan shall continue to cover services rendered by the Provider for the duration of the treatment, up to six months. In the event that a Covered Person is receiving oncological or psychiatric treatment, the Plan shall continue to cover services rendered by the Provider for the duration of the treatment, up to one year. If the services are provided in an acute care Facility, the Plan will continue to cover them regardless of whether the Facility is under contract or agreement with Horizon BCBSNJ.
Covered Services and Supplies shall be covered to the same extent as when the Provider was employed by or under contract with Horizon BCBSNJ. Payment for Covered Services and Supplies shall be made based on the same methodology used to reimburse the Provider while the Provider was employed by or under contract with Horizon BCBSNJ.
The Plan shall not allow continued services in cases where the Provider was terminated due to: (a) Horizon BCBSNJ Medical Director's opinion that the Provider is an imminent danger to a patient or to the public health, safety and welfare, (b) a determination of fraud; or (c) a breach of contract.
Medical Necessity And Appropriateness
We will make payment for benefits under this Plan only when:
• Services are performed or prescribed by your attending physician;
• Services, in our judgment, are provided at the proper level of care (Inpatient; Outpatient; Out-of-Hospital; etc.);
• Services or supplies are Medically Necessary and Appropriate for the diagnosis and
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treatment of an Illness or Injury.
THE FACT THAT YOUR ATTENDING PHYSICIAN MAY PRESCRIBE, ORDER, RECOMMEND OR APPROVE A SERVICE OR SUPPLY DOES NOT, IN ITSELF, MAKE IT MEDICALLY NECESSARY AND APPROPRIATE FOR THE DIAGNOSIS AND TREATMENT OF AN ILLNESS OR INJURY OR MAKE IT AN ELIGIBLE MEDICAL EXPENSE.
Cost Containment
If it has been determined that an eligible service can be provided in a medically acceptable, cost-effective alternative setting, we reserve the right to provide benefits for such a service when it is performed in that setting.
Managed Care Provisions
Member Services
The Member Services Representatives who staff Horizon BCBSNJ Member Services Departments are there to answer Covered Persons' questions about the Plan and to assist in managing their care. To contact Member Services, a Covered Person should call the number on his/her Identification (ID) Card.
Miscellaneous Provisions
a. This Plan is intended to pay for Covered Services and Supplies as described in this Booklet. The Plan does not provide the services or supplies themselves, which may, or may not, be available.
b. The Plan is only required to provide its Allowance for Covered Services and Supplies, to the extent stated in the Plan. The Plan has no other liability.
c. Benefits are to be provided in the most cost-effective manner practicable. If the Plan determines that a more cost-effective manner exists, the Plan reserves the right to require that care be rendered in an alternate setting as a condition of providing payment for benefits.
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YOUR PREFERRED PROVIDER ORGANIZATION (PPO) PROGRAM
Your PPO Program provides you with the freedom to choose any Provider; however, your choice of Providers will determine how your benefits are paid. Benefits provided by In-Network Providers will be paid at a higher benefit level than benefits provided for an Out-of-Network Provider. You will be responsible for any Deductible, Coinsurance and Copayments that apply; however, if you use In-Network Providers, you will not have to file claims. In-Network Providers will accept our payment as payment in full. Out-of-Network Providers may balance bill to charges, and you will generally need to file claims to receive benefits.
Your Plan shares the cost of your health care expenses with you. This section explains what you pay, and how Deductibles, Coinsurance and Copayments work together.
Note: Coverage will be reduced if a Covered Person does not comply with the Utilization Review and Management and Prior Authorization requirements contained in this Plan.
BENEFIT PROVISIONS
The Deductible
Each Benefit Period, each Covered Person must have Covered Charges that exceed the Deductible before the Plan provides coverage for that person. The In-Network and Out-of-Network Deductibles are shown in the Schedule of Covered Services and Supplies. The Deductible cannot be met with Non-Covered Charges. Only Covered Charges Incurred by the Covered Person while covered by this Plan can be used to meet this Deductible.
Once the Deductible is met, the Plan provides benefits, up to its Allowance, for other Covered Charges above the Deductible Incurred by that Covered Person, less any applicable Coinsurance or Copayments, for the rest of that Benefit Period. But, all charges must be incurred while that Covered Person is covered by this Plan. Also, what coverage the Plan provides is based on all the terms of this Plan.
Family Aggregate Deductible
The total Deductible for a family in any one Benefit Period will not be more than $600 for In-Network Services and $2,250 for Out-of-Network Services. This family Deductible can be met by any combination of Covered Charges Incurred by some of all of the covered family members, except that no individual can contribute more than the individual Deductible amount. If a covered family member meets the individual Deductible, the Plan will cover that person's additional Covered Charges Incurred during that Benefit Period even if the Deductible for the entire family has not been met.
Out-of-Pocket Maximum
Once a Covered Person Incurs, during a Benefit Period, an amount of Covered Charges for which no benefits are paid or payable under the Plan equal to the Out-of-Pocket Maximum (see the Schedule of Covered Services and Supplies), the Plan will waive any applicable Deductible,
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Copayment or Coinsurance with respect to Covered Charges Incurred by the Covered Person for the remainder of that Benefit Period.
Once the covered members of a family collectively Incur, during a Benefit Period, an amount of Covered Charges for which no benefits are paid or payable under the Program, the Plan will waive any applicable Deductible, Copayment or Coinsurance with respect to Covered Charges Incurred by the covered family members for the remainder of that Benefit Period.
An Out-of-Pocket Maximum cannot be met with Non-Covered Charges.
Payment Limits
The Plan limits what it will pay for certain types of charges. See the Schedule of Covered Services and Supplies for these limits.
Benefits From Other Plans
The benefits the Plan will provide may also be affected by benefits from Medicare and other health benefit plans. Read The Effect of Medicare on Benefits and Coordination of Benefits and Services sections of this Booklet for an explanation of how this works.
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Summary of Covered Services and Supplies
This section lists the types of services and supplies that the Plan will consider as Covered Services or Supplies, up to its Allowance and subject to all the terms of this Plan. These terms include, but are not limited to, Medical Necessity and Appropriateness, Utilization Review and Management features, the Schedule of Covered Services and Supplies, benefit limitations and exclusions.
A. ELIGIBLE BASIC SERVICES AND SUPPLIES
Allergy Testing and Treatment
This Plan covers allergy testing and treatment, including routine allergy injections.
Ambulatory Surgery
This Plan covers Ambulatory Surgery performed in a Hospital Outpatient department or Out-of-Hospital, a Practitioner's office or an Ambulatory Surgical Center in connection with covered surgery.
Anesthesia
The Plan covers anesthetics and their administration.
Audiology Services
This Plan covers audiology services rendered by a physician or licensed audiologist or licensed speech-language pathologist. The services must be: (a) determined to be Medically Necessary and Appropriate; and (b) performed within the scope of the Practitioner's practice.
Birthing Centers
Deliveries in Birthing Centers, in many cases, are deemed an effective cost-saving alternative to
Inpatient Hospital care. At a Birthing Center, deliveries take place in “birthing rooms,” where decor and furnishings are designed to provide a more natural, home-like atmosphere.
All care is coordinated by a team of certified nurse-midwives and pediatric nurse-practitioners. Obstetricians, pediatricians and a nearby Hospital are available in case of complications. Prospective Birthing Center patients are carefully screened. Only low-risk pregnancies are accepted. High-risk patients are referred to a Hospital maternity program.
The Birthing Center's services, including pre-natal, delivery and post-natal care, will be covered
in full. If complications occur during labor, delivery may take place in a Hospital because of the need for emergency and/or Inpatient care. If, for any reason, the pregnancy does not go to term, the Plan will not provide payment to the Birthing Center.
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Dental Care and Treatment
This Plan covers:
a. the diagnosis and treatment of oral tumors and cysts; and
b. the surgical removal of bony impacted teeth; and
c. Surgical and non-Surgical treatment of temporomandibular joint dysfunction syndrome (TMJ) in a Covered Person. But, this Plan does not cover charges for orthodontia, crowns or bridgework. "Surgery", if needed, includes the pre-operative and post-operative care connected with it.
This Plan also covers charges for the treatment of Injury to sound natural teeth or the jaw that are Incurred within 18 months after the accident. But, this is only if the Injury was not caused, directly or indirectly, by biting or chewing. Treatment includes replacing sound natural teeth lost due to Injury. But, it does not include orthodontic treatment.
For a Covered Person who is severely disabled or who is a Child Dependent under age six, coverage shall also be provided for the following:
a. general anesthesia and Hospital Admission for dental services; or
b. dental services rendered by a dentist, regardless of where the dental services are rendered, for medical conditions that: (a) are covered by this Plan; and (b) require a Hospital Admission for general anesthesia.
This coverage shall be subject to the same Utilization Review and Management rules imposed upon all Inpatient stays.
Diagnosis and Treatment of Autism
This Plan provides coverage for charges for the screening and diagnosis of autism.
If a Covered Person’s primary diagnosis is autism, and regardless of anything in the Plan to the contrary, the Plan provides coverage when: (i) the services are given Prior Authorization; and (ii) the services are for the following Medically Necessary and Appropriate Therapy Services, as prescribed in a treatment plan:
(a) Occupational Therapy needed to develop the Covered Person’s ability to perform the ordinary tasks of daily living;
(b) Physical Therapy needed to develop the Covered Person’s physical functions; and
(c) Speech Therapy needed to treat the Covered Person’s speech impairment.
Notwithstanding anything in the Plan to the contrary, the foregoing Therapy Services as prescribed in a treatment plan will not be subject to benefit Visit maximums.
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Also, if a Covered Person’s primary diagnosis is autism, in addition to coverage for certain Therapy Services, as described above, the Plan also covers Medically Necessary and Appropriate: (a) Behavioral Interventions Based on Applied Behavioral Analysis (ABA); and (b) Related Structured Behavioral Plans. Such interventions and programs must be prescribed in a treatment plan.
Benefits for these services are payable on the same basis as for other conditions, and they are available under this provision whether or not the services are restorative. Benefits for the above Therapy Services available pursuant to this provision are payable separately from those payable for other conditions and will not operate to reduce the Therapy Services benefits available under the Plan for those other conditions.
Any treatment plan referred to above must: (a) be in writing; (b) be signed by the treating Practitioner; and (c) include: (i) a diagnosis; (ii) proposed treatment by type, frequency and duration; (iii) the anticipated outcomes stated as goals; and (iv) the frequency by which the treatment plan will be updated.
With respect to the covered behavioral interventions and programs mentioned above, the term “Practitioner” shall also include a person who is credentialed by the national Analyst Certification Board as either: (a) a Board Certified Behavior Analyst-Doctoral; or (b) a Board Certified Behavior Analyst.
The Plan may request more information if it is needed to determine the coverage under the Plan. The Plan may also require the submission of an updated treatment plan once every six months, unless the Plan and the treating physician agree to more frequent updates.
Diagnostic X-rays and Laboratory Tests
This Plan covers diagnostic X-ray and lab tests.
Emergency Room
This Plan covers services provided by a Hospital emergency room to treat a Medical Emergency or provide a Medical Screening Examination. Each time a Covered Person uses the Hospital emergency room, he/she must pay a Copayment, as shown in the Schedule of Covered Services and Supplies. But, this does not apply if the Covered Person is admitted to the Hospital within 24 hours.
Facility Charges
This Plan covers Hospital semi-private room and board and Routine Nursing Care provided by a Hospital on an Inpatient basis. The Plan limits what it covers each day to the room and board limit shown in the Schedule of Covered Services and Supplies.
If a Covered Person Incurs charges as an Inpatient in a Special Care Unit, this Plan covers the charges the same way it covers charges for any Illness.
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This Plan also covers: (a) Outpatient Hospital services, including services furnished by a Hospital Outpatient clinic; and (b) emergency room care, as described above.
If a Covered Person is an Inpatient in a Facility at the time this Plan ends, this Plan will continue to cover that Facility stay, subject to all other terms of this Plan.
A Covered Person must pay a Per Period of Confinement Deductible as shown in the Schedule of Covered Services and Supplies.
Fertility Services
This Plan covers charges for procedures designed to enhance fertility, including, artificial insemination. However, fertility enhancement treatments, such as in-vitro fertilization, in-vivo fertilization, gamete-intra-fallopian-transfer (GIFT), Zygote Intra-fallopian-transfer (ZIFT), sperm, egg, and/or inseminated eggs procurement and processing and freezing, and storage and thawing of sperm and/or embryos are specifically excluded.
Home Health Care
This Plan covers Home Health Care services furnished by Home Health Agency.
In order for Home Health Agency charges to be considered Covered Charges, the Covered Person's Admission to Home Health Agency care may be direct to Home Health Agency care with no prior Inpatient Admission.
This Plan does not cover:
a. services furnished to family members, other than the patient; or
b. services and supplies not included in the Home Health Care plan; or
c. services that are mainly Custodial Care.
Hospice Care
Hospice Care benefits will be provided for:
1. part-time professional nursing services of an R.N., L.P.N. or Licensed Viatical Nurse (L.V.N.);
2. home health aide services provided under the supervision of an R.N.;
3. medical care rendered by a Hospice Care Program Practitioner;
4. therapy services;
5. Diagnostic Services;
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6. medical and Surgical supplies and Durable Medical Equipment if given Prior Authorization by Horizon BCBSNJ;
7. Prescription Drugs;
8. oxygen and its administration;
9. medical social services;
10. respite care;
11. psychological support services to the Terminally Ill or Injured patient;
12. family counseling related to the patient's terminal condition;
13. dietician services;
14. Inpatient room, board and general nursing services; and
15. Bereavement counseling.
No Hospice Care benefits will be provided for:
1. medical care rendered by the patient's private Practitioner;
2. volunteer services or services provided by others without charge;
3. pastoral services;
4. homemaker services;
5. food or home-delivered meals;
6. Private-Duty Nursing services;
7. dialysis treatment;
8. treatment not included in the Hospice Care Program;
9. services and supplies provided by volunteers or others who do not normally charge for their services;
10. funeral services and arrangements;
11. legal or financial counseling or services; or
12. any Hospice Care services that are not given Prior Authorization by Horizon BCBSNJ.
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Respite care benefits are limited to a maximum of 15 days per Covered Person per Benefit Period;
Bereavement counseling is covered for a maximum of 15 visits;
“Terminally Ill or Injured” means that the Covered Person’s Practitioner has certified in writing that the Covered Person’s life expectancy is six months or less.
Hospice care must be furnished according to a written “Hospice Care Program”.
Inpatient Physician Services
This Plan provides benefits for Covered Services and Supplies furnished by a physician to a Covered Person who is a registered Inpatient in a Facility.
Mastectomy Benefits
This Plan covers a Hospital stay of at least 72 hours following a modified radical mastectomy
and a Hospital stay of at least 48 hours following a simple mastectomy. A shorter length of stay
may be covered if the patient, in consultation with her physician, determines that it is Medically Necessary and Appropriate. The patient’s Provider does not need to obtain Prior Authorization for prescribing 72 or 48 hours, as appropriate, of Inpatient care. But, any rule of this Plan that that the patient or her Provider notify Horizon BSBSNJ about the stay remains in force.
Benefits for these services shall be subject to the same Deductible, Copayments and/or
Coinsurance as for other Hospital services covered under this Plan.
Maternity/Obstetrical Care
Pursuant to both federal and state law, covered medical care related to pregnancy; childbirth; abortion; or miscarriage, includes: (a) the Hospital delivery; and (b) a Hospital Inpatient stay for at least 48 hours after a vaginal delivery or 96 hours after a cesarean section. This applies if: (a)
the attending physician determines that Inpatient care is Medically Necessary and Appropriate;
or (b) if it is requested by the mother (regardless of Medical Necessity and Appropriateness). For the purposes of this subsection and as required by state law, “attending physician” shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child. For the purposes of this provision and as required by federal law, a Hospital
Inpatient stay is deemed to start:
(a) at the time of delivery; or
(b) in the case of multiple births, at the time of the last delivery; or
(c) if the delivery occurs out of the Hospital, at the time the mother or newborn is admitted to the Hospital.
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Services and supplies provided by a Hospital to a newborn child during the initial Hospital stay
of the mother and child are covered as part of the obstetrical care benefits. But, if the child's care
is given by a different physician from the one who provided the mother's obstetrical care, the child's care will be covered separately.
If they are given Prior Authorization by Horizon BCBSNJ, this Plan also covers Birthing Center charges (see above) made by a Practitioner for: (a) pre-natal care; (b) delivery; and (c) post-partum care for a Covered Person's pregnancy.
Maternity/Obstetrical Care for Child Dependents
This Plan covers a Child Dependent's obstetrical care, including any services incident to or resulting from her pregnancy. But, this Plan does not provide coverage for the newborn child of the Child Dependent.
Medical Emergency
This Plan covers charges relating to a Medical Emergency. This includes diagnostic X-ray and lab charges Incurred due to the Medical Emergency.
Benefits include coverage of trauma at any designated level I or II trauma center, as Medically Necessary and Appropriate. The coverage continues at least until, in the judgment of the attending physician, the Covered Person: (a) is medically stable; (b) no longer requires critical care; and (c) can be safely transferred to another Facility, if needed. The Plan will also cover a medical screening exam that is: (a) rendered upon a Covered Person’s arrival at a Hospital; (b) required under federal law to be performed by the Hospital; and (c) needed to determine whether
a Medical Emergency situation exists.
In the event of a potentially life-threatening condition, the Covered Person should use the 911 emergency response system. Further 911 information is available on the Identification Card.
Mental or Nervous Disorders (including Group Therapy) and Substance Abuse
The Plan covers treatment for Mental or Nervous Disorders and Substance Abuse.
A Covered Person may receive covered treatment as an Inpatient in a Hospital or a Substance Abuse Center. He/she may also receive covered treatment at a Hospital Outpatient Substance
Abuse Center, or from any Practitioner (including a psychologist or social worker).
The benefits for the covered treatment of Mental or Nervous Disorders or Substance Abuse are provided on the same basis and subject to the same terms and conditions as for other Illnesses.
Nutritional Counseling
This Plan covers charges for nutritional counseling for the management of a medical condition that has a specific diagnostic criteria that can be verified. The nutritional counseling must be prescribed by a Practitioner. This section does not apply to nutritional counseling related to
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"Diabetes Benefits".
Physical Rehabilitation
This Plan covers Inpatient treatment in a Physical Rehabilitation Center. Inpatient treatment will include the same services and supplies available to any other Facility Inpatient.
Practitioner’s Charges for Non-Surgical Care and Treatment
This Plan covers Practitioner's charges for the non-Surgical care and treatment of an Illness, Injury, Mental or Nervous Disorder or Substance Abuse. This includes Medically Necessary pharmaceuticals, which in the usual course of medical practice are administered by a Practitioner, if the pharmaceuticals are billed by the Practitioner or by a Specialty Pharmaceutical Provider.
Practitioner’s Charges for Surgery
This Plan covers Practitioners' charges for Surgery. This Plan does not cover Cosmetic Surgery. Surgical procedures include: (a) those after a mastectomy on one or both breasts; (b) reconstructive breast Surgery; and (c) Surgery to achieve symmetry between both breasts.
Pre-Admission Testing Charges
This Plan covers Pre-Admission diagnostic X-ray and lab tests needed for a planned Hospital Admission or Surgery. To be covered, these tests must be done on an Outpatient or Out-of-Hospital basis within seven days of the planned Admission or Surgery.
This Plan does not cover tests that are repeated after Admission or before Surgery. But, this does not apply if the Admission or Surgery is deferred solely due to a change in the Covered Person's health.
Preventive Care
This Program provides benefits for certain Covered Services and Supplies relating to Preventive Care including: related diagnostic X-rays and lab tests; and screening tests. The covered Preventive Care is as follows:
a. Gynecological Care and Examinations
This Plan covers routine gynecological examinations including Pap smears.
b. Mammography
This Plan covers charges made for mammograms provided to a female Covered Person according to the schedule below. Coverage will be provided, subject to all the terms of this Plan, and these rules:
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1. one baseline mammogram for female Covered Persons who are at least 35 but less than 40 years of age. (However, if the woman is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, the Plan will cover a mammogram at such age and intervals as deemed needed by the woman's Practitioner.)
2. one mammogram each year for female Covered Persons age 40 and older.
c. Pap Smears
This program provides benefits for charges Incurred in conducting a Pap smear. This benefit, except as may be Medically Necessary and Appropriate for diagnostic purposes, shall be limited to one pap smear per Benefit Period. d. Routine Physicals and Immunizations
This program covers routine physical examination(s) and immunizations for you and your Spouse and Dependent Children over the age of 7 as designated in the Schedule of Covered Services and Supplies. e. Well-Child Care Benefits
Benefit are provided for well-child care for your enrolled child dependents through the end of the day before the child attains age seven. Well-child care services according to the following schedule:
• 7 visits up to age 1;
• 3 visits age 1 up to age 2;
• 1 visit each year ages 2 up to age 18. f. Well-Child Immunizations and Lead Poisoning Screening and Treatment
Well-Child immunizations and lead poisoning screening and treatment are covered without age restriction. In order to be covered under this section:
i. childhood immunizations must be as recommended by the Advisory Committee on Immunization Practices of the United States Public Health Service and the Department of Health pursuant to Section 7. of P.L. 1995, Ch 316.
ii. screening by blood lead measurement for lead poisoning for children, including confirmatory blood lead testing must be as specified by the Department of Health pursuant to Section 7. of P.L. 1995, Ch 316. Medical evaluation and any necessary follow-up and treatment for lead-poisoned children are also covered.
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g. Prostate Cancer Screening
This program covers 1 routine office visit per Benefit Period for adult Covered Persons, including a digital rectal examination and a prostate-specific antigen test for adult male Covered Persons.
h. Colorectal Cancer Screening
This Plan covers colorectal cancer screening rendered at regular intervals for: (a) Covered Persons age 50 or over; and (b) Covered Persons of any age who are deemed to be at high risk for this type of cancer.
Covered tests include: a screening fecal occult blood test; flexible sigmoidoscopy; colonoscopy; barium enema; any combination of these tests; or the most reliable, medically recognized screening test available.
For the purposes of this part, “high risk for colorectal cancer” means that a Covered Person has: (a) a family history of: familial adenomatous polyposis; hereditary non-polyposis colon cancer; or breast, ovarian, endometrial, or colon cancer or polyps; (b) chronic inflammatory bowel disease; or (c) a background, ethnicity or lifestyle that the Covered Person’s physician believes puts the Covered Person at elevated risk for colorectal cancer.
The method and frequency of screening shall be: (a) in accordance with the most recent published guidelines of the American Cancer Society; and (b) as deemed to be Medically Necessary and Appropriate by the Covered Person's physician, in consultation with the Covered Person.
i. Routine vision exam.
Routine vision screening (one per year) as part of wellness exam.
j. Hearing Exam.
One routine hearing exam or audiology function test per year for adults and children.
k. Additional Preventive Services
In addition to any other Preventive Care benefits described above, the Plan shall cover the following preventive services and shall not impose any cost-sharing requirements, such as Deductibles, Copayments or Coinsurance, on any Covered Person receiving them:
1. Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force;
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2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person;
3. For infants and children (if coverage under the Plan are provided for them) and adolescents who are Covered Persons, evidence-informed Preventive Care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
4. With respect to female Covered Persons, such additional preventive care and screenings, not described in part 1, above, as are provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
New recommendations to the preventive services listed above at the schedule established by the Secretary of Health and Human Services shall administratively updated.
Second Opinion Charges
If a covered Person is scheduled for an Elective Surgical Procedure, this Plan covers a Practitioner's charges for a second opinion and charges for related diagnostic X-ray and lab tests. If the second opinion does not confirm the need for the Surgery, this Plan will cover a Practitioner's charges for a third opinion regarding the need for the Surgery. This Plan will cover charges if the Practitioner(s) who gives the opinion:
a. are board certified and qualified, by reason of his/her specialty, to give an opinion on the proposed Surgery or Hospital Admission;
b. are not a business associate of the Practitioner who recommended the Surgery; and
c. do not perform or assist in the Surgery if it is needed.
Skilled Nursing Facility Charges
This Plan covers bed and board (including diets, drugs, medicines and dressings and general nursing service) in a Skilled Nursing Facility. The Covered Person must be admitted to the Skilled Nursing Facility within 14 days of discharge from a Hospital, for continuing medical care and treatment prescribed by a Practitioner.
Surgical Services
Subject to all of the Plan’s other terms and conditions, the Plan covers Surgery, subject also to the following requirements:
a. The Plan will not make separate payment for pre- and post-operative care.
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b. Subject to the following exception, if more than one surgical procedure is performed: (i) on the same patient; (ii) by the same physician; and (iii) on the same day, the following rules apply:
1 The Plan will cover the primary procedure, plus 50% of what the Plan would have paid for each of the other procedures, up to five, had those procedures been performed alone.
2. If more than five surgical procedures are performed, each of the procedures beyond the fifth will be reviewed. The amount that the Plan will pay for each such procedure will then be based on the circumstances of the particular case.
Exception: The Plan will not cover or make payment for any secondary procedure that, after review, is deemed to be a Mutually Exclusive Surgical Procedure or an Incidental Surgical Procedure.
As part of the coverage for Surgery, if a Covered Person is receiving benefits for a mastectomy, the Plan will also cover the following, as determined after consultation between the attending physician and the Covered Person:
• Reconstruction of the breast on which the mastectomy was performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Prostheses and the treatment of physical complications at all stages of the mastectomy, including lymphodemas.
Also, see “Transplant Benefits”.
Telemedicine Services, provided by Horizon CareOnline
SUEZ Water Resources Inc. has selected an innovative Telemedicine Program, Horizon CareOnline, for its members through Horizon BCBSNJ, currently powered by American Well. This additional Program allows you to visit with an American Well general practitioner via telecommunication using a computer, tablet or smart phone. This Program also allows you to visit with American Well psychiatrists, psychologists, or social workers for treatment of Mental or Nervous Disorders via telecommunication using a computer, tablet or smart phone. The Program does not provide additional covered services (or benefits) under your health benefit plan. Telemedicine is a covered benefit only when provided through Horizon BCBSNJ’s designated telemedicine vendor. The Telemedicine Program is not available to Covered Persons who are eligible for Medicare when Medicare is primary to this Plan.
Therapeutic Manipulation
The Plan covers charges for Therapeutic Manipulations.
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Therapy Services
The Plan covers charges for all Therapy Services.
Transplant Benefits
This Plan covers services and supplies for the following types of transplants:
a. Cornea;
b. Kidney;
c. Lung;
d. Liver;
e. Heart;
f. Heart valve;
g. Pancreas;
h. Small bowel;
i. Chondrocycte (for knee);
j. Heart/Lung;
k. Kidney/Pancreas;
l. Liver/Pancreas;
m. Double lung;
n. Heart/Kidney;
o. Kidney/Liver;
p. Liver/Small Bowel;
q. Multi-visceral transplant (small bowel and liver with one or more of the following: stomach; duodenum; jejunum; ileum; pancreas; colon);
r. Allogeneic bone marrow;
s. Allogeneic stem cell;
t. Non-myeloblative stem cell;
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u. Tandem stem cell.
This Plan also provides benefits for the treatment of cancer by dose-intensive Chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants. This applies only to transplants that are performed:
a by institutions approved by the National Cancer Institute; or
b. pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Such treatment will be covered to the same extent as for any other Illness.
When organs/tissues are harvested from a cadaver, this Plan will also cover those charges for Surgical, storage and transportation services that: (a) are directly related to donation of the organs/tissues; and (b) are billed for by the Hospital where the transplant is performed.
Eligible expenses include transportation of the patient and one companion who is traveling on the same days to and or from the site of the transplant of the purpose of an evaluation, the transplant procedure or necessary post- discharge follow up, reasonable and necessary expense for lodging and meals for the patient (while not confined) and one companion, benefits are paid at a per diem rate of up to $50 for one person or up to $100 for two people, travel and lodging expense are only available if the transplant recipient resides more than 50 miles from the facility performing the transplant, if the patient is a dependant minor child- then the transportation expenses of two companions will be covered and lodging and meal expenses will be reimbursed up to the $100 per diem rate, there is a combined overall LIFETIME MAX OF $10,000.00 per covered person for ALL transportation, lodging and meal expenses incurred by the transplant recipient and companion's) and reimbursed under this plan in connection with all transplant procedures
Urgent Care
This Plan provides benefits for Covered Services and Supplies furnished for Urgent Care of a Covered Person.

