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2015 JPT RESTATED JULY 1 *e PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR JEFFERSON COUNTY HEALTH PLAN / EFFECTIVE: SEPTEMBER 1,2006 y+_. RESTATED: JULY 1,201 ; J1 I l ro �S f 1 t � y r JOINT ;ROWE , --:*TRUST IL t " PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR JEFFERSON COUNTY x HEALTH PLANrfr, « <.�. .. EFFECTIVE: SEPTEMBER 1,2Q06 "� +,m► r_ RESTATED: JULY 1; ^' u r r R i 1y 4 A JOI T F, . OWE RUS TABLE OF CONTENTS INTRODUCTION................................................................................................................................................1 SCHEDULEOF BENEFITS................................................................................................................................3 MEDICALBENEFITS...................................................................................................................................3 PRESCRIPTIONDRUG BENEFITS.............................................................................................................9 DENTALBENEFITS...................................................................................................................................10 VISIONCARE BENEFITS..........................................................................................................................11 SUPPLEMENTARY ACCIDENT CHARGE BENEFITS............................................................................12 ELIGIBILITY,FUNDING,EFFECTIVE DATE AND TERMINATION PROVISIONS................................13 ELIGIBILITY...............................................................................................................................................13 FUNDING....................................................................................................................................................15 ENROLLMENT..........................................................................................................................................15 EFFECTIVEDATE......................................................................................................................................19 TERMINATIONOF COVERAGE..............................................................................................................19 MEDICALBENEFITS.......................................................................................................................................25 DEDUCTIBLE.............................................................................................................................................25 OUT-OF-POCKET LIMIT...........................................................................................................................25 COVEREDCHARGES................................................................................................................................25 MEDICAL EXPENSE AUDIT BONUS.......................................................................................................35 CARE MANAGEMENT SERVICES................................................................................................................36 UTILIZATION MANAGEMENT................................................................................................................36 PRE-NOTIFICATION DETERMINATION AND REVIEW PROCESS.....................................................37 CASEMANAGEMENT..............................................................................................................................37 ITSTARTS WITH ME......................................................................................................................................38 DEFINEDTERMS.............................................................................................................................................39 PLANEXCLUSIONS........................................................................................................................................45 PRESCRIPTION DRUG BENEFITS.................................................................................................................48 COVEREDPRESCRIPTION DRUGS.........................................................................................................48 EXPENSESNOT COVERED......................................................................................................................49 HOT TO SUBMIT PHARMACY CLAIMS.................................................................................................50 WHERE TO SUBMIT PHARMACY CLAIMS...........................................................................................51 VISION CARE BENEFI TS................................................................................................................................52 DENTALBENEFITS.........................................................................................................................................53 HOWTO SUBMff A CLAIM............................................................................................................................56 WHERETO SUBMIT CLAIMS..................................................................................................................56 WHEN CLAIMS SHOULD BE FILED........................................................................................................56 CLAIMSPROCEDURE...............................................................................................................................56 COORDINATION OF BENEFITS.....................................................................................................................60 THIRDPARTY RECOVERY............................................................................................................................63 COBRA CONTINUATION COVERAGE.........................................................................................................64 COBRA CONTINUATION COVERAGE FOR RETIREES AND/OR THEIR DEPENDENTS.....................69 RESPONSIBILITIES FOR PLAN ADMINISTRATION..................................................................................74 HIPAAPRIVACY STANDARDS...............................................................................................................75 H1PAASECURITY STANDARDS.............................................................................................................77 GENERAL PLAN INFORMATION .................................................................................................................78 INTRODUCTION This document is a description of Jefferson County Health Plan(the Plan). The Plan participates in the Joint Powers Trust also known as Montana Joint Powers Trust. The benefits and principal provisions of the group contract that apply to individuals covered under the Plan are described herein. This documentation replaces and supersedes any Plan Document or Summary Plan Description issued to Covered Persons of the Employer by the Joint Powers Trust also known as Montana Joint Powers Trust to provide the coverages set forth herein. If the Joint Powers Trust also known as Montana Joint Powers Trust does not grant such approval the coverages will not go into effect. If the Joint Powers Trust also known as Montana Joint Powers Trust does grant approval,identification cards will be distributed. No oral interpretations can change this Plan.The Plan described is designed to protect Plan Participants against certain catastrophic health expenses. Coverage under the Plan will take effect for an eligible Employee and designated Dependents when the Employee and such Dependents satisfy the Waiting Period and all the eligibility requirements of the Plan. Changes in the Plan may occur in any or all parts of the Plan including benefit coverage,deductibles, maximums,copayments,exclusions,limitations,definitions,eligibility and the like. Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no coverage at all.Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan,such as coordination of benefits,subrogation,exclusions,timeliness of COBRA elections,utilization review or other cost management requirements,lack of Medical Necessity,lack of timely filing of claims or lack of coverage. The Plan will pay benefits only for the expenses incurred while this coverage is in force.No benefits are payable for expenses incurred before coverage began or after coverage terminated.An expense for a service or supply is incurred on the date the service or supply is furnished. If the Plan is terminated,amended,or benefits are eliminated,the rights of Covered Persons are limited to Covered Charges incurred before termination,amendment or elimination. No action at law or in equity shall be brought to recover under any section of this Plan until the appeal rights provided have been exercised and the Plan benefits requested in such appeals have been denied in whole or in part. Grandfathered Health Plan. This Plan believes it is a"grandfathered health plan"under the Patient Protection and Affordable Care Act(the Affordable Care Act).As permitted by the Affordable Care Act,a grandf tthered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.Being a grandfsthered health plan means that the Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans.However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status,can be directed to the Plan Administrator. You may also contact the Employee Benefits Security Administration,U.S.Department of Labor at 1 (866)444-3272 or the U.S.Department of Health and Human Services at www.HealthCare.gov.This website has a table summarizing which protections do and do not apply to grandfathered health plans. This document summarizes the Plan rights and benefits for covered Employees and their Dependents and is divided into the following parts: Eligibility,Funding,Effective Date and Termination.Explains eligibility for coverage under the Plan, funding of the Plan and when the coverage takes effect and terminates. Schedule of Benefits.Provides an outline of the Plan reimbursement formulas as well as payment limits on certain services. Jefferson county I July 1,2015 Benefit Descriptions.Explains when the benefit applies and the types of charges covered. Care Management Services.Explains the methods used to curb unnecessary and excessive charges. Defined Terms.Defines time Plan terms that have a specific meaning. Plan Exclusions.Shows what charges are not covered. Claim Provisions.Explains the rules for filing claims. Coordination of Benefits.Shows the Plan payment order when a person is covered under more than one plan. Third Party Recovery Provision.Explains the Plan's rights to recover payment of charges when a Covered Person has a claim against another person because of injuries sustained. COBRA Continuation Coverage.Explains when a person's coverage under the Plan ceases and the continuation options which are available. Jefferson County 2 July 1,2015 SCHEDULE OF BENEFITS MEDICAL BENEFITS All benefits described in this Schedule are subject to the exclusions and limitations described more fully herein including,but not limited to,the Plan Administrator's determination that:care and treatment is Medically Necessary;that charges are reasonable and customary(as defined as an Allowable Charge);that services, supplies and care are not Experimental and/or Investigational.The meanings of these capitalized terms are in the Defined Terms section of this document. Pre-notification of certain services is strongly recommended,but not required by the Plan.Pre-notification provides information regarding coverage before the Covered Person receives treatmeM,services and/or supplies.A benefit determination on a Claim will be made only after the Claim has been submitted.A pre- notification of services by CareLink is not a determination by the Plan that a Claim will be paid.All Claims are subject to the terms and conditions, limitations and exclusions of the Plan at the time services are provided A pre-notification is not required as a condition precedent to paying benefits, and can only be appealed under the procedures in the Care Management Services Section A pre notification cannot be appealed under the Plan's Claims Procedure. NOTE: ALL BENEFIT MAXIMUMS,DEDUCTIBLES AND OUT-OF-POCKET AMOUNTS ACCUMULATE ON A CALENDAR YEAR BASIS. Deductibles/Copayments payable by Plan Participants Deductibles/Copayments are dollar amounts that the Covered Person must pay before the Plan pays. A deductible is an amount of money that is paid once a Calendar Year per Covered Person.Typically,there is one deductible amount per Plan and it must be paid before any money is paid by the Plan for any covered services. Each January I at a new deductible amount is required.However,covered expenses incurred in,and applied toward the deductible in October,November and December will be applied to the deductible in the next Calendar Year as well as the current Calendar Year. Deductibles do not accrue toward the 100'1 maximum out-of-pocket payment. A copayment is a smaller amount of money that is paid each time a particular service is used.Typically,there may be copayments on some services and other services will not have any copayments. Copaymems do not accrue toward the 100.16 maximum out-of-packet payment. Copayments do not accrue toward the deductible. Deductibles,per Calendar Year Per Covered Person.............................................................................................. $400 PerFamily Unit.................................................................................................... $800 Maximum out-of-pocket payments,per Calendar Year The Plan will pay the percentage of Covered Charges designated until the following amounts of out-of-pocket payments are reached,at which time the Plan will pay 100%of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. Per Covered Person.............................................................................................. $1,500 Jefferson county 3 July 1,2015 The charges for the following do not apply to the 100%benefit limit and are never paid at 100%. (1) Deductible(s) (2) Copayments (3) Prescription copayments and prescription charges SUPPLEMENTARY ACCIDENT CHARGE BENEFITS Maximum benefit per accident............................................................................. first$400,payable at 100%,deductible waived Following are other maximums on individual benefits: Hospital Room and Board— Daily l imit............................................................................................................ the average semiprivate room rate Reimbursement rate............................................................................................. 800/6 after deductible Intensive Care Unit— Daily limit............................................................................................................ Hospital's ICU Charge Reimbursement rate............................................................................................. 801/9 after deductible When inpatient Hospital services are provided in Billings,MT it is required that Billings Clinic be utilized in order for benefits to be payable under the Plan.Inpatient Hospital services vrovided at any other full-service intensive care Hospital will be considered inelieible for payment. If these services cannot be provided at the above referenced full-service intensive care Hospitals,charges incurred at another full-service intensive care Hospital will be eligible for payment. In all other regions of the State of Montana any Hospital may be utilized for inpatient Hospital services and charges will be eligible for payment under the Plan,including inpatient Hospital charges incurred outside of the State of Montana Emergency care can be provided at any facility.When in Billings,MT if an inpatient Hospital stay is required for a Medical Emergency,the patient will need to be moved to the above referenced facilities after the patient has been stabilized and the move is deemed medically appropriate by the attending Physician. Ambulance Service— Reimbursement rate............................................................................................. 8016 after deductible Applied Behavioral Analysis—(for covered Dependent children from birth through 18 years only) Reimbursement rate............................................................................................. 8010 after deductible Calendar Year maximums Birththrough 8 years .......................................................................................... $50,000 9 years through 18 years...................................................................................... $20,000 Jefferson County 4 July 1,2015 Diabetes Education— Reimbursement rate............................................................................................. 80%after deductible Calendar Year maximum..................................................................................... 