B. ELIGIBLE SUPPLEMENTAL SERVICES AND SUPPLIES
Ambulance Services
The Plan covers charges for transporting a Covered Person to:
a. a local Hospital, if needed care and treatment can be provided by a local Hospital;
b. the nearest Hospital where needed care and treatment can be given, if a local Hospital cannot provide it. It must be connected with an inpatient admission; or
c. another inpatient Facility when Medically Necessary and Appropriate.
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Coverage can be by professional ambulance service, ground or air. Your group’s plan does not cover chartered air flights. The Plan will also not cover other travel or communication expenses of patients, Practitioners, Nurses or family members.
Blood
This Plan covers: (a) blood; (b) blood products; (c) blood transfusions; and (d) the cost of testing and processing blood. This Plan does not pay for blood that has been donated or replaced on behalf of the Covered Person.
This Plan also covers expenses Incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia. The home treatment program must be under the supervision of a State approved hemophilia treatment center. A home treatment program will not preclude further or additional treatment or care at an eligible Facility. But, the number of home treatments, according to a ratio of home treatments to Benefit Days, cannot exceed the total number of benefit days allowed for any other Illness under this Plan.
As used above: (a) “blood product” includes but is not limited to Factor VIII, Factor IX and cryoprecipitate; and (b) “blood infusion equipment” includes but is not limited to syringes and needles.
Diabetes Benefits
Benefits are provided for expenses incurred for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist:
a. blood glucose monitors and blood glucose monitors for the legally blind;
b. test strips for glucose monitors and visual reading and urine testing strips;
c. insulin;
d. injection aids;
e. cartridges for the legally blind;
f. syringes;
g. insulin pumps and appurtenances thereto;
h. insulin infusion devices; and
i. oral agents for controlling blood sugar.
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The Plan provides benefits for expenses incurred for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of his condition, including information on proper diet.
a. Benefits for self-management education and education relating to diet shall be limited to medically necessary visits upon:
1. the diagnosis of diabetes;
2. the diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in your symptoms or conditions which necessitate changes in your self-management; and
3. determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary.
b. Diabetes self-management education is covered when provided by:
1. a dietitian registered by a nationally recognized professional association of dietitians,
2. a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators, or
3. a registered pharmacist in New Jersey qualified with regard to management education for diabetes by any institution recognized by board of Pharmacy of the State of New Jersey.
Durable Medical Equipment
Your plan covers charges for the rental of Durable Medical Equipment needed for therapeutic use. The Plan may Determine to cover the purchase of such items when it is less costly and more practical than to rent such items. The Plan does not cover:
a. replacements or repairs; or
b. the rental or purchase of any items (such as air conditioners, exercise equipment, saunas and air humidifiers) which do not fully meet the definition of Durable Medical Equipment.
Home Infusion Therapy
Home Infusion Therapy is a method of administering intravenous (IV) medications or nutrients via pump or gravity in the home. These services and supplies are eligible when rendered or used in connection with Home Infusion Therapy:
• Solutions and pharmaceutical additives,
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• Pharmacy compounding and dispensing services,
• Ancillary medical supplies, and
• Nursing services associated with patient and/or alternative caregiver training, visits necessary to monitor intravenous therapy regimen and medical emergency care, but not for administration of home infusion therapy.
Home Infusion Therapy includes chemotherapy, intravenous antibiotic therapy, total parenteral nutrition, enteral nutrition (when sole source of nutrition) hydration therapy, intravenous pain management, gammaglobulin infusion therapy (IVIG), and prolastin therapy.
Note: Home Infusion Therapy must be authorized by the Plan.
Foot Orthotics
The Plan covers foot orthotics. Custom inserts prescribed by a MD are covered.
Oxygen and its Administration
The Plan covers oxygen and its administration.
Private Duty Nursing Care
This Plan covers the services of a Nurse for Private Duty Nursing care. These conditions apply:
a. The care must be ordered by a physician.
b. The care must be furnished while: (i) intensive skilled nursing care is required in the treatment of an acute Illness or during the acute period after an Injury; and (ii) the patient is not in a Facility that provides nursing care.
Requirement (b)(i), above, will not be deemed to be met if the care actually furnished is mainly Custodial Care or maintenance. Also, no benefits will be provided for the services of a Nurse who: (a) ordinarily resides in the patient's home; or (b) is a member of the patient's immediate family.
Prosthetic Devices
This Plan limits coverage for prosthetic devices. This Plan covers only the initial fitting and purchase of artificial limbs and eyes, and other prosthetic devices. To be covered, such devices must: (a) take the place of a natural part of a Covered Person's body; or (b) be needed due to a functional birth defect in a covered Child Dependent; or (c) be needed for reconstructive breast Surgery. This Plan does not cover: repairs of prosthetic devices or dental prosthetics or devices.
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Specialized Non-Standard Infant Formulas
This Plan covers specialized non-standard infant formulas, if these conditions are met:
a. The covered infant's physician has diagnosed him/her as having multiple food protein intolerance;
b. The physician has determined that the formula is Medically Necessary and Appropriate; and
c. The infant has not responded to trials of standard non-cow milk-based formulas, including soybean and goat milk.
Wigs Benefit
Wigs are covered as a result of hair loss due to radiation therapy, chemotherapy, and second degree burns.
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Utilization Management
IMPORTANT NOTICE – THIS NOTICE APPLIES TO ALL FEATURES UNDER THIS UTILIZATION REVIEW SECTION.
BENEFITS WILL BE REDUCED FOR NON-COMPLIANCE WITH THE PROVISIONS OF THIS UTILIZATION MANAGEMENT SECTION. YOUR PLAN DOES NOT COVER ANY INPATIENT ADMISSION, OR ANY OTHER SERVICE OR SUPPLIES, THAT IS NOT MEDICALLY NECESSARY AND APPROPRIATE. HORIZON BCBSNJ DETERMINES WHAT IS MEDICALLY NECESSARY AND APPROPRIATE UNDER YOUR PLAN.
Your plan has utilization review features under which Horizon BCBSNJ or its designee reviews Hospital Admissions and listed procedures. These features must be complied with if you:
a. are admitted as an inpatient or outpatient to a Hospital or other Facility or on an out-of-hospital basis; or
b. are advised to enter a Hospital or other Facility; or
c. plan to have a listed procedure performed. If you or your Provider do not comply with this Utilization Management section, you will not be eligible for full benefits under your plan. Your Plan has Medical Appropriateness Review features. Under these features, Horizon BCBSNJ reviews the medical appropriateness of the care that is expected to be rendered.
In addition, what Horizon BCBSNJ covers is subject to all of the terms and conditions of your group’s plan.
With respect to Covered Charges incurred in connection with Mental or Nervous Disorders, all notices required to be given in accordance with this Utilization Management section must be given to the Care Manager.
Your Plan has Individual Case Management features. Under these features, a case coordinator reviews your medical needs in clinical situations with the potential for catastrophic claims to Determine whether alternative treatment may be available and appropriate. See the Alternative Treatment Features description for details.
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REQUIRED HOSPITAL STAY REVIEW
Notice of Hospital Admission Required
If you plan to use a Hospital in the Select Hospital Network, the Hospital will make all necessary arrangements for Pre Admission Review. If you plan to use a Out-of-Network Hospital, you must notify Horizon BCBSNJ of the Hospital Admission. The time and manner in which the notice must be given is described below. When you or your Provider do not comply with the requirements of this section, Horizon BCBSNJ reduces coverage for those Covered Charges.
Continued Stay Review
Horizon BCBSNJ has the right to initiate a continued stay review of any inpatient admission; and Horizon BCBSNJ may contact your Practitioner or Facility by phone or in writing.
You or your Provider must initiate a continued stay review whenever it is Medically Necessary and Appropriate to change the authorized length of an inpatient stay. This must be done before the end of the previously authorized length of stay.
In the case of an Admission, the continued stay review Determines:
a. the Medical Necessity and Appropriateness of Admission;
b. the anticipated length of stay and extended length of stay; and
c. the appropriateness of health care alternatives.
Horizon BCBSNJ notifies the Practitioner and Facility by phone of the outcome of the review. Horizon BCBSNJ confirms in writing the outcome of a review that results in a denial. The notice always includes any newly authorized length of stay.
NOTE: YOUR PLAN DOES NOT COVER ANY CHARGES THAT ARE INCURRED WITH RESPECT TO INPATIENT SERVICES OR SUPPLIES THAT ARE NOT AUTHORIZED IN ACCORDANCE WITH THIS CONTINUED STAY REVIEW.
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ALTERNATE TREATMENT FEATURES/INDIVIDUAL CASE MANAGEMENT
Definitions
“Alternate Treatment” means those services and supplies which meet both of the following tests:
a. They are Determined, in advance, by Horizon BCBSNJ to be Medically Necessary and Appropriate and cost effective in meeting your long-term or intensive care needs in connection with a Catastrophic Illness, Accidental Injury; or in completing a course of care outside of the acute Hospital setting, for example, completing a course of IV antibiotics at home.
b. Benefits for charges incurred for the services and supplies would not otherwise be payable under the Plan.
“Catastrophic Illness or Injury” means one of the following:
a. head injury requiring an inpatient stay;
b. spinal cord injury;
c. severe burn over 20% or more of the body;
d. multiple injuries due to an accident;
e. premature birth;
f. CVA or stroke;
g. congenital defect which severely impairs a bodily function;
h. brain damage due to either an accident or cardiac arrest or resulting from a Surgical procedure;
i. terminal Illness, with a prognosis of death within 6 months;
j. Acquired Immune Deficiency Syndrome (AIDS);
k. Substance Abuse;
l. a Mental or Nervous Disorder; or
m. any other Illness or injury determined by Horizon BCBSNJ to be catastrophic.
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Alternate Treatment/Individual Case Management Plan
Horizon BCBSNJ will identify cases of Catastrophic Illness or Accidental Injury. The appropriateness of the level of patient care given to you as well as the setting in which it is received will be evaluated. In order to maintain or enhance the quality of patient care for you, Horizon BCBSNJ will develop an Alternate Treatment/Individual Case Management Plan.
a. An Alternate Treatment/Individual Case Management Plan is a specific written document, developed by Horizon BCBSNJ through discussion and agreement with:
1. you, or your legal guardian if necessary;
2. your attending Practitioner; and
3. Horizon BCBSNJ or its designee.
b. The Alternate Treatment/Individual Case Management Plan includes:
1. treatment plan objectives;
2. course of treatment to accomplish the stated objectives;
3. the responsibility of each of the following parties in implementing the Plan:
(a) Horizon BCBSNJ (b) attending Practitioner (c) you (d) your family, if any; and
4. estimated cost and savings.
If Horizon BCBSNJ, the attending Practitioner, and you agree in writing on an Alternate Treatment/Individual Case Management Plan, the services and supplies required in connection with such Alternate treatment plan/Individual Case Management will be considered as Covered Charges under the terms of your Plan.
The agreed upon alternate treatment must be ordered by your Practitioner.
Benefits payable under the Alternate Treatment/Individual Case Management Plan will be considered in the accumulation of any Benefit Period and Per Lifetime maximums.
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Exclusion
Alternate Treatment/Individual Case Management does not include services and supplies that Horizon BCBSNJ Determines to be Experimental or Investigational.
Important Notice: You are not required, in any way, to accept an Alternate Treatment/Individual Case Management Plan recommended by Horizon BCBSNJ.
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SCHEDULE OF PROCEDURES,TREATMENT AND SUPPLIES REQUIRING PRIOR AUTHORIZATION
• All Admissions to a Skilled Nursing Facility.
• Hospice Care.
• Inpatient Hospital Care for Medical or Mental Health/Substance Abuse care.
• Private Duty Nursing.
Note: Network providers will handle all pre-certifications. In the event any portion of a facility day is determined not medically necessary, it will be the facility and not the patient's liability.

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CLAIMS PROCEDURES
Claim forms and instructions for filing claims will be provided to Covered Persons. Completed claim forms and any other required materials must be submitted to Horizon BCBSNJ or its designees for processing. Covered Persons do not need to file claims for In-Network Covered Services and Supplies. For Out-of-Network Covered Services and Supplies, Covered Persons will generally have to file a claim for benefits, unless a state law requires Providers to file claims on behalf of Covered Persons. In this case, however, a Covered Person still has the option to file claims on his/her own behalf.
Submission of Claims
These procedures apply to the filing of claims. All notices will be in writing.
a. Claim forms must be filed no later than 18 months after the date the services were Incurred.
b. Itemized bills must accompany each claim form. A separate claim form is needed for each claim filed. In general, the bills must contain enough data to identify: the patient; the Provider; the type of service and the charge for each service and the Provider's license number.
Bills for Private Duty Nursing must state that the Nurse is a Registered Nurse (R.N.) or a Licensed Practical Nurse (L.P.N.) and must contain the Nurse's license number.
c If a claim is denied or disputed, in whole or in part, Horizon BCBSNJ will notify the claimant (or his/her agent or designee) of it within 30 calendar days after receipt of the claim.
The denial notice will set forth:
1. the reason(s) the claim is denied;
2. specific references to the main Plan provision(s) on which the denial is based;
3. a specific description of any further material or information needed to complete the claim, and why it is needed;
4. a statement that the claim is disputed, if this is so. If the dispute is about the amount of the claim, Horizon BCBSNJ will explain why and also explain why any coding changes were made5. a statement of the special needs to which the claim is subject, if this is the case;
6. an explanation of the Plan's claim review procedure, including any rights to pursue civil action;
7. if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the decision, either the specific rule or a statement that such a rule was
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relied upon in making the decision, and that a copy of such rule will be provided free of charge upon request;
8. if the decision is based on Medical Necessity and Appropriateness or an Experimental or Investigational (or similar) exclusion or limitation, either an explanation of the scientific or clinical judgment for the decision, applying the terms of the Plan to the medical circumstances, or a statement that such explanation will be provided free of charge upon request;
9. if the decision involves a Medical Emergency or Urgent Care, a description of the expedited review process applicable to such claims; and
10. the toll free number that the Covered Person or his/her Provider can call to discuss the claim.
d. This applies if you are the non-custodial parent of a Child Dependent. In this case, Horizon BCBSNJ will give the custodial parent the information needed for the Child Dependent to obtain benefits under the Plan. Horizon BCBSNJ will also permit the custodial parent, or the Provider with the authorization of the custodial parent, to submit claims for Covered Services and Supplies without your approval.
To Whom Payment Will Be Made
a. Payment for services of an In-Network Provider or a BlueCard Provider will be made directly to that Provider if the Provider bills Horizon BCBSNJ, as Horizon BCBSNJ determines. To receive In-Network coverage, a Covered Person must show his/her ID card when requesting Covered Services and Supplies from a Provider that has such an agreement.
b. Payment for services of Out-of-Network Providers will be made to you.
c. Except as stated above, in the event of a Covered Person's death or total incapacity, any payment or refund due will be made to his/her heirs, beneficiaries, trustees or estate.
d. If you are the non-custodial parent of a Child Dependent, Horizon BCBSNJ will pay claims filed as described above under "Submission of Claims" directly to: the Provider or Custodial parent; or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate.
If Horizon BCBSNJ pays anyone who is not entitled to benefits under this Plan, Horizon BCBSNJ has the right to recover those payments on behalf of the Plan.
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BLUECARD
Overview
Horizon BCBSNJ has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “Inter-Plan Arrangements.” These Inter- Plan Arrangements operate under rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever Covered Persons access healthcare services outside the geographic area we serve, the claims for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described generally below.
Typically, when accessing care outside the geographic area we serve, Covered Persons obtain care from healthcare providers that have a contractual agreement (“BlueCard Providers”) with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, Covered Persons may obtain care from healthcare providers in the Host Blue geographic area that do not have a contractual agreement (“nonparticipating providers”) with the Host Blue. Horizon BCBSNJ remains responsible for fulfilling our contractual obligations to the Covered Person. Horizon BCBSNJ's payment practices in both instances are described below.
This disclosure describes how claims are administered for Inter-Plan Arrangements and the fees that are charged in connection with Inter-Plan Arrangements.
Note that Dental Care Benefits that are not paid as medical claims/benefits, and those Prescription Drug Benefits or Vision Care Benefits that may be administered by a third party contracted by Horizon BCBSNJ to provide the specific service or services, are not processed through Inter-Plan Arrangements.
BlueCard® Program
The BlueCard Program is an Inter-Plan Arrangement. Under this Inter-Plan Arrangement, when Covered Persons access Covered Services and Supplies within the geographic area served by a Host Blue, the Host Blue will be responsible for contracting and handling all interactions with its BlueCard Providers. The financial terms of the Inter-Plan Arrangements are described generally below.
Liability Calculation Method Per Claim – In General
Covered Person's Liability Calculation
Unless subject to a fixed dollar copayment, the calculation of the Covered Person’s liability on claims for Covered Services and Supplies will be based on the lower of the BlueCard Provider's billed Covered Charges or the negotiated price made available to Horizon BCBSNJ by the Host Blue.
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Claims Pricing
Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s healthcare provider contracts. The negotiated price made available to us by the Host Blue may be represented by one of the following:
(i) An actual price. An actual price is a negotiated rate of payment in effect at the time a claim is processed without any other increases or decreases; or
(ii) An estimated price. An estimated price is a negotiated rate of payment in effect at the time a claim is processed, reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim- and non-claim-related transactions. Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements and performance-related bonuses or incentives; or
(iii) An average price. An average price is a percentage of billed Covered Charges in effect at the time a claim is processed representing the aggregate payments negotiated by the Host Blue with all of its healthcare providers or a similar classification of its providers and other claim- and non-claim-related transactions. Such transactions may include the same ones as noted above for an estimated price.
The Host Blue determines whether it will use an actual, estimated or average price. Host Blues using either an estimated price or an average price may prospectively increase or reduce such prices to correct for over- or underestimation of past prices (i.e., prospective adjustment may mean that a current price reflects additional amounts or credits for claims already paid or anticipated to be paid to providers or refunds received or anticipated to be received from providers). However, the BlueCard Program requires that the amount paid by the Covered Person is a final price; no future price adjustment will result in increases or decreases to the pricing of past claims. The method of claims payment by Host Blues is taken into account by Horizon BCBSNJ in determining the group’s premiums.
Negotiated (non-BlueCard Program) National Account Arrangements
With respect to one or more Host Plans, instead of using the BlueCard Program, Horizon BCBSNJ may process the Covered Person’s claims for Covered Services and Supplies through Negotiated National Account Arrangements.
In addition, if Horizon BCBSNJ and the group have agreed that (a) Host Blue(s) shall make available (a) custom healthcare provider network(s) in connection with this agreement, then the terms and conditions set forth in Horizon BCBSNJ's Negotiated National Account Arrangement(s) with such Host Blue(s) shall apply. These include the provisions governing the processing and payment of claims when Covered Persons access such network(s). In negotiating such Negotiated National Account Arrangements, Horizon BCBSNJ is not acting on behalf of or as an agent for the group or the group health plan.
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Covered Person's Liability Calculation.
Covered Person liability calculation will be based on the lower of either billed Covered Charges or negotiated price (refer to the description of negotiated price under "Claims Pricing" in the "Liability Calculation Method Per Claim – In General" provision above) made available to Horizon BCBSNJ by the Host Blue that allows the Covered Person access to negotiated participation agreement networks of specified participating healthcare providers outside of Horizon BCBSNJ's service area.
Special Cases: Value-Based Programs
Value-Based Programs Overview
The Covered Person may access Covered Services and Supplies from providers that participate in a Host Blue’s Value-Based Program. Value-Based Programs may be delivered either through the BlueCard Program or a Negotiated National Account Arrangement(s).
Value-Based Programs under the BlueCard Program
Horizon BCBSNJ has included a factor for bulk distributions from Host Blues in a group's premium for Value-Based Programs when applicable under this Booklet.
Value-Based Programs under Negotiated National Account Arrangements
If Horizon BCBSNJ has entered into a Negotiated National Account Arrangement with a Host Blue to provide Value-Based Programs to Covered Persons, Horizon BCBSNJ will follow the same procedures for Value-Based Programs as noted above in the Liability Calculation Method Per Claim – In General section.
Return of Overpayments
Recoveries of overpayments from a Host Blue or its BlueCard Providers and nonparticipating providers can arise in several ways, including, but not limited to, anti-fraud and abuse recoveries, audits, utilization review refunds and unsolicited refunds. Recoveries will be applied so that corrections will be made, in general, on either a claim-by-claim or prospective basis.
Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees
In some instances federal or state laws or regulations may impose a surcharge, tax or other fee that applies to insured accounts. If applicable, Horizon BCBSNJ will include any such surcharge, tax or other fee in determining a group's premium.
Non-Participating Healthcare Providers Outside Horizon BCBSNJ's Service Area
Covered Person's Liability Calculation
In General
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When Covered Services and Supplies are provided outside of Horizon BCBSNJ's service area by nonparticipating providers, the amount(s) a Covered Person pays for such services will be based on either the Host Blue’s nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law. In these situations, the Covered Person may be responsible for the difference between the amount that the nonparticipating provider bills and the payment Horizon BCBSNJ will make for the Covered Services and Supplies as set forth in this paragraph. Payments for out-of-network emergency services will be provided as if the care was provided by a participating healthcare provider with respect to application of the Covered Person's copayment, deductible or coinsurance.
Exceptions
In some exception cases, at the group's direction Horizon BCBSNJ may pay claims from nonparticipating healthcare providers outside of Horizon BCBSNJ's service area based on the provider’s billed charge. This may occur in situations where a Covered Person did not have reasonable access to a BlueCard Provider, as Determined by Horizon BCBSNJ in Horizon BCBSNJ's sole and absolute discretion in accordance with this Booklet or by state and/or federal law, as applicable. Adverse Determinations can be reviewed by an independent utilization review agency (IURO), court of law, arbitrator or any administrative agency having the appropriate jurisdiction.
In other exception cases, at the group's direction, Horizon BCBSNJ may pay such claims based on the payment Horizon BCBSNJ would make if Horizon BCBSNJ were paying a nonparticipating provider inside of Horizon BCBSNJ's service area, as described elsewhere in this Booklet. This may occur where the Host Blue’s corresponding payment would be more than Horizon BCBSNJ's in-service area nonparticipating provider payment. Horizon BCBSNJ may choose to negotiate a payment with such a provider on an exception basis.
Unless otherwise stated, in any of these exception situations, the Covered Person may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and the payment Horizon BCBSNJ will make for the Covered Services and Supplies as set forth in this paragraph.
BCBS Global Core Coverage TM
General Information. If Covered Persons are outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands (hereinafter: “BlueCard service area”), they may be able to take advantage of BCBS Global Core when accessing Covered Services and Supplies. The BCBS Global Core Coverage is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although BCBS Global Core assists Covered Persons with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when Covered Persons receive care from providers outside the BlueCard service area, the Covered Persons will typically have to pay the providers and submit the claims themselves to obtain reimbursement for these services.
Inpatient Services
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In most cases, if Covered Persons contacts the BCBS Global Core Service Center for assistance, hospitals will not require Covered Persons to pay for covered inpatient services, except for their cost-share amounts. In such cases, the hospital will submit Covered Persons' claims to the BCBS Global Core Service Center to initiate claims processing.
However, if Covered Persons paid in full at the time of service, the Covered Persons must submit a claim to obtain reimbursement for Covered Services and Supplies. Covered Persons must contact Horizon BCBSNJ to obtain precertification for non-emergency inpatient services.
Outpatient Services
Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require Covered Persons to pay in full at the time of service. Covered Persons must submit a claim to obtain reimbursement for Covered Services and Supplies.
Submitting a BCBS Global Core Claim
When Covered Persons pay for Covered Services and Supplies outside the BlueCard service area, they must submit a claim to obtain reimbursement. For institutional and professional claims, Covered Persons should complete a BCBS Global Core claim form and send the claim form with the provider’s itemized bill(s) to the BCBS Global Core Service Center address on the form to initiate claims processing. The claim form is available from Horizon BCBSNJ, BCBS Global Core Service Center, or online at www.bcbsglobalcore.com. If Covered Persons need assistance with their claim submissions, they should call BCBS Global Core at 1.800.810.BLUE (2583) or call collect at 1.804.673.1177, 24 hours a day, seven days a week.