4 Visits Down Syndrome Therapies—(for covered Dependent children from birth up to age 19 only) Reimbursement rate............................................................................................. 80%after deductible Calendar Year maximums Occupational therapy visits ............................................................................. 52 visits Physical therapy visit........................................................................................ 52 visits Speech therapy visit.......................................................................................... 104 visits Durable Medical Equipment,Prosthetics and Orthotics— Reimbursement rate............................................................................................. 80%after deductible CPAP Device—(This benefit is for the CRAP machine only.Any ancillary items will be payable the same as any other Covered Charge). Reimbursement rate............................................................................................. 100%,no deductible applies Calendar Year maximum..................................................................................... $1,000;thereafter 80% after deductible Home Health Care— Reimbursement rate............................................................................................. 80%after deductible Home Infusion Therapy— Reimbursement rate............................................................................................. 80°/a after deductible Hospice Care— Reimbursement rate............................................................................................. 801/a after deductible Mental Disorders and Substance Abuse Treatment— Inpatient services................................................................................................. 80%after deductible Outpatient visits .................................................................................................. First 5 visits 100%after $20 copayment (combined visits"),no deductible applies; thereafter,80%after deductible *Combined Physician Office Visits,Mental Disorders and Substance Abuse outpatient visits,per Calendar Year. Jefferson County 5 July 1.2015 Occupational Therapy- Reimbursement rate............................................................................................. 80%after deductible Organ Transplant Coverage Limits— Reimbursement rate............................................................................................. 80*/*after deductible Transportation and lodging Per transplant procedure............................................................................................ $10,000 Lodging and meals Per transplant procedure............................................................................... $200 per day Physical Therapy— Reimbursement rate............................................................................................. 80%after deductible Physician Services— invatient Reimbursement rate............................................................................................. 80%after deductible Office visit Reimbursement rate............................................................................................. First 5 visits 1000/6 after $20 copayment (combined visits*),no deductible applies; thereafter,80%after deductible *Combined Physician Mice Visits,Mental Disorders and Substance Abuse outpatient visits,per Calendar Year. Surgical services Reimbursement rate............................................................................................. 80%after deductible Allerev Testing Reimbursement rate............................................................................................. 80%after deductible Allerev serum and infections Reimbursement rate............................................................................................. 80%after deductible Pregnancy Benefits— Reimbursement rate............................................................................................. 80%after deductible Preventive Care— Routine Well Care—An 8 and over Jefferson County 6 July 1,2015 Reimbursement rate................................................................................................... 100%,no deductible applies Calendar Year maximum........................................................................................... $500;thereafter 801/6 after deductible Coverage includes but is not limited to: Office visits,gynecological examination,routine physical examination, immunizations/vaccinations,x-rays,and laboratory tests. Prostate screening,marnmouams.Pao smear(lab services only) Reimbursement rate................................................................................................... IW/u,no deductible applies Routine and diagnostic Siamoidosconv/Colonoscouv Reimbursement rate................................................................................................... 100% no deductible applies Calendar Year maximum........................................................................................... $1,500;thereafter 80'/0 after deductible Routine Well Child Care—Birth through age 7 Reimbursement rate................................................................................................... 100%0,no deductible applies Coverage includes the Allowable Charges for Well Child Care and includes one visit per provider per day. Well Child Care means Physician-delivered or Physician-supervised services and includes the following: - Routine office visits,routine physical exam,history,developmental assessment,anticipatory guidance,routine laboratory tests and x-rays,not to exceed 10 visits from birth up to age 2 years, and one visit annually thereafter through age 7 years;and - Routine immunizations to include the schedule for immunizations recommended by the immunization practices advisory committee of the U.S.Department of Health and Human Services. "Developmental assessment"and"anticipatory guidance"mean the services described in the Guidelines for Health Supervision II,published by the American Academy of Pediatrics. Skilled Nursing Facility— Daily limit............................................................................................................ the facility's average semiprivate room rate Reimbursement rate............................................................................................. 80%after deductible Calendar Year maximum..................................................................................... 60 days Smoking Cessation benefit— Reimbursement rate............................................................................................. 80%after deductible Lifetime maximum............................................................................................... one 3-month supply of prescription or over-the- counter products or medications Jefferson County 7 July 1,2015 Speech Therapy— Reimbursement rate............................................................................................. 80%after deductible Spinal Manipulation/Chiropractic— Reimbursement rate............................................................................................. 800/6 after deductible Calendar Year maximum..................................................................................... 35 visits Maximum benefit per visit................................................................................... $25 Laboratory and diagnostic x-rays ordered by a chiropractor will be payable subject to the separate Diagnostic Lab and X-ray benefit. Well Newborn Care Limits— Reimbursement rate............................................................................................. 80%after deductible All Other Eligible Charges— Reimbursement rate............................................................................................. 80%after deductible Jefferson County B July 1,2015 PRESCRIPTION DRUG BENEFITS As administered by Navitus Retail Prescription Drug Option—Limited to a 34-day supply Copayment,per Prescription.No deductible will apply. Genericdrugs....................................................................................................... $0 NameBrand drugs............................................................................................... 40% Name Brand drugs without a Generic equivalent................................................ 20% Mail Order Prescription Drug Option—Limited to a 90-day supply Copayment,per Prescription.No deductible will apply. Genericdrugs....................................................................................................... $0 NameBrand drugs............................................................................................... 40% Name Brand drugs without a Generic equivalent................................................ 20% Additional information on Prescription Drug Benefits may be found in the Nescr4nion Drug Benefits section of this document Jefferson County 9 July I,2015 DENTAL BENEFITS Dental Percentage Payable Class A Services— Preventive............................................................................................................ 100%,no deductible Class B Services— Basic..................................................................................................................... 80%,no deductible Class C Services— Major.................................................................................................................... 50%,no deductible Maximum Benefit Amount For Class A services,age 18 and under: Per person per Calendar Year.............................................................................. No maximum For Class A services for Covered Persons age 19 and over;and Class B and C services for pal Covered Persons: Per person per Calendar Year.............................................................................. $1,000 Additional information on Dental Benefits may be found In the Dental Benefits section of this document Jefferson Comuy 10 July 1,2015 VISION CARE BENEFITS Calendar Year maximum benefit—Covered Persons age 19 and over Examination and hardware maximum,per Calendar Year........................... $500 Reimbursement: Eye exam,per Covered Person,: Reimbursement rate...................................................................................... 1001/o,no deductible Limited to...................................................................................................... One(1)examination per Calendar Year Frame-type lenses,per Covered Person: Reimbursement rate...................................................................................... 100'/0,no deductible Limited to...................................................................................................... One(1)pair per Calendar Year Frames,per Covered Person: Reimbursement rate...................................................................................... 1001/0,no deductible Limited to...................................................................................................... One(1)pair per two(2) Calendar Years Contact Lenses per Covered Person: Reimbursement rate...................................................................................... 100%,no deductible Limited to...................................................................................................... 12 month supply Per eye, per Calendar Year Examination and Hardware—Covered Persons age 18 and under Reimbursement: Eye exam,per Covered Person,: Reimbursement rate ...................................................................................... 1000/6,no deductible Limited to...................................................................................................... One(1)examination per Calendar Year Frame-type lenses,per Covered Person: Reimbursement rate...................................................................................... I00%,no deductible Limited to...................................................................................................... One(1)Pair Per Calendar Year Frames,per Covered Person: Reimbursement rate...................................................................................... 100%,no deductible Limited to...................................................................................................... One(1)pair per two(2) Calendar Years Contact Lenses per Covered Person: Reimbursement rate...................................................................................... 100%,no deductible Limitedto...................................................................................................... 