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Exclusions Under The Blue Card PPO Program
The following are not Covered Services and Supplies under the plan. The Plan will not pay for any charges incurred for, or in connection, with:
Acupuncture.
Administration of oxygen, except as otherwise stated in this booklet.
Ambulance, in the case of a non-Medical Emergency.
Anesthesia and consultation services when they are given in connection with Non-Covered Charges.
An inpatient admission or any part of an inpatient admission primarily for:
• Physical Therapy, except as otherwise specified in this booklet; and/or • rehabilitation therapy, except as otherwise specified in this booklet.
Any charge to the extent it exceeds the Allowance.
Any therapy not included in the definition of Therapy Services.
Balances for services and supplies after payment has been made under the plan.
Blood or blood plasma or other blood derivatives or components which is replaced by a Covered Person.
Broken appointments.
Charges incurred during a person’s temporary absence from an eligible Provider’s grounds before discharge.
Claims that are not submitted within eighteen months in which the eligible expenses were incurred.
Completion of claim forms.
Copayments, Deductibles, and the individual’s part of any Coinsurance; expenses incurred after any Payment maximum is or would be reached.
Cosmetic Services, including cosmetic Surgery, procedures, treatment, drugs or biological products, unless required as a result of an accidental Injury or to correct a functional defect resulting from a congenital abnormality or developmental anomaly; complications of cosmetic Surgery; drugs prescribed for cosmetic purposes.
Court ordered treatment which is not Medically Necessary.
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Custodial Care or domiciliary care, including respite care except as specifically covered under your Plan.
Dental care or treatment, including appliances, except as otherwise stated in this booklet.
Diversional/recreational therapy or activity.
Drugs dispensed to a Covered Person while a patient in a Facility.
Drugs, obtained from a State or local public health agency, for the treatment of venereal disease or mental disease.
Drugs dispensed by other than a Pharmacist or a Pharmacy or for services rendered by a Pharmacist which are beyond the scope of his license. Benefits are not provided for drugs given by a physician or other practitioner.
Education or training while a Covered Person is confined in an institution that is primarily an institution for learning or training.
Employment/career counseling.
Experimental or Investigational treatments, procedures, Hospitalizations, drugs, biological products or medical devices.
Eye Examinations, eyeglasses, contact lenses, and all fittings, except as specified in this booklet; surgical treatment for the correction of a refractive error including, but not limited to, radial keratotomy.
Facility charges (e.g., operating room, recovery room, use of equipment) when billed for by a Provider that is not an eligible Facility.
Hearing aids or fitting of hearing aids.
Herbal medicine.
Home Health Care Visits connected with administration of dialysis.
Housekeeping services except as an incidental part of the Eligible services of a Home Health Care Agency.
Hypnotism.
Illness or Injury, including a condition which is the result of an Illness or Injury, which: (a) occurred on the job; and (b) is covered or could have been covered for benefits provided under a workers' compensation, employer's liability, occupational disease or similar law. However, this exclusion does not apply to the following persons for whom coverage under workers’
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compensation is optional, unless such persons are actually covered for workers’ compensation: a self-employed person or a partner of a limited liability partnership; members of a limited liability company or partners of a partnership who actively perform services on behalf of the self-employed business, the limited liability partnership, limited liability company or the partnership.
Immunizations, except as otherwise specified in this booklet.
Local anesthesia charges billed separately by a Practitioner for Surgery he performed on an Outpatient basis.
Maintenance therapy for:
• Physical Therapy; • Manipulative Therapy; • Occupational Therapy; and • Speech Therapy.
Marriage, career or financial counseling; sex therapy.
Medical Emergency services, or supplies, when not rendered by a Practitioner.
Membership costs for health clubs, weight loss clinics and similar programs.
Methadone maintenance.
Milieu Therapy:
Inpatient services and supplies which are primarily for milieu therapy even though eligible treatment may also be provided.
This means that the Plan has Determined:
1. the purpose of an entire or portion of an inpatient stay is chiefly to change or control a patient’s environment; and
2. an inpatient setting is not Medically Necessary for the treatment provided, if any.
Non-medical equipment which may be used primarily for personal hygiene or for comfort or convenience of a Covered Person rather than for a medical purpose, including air conditioners, dehumidifiers, purifiers, saunas, hot tubs, televisions, telephones, first aid kits, exercise equipment, heating pads and similar supplies which are useful to a person in the absence of Illness or injury.
Non-Prescription Drugs or supplies, except as may be Medically Necessary and Appropriate for the treatment of certain illness or Injury, except as otherwise stated in this Plan.
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Pastoral counseling.
Personal comfort and convenience items.
Prescription Drugs purchased from a pharmacy.
Psychoanalysis to complete the requirements of an educational degree or residency program.
Psychological testing for educational purposes.
Removal of abnormal skin outgrowths and other growths including, but not limited to, paring or chemical treatments to remove corns, callouses, warts, hornified nails and all other growths, unless it involves cutting through all layers of the skin.
Rest or convalescent cures.
Room and board charges for any period of time during which the Covered Person was not physically present in the room.
Routine exams (including related diagnostic X-rays and lab tests) and other services connected with activities such as the following: pre-marital or similar exams or tests; research studies; education or experimentation; mandatory consultations required by Hospital regulations.
Routine foot care, except as may be Medically Necessary and Appropriate for the treatment of certain Illness or Accidental Injury, including treatment for corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, symptomatic complaints of the feet.
Self-administered services such as: biofeedback, patient-controlled analgesia, related diagnostic testing, self-care and self-help training.
Services involving equipment or Facilities used when the purchase, rental or construction has not been approved in compliance with applicable state laws or regulations.
Services performed by any of the following:
a. A Hospital resident, intern or other Practitioner who is paid by a Facility or other source, who is not permitted to charge for services covered under the Plan, whether or not the Practitioner is in training. However, Hospital-employed Physician specialists may bill separately for their services.
b. Anyone who does not qualify as a physician.
Services provided during a stay at a Facility which in whole or in part was for diagnostic studies. This exclusion applies when the services were provided for any of the following reasons: diagnosis, evaluation, confirmation (or to rule out), or to check the current status of a condition which was treated in the past.
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Services required by the group as a condition of employment or rendered through a medical department, clinic, or other similar service provided or maintained by the group.
Services or supplies:
- eligible for payment under either federal or state programs (except Medicaid). This provision applies whether or not the Covered Person asserts his rights to obtain this coverage or payment for these services;
- for which a charge is not usually made, such as a Practitioner treating a professional or business associate, or services at a public health fair;
- for which the Provider has not received a certificate of need or such other approvals as are required by law;
- for which the Covered Person would not have been charged if he did not have health care coverage;
- furnished by one of the following members of the Covered Person’s family, unless otherwise stated in this booklet: Spouse, Child, parent, in-law, brother or sister;
- in connection with any procedure or examination not necessary for the diagnosis or treatment of injury or sickness for which a bonafide diagnosis has been made because of existing symptoms.
- needed because the Covered Person engaged, or tried to engage, in an illegal occupation or committed, or tried to commit, a felony;
- not specifically covered under your plan;
- provided by a Practitioner if the Practitioner bills the Covered Person directly for the services or supplies, regardless of the existence of any financial or contractual arrangement between the Practitioner and the Provider;
- provided by or in a Government Hospital unless the services are for treatment:
a. of a non-service Medical Emergency;
b. by a Veterans’ Administration Hospital of a non-service related Illness or Accidental Injury; or the Hospital is located outside of the United States and Puerto Rico; or unless otherwise required by law;
NOTE: The above limitations do not apply to military retirees, their dependents, and the dependents of active duty military personnel who have both military health coverage and coverage under your Plan, and receive care in Facilities run by the Department of Defense or Veteran’s Administration;
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- provided by a licensed pastoral counselor in the course of his normal duties as a pastor or minister;
- provided by a social worker, except as otherwise stated in this booklet;
- provided during any part of a stay at a Facility, or during Home Health Care chiefly for bed rest, rest cure, convalescence, custodial or sanatorium care, diet therapy or occupational therapy;
- received as a result of: war, declared or undeclared; police actions; service in the armed forces or units auxiliary thereto; or riots or insurrection;
- rendered prior to the Covered Person’s Effective Date or after his termination date of coverage under the program, unless specified otherwise;
- which are specifically limited or excluded elsewhere in this booklet;
- which are not Medically Necessary and Appropriate; or
- which a Covered Person is not legally obligated to pay for.
Special medical reports not directly related to treatment of the Covered Person (e.g. employment physicals, reports prepared in connection with litigation.)
Stand-by services required by a Practitioner; services performed by Surgical assistants not employed by a Facility.
Sterilization reversal.
Sunglasses even if by Prescription.
Surrogate Motherhood
Telephone consultations, except as the Plan may request.
TMJ syndrome treatment, except as otherwise stated in this booklet.
Transplants, except as otherwise stated in this booklet.
Transportation; travel.
Vision therapy, vision or visual acuity training, orthoptics and pleoptics.
Vitamins and dietary supplements.
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Weight reduction or control, unless there is a diagnosis of morbid obesity; special foods, food supplements, liquid diets, diet plans or any related products, except as specifically covered under the Plan. Wigs, toupees, hair transplants, hair weaving, or any drug used to eliminate baldness unless deemed Medically Necessary and Appropriate.
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BENEFITS PAYABLE FOR AUTOMOBILE RELATED INJURIES
This section applies when expenses are Incurred by a Covered Person due to an Automobile Related Injury.
Definitions
"Automobile Related Injury": Bodily injury of a Covered Person due to an accident while occupying, entering into, alighting from or using an auto; or if the Covered Person was a pedestrian, caused by an auto or by an object propelled by or from an auto.
"Allowable Expense": A Medically Necessary and Appropriate, reasonable and customary item of expense that is at least in part a Covered Charge under this Plan or PIP.
"Eligible Expense": That portion of expense Incurred for treatment of an Injury, which is covered under this Plan without application of Deductibles or Copayments, if any.
"Out-of-State Automobile Insurance Coverage" or "OSAIC": Any coverage for medical expenses under an auto insurance contract other than PIP. This includes auto insurance contracts issued in another state or jurisdiction.
"PIP": Personal injury protection coverage (i.e., medical expense coverage) that is part of an auto insurance contract issued in New Jersey.
Application of this Provision
When expenses are Incurred as a result of an Automobile Related Injury, and the injured person has coverage under PIP or OSAIC, this provision will be used to determine whether this Plan provides coverage that is primary to such coverage or secondary to such coverage. It will also be used to determine the amount payable if this Plan provides primary or secondary coverage.
Determination of Primary or Secondary Coverage
This Plan provides secondary coverage to PIP unless this Plan's health coverage has been elected as primary by or for the Covered Person. This election is made by the named insured under a PIP contract. It applies to that person's family members who are not themselves named insured under other auto contracts. This Plan may be primary for one Covered Person, but not for another if the persons have separate auto contracts and have made different selections regarding the primary of health coverage.
This Plan is secondary to OSAIC. But, this does not apply if the OSAIC contains provisions that make it secondary or excess to the Covered Person's other health benefits. In that case, this Plan is primary.
If the above rules do not determine which health coverage is primary, or if there is a dispute as to whether this Plan will provide benefits for Covered Charges as if it were primary.
Benefits This Plan Will Pay if it is Primary to PIP or OSAIC
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If this Plan is primary to PIP or OSAIC, it will pay benefits for Covered Charges in accordance with its terms. If there are other plans that: (a) provide benefits to the Covered Person; and (b) are primary to auto insurance coverage, then this Plan's rules regarding the coordination of benefits will apply.
Benefits This Plan Will Pay if it is Secondary to PIP
If this Plan is secondary to PIP, the actual coverage will be the lesser of:
a. the Allowable Expenses left uncovered after PIP has provided coverage (minus this Plan's Deductibles, Copayments, and/or Coinsurance); or
b. the actual benefits that this Plan would have paid if it provided its coverage primary to PIP.
Medicare
To the extent that this Plan provides coverage that supplements Medicare's, then this Plan can be primary to automobile insurance only insofar as Medicare is primary to auto insurance.
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Subrogation and Reimbursement
If another person or entity, through an act or omission, causes any participant, beneficiary, or any other covered person receiving benefits under this Plan, hereinafter individually and collectively referred to as “Covered Person”, to suffer an injury or illness, and in the event benefits were paid under the Plan for that injury or illness, a Covered Person must agree to the provisions listed below. Additionally, if a Covered Person is injured and no other person or entity is responsible but a Covered Person receives (or is entitled to) a recovery from another source, and if the Plan paid benefits for that injury, a Covered Person must also agree to the provisions listed below.
This Plan provides benefits to or on behalf of said Covered Person only on the following terms and conditions:
1. In the event that benefits are provided under this Plan, the Plan shall be subrogated to all of the Covered Person’s or the Covered Person’s representative’s (representative for this purpose includes, if applicable, heirs, administrators, legal representatives, parents (if a minor), successors, or assignees) rights of recovery against any person or organization to the extent of the benefits provided to the Covered Person. The Covered Person shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Covered Person shall do nothing after loss to prejudice such rights. The Covered Person hereby agrees to cooperate with the Plan and/or any representatives of the Plan in completing such forms and in giving such information surrounding any injury, illness, or accident as the Plan or the Plan representatives deem necessary to fully investigate the incident.
2. The Plan is also granted a right of reimbursement from the proceeds of any recovery whether by settlement, judgment, or otherwise. This right of reimbursement is cumulative with and not exclusive of the subrogation right granted in paragraph 1, but only to the extent of the benefits provided by the Plan. The Plan is entitled under its right of recovery to be reimbursed for the Plan’s benefit payments even if the Covered Person is not “made whole” for all of his or her damages in the recoveries the he or she receives.
3. By accepting benefits hereunder, the Covered Person hereby grants an automatic lien against and assigns to the Plan, in an amount equal to the benefits paid by the Plan, any recovery, whether by settlement, judgment, or other payment intended for, payable to, or received by the Covered Person, or on behalf of the Covered Person. The Covered Person hereby consents to said lien and/or assignment and agrees to take whatever steps are necessary to help the Plan secure said lien and/or assignment. The Covered Person agrees that said lien and/or assignment shall constitute a charge upon the proceeds of any recovery and the Plan shall be entitled to assert security interest thereon. By the acceptance of benefits under the Plan, the Covered Person and his or her representatives agree to hold the proceeds of any settlement, judgment and/or other payment in trust for the benefit of the Plan to the extent of 100% of all benefits paid on behalf of the Covered Person.
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4. The subrogation and reimbursement rights and liens apply to any recoveries made by the Covered Person as a result of the injuries sustained, including but not limited to the following:
a. Payments made directly by the third party tortfeasor, or any insurance company on behalf of the third party tortfeasor, or any other payments on behalf of the third party tortfeasor.
b. Any payments or settlements or judgment or arbitration awards paid by any insurance company under an uninsured or underinsured motorist coverage, whether on behalf of a Covered Person or other person.
c. Any other payments from any source designed or intended to compensate a Covered Person for injuries sustained.
d. Any worker’s compensation award or settlement.
e. Any recovery made pursuant to no-fault insurance.
f. Any medical payments made as a result of such coverage in any automobile or homeowners insurance policy.
5. The Covered Person shall not take action that may prejudice the Plan’s right of recovery, including but not limited to the assignment of any rights of recovery from any tortfeasor or other person or entity. No Covered Person shall make any settlement which specifically reduces or excludes, or attempts to reduce or exclude the benefits provided by the Plan. The Plan will not reduce its share of any recovery unless, in the exercise of its discretion, the Plan agrees in writing.
6. The Plan’s right of recovery shall be a prior lien against any proceeds recovered by the Covered Person, which right shall not be defeated nor reduced by the application of any doctrine purporting to defeat the Plan’s recovery rights by allocating the proceeds exclusively to non-medical expense damages. Accordingly, the Plan is entitled under its right of recovery to be reimbursed for its benefit payments even if the Covered Person is not “made whole” for all of his or her damages in the recoveries he or she receives; there shall be no application of the “made whole” doctrine, “rimes doctrine” or any such doctrine defeating the Plan’s right of recovery.
7. No Covered Person hereunder shall incur any expenses on behalf of the Plan in pursuit of the Plan’s rights hereunder. Specifically, no court costs or attorney’s fees may be deducted from the Plan’s recovery without the prior express written consent of the Plan and the Plan’s right of recovery is not subject to reduction of attorney’s fees and costs under the “common fund” or any other doctrine.
8. In the event that a Covered Person shall fail or refuse to honor its obligations hereunder, then the Plan shall be entitled to recover any costs incurred in enforcing the terms hereof including but not limited to attorney’s fees, litigation, court costs, and other expenses.
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The Plan shall also be entitled to offset the reimbursement obligation against any entitlement to future Plan benefits hereunder until the Covered Person has fully complied with his or her reimbursement obligations hereunder, regardless of how those future Plan benefits are incurred.
9. Any reference to state law in any other provision of this policy shall not be applicable to this provision, if the Plan is governed by ERISA. By acceptance of benefits under the Plan, the Covered Person agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, the Plan shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the Plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief.

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THE EFFECT OF MEDICARE ON BENEFITS
IMPORTANT NOTICE
For the purposes of this Booklet’s “Coordination of Benefits and Services” provision, the benefits for a Covered Person may be affected by whether he/she is eligible for Medicare and whether the "Medicare as Secondary Payer" rules apply to the Plan. This section, on "Medicare as Secondary Payer", or parts of it, may not apply to this Plan. The Employee must contact the Employer to find out if the Employer is subject to Medicare as Secondary Payer rules.
For the purpose of this section:
a. "Medicare" means Part A and B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time.
b. A Covered Person is deemed to be eligible for Medicare by reason of age from the first day of the month during which he/she reaches age 65. But, if the Covered Person is born on the first day of a month, he/she is deemed to be eligible for Medicare from the first day of the month that is immediately prior to his/her 65th birthday. A Covered Person may also be eligible for Medicare by reason of disability or End-Stage Renal Disease (ESRD).
c. Under the rules for coordination of benefits and services described earlier, a "Primary Plan" pays benefits for a Covered Person's Covered Charges first, ignoring what the Covered Person's "Secondary Plan(s)" pays. The "Secondary Plan(s)" then pays the remaining unpaid Allowable Expenses in accordance with the provisions of the Covered Person's secondary health plan.
The following rules explain how this Plan's group health benefits interact with the benefits available under Medicare as Secondary Payer rules. A Covered Person may be eligible for Medicare by reason of age, disability or ESRD. Different rules apply to each type of Medicare eligibility as explained below:
In all cases where a person is eligible for Medicare and this Plan is the secondary plan, the Allowable Expenses under this Plan and for the purposes of the Coordination of Benefits and Services rules, will be reduced by what Medicare would have paid if the Covered Person had enrolled for full Medicare coverage. But this will not apply, however, if; (a) the Covered Person is eligible for, but not covered, under Part A of Medicare; and (b) he/she could become covered under Part A only by enrolling and paying the required premium for it.
Medicare Eligibility by Reason of Age
This section applies to a Covered Person who is:
a. The Employee or covered spouse;
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b. eligible for Medicare by reason of age; and
c. has coverage under this program due to the current employment status of the Employee.
Under this section, such a covered person is referred to as a "Medicare eligible".
This section does not apply to:
a. a Covered Person, other than an Employee or covered Spouse;
b. a Covered Person who is under age 65; or
c. a Covered Person who is eligible for Medicare solely on the basis of End Stage Renal Disease
When a Covered Person becomes eligible for Medicare by reason of age, this Plan permits the Covered Person to make a prospective election change that cancels coverage under this Plan and elect Medicare as the primary health plan.
If a Covered Person cancels coverage under this Plan, the Covered Person will no longer be covered by this Plan. Medicare will be the primary payer. Coverage under this plan will end on the last day of the month in which the Covered Person elects Medicare the primary health plan.
If a Covered Person does not make an election upon becoming eligible for Medicare by reason of age, this Plan will continue to be the primary health plan. This plan pays first, ignoring Medicare. Medicare will be considered the secondary health plan.
Medicare Eligibility by Reason of Disability
This part applies to a Covered Person who:
a. is under age 65;
b. is eligible for Medicare by reason of disability; and
c. has coverage under this Plan due to the current employment status of the Employee.
This part does not apply to:
a. a Covered Person who is eligible for Medicare by reason of age; or
b. a Covered Person who is eligible for Medicare solely on the basis of ESRD.
When a Covered Person becomes eligible for Medicare by reason of disability, this Plan is the primary plan; Medicare is the secondary plan.
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Medicare Eligibility by Reason of End Stage Renal Disease
This part applies to a Covered Person who is eligible for Medicare solely on the basis of ESRD.
This part does not apply to a Covered Person who is:
a. eligible for Medicare by reason of age ; or
b. eligible for Medicare by reason of disability.
When (a) a Covered Person becomes eligible for Medicare solely on the basis of ESRD; and (b) Incurs a charge for the treatment of ESRD for which benefits are payable under both this Plan and Medicare, this Plan is deemed the Primary Plan for a specified time, referred to as the “coordination period”. This Plan pays first, ignoring Medicare. Medicare is the Secondary Plan. The coordination period is up to 30 consecutive months.
The coordination period starts on the earlier of:
a. the first month of a Covered Person’s Medicare Part A entitlement based on ESRD; or
b. the first month in which he/she could become entitled to Medicare if he/she filed a timely application.
After the 30-month period described above ends, if an ESRD Medicare eligible person Incurs a charge for which benefits are payable under both this Plan and Medicare, Medicare is the Primary Plan and this Plan is the Secondary Plan.
Dual Medicare Eligibility
This part applies to a Covered Person who is eligible for Medicare on the basis of ESRD and either age or disability.
When a Covered Person who is eligible for Medicare due to either age or disability (other than ESRD) has this Plan as the primary payer, then becomes eligible for Medicare based on ESRD, this Plan continues to be the primary payer for the first 30 months of dual eligibility. After the 30-month period, Medicare becomes the primary payer (as long as Medicare dual eligibility still exists).
When a Covered Person who is eligible for Medicare due to either age or disability (other than ESRD) has this Plan as the secondary payer, then becomes eligible for Medicare based on ESRD, this Plan continues to be the secondary payer.
When a Covered Person who is eligible for Medicare based on ESRD also becomes eligible for Medicare based on age or disability (other than ESRD), this Plan continues to be the primary payer for 30 months after the date of Medicare eligibility based on ESRD.
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How To File A Claim If You Are Eligible For Medicare
Follow the procedure that applies to you or the Covered Person from the categories listed below when filing a claim.
New Jersey Providers:
• The Covered Person should give the Practitioner or other Provider his/her identification number. This number is shown on the Medicare Request for Payment (claim form) under “Other Health Insurance”;
• The Provider will then submit the Medicare Request for Payment to the Medicare Part B carrier;
• After Medicare has taken action, the Covered Person will receive an Explanation of Benefits form from Medicare;
• If the remarks section of the Explanation of Benefits contains this statement, no further action is needed: “This information has been forwarded to Horizon Blue Cross Blue Shield of New Jersey for their consideration in processing supplementary coverage benefits;”
• If the above statement does not appear on the Explanation of Benefits, the Covered Person should include his/her Identification number and the name and address of the Provider in the remarks section of the Explanation of Benefits and send it to Horizon BCBSNJ.
Out-of-State Providers:
• The request for Medicare payment should be submitted to the Medicare Part B carrier in the area where services were performed. Call your local Social Security office for information;
• Upon receipt of the Explanation of Benefits, show the Identification Card number and the name and address of the Provider in the remarks section and send the Explanation of Benefits to Horizon BCBSNJ for processing.

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APPEALS PROCESS
A Covered Person (or a Provider or authorized representative acting on behalf of the Covered Person and with his/her consent) may appeal Adverse Benefit Determinations. There are two types of Adverse Benefit Determinations, administrative and utilization management. “Administrative” determinations involve issues such as eligibility for coverage, benefit decisions, etc. “Utilization management” determinations are decisions to deny or limit an admission, service, procedure or extension of stay based on the Plan's clinical and medical necessity criteria. The appeal processes for the two types differ and are described briefly below.
No Covered Person or Provider who files an appeal will be subject to disenrollment, discrimination or penalty. If there is a claim denial for either type of decision, you will receive information that includes the reason for the denial, a reference to the Plan provision on which it is based, and a description of any internal rule or protocol that affected the decision.
Appeals Process for Adverse Administrative Decisions
For this type of adverse claim decisions, you will be notified of a denial as quickly as possible, but not later than the following:
a. For Urgent Care Claims, 72 hours from receipt of the claim;
b. For Pre-Service Claims, 15 calendar days from receipt of the claim;
c. For Post-Service Claims, 30 calendar days from receipt of the claim.
If you wish to appeal the decision, you have 180 days to do so. Your written request for a review of the decision should include the reason(s) why you feel the claim should not have been denied. It should also include any additional information (e.g., medical records) that you feel support your appeal.
The decision regarding your appeal will be reached as soon as possible, but not later than the following:
• For Urgent Care Claims, 72 hours from receipt of your appeal;
• For Pre-Service Claims, 30 calendar days from receipt of your appeal;
• For Post-Service Claims, 60 calendar days from receipt of your appeal.
If the initial decision on your claim is upheld upon review, you will also be informed of any additional appeal rights that you may have.
Appeals Process for Adverse Utilization Management Decisions
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The process for this type of adverse decision is briefly described below. A denial notification will include a brochure that fully describes your appeal rights and how you go about exercising them.
If such a claim is denied, your treating Provider can discuss your case with a Horizon BCBSNJ Medical Director, who can be reached by telephone at the number provided in the brochure. If the initial denial is upheld, you or the Provider can further appeal the decision within one year after receiving the denial letter. The appeal can be in writing or can be initiated by telephone. The applicable address and telephone number will be provided in the brochure.
Your appeal must include the following information:
• The name(s) and address(es) of the Covered Person and/or the Provider(s);
• The Covered Person's identification number;
• The date(s) of service;
• The nature of and reason behind your appeal;
• The remedy sought; and
• Any documentation that supports your appeal.
Your appeal will be decided as soon as possible, but not later than the following:
• For Urgent Care Claims, within 72 hours from receipt of your appeal;
• For other claims, within 30 calendar days from receipt of your appeal.
External Appeal Rights
If the initial denial is upheld pursuant to the internal appeal process and you are still dissatisfied, you have the additional right to pursue an external appeal with an Independent Review Organization (IRO). To exercise this right, you must request an external appeal in writing within four months after receiving our final internal appeal decision regarding your claim. The brochure accompanying our initial denial and final internal appeal decision will provide full details regarding the process that must be followed to request and obtain an external review. Generally, you must complete the internal appeal process before your claim will be eligible for external review. A small filing fee may be required. If so, it will be noted in the brochure.
If the process for obtaining this review is successfully completed, and your claim is deemed eligible, you will be notified and your appeal will be assigned to an IRO. Once it is assigned, the IRO will notify you about any additional steps that must be taken to complete your appeal. Once all of these additional steps are completed, the IRO will review all of the information in your
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case as if it were new. The IRO is not bound by any decisions or conclusions that were reached during the internal appeals process.
The IRO's decision will be communicated to you in writing within 45 calendar days after its receipt of the appeal, or, if your external appeal request was handled on an expedited basis due to your medical circumstances, within 72 hours. The written decision issued by the IRO will include complete information regarding your appeal and the rationale for the decision. The decision will also include a statement that the IRO's decision is binding except to the extent that other remedies may be available to you or the Plan pursuant to state or federal law. The decision will also advise you about other resources that may be available to you for additional assistance.

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Non-Duplication of Benefits
As with most group health care programs, this program contains a type of coordination of benefits provision called “non-duplication of benefits.” This provision is used when you and your covered dependents (spouse or child) receive services which are eligible for payment under more than one group health program. The main objective is to assure that your covered expenses will be paid, but that the combined payments do not amount to more than the amount this program would pay if it were the only program. Under this arrangement, the benefits of one program are reduced to the extent they are payable by another program. Here is how the order of benefits works: • When the other group coverage does not have a “coordination of benefits” provision then that coverage pays first. • When the person who received care is covered as an employee under one group coverage, and as a dependent under another, then the employee coverage pays first. • When a dependent child is covered under two group coverages and his parents are not separated or divorced, the coverage of the parent whose birthday (according to month and day) falls earlier in the year first; if both parents have the same birthday, the Plan covering the parent for the longer time pays first. • If the dependent child’s parents are separated or divorced, the following applies: 1. The coverage of the parent with custody of the child pays first; 2. Then, the coverage of the spouse (if any) of the parent with custody of the child pays; and 3. Finally, the coverage of the parent without custody of the child pays. 4. Regardless of which parent has custody, whenever a court decree specifies the parent who is financially responsible for the child’s health care expenses, the coverage of that parent pays first. • The Plan which covers a person as an active employee or his dependent will pay before the plan which covers such person as a laid off or retired employee or his dependent. If the other plan does not have a coordination of benefits provision concerning laid off or retired employees, then this rule does not apply. • When none of the above circumstances applies, the coverage you have had for the longest time pays first.
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If you receive more than you should have when your benefits are coordinated, you will be expected to repay any overpayment. This program will provide its regular benefits in full when it is primarily liable (the program which pays first). When this program is secondary liable (pays second), it will provide a reduced amount. This reduced amount is determined as follows: 1. The benefits that would be payable for allowable expenses under this program (without considering other programs’ benefits) are calculated; 2. The benefits payable under all other programs (for the same allowable expenses) are subtracted from (1); and 3. The difference, if any, is payable by this program. In no event will this program’s liability as a secondary program exceed its liability as a primary program.
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Service Centers
If you have any questions about the Plan, call your nearest Service Center.
Telephone personnel are available:
Monday, Tuesday, Wednesday and Friday from 8:00 a.m. to 8:00 p.m.
Thursday from 9:00 a.m. to 8:00 p.m. (E.T.) Eastern Time
For questions and assistance with your Blue Card PPO benefits and services, please call:
1-800-355-BLUE (2583)
When you are outside of New Jersey and need to locate a nationwide Network PPO Provider, please call:
1-800-810-BLUE (2583)
For Mental Health and Substance Abuse, please call:
1-800-626-2212
Always have your identification card handy when calling. Your ID number helps get prompt answers to your questions about enrollment, benefits or claims.
Use this space for information you will need when asking about your coverage.
The company office or enrollment official to contact about coverage:
__________________________________________________________________
The identification number shown on my identification card:
__________________________________________________________________
The effective date when my coverage begins:
__________________________________________________________________
My group number is:
__________________________________________________________________
SUZ-W-20-02 IPUC DR 3 Attachment 3
Page 112 of 116

103
ERISA INFORMATION The following information, together with the information contained in the rest of this Booklet, comprise the Summary Plan Description required by the Employee Retirement Income Security Act of 1974, as amended (ERISA).
Name of Plan: The SUEZ Water Resources Inc. Medical Plan
Plan Sponsor: SUEZ Water Resources Inc.
461 From Rd., Suite 400
Paramus, New Jersey 07652
Plan Administrator: SUEZ Water Resources Inc. 461 From Rd., Suite 400 Paramus, New Jersey 07652
Employer Identification Number: 22-2441477
Plan Number: 501
Classification and Funding:
The Plan described in this Booklet is classified as a welfare benefits plan by the Department of
Labor. It is funded by both the company and Employee contributions.
Type of Administration: Contract Administration. Benefits are provided in accordance with the
provisions of the Plan Sponsor. Horizon Blue Cross Blue Shield of New Jersey provides
administrative services only.
Claims Administrator: Horizon Blue Cross Blue Shield of New Jersey, Inc.
Agent for Service of Legal Process: Plan Administrator
The Plan Year begins on January 1 and ends on December 31.
Plan Administrator Authority and Powers:
The Plan Administrator shall have exclusive discretionary authority and power to determine eligibility for benefits and to construe the terms and provisions of this Plan, to determine questions of fact and law arising under this Plan, and to exercise all of the powers necessary for
the operation of this Plan. However, the Plan has delegated to the Claims Administrator the authority to make final claims determinations and to decide initial and final claims appeals on the Plan's behalf.
Plan Modification and Termination Information
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104
Not withstanding anything to the contrary in this Summary Plan Description, the Plan Sponsor/Administrator expressly reserves the right, at any time, for any reason and without limitation to terminate, modify or otherwise amend this Plan and any or all of the benefits provided there under, either in whole or in part, whether to all persons covered thereby or one or more groups thereof. These rights include specifically, but are not limited to, (1) the right to terminate benefits under the Plan with respect to any participant therein; (2) the right to modify benefits under this Plan to all or any group of participants therein; (3) the right to require or increase contributions by any participants therein towards the cost of this Plan; and (4) the right to amend this Plan or any term or condition thereof; in each case, whether or not such rights are exercised with respect to any other participant or group of participants in this plan.
Not a Contract of Employment
No provision of the Plan described in this Booklet is to be considered a contract of employment. The Employer’s rights with respect to disciplinary actions and termination of Employees are in no way changed by the provisions of the Plan.
If you have any questions about the Plan, contact the Plan Administrator.
SUZ-W-20-02 IPUC DR 3 Attachment 3
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105
STATEMENT OF ERISA RIGHTS
As a participant in SUEZ Water Resources Inc. Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
• Receive information about your plan and benefits.
• Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.
• Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.
• Receive a summary of the plan's annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report.
• Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110.00 a day until you receive
SUZ-W-20-02 IPUC DR 3 Attachment 3
Page 115 of 116

106
the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plans' decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your fights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example if it finds your claim is frivolous.
Assistance with Your Questions
If your have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquires, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

SUZ-W-20-02 IPUC DR 3 Attachment 3
Page 116 of 116
PLA-9312 Page 1 of 2

NEW JERSEY LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION ACT

Residents of New Jersey who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the New Jersey Life and Health Insurance Guaranty Association.

The purpose of this association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force.
The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted below, this protection is not a substitute for consumers’ care in selecting companies that are well-managed and financially stable.

DISCLAIMER

The state law that provides for this safety-net coverage is called the New Jersey Life and Health
Insurance Guaranty Association Act, N.J.S.A. 17B: 32A-1, et seq. (the "Act").

COVERAGE
The following is a brief summary of this law’s coverages, exclusions and limits. This summary does not cover all provisions of the law; not does it in any way change anyone’s rights or obligations of the guaranty association.

Generally, individuals will be protected by the Life and Health Insurance Guaranty Association if they live in New Jersey and hold a life, health or long-term care insurance contract, annuity contract, or if they are insured under a group insurance contract, issued by a member insurer.

The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state.
Jersey. You should not rely on coverage by the New Jersey Life and Health

NOT provided for your policy or any portion of it that is not guaranteed by the insurer or

tice. However,
way Center 9th Floor
NOTICE
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 1 of 71
PLA-9312 Page 2 of 2
EXCLUSIONS FROM COVERAGE
However, persons holding such policies are not protected by this Association if:
• They are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); • the insurer was not authorized to do business in this state;
• the policy is issued by an organization which is not a member of the New Jersey Life and Health Insurance Guaranty Association.

The Association also does not provide coverage for:
• Any policy or portion of a policy which is not guaranteed by the insurer or for which the
individual has assumed the risk, such as a variable contract sold by prospectus;
• any policy of reinsurance (unless an assumption certificate was issued); • interest rate yields that exceed an average rate as more fully described in Section 3 of the Act;
• dividends;
• credits given in connection with the administration of a policy by a group contract holder;
• employers’ plans to the extent they are self-funded (that is, not insured by an insurance company, even if an insurance company administers them).

LIMITS ON AMOUNT OF COVERAGE
The act also limits the amount the Association is obligated to pay out. The Association cannot pay more
than what the insurance company would owe under a policy contract.
With respect to any one insured individual, regardless of the number of policies or contracts, the Association will pay not more than $500,000 in life insurance death benefits and present value annuity
benefits, including net cash surrender and net cash withdrawal values. Within this overall limit, the
Association will not pay more than $100,000 in cash surrender values for life insurance, $100,000 in cash surrender values for annuity benefits, $500,000 in life insurance death benefits or $500,000 in present value of annuities - again no matter how many policies and contracts that were with the same company, and no matter how many different types of coverages.
The Association will not pay more than $2,000,000 in benefits to any one contract holder under any one unallocated annuity contract.

There are no limits on the benefits the Association will pay with respect to any one group, blanket or individual accident and health insurance policy.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 2 of 71

GROUP LIFE INSURANCE POLICY

Sponsor: SUEZ Water Resources Inc
Policy Number: SA3-830-509893-01
Effective Date: June 1, 2010
Governing Jurisdiction is New Jersey and subject to the laws of that State.

Premiums are due and payable monthly on the first day of each month.

Policy Anniversaries shall occur each June 1st beginning in 2011.

Lincoln Life Assurance Company of Boston (hereinafter referred to as Lincoln) agrees to pay the benefits
provided by this policy in accordance with its provisions.
PLEASE READ THIS POLICY CAREFULLY FOR FULL DETAILS.
This policy is a legal contract and is issued in consideration of the Application of the Sponsor, a copy of which is attached, and of the payment of premiums by the Sponsor.
For purposes of this policy, the Sponsor acts on its own behalf or as the Covered Employee's agent. Under no circumstances will the Sponsor be deemed the agent of Lincoln.

This policy is delivered in and governed by the laws of the governing jurisdiction and to the extent
applicable by The Employee Retirement Income Security Act of 1974 (ERISA) and any subsequent amendments.

The following pages including any amendments, riders or endorsements are a part of this policy.
Signed at Lincoln's Home Office, 100 Liberty Way, Suite 100, Dover, New Hampshire 03820-4695.

Form GLP

SA3-830-509893-01 R (1) Effective November 9, 2016
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 3 of 71
Form GLP-TOC Table of Contents

TABLE OF CONTENTS

SECTION 1 ................................................................... SCHEDULE OF BENEFITS

SECTION 2 ................................................................... DEFINITIONS

SECTION 3 ................................................................... ELIGIBILITY AND EFFECTIVE DATES

SECTION 4 ................................................................... INSURANCE BENEFITS

SECTION 5 ................................................................... EXCLUSIONS

SECTION 6 ................................................................... TERMINATION PROVISIONS

SECTION 7 ................................................................... GENERAL PROVISIONS

SECTION 8 ................................................................... PREMIUMS

SECTION 9 ................................................................... APPLICATION
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 4 of 71
Form GLP-SCH-1 Schedule of Benefits
SECTION 1 - SCHEDULE OF BENEFITS

ELIGIBILITY REQUIREMENTS FOR INSURANCE BENEFITS

Minimum Hourly Requirement:

Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 12A, 12B, 13A, 13B:
Employees working a minimum of 30 regularly scheduled hours per week

Applicable to Class 10, 11:
Employees working a minimum of 20 regularly scheduled hours per week

Applicable to Class 14, 15, 16, 17, 18, 19:
None

Classification of Covered Employees:
Class 1: All full time Employees of SUEZ Management of Services, Environmental Services and
Utility hired before January 1, 2010 excluding:• BU002 – Bloomsburg, PA Union, •
BU027 – Delaware Production Union, • BU053 – New Rochelle, NY Union, • BU675 –
Newport, RI Union, • BU675 – Pawtucket, RI Union, • BU675 – Woonsocket, RI Union,
• BU675 – Portage, MI Union, • BU687 – Middletown, PA Union
Class 2: All full time Employees of SUEZ Management of Services, Environmental Services and
Utility hired on or after January 1, 2010 excluding: • BU002 – Bloomsburg, PA Union, •
BU027 – Delaware Production Union, • BU053 – New Rochelle, NY Union, • BU675 – Newport, RI Union, • BU675 – Pawtucket, RI Union, • BU675 – Woonsocket, RI Union • BU675 – Portage, MI Union, • BU687 – Middletown, PA Union

Class 3: All full time Employees of BU002 – Bloomsburg, PA Union
Class 4: All full time Employees of BU027 – Delaware Production Union
Class 5: All full time Employees of BU053 – New Rochelle, NY Union
Class 6: All full time Employees of BU675 – Newport, RI Union
Class 7: All full time Employees of BU675 – Pawtucket, RI Union
Class 8: All full time Employees of BU675 – Woonsocket, RI Union
Class 9: All full time Employees of BU675 – Portage, MI Union
Class 10: All full time Employees of BU687 – Middletown, PA Union
Class 11: All part time employees with more than 1 year of service of BU687 – Middletown, PA
Union

Class 12A: All non-union employees of BU675 hired before January 1, 2010
Class 12B: All non-union employees of BU675 hired on or after January 1, 2010
Class 13A: All non-union employees of BU687 hired before January 1, 2010
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 5 of 71
Form GLP-SCH-1 (continued) Schedule of Benefits
Class 13B: All non-union employees of BU687 hired on or after January 1, 2010

Class 14: Retired Non-Union Employees of the United Resource Companies, United Water M&S,
United Water New Jersey, United Water Rahway, United Water New York, United
Water Jersey City, United Properties Group, United Water Mid-Atlantic & UW New Rochelle.
Class 15: Retired Union & Non-Union Employees of the United Water Works Companies, United
Water Pennsylvania, United Water Arkansas, United Water Delaware, United Water
Toms River, United Water Owego, United Water Florida, United Water Connecticut,
United Water Idaho and United Water Rhode Island.

Class 16: Retired Union Employees at United Water New Jersey.
Class 17: Retired Union Employees at United Water New York.
Class 18: Retired Union Employees at United Water New Rochelle.
Class 19: Retired Union Employees of United Water Bloomsburg.
Note: This policy does not cover the following Employees. Temporary and seasonal Employees;
Employees who are not legal residents working in the United States.

Eligibility Waiting Period:
1. If the Covered Person is employed by the Sponsor on the policy effective date - None

2. If the Covered Person begins employment for the Sponsor after the policy effective date -
None

Employee Contributions Required:

Active Employees:

Employee Basic Life Insurance Benefits: No
Employee Optional Life Insurance Benefits: Yes Employee Basic Accidental Death and Dismemberment Insurance Benefits: No Dependent Optional Life Insurance Benefits: Yes

Retired Employees:

Basic Life Insurance Benefits: No
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 6 of 71
SA3-830-509893-01 R (15) Effective January 1, 2020

LIFE INSURANCE
Amount of Insurance:
SECTION 1 - SCHEDULE OF BENEFITS
(Continued)

Employee Basic Life Insurance:

Applicable to Class 1, 12A, 13A:
An amount equal to 3 times Annual Earnings. If not a multiple of $1,000.00, this amount will be rounded to the next higher multiple of $1,000.00. This amount may not exceed $900,000.00.

Applicable to Class 2, 6, 7, 8, 9, 12B, 13B: An amount equal to 1 times Annual Earnings. If not a multiple of $1,000.00, this amount will be
rounded to the next higher multiple of $1,000.00. This amount may not exceed $300,000.00.

Applicable to Class 3:
Less than 10 years of Actvie Employment: $20,000.00
10 years or more of Active Employment: $37,000.00
Applicable to Class 4: Employees hired prior to 4/11/2011: An amount equal to 3 times Annual Earnings. If not a multiple of $1,000.00, this amount will be rounded to the next higher multiple of $1,000.00. This
amount may not exceed $900,000.00
Employees hired on or after 4/11/2011: An amount equal to 1 times Annual Earnings. If not a multiple of $1,000.00, this amount will be rounded to the next higher multiple of $1,000.00. This
amount may not exceed $300,000.00

Applicable to Class 5:
Less than 5 years of Active Employment: $150,000.00
5 years or more of Active employment: $200,000.00
Applicable to Class 10:
$30,000.00

Applicable to Class 11:
$4,000.00
Applicable to Class 14:
The amount of file with the Sponsor and with Liberty, not to exceed $50,000.00.

Applicable to Class 15:
If retired prior to age 65 - 50.00% of the pre-retirement non-contributory benefit. At age 65, the
benefit is $5,000.00.

Applicable to Class 16:

Form GLP-SCH-2.8 Schedule of Benefits
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 7 of 71
Form GLP-SCH-2.8 (continued) Schedule of Benefits
SA3-830-509893-01 R (15) Effective January 1, 2020

If retired prior to March 1, 2006 - The lesser of the amount on file with Liberty and the Sponsor or
$30,000.00.

If retired on or after March 1, 2006, but before March 1, 2012 - $40,000.00.
If retired on or after March 1, 2012 - $50,000.00.
Applicable to Class 17:
If retired prior to August 31, 2003 with less than 20 years of service - The lesser of $15,500.00 or the amount as on file with Liberty and the Sponsor.

If retired prior to August 31, 2003 with 20 or more years of service - The lesser of $16,500.00 or the
amount as on file with Liberty and the Sponsor.
If retired between September 1, 2003 and November 30, 2009 - The lesser of $20,000.00 or the
amount as on file with Liberty and the Sponsor.
If retired on December 1, 2009 or later - $25,000.00.

Applicable to Class 18: $20,000.00
Applicable to Class 19:
$10,000.00
Employee Optional Life Insurance:
Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B: An amount equal to 1, 2, 3, 4, or 5 times Annual Earnings. If not a multiple of $1,000.00, this amount will be rounded to the next higher multiple of $1,000.00. This amount may not exceed
$500,000.00.
The overall combined Employee Life maximum is $1,100,000.00

Dependent Optional Life Insurance:

Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:
There are three Dependent Life options available: Spouse only, Spouse and Children, Children only.
SPOUSE
Spouse or Domestic Partner:

Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:
An amount in increments of $10,000.00. This amount may not exceed $100,000.00. The minimum
amount is $10,000.00.

CHILD Children (Age at Death):

15 days, but under 26 years.

Applicable Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:
An amount in increments of $5,000.00. This amount may not exceed $25,000.00.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 8 of 71
Form GLP-SCH-2.8 (continued) Schedule of Benefits
SA3-830-509893-01 R (15) Effective January 1, 2020

Note: The amount of Dependent Life Insurance may not exceed 100.00% of the amount of Employee
Life Insurance in force on the Covered Employee.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 9 of 71
SECTION 1 - SCHEDULE OF BENEFITS
(Continued)
Form GLP-SCH-3.5 Schedule of Benefits
SA3-830-509893-01 R (2) Effective January 1, 2020

ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Full Amount of Insurance:

Employee Basic Accidental Death and Dismemberment Insurance:

Applicable to Class 7, 8, 9, 13A, 13B:
An amount equal to 2 times Annual Earnings. If not a multiple of $1,000.00, this amount will be
rounded to the next higher multiple of $1,000.00. This amount may not exceed $500,000.00.

Applicable to Class 10, 11: An amount equal to 1 times Annual Earnings. If not a multiple of $1,000.00, this amount will be
rounded to the next higher multiple of $1,000.00. This amount may not exceed $300,000.00.

Applicable to Class 12A, 12B: An amount equal to 1 times Annual Earnings. If not a multiple of $1,000.00, this amount will be rounded to the next higher multiple of $1,000.00. This amount may not exceed $500,000.00.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 10 of 71
SECTION 1 - SCHEDULE OF BENEFITS
(Continued)
SA3-830-509893-01 R (5) Effective January 1, 2020

ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Employee Seat Belt Benefit:

Maximum Benefit Amount: 10.00% of Full Amount up to $25,000.00

Employee Air Bag Benefit:

Maximum Benefit Amount: 10.00% of Full Amount up to $10,000.00

Employee Common Carrier Benefit:

Maximum Benefit Amount: Full Amount up to $150,000.00

Employee Child Education Benefit:

Maximum Annual Benefit (Per Dependent child): $2,500.00
Maximum Lifetime Family Benefit Amount: $50,000.00

Dependent Children Maximum Age: 26 years
Employee Child Care Benefit:

Maximum Annual Benefit (Per Dependent child): $2,500.00
Maximum Lifetime Family Benefit Amount: $50,000.00

Dependent spouse or Civil Union Partner or Domestic Partner Training Benefit:

Maximum Benefit Amount: $5,000.00

Employee Coma Benefit:

Maximum Benefit Amount: 10.00% of Full Amount up to $25,000.00

Employee Critical Burn Benefit:

Maximum Benefit Amount: 10.00% of Full Amount up to $25,000.00

Employee Adaptive Home or Adaptive Vehicle Benefit:

Maximum Benefit Amount: 10.00% of Full Amount up to $25,000.00

Reduction Formula:
Applicable to Basic Insurance:
Applicable to Class 1, 3, 4, 12A, 13A:

Form GLP-SCH-4.21 Schedule of Benefits
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 11 of 71
Form GLP-SCH-4.21 (continued) Schedule of Benefits
SA3-830-509893-01 R (5) Effective January 1, 2020

The amount of Life and Accidental Death and Dismemberment Insurance applicable to the Covered Person's class of benefits will reduce at age 65 or older as follows:

Age if hired prior to January 1, 2001: Percentage:
age 65 & up: to 65.00%
Age if hire on or after January 1, 2001: Percentage: age 65 - 74: to 65.00% age 75 & up: to 45.00%
Applicable to Class 2, 7, 8, 9, 10, 11, 12B, 13B:
The amount of Life and Accidental Death and Dismemberment Insurance applicable to the Covered
Person's class of benefits will reduce at age 65 or older as follows:

age 65 - 74: to 65.00%
age 75 & up: to 45.00%
Applicable to Class 5:
The amount of Life and Accidental Death and Dismemberment Insurance applicable to the Covered Person's class of benefits will reduce at age 65 or older as follows:

Age if hired prior to January 1, 2001: Percentage: age 65 & up: to 65.00%
Age if hired on or after January 1, 2001: Percentage:
age 65 - 74: to 65.00%
age 75 & up: to 45.00%
Applicable to Class 6:
The amount of Life and Accidental Death and Dismemberment Insurance applicable to the Covered Person's class of benefits will reduce at age 65 or older as follows:

Age if hired prior to January 1, 2001: Percentage:
age 65 & up: to 65.00% Age if hired on or after January 1, 2001: Percentage age 65 - 74: to 65.00% age 75 & up: to 45.00%
Applicable to Class 15:
The amount of Life and Accidental Death and Dismemberment Insurance applicable to the Covered
Person's class of benefits will reduce at age 65 or older as follows:

age 65 & up: to $5,000.00
Applicable to Optional Insurance excluding Dependent Optional Life:
The amount of Life Insurance applicable to the Covered Person's class of benefits will reduce at age 65
or older as follows:
Age if hired prior to January 1, 2001: Percentage: at age 65 & up to 65.00% Age if hired on or after January 1, 2001: Percentage:
at age 65 to 74 65.00%
at age 75 & up to 45.00%
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 12 of 71
Form GLP-SCH-4.21 (continued) Schedule of Benefits
SA3-830-509893-01 R (5) Effective January 1, 2020

Applicable to Dependent Optional Life Insurance:
Coverage terminates at age 70.
Note: Reductions occur 1/1 of the following calendar year
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 13 of 71
SA3-830-509893-01 R (3) Effective January 1, 2020

SECTION 1 - SCHEDULE OF BENEFITS
(Continued)
Evidence of Insurability Requirements
Non-Medical Maximum:
Employee Optional Life Insurance Benefits: $500,000.00
Dependent Spouse or Domestic Partner
Any amounts of insurance in excess of the amount shown above that are due solely to salary increases are not subject to Evidence of Insurability.

Annual Enrollment:
Employee Optional
Life Insurance Benefits:

Any increases above the current
benefit level will be subject to
Evidence of Insurability.

Any increases elected during Annual Enrollment will be subject to Evidence of Insurability if an Employee has previously been denied coverage. The Non-Medical Maximum will apply to any changes made during the Annual Enrollment Period.

Dependent Spouse or Domestic Partner Optional Life Insurance: Any increases above the current benefit level will be subject to Evidence of Insurability.

Family Status Change:
Employee Optional Life Insurance Benefits:

Any increases above the current
benefit level will be subject to
Evidence of Insurability.

Any increases elected due to a Family Status Change will be subject to Evidence of Insurability if an Employee has previously been denied coverage. The Non-Medical Maximum will apply to any changes made due to a Family Status Change.

Dependent Spouse or Domestic Partner
Optional Life Insurance:
Any increases above the current
benefit level will be subject to Evidence of Insurability.

Form GLP-SCH-5 Schedule of Benefits
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 14 of 71
SECTION 2 - DEFINITIONS
SA3-830-509893-01 R (3) Effective January 1, 2020

In this section Lincoln defines some basic terms needed to understand this policy. The male pronoun whenever used in this policy includes the female.

"Active Employment" means the Employee must be actively at work for the Sponsor:

1. on a full-time basis and paid regular earnings;
2. for at least the minimum number of hours shown in the Schedule of Benefits; and either perform
such work:

a. at the Sponsor's usual place of business; or
b. at a location to which the Sponsor's business requires the Employee to travel.
An Employee will be considered actively at work if he was actually at work on the day immediately
preceding:

1. a weekend (except where one or both of these days are scheduled work days);
2. holidays (except when the holiday is a scheduled work day); 3. paid vacations; 4. any non-scheduled work day;
5. an excused leave of absence (except medical leave for the Covered Person's own disabling condition and lay-off); and 6. an emergency leave of absence (except emergency medical leave for the Covered Person's own disabling condition).

"Administrative Office" means Lincoln Life Assurance Company of Boston, 100 Liberty Way, Suite 100,
Dover, New Hampshire 03820-4695.

Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:

"Annual Earnings" means the Covered Person's annual rate of earnings from the Sponsor. However,
such earnings will not include bonuses, commissions, overtime pay and extra compensation.

"Annual Enrollment Period" or "Enrollment Period" means the period before each policy anniversary
so designated by the Sponsor and Lincoln during which an Employee may enroll for coverage under this
policy.

Form GLP-DEF-1 Definitions
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 15 of 71
SECTION 2 - DEFINITIONS
(Continued)
Form GLP-DEF-2.5 Definitions

"Application" is the document designated in Section 9; it is attached to and is made a part of this policy.

“ Civil Union Partner” means an unmarried person of the legally recognized union of two eligible
individuals of the same sex established pursuant to the New Jersey Chapter 103 Act.

"Confined" means confinement in a hospital, skilled nursing facility or rehabilitation facility.

"Covered Dependent" means a Dependent whose coverage is in effect. It does not include a Dependent
whose coverage has ended.

"Covered Employee" means a person in Active Employment insured under this policy or a Retired
Employee whose coverage is in effect. It does not include an employee whose coverage has ended.

"Covered Person" means an Employee in Active Employment, a Dependent, or a Retired Employee
insured under this policy.

"Dependent" means:

1. a Covered Employee's lawful spouse, including a legally separated spouse or Civil Union
Partner or Domestic Partner; and
2. a Covered Employee's unmarried children, who meet the age requirements shown in the Schedule of Benefits.

Children include the Covered Employee's own natural offspring, lawfully adopted children, and
full-time students as defined by the school being attended. A child will be considered adopted on the
date of placement in the Covered Employee's home.
They also include stepchildren who are dependent on the Covered Employee for support and
maintenance and living with the Covered Employee in a regular parent-child relationship.
They also include children who, on and after the date on which insurance would otherwise end because of the children's age, are Continuously Disabled.

With respect to this provision, "Continuously Disabled" means a child who is incapable of self-sustaining employment because of mental or physical disabilities and is chiefly dependent on the Covered Employee for support and maintenance, or institutionalized because of mental or physical
disabilities.

Dependent does not include a person who is an eligible Employee or a member of the armed forces.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 16 of 71
SECTION 2 - DEFINITIONS
(Continued)
Form GLP-DEF-3.5 Definitions

"Domestic Partner" means an unmarried person of the same sex, or opposite sex over the age of 62 with whom the Covered Employee shares a committed relationship, is jointly responsible for the other's welfare and financial obligations, at least 18 years of age and mentally competent to consent to a contract, not related by blood to a degree that could prohibit legal marriage in the state where legally
residing, maintains the same residence(s) and is not married to or legally separated from anyone else. A
Domestic Partner certification must be completed and filed with the Sponsor before the partner can be designated as a Dependent.
A domestic partnership can only be established when neither person has been a partner in a domestic
partnership that was terminated less than 180 days prior to the filing of the current certification of
domestic partnership. This prohibition does not apply if one of the partners died.

"Eligibility Date" means the date an Employee becomes eligible for insurance under this policy.
Eligibility Requirements are shown in the Schedule of Benefits.

"Eligibility Waiting Period" means the continuous length of time an Employee must be in Active
Employment in an eligible class to reach his Eligibility Date.

"Employee" means a person in Active Employment with the Sponsor.

"Enrollment Form" is the document completed by the Covered Employee, if required, when enrolling
for coverage. This form must be satisfactory to Lincoln.

"Evidence of Insurability" means a statement of proof of the Covered Person's medical history upon
which acceptance for insurance will be determined by Lincoln.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 17 of 71
SECTION 2 - DEFINITIONS
(Continued)
Form GLP-DEF-4.5 Definitions

"Family and Medical Leave" means a leave of absence for the birth, adoption or foster care of a child, or for the care of the Covered Employee's child, spouse or parent or for the Covered Employee's own serious health condition as those terms are defined by the Federal Family and Medical Leave Act of 1993 (FMLA) and any amendments, or by applicable state law.

Applicable to Optional Insurance:

"Family Status Change" means any one of the following events that may occur:

1. the Employee's marriage or divorce;
2. the Employee’s filing or rescinding of a Civil Union Partner or Domestic Partner certification;
3. the birth of a child to the Employee;
4. the adoption of a child by the Employee; 5. the death of the Employee's spouse or Civil Union Partner or Domestic Partner or child; 6. the commencement or termination of employment of the Employee's spouse or Civil Union
Partner or Domestic Partner;
7. the change from part-time employment to full-time employment by the Employee or the Employee's spouse or Domestic Partner; 8. the change from full-time employment to part-time employment by the Employee or the
Employee's spouse or Civil Union Partner or Domestic Partner;
9. the taking of unpaid leave of absence by the Employee or the Employee's spouse or Civil Union Partner or Domestic Partner.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 18 of 71
SECTION 2 - DEFINITIONS
(Continued)
Form GLP-DEF-5 Definitions

"Initial Enrollment Period" means one of the following periods during which an Employee may first
enroll for coverage under this policy:
1. if the Employee is eligible for insurance on the policy effective date, a period before the policy effective date set by the Sponsor and Lincoln.

2. if the Employee becomes eligible for insurance after the policy effective date, the period which
ends 31 days after his Eligibility Date.

"Injury" means bodily impairment resulting directly from an accident and independently of all other
causes.
"Non-Medical Maximum" means an amount of insurance on a Covered Person which is not subject to
Evidence of Insurability. The Non-Medical Maximum amounts are shown in the Schedule of Benefits.
Any amounts of insurance in excess of the Non-Medical Maximums are subject to Evidence of Insurability. Evidence of Insurability will be at the Covered Employee's expense.

"Physician" means a person who:

1. is licensed to practice medicine and is practicing within the terms of his license; or

2. is a licensed practitioner of the healing arts in a category specifically favored under the health insurance laws of the state where the treatment is received and is practicing within the terms of his license.

It does not include a Covered Person, any family member or domestic partner.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 19 of 71
SECTION 2 - DEFINITIONS
(Continued)
Form GLP-DEF-6 Definitions

"Proof" means the evidence in support of a claim for benefits and includes, but is not limited to, the
following:
1. a claim form completed and signed (or otherwise formally submitted) by the Covered Employee or his beneficiary claiming benefits;

2. an attending Physician's statement completed and signed (or otherwise formally submitted) by
the Covered Person's attending Physician; and
3. the provision by the attending Physician of standard diagnosis, chart notes, lab findings, test results, x-rays and/or other forms of objective medical evidence in support of a claim for
benefits;

4. a certified copy of a death certificate.

Proof must be submitted in a form or format satisfactory to Lincoln.

"Retired Employee" means a person is so classified by the Sponsor.

"Schedule of Benefits" means the section of this policy which shows, among other things, the Eligibility
Requirements, Eligibility Waiting Period, and Amount of Insurance Benefit.
"Sickness" means disease or illness including related conditions and recurrent symptoms of the sickness. Sickness also includes pregnancy.

"Sponsor" means the entity to whom this policy is issued.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 20 of 71
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
Form GLP-ELG-1 Eligibility and Effective Dates
SA3-830-509893-01 R (3) Effective January 1, 2020

Eligibility Requirements for Employee and Dependent Insurance Benefits

The eligibility requirements for insurance benefits are shown in the Schedule of Benefits.

Eligibility Date for Insurance Benefits
Employee Coverage:
If the Employee is in an eligible class he will qualify for insurance on the later of:

1. this policy's effective date; or

2. the day after he completes the Eligibility Waiting Period shown in the Schedule of Benefits.

Dependent Coverage:
If the Employee is eligible for Employee coverage he will be eligible for Dependent coverage on the later
of:

1. the date he is eligible for Employee coverage if on that date he has a Dependent; or

2. the date he acquires a Dependent if on that date he is eligible for Employee coverage.

If both parents are Employees, only one will be eligible for Dependent coverage with respect to their Dependent children.
Applicable to Employee Optional Life Insurance Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B,
Dependent Optional Life Insurance Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:
Annual Enrollment Period
During each Annual Enrollment Period, an Employee may keep his coverage at the same level or make any one of the following changes in coverage for the next policy year, subject to any Evidence of Insurability Requirements as shown in the Schedule of Benefits:
1. decrease his coverage;

2. increase his coverage including enrolling for the first time.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 21 of 71
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
SA3-830-509893-01 R (3) Effective January 1, 2020

(Continued)

Applicable to Optional Employee Life Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B, Optional
Dependent Life Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:

Family Status Change
When a Covered Employee experiences a Family Status Change, a Covered Employee may keep his coverage at the same level or make any one of the following changes in coverage, subject to any
Evidence of Insurability Requirements as shown in the Schedule of Benefits:

1. decrease his coverage;

2. increase his coverage including enrolling for the first time.

Applicable to Optional Employee Life Insurance:

The Covered Employee must apply for the change in coverage within 31 days of the date of the Family Status Change. Such changes in coverage must be due to or consistent with the reason that the change in coverage was permitted. A change in coverage is consistent with a Family Status Change only if it is necessary or appropriate as the result of the Family Status Change.

Applicable to Optional Dependent Life Insurance:
The Covered Employee must apply for the change in coverage within 31 days of the date of the Family Status Change. Such changes in coverage must be due to or consistent with the reason that the change in coverage was permitted. A change in coverage is consistent with a Family Status Change only if it is
necessary or appropriate as the result of the Family Status Change.

Effective Date for Insurance Benefits

Insurance will be effective at 12:01 A.M. Standard Time in the governing jurisdiction on the day
determined as follows, but only if the Employee's application or enrollment for insurance is made with
Lincoln through the Sponsor in a form or format satisfactory to Lincoln.

Employee Coverage:

1. For non-contributory coverage not subject to Evidence of Insurability, the Covered Employee will be insured on his Eligibility Date.
2. For non-contributory coverage subject to Evidence of Insurability, the Covered Employee will be
insured on the later of the date Lincoln gives approval or his Eligibility Date.