12 month supply Per eye, per Calendar Year Additional Information on Vision Benefds may be found In the Vision Benefrts section of this document Jefferson County I I July 1,2015 SUPPLEMENTARY ACCIDENT CHARGE BENEFITS This benefit applies when an accident charge is incurred for care and treatment of a Covered Person's Injury and: (1) The Injury is sustained while the person is covered for these benefits;and (2) The charge is for a service initiated within 72 hours and completed within 90 days of the date of the accident;and (3) To the extent that the charge is not payable under any other benefits under the Plan(other than Medical Benefits). BENEFIT PAYMENT Benefits will be paid as described in the Schedule of Benefits. ACCIDENT CHARGE An accident charge is an Allowable Charge incurred for the following: (1) Physician services (2) Hospital care and treatment (3) Diagnostic x-rays and lab tests (4) Local professional ambulance service (5) Surgical dressings,splints and casts and other devices used in the reduction of fractures and dislocations (6) Nursing service (7) Anesthesia (8) Covered Prescription Drugs (9) Use of a Physician's office or clinic operating room Jefferson County 12 July 1,2015 ELIGIBILITY,FUNDING,EFFECTIVE DATE AND TERMINATION PROVISIONS A Plan Participant should contact the Claims Administrator to obtain additional information,free of charge, about Plan coverage of a specific benefit,particular drug,treatment,test or any other aspect of Plan benefits or requirements. ELIGIBILITY Eligible Classes of Employees. All Active and Retired Employees of the Employer. All elected officials of the Employer. Eligibility Requirements for Employee Coverage.A person is eligible for Employee coverage from the first day that he or she: (1) Is a Full-Time,Active Employee of the Employer.An Employee is considered to be Full-Time if he or she normally works at least 128 hours per month and is on the regular payroll of the Employer for that work. (2) Is in a class eligible for coverage. (3) Completes the employment Waiting Period of 30 consecutive days as an Active Employee.A "Waiting Period"is the time between the first day of employment and the first day of coverage under the Plan. Eligibility Requirements for Elected Official Coverage. A Person is eligible for elected official coverage from the first day and throughout the time that he or she: (1) Officially functions in the office to which he or she was elected. For purposes of this Plan,such an elected official shall be considered a Full-Time,Active Employee of the Employer. Eligibility Requirements for Retired Employee Coverage. (1) A person is eligible for Retired Employee coverage as long as he or she was a Covered Person under the Plan on the day immediately before the date of retirement and retired pursuant to the terms of the Public Employees Retirement laws and is eligible for coverage pursuant to the terms of 2-18-704,MCA,as amended from time to time or was eligible for retirement under the terms and conditions of the employment policies and practices of the Employer. In all cases,upon retirement,an Employee can choose between COBRA Continuation Coverage or continuing under the terms of the Plan as a Retired Employee if the Retired Employee satisfies the criteria as set forth above. If the Employee is eligible and chooses to continue coverage under the terms of the Plan as Retired Employee,he or she will forfeit his or her right to elect COBRA Continuation Coverage at a later date.In the event the Employee chooses to continue under the terms of the Plan as a Retired Employee,the Employee and his or her Spouse and Dependent children who are active Plan Participants at the time of the Employee's retirement with the Employer,may remain eligible for coverage up to the limitations as stated under the Plan providing enrollment is made on a timely basis as defined in the section "Timely Enrollment-in the Enrollment section of this Plan. Joffe County 15 July 1,2015 Eligible Classes of Dependents.A Dependent is any one of the following persons: (1) A covered Employee's or Retired Employee's Spouse or Domestic Partner and children from birth to the limiting age of 26 years. If an otherwise eligible Dependent is not the covered Employee's true tax dependent as defined by the Internal Revenue Service(IRS), benefits for that Dependent will NOT be provided on a lax- free basis and therefore, the Employee may be required to pay the cost of the benefits on an after- tax basis and the employee may,be subject to additional tax consequences. The term"Spouse"shall mean a person of the opposite or same sex recognized as the covered Employee's husband or wife by the laws of the state in which the marriage was formalized. Spouse will not include a common-law Spouse.The Plan Administrator may require documentation proving a legal marital relationship. The term"Domestic Partner"shall mean a person of either opposite sex or of the same sex meeting the following criteria:Share an intimate,exclusive committed personal relationship of mutual caring;are not related by blood closer than permitted under marriage laws of the state;are not married;are not acting under fraud or duress,and who are both at least 18 years old and competent to enter into a contract;have no other Domestic Partner nor had a different Domestic Partner in the last 12 consecutive months;shared the same principle residence for the last 12 consecutive months;are jointly responsible for each other's basic living expenses and agree that anyone who is owed for these expenses can collect from either person;and each declares in writing,under penalty of perjury,that she or he is the other's Domestic Partner.All references to Spouse will also be applicable to a Domestic Partner, unless otherwise indicated. The tern"children"shall include natural children or stepchildren of the covered Employee, Retiree or Domestic Partner,adopted children,children placed with the covered Employee, Retiree or Domestic Partner in anticipation of adoption or Foster Children.When the child reaches the applicable limiting age,coverage will end on the last day of the child's birthday month. If a covered Employee or Retiree is the Legal Guardian of a child or children,these children may be enrolled in this Plan as covered Dependents.The Plan Administrator may require documentation proving a legal guardianship. The phrase"child placed with a covered Employee,Retiree or Domestic Partner in anticipation of adoption"refers to a child whom the Employee,Retiree or Domestic Partner intends to adopt,whether or not the adoption has become final,who has not attained the age of 18 as of the date of such placement for adoption.The term"placed"means the assumption and retention by such Employee,Retiree or Domestic Partner of a legal obligation for total or partial support of the child in anticipation of adoption of the child.The child must be available for adoption and legal process must have commenced. Please be advised, the definition of"Dependent"for purposes of group health plan eligibility may not allow for tax-free benefits for all eligible "Dependents". For more information questions or concerns,please contact your tax advisor. Any child of a Plan Participant who is an alternate recipient under a Qualified Medical Child Support Order(QMCSO)shall be considered as having a right to Dependent coverage under this Plan. A participant of this Plan may obtain,without charge,a copy of the procedures governing QMCSO determinations from the Plan Administrator. The Plan Administrator may require documentation proving dependency,including birth certificates or initiation of legal proceedings severing parental rights. Jefferson County 14 July 1,2015 (2) A covered Dependent child who reaches the limiting age and is Totally Disabled,incapable of self-sustaining employment by reason of mental or physical handicap,primarily dependent upon the covered Employee,Retiree or Domestic Partner for support and maintenance and unmarried. The Plan Administrator may require,at reasonable intervals during the two years following the Dependent's reaching the limiting age,subsequent proof of the child's Total Disability and dependency. After such two-year period,the Plan Administrator may require subsequent proof not more than once each year.The Plan Administrator reserves the right to have such Dependent examined by a Physician of the Plan Administrators choice,at the Plan's expense,to determine the existence of such incapacity. These persons are excluded as Dependents:other individuals living in the covered Employee's or Retiree's home,but who are not eligible as defined;the legally separated or divorced former Spouse of the Employee or Retiree;any former Domestic Partner of the Employee;or any person who is covered under the Plan as an Employee or Retiree. If a person covered under this Plan changes status from Employee to Dependent or Dependent to Employee, and the person is covered continuously under this Plan before,during and after the change in status,credit will be given for deductibles and all amounts applied to maximums. If both husband and wife are Active Employees,they may each be covered as both an Employee and a Dependent of the other. In addition, if both mother and father or Domestic Partner are Active Employees, their children may be covered as Dependents of both the mother and father or Domestic Partner. Eligibility Requirements for Dependent Coverage.A family member of an Employee will become eligible for Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family member satisfies the requirements for Dependent coverage. At any time,the Plan may require proof that a Spouse,Domestic Partner,Qualified Dependent or a Child qualifies or continues to qualify as a Dependent as defined by this Plan. Eligibility Requirements for Dependent Coverage.A family member of an Employee will become eligible for Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family member satisfies the requirements for Dependent coverage. At any time,the Plan may require proof that a Spouse or a child qualifies or continues to qualify as a Dependent as defined by this Plan. FUNDING Cost of the Plan.The level of any Employee contributions is set by the Employer. ENROLLMENT Enrollment Requirements.An Employee must enroll for coverage by filling out and signing an enrollment application along with the appropriate payroll deduction authorization.The covered Employee is required to enroll for Dependent coverage also. To continue coverage under the Plan as a Retired Employee, an Employee must enroll for Retired Employee coverage(including eltgible Dependent coverage)by filling out and signing an enrollment application within 31 days from the date the Employee meets the Retired Employee requirements as stated in the Eligibility Requirements section of this Plan. Enrollment Requirements for Newborn Children. A newborn child of a covered Employee is not automatically enrolled in this Plan. There is a 31 day enrollment period beginning on the date of birth. If enrolled within the first 31 days,coverage will be Jefferson Comity 15 July 1,2015 retroactive to the date of birth. if the newborn child is not enrolled in this Plan during the initial 31-day enrollment period,the enrollment will be considered a Late Enrollment,there will be no payment from the Plan and the covered parent will be responsible for all costs. (Refer to the Late Enrollment and Open Enrollment sections below.)Any applicable premium will be charged starting with the month the baby is bom if added to the policy TIMELY,LATE OR OPEN ENROLLMENT (1) Timely Enrollment-The enrollment will be"timely"if the completed form is received by the Claims Administrator no later than 31 days after the person becomes eligible for the coverage,either initially or under a Special Enrollment Period. If two Employees or Retired Employees(mother and father,or Domestic Partner)are covered under the Plan and the Employee or Retired Employee who is covering the Dependent children terminates coverage,the Dependent coverage may be continued by the other covered Employee or Retired Employee with no Waiting Period as long as coverage has been continuous. (2) Late Enrollment—An enrollment is"late"if it is not made on a`timely basis"or during a Special Enrollment Period Late Enrollees and their Dependents who are not eligible to join the Plan during a Special Enrollment Period may join only during open enrollment. If an individual loses eligibility for coverage as a result of terminating employment,reduction of hours of employment,or a general suspension of coverage under the Plan,then upon becoming eligible again due to resumption of employment or due to resumption of Plan coverage,only the most recent period of eligibility will be considered for purposes of determining whether the individual is a Late Enrollee. The time between the date a Late Enrollee first becomes eligible for enrollment under the Plan and the first day of coverage is not treated as a Waiting Period. Coverage begins as stated in the Open Enrollment provision. (3) Open Enrollment.Every June,the annual open enrollment period,Employees and their Dependents who are Late Enrollees will be able to enroll in the Plan. Benefit choices for Late Enrollees made during the open enrollment period will become effective July 1. Plan Participants will receive detailed infomlation regarding open enrollment from their Employer. (4) Enrollment Folbwing a Benefit Measurement Period.Employees who were determined to be Full- Time Active Employees during the applicable measurement period(and their eligible Dependents) may enroll in the Plan the first day of the first full calendar month of the following stability period. SPECIAL ENROLLMENT RIGHTS Federal law provides Special Enrollment provisions under some circumstances.If an Employee is declining enrollment for himself or herself or his or her dependents(including their spouse)because of other health insurance or group health plan coverage,there may be a right to enroll in this Plan if there is a loss of eligibility for that other coverage(or if the employer stops contributing towards the other coverage).However, a request for enrollment must be made within 31 days after the coverage ends(or after the employer stops contributing towards the other coverage). In addition,in the case of a birth,marriage,adoption or placement for adoption,there may be a right to enroll in this Plan.However,a request for enrollment must be made within 31 days after the birth,marriage, Domestic Partner,adoption or placement for adoption. The Special Enrollment rules are described in more detail below.To request Special Enrollment or obtain more detailed information of these portability provisions,contact the Plan Administrator. Jefferson Canty 16 July I,2015 SPECIAL ENROLLMENT PERIODS The Enrollment Date for anyone who enrolls under a Special Enrollment Period is the first date of coverage. Thus,the time between the date a special enrollee first becomes eligible for enrollment under the Plan and the first day of coverage is riot treated as a Waiting Period.