3. For contributory coverage not subject to Evidence of Insurability, the Covered Employee will be
insured on the later of the date he makes application or his Eligibility Date, provided he makes application no later than 31 days after his Eligibility Date.
4. For contributory coverage subject to Evidence of Insurability, the Covered Employee will be
insured on the later of the date Lincoln gives approval or his Eligibility Date, provided he makes
application no later than 31 days after his Eligibility Date.

Form GLP-ELG-2 Eligibility and Effective Dates
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 22 of 71
SA3-830-509893-01 R (3) Effective January 1, 2020

5. If a Covered Employee makes application for contributory coverage more than 31 days after his Eligibility Date, he must submit Evidence of Insurability. He will be insured on the date Lincoln
gives approval.

Evidence of Insurability will be at the Covered Employee's Expense.

Form GLP-ELG-2 (continued) Eligibility and Effective Dates
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 23 of 71
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)

Effective Date for Insurance Benefits (Continued)

Dependent Coverage:

1. For contributory coverage not subject to Evidence of Insurability, the Covered Employee's
Dependent will be insured on the later of the date the Covered Employee makes application or his Eligibility Date, provided he makes application no later than 31 days after his Eligibility Date.

2. For contributory coverage subject to Evidence of Insurability, the Covered Employee's
Dependent will be insured on the later of the date Lincoln gives approval or his Eligibility Date, provided he makes application no later than 31 days after his Eligibility Date.
3. If a Covered Employee makes application for contributory coverage more than 31 days after his
Eligibility Date, he must submit Evidence of Insurability. The Covered Employee's Dependent
will be insured on the date Lincoln gives approval.
Evidence of Insurability will be at the Covered Employee's Expense.

Increases or Decreases:

Any increase in or addition to coverage will take effect on the first of the month following the change.
Any decrease in or deletion of coverage will take effect on the first of the month following the change.
Any such change applies to loss of life or accidental Injury that occurs on or after the effective date of
the change.

Delayed Effective Date for Employee Insurance
The effective date of any initial, increased or additional insurance will be delayed for an individual if he
is not in Active Employment because of Injury or Sickness. The initial, increased or additional insurance
will begin on the date the individual returns to Active Employment.

Delayed Effective Date for Dependent and Retired Employee Insurance

If a Covered Dependent or Retired Employee is Confined on the date the increase or addition is to take
effect, it will take effect when the confinement ends.

Form GLP-ELG-3 Eligibility and Effective Dates
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 24 of 71
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
SA3-830-509893-01 R (5) Effective January 1, 2020

Family and Medical Leave

A Covered Employee's coverage may be continued under this policy for an approved family or medical leave of absence for up to 12 weeks following the date coverage would have terminated, subject to the following:

1. the authorized leave is in writing;

2. the required premium is paid;
3. the Covered Employee's benefit level, or the amount of earnings upon which the Covered Employee's benefit may be based, will be that in effect on the date before said leave begins; and

4. continuation of coverage will cease immediately if any one of the following events should occur:

a. the Covered Employee returns to work;
b. this policy terminates; c. the Covered Employee is no longer in an eligible class; d. nonpayment of premium when due by the Sponsor;
e. the Covered Employee's employment terminates.

Lay-off

Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:
The Sponsor may continue the Covered Employee's coverage(s) by paying the required premiums, if the Covered Employee's is temporarily laid off.

The Covered Employee's coverage(s) will not continue beyond the end of the month in which the lay-off
begins. In continuing such coverage(s) under this provision, the Sponsor agrees to treat all Covered Employees equally.

Leave of Absence

Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:
The Sponsor may continue the Covered Employee's coverage(s) by paying the required premiums, if the Covered Person is granted an approved leave of absence.

The Covered Employee's coverage(s) will not continue beyond the end of the month in which the leave
of absence begins. In continuing such coverage(s) under this provision, the Sponsor agrees to treat all
Covered Employees equally.

Form GLP-ELG-4.4 (NJ) Eligibility and Effective Dates
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 25 of 71
SA3-830-509893-01 R (5) Effective January 1, 2020

Leave of Absence Due to Disability

Applicable to Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B:

The Sponsor may continue the Covered Employee's coverage(s) by paying the required premiums, if the Covered Employee is granted an approved leave of absence due to a disability.
The Covered Employee's coverage(s) will not continue beyond a period of twelve months. In continuing
such coverage(s) under this provision, the Sponsor agrees to treat all Covered Employees equally.

Form GLP-ELG-4.4 (NJ) (continued) Eligibility and Effective Dates
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 26 of 71
SECTION 4 - INSURANCE BENEFITS

EMPLOYEE LIFE INSURANCE

Benefits
When Lincoln receives satisfactory Proof of the Covered Employee's death, Lincoln will pay the proceeds of the Life Insurance in force on the Covered Employee's life under this policy. The benefit
payable is shown in the Schedule of Benefits.

Conversion Privilege

Conversion Privilege at Individual Termination or Reduction of Benefits:

If all or part of a Covered Employee's coverage ends, the Covered Employee may convert the amount that ends to an individual Life Insurance policy. Conversion is subject to the following conditions:

1. within 31 days after coverage ends or is reduced, the Covered Employee must make written
application to Lincoln and pay the first premium payment.

2. the individual policy will be issued without Evidence of Insurability. It will contain Life Insurance benefits only. The policy will be one then being offered by Lincoln. The premium due will be based on the premium schedule of Lincoln's conversion policy that applies to the
Covered Employee's class of risk and age at the birthday nearest to the effective date of the
individual policy.

The individual policy will be effective 31 days after the Covered Employee's group coverage ends.

Conversion Privilege at Class or Policy Termination:

If coverage ends for all employees or for a Covered Employee's class, the Covered Employee is entitled to a limited conversion privilege. The Covered Employee must have been covered under this policy or under a prior group life policy with the Sponsor for at least 5 years. The Covered Employee must apply
for the individual policy in the same manner as described above. The amount the Covered Employee
may convert is limited to the lesser of:
1. the amount the Covered Employee was covered for on the date the group coverage terminated less any group insurance he becomes eligible for within 31 days; or

2. $10,000.

The individual policy will be effective 31 days after the Covered Employee's group coverage ends.

Death Within the 31 Days Allowed for Conversion:

If a Covered Employee dies within the 31 days allowed for conversion, Lincoln will pay to his
beneficiary the amount he was eligible to convert. Such insurance will be paid as a claim under this policy. Any premiums paid for a conversion policy will be refunded.

Form GLP-LIF-1.18 (NJ) Employee Life Insurance
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 27 of 71
SECTION 4 - INSURANCE BENEFITS
SA3-830-509893-01 R (5) Effective January 1, 2020

(Continued)

Applicable to Basic Insurance Class 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12A, 12B, 13A, 13B, Optional
Insurance:

EMPLOYEE LIFE INSURANCE COVERAGE (Continued)

Accelerated Death Benefit

Note: The receipt of an Accelerated Death Benefit may be taxable. A Covered Employee should
consult his tax consultant or legal advisor before applying for an Accelerated Death Benefit.

If, while insured under this policy, a Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner gives Lincoln satisfactory Proof of having a Terminal Condition, the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner may
receive a portion of his Life Insurance as an Accelerated Death Benefit. Such insurance will be paid one
time to the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner in one lump sum.

The amount of Accelerated Death Benefit payable under this policy is limited to the lesser of the
following:

1. the Accelerated Death Benefit amount requested by the Covered Employee;

2. 80.00% of the Covered Employee's Life Insurance that is in force on the date the Covered
Employee applies for an Accelerated Death Benefit; or

3. $500,000.00.
The amount of Accelerated Death Benefit payable to the Covered Dependent spouse or Civil Union Partner or Domestic Partner under this policy is limited to the lesser of the following:

1. the Accelerated Death Benefit amount requested by the Covered Dependent spouse or Civil
Union Partner or Domestic Partner;
2. 80.00% of the Covered Dependent spouse's or Civil Union Partner's or Domestic Partner's Life
Insurance that is in force on the date the Covered Dependent spouse or Civil Union Partner or
Domestic Partner applies for an Accelerated Death Benefit; or

3. $80,000.00.

If the amount of a Covered Employee's or Covered Dependent spouse's or Civil Union Partner's or
Domestic Partner's Life Insurance under this policy is scheduled to reduce within 12 months following
the date the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner applies for the Accelerated Death Benefit, the benefit payable under this policy will be based on the reduced amount.

Application for an Accelerated Death Benefit

Form GLP-LIF-2.13 Employee Life Insurance
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 28 of 71
SA3-830-509893-01 R (5) Effective January 1, 2020

A Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner must apply for an Accelerated Death Benefit. To apply, the Covered Employee or Covered Dependent spouse
or Civil Union Partner or Domestic Partner must give Lincoln:
1. certification, from a Physician, that he has a Terminal Condition, as defined by this policy; 2. supporting evidence satisfactory to Lincoln, documenting the Terminal Condition; 3. a completed claims form.

Form GLP-LIF-2.13 (continued) Employee Life Insurance
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 29 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
Form GLP-LIF-3.11 Employee Life Insurance

EMPLOYEE LIFE INSURANCE COVERAGE (Continued)

Accelerated Death Benefit (Continued)

Application for an Accelerated Death Benefit (Continued)

During the pendency of a claim, Lincoln may, at its own expense, have a Physician examine the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner.
If the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner has
assigned all or a portion of the Life Insurance under this policy or named an irrevocable beneficiary, the
Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner must also give Lincoln a signed written consent form from the assignee or irrevocable beneficiary. If the Covered Employee dies before all payments of the Accelerated Death Benefit are paid, the election will be cancelled and the death benefit will be paid pursuant to this policy.

The Accelerated Death Benefit will be payable upon receipt of satisfactory Proof of a Terminal Condition; and signed written consent from an assignee or irrevocable beneficiary, if required.

With respect to this provision "Terminal Condition" means a condition:
1. which is expected to result in the Covered Employee's or Covered Dependent spouse's or Civil Union Partner's or Domestic Partner's death within 12 months; and
2. from which there is no reasonable prospect of recovery.

Effect on Insurance
The amount of a Covered Employee's or Covered Dependent spouse's or Civil Union Partner's or
Domestic Partner's Life Insurance will be reduced by the amount paid as an Accelerated Death Benefit.
Premiums, if any, for the remaining portion of a Covered Employee's or Covered Dependent spouse's or Civil Union Partner's or Domestic Partner's Life Insurance will be based on the amount of the remaining Life Insurance in effect after payment of the Accelerated Death Benefit. All other terms and provisions of this policy will apply to the remaining portion. Receipt of an Accelerated Death Benefit does not
affect any Accidental Death or Dismemberment insurance benefit in force on a Covered Employee's or
Covered Dependent spouse's or Civil Union Partner's or Domestic Partner's life.

Exceptions

No Accelerated Death Benefit will be paid if:
1. the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner is required by a court of law to exercise this option to satisfy a claim of creditors, whether in bankruptcy or otherwise; 2. the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic
Partner is required by a governmental agency to exercise this option in order to apply for,
receive, or continue a government benefit or entitlement; 3. all or a part of a Covered Employee's insurance must be paid to the Covered Employee's children or spouse or former spouse as part of a divorce decree, separate maintenance
agreement or property settlement agreement;
4. the Covered Employee is married and lives in a community property state, unless the Covered
Employee's spouse has given Lincoln signed written consent; or 5. the Covered Employee or Covered Dependent spouse or Civil Union Partner or Domestic Partner has previously received an Accelerated Death Benefit under this policy.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 30 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
Form GLP-DEP-1.21 Dependent Life Insurance

DEPENDENT LIFE INSURANCE

Benefits

When Lincoln receives satisfactory Proof of the Covered Dependent's death, Lincoln will pay to the Covered Employee the amount in force on such Covered Dependent's life under this policy. The Dependent Life Insurance benefit will be paid in one sum. It is shown in the Schedule of Benefits.
Conversion Privilege

Conversion Privilege at Individual Termination or Reduction of Benefits:

If a Covered Dependent's coverage ends because:

1. of the Covered Employee's death; or
2. the Covered Employee's employment in an eligible class for Dependent Life Insurance ends,
the Covered Employee's Covered Dependent spouse or Civil Union Partner or Domestic Partner may
convert Dependent Life Insurance to an individual policy. Within 31 days after coverage ends, the
Covered Dependent spouse or Civil Union Partner or Domestic Partner must make written application
to Lincoln and pay the first premium payment. The individual policy will contain Life Insurance benefits only. The policy will be one then being offered by Lincoln. Evidence of Insurability will not be required.

Conversion Privilege at Class or Policy Termination:

If a Covered Dependent's coverage ends because:

1. coverage ends for all employees; or
2. coverage ends for all employees in the Covered Employee's eligible class,
the Covered Dependent spouse or Civil Union Partner or Domestic Partner is entitled to a limited conversion privilege. The Covered Employee must be entitled to convert to an individual policy in order for his Covered Dependent spouse or Civil Union Partner or Domestic Partner to have this limited
privilege. Conversion must be applied for in the same way as stated above. The amount the Covered
Dependent spouse or Civil Union Partner or Domestic Partner may convert is limited to the lesser of:
1. the amount the Covered Dependent spouse or Civil Union Partner or Domestic Partner was covered for on the date coverage ended less any group insurance he becomes eligible for within
31 days; or
2. $10,000.
The individual policy will become effective 31 days after the Covered Dependent spouse's or Civil Union Partner's or Domestic Partner coverage ends.
Death Within the 31 Days Allowed for Conversion:
Dependent Life Insurance is payable if a Covered Dependent spouse or Civil Union Partner or Domestic Partner dies during this period. The amount payable is the amount the Covered Dependent spouse or
Civil Union Partner or Domestic Partner was entitled to convert. Such insurance will be paid under this
policy. Any premium paid for an individual policy will be refunded. SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 31 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
Form GLP-ADD-1 Accidental Death and Dismemberment Insurance

EMPLOYEE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Benefits
Accidental Death and Dismemberment benefits are payable when a Covered Employee suffers a loss
solely as the result of accidental Injury that occurs while covered. The loss must occur within 365 days
after the date of the accident. The benefit payable is called the Full Amount. It is shown in the Schedule of Benefits.

Loss Schedule: Benefit Payable:

Life Full Amount
Both Hands or Both Feet Full Amount Sight of Both Eyes Full Amount One Hand and One Foot Full Amount
One Hand and Sight of One Eye Full Amount One Foot and Sight of One Eye Full Amount Speech and Hearing in Both Ears Full Amount One Hand or One Foot One-half Full Amount
Sight of One Eye One-half Full Amount Speech or Hearing in Both Ears One-half Full Amount Thumb and Index Finger of the Same Hand One-quarter Full Amount

Payment is made for loss due to each accident without regard to loss resulting from any prior accident.
In no event may the total amount payable for all losses due to any one accident exceed the Full Amount.

Loss of hands or feet means complete severance through or above the wrist or ankle joint.
Loss of sight, speech or hearing must be total and irrecoverable.
Loss of thumb and index finger means that all of the thumb and index finger are cut off at or above the
joint closest to the wrist. This benefit is not payable if a benefit is payable for the loss of the same entire
hand.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 32 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
Form GLP-ADD-2.2 Additional Accidental Death and Dismemberment Insurance

ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Benefits

Seat Belt Benefit

Lincoln will pay an additional benefit if accidental death was caused by an Automobile accident while the Covered Person was driving or riding in an Automobile and the Covered Person was covered by this policy. The benefit is payable if the Covered Person was wearing a Seat Belt at the time of the
accident. The benefit payable is shown in the Schedule of Benefits.

Lincoln must be given satisfactory written Proof that the Covered Person's death resulted from an
Automobile accident while wearing a Seat Belt. A copy of the police accident report should be submitted with the claim. If a copy of the police accident report is not available, or if it is unclear that the Covered Person was wearing a Seat Belt, Lincoln will pay 10.00% of the maximum benefit as shown in the Schedule of Benefits.

No benefit will be paid if the Covered Person was the driver of the Automobile and did not hold a
current valid driver's license.

Air Bag Benefit

Lincoln will pay an additional benefit if accidental death was caused by an Automobile accident while the Covered Person was driving or riding in an Automobile and the Covered Person was covered by this policy. The benefit is payable if the Covered Person was wearing a Seat Belt at the time of the accident and was seated behind a properly installed Air Bag. The benefit payable is shown in the
Schedule of Benefits.
Lincoln must be given satisfactory written Proof that the Covered Person's death resulted from an Automobile accident while wearing a Seat Belt and the Automobile was equipped with an Air Bag directly in front of the Covered Person. A copy of the police accident report should be submitted with
the claim.

No benefit will be paid if the Covered Person was the driver of the Automobile and did not hold a current valid driver's license.

With respect to this provision, "Air Bag" means the passive restraint device in an Automobile which inflates automatically upon collision to provide protection in Automobile accidents. The Air Bag must meet the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration and be
installed by the manufacturer or an authorized dealership of the manufacturer.

With respect to this provision, "Automobile" means a private passenger motor vehicle licensed for use on public highways.
With respect to this provision, "Seat Belt" means a combination lap and shoulder restraint system that must meet the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration and be installed by the manufacturer or an authorized dealership of the manufacturer. A Seat Belt will
include a lap belt alone, but only if the Automobile did not have a combination lap and shoulder
restraint system when manufactured. Seat Belt does not include a shoulder restraint alone.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 33 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (Continued)
Benefits (Continued)
Form GLP-ADD-3.2 Additional Accidental Death and Dismemberment Insurance

Common Carrier Benefit

Lincoln will pay an additional benefit to the beneficiary if the Covered Person suffers loss of life as a
result of an accident occurring while riding as a fare-paying Passenger on a public conveyance. The benefit payable is equal to the Full Amount payable under Accidental Death and Dismemberment up to the maximum benefit shown in the Schedule of Benefits.
With respect to this provision, "Common Carrier" means a public conveyance operated by a licensed Common Carrier for the transportation of the general public for a fare and operating on regular
passenger routes, within the contiguous United States, Alaska and Hawaii, with a definite schedule of
departures and arrivals.

With respect to this provision, "Passenger" is defined as an individual other than a pilot, operator or
crew member who is riding in or on, boarding, or dismounting from a public conveyance.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 34 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (Continued)
Benefits (Continued)
Form GLP-ADD-4.2 Additional Accidental Death and Dismemberment Insurance

Child Education Benefit

Lincoln will pay a one-time benefit to the Covered Person or beneficiary on behalf of the Covered
Person's Dependent children if the Covered Employee suffers loss of life as a result of an accident provided:

1. the Dependent child meets the definition of Dependent under this policy; and

2. satisfactory proof is furnished to Lincoln that the child is a Dependent child; and

3. on the date of the accident the Dependent child was at the 12th grade level and enrolls as a full-time student in an accredited post-secondary institution of higher learning within 365 days of the Covered Person's death; or

4. the Dependent child continues to be enrolled as a full-time student in an accredited post-
secondary institution of higher learning.
The one-time benefit payable is shown in the Schedule of Benefits. A benefit will not be payable beyond the earlier of:

a. 4 years;
b. the attainment of a bachelor's degree; or
c. the attainment of the Dependent maximum age shown in the Schedule of Benefits.

The maximum benefit payable under this provision is shown in the Schedule of Benefits.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 35 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (Continued)
Benefits (Continued)
Form GLP-ADD-5.2 Additional Accidental Death and Dismemberment Insurance

Child Care Benefit

Lincoln will pay a one-time benefit to the Covered Person or beneficiary on behalf of the Covered
Person's Dependent children if the Covered Employee suffers loss of life as a result of an accident provided:

1. the Dependent child meets the definition of Dependent under this policy; and

2. proof is furnished to Lincoln that the child is a Dependent child and is age 7 or under; and

3. the Dependent child is enrolled within 365 days of the Covered Person's death or continues to be enrolled in a legally licensed Child Care Program.
Proof of a Dependent child's enrollment in a Child Care Program may be in the form of, but not limited
to, the following:

1. a copy of the Dependent child's approved enrollment application in a Child Care Program; or
2. a canceled check which proves payment for a Child Care Program; or
3. a letter from the Child Care Program stating the Dependent child is attending a Child Care
Program or has been enrolled in a Child Care Program and will be attending within 365 days of
the date of the Covered Person's death.
The benefit payable is shown in the Schedule of Benefits. The maximum benefit payable under this provision is shown in the Schedule of Benefits.

With respect to this provision, "Child Care Program" means a center of child care which:
1. holds a license as a day care center, or is operated by a licensed day care provider, if required; or 2. if licensing is not required, operates primarily for the care of children on a daily basis for 12
months a year; and
3. is operated in a private home, school or other facility; and
4. customarily charges for the care provided.
A Child Care Program does not include a hospital; the Dependent child’s home or care provided during
normal school hours while a Dependent child is attending grades one through three.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 36 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (Continued)
Benefits (Continued)
Form GLP-ADD-6.2 Additional Accidental Death and Dismemberment Insurance

Spouse Training Benefit

Lincoln will pay a one-time benefit to a surviving Dependent spouse or Civil Union Partner or Domestic
Partner if the Covered Employee suffers loss of life as a result of an accident provided:
1. satisfactory proof is furnished to Lincoln that the Dependent spouse or Civil Union Partner or Domestic Partner meets the definition of Dependent under this policy; and

2. within 365 days after the Covered Employee's death, the surviving Dependent spouse or Civil
Union Partner or Domestic Partner is enrolled and attending an accredited institution or trades program for the purpose of obtaining employment or increasing earnings.

The benefit payable is shown in the Schedule of Benefits.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 37 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (Continued)
Benefits (Continued)
Form GLP-ADD-7.2 Additional Accidental Death and Dismemberment Insurance

Coma Benefit

Subject to all terms, conditions, and limitations of the Policy, Lincoln will pay a Coma Benefit if, as a
result of an accident, the Covered Employee becomes Comatose.

For the Coma benefit to be payable:
1. the Covered Employee must become comatose within a 31 day period from the date of the
accident; and

2. remain Comatose for at least 30 days.

The Coma Benefit payable is:

1. 10.00% of the full Accidental Death and Dismemberment benefit amount up to a maximum of
$25,000.00; and

2. in addition to the Accidental Death and Dismemberment benefit payable under the policy.

The Coma Benefit will be paid to the Covered Person or the designated beneficiary.

For the purposes of this provision, “ Coma” or “ Comatose” means complete and continuous:

1. unconsciousness; and

2. inability to respond to external or internal stimuli.

Lincoln must be given satisfactory written proof of the Covered Employee’s medical condition.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 38 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (Continued)
Benefits (Continued)
Form GLP-ADD-8.2 Additional Accidental Death and Dismemberment Insurance

Critical Burn Benefit

Subject to all terms, conditions, and limitations of the Policy, Lincoln will pay a Critical Burn Benefit if,
as a result of an accident, the Covered Employee suffers a Critical Burn.

For the Critical Burn Benefit to be payable:
1. the Covered Employee must, as a result of an accident that occurred while covered under the
Policy Accidental Death and Dismemberment provision;

2. be Critically Burned and suffer scarring over at least 25% of their body; and

3. require reconstructive surgery.

The Critical Burn Benefit payable is:

1. 10.00% of the full Accidental Death and Dismemberment benefit amount up to a maximum of
$25,000.00; and
2. in addition to the Accidental Death and Dismemberment benefit payable under the terms of the
policy.

With respect to this provision “ Critical Burn” or “ Critically Burned” means a third degree burn
certified by a Physician that occurs while the Covered Employee is covered for this Benefit.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 39 of 71
SECTION 4 - INSURANCE BENEFITS
(Continued)
ADDITIONAL ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE (Continued)
Benefits (Continued)
Form GLP-ADD-13.2 Additional Accidental Death and Dismemberment Insurance

Adaptive Home or Adaptive Vehicle Benefit

Subject to all terms, conditions, and limitations of the Policy, Lincoln will pay, in addition to the
Accidental Death And Dismemberment benefit on the Loss Schedule, a one time benefit for reimbursement of Expense Incurred for either Adaptive Home or Vehicle Modifications if, as the result of an accident, the Covered Employee suffers a loss listed on the Loss Schedule, other than a loss of life.

For the Home Modification Reimbursement Benefit to be payable, the Home Modifications must be:

1. necessary, due to the accident, to make the Covered Employee's home accessible; and
2. performed by a licensed contractor, if such a license is required in the state, who is not the Covered Person, any family member, or domestic partner.

For the Vehicle Modification Reimbursement Benefit to be payable, the Vehicle Modifications must be:

1. necessary, due to the accident, to make the Covered Employee's private automobile accessible for driving or riding by the Covered Employee.
2. performed by a licensed contractor, if such a license is required in the state, who is not the
Covered Person, any family member, or domestic partner.

The Adaptive Home or Vehicle Modification Benefit payable is the lesser of:

1. Expense Incurred; or

2. 10.00% of the full Accidental Death and Dismemberment benefit amount up to a maximum of
$25,000.00.

With respect to this provision, “ Expense Incurred” means the actual cost of the Home or Vehicle
Modifications.

The Home or Vehicle Modifications must be made within the two year period that begins on the date of the Covered Employee's accident.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 40 of 71
SECTION 5 - EXCLUSIONS
Form GLP-LEX-1.4 Life Insurance Exclusions

LIFE INSURANCE EXCLUSIONS

Applicable to Optional Insurance:

No benefits are payable for any loss for death that results from, is contributed to or caused by:
1. suicide, committed while sane or insane, occurring within 24 months after the Covered Person’s
initial effective date of insurance with the Sponsor; and

2. suicide, committed while sane or insane, occurring within 24 months after the date any
additional insurance elected by the Covered Person becomes effective under this Policy.
The suicide exclusion will apply to any amounts of insurance for which the Covered Person pays all or
part of the premium.

The suicide exclusion will also apply to any amount that is subject to Evidence of Insurability Lincoln approved.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 41 of 71
SECTION 5 - EXCLUSIONS
Form GLP-AEX-1.8 Accidental Death and Dismemberment Insurance Exclusions

(Continued)
ACCIDENTAL DEATH AND DISMEMBERMENT EXCLUSIONS

No benefits are payable for any loss that is contributed to or caused by:

1. war, declared or undeclared, or any act of war;

2. intentionally self-inflicted injuries, while sane or insane;

3. suicide, or suicide attempt, while sane or insane;

4. active Participation in a Riot;

5. committing or attempting to commit a felony or the engagement in an illegal occupation;

6. disease, bodily or mental illness (or medical or surgical treatment thereof);

7. infections, except septic infections of and through a visible wound;
8. being under the influence of any narcotic that is voluntarily taken, ingested or injected, unless
administered or consumed on the advice of a Physician

9. serving full-time active duty in the Armed Forces of any country or international authority;
10. boarding, leaving or being in or on any kind of aircraft. However, this exclusion will not apply if the Covered Person is a fare paying passenger on a commercial aircraft or traveling as a passenger in any aircraft that is owned or leased by or on behalf of the Sponsor; or

11. the presence of alcohol in the Covered Person's blood which raises a presumption that the
Covered Person was under the influence of alcohol and contributed to the cause of the accident. The blood alcohol level is governed by the jurisdiction of the state in which the accident occurred.

No benefit will be payable for any loss suffered as a result of Accidental Injury during any period of
imprisonment as a result of the Covered Employee’s conviction of a crime.

With respect to this provision, "Participation" shall include promoting, inciting, conspiring to promote
or incite, aiding, abetting, and all forms of taking part in, but shall not include actions taken in defense of public or private property, or actions taken in defense of the Covered Person, if such actions of defense are not taken against persons seeking to maintain or restore law and order including, but not
limited to police officers and fire fighters.
With respect to this provision, "Riot" shall include all forms of public violence, disorder or disturbance of the public peace, by three or more persons assembled together, whether or not acting with a common
intent and whether or not damage to persons or property or unlawful act or acts is the intent or the
consequence of such disorder.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 42 of 71
SECTION 6 - TERMINATION PROVISIONS
Form GLP-TER-1 Termination Provisions

Termination of a Covered Person's Insurance

A Covered Person will cease to be insured on the earliest of the following dates:
1. the date this policy terminates, but without prejudice to any claim originating prior to the time of termination;

2. the date the Covered Employee is no longer in an eligible class;

3. the date the Covered Employee's class is no longer included for insurance;

4. the last day for which any required Employee contribution has been made;

5. the date employment (status as an active Employee) or eligibility ends for any reason; or

6. the date the Covered Employee ceases to be in Active Employment due to a labor dispute,
including any strike, work slowdown, or lockout.
Lincoln reserves the right to review and terminate all classes insured under this policy if any class(es) cease(s) to be covered.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 43 of 71
SECTION 6 - TERMINATION PROVISIONS
Form GLP-TER-2 Termination Provisions

(Continued)

Policy Termination

1. Termination of this policy under any conditions will not prejudice any claim which occurs while this policy is in force.
2. If the Sponsor fails to pay any premium within the grace period, this policy will terminate at 12:00
midnight Standard Time on the last day of the grace period. The Sponsor may terminate this policy
by advance written notice delivered to Lincoln at least 31 days prior to the termination date. This
policy will not terminate during any period for which premium has been paid. The Sponsor will be liable to Lincoln for all premiums due and unpaid for the full period for which this policy is in force.
3. Lincoln may terminate this policy on any premium due date by giving written notice to the Sponsor
at least 31 days in advance if:

a. the number of Employees insured is fewer than 10; or
b. less than 100% of the Employees eligible for any non-contributory insurance are insured for it; or
c. less than 25.00% of the Employees eligible for any contributory basic insurance are insured for it; or d. the Sponsor fails:
i. to furnish promptly any information which Lincoln may reasonably require; or
ii. to perform any other obligations pertaining to this policy.