(Note.A Retired Employee who declines coverage at retirement and later loses other coverage will not be entitled to special enrollment, nor will the Retired Emplo)ee's eligible Spouse,Domestic Partner, or Dependent children.) (1) Individuals losing other coverage creating a Special Enrollment right.An Employee or Dependent who is eligible,but not enrolled in this Plan,may enroll if loss of eligibility for coverage meets all of the following conditions(Note:the following provisions will not be applicable to a Retired Employee and/or their Spouse,Domestic Partner,or Dependent children): (a) The Employee or Dependent was covered under a group health plan or had health insurance coverage at the time coverage under this Plan was previously offered to the individual. (b) If required by the Plan Administrator,the Employee stated in writing at the time that coverage was offered that the other health coverage was the reason for declining enrollment. (c) The coverage of the Employee or Dependent who had lost the coverage was under COBRA and the COBRA coverage was exhausted,or was not under COBRA and either the coverage was terminated as a result of loss of eligibility for the coverage or because employer contributions towards the coverage were terminated.Coverage will begin no later than the first day of the first calendar month following the date the completed enrollment form is received. (d) The Employee or Dependent requests enrollment in this Plan not later than 31 days after the date of exhaustion of COBRA coverage or the termination of non-COBRA coverage due to loss of eligibility or termination of employer contributions,described above. Coverage will begin no later than the first day of the first calendar month following the date the completed enrollment form is received. (2) For purposes of these rules,a loss of eligibility occurs if one of the following occurs: (I) The Employee or Dependent has a loss of eligibility due to the plan no longer offering any benefits to a class of similarly situated individuals(i.e.:part-time employees). (ii) The Employee or Dependent has a loss of eligibility as a result of legal separation, divorce,cessation of dependent status(such as attaining the maximum age to be eligible as a dependent child under the plan),death,termination of employment,or reduction in the number of hours of employment or contributions towards the coverage were terminated. (iii) The Employee or Dependent has a loss of eligibility when coverage is offered through an HMO,or other arrangement,in the individual market that does not provide benefits to individuals who no longer reside,live or work in a service area,(whether or not within the choice of the individual). (iv) The Employee or Dependent has a loss of eligibility when coverage is offered through an HMO,or other arrangement,in the group market that does not provide benefits to individuals who no longer reside,live or work in a service area,(whether or not within the choice of the individual),and no other benefit package is available to the individual. Jeffers C"* 17 July t,2015 If the Employee or Dependent lost the other coverage as a result of the individual's failure to pay premiums or required contributiow or for cause(such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan),that individual does not have a Special Enrollment right (3) Dependent beneficiaries, IP (a) The Employee is a participant under this Plan(or has met the Waiting Period applicable to becoming a participant under this Plan and is eligible to be enrolled under this Plan but for a failure to enroll during a previous enrollment period),or (b) The Retired Employee is a participant under this Plan;and (c) A person becomes a Dependent of the Employee or Retired Employee through marriage, registration of Domestic Partnership,birth,adoption or placement for adoption, then the Dependent(and if not otherwise enrolled,the Employee)may be enrolled under this Plan. In the case of the birth or adoption of a child,the Spouse or Domestic Partner of the covered Employee may be enrolled as a Dependent of the covered Employee if the Spouse or Domestic Partner is otherwise eligible for coverage. In the case of marriage, birth, adoption or placement for adoption, the Spouse,Domestic Partner, or Dependent of a covered Retired Employee may be enrolled as a Spouse,Domestic Partner or Dependent of the covered Retired Employee ifthe Spouse, Domestic Partner•, or Dependent is otherwise eligible for coverage under the Plan. If the Employee is not enrolled at the time of the event,the Employee must enroll under this Special Enrollment Period in order for his eligible Dependents to enroll.If the Retiree is not enrolled at the time of he event, this Special Enrollment right will not be applicable. The Dependent Special Enrollment Period is a period of 31 days and begins on the date of the marriage,the date of registration of Domestic Partnership or the date of Foster Child placement birth,adoption or placement for adoption.To be eligible for this Special Enrollment,the Dependent and/or Employee or Retired Employee must request enrollment during this period. The coverage of the Dependent and/or Employee or Retired Employee enrolled in the Special Enrollment Period will be effective: (a) In the case of marriage,the day of marriage,or (b) In the case of Domestic Partner relationship,on the date of registration of the domestic partner relationship;or (c) In the case of a Dependents birth,as of the date of birth;or (d) In the case of a Dependents adoption,placement for adoption,or Foster Child placement, the date of the adoption,placement for adoption,or Foster Child placement. Children's Health Insurance Program Reauthorization Act of 2009(CHIPRA) Employees and their Dependents who are otherwise eligible for coverage under the Plan but who are not enrolled can enroll in the Plan provided that they request enrollment in writing within sixty(60)days from the date of the following loss of coverage or gain in eligibility: Jefferson CMUq 18 My I,2015 (a) The eligible person ceases to be eligible for Medicaid or Children's Health Insurance Program(CHIP) coverage;or (b) The eligible person becomes newly eligible for a premium subsidy under Medicaid or CHIP. If eligible,the Dependent(and if not otherwise enrolled,the Employee)may be enrolled under this Plan. This Dependent Special Enrollment Period is a period of 60 days and begins on the date of the loss of coverage under the Medicaid or CHIP plan OR on the date of the determination of eligibility for a premium subsidy under Medicaid or CHIP. To be eligible for this Special Enrollment,the Employee must request enrollment in writing during this 60-day period. The effective date of coverage will begin the first day of thefirst calendar month following the date of loss of coverage or gain in eligibility. If a State in which the Employee lives offers any type of subsidy,this Plan shall also comply with any other State laws as set forth in statutes enacted by State legislature and amended from time to time,to the extent that the State law is applicable to the Plan,the Employer and its Employees. For more information regarding special enrollment rights, contact the Plan Administrator. EFFECTIVE DATE Effective Date of Employee Coverage.An Employee will be covered under this Plan as of the first day of the calendar month following the date that the Employee satisfies all of the following: (1) The Eligibility Requirement. (2) The Active Employee Requirement. (3) The Enrollment Requirements of the Plan. Active Employee Requirement. An Employee must be an Active Employee(as defined by this Plan)for this coverage to take effect Effective Date of Dependent Coverage.A Dependent's coverage will take effect on the day that the Eligibility Requirements are met;the Employee is covered under the Plan;and all Enrollment Requirements are met. TERMINATION OF COVERAGE The Employer or Plan has the right to rescind any coverage of the Employee and/or Retired Employee and/or Dependents for cause, making a fraudulent claim or an intentional material misrepresentation in applying for or obtaining coverage,or obtaining benefits under the Plan. The Employer or Plan may either void coverage for the Employee and/or covered Retired Employees and/or covered Dependents for the period of time coverage was in effect, may terminate coverage as of date to be determined at the Plan's discretion, or may immediately terminate coverage. The employer will refund all contributions paid for any coverage rescinded,• however, claims paid will be offset from this amount. The employer reserves the right to collect additional monies if claims are paid in excess of the Employee's and/or Retired Employee's and/or Dependent's paid contributions. When Employee Coverage Terminates.Employee coverage will terminate on the earliest of these dates: (1) The date the Plan is terminated; (2) The date the covered Employee's employer ceases to be a covered Employer,if applicable; (3) The date the covered Employee's Eligible Class is eliminated; Jefferson County 19 July 1,2015 (4) The last day of the calendar month in which the covered Employee ceases to be in one of the Eligible Classes or, if applicable, the last day of the stability period for which the covered Employee met the required minimum hours ofservice established by the Employer.This includes death or termination of Active Employment of the covered Employee.(See the section entitled COBRA Continuation Coverage.) It also includes an Employee on disability,leave of absence or other leave of absence,unless the Plan specifically provides for continuation during these periods; (S) The end of the period for which the required contribution has been paid if the charge for the next period is not paid when due; (6) If the Employee commits fraud or makes an intentional material misrepresentation in applying for or obtaining coverage,or obtaining benefits under the Plan,then the Employer or Plan may either void coverage for the Employee and covered Dependents for the period of time coverage was in effect,may terminate coverage as of a date to be determined at the Plan's discretion,or may immediately terminate coverage;or (7) As otherwise specified in the Eligibility section of this Plan. Note: Except in certain circumstances,a covered Employee may be eligible for COBRA continuation coverage.For a complete explanation of when COBRA continuation coverage is available,what conditions apply and how to select it see the section entitled COBRA Continuation Coverage. Continuation During Periods of Employer-Certified Disability.A person may remain eligible for a limited time if Active,full-time work ceases due to disability.This continuance will end as follows: For disability leave only:the end of the three calendar month period that next follows the month in which the person last worked as an Active Employee. The above disability leave continuation provision will run concurrently with COBRA Continuation Coverage.(See the Continuation Coverage Rights under COBRA.) While continued,coverage will be that which was in force on the last day worked as an Active Employee. However,if benefits reduce for others in the class,they will also reduce for the continued person. Continuation During Family and Medical Leave.Regardless of the established leave policies mentioned above,this Plan shall at all times comply with the Family and Medical Leave Act of 1993(FMLA)as promulgated in regulations issued by the Department of Labor,if,in fact,FMLA is applicable to the Employer and all of its Employees and locations.This Plan shall also comply with any other State leave laws as set forth in statutes enacted by State legislature and amended from time to time,to the extent that the State leave law is applicable to the Employer and all of its Employees. Leave taken pursuant to any other State leave law shall run concurrently with leave taken under FMLA,to the extent consistent with applicable law. If applicable,during any leave taken under the FMLA and/or other State leave law,the Employer will maintain coverage under this Plan on the same conditions as coverage would have been provided if the covered Employee had been continuously employed during the entire leave period. If Plan coverage terminates during the FMLA,coverage will be reinstated for the Employee and his or her covered Dependents if the Employee returns to work in accordance with the terms of the FMLA and/or other State leave law.Coverage will be reinstated only if the person(s)had coverage under this Plan when the FMLA leave started,and will be reinstated to the same extent that it was in force when that coverage terminated. Rehiring a Terminated Employee.A terminated Employee who is rehired prior to the end of a 13 consecutive week period after the date of termination will have coverage reinstated the first day of the first calendar month following the date of rehire.Employees rehired after a break in service of 13 consecutive weeks or more will be treated as a new hire. Joffe County 20 Jury 1,2015 However,if the Employee is returning to work directly from COBRA coverage,this Employee will be credited with time met towards the employment Waiting Period as of the date the Employee elected COBRA continuation coverage. Employees on Military Leave.Employees going into or returning from military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act under the following circumstances.These rights apply only to Employees and their Dependents covered under the Plan before leaving for military service. (1) The maximum period of coverage of a person under such an election shall be the lesser of (a) The 24-month period beginning on the date on which the person's absence begins;or (b) The day after the date on which the person was required to apply for or return to a position of employment and fails to do so. (2) A person who elects to continue health plan coverage may be required to pay up to 102%of the full contribution under the Plan,except a person on active duty for 30 days or less cannot be required to pay more than the Employee's share,if any,for the coverage. (3) An exclusion or Waiting Period may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated because of service.However,an exclusion or Waiting Period may be imposed for coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been incurred in,or aggravated during,the performance of uniformed service. If the Employee wishes to elect this coverage or obtain more detailed information,contact the Plan Administrator. The Employee may also have continuation rights under USERRA.In general,the Employee must meet the same requirements for electing USERRA coverage as are required under COBRA continuation coverage