4. Lincoln may terminate this policy or any coverage(s) afforded hereunder and for any class of covered
Employees on any premium due date after it has been in force for 12 months. Lincoln will provide
written notice of such termination to the Sponsor at least 31 days before the termination is effective.

5. Termination may take effect on an earlier date if agreed to by the Sponsor and Lincoln.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 44 of 71
SECTION 7 - GENERAL PROVISIONS
Form GLP-GNP-1.14 General Provisions

Appeal Process
Lincoln will notify in writing any Covered Person or beneficiary whose claim is denied in whole or part.
That written notice will explain the reasons for denial. If the claimant does not agree with the reasons
given, he may request an appeal of the claim. To do so, the claimant should write to Lincoln within 60 days after the notice of denial was received. The claimant should state why he believes the claim was improperly denied. Any data, questions or comments that the claimant thinks are appropriate should be included. Unless Lincoln requests additional material in a timely fashion, the claimant will be
advised of Lincoln’s decision within 60 days after his or her letter is received.

Assignment
The coverage under this policy is not assignable by the Sponsor without Lincoln's written consent. A Covered Employee may assign all of his present and future right, title, interest, and incidents of ownership of:

1. any Life Insurance; 2. any disability provision of Life Insurance; and 3. any Accidental Death and Dismemberment Insurance under this policy.
Such assignment will include, but is not limited to, the rights:
1. to make any contribution required to keep the coverage in force;
2. to exercise any conversion privilege; and
3. to change the beneficiary.
Beneficiary
Each Covered Employee must name a beneficiary to whom the insurance benefits under this policy are
payable. If more than one beneficiary is named and if their interests are not specified, any surviving
Beneficiaries will share equally. For any Dependent Life Insurance, the Covered Employee is automatically designated as the beneficiary.

If, at the death of a Covered Employee, there is no named or surviving beneficiary, Lincoln will pay the
benefits to the executor or administrator of the Covered Employee's estate. Lincoln may, at its option, pay the benefits to a surviving relative in the following order: spouse, child, parent, sibling. Such payment will release Lincoln of all further liability to the extent of payment.

A Covered Employee may change his beneficiary at any time by written request. Lincoln or the Sponsor will provide a form for that purpose. Any change of beneficiary will take effect when the Sponsor receives the written request whether or not the Covered Employee is alive at that time. Such change will relate back to the date of the request. Any change of beneficiary will not apply to any payment
made before the request was received by the Sponsor.

Conformity with State Statutes
Any provision of this policy which, on its effective date, is in conflict with the statutes of the governing jurisdiction of this policy is hereby amended to conform to the minimum requirements of such statute.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 45 of 71
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form GLP-GNP-2.9 General Provisions

Employee's Certificate

Lincoln will provide a Certificate to the Sponsor for delivery to Covered Employees. It will state:

1. the name of the insurance company and the policy number;
2. a description of the insurance provided; 3. the method used to determine the amount of benefits; 4. to whom benefits are payable;
5. limitations or reductions that may apply;
6. the circumstances under which insurance terminates; and
7. the rights of the Covered Person upon termination of this policy.
If the terms of a Certificate and this policy differ, this policy will govern.
Entire Contract - Policy Changes
1. This policy is the entire contract. It consists of:

a. all of the pages;
b. the attached signed Application of the Sponsor; and
c. if contributory each Employee's signed application for insurance.

2. This policy may be changed in whole or in part. Only an officer of Lincoln can approve a change to
the policy. The approval must be in writing and endorsed on or attached to this policy.

3. No other person, including an agent, may change this policy or waive any part of it.
Examination
Lincoln, at its own expense, has the right and opportunity to have a Covered Person, whose Injury or
Sickness is the basis of a claim, examined or evaluated at reasonable intervals deemed necessary by
Lincoln. This right may be used as often as reasonably required.

Facility of Payment
Lincoln has the right, at its option, to pay up to $500 to any person whom Lincoln considers equitably entitled thereto by reason of having incurred funeral or other expenses incident to the last illness or
death of the Covered Person. Such payment will release Lincoln of all further liability to the extent of
payment.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 46 of 71
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form GLP-GNP-3.9 General Provisions

Furnishing of Information - Access to Records

1. The Sponsor will furnish at regular intervals to Lincoln:

a. information relative to Employees:

i. who qualify to become insured; ii. whose amounts of insurance change; and/or
iii. whose insurance terminates.

b. any other information about this policy that may be reasonably required.

The Sponsor's records which, in the opinion of Lincoln, have a bearing on the insurance will be opened for inspection at any time that is reasonable.

2. Clerical error or omission will not deprive an Employee of insurance.

Incontestability

This policy will not be contested, except for the nonpayment of premium, after it has been in force for
two years from the date of issue. The coverage of any Covered Person shall not be contested, except for the nonpayment of premium, on the basis of a statement that is made relating to insurability of the Covered Person after such coverage has been in force for two years during the Covered Person's
lifetime.
Any statements in any application will be deemed to be representations and not to be warranties. No representation made by:

1. the Sponsor in applying for this policy will make it void unless the representation is contained in the Sponsor’s signed Application; or
2. any Covered Person in enrolling for insurance under this policy will be used to reduce or deny a
claim unless the representation is contained in an application signed by him and such
application is given to him or his beneficiary.

Interpretation of the Policy
Lincoln shall possess the authority, in its sole discretion, to construe the terms of this policy and to
determine benefit eligibility hereunder. Lincoln's decisions regarding the construction of the terms of
this policy and benefit eligibility shall be conclusive and binding. However, these decisions may be
modified or reversed by a court or by a regulatory agency with appropriate jurisdiction.

Legal Proceedings (Applicable to Accidental Death & Dismemberment)

A claimant or the claimant's authorized representative cannot start any legal action:

1. until 60 days after Proof of claim has been given; or
2. more than three years after the time Proof of claim is required.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 47 of 71
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form GLP-GNP-4.9 General Provisions

Misstatement of Age
If a Covered Person's age has been misstated, an equitable adjustment will be made in the premium. If the amount of the benefit is dependent upon the Covered Person's age, the amount of the benefit will be
the amount the Covered Person would have been entitled to if his correct age were known.

A refund of premium will not be made for a period more than 12 months before the date Lincoln is advised of the error.

Notice and Proof of Claim (Applicable to Accidental Death & Dismemberment)

1. Notice

a. Notice of claim must be given to Lincoln within 20 days of the date of the loss on which the
claim is based. If that is not possible, Lincoln must be notified as soon as it is reasonably possible to do so. Such notice of claim must be received in a form or format satisfactory to Lincoln.
b. When written notice of claim is applicable and has been received by Lincoln, the Covered
Person will be sent claim forms. If the forms are not received within 15 days after written notice
of claim is sent, the Covered Person can send to Lincoln written Proof of claim without waiting for the forms.

2. Proof

a. Satisfactory Proof of loss must be given to Lincoln no later than 30 days after the date of loss.
b. Failure to furnish such Proof within such time shall not invalidate or reduce any claim if it was not reasonably possible to furnish such Proof within such time. Such Proof must be furnished as soon as reasonably possible.

Lincoln reserves the right to determine if the Covered Person’s Proof of loss is satisfactory.

Optional Methods of Settlement
Benefits are usually payable in one sum. However, the Covered Person may elect in writing to have the proceeds paid through an installment program offered by Lincoln. If the Covered Person makes no such
election, his beneficiary may do so at the Covered Person's death.

Any installments remaining after the death of the payee will be paid as directed in the election of this option. Such direction is subject to the approval of Lincoln.

Lincoln Security Account

If the benefits to be paid total more than $10,000, a beneficiary may elect to have the proceeds deposited into a Lincoln Security Account. The Lincoln Security Account is an interest-bearing checking account, that is fully guaranteed by Lincoln, and the beneficiary may draw on the entire sum of the proceeds at
any time. If the Lincoln Security Account is not elected, benefits may be paid in one sum.

Payment of Benefits

All benefits are payable when Lincoln receives written satisfactory Proof of loss. Benefits for loss of life
of the Covered Employee are paid to the beneficiary. Benefits for loss of life of the Covered Dependent are paid to the Covered Employee. Benefits for other losses are paid to the Covered Employee. SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 48 of 71
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form GLP-GNP-5.9 General Provisions

Right of Recovery

Lincoln has the right to recover any overpayment of benefits caused by, but not limited to, the following:

1. fraud;
2. any error made by Lincoln in processing a claim; or
3. any error made in the eligibility or administration of this policy by the Sponsor.
Lincoln may recover an overpayment by, but not limited to, the following:
1. requesting a lump sum payment of the overpaid amount; 2. reducing any benefits payable under this policy; or 3. taking any appropriate collection activity available including any legal action needed.
It is required that full reimbursement be made to Lincoln.
Time Payment of Claim
When Lincoln receives satisfactory proof of claim, the benefit payable under this policy will be paid
within 60 days of receipt of such proof. The benefit payable will be paid at least monthly, depending on
the coverage for which claim is made, during any period for which Lincoln is liable.

Workers' Compensation
This Policy and the coverages provided are not in lieu of, nor will they affect any requirements for
coverage under any Workers' Compensation Law or other similar law.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 49 of 71
SECTION 8 - PREMIUMS
Form GLP-PRE-1 Premiums

Premium Rates
Lincoln has set the premiums that apply to the coverage(s) provided under this policy. Those premiums
are shown in a notice given to the Sponsor with or prior to delivery of this policy.

A change in the initial premium rate(s) will not take effect within the first 36 months except that Lincoln may change premium rates at any time for reasons which affect the risk assumed, including those reasons shown below:

1. a change occurs in the policy design;

2. a division, subsidiary or Associated Company is added to or deleted from this policy;

3. when the number of Covered Persons changes by 15.00% or more from the number insured on this policy's effective date; or

4. a change in existing law which affects this policy.
Lincoln may, upon notice to the Sponsor, set new premium rates to become effective on or at any time after the first anniversary date of this policy. However, no premium may be changed unless Lincoln notifies the Sponsor at least 31 days in advance. Premium changes may take effect on an earlier date
when both Lincoln and the Sponsor agree.

Payment of Premiums
1. All premiums due under this policy, including adjustments, if any, are payable by the Sponsor on or before their due dates at Lincoln's Administrative Office, or to Lincoln's agent. The due dates are specified on the first page of this policy.

2. All payments made to or by Lincoln shall be in United States dollars.

3. If premiums are payable on a monthly basis, premiums for additional or increased insurance
becoming effective during a policy month will be charged from the next premium due date.
4. The premium charge for insurance terminated during a policy month will cease at the end of the policy month in which such insurance terminates. This manner of charging premium is for accounting purposes only. It will not extend insurance coverage beyond a date it would have
otherwise terminated as shown in the "Termination of a Covered Person's Insurance" provision of
this policy.
5. If premiums are payable on other than a monthly basis, premiums for additional, increased, reduced
or terminated insurance will cause a prorated adjustment on the next premium due date.

6. Except for fraud and premium adjustments, refunds of premiums or charges will be made only for:

a. the current policy year; and
b. the immediately preceding policy year.
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 50 of 71
SECTION 8 - PREMIUMS
(Continued)
Grace Period

A grace period of 45 days will be allowed for the payment of premium after a premium due date other than the first. No interest will be charged. During this period this policy will continue in force. But, if
the Sponsor gives Lincoln written notice to terminate the policy on an earlier date, then this policy will
end on such earlier date. The Sponsor must pay the pro rata premium for the time the policy was in force during the grace period.

Form GLP-PRE-2 Premiums

SA3-830-509893-01 R (1) Effective October 1, 2017
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 51 of 71
AMENDMENT NO. 1
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is July 1, 2010.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 8th day of July, 2010.
Issued to and Accepted by:
SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 52 of 71
AMENDMENT NO. 2
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is September 4, 2010.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 1st day of October, 2010.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 53 of 71
AMENDMENT NO. 3
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is June 1, 2010.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 10th day of December, 2010.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 54 of 71
AMENDMENT NO. 4
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is January 1, 2011.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 17th day of December, 2010.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 55 of 71
AMENDMENT NO. 5
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is June 1, 2010.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 22nd day of February, 2011.
Issued to and Accepted by:
SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 56 of 71
AMENDMENT NO. 6
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is August 1, 2011.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 2nd day of August, 2011.
Issued to and Accepted by:
SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 57 of 71
AMENDMENT NO. 7
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is January 1, 2012.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 14th day of December, 2011.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 58 of 71
AMENDMENT NO. 8
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is December 2, 2011.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 21st day of March, 2012.
Issued to and Accepted by:
SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 59 of 71
AMENDMENT NO. 9
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is March 1, 2012.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 29th day of March, 2012.
Issued to and Accepted by:
SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 60 of 71
AMENDMENT NO. 10
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is February 29, 2012.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 23rd day of April, 2012.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 61 of 71
AMENDMENT NO. 11
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is January 1, 2012.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 25th day of June, 2012.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 62 of 71
AMENDMENT NO. 12
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is July 1, 2011.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 25th day of September, 2012.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 63 of 71
AMENDMENT NO. 13
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is January 1, 2012.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 12th day of October, 2012.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 64 of 71
AMENDMENT NO. 14
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is September 1, 2012.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 11th day of April, 2013.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 65 of 71
AMENDMENT NO. 15
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is June 20, 2014.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 5th day of March, 2015.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 66 of 71
AMENDMENT NO. 16
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is December 31, 2014.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 12th day of March, 2015.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 67 of 71
AMENDMENT NO. 17
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is November 9, 2016.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 22nd day of June, 2016.
Issued to and Accepted by:
SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 68 of 71
AMENDMENT NO. 18
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions

The effective date of this change is October 1, 2017.
This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 17th day of November, 2017.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 69 of 71
AMENDMENT NO. 19
Form GLP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: SA3-830-509893-01

Changes Additions Deletions
-SCH-2.8 R (15) -SCH-3.5 R (2) -SCH-4.21 R (5) -SCH-5 R (3)
-DEF-1 R (3)
-ELG-1 R (3)
-ELG-2 R (3) -ELG-4.4 (NJ) R (5) -LIF-2.13 R (5)
P-SCH-2.8 R (14) -SCH-3.5 R (1) -SCH-4.21 R (4) -SCH-5 R (2)
-DEF-1 R (2)
-ELG-1 R (2)
-ELG-2 R (2) -ELG-4.4 (NJ) R (4) -LIF-2.13 R (4)

-medical

-Medicial

The effective date of this change is January 1, 2020.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 24th day of January, 2020.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor
By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston
SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 70 of 71
Form GLP-AMENDMENT (continued) Delete/Add Policy Pages

SUZ-W-20-02 IPUC DR 57 Attachment 4
Page 71 of 71
PLA-9312 Page 1 of 2

NEW JERSEY LIFE AND HEALTH
INSURANCE GUARANTY ASSOCIATION ACT

Residents of New Jersey who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the New Jersey Life and Health Insurance Guaranty Association.

The purpose of this association is to assure that policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force.
The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted below, this protection is not a substitute for consumers’ care in selecting companies that are well-managed and financially stable.

DISCLAIMER

The state law that provides for this safety-net coverage is called the New Jersey Life and Health
Insurance Guaranty Association Act, N.J.S.A. 17B: 32A-1, et seq. (the "Act").

COVERAGE
The following is a brief summary of this law’s coverages, exclusions and limits. This summary does not cover all provisions of the law; not does it in any way change anyone’s rights or obligations of the guaranty association.

Generally, individuals will be protected by the Life and Health Insurance Guaranty Association if they live in New Jersey and hold a life, health or long-term care insurance contract, annuity contract, or if they are insured under a group insurance contract, issued by a member insurer.

The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state.
Jersey. You should not rely on coverage by the New Jersey Life and Health

NOT provided for your policy or any portion of it that is not guaranteed by the insurer or

tice. However,
way Center 9th Floor
NOTICE
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 1 of 48
PLA-9312 Page 2 of 2
EXCLUSIONS FROM COVERAGE
However, persons holding such policies are not protected by this Association if:
• They are eligible for protection under the laws of another state (this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); • the insurer was not authorized to do business in this state;
• the policy is issued by an organization which is not a member of the New Jersey Life and Health Insurance Guaranty Association.

The Association also does not provide coverage for:
• Any policy or portion of a policy which is not guaranteed by the insurer or for which the
individual has assumed the risk, such as a variable contract sold by prospectus;
• any policy of reinsurance (unless an assumption certificate was issued); • interest rate yields that exceed an average rate as more fully described in Section 3 of the Act;
• dividends;
• credits given in connection with the administration of a policy by a group contract holder;
• employers’ plans to the extent they are self-funded (that is, not insured by an insurance company, even if an insurance company administers them).

LIMITS ON AMOUNT OF COVERAGE
The act also limits the amount the Association is obligated to pay out. The Association cannot pay more
than what the insurance company would owe under a policy contract.
With respect to any one insured individual, regardless of the number of policies or contracts, the Association will pay not more than $500,000 in life insurance death benefits and present value annuity
benefits, including net cash surrender and net cash withdrawal values. Within this overall limit, the
Association will not pay more than $100,000 in cash surrender values for life insurance, $100,000 in cash surrender values for annuity benefits, $500,000 in life insurance death benefits or $500,000 in present value of annuities - again no matter how many policies and contracts that were with the same company, and no matter how many different types of coverages.
The Association will not pay more than $2,000,000 in benefits to any one contract holder under any one unallocated annuity contract.

There are no limits on the benefits the Association will pay with respect to any one group, blanket or individual accident and health insurance policy.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 2 of 48

GROUP DISABILITY INCOME POLICY

Sponsor: SUEZ Water Resources Inc
Policy Number: GF3-830-509893-01
Effective Date: April 1, 2016
Governing Jurisdiction is New Jersey and subject to the laws of that State.

Premiums are due and payable monthly on the first day of each month.

Policy Anniversaries shall occur each April 1st beginning in 2017.

Lincoln Life Assurance Company of Boston (hereinafter referred to as Lincoln) agrees to pay benefits provided by this policy in accordance with its provisions. This policy provides Long Term Disability coverage.
PLEASE READ THIS POLICY CAREFULLY FOR FULL DETAILS.

This policy is a legal contract and is issued in consideration of the Application of the Sponsor, a copy of which is attached, and of the payment of premiums by the Sponsor.

For purposes of this policy, the Sponsor acts on its own behalf or as the Covered Person's agent. Under
no circumstances will the Sponsor be deemed the agent of Lincoln.
This policy is delivered in and governed by the laws of the governing jurisdiction and to the extent applicable by The Employee Retirement Income Security Act of 1974 (ERISA) and any subsequent
amendments.
The following pages including any amendments, riders or endorsements are a part of this policy.
Signed at Lincoln's Home Office, 100 Liberty Way, Suite 100, Dover, New Hampshire 03820-4695

NON-PARTICIPATING

FORM ADOP
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 3 of 48

TABLE OF CONTENTS

SECTION 1 ................................................................... SCHEDULE OF BENEFITS

SECTION 2 ................................................................... DEFINITIONS

SECTION 3 ................................................................... ELIGIBILITY AND EFFECTIVE DATES

SECTION 4 ................................................................... DISABILITY INCOME BENEFITS

SECTION 5 ................................................................... EXCLUSIONS

SECTION 6 ................................................................... TERMINATION PROVISIONS

SECTION 7 ................................................................... GENERAL PROVISIONS

SECTION 8 ................................................................... PREMIUMS

SECTION 9 ................................................................... APPLICATION

Form ADOP-TOC Table of Contents
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 4 of 48
SECTION 1 - SCHEDULE OF BENEFITS
Form ADOP-SCH-1 Schedule of Benefits
GF3-830-509893-01 R (1) Effective January 1, 2020

ELIGIBILITY REQUIREMENTS FOR INSURANCE BENEFITS
Minimum Hourly Requirement:

Employees working a minimum of 30 regularly scheduled hours per week

Long Term Disability Benefits:
Class 1A: All full time employees of SUEZ Management of Services, Environmental Services and Utility electing the Core LTD Option excluding: • BU575 – Springfield, MA Unions •
BU675 – Woonsocket, RI union

Class 1B: All full time employees of SUEZ Management of Services, Environmental Services and Utility electing the Buy-up LTD Option excluding: • BU575 – Springfield, MA Unions • BU675 – Woonsocket, RI union

Note: This policy does not cover the following Employees: Temporary and Seasonal Employees, Employees who are not legal residents working in the United States.
Eligibility Waiting Period:
1. If the Covered Person is employed by the Sponsor on the policy effective date - None

2. If the Covered Person begins employment for the Sponsor after the policy effective date - None

Employee Contributions Required:

Applicable to Class 1A
No
Applicable to Class 1B
Yes
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 5 of 48
SECTION 1 - SCHEDULE OF BENEFITS
(Continued)
Form ADOP-SCH-3 Schedule of Benefits
GF3-830-509893-01 R (1) Effective January 1, 2020

LONG TERM DISABILITY COVERAGE
Elimination Period:

180 days

Amount of Insurance:

Applicable to Class 1A:
50.00% of Basic Monthly Earnings not to exceed a Maximum Monthly Benefit of $15,000.00 less
Other Income Benefits and Other Income Earnings as outlined in Section 4.
Applicable to Class 1B:
66.67% of Basic Monthly Earnings not to exceed a Maximum Monthly Benefit of $15,000.00 less
Other Income Benefits and Other Income Earnings as outlined in Section 4.

Maximum Basic Monthly Earnings on which the Benefit is Based:

Applicable to Class 1A: $30,000.00

Applicable to Class 1B: $22,498.88

Own Occupation Duration:

24 Month Own Occupation
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 6 of 48
SECTION 1 - SCHEDULE OF BENEFITS
(Continued)
Form ADOP-SCH-4 Schedule of Benefits

LONG TERM DISABILITY COVERAGE (Continued)
Minimum Monthly Benefit:

The Minimum Monthly Benefit is $100.00.

Maximum Benefit Period:

Age at Disability Maximum Benefit Period

Less than age 60 Greater of SSNRA* or to age 65 (but not less than 5 years)
60 60 months 61 48 months 62 42 months
63 36 months
64 30 months 65 24 months 66 21 months
67 18 months
68 15 months
69 and over 12 months

* SSNRA means the Social Security Normal Retirement Age as figured by the 1983 amendment to the
Social Security Act and any subsequent amendments and provides:
Year of Birth Normal Retirement Age
Before 1938 65
1938 65 and 2 months 1939 65 and 4 months 1940 65 and 6 months 1941 65 and 8 months
1942 65 and 10 months
1943-1954 66 1955 66 and 2 months 1956 66 and 4 months
1957 66 and 6 months
1958 66 and 8 months 1959 66 and 10 months 1960 and after 67
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 7 of 48
SECTION 2 - DEFINITIONS
Form ADOP-DEF-1 Definitions

In this section Lincoln defines some basic terms needed to understand this policy. The male pronoun
whenever used in this policy includes the female.

"Active Employment" means the Employee must be actively at work for the Sponsor:

1. on a full-time basis and paid regular earnings;

2. for at least the minimum number of hours shown in the Schedule of Benefits; and either perform
such work:

a. at the Sponsor's usual place of business; or
b. at a location to which the Sponsor's business requires the Employee to travel.
An Employee will be considered actively at work if he was actually at work on the day immediately preceding:

1. a weekend (except where one or both of these days are scheduled work days);
2. holidays (except when the holiday is a scheduled work day); 3. paid vacations; 4. any non-scheduled work day;
5. an excused leave of absence (except medical leave for the Covered Person's own disabling
condition and lay-off); and 6. an emergency leave of absence (except emergency medical leave for the Covered Person's own disabling condition).

"Administrative Office" means Lincoln Life Assurance Company of Boston, 100 Liberty Way, Suite 100,
Dover, New Hampshire 03820-4695.

"Annual Enrollment Period" or "Enrollment Period" means the period before each policy anniversary
so designated by the Sponsor and Lincoln during which an Employee may enroll for coverage under this
policy.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 8 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-2 Definitions

"Any Occupation" means any occupation that the Covered Person is or becomes reasonably fitted by
training, education, experience, age, physical and mental capacity.

"Application" is the document designated in Section 9; it is attached to and is made a part of this policy.

"Appropriate Available Treatment" means care or services which are:
1. generally acknowledged by Physicians to cure, correct, limit, treat or manage the disabling condition; 2. accessible within the Covered Person's geographical region;
3. provided by a Physician who is licensed and qualified in a discipline suitable to treat the disabling Injury or Sickness;
4. in accordance with generally accepted medical standards of practice.

"Basic Monthly Earnings" means the Covered Person's monthly rate of earnings from the Sponsor in effect immediately prior to the date Disability or Partial Disability begins. However, such earnings will not include bonuses, commissions, overtime pay and extra compensation.
"Consumer Price Index" means the government publication “ The Consumer Price Index for Urban Wage Earners and Clerical Workers” provided monthly by the U.S. Department of Labor, or its successor or in the event of no successor a similar Index of comparable purpose chosen by Lincoln.

"Covered Person" means an Employee insured under this policy.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 9 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-3 Definitions

"Disability" or "Disabled" means:

1. For persons other than pilots, co-pilots, and crewmembers of an aircraft:
i. that during the Elimination Period and the next 24 months of Disability the Covered Person, as a result of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own Occupation; and

ii. thereafter, the Covered Person is unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation.

2. With respect to Covered Persons employed as pilots, co-pilots and crewmembers of an aircraft:

"Disability" or "Disabled" means as a result of Injury or Sickness the Covered Person is unable to perform the Material and Substantial Duties of Any Occupation.

"Disability Benefits under a Retirement Plan" means money which:

1. is payable under a Retirement Plan due to Disability as defined in that plan; and

2. does not reduce the amount of money which would have been paid as retirement benefits at the
normal retirement age under the plan if the Disability had not occurred. (If the payment does cause such a reduction, it will be deemed a Retirement Benefit as defined in this policy.)
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 10 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-4 Definitions

"Domestic Partner" means an unmarried person of the same or opposite sex with whom the Covered Person shares a committed relationship, are jointly responsible for each other's welfare and financial obligations, at least 18 years of age and mentally competent to consent to a contract, not related by blood to a degree that could prohibit legal marriage in the state where they legally reside, maintain the same
residence(s) and are not married to or legally separated from anyone else. A Domestic Partner
certification must be completed and filed with the Sponsor before the partner can be designated as an Eligible Survivor.
"Eligibility Date" means the date an Employee becomes eligible for insurance under this policy. Eligibility Requirements are shown in the Schedule of Benefits.
"Eligible Survivor" means the Covered Person's spouse or Domestic Partner, if living, otherwise the
Covered Person's children under age 25.
"Eligibility Waiting Period" means the continuous length of time an Employee must be in Active Employment in an eligible class to reach his Eligibility Date.

"Elimination Period" means a period of consecutive days of Disability or Partial Disability for which no benefit is payable. The Elimination Period is shown in the Schedule of Benefits and begins on the first day of Disability.

If the Covered Person returns to work for any thirty or fewer days during the Elimination Period and cannot continue, Lincoln will count only those days the Covered Person is Disabled or Partially Disabled to satisfy the Elimination Period.

"Employee" means a person in Active Employment with the Sponsor.

"Enrollment Form" is the document completed by the Covered Person, if required, when enrolling for
coverage. This form must be satisfactory to Lincoln.

"Evidence of Insurability" means a statement of proof of an Employee's medical history upon which
acceptance for insurance will be determined by Lincoln.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 11 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-5 Definitions

"Extended Treatment Plan" means continued care that is consistent with the American Psychiatric Association's standard principles of Treatment, and is in lieu of confinement in a Hospital or Institution. It must be approved in writing by a Physician.

"Family and Medical Leave" means a leave of absence for the birth, adoption or foster care of a child, or for the care of the Covered Person's child, spouse or parent or for the Covered Person's own serious
health condition as those terms are defined by the Federal Family and Medical Leave Act of 1993
(FMLA) and any amendments, or by applicable state law.

"Family Status Change" means any one of the following events that may occur:
1. the Employee's marriage or divorce;
2. the Employee's filing or rescinding of a Domestic Partner certification;
3. the birth of a child to the Employee; 4. the adoption of a child by the Employee; 5. the death of the Employee's spouse or Domestic Partner or child;
6. the commencement or termination of employment of the Employee's spouse or Domestic
Partner; 7. the change from part-time employment to full-time employment by the Employee or the Employee's spouse or Domestic Partner;
8. the change from full-time employment to part-time employment by the Employee or the
Employee's spouse or Domestic Partner;
9. the taking of unpaid leave of absence by the Employee or the Employee's spouse or Domestic Partner.

"Gross Monthly Benefit" means the Covered Person's Monthly Benefit before any reduction for Other
Income Benefits and Other Income Earnings.

"Hospital" or "Institution" means a facility licensed to provide Treatment for the condition causing the
Covered Person's Disability.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 12 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-6 Definitions

"Indexed Basic Monthly Earnings" means the Covered Person's Basic Monthly Earnings in effect just prior to the date Disability or Partial Disability began adjusted on the first anniversary of benefit payments and each anniversary thereafter.

"Initial Enrollment Period" means one of the following periods during which an Employee may first enroll for coverage under this policy:

1. for an Employee who is eligible for insurance on the policy effective date, a period before the policy effective date set by the Sponsor and Lincoln.
2. for an Employee who becomes eligible for insurance after the policy effective date, the period
which ends 31 days after his Eligibility Date.

"Injury" means bodily impairment resulting directly from an accident and independently of all other
causes. For the purpose of determining benefits under this policy:

1. any Disability which begins more than 60 days after an Injury will be considered a Sickness; and

2. any Injury which occurs before the Covered Person is covered under this policy, but which
accounts for a medical condition that arises while the Covered Person is covered under this policy will be treated as a Sickness.
"Last Monthly Benefit" means the gross Monthly Benefit payable to the Covered Person prior to his death without any reduction for earnings received from employment.
"Material and Substantial Duties" means responsibilities that are normally required to perform the Covered Person's Own Occupation, or any other occupation, and cannot be reasonably eliminated or modified.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 13 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-7.3 Definitions

"Mental Illness" means a psychiatric or psychological condition classified as such in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) regardless of the underlying cause of the Mental Illness. If the DSM is discontinued, Lincoln will use the replacement chosen or published by the American Psychiatric Association.

"Monthly Benefit" means the monthly amount payable by Lincoln to the Disabled or Partially Disabled
Covered Person.

"Own Occupation" means the Covered Person's occupation that he was performing when his Disability
or Partial Disability began. For the purposes of determining Disability under this policy, Lincoln will
consider the Covered Person's occupation as it is normally performed in the national economy.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 14 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-8 Definitions

"Partial Disability" or "Partially Disabled" means the Covered Person, as a result of Injury or Sickness,
is able to:
1. perform one or more, but not all, of the Material and Substantial Duties of his Own Occupation
or Any Occupation on an Active Employment or a part-time basis; or
2. perform all of the Material and Substantial Duties of his Own Occupation or Any Occupation on a part-time basis; and

3. earn between 20.00% and 80.00% of his Basic Monthly Earnings.

"Physician" means a person who:

1. is licensed to practice medicine and is practicing within the terms of his license; or

2. is a licensed practitioner of the healing arts in a category specifically favored under the health
insurance laws of the state where the Treatment is received and is practicing within the terms of his license.

It does not include a Covered Person, any family member or domestic partner.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 15 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-9 Definitions

"Proof" means the evidence in support of a claim for benefits and includes, but is not limited to, the
following:
1. a claim form completed and signed (or otherwise formally submitted) by the Covered Person
claiming benefits;
2. an attending Physician's statement completed and signed (or otherwise formally submitted) by the Covered Person's attending Physician; and

3. the provision by the attending Physician of standard diagnosis, chart notes, lab findings, test results, x-rays and/or other forms of objective medical evidence in support of a claim for benefits.

Proof must be submitted in a form or format satisfactory to Lincoln.

"Regular Attendance" means the Covered Person's personal visits to a Physician which are medically
necessary according to generally accepted medical standards to effectively manage and treat the Covered Person's Disability or Partial Disability.

"Retirement Benefit under a Retirement Plan" means money which:

1. is payable under a Retirement Plan either in a lump sum or in the form of periodic payments;

2. does not represent contributions made by an Employee (payments which represent Employee contributions are deemed to be received over the Employee's expected remaining life regardless of when such payments are actually received); and

3. is payable upon:

a. early or normal retirement; or b. Disability, if the payment does reduce the amount of money which would have been paid
under the plan at the normal retirement age.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 16 of 48
SECTION 2 - DEFINITIONS
(Continued)
Form ADOP-DEF-10 Definitions

"Retirement Plan" means a plan which provides retirement benefits to Employees and which is not funded wholly by Employee contributions. The term shall not include a profit-sharing plan, informal salary continuation plan, registered retirement savings plan, stock ownership plan, 401(K) or a non-qualified plan of deferred compensation.

"Schedule of Benefits" means the section of this policy which shows, among other things, the Eligibility
Requirements, Eligibility Waiting Period, Elimination Period, Amount of Insurance, Minimum Benefit,
and Maximum Benefit Period.

"Sickness" means illness, disease, pregnancy or complications of pregnancy.

"Sponsor" means the entity to whom this policy is issued.

"Sponsor's Retirement Plan" is deemed to include any Retirement Plan:

1. which is part of any Federal, State, Municipal or Association retirement system; or

2. for which the Employee is eligible as a result of employment with the Sponsor.

"Substance Abuse" means alcohol and/or drug abuse, addiction or dependency.

"Treatment" means consulting, receiving care or services provided by or under the direction of a
Physician including diagnostic measures, being prescribed drugs and/or medicines, whether the
Covered Person chooses to take them or not, and taking drugs and/or medicines.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 17 of 48
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
Multiple Option Plan With Family Status Change
Eligibility and Effective Dates Form ADOP-ELG-4
GF3-830-509893-01 R (1) Effective January 1, 2020

Eligibility Requirements for Insurance Benefits

The eligibility requirements for insurance benefits are shown in the Schedule of Benefits.
Eligibility Date for Insurance Benefits

An Employee in an eligible class will qualify for insurance on the later of:

1. this policy's effective date; or
2. the day after the Employee completes the Eligibility Waiting Period shown in the Schedule of
Benefits.

Initial Enrollment Period

During the Initial Enrollment Period an Employee can enroll in any one coverage or coverage option
shown in the Schedule of Benefits. If he does not choose any coverage or coverage option, he will automatically be enrolled in the 50% Core Plan. If an Employee's Initial Enrollment Period takes place during or after the Annual Enrollment Period, but before the policy anniversary his coverage option will apply for (a) the rest of the policy year in which he first becomes eligible; and (b) the next policy year.

Applicable to Long Term Disability Class 1A:

Annual Enrollment Period

During each Annual Enrollment Period, a Covered Person may keep his coverage at the same level or make one of the following changes in coverage for the next policy year:

1. a decrease in coverage;

2. an increase in coverage without Evidence of Insurability.

Applicable to Long Term Disability Class 1B:
Annual Enrollment Period
During each Annual Enrollment Period, a Covered Person may keep his coverage at the same level or
make one of the following changes in coverage for the next policy year:
1. a decrease in coverage;

2. an increase in coverage subject to Evidence of Insurability and the Pre-Existing Condition
Exclusion defined herein.

If a Covered Person fails to enroll for a change in his coverage option during any Annual Enrollment
Period he will continue to be insured for the same coverage option during the next policy year and no change in that coverage can be made during the next policy year, unless the Covered Person experiences a Family Status Change.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 18 of 48
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
Multiple Option Plan With Family Status Change
Eligibility and Effective Dates Form ADOP-ELG-5
GF3-830-509893-01 R (1) Effective January 1, 2020

Applicable To Long Term Disability Class 1A:
Family Status Change
When an Employee experiences a Family Status Change, he may keep his coverage at the same level or
make one of the following changes in coverage:

1. a decrease in coverage;

2. an increase in coverage without Evidence of Insurability.

Applicable To Long Term Disability Class 1B:

Family Status Change

When an Employee experiences a Family Status Change, he may keep his coverage at the same level or make one of the following changes in coverage:

1. a decrease in coverage;

2. an increase in coverage subject to Evidence of Insurability and the Pre-Existing Condition
Exclusion defined herein.

The Covered Person must apply for the change in coverage within 31 Days of the date of the Family
Status Change. Such changes in coverage must be due to or consistent with the reason that the change in coverage was permitted. A change in coverage is consistent with a Family Status Change only if it is necessary or appropriate as the result of the Family Status Change.

Effective Date of Insurance
Insurance will be effective at 12:01 A.M. Standard Time in the governing jurisdiction on the day
determined as follows, but only if the Employee's application or enrollment for insurance is made with
Lincoln through the Sponsor in a form or format satisfactory to Lincoln.

1. For Coverage Applied for During Initial Enrollment Periods:

a. an Employee will be insured for non-contributory coverage on his Eligibility Date.
b. an Employee will be insured for contributory coverage on the date the Employee makes application for insurance if he enrolls on or before the 31st day after his Eligibility Date; or c. an Employee who does not enroll for contributory coverage on or before the 31st day after his
Eligibility Date, or terminated his insurance while continuing to be eligible may not enroll for
contributory coverage until the next Annual Enrollment Period or following a Family Status
Change.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 19 of 48
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
GF3-830-509893-01 R (1) Effective January 1, 2020

Effective Date of Insurance (Continued)

Applicable to Long Term Disability Class 1A:

2. For Contributory Coverage Applied for During Annual Enrollment Periods

An Employee will be insured for the selected contributory coverage on the first day of the next
policy anniversary.

3. For Coverage Applied for Due to a Family Status Change
An Employee will be insured for the selected coverage on the later of the following dates,
provided he applies or enrolls for the change in coverage before the end of the 31st Day following the Family Status Change:

a. the date of the Family Status Change;
b. the date the Employee applies or enrolls for the change in coverage.

Applicable to Long Term Disability Class 1B:

2. For Contributory Coverage Applied for During Annual Enrollment Periods

An Employee will be insured for the selected contributory coverage on the later of these dates:
a. the first day of the next policy anniversary; or b. the date Lincoln gives its approval, if the Employee:

i. increases his coverage option; or
ii. terminated his insurance while continuing to be eligible.

In the case of i. and ii. above, the Employee must submit an application and Evidence of
Insurability to Lincoln for approval. This will be at the Employee's expense.

3. For Coverage Applied for Due to a Family Status Change

An Employee will be insured for the selected coverage on the later of the following dates,
provided he applies or enrolls for the change in coverage before the end of the 31st Day following the Family Status Change:

a. the date of the Family Status Change;
b. the date the Employee applies or enrolls for the change in coverage; or
c. the date Lincoln gives its approval, if the Employee:

i. increases his coverage option; or
ii terminated his insurance while continuing to be eligible.
In the case of i. and ii. above, the Employee must submit an application and Evidence of
Insurability to Lincoln for approval. This will be at the Employee's expense.

Delayed Effective Date for Insurance

Multiple Option Plan With Family Status Change
Form ADOP-ELG-6 Eligibility and Effective Dates
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 20 of 48
GF3-830-509893-01 R (1) Effective January 1, 2020

The effective date of any initial, increased or additional insurance will be delayed for an individual if he is not in Active Employment because of Injury or Sickness. The initial, increased or additional insurance
will begin on the date the individual returns to Active Employment.

Multiple Option Plan With Family Status Change
Form ADOP-ELG-6 (continued) Eligibility and Effective Dates
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 21 of 48
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
Family and Medical Leave/Multiple Option Plan Rehire
Eligibility and Effective

Family and Medical Leave
An Employee's coverage may be continued under this policy for an approved family or medical leave of absence for up to 12 weeks following the date coverage would have terminated, subject to the following:

1. the authorized leave is in writing;

2. the required premium is paid;

3. the Covered Person's benefit level, or the amount of earnings upon which the Covered Person's benefit may be based, will be that in effect on the date before said leave begins; and

4. continuation of coverage will cease immediately if any one of the following events should occur:

a. the Covered Person returns to work; b. this group insurance policy terminates; c. the Covered Person is no longer in an eligible class;
d. nonpayment of premium when due by the Sponsor or the Covered Person;
e. the Covered Person's employment terminates.

Rehire Terms

If a former Employee is re-hired by the Sponsor within 12 months of his termination date:
1. all past periods of Active Employment with the Sponsor will be used in determining the re-hired
Employee's Eligibility Date; and

2. if an Employee is re-hired by the Sponsor he will be insured for the same coverage that was in effect for him on the date his employment terminated and no change in that coverage may be made during the rest of that policy year, unless he experiences a Family Status Change. He may
make changes in his coverage options at the next Annual Enrollment Period.
If a former Employee is re-hired by the Sponsor more than 12 months after his termination date, he is considered to be a new Employee when determining his Eligibility Date.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 22 of 48
SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES
(Continued)
Leave of Absence/Lay-off
Eligibility and Effective Dates

Leave of Absence

The Sponsor may continue the Covered Person's coverage(s) by paying the required premiums, if the Covered Person is given a leave of absence.

The Covered Person's coverage will not continue beyond the end of the policy month following the
policy month in which the leave of absence begins. In continuing such coverage under this provision,
the Sponsor agrees to treat all Covered Persons equally.

Lay-off

The Sponsor may continue the Covered Person's coverage(s) by paying the required premiums, if the Covered Person is temporarily laid off.

The Covered Person's coverage will not continue beyond the end of the policy month in which the lay-
off begins. In continuing such coverage under this provision, the Sponsor agrees to treat all Covered
Persons equally.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 23 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
Long Term Disability
Standard Integration Form ADOP-LTD-1

LONG TERM DISABILITY COVERAGE

Disability Benefit
When Lincoln receives Proof that a Covered Person is Disabled due to Injury or Sickness and requires the Regular Attendance of a Physician, Lincoln will pay the Covered Person a Monthly Benefit after the
end of the Elimination Period, subject to any other provisions of this policy. The benefit will be paid for
the period of Disability if the Covered Person gives to Lincoln Proof of continued:

1. Disability;

2. Regular Attendance of a Physician; and

3. Appropriate Available Treatment.

The Proof must be given upon Lincoln's request and at the Covered Person's expense. In determining whether the Covered Person is Disabled, Lincoln will not consider employment factors including, but not limited to, interpersonal conflict in the workplace, recession, job obsolescence, paycuts, job sharing and loss of a professional or occupational license or certification.
For purposes of determining Disability, the Injury must occur and Disability must begin while the Employee is insured for this coverage.

The Monthly Benefit will not:
1. exceed the Covered Person's Amount of Insurance; or

2. be paid for longer than the Maximum Benefit Period.
The Amount of Insurance and the Maximum Benefit Period are shown in the Schedule of Benefits.

Amount of Disability Monthly Benefit
To figure the amount of Monthly Benefit:

1. Take the lesser of:
a. the Covered Person's Basic Monthly Earnings multiplied by the benefit percentage shown in
the Schedule of Benefits; or

b. the Maximum Monthly Benefit shown in the Schedule of Benefits; and then

2. Deduct Other Income Benefits and Other Income Earnings, (shown in the Other Income Benefits
and Other Income Earnings provision of this policy), from this amount.
The Monthly Benefit payable will not be less than the Minimum Monthly Benefit shown in the Schedule of Benefits. However, if an overpayment is due to Lincoln, the Minimum Monthly Benefit otherwise
payable under this provision will be applied toward satisfying the overpayment.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 24 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
Long Term Partial Disability with Work Incentive
Proportionate Loss Form ADOP-LTD-5

LONG TERM DISABILITY COVERAGE (Continued)

Partial Disability
When Lincoln receives Proof that a Covered Person is Partially Disabled and has experienced a loss of
earnings due to Injury or Sickness and requires the Regular Attendance of a Physician, he may be
eligible to receive a Monthly Benefit, subject to any other provisions of this policy. To be eligible to
receive Partial Disability benefits, the Covered Person may be employed in his Own Occupation or another occupation, must satisfy the Elimination Period and must be earning between 20.00% and 80.00% of his Basic Monthly Earnings.

A Monthly Benefit will be paid for the period of Partial Disability if the Covered Person gives to Lincoln Proof of continued:

1. Partial Disability;
2. Regular Attendance of a Physician; and

3. Appropriate Available Treatment.
The Proof must be given upon Lincoln's request and at the Covered Person's expense. In determining whether the Covered Person is Partially Disabled, Lincoln will not consider employment factors including, but not limited to, interpersonal conflict in the workplace, recession, job obsolescence,
paycuts, job sharing and loss of a professional or occupational license or certification.
For purposes of determining Partial Disability, the Injury must occur and Partial Disability must begin while the Employee is insured for this coverage.

Proportionate Loss Monthly Calculation with Work Incentive Benefit

For the first 24 months, the work incentive benefit will be an amount equal to the Covered Person's Basic
Monthly Earnings multiplied by the benefit percentage shown in the Schedule of Benefits, without any reductions from earnings. The work incentive benefit will only be reduced, if the Monthly Benefit payable plus any earnings exceed 100% of the Covered Person's Basic Monthly Earnings. If the
combined total is more, the Monthly Benefit will be reduced by the excess amount so that the Monthly
Benefit plus the Covered Person's earnings does not exceed 100% of his Basic Monthly Earnings.

Thereafter, to figure the Amount of Monthly Benefit the formula (A divided by B) x C will be used.

A = The Covered Person's Basic Monthly Earnings minus the Covered Person's earnings received while he is Partially Disabled. This figure represents the amount of lost earnings.

B = The Covered Person's Basic Monthly Earnings.
C = The Monthly Benefit as figured in the Disability provision of this policy plus the Covered Person's earnings received while he is Partially Disabled, (but, not including adjustments
under the Cost of Living Adjustment Benefit, if included).
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 25 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
Long Term Partial Disability with Work Incentive
Proportionate Loss Form ADOP-LTD-6

LONG TERM DISABILITY COVERAGE (Continued)

Partial Disability (Continued)

Proportionate Loss Monthly Calculation with Work Incentive Benefit (Continued)
On the first anniversary of benefit payments and each anniversary thereafter, for the purpose of calculating the benefit, the term "Basic Monthly Earnings" is:

1. replaced by "Indexed Basic Monthly Earnings"; and
2. increased annually by 7.00%, or the current annual percentage increase in the Consumer Price
Index, whichever is less.
The Monthly Benefit payable will not be less than the Minimum Monthly Benefit shown in the Schedule of Benefits. However, if an overpayment is due to Lincoln, the Minimum Monthly Benefit otherwise
payable under this provision will be applied toward satisfying the overpayment.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 26 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
Long Term Disability
Mental Illness/Substance Abuse Limitation Form ADOP-LTD-7.1

LONG TERM DISABILITY COVERAGE (Continued)

Mental Illness and/or Substance Abuse Limitation
The benefit for Disability due to Mental Illness and/or Substance Abuse will not exceed a combined
period of 24 months of Monthly Benefit payments while the Covered Person is insured under this
policy.
If the Covered Person is in a Hospital or Institution for Mental Illness and/or Substance Abuse at the
end of the combined period of 24 months, the Monthly Benefit will be paid during the confinement.
If the Covered Person is not confined in a Hospital or Institution for Mental Illness and/or Substance Abuse, but is fully participating in an Extended Treatment Plan for the condition that caused Disability, the Monthly Benefit will be payable to a Covered Person for up to a combined period of 36 months.
In no event will the Monthly Benefit be payable beyond the Maximum Benefit Period shown in the Schedule of Benefits.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 27 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Long Term Disability
3 Month Survivor Form ADOP-LTD-10

Three Month Survivor Benefit

Lincoln will pay a lump sum benefit to the Eligible Survivor when Proof is received that a Covered
Person died:

1. after Disability had continued for 6 or more consecutive months; and

2. while receiving a Monthly Benefit.
The lump sum benefit will be an amount equal to three times the Covered Person's Last Monthly
Benefit.

If the survivor benefit is payable to the Covered Person's children, payment will be made in equal shares to the children, including step children and legally adopted children. However, if any of said children are minors or incapacitated, payment will be made on their behalf to the court appointed guardian of the children's property. This payment will be valid and effective against all claims by others
representing or claiming to represent the children.
If there is no Eligible Survivor, the benefit is payable to the estate.

If an overpayment is due to Lincoln at the time of a Covered Person's death, the benefit payable under
this provision will be applied toward satisfying the overpayment.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 28 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE (Continued)
Long Term Disability
Workplace Modification Form ADOP-LTD-14

Workplace Modification Benefit
If a Covered Person is Disabled or Partially Disabled and receiving a benefit from Lincoln, a benefit may be payable to the Sponsor as part of the Covered Person's benefit for modifications to the workplace to accommodate the Covered Person's return to work or to assist the Covered Person in remaining at work.

Lincoln will reimburse the Sponsor for up to 100% of reasonable costs the Sponsor incurs for the
modification, up to the greater of:

1. $1,000.00; or

2. the equivalent of 2 months of the Covered Person's Monthly Benefit.

To qualify for this benefit:

1. the Disability or Partial Disability must prevent the Covered Person from performing some or
all of the Material and Substantial Duties of his occupation; and
2. any proposed modifications must be approved in writing and signed by the Covered Person, the
Sponsor and Lincoln; and
3. the Sponsor must agree to make the modifications to the workplace to reasonably accommodate the Covered Person's return to work or to assist the Covered Person in remaining at work.

The Sponsor's costs for the approved modifications will be reimbursed after:

1. the proposed modifications have been made; and
2. written proof of the expenses incurred by the Sponsor has been provided to Lincoln; and

3. Lincoln has received proof that the Covered Person has returned to and/or remains at work.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 29 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE
Long Term Disability Primary and Family Integration
Other Income Benefits and Other Income Earnings Form ADOP-LTD-22.10

Other Income Benefits and Other Income Earnings
Other Income Benefits means:
1. The amount for which the Covered Person is eligible under:

a. Workers' or Workmen's Compensation Laws;
b. Occupational Disease Law;
c. Title 46, United States Code Section 688 (The Jones Act);
d. Railroad Retirement Act; e. any governmental compulsory benefit act or law (except military and veteran benefits
incurred prior to the date of Disability); or
f. any other act or law of like intent.

2. The amount of any Disability benefits which the Covered Person is eligible to receive under:

a. any other group insurance plan of the Sponsor; b. any governmental retirement system as a result of his employment with the Sponsor.

3. The amount of benefits the Covered Person receives, attributable to the Sponsor's contributions, under the Sponsor's Retirement Plan as follows:
a. the amount of any Disability Benefits under a Retirement Plan, or Retirement Benefits under
a Retirement Plan the Covered Person voluntarily elects to receive as retirement payment
under the Sponsor's Retirement Plan; and b. the amount the Covered Person receives as retirement payments when he reaches the later of age 62, or normal retirement age as defined in the Sponsor's plan.
4. The amount of Disability and/or Retirement Benefits under the United States Social Security Act, the Canada Pension Plan, the Quebec Pension Plan, or any similar plan or act, which:

a. the Covered Person receives or is eligible to receive; and
b. his spouse, child or children receives or are eligible to receive because of his Disability; or c. his spouse, child or children receives or are eligible to receive because of his eligibility for retirement benefits.

5. Any amount the Covered Person receives from any unemployment benefits.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 30 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE
Long Term Disability Primary and Family Integration
Other Income Benefits and Other Income Earnings Form ADOP-LTD-23.10

Other Income Benefits and Other Income Earnings (Continued)

Other Income Earnings means:

1. the amount of earnings the Covered Person earns or receives from any form of employment
obtained after the date of Disablity including severance; and
2. any amount the Covered Person receives from any formal or informal sick leave or salary continuation plan(s).

Other Income Benefits must be payable as a result of the same Disability for which Lincoln pays a benefit. The sum of Other Income Benefits and Other Income Earnings will be deducted in accordance with the provisions of this policy.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 31 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE
Form ADOP-LTD-24.3 Estimation of Benefits and Social Security Assistance

Estimation of Benefits

Lincoln will reduce the Covered Person's Disability or Partial Disability benefits by the amount of Other Income Benefits that we estimate are payable to the Covered Person and his dependents.

The Covered Person's Disability benefit will not be reduced by the estimated amount of Other Income
Benefits if the Covered Person:

1. provides satisfactory proof of application for Other Income Benefits;

2. signs a reimbursement agreement under which, in part, the Covered Person agrees to repay Lincoln for any overpayment resulting from the award or receipt of Other Income Benefits;

3. if applicable, provides satisfactory proof that all appeals for Other Income Benefits have been
made on a timely basis to the highest administrative level unless Lincoln determines that further appeals are not likely to succeed; and

4. if applicable, submits satisfactory proof that Other Income Benefits have been denied at the
highest administrative level unless Lincoln determines that further appeals are not likely to
succeed.
Lincoln will not estimate or reduce for any benefits under the Sponsor's pension or retirement benefit
plan according to applicable law, until the Covered Person actually receives them.
In the event that Lincoln overestimates the amount payable to the Covered Person from any plans referred to in the Other Income Benefits and Other Income Earnings provision of this policy, Lincoln
will reimburse, with interest, if any, the Covered Person for such amount upon receipt of written proof
of the amount of Other Income Benefits awarded (whether by compromise, settlement, award or judgement) or denied (after appeal through the highest administrative level). Lincoln agrees to pay for legal expenses and other costs incurred by the Covered Person in proceeding with a hearing.

Social Security Assistance

Lincoln may help a Covered Person in applying for Social Security Disability Income Benefits. In order
to be eligible for assistance the Covered Person must be receiving a Monthly Benefit from Lincoln. Such assistance will be provided only if Lincoln determines that assistance would be beneficial.

Long Term Disability
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 32 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE
Form ADOP-LTD-25.3 Long Term Disability

Lump Sum Payments
Other Income Benefits from a compromise, settlement, award or judgement which are paid to the Covered Person in a lump sum and are meant to compensate the Covered Person for any one or more of
the following:
1. loss of past or future wages; 2. impaired earnings capacity; 3. lessened ability to compete in the open labor market;
4. any degree of permanent impairment; and
5. any degree of loss of bodily function or capacity;
will be prorated on a monthly basis as follows:
1. over the period of time such benefits would have been paid if not in a lump sum; or
2. if such period of time cannot be determined, the sum will be paid on a monthly basis over the
Covered Person's expected lifetime.

Cost of Living Freeze
After the first deduction for each of the Other Income Benefits, the Monthly Benefit will not be further reduced due to any cost of living increases payable under the Other Income Benefits and Other Income Earnings provision of this policy. This provision does not apply to increases received from any form of
employment.

Prorated Benefits

For any period for which a Long Term Disability benefit is payable that does not extend through a full month, the benefit will be paid on a prorated basis. The rate will be 1/30th for each day for such period of Disability.

Discontinuation of the Long Term Disability Benefit

The Monthly Benefit will cease on the earliest of:
1. the date the Covered Person fails to provide Proof of continued Disability or Partial Disability and Regular Attendance of a Physician;

2. the date the Covered Person fails to cooperate in the administration of the claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 33 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE
Form ADOP-LTD-26.3 Long Term Disability

Discontinuation of the Long Term Disability Benefit (Continued)
The Monthly Benefit will cease on the earliest of: (Continued)
3. the date the Covered Person refuses to be examined or evaluated at reasonable intervals;
4. the date the Covered Person refuses to receive Appropriate Available Treatment;
5. the date the Covered Person refuses a job with the Sponsor where workplace modifications or
accommodations were made to allow the Covered Person to perform the Material and
Substantial Duties of the job;

6. the date the Covered Person is able to work in his Own Occupation on a part-time basis, but chooses not to;

7. the date the Covered Person's current Partial Disability earnings exceed 80.00% of his Indexed
Basic Monthly Earnings;
Because the Covered Person's current earnings may fluctuate, Lincoln will average earnings
over three consecutive months rather than immediately terminating his benefit once 80.00% of
Indexed Basic Monthly Earnings has been exceeded.

8. the date the Covered Person is no longer Disabled according to this policy;

9. the end of the Maximum Benefit Period; or

10. the date the Covered Person dies.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 34 of 48
SECTION 4 - DISABILITY INCOME BENEFITS
(Continued)
LONG TERM DISABILITY COVERAGE
Form ADOP-LTD-27 Successive Disability

Successive Periods of Disability

With respect to this policy, "Successive Periods of Disability" means a Disability which is related or
due to the same cause(s) as a prior Disability for which a Monthly Benefit was payable.
A Successive Period of Disability will be treated as part of the prior Disability if, after receiving Disability benefits under this policy, a Covered Person:

1. returns to his Own Occupation on an Active Employment basis for less than six continuous months; and

2. performs all the Material and Substantial Duties of his Own Occupation.
To qualify for a Successive Periods of Disability benefit, the Covered Person must experience more than a 20% loss of Basic Monthly Earnings.

Benefit payments will be subject to the terms of this policy for the prior Disability.
If a Covered Person returns to his Own Occupation on an Active Employment basis for six continuous
months or more, the Successive Period of Disability will be treated as a new period of Disability. The
Covered Person must complete another Elimination Period.
If a Covered Person becomes eligible for coverage under any other group long term disability coverage,
this Successive Period of Disability provision will cease to apply to that Covered Person.