requirements.Coverage elected under these circumstances is concurrent not cumulative.The Employee may elect USERRA continuation coverage for the Employee and their Dependents.Only the Employee has election rights.Dependents do not have any independent right to elect USERRA health plan continuation. Montana National Guard Members. Participants performing State active duty as a Montana National Guard member may elect to continue Plan coverage subject to the terms of the Montana Military Service Employment Rights Act(MMSERA)under the following circumstances: (I) The period of coverage ofa person under such an election shall be the period of time beginning on the date on which the person's absence for State active duty begins,and ending: (a) The next regularly scheduled day of employment following travel time plus 8 hours,if State active duty is 30 days or less;or (b) The next regularly scheduled day of employment following 14 days after termination of State active duty,if State active duty is not more than 180 days;or (c) The next regularly scheduled day of employment following 90 days after termination of State active duty,if State active duty is more than 180 days. (2) A person who elects to continue health plan coverage may be required to pay up to 102%of the full contribution under the Plan,except that a person on State active duty for less than 180 days may not be required to pay more than the regular Participant's share, if any,for the coverage. (3) An exclusion or Waiting Period may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated because of Jefferson County 21 July 1,2015 service.However,an exclusion or Waiting Period may be imposed for coverage of any Illness or Injury determined by the Montana Department of Military Affairs to have been caused by or aggravated during,performance of State active duty. When Retired Employee Coverage Terminates.Retired Employee coverage will terminate on the earliest of these dates: (1) The date the Plan is terminated; (2) The date the covered Retired Employee's Eligible Class is eliminated; (3) The date of the death of the covered Retired Employee; (4) The day the covered Retired Employee becomes a participant in another group plan with substantially equivalent benefits and rates,or becomes employed and therefore eligible to participate in another group plan with substantially equivalent benefits and rates; (5) The end of the period for which the required contribution has been paid if the charge for the next period is not paid when due; (6) If a Retired Employee commits fraud or makes an intentional material misrepresentation in applying for or obtaining coverage,or obtaining benefits under the Plan,then the Employer or Plan may either void coverage for the Retired Employee and covered Dependents for the period of time coverage was in effect,may terminate the coverage as of a date to be determined at the Plan's discretion,or may immediately terminate coverage;or ('n As otherwise specified in the Eligibility section of this Plan. When Dependent Coverage Terminates.A Dependent's coverage will terminate on the earliest of theme dates: (1) The date the Plan or Dependent coverage under the Plan is terminated; (2) The date that the Employee's coverage under the Plan terminates for any reason including death. (See the section entitled COBRA Continuation Coverage.); (3) The last day of the month a covered Spouse or Domestic Partner loses coverage due to loss of eligibility status.(See the section entitled Continuation Coverage Rights under COBRA.)In the even the Domestic Partnership is terminated either partner is required to inform the Plan Administrator of the termination of the Domestic Partnership. (4) On the last day of the calendar month that a Dependent child ceases to be a Dependent as defined by the Plan.(See the section entitled COBRA Continuation Coverage.); (5) The end of the period for which the required contribution has been paid if the charge for the next period is not paid when due; (6) If a Dependent commits fraud or makes an intentional material misrepresentation in applying for or obtaining coverage,or obtaining benefits under the Plan,then the Employer or Plan may either void coverage for the Dependent for the period of time coverage was in effect,may terminate coverage as of a date to be determined at the Plan's discretion,or may immediately terminate coverage;or ('n As otherwise specified in the Eligibility section of this Plan. Jefferson Canty 22 July 1,2013 Note: A covered Dependent may be eligible for COBRA continuation coverage.For a complete explanation of when COBRA continuation coverage is available,what conditions apply and how to select it,see the section entitled COBRA Continuation Coverage. The Spouse of a covered Retired Employee may remain a member of the Plan unless a participant in another group plan with substantially equivalent benefits and rates,or employed and therefore eligible to participate in another group plan with substantially equivalent benefits and rates. Surviving Dependent of Retired Employee Coverage. The surviving Spouse of a deceased covered Retired Employee may remain a member of the Plan as long as the Spouse is eligible for retirement benefits accrued by the deceased covered Retired Employee unless a participant in another group plan with substantially equivalent benefits and rates,or employed and therefore eligible to participate in another group plan with substantially equivalent benefits and rates. The surviving children of deceased covered Retired Employee may remain members of the Plan as long as they are eligible for retirement benefits accrued by the deceased covered Retired Employee unless they have equivalent coverage in another group plan with substantially equivalent benefits and rates,or unless employed and therefore eligible to participate in another group plan with substantially equivalent benefits and rates or are eligible for health coverage under a surviving parent's or legal guardian's employment plan. Persons meeting these requirements who wish to remain a member of the Plan must furnish satisfactory evidence of their qualifications to the Claims Administrator within 20 days after such eligibility commences and make arrangements for payment. Note: A covered Dependent may be eligible for COBRA continuation coverage.For a complete explanation of when COBRA continuation coverage is available,what conditions apply and how to select it,see the section entitled COBRA Continuation Coverage. Spouse of Retired Employee Coverage The Spouse of a Retired Employee may remain a member of the Plan as long as the Spouse was a Covered Person under the Plan on the day immediately before the date of the Retired Employee's retirement or the date the covered Retiree becomes Medicare eligible as a result of age(whether or not the Retiree enrolls in Medicare)unless the Spouse is eligible for Medicare as a result of age or has or is eligible for coverage in another group plan with substantially equivalent benefits and rates. Spouse of Retired Employee Coverage does not include children of the covered Spouse, covered Employe4 or covered Retired Employee. A covered Spouse meeting these requirements who wishes to remain a member of the Plan must furnish satisfactory evidence of their qualifications to the Claims Administrator within 20 days after such eligibility commences and make arrangements for payment. When Spouse of Retired Employee Coverage Terminates.Spouse of Retired Employee coverage will terminate on the earliest of these dates: (1) The date the Plan is tenninated; (2) The date the covered Spouse of Retired Employee becomes a participant in another group plan with substantially equivalent benefits and rates,or becomes employed and therefore eligible to participate in another group plan with substantially equivalent benefits and rates. (3) The last day of the calendar month in which the Spouse of Retired Employee becomes Medicare eligible(whether or not the Spouse of Retired Employee enrolls in Medicare)or has reached the limiting age; (4) The end of the period for which the required contribution has been paid if the charge for the next period is trot paid when due;or Jefferson County 23 July 1,2015 (5) If a Spouse of Retired Employee commits fraud or makes an intentional material misrepresentation in applying for or obtaining coverage,or obtaining benefits under the Plan, then the Employer or Plan may either void coverage for the Spouse of Retired Employee for the period of time coverage was in effect,may terminate coverage as of a date to be determined at the Plan's discretion,or may immediately terminate coverage; (6) As otherwise specified in the Eligibility section of this Plan. Jeff t n County 24 July 1,2015 MEDICAL BENEFITS Medical Benefits apply when Covered Charges are incurred by a Covered Person for care of an Injury or Sickness and while the person is covered for these benefits under the Plan. DEDUCTIBLE Deductible Amount.This is an amount of Covered Charges for which no benefits will be paid.Before benefits can be paid in a Calendar Year a Covered Person must meet the deductible shown in the Schedule of Benefits. This amount will not accrue toward the 100.16 maximum out-of-pocket payment Deductible Three Month Carryover.Covered expenses incurred in,and applied toward the deductible in October,November and December will be applied toward the deductible in the next Calendar Year. Family Unit Limit When the maximum amount shown in the Schedule of Benefits has been incurred by members of a Family Unit toward their Calendar Year deductibles,the deductibles of all members of that Family Unit will be considered satisfied for that year. Deductible For A Common Accident This provision applies when two or more Covered Persons in a Family Unit are injured in the same accident. These persons need not meet separate deductibles for treatment of injuries incurred in this accident;instead, only one deductible for the Calendar Year in which the accident occurred will be required for them as a unit for expenses arising from the accident BENEFIT PAYMENT Each Calendar Year,benefits will be paid for the Covered Charges of a Covered Person that are in excess of the deductible.Payment will be made at the rate shown under reimbursement rate in the Schedule of Benefits. No benefits will be paid in excess of any listed limit of the Plan. OUT-OF-POCKET LIMIT Covered Charges are payable at the percentages shown each Calendar Year until the out-of-pocket limit shown in the Schedule of Benefits is reached.Then,Covered Charges incurred by a Covered Person will be payable at 1000/9(except for the charges excluded)for the rest of the Calendar Year. When a Family Unit reaches the out-of-pocket limit,Covered Charges for that Family Unit will be payable at 100%(except for the charges excluded)for the rest of the Calendar Year. COVERED CHARGES Covered charges are the Allowable Charges that are incurred for the following items of service and supply. These charges are subject to the benefit limits,exclusions and other provisions of this Plan.A charge is incurred on the date that the service or supply is performed or furnished. (1) Hospital Care.The medical services and supplies furnished by a Hospital or Outpatient Surgical Center or a Birthing Center.Covered charges for room and board will be payable as shown in the Schedule of Benefits.After 23 observation hours,a confinement will be considered an inpatient confinement. Room charges made by a Hospital having only private rooms will be payable at the average private room rate of that facility. Charges for an Intensive Care Unit stay are payable as described in the Schedule of Benefits. Jefferson Cwnty 25 July 1,2015 (2) Coverage of Pregnancy.The Allowable Charges for the care and treatment of Pregnancy are covered the same as any other Sickness. Group health plans generally may not,under Federal law,restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery,or less than 96 hours following a cesarean section.However,Federal law generally does not prohibit the mother's or newborn's attending provider,after consulting with the mother,from discharging the mother or her newborn earlier than 48 hours(or 96 hours as applicable).In any case,plans and issuers may not,under Federal law,require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours(or 96 hours). (3) Skilled Nursing Facility Care.The room and board and nursing care furnished by a Skilled Nursing Facility will be payable if and when: (a) The patient is confined as a bed patient in the facility; (b) The confinement starts within 7 days of a Hospital confinement of at least 5 days; (e) The attending Physician certifies that the confinement is needed for further care of the condition that caused the Hospital confinement;and (d) The attending Physician completes a treatment plan which includes a diagnosis,the proposed course of treatment and the projected date of discharge from the Skilled Nursing Facility. Covered charges for a Covered Person's care in these facilities is limited to the covered daily maximum shown in the Schedule of Benefits. (4) Physician Care.The professional services of a Physician for surgical or medical services. (a) Charges for multiple surgical procedures will be a covered expense subject to the following provisions: (i) If bilateral or multiple surgical procedures are performed by one(1)surgeon, benefits will be determined based on the reasonable and customary charge that is allowed for the primary procedures;50%of the reasonable and customary charge will be allowed for each additional procedure performed through the same incision or during the same operative session.Any procedure that would not be an integral part of the primary procedure or is unrelated to the diagnosis will be considered"incidental"and no benefits will be provided for such procedures; (ii) If multiple unrelated surgical procedures are performed by two(2)or more surgeons on separate operative fields,benefits will be based on the reasonable and customary charge for each surgeon's primary procedure.If two(2)or more surgeons perform a procedure that is normally performed by one(1)surgeon, benefits for all surgeons will not exceed the reasonable and customary percentage allowed for that procedure;and (iii) If an assistant surgeon is required,the assistant surgeon's covered charge will not exceed 201/o of the surgeon's reasonable and customary allowance. (5) Home Health Care Services and Supplies.Charges for home health care services and supplies are covered only for care and treatment of an Injury or Sickness.The diagnosis,care and treatment must be certified by the attending Physician and be contained in a Home Health Care Plan. Jefferson Co iy 26 July 1,2015 Benefit payment for nursing,home health aide and therapy services is subject to the Home Health Care limit shown in the Schedule of Benefits. A home health care visit will be considered a periodic visit by either a nurse or therapist,as the case may be,or four hours of home health aide services. (6) Hospice Care Services and Supplies.Charges for hospice care services and supplies are covered only when the attending Physician has diagnosed the Covered Person's condition as being terminal,determined that the person is not expected to live more than six months and placed the person under a Hospice Care Plan. Covered charges for Hospice Care Services and Supplies are payable as described in the Schedule of Benefits. (7) Other Medical Services and Supplies.These services and supplies not otherwise included in the items above are covered as follows: (a) Abortion.Services,supplies,care or treatment in connection with an abortion. (b) Acupuncture.Medically Necessary treatment by a licensed acupuncturist. (c) Ambulance.Local Medically Necessary professional land or air ambulance service.A charge for this item will be a Covered Charge only if the service is to the nearest Hospital or Skilled Nursing Facility where necessary treatment can be provided unless the Plan Administrator finds a longer trip was Medically Necessary. (d) Anesthetic;oxygen;blood and blood derivatives that are not donated or replaced; intravenous injections and solutions.Administration of these items is included. (e) Applied Behavioral Analysis or other similar services,including Habilitative and Rehabilitative Care when provided by an individual licensed by the behavioral analyst certification board or certified by the Department of Public Health and Human Services as a family support specialist with an autism endorsement Note:Benefits are limited to treatment that is prescribed by a Physician and documented by a written Plan of Care provided by the treating Physician.The Plan Administrator may request periodic documentation of continued progress to goals identified in the Plan of Care. Benefits will be payable only for covered Dependent child(ren)from birth through age 18 years and will be payable up to the limits as stated in the Schedule of Benefits. (f) Cardiac rehabilitation as deemed Medically Necessary provided services are rendered (a)under the supervision of a Physician;(b)in connection with a myocardial infarction, coronary occlusion or coronary bypass surgery;(c)initiated within 12 weeks after other treatment for the medical condition ends;and(d)in a Medical Care Facility as defined by this Plan. (g) Radiation or chemotherapy and treatment with radioactive substances.The materials and services of technicians are included. Pre-notification of services,by the Plan Participant,for cancer treatment services is strongly recommended.The pre-notification request to the Claims Administrator should include the Covered Person's plan of care and treatment protocol.Pre-notification of services should occur at least seven(7)days prior to the initiation of treatment. For pre-notification of services,call CareLink at the following numbers: Toll Free in the United States: (866)894-1505 Local Call in Billings,Montana: (406)245-3575 Jefferson County 27 July 1,2015 A pre-notification ofservices by CareLink is not a determination by the Plan that claims will be paid All claims are subject to the terms and conditions, limitations and exclusions of the Plan, in effect when services are provided.A pre-notification is not required as a condition to paying benefits, and can only be appealed under the procedures in this Care Management Services Section.A pre-rwtification cannot be appealed under the Plan's Claims Procedure. (h) Initial contact lenses or glasses required following cataract surgery. (i) Contraceptives,when prescribed by a Physician,including but not limited to intrauterine devices(IUDs),implants,and injections,and any related Physician charges. Contraceptive medications,when prescribed by a Physician,are covered under the Prescription Drug Benefit. (j) Diabetes Education benefit.Outpatient self-management training and education for the treatment of diabetes,provided by a licensed health care professional with expertise in diabetes,up to the limits as stated in the Schedule of Benefits. (k) Down Syndrome Treatment, including Habilitative and Rehabilitative Care including professional,counseling,and guidance services and treatment programs,and therapy services that are Medically Necessary to develop and restore,to the maximum extent practicable,the functioning of the covered Dependent child(ren). Note.Benefits are limited to treatment that is prescribed by a Physician and documented by a written Plan of Care and provided by the treating Physician. The Plan may require an updated treatment plan and documentation of continued medical necessity updated every 6(six)months. The Plan Administrator may request periodic documentation ofcontmued progress to goals identified in the Plan of Care Benefits will be payable only for covered Dependent child(ren)from birth through age 18 years and will be payable up to the limits as stated in the Schedule of Benefits (1) Durable Medical Equipment(DME). Charges for Durable Medical Equipment and supplies necessary for the maintenance and operation of the Durable Medical Equipment that meet all of the following criteria: • Medically Necessary; • Prescribed by a Physician for outpatient use; • Is NOT primarily for the comfort and convenience of the Covered Person; • Does NOT have significant non-medical uses(i.e.air conditioners,air filters, humidifiers,environmental control devices). If more than one item of Durable Medical Equipment can meet a Covered Person's needs,Plan benefits are only available for the least cost alternative as determined by the Plan Administrator. Benefits are not available for certain convenience or luxury features that are considered non-standard. Rental of a Durable Medical Equipment item will be a Covered Charge up to a maximum of the lesser of 24 months or the warranty period of the item,commencing on the date the item is first delivered to the Covered Person. A Durable Medical Equipment item may be purchased,rather than rented,with the cost not to exceed the actual acquisition cost of the item to the Covered Person if the Covered Jefferson cuuray 29 July I,2015 Person were to purchase the item directly.The acquisition cost of the item may be prorated over a 6 month period,subject to prior approval by the Plan Administrator. Replacement of a Durable Medical Equipment item,rented or purchased,will be a Covered Charge limited to once every 4 Calendar Years. • Subject to prior approval of the Plan Administrator,replacement for a purchased Durable Medical Equipment item may be available for damage beyond repair with normal wear and tear,when repair costs exceed the acquisition cost,or when a change in the Covered Person's medical condition occurs sooner than the 4 Calendar Year period. • Subject to prior approval of the Plan Administrator,replacement for a rented Durable Medical Equipment item may be available when a change in the Covered Person's medical condition occurs sooner than the 4 Calendar Year period. Repair of a Durable Medical Equipment item including the replacement of essential accessories such as hoses,tubing,mouth pieces,etc.,are Covered Charges only when necessary to make the item serviceable and the total estimated repair and replacement costs do not exceed the acquisition cost of the item.Rental charges for a temporary replacement Durable Medical Equipment item are Covered Charges up to a maximum of two consecutive months.Requests to repair a Durable Medical Equipment item are not subject to the 4 Calendar Year limit The Plan Administrator may require documentation,including but not limited to the make and model number of the Durable Medical Equipment item,the acquisition cost to the provider,and documentation to support Medical Necessity. (m) Homeopathic services.Medically Necessary services provided by a homeopath. (o) Home Infusion Therapy. The Plan will cover home infusion therapy services and supplies when provided by an accredited home infusion therapy agency,which is not a licensed Home Health Agency.These services must be Medically Necessary and are required for the administration of a home infusion therapy regimen when ordered by and are part of a formal written plan prescribed by a Physician.The benefit will include all Medically Necessary services and supplies including the nursing services associated with patient and/or alternative care giver training,visits to monitor intravenous therapy regimen,emergency care,prescription drugs,administration of therapy and the collection,analysis and reporting of the results of laboratory testing services required to monitor a response to therapy. (o) Iaborstory studies. (p) Treatment of Mental Disorders and Substance Abuse.Covered charges are payable for care,supplies and treatment of Mental Disorders and Substance Abuse. Employee Assistance Program(EAP) The JPT has contracted with Sapphire Resource Connection(SRC)to provide Covered Persons with an Employee Assistance Program. Each Covered Person will be eligible for up to four(4)confidential therapeutic sessions per contract year.The Plan will pay the cost of each covered therapeutic session with licensed clinical professional counselors (LMSW,LCPC,Ph.D),and certified chemical dependency counselors(SAP or LAC). SRC can help Covered Persons better deal with personal,family or work-related concerns including but not limited to;marital/relationship problems,stress,depression/grief, anxiety or panic disorders,and many other common issues such as parenting,addiction, illness,financial and legal problems. Jefferson County 29 July I,2015 To access your EAP benefits,please contact Sapphire Resource Connection for more information: • Call(406)523-7707 or the 24-hour Help Line at(9m)767-9511 • Login at http://www.sr-connection.com(user name:jpt; password:jpt) Note:The contract year will run from July I through June 30. (q) Morbid Obesity.Medically Necessary surgical and non-surgical charges for Morbid Obesity will be covered. Treatment ofcomplications and/or secondary surgeries related to the initial surgery will be covered only when deemed Medically Necessary. Surgical treatment ofMorbid Obesity will be limited to once per Lifetime. The term"Morbid Obesity"means a serious disease associated with a high incidence of medical complications and a significantly shortened life span. For non-surgical treatment,Morbid Obesity is defined as a body mass index(BMI)of 30 or above. Treatment includes services by licensed health care providers,including but not limited to dieticians;Prescription Drugs that are FDA-approved for the management of weight loss due to Morbid Obesity;nutritional counseling;office visits and associated lab work ordered by the provider. For surgical treatment,the definition of"Morbid Obesity"means a condition of persistent and uncontrollable weight gain and is defined as a body mass index(BMI)of 35 to 39 with any comorbid conditions that are expected to improve,reverse,or be limited by this surgical treatment or a BMI of 40 with or without accompanying comorbid conditions.Treatment must be documented in a record or letter of medical necessity that demonstrates the diagnosis of Morbid Obesity. Note: The BMI is a factor produced by dividing a person's weight(in kilograms)by his/her height squared(in meters). A pre-notification of services,by the Plan Participant is strongly recommended for either inpatient or outpatient surgical procedures and will require the following documentation including,but not limited to,a written treatment plan by the attending Physician and documentation that all required medical criteria in advance of any surgical treatment has been met. Please contact the Claims Administrator for further information regarding pre- notification procedures and requirements for this benefit. A pre-notification of services by CareLink is not a determination by the Plan that claims will be paid.All claims are subject to the tears and conditions,limitations and exclusions of the Plan,in effect at the time services are provided.A pre-notification is not required as a condition precedent to paying benefits,and can only be appealed under the procedures in the Care Management Services section.A pre-notification cannot be appealed under the Plan's Claims Procedures. (r) Injury to or care of mouth,teeth and gums.Charges for Injury to or care of the mouth, teeth,gums and alveolar processes will be Covered Charges under Medical Benefits only if that care is for the following oral surgical procedures: • Excision of tumors and cysts of the jaws,cheeks,lips,tongue,roof and floor of the mouth. • Emergency repair due to Injury to sound natural teeth,within two years from the date of the accident. • Surgery needed to correct accidental injuries to the jaws,cheeks,lips,tongue,floor and roof of the mouth. Jefferson County 30 July I,2015 • Excision of benign bony growths of the jaw and hard palate. • External incision and drainage of cellulitis. • Incision of sensory sinuses,salivary glands or ducts. No charge will be covered under Medical Benefits for dental and oral surgical procedures involving orthodontic care of the teeth,periodontal disease and preparing the mouth for the fitting of or continued use of dentures. (s) Naturopathic services.Medically Necessary services provided by a naturopath. (t) Occupational therapy by a licensed occupational therapist. Therapy must be ordered by a Physician,result from an Injury or Sickness and improve a body function.Covered expenses do not include recreational programs,maintenance therapy or supplies used in occupational therapy. (u) Organ transplant benefits.Medically Necessary charges incurred for the care and treatment due to an organ or tissue transplant,which are not considered Experimental or Investigational,are subject to the following criteria and are subject to the limits as stated in the Schedule of Benefits: • The transplant must be performed to replace an organ or tissue. • Organ transplant benefit period:A period of 365 continuous days beginning five(5) days immediately prior to an approved organ transplant procedure.In the case of a bone marrow transplant,the date the transplant begins will be defined as either the earlier of the date of the beginning of the preparatory regimen(marrow ablation therapy)or the date the marrow/stem cells is/are infused. • Organ procurement limits.Charges for obtaining donor organs or tissues are Covered Charges under the Plan only when the recipient is a Covered Person.When the donor has medical coverage,his or her plan will pay first.The donor benefits under this Plan will be reduced by those payable under the donor's plan.Donor charges include those for: (i) Evaluating the organ or tissue; (ii) Removing the organ or tissue from the donor;and (iii) Transportation of the organ or tissue from within the United States or Canada to the facility where the transplant is to be performed. Note: Expenses related