Long Term Disability
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 35 of 48
SECTION 5 - EXCLUSIONS
Form ADOP-EXC-1 General Exclusions

GENERAL EXCLUSIONS

This policy will not cover any Disability due to:

1. war, declared or undeclared, or any act of war;

2. intentionally self-inflicted injuries, while sane or insane;

3. active Participation in a Riot;

4. the committing of or attempting to commit a felony or misdemeanor;

5. cosmetic surgery unless such surgery is in connection with an Injury or Sickness sustained while
the individual is a Covered Person; or
6. a gender change, including, but not limited to, any operation, drug therapy or any other procedure related to a gender change.

No benefit will be payable during any period of incarceration.

With respect to this provision, Participation shall include promoting, inciting, conspiring to promote or incite, aiding, abetting, and all forms of taking part in, but shall not include actions taken in defense of public or private property, or actions taken in defense of the Covered Person, if such actions of defense are not taken against persons seeking to maintain or restore law and order including, but not limited to
police officers and fire fighters.

With respect to this provision, Riot shall include all forms of public violence, disorder or disturbance of
the public peace, by three or more persons assembled together, whether or not acting with a common
intent and whether or not damage to persons or property or unlawful act or acts is the intent or the consequence of such disorder.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 36 of 48
SECTION 5 - EXCLUSIONS
(Continued)

LONG TERM DISABILITY COVERAGE

Pre-Existing Condition Exclusion(s)

This policy will not cover any Disability or Partial Disability:

1. which is caused or contributed to by, or results from, a Pre-Existing Condition; and

2. which begins in the first 12 months immediately after the Covered Person's effective date of coverage.

"Pre-Existing Condition" means a condition resulting from an Injury or Sickness for which the Covered
Person is diagnosed or received Treatment within three months prior to the Covered Person's effective
date of coverage.

Applicable to Class 1B:
For Employees who Increase their Coverage Option During an Annual Enrollment Period or Due to a
Family Status Change:

This policy will not cover any increase in amount of coverage for any Disability or Partial Disability:

1. which is caused or contributed to by, or results from, a Pre-Existing Condition; and

2. which begins in the first 12 months immediately after the Covered Person's effective date of
increased coverage.

"Pre-Existing Condition" means a condition resulting from an Injury or Sickness for which the Covered
Person is diagnosed or received Treatment within three months prior to the Covered Person's effective
date of increased coverage.

Pre-Existing Condition Exclusion Waiver

This Pre-Existing Condition Exclusion will not apply:

1. if the Covered Person was covered by another group policy issued by Lincoln immediately prior
to being covered by this policy; and
2. if Lincoln paid the Covered Person benefits for the Pre-Existing Condition under the prior group
policy.

Long Term Disability
Form ADOP-EXC-7.4 Multiple Option 3-12 Plan Pre-Existing Exclusions

GF3-830-509893-01 R (1) Effective January 1, 2020
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 37 of 48
SECTION 6 - TERMINATION PROVISIONS
Form ADOP-TER-1 Termination Provisions

Termination of a Covered Person's Insurance

A Covered Person will cease to be insured on the earliest of the following dates:

1. the date this policy terminates, but without prejudice to any claim originating prior to the
time of termination;

2. the date the Covered Person is no longer in an eligible class;

3. the date the Covered Person's class is no longer included for insurance;

4. the last day for which any required Employee contribution has been made;

5. the date employment terminates. Cessation of Active Employment will be deemed termination of employment, except the insurance will be continued for an Employee absent due to Disability during:

a. the Elimination Period; and
b. any period during which premium is being waived.
6. the date the Covered Person ceases active work due to a labor dispute, including any strike,
work slowdown, or lockout.

Lincoln reserves the right to review and terminate all classes insured under this policy if any class(es)
cease(s) to be covered.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 38 of 48
SECTION 6 - TERMINATION PROVISIONS
Form ADOP-TER-3.6 Termination Provisions

(Continued)

Policy Termination
1. Termination of this policy under any conditions will not prejudice any claim for loss where the loss
occurred on or before the date of termination.
2. If the Sponsor fails to pay any premium within the grace period, this policy will terminate at 12:00
midnight Standard Time on the last day of the grace period. The Sponsor may terminate this policy
by advance written notice delivered to Lincoln at least 31 days prior to the termination date. This
policy will not terminate during any period for which premium has been paid. The Sponsor will be liable to Lincoln for all premiums due and unpaid for the full period for which this policy is in force.

3. Lincoln may terminate this policy on any premium due date by giving written notice to the Sponsor
at least 31 days in advance if:

a. the number of Employees insured is fewer than 10; or

b. less than 100.00% of all the Employees eligible for any non-contributory insurance are insured
for it; or
c. less than 100.00% of all the Employees eligible for any contributory insurance are insured for it; or

d. the Sponsor fails:
i. to furnish promptly any information which Lincoln may reasonably require; or
ii. to perform any other obligations pertaining to this policy.

4. Lincoln may terminate this policy or any coverage(s) afforded hereunder and for any class of
covered Employees on any premium due date after it has been in force for 12 months. Lincoln will provide written notice of such termination to the Sponsor at least 31 days before the termination is effective.

5. Termination may take effect on an earlier date if agreed to by the Sponsor and Lincoln.

Termination of Coverage Option(s)
Participation Requirements
Lincoln may terminate coverage or any coverage option afforded hereunder on any premium due date by giving written notice to the Sponsor at least 31 days in advance:
1. if the overall participation for all coverage options falls below 75.00% of the Employees eligible for benefits under this policy; and

2. if less than 25.00% of the Employees eligible for each coverage option are insured for it.
Termination may take effect on an earlier date if agreed to by the Sponsor and Lincoln.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 39 of 48
SECTION 7 - GENERAL PROVISIONS
Form ADOP-GNP-1.3 General Provisions

Assignment

No assignment of any present or future right or benefit under this policy will be allowed.

Complete Contract - Policy Changes

1. This policy is the entire contract. It consists of:
a. all of the pages; and b. the attached signed Application of the Sponsor; and c. if contributory each Employee's signed application for insurance.
2. This policy may be changed in whole or in part. Only an officer of Lincoln can approve a change. The approval must be in writing and endorsed on the policy or by amendment to the policy signed by the Sponsor and Lincoln.

3. No other person, including an agent, may change this policy or waive any part of it.

Conformity with State Statutes
Any provision of this policy which, on its effective date, is in conflict with the statutes of the governing jurisdiction of this policy is hereby amended to conform to the minimum requirements of such statute.

Employee's Certificate

Lincoln will provide a Certificate to the Sponsor for delivery to Covered Persons. It will state:

1. the name of the insurance company and the policy number; 2. a description of the insurance provided; 3. the method used to determine the amount of benefits;
4. to whom benefits are payable;
5. limitations or reductions that may apply; 6. the circumstances under which insurance terminates; and 7. the rights of the Covered Person upon termination of this policy.
If the terms of a Certificate and this policy differ, this policy will govern.
Examination
Lincoln, at its own expense, may have the right and opportunity to have a Covered Person, whose
Injury or Sickness is the basis of a claim, examined or evaluated at reasonable intervals deemed
necessary by Lincoln. This right may be used as often as reasonably required.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 40 of 48
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form ADOP-GNP-2.19 General Provisions

Furnishing of Information - Access to Records
1. The Sponsor will furnish at regular intervals to Lincoln:

a. information relative to Employees:

i. who qualify to become insured; ii. whose amounts of insurance change; and/or iii. whose insurance terminates.

b. any other information about this policy that may be reasonably required.
The Sponsor's records which, in the opinion of Lincoln, have a bearing on the insurance will be
opened for inspection at any reasonable time.

2. Clerical error or omission will not:

a. deprive an Employee of insurance;
b. affect an Employee's Amount of Insurance; or
c. effect or continue an Employee's insurance which otherwise would not be in force.
Interpretation of the Policy
Lincoln shall possess the authority, in its sole discretion, to construe the terms of this policy and to
determine benefit eligibility hereunder. Lincoln's decisions regarding the construction of the terms of
this policy and benefit eligibility shall be conclusive and binding. However, these decisions may be modified or reversed by a court or by a regulatory agency with appropriate jurisdiction.
Incontestability
The validity of this policy shall not be contested, except for non-payment of premiums, after it has been
in force for two years from the date of issue. The validity of this policy shall not be contested on the
basis of a statement made relating to insurability by any person covered under this policy after such insurance has been in force for two years during such person's lifetime, and shall not be contested unless the statement is contained in a written instrument signed by the person making such statement.

Legal Proceedings

A claimant or the claimant's authorized representative cannot start any legal action:

1. until 60 days after Proof of claim has been given; or

2. more than one year after the time Proof of claim is required.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 41 of 48
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form ADOP-GNP-3.19 General Provisions

Misstatement of Age
If a Covered Person's age has been misstated, an equitable adjustment will be made in the premium. If
the amount of the benefit is dependent upon an Employee's age, the amount of the benefit will be the
amount an Employee would have been entitled to if his correct age were known.
A refund of premium will not be made for a period more than 12 months before the date Lincoln is
advised of the error.

Notice and Proof of Claim

1. Notice

a. Notice of claim must be given to Lincoln within 30 days of the date of the loss on which the claim is based. If that is not possible, Lincoln must be notified as soon as it is reasonably possible to do so. Such notice of claim must be received in a form or format satisfactory to Lincoln.
b. When written notice of claim is applicable and has been received by Lincoln, the Covered Person will be sent claim forms. If the forms are not received within 15 days after written notice
of claim is sent, the Covered Person can send to Lincoln written Proof of claim without waiting
for the forms.

2. Proof
a. Satisfactory Proof of loss must be given to Lincoln no later than 30 days after the end of the
Elimination Period.
b. Failure to furnish such Proof within such time shall not invalidate or reduce any claim if it was not reasonably possible to furnish such Proof within such time. Such Proof must be furnished as
soon as reasonably possible.
c. Proof of continued loss, continued Disability or Partial Disability, when applicable, and Regular Attendance of a Physician must be given to Lincoln within 30 days of the request for such Proof.

Lincoln reserves the right to determine if the Covered Person's Proof of loss is satisfactory.

Payment of Claims
The benefit is payable to the Covered Person. But, if a benefit is payable to a Covered Person's estate, a Covered Person who is a minor, or who is not competent, Lincoln has the right to pay up to $2,000 to
any of the Covered Person's relatives or any other person whom Lincoln considers entitled thereto by
reason of having incurred expense for the maintenance, medical attendance or burial of the Covered
Person. If Lincoln in good faith pays the benefit in such a manner, any such payment shall fulfill Lincoln's responsibility for the amount paid.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 42 of 48
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form ADOP-GNP-4.19 General Provisions

Statements
All statements made in any application are considered representations and not warranties (absolute
guarantees). No representation by:
1. the Sponsor in applying for this policy will make it void unless the representation is contained in the signed Application; or

2. any Employee in enrolling for insurance under this policy will be used to reduce or deny a claim
unless a copy of the Enrollment Form, signed by the Employee if required, is or has been given to the Employee.

Time Payment of Claims
When Lincoln receives satisfactory proof of claim, the benefit payable under this policy will be paid
within 60 days of receipt of such proof. The benefit payable will be paid at least monthly, depending on
the coverage for which claim is made, during any period for which Lincoln is liable. Any balance remaining unpaid upon the termination of the period of liability will be paid immediately upon receipt of due written proof.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 43 of 48
SECTION 7 - GENERAL PROVISIONS
(Continued)
Form ADOP-GNP-5 General Provisions

Workers' Compensation
This policy and the coverages provided are not in lieu of, nor will they affect any requirements for
coverage under any Workers' Compensation Law or other similar law.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 44 of 48
SECTION 8 - PREMIUMS
Form ADOP-PRE-1.4 Premiums

Premium Rates
Lincoln has set the premiums that apply to the coverage(s) provided under this policy. Those premiums
are shown in a notice given to the Sponsor with or prior to delivery of this policy.

A change in the initial premium rate(s) will not take effect within the first 21 months except that Lincoln may change premium rates at any time for reasons which affect the risk assumed, including those reasons shown below:

1. a change occurs in the policy design;
2. a division, subsidiary or Associated Company is added to or deleted from this policy;

3. when the number of Covered Persons changes by 15.00% or more from the number insured on this policy's effective date; or

4. a change in existing law which affects this policy.
No premium may be changed unless Lincoln notifies the Sponsor at least 31 days in advance. Premium
changes may take effect on an earlier date when both Lincoln and the Sponsor agree.

Payment of Premiums

1. All premiums due under this policy, including adjustments, if any, are payable by the Sponsor on or before their due dates at Lincoln's Administrative Office, or to Lincoln's agent. The due dates are specified on the first page of this policy.

2. All payments made to or by Lincoln shall be in United States dollars.

3. If premiums are payable on a monthly basis, premiums for additional or increased insurance
becoming effective during a policy month will be charged from the next premium due date.
4. The premium charge for insurance terminated during a policy month will cease at the end of the
policy month in which such insurance terminates. This manner of charging premium is for
accounting purposes only. It will not extend insurance coverage beyond a date it would have otherwise terminated as shown in the "Termination of a Covered Person's Insurance" provision of this policy.
5. If premiums are payable on other than a monthly basis, premiums for additional, increased, reduced or terminated insurance will cause a prorated adjustment on the next premium due date.

6. Except for premium adjustments, refunds of premiums or charges will be made only for:
1. the current policy year; and

2. the immediately preceding policy year.
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 45 of 48
SECTION 8 - PREMIUMS
(Continued)
Grace Period

This is the 45 days following a premium due date, other than the first, during which premium payment may be made. During the grace period this policy shall continue in force, unless the Sponsor has given
Lincoln written notice 31 days in advance of discontinuance of this policy.

Waiver of Premium

Premium payments for a Covered Person are waived during any period for which benefits are payable.
If coverage is to be continued, premium payments must be resumed following a period during which
they were waived.

Form ADOP-PRE-2 Premiums

GF3-830-509893-01 R (1) Effective October 1, 2017
SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 46 of 48
AMENDMENT NO. 1
Form ADOP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: GF3-830-509893-01

Changes Additions Deletions

The effective date of this change is October 1, 2017.
The changes will only apply to Disabilities or Partial Disabilities which start on or after the effective date of this change.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 17th day of November, 2017.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor

By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 47 of 48
AMENDMENT NO. 2
Form ADOP-AMENDMENT Delete/Add Policy Pages

It is agreed the following changes are hereby made to this policy: GF3-830-509893-01

Changes Additions Deletions

-SCH-3 R (1) -ELG-4 R (1) -ELG-5 R (1) -ELG-6 R (1)
Form ADOP-SCH-3 Form ADOP-ELG-4 Form ADOP-ELG-5 Form ADOP-ELG-6

The effective date of this change is January 1, 2020.

The changes will only apply to Disabilities or Partial Disabilities which start on or after the effective date of this change.

This policy's terms and provisions will apply other than as stated in this amendment.
Dated this 24th day of January, 2020.
Issued to and Accepted by:

SUEZ Water Resources Inc
Sponsor
By
Signature and Title of Officer

Lincoln Life Assurance Company of Boston

SUZ-W-20-02 IPUC DR 57 Atachment 5
Page 48 of 48

CASE NO. SUZ-W-20-02

Response No. 57 Attachment 6

EXCEL Spreadsheet Provided Separately
in Native Format
SUZ-W-20-02 IPUC DR 58
Page 1 of 1
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 58:
With reference to adjustment No. 7 Other Employee Benefits on Page 7 of the testimony, please provide the policy for tuition assistance. Please provide the amount and type of tuition assistance by year for years 2015 through 2020
RESPONSE NO. 58: Please see Attachment 1 for policy on tuition assistance and Attachment 2 for tuition assistance provided for years 2015 through 2020 to date. Such benefits include tuition, university fees, lab fees and books per the policy.

Prior to 2019, General Ledger Account 91850 included tuition assistance and additional employee benefit expenses such as Long Term Disability Insurance and 401k/VEBA (Voluntary Employee Beneficiary Association) administrative costs for voluntary employee benefits. Voluntary benefits include optional coverage such as accidental
insurance or life insurance benefits. The administrative costs for these voluntary benefit
programs are now captured in General Ledger Account 91700 with other health plan costs.
Reissued/Amended July 2016 Page 109
Employee Policy Manual
SECTION 9: OTHER POLICIES
9.1 TUITION AND EDUCATION ASSISTANCE
It is the policy of SUEZ-NA to provide educational assistance to eligible employees as a means of
enhancing their level of occupational proficiency or to provide career development potential within the
organization. The intent of this policy is to provide financial assistance to support external initiatives in
acquiring additional knowledge and/or skills and/or capabilities. SUEZ-NA encourages our employees
to further their formal education, improve their personal competencies, and maintain a high level of
knowledge and skill in order to meet current challenges and prepare for opportunities for advancement
within the company.
9.1.1 Eligibility
All regular active employees, in good standing, with at least six (6) months of continuous employment
with SUEZ-NA at the time the coursework begins and who work a minimum of 30 hours per week are
eligible for participation in the Tuition and Education Assistance Program.
The course or program for which an employee seeks reimbursement must be assessed by SUEZ-NA
to meet the following criteria:
•Certificate or degree program relates to the business of the Company.
•Course(s) is related to employee’s current position and/or developmental opportunities, including
another appropriate position within the Company, and is of value to the Company. OR
•Course(s) is required for matriculation or fulfillment of a pre-approved certificate or degree
program’s requirements. AND
•Course(s) is offered through an accredited institution, college, university, vocational or trade
school or through an accredited E-learning, distance learning or Web-based program.
The employee must complete a Tuition and Education Assistance Request for each course or
semester of courses that assistance is sought. The request must be submitted by the employee for
approval by both the employee’s supervisor/manager and the department head. The application must
be submitted to the employee’s supervisor AT LEAST one month prior to the beginning of the course
or the semester.
9.1.2 The Program
The Tuition and Education Assistance Policy provides 100% reimbursement of credit hours/course or
certificate hours satisfactorily completed by an eligible employee, not to exceed the tax-free maximum
annual reimbursable amount allowable by the IRS
Reimbursement requires successful completion of a course(s) (i.e., “Pass” or “C” grade or better) in
any pre-approved course(s) offered through an accredited institution, college, university, vocational or
trade school or through accredited E-learning, distance learning or Web-based courses.
Tuition Assistance will be given to all eligible employees pursuing degrees or taking courses at the
Associate, Bachelor, Master or Post-Graduate level, or pursuing completion of or course work in
certificate-bearing or other pre-approved programs.
9.1.3 Program Reimbursement Guidelines
A. Reimbursable items include:
•Tuition
•University fees
•Lab fees and books
Expenses associated with “Credit for Examination” are also reimbursable. Any employee who is
unsure if an item is reimbursable should contact his/her Human Resources Business Partner for
eligibility determination. SUZ-W-20-02
IPUC DR 58 Attachment 1
Page 1 of 3
Reissued/Amended July 2016 Page 110
Employee Policy Manual
SECTION 9: OTHER POLICIES
B. Non-reimbursable items include:
•Courses that involve sports, games or hobbies
•The cost of tools and supplies that the employee may retain after completion of a course
•Meals, lodging or transportation expenses
9.1.4 Tax Implications
As per IRS SEC. 127 and the Economic Growth and Tax Relief Reconciliation Act of 2001:
•The Federal Government allows all employees to be eligible for up to $5,250 per year of tax-free
educational assistance. Therefore, generally, any reimbursement in excess of this amount will be
taxable to the employee and subject to income and employment tax withholding. Employees who
require further clarification should contact their own tax professional.
•The $5,250 per year of tax-free educational assistance is defined as per calendar year or the year
in which the payment is made to the employee, NOT when the course was taken by the
employee or the expense incurred by the employee. Therefore, any request for educational
assistance payment must be received by Human Resources prior to the last pay period in
December or the payment will be attributed to the following tax year’s allowable limit.
9.1.5 Reimbursement Options
If requested on the application, fifty percent (50%) advance reimbursement of the amount paid toward
the eligible tuition can be made upfront after the Tuition and Education Assistance Request Form is
approved and appropriate documentation of expenses paid is provided to Human Resources.
The remaining fifty percent (50%) of tuition and fees will be reimbursed only after the employee
submits appropriate documentation of any additional expenses (i.e. books) and evidence of
satisfactory completion of the course(s) to the local Human Resources Business Partner/liaison.
If the employee did not request/receive an advance reimbursement or deferred payment with his/her
institution, he/she will be reimbursed for the full amount that was approved. Reimbursement occurs
only after the employee submits appropriate documentation of any additional expenses (e.g., books)
and evidence of satisfactory completion of the course(s) to the local Human Resources Business
Partner/liaison.
A.Applicable Reimbursement Conditions
In all cases, reimbursement requires successful completion of a course (i.e., “Pass” or “C” grade or
better).
SUEZ-NA will not reimburse an employee for any course for which they have received a failing grade
or which they have failed to complete. Unsuccessful completion (Fail, Drop, Grades below “C”,
{including a grade of C-}) requires reimbursement of any advanced money by the employee to the
Company.
Courses must not interfere with the employee’s responsibilities and job performance and must be
taken on non-company time. If specifically pre-approved in writing by their department head, an
employee may be granted alternative work schedules and/or allowed the use of annual leave to
accommodate class(es). However, this accommodation is at the sole discretion of the department
head and must not interfere with the employee’s responsibilities.
Applicants must disclose any supplemental assistance received from scholarships, veteran’s benefits,
funds, taxes or other sources on the Tuition and Education Assistance Application Form. Additional
reimbursement under the company Tuition and Educational Assistance Policy will be made up to
$5250.00 or, if approved, the enhanced rate, but not to exceed the actual cost of tuition, university
fees, lab fees, and books incurred by the applicant for that semester.
Reimbursement will not be provided during an employee’s leave of absence.
SUZ-W-20-02
IPUC DR 58 Attachment 1
Page 2 of 3
Reissued/Amended July 2016 Page 111

Employee Policy Manual
SECTION 9: OTHER POLICIES
Participating employees who are unable to complete their course(s) due to: 1. medical or military
leave of absence; or 2. Company action other than discharge for cause, will be reimbursed the amount
provided under the Tuition and Education Assistance Program less any money refunded by the
educational institution or other sources.
If the Tuition and Education Assistance Program is discontinued, employees whose applications have
been approved will be fully reimbursed for those courses they are taking at the time of discontinuance,
as provided in the Program.
9.1.6 Service Obligation
In consideration of receiving tuition and education assistance under this policy, the employee is
obligated to commit to twelve (12) months of continuous service with the Company following receipt of
any reimbursement.
If an employee resigns or is terminated for cause prior to a course completion date, the employee is
ineligible for tuition and education reimbursement and is responsible for the reimbursement to the
Company for any advance money.
If the employee voluntarily resigns or is terminated for cause, the employee is responsible for
reimbursing the Company for all advances, reimbursements and expenses related to the Tuition and
Education Assistance Policy retroactive for the prior twelve (12) months.
9.1.7 Approval and Processing
Before enrolling in a course of study or specific class, the employee must complete a Tuition and
Educational Assistance Request Form. The approval process is as follows:
1. Employee fully completes and signs the Tuition and Educational Assistance Request Form.
a. Employees should obtain a TEAP form from the HR Employee Service Center.
2. Employee’s supervisor/manager indicates approval of the request by signing the form.
3. Department head indicates approval of the request by signing the form.
4. Employee attaches tuition bill or paid receipt to form and submits to his/her local Human
Resources Business Partner for processing.
5. Employee is reimbursed ½ (Advance) of the tuition bill or paid receipt, if requested on application.
6. Employee provides copy of course completion grade, plus additional expense receipts (e.g., book
fees), to his/her local Human Resources Business Partner /liaison.
7. Employee is reimbursed for the tuition bill plus covered related expenses or, if applicable, one-half
(balance of advance reimbursement), up to the remaining allowable amount of assistance for the
year.
9.1.8 Learning Recognition Program
The Company’s Learning Recognition Program celebrates employees’ educational accomplishments
and reinforces to all employees the importance of education. Employees are an important part of the
Company’s success and the Company is invested in their education and skill development.
The program recognizes employees who successfully complete an accredited degree program or
obtain a new license and/or certificate which enhance their job-related skills, increase their eligibility for
other career opportunities and assist the Company with building bench strength and continuing to
develop a qualified pool of talent.
Official documentation that an employee has received a new license/certificate or official notice of
degree completion from the educational institution must be submitted to Corporate Training through
the employee’s local Human Resources Business Partner or their Direct Manager for recognition.
Employees are not required to participate in the Company’s Tuition and Educational Assistance
Program (TEAP) to receive recognition.
SUZ-W-20-02
IPUC DR 58 Attachment 1
Page 3 of 3
SUZ-W-20-02
IPUC DR 58
Attachment 2
1 of 1
SUZ-W-20-02
Tuiton Assistance
Dept File #Amt Paydate Check #Payroll Dept Nbr
060 000138 (1,793.00)$ 01/23/2015 40046 060305
060 000138 (1,784.20)$ 07/24/2015 300045 060305
060 000138 (1,051.33)$ 09/04/2015 360045 060305
060 000138 (2,286.45)$ 02/05/2016 50046 060305
060 000138 (1,686.95)$ 07/22/2016 290045 060305
060 105166 (996.00)$ 01/20/2017 30051 060304
060 000138 (556.00)$ 02/17/2017 70043 060305
060 105166 (1,174.35)$ 05/26/2017 210037 060304
060 000138 (1,122.00)$ 06/23/2017 250045 060305
060 105166 (1,178.74)$ 01/05/2018 10035 060304
060 000198 (2,055.00)$ 11/09/2018 450017 060100
060 000198 (3,744.00)$ 03/29/2019 130017 060100
060 105185 (2,876.61)$ 05/10/2019 190040 060415
060 000198 (1,506.00)$ 06/07/2019 230015 060100
060 105146 (945.00)$ 11/22/2019 470014 060205
060 000212 (1,057.50)$ 12/20/2019 510036 060113
060 105146 (945.00)$ 01/31/2020 50013 060205
060 105185 (2,991.86)$ 01/31/2020 50044 060415
060 000189 (945.00)$ 03/27/2020 130022 060100
060 105185 (2,258.14)$ 05/22/2020 210046 060415
SUZ-W-20-02 IPUC DR 59
Page 1 of 2
SUEZ WATER IDAHO INC. CASE SUZ-W-20-02
SECOND PRODUCTION REQUEST OF THE COMMISSION STAFF
Preparer/Sponsoring Witness: J. Cary

REQUEST NO. 59:
With reference to Adju stment No. 8 Payroll Overhead s on Page 8 of the testimony, please provide an overview of the fringe benefit allocation method. Please provide the calculation for this adjustment, including the inputs used and the source documents for the inputs.
RESPONSE NO. 59: Please see Attachment 1 for an overview of the fringe benefit allocation method and example of the calculation using June 2018 data.

The fringe benefit allocation amount in account 90950 for June 2018 is comprised of two components: 1) the $69,275.11 of fringe benefit allocation, and 2) $2,460.94 of fringe benefits for Mechanic labor allocated to account 50645 through the separate vehicle allocation process.

In short, actual fringe benefit costs are allocated proportionately to where labor is coded on a monthly basis. This methodology and steps of Fringe Benefit Allocation remain unchanged since 2015.
Fringe benefit related costs (pool) captured in the following accounts:
70250 Payroll Taxes 91460 Workers compensation 91500 Pension 91550 Post Retirement PBOP
91560 Pens/PBOP Deferred
91700 Employee Group Health & Life 91800 Employee 401K 91850 Other Employee Benefits (tuition) 92056 Amortization of OPEB Costs
Process Overview: Step -0- Sets the %'s for fringe costs (By BU) to be transferred to Capex, Opex and Deferred based on PAID payroll for the month (Labor transferred out/Gross
Labor)
Step -1- Takes the total fringe costs for the month (By BU) and multiplies those against the %'s set in Step -0-, arriving at the total fringe costs transferred to Capex, Opex and Deferred
SUZ-W-20-02 IPUC DR 59 Page 2 of 2
Step -2- Applies the fringe costs calculated in Step -1- to Capex projects based on
PAID payroll for the month (Offset 90950000)
Step -3- Applies the fringe costs calculated in Step -1- to Opex projects based on PAID payroll for the month (Offset 90950000)
Step -4- Applies the fringe costs calculated in Step -1- to Deferred projects based on
PAID payroll for the month (Offset 90950000) Step -5- Takes the difference between the fringe costs transferred to (Capex, Opex & Deferred) and TOTAL fringe costs for the month and spreads them to
fringe benefits transferred (90950xxx) by NARUC, based on PAID payroll

CASE NO. SUZ-W-20-02

Response No. 59 Attachment 1

EXCEL Spreadsheet Provided Separately
in Native Format