to the purchase of any organ will not be covered. As soon as reasonably possible,but in no event more than ten(10)days after a Covered Person's attending Physician has indicated that the Covered Person is a potential candidate for a transplant,the Covered Person or his or her Physician must contact CareLink at(866)8941503. A Center of Excellence is a licensed healthcare facility that has entered into a participation agreement with a national transplant network to provide approved transplant services,at a negotiated rate,to which the Plan has access.A Covered Person may contact CareLink to determine whether or not a facility is considered a Center of Excellence. Jefferson County 31 July 1,2015 There is no obligation to the Covered Person to use a Center of Excellence facility; however,benefits for the transplant and related expenses may vary depending upon whether or not a Center of Excellence facility is utilized. Travel and Lodging Expenses If a transplant is performed at a Network Provider transplant facility or a Center of Excellence facility and the Covered Person resides 50 miles or more from the transplant facility,the Plan will pay for the following services incurred during the transplant benefit period subject to any maximum benefit as specifically stated in the Schedule of Benefits: A. Transportation expenses to and from the Network Provider transplant facility or Center of Excellence facility for the following individuals: • The Covered Person;and • One or both parents of the Covered Person(only if the Covered Person is a Dependent minor child);or • One adult to accompany the Covered Person. • Living donor(if applicable under the Plan) Transportation expenses include commercial transportation(coach class only). B. Reasonable lodging and meal expenses incurred for the living donor,Covered Person,and one or both parents of the Covered Person(only if the Covered Person is a Dependent minor child),or one adult companion who is accompanying the Covered Person,only while the Covered Person is receiving transplant-related services at a Center of Excellence facility. Lodging,for purposes of this Plan,will not include private residences. Special Transplant Benefits Under certain circumstances,there may be special transplant benefits available when the group health plan and/or a Covered Person participates in a special transplant program and/or contracts with a specific transplant network. Therefore,it is very important to contact CareLink at(866)894-1505 as soon as reasonably possible so that the Plan can advise the Covered Person or his or her Physician of the transplant benefits that may be available. Transplant Exclusions Coverage for the following procedures,when Medically Necessary,will be provided under the regular medical benefits provision under this Plan,subject to any Plan provisions and applicable benefits limitations as stated in the Schedule of Benefits. (1) Comes transplantation (2) Skin grafts (3) Artery (4) Vein (5) Valve (6) Transplantation of blood or blood derivatives(except for bone marrow or stem cells). Jefferson County 32 July 1,2015 (w) Orthoties.The initial purchase, fitting and repair of orthotic appliances such as braces, splints or other appliances which are required for support for an injured or deformed part of the body as a result of a disabling congenital condition or an Injury or Sickness. Foot orthotics will be allowed once per Covered Person while covered under this Plan. (x) Physical therapy by a licensed physical therapist.The therapy must be in accord with a Physician's exact orders as to type,frequency and duration and for conditions which are subject to significant improvement through short-tern therapy. (y) Prescription Drugs(as defined).Outpatient Prescription Drugs will be payable under the separate Prescription Drug Benefit section under this Plan: (z) Routine Preventive Care.Covered charges under Medical Benefits are payable for routine Preventive Care as described in the Schedule of Benefits. Charges for Routine Well Care.Routine well care is routine care by a Physician that is not for an Injury or Sickness. (al) Prosthetics.The initial purchase,fitting and repair of fitted prosthetic devices which replace body parts. (bl) Reconstructive Surgery.Correction of abnormal congenital conditions and reconstructive mammoplasties will be considered Covered Charges. This mammoplasty coverage will include reimbursement for: • Reconstruction of the breast on which a mastectomy has been pert nmed, • Surgery and reconstruction of the other breast to produce a symmetrical appearance, and • Coverage of prostheses and physical complications during all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending Physician and the patient. (cl) Charges for Rehabilitation therapy. Services must be Medically Necessary to restore and improve a bodily or cognitive function that was previously normal but was lost as a result of an accidental injury,illness,or surgery. Inpatient Care.Services must be furnished in a specialized rehabilitative unit of a hospital and billed by the hospital or be furnished and billed by a rehabilitation facility approved by the Plain.This benefit only covers care the Covered Person received within 24 months from the onset of the injury or illness or from the date of the surgery that made rehabilitation necessary. The cam must also be part of a written plan of multidisciplinary treatment prescribed and periodically reviewed by a physiatrist(a physician specializing in rehabilitative medicine). (dl) Smoking Cessation benefit limited to prescription and non-prescription smoking cessation products,up to the limits as stated in the Schedule of Benefits. (el) Speech therapy by a licensed speech therapist.Therapy must be ordered by a Physician and follow either. (i) Surgery for correction of a congenital condition of the oral cavity,throat or nasal complex(other than a frenectomy)of a person; (ii) An Injury;or Jefferson County 33 July 1.2015 (iii) A Sickness. (fl) Spinal Manipulation/Chiropractic services by a licensed M.D.,D.O.,or D.C.,subject to Medical Necessity and non-maintenance care. Laboratory and diagnostic x-rays ordered by a chiropractor will be payable subject to the separate Diagnostic Lab and X-ray benefit. (gl) Sterilization procedures. (hl) Surgical dressings,splints,casts and other devices used in the reduction of fractures and dislocations. (U) Coverage of Well Newborn Nursery/Physician Care. Charges for Routine Nursery Care.Routine well newborn nursery care is care while the newborn is Hospital-confined after birth and includes room,board and other normal care for which a Hospital makes a charge. This coverage is only provided if the newborn child is an eligible Dependent who is neither injured nor ill and a parent(1)is a Covered Person who was covered under the Plan at the time of the birth,or(2)enrolls himself or herself(as well as the newborn child if required by the Plan)in accordance with the Special Enrollment provisions with coverage effective as of the date of birth. The benefit is limited to Allowable Charges for nursery care for the newborn child while Hospital confined as a result of the child's birth. Charges for covered routine nursery care will be applied toward the Plan of the newborn child. Group health plans generally may not,under Federal law,restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery,or less than 96 hours following a cesarean section.However,Federal law generally does not prohibit the mother's or newborn's attending provider,after consulting with the mother,from discharging the mother or her newborn earlier than 48 hour:(or 96 hours as applicable).In any case, plans and issuers may not,under Federal law,require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours(or 96 hours). Charges for Routine Physician Care.The benefit is limited to the Allowable Charges made by a Physician for the newborn child while Hospital confined as a result of the child's birth. Charges for covered routine Physician care will be applied toward the Plan of the newborn child. (j 1) Charges associated with the initial purchase of a wig after chemotherapy. (kl) Diagnostic x-rays. Jefferson Cody 34 July 1,2015 MEDICAL EXPENSE AUDIT BONUS The Plan offers an incentive to all Covered Persons to encourage examination and self-auditing of eligible medical bills to ensure the amounts billed by any provider accurately reflect the services and supplies received by the Covered Person. The Covered Person should review all medical charges and verify that each itemized service has been received and that the bill does not represent either an overcharge or a charge for services never received. Participation in this self-auditing procedure is strictly voluntary;however,it is to the advantage of the Plan as well as the Covered Person to avoid unnecessary payment of health care costs. In the event a self-audit results in elimination or reduction of charges fifty percent(50%)of the amount eliminated or reduced will be paid directly to the employee as a bonus,provided the savings are accurately documented,and satisfactory evidence of a reduction in charges is submitted to the Claims Administrator(e.g., a copy of the incorrect bill and a copy of the corrected billing.) The bonus shall only apply to charges which have been submitted to and paid by the Plan,and for which an erroneous charge was paid by the Plan. Erroneous charges corrected by the Plan during the claims adjudication process are not eligible for this bonus. Rewards are subject to the following: • A minimum reward of$25(on an overcharge of$50) • A maximum reward of$1,000(on a charge of$2,000 or more) This self audit is a bonus in addition to the benefits of this Plan. The Covered Person must indicate on the corrected billing statement"This is a claim for the Medical Expense Audit Bonus"and submit to the Claims Administrator at the following address a copy of the incorrect bill and a copy of the corrected billing in order to receive the bonus: The Joint Powers Trust aka.The Montana Joint Powers Trust c/o Employee Benefit Management Services,Inc. P.O.Box 21367 Billings,Montana 59104 Jefferson County 35 July 1,2015 CARE MANAGEMENT SERVICES UTILIZATION MANAGEMENT Utilization Management is a program designed to assist Covered Persons in understanding and becoming involved with their diagnosis and medical plan of cane,and advocates patient involvement in choosing a medical plan of care.Utilization Management begins with the prenotification process. Pre-notification of certain services is strongly recommended,but not required by the Plan.Prenotification provides information regarding coverage before the Covered Person receives treatment,services and/or supplies.A benefit determination on a Claim will be made only after the Claim has been submitted.A pre- notification of services by CareLink is not a determination by the Plan that a Claim will be paid.All Claims are subject to the terms and conditions, limitations and exclusions of the Plan in effect at the time services are provided A pre-notification is not required as a condition precedent to paying benefits, and can only be appealed under the procedures in this Care Management Services Section.A pre-notifcation cannot be appealed under the Plan's Claims Procedure. Examples of when the Physician and Covered Person should contact CareLink prior to treatment include: • Inpatient admissions to a Hospital • Inpatient admissions to free-standing chemical dependency,mental health,and rehabilitation facilities • Cancer treatment plan of care,administered on an inpatient or outpatient basis • Inpatient or outpatient surgeries relating to,but not limited to,hysterectomies,back surgery,or bariatric surgery(if applicable under this Plan);and • Outpatient services as follows: • Dialysis • Genetic testing • Injectables • Home Health Care • Hospice • Durable Medical Equipment(DME)over$2,000 All Claims are subject to the terms and conditions,limitations and exclusions of the Plan at the time services are provided The Physician or Covered Person should notify CareLink at least seven(T)days before services are scheduled to be rendered with the following information: • The name of the patient and relationship to the covered Employee • The name,Employee identification number and address of the Covered Person • The name of the Employer • The name and telephone number of the attending Physician • The name of the Hospital,proposed date of admission,and proposed length of stay • The diagnosis and/or type of surgery • The plan of care,treatment protocol and/or informed consent,if applicable If there is an emergency admission to the Hospital,the Covered Person,Covered Person's family member, Hospital or attending Physician should notify CareLink within two(2)business days after the admission. Jefferson County 36 July 1,2015 Hospital Observation Room stays in excess of 23 hours are considered an admission for purposes of this program,therefore CareLink should be notified. Contact the Care Management administrator at CareLink(406)245-3575 or(866)8941505 Monday through Friday,6:00 a.m.to 7:00 p.m.(Mountain Time) PRE-ADMISSION AND POST DISCHARGE CARE CALLS A CareLink nurse will contact the Covered Person to provide health education,pre-surgical counseling, inpatient care coordination,facilitation of discharge plan and post-discharge follow-up. PRE-NOTIFICATION DETERMINATION AND REVIEW PROCESS The Plan Administrator or its designee,on the Plan's behalf,will review the submitted information and make a determination on a pre-notification request within fifteen(15)days of receipt of the pre-notification request and all supporting documentation.If additional records are necessary to process the pre-notification request, the Plan Administrator or its designee will notify the Covered Person or the Physician.The time for making a determination on the request will be tolled from the date that the additional information is requested until the date that the information is received. The Physician and Covered Person will be provided notice of the Plan's determination.If the pre-notification request is denied,written notice will provide the reason for the adverse pre-notification determination. The Plan offers a one-level review procedure for adverse pre-notification determinations.The request for reconsideration must be submitted in writing within thirty(30)days of the receipt of the adverse pre- notification determination and include a statement as to why the Covered Person disagrees with the adverse pre-notification determination.The Covered Person may include any additional documentation,medical records,and/or letters from the Covered Person's treating Physician(s). The request for reconsideration should be addressed to: CareLink Attn:Appeals 7400 West Campus Rd New Albany,OH 43054 The Plan Administrator or its designee will perform the reconsideration review.The Plan Administrator or its designee will review the information initially received and any additional information provided by the Covered Person,and determine if the pre-notification determination was appropriate.If the adverse pre-notification determination was based upon the medical necessity,the Experimental/Investigational nature of the treatment, service or supply or an equivalent exclusion,the Plan may consult with a health care professional who has the appropriate training and experience in the applicable field of medicine. Written or electronic notice of the determination upon reconsideration will be provided within thirty(30)days of the receipt of the request for reconsideration. CASE MANAGEMENT If a Covered Person has an ongoing medical condition or catastrophic Illness,a Case Manager may be assigned to monitor this Covered Person,and to work with the attending Physician and Covered Person to design a treatment plan and coordinate appropriate Medically Necessary care.The Case Manager will consult with the Covered Person,the family,and the attending Physician in order to assist in coordinating the plan of care approved by the Covered Person's attending Physician and the Covered Person. This plan of care may include some or all of the following: Individualized support to the patient; Jefferson Carty 37 July 1,2015 • Contacting the family to offer assistance for coordination of medical care needs; • Monitoring response to treatment; • Evaluating outcomes;and • Assisting in obtaining any necessary equipment and services, Case Management is not a requirement of the Plan.There are no reductions of benefits or penalties if the Covered Person and family choose not to participate. Each treatment plan is individualized to a specific Covered Person and is not appropriate or recommended for any other patient,even one with the same diagnosis.All treatment and care decisions will be the sole determination of the Covered Person and the attending Physician. IT STARTS WITH reE HEALTH SOLUMNS The Joint Powers Trust also known as Montana Joint Powers Trust has contracted with It Starts With Me Health Solutions to provide a means of knowledge and management of personal health,It Starts With Me makes available the tools individuals need to take control of their health. By meeting various requirements or completing appropriate alternative standards under the Program, participants may qualify for incentives such as but not limited to gifl cards,wellness coaching,and fitness programs. Program participants may also be given opportunities to access health improvement resources and benefits designed to improve their overall health status. The program may require an annual health screening or other completed activities to qualms for incentives. Covered Persons should refer to Jefferson County Health Plan Wellness Bookletfor additional details regarding the program. leffa County 38 July I,2015 DEFINED TERMS The following terms have special meanings and when used in this Plan will be capitalized. Active Employee is an Employee who is on the regular payroll of the Employer and who has begun to perform the duties of his or her job with the Employer on a full-time basis. Allowable Charge means the charge for a treatment,service,or supply that is the lesser of: 1)the charge made by the provider that furnished the care,service,or supply;2)the negotiated amount established by a discounting or negotiated arrangement other than the Aetna network;3)the reasonable and customary charge for the same treatment,service,or supply furnished in the same geographic area by a provider of like service as further described below;or 4)an amount equivalent to the following: 1. For specialty drugs,the lesser of A WP minus 100/a or the amount set by the Plan's prescription drug service vendor; 2. For inpatient or outpatient facility claims,an amount equivalent to 200%of the Medicare equivalent allowable. The reasonable and customary charge shall mean an amount equivalent to the 90th percentile of a commercially available database,or such other cost or quality-based reimbursement methodologies as may be available and adopted by the Plan.If there are insufficient charges submitted for a given procedure,the Plan will determine an Allowable Charge based upon charges made for similar services. Determination of the reasonable and customary charge will consider the nature and severity of the condition being treated,medical complications or unusual circumstances that require more time,skill or experience,and the cost and quality data for that provider. For Covered Charges rendered by a Physician,Hospital or Ancillary Provider in a geographic area where applicable law dictates the maximum amount that can be billed by the rendering provider,the Allowable Charge shall mean the amount established by applicable law for that Covered Charge. For Covered Charges rendered by a Physician,Hospital,or Ancillary Provider that is a contracted provider with the Aetna network,the negotiated rate of that preferred provider arrangement shall be the Allowable Charge. The Plan Administrator or its designee has the ultimate discretionary authority to determine an Allowable Charge,including establishing the negotiated terms of a provider arrangement as the Allowable Charge even if such negotiated terns do not satisfy the lesser of test described above. Applied Behavioral Analysis,also known as Lovaas therapy,must be provided by an individual who is licensed by the behavior analyst certification board or is certified by the Department of Public Health and Human Services as a family support specialist with an autism endorsement. Birthing Center means any freestanding health facility,place,professional office or institution which is not a Hospital or in a Hospital,where births occur in a home-tike atmosphere.This facility must be licensed and operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the facility is located. The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide care under the full-tine supervision of a Physician and either a registered nurse(R.N.)or a licensed nurse-midwife;and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop complications or require pre-or post-delivery confinement. Brand Name means a trade name medication. Calendar Year means January 1st through December 31st of the same year. COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985,as amended. Jefferson County 39 July 1,2015 Cosmetic Dentistry means dentally unnecessary procedures. Covered Charge(s)means those Medically Necessary services or supplies that are covered under this Plan. Covered Person is an Employee,Retiree or Dependent who is covered under this Plan. Custodial Care is care(including room and board needed to provide that care)that is given principally for personal hygiene or for assistance in daily activities and can,according to generally accepted medical standards,be performed by persons who have no medical training. Examples of Custodial Care are help in walking and getting out of bed;assistance in bathing,dressing,feeding;or supervision over medication which could normally be self-administered. Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license. Durable Medical Equipment means equipment which(a)can withstand repeated use,(b)is primarily and customarily used to serve a medical purpose,(c)generally is not useful to a person in the absence of an Illness or Injury and(d)is appropriate for use in the home. Employee means a person who is an Active,regular Employee of the Employer,regularly scheduled to work for the Employer in an Employee/Employer relationship. Employer is Jefferson County. Enrollment Date is the first day of coverage or,if there is a Waiting Period,the first day of the Waiting Period. Experimental and/or Investigational means services,supplies,care and treatment which does not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial,qualified,responsible,relevant segment of the medical community or government oversight agencies at the time services were rendered. The Plan Administrator must make an independent evaluation of the experimental/nonexperimental standings of specific technologies.The Plan Administrator shall be guided by a reasonable interpretation of Plan provisions.The decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim and the proposed treatment.The decision of the Plan Administrator will be final and binding on the Plan.The Plan Administrator will be guided by the following principles: (1) If the drug or device cannot be lawfully marketed without approval of the U.S.Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;or (2) If the drug,device,medical treatment or procedure,or the patient informed consent document utilized with the drug,device,treatment or procedure,was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function,or if federal law requires such review or approval;or (3) If Reliable Evidence shows that the drug,device,medical treatment or procedure is the subject of on-going phase I or phase II clinical trials, is the research,experimental,study or Investigational arm of on-going phase III clinical trials,or is otherwise under study to determine its maximum tolerated dose,its toxicity,its safety,its efficacy or its efficacy as compared with a standard means of treatment or diagnosis;or (4) If Reliable Evidence shows that the prevailing opinion among experts regarding the drug,device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose,its toxicity,its safety,its efficacy or its efficacy as compared with a standard means of treatment or diagnosis. Jefferson County 40 Juty 1,2015 Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature;the written protocol or protocols used by the treating facility or the protocol(s)of another facility studying substantially the same drug,service,medical treatment or procedure;or the written informed consent used by the treating facility or by another facility studying substantially the same drug,device,medical treatment or procedure. Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved by the Food and Drug Administration for general use. Family Unit is the covered Employee or Retiree and the family members who are coveted as Dependents under the Plan. Formulary means a list of prescription medications compiled by the third party payor of safe,effective therapeutic drugs specifically covered by this Plan. Foster Child means a child under the limiting age shown in the Dependent Eligibility Section of this Plan for whom a covered Employee has assumed a legal obligation and who is being raised as the covered Employee's child. A covered Foster Child is not a child temporarily living in the covered Employee's home;one placed in the covered Employee's home by a social service agency which retains control of the child;or whose natural parent(s)may exercise or share parental responsibility and control. Generic drug means a Prescription Drug which has the equivalency of the brand name drug with the same use and metabolic disintegration.This Plan will consider as a Generic drug any Food and Drug Administration approved generic pharmaceutical dispensed according to the professional standards of licensed pharmacist and clearly designated by the pharmacist as being generic. Habilitative and Rehabilitative Care shall include Medically Necessary interactive therapies derived from evidence-based research,discrete trial training,pivotal response training,intensive intervention programs,and early intensive behavioral intervention. Home Health Care Agency is an organization that meets all of these tests:its main function is to provide Home Health Care Services and Supplies;it is federally certified as a Home Health Care Agency;and it is licensed by the state in which it is located,if licensing is required. Home Health Care Plan must meet these tests:it must be a formal written plan made by the patient's attending Physician which is reviewed at least every 30 days;it must state the diagnosis and it must specify the type and extent of Home Health Care required for the treatment of the patient Home Health Care Services and Supplies include:part-time or intermittent nursing care by or under the supervision of a registered nurse(R.N.);part-time or intermittent home health aide services provided through a Home Health Care Agency(this does not include general housekeeping services);physical,occupational and speech therapy;medical supplies;and laboratory services by or on behalf of the Hospital. Hospice Agency is an organization where its train function is to provide Hospice Care Services and Supplies and it is licensed by the state in which it is located,if licensing is required. Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice Agency and supervised by a Physician. Hospice Care Services and Supplies are those provided through a Hospice Agency and under a Hospice Care Plan and include inpatient care in a Hospice Unit or other licensed facility,home care,and family counseling during the bereavement period. Hospice Unit is a facility or separate Hospital Unit,that provides treatment under a Hospice Care Plan and admits at least two unrelated persons who are expected to die within six months. Jefferson County 41 July 1,2015 Hospital is an institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense and which fully meets these tests: it is approved by Medicare as a Hospital;it maintains diagnostic and therapeutic facilities on the premises for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of Physicians;it continuously provides on the premises 24-hour-a-day nursing services by or under the supervision of registered nurses(R.N.$);and it is operated continuously with organized facilities for operative surgery on the premises. The definition of"Hospital"shall be expanded to include the following: — A facility operating legally as a psychiatric Hospital or residential treatment facility for mental health and licensed as such by the state in which the facility operates. — A facility operating primarily for the treatment of Substance Abuse if it has received accreditation from CARF(Commission of Accreditation of Rehabilitation Facilities)or JCAHO(Joint Commission of Accreditation of Hospital Organizations)or if it meets these tests:maintains permanent and full-time facilities for bed care and full-time confinement of at least 15 resident patients;has a Physician in regular attendance;continuously provides 24-hour a day nursing service by a registered nurse(R.N.);has a full-time psychiatrist or psychologist on the staff;and is primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Substance Abuse. Illness means a bodily disorder,disease,physical Sickness or Mental Disorder.Illness includes Pregnancy, childbirth,miscarriage or complications of Pregnancy. Injury means an accidental physical Injury to the body caused by unexpected external means. Intensive Care Unit is defined as a separate,clearly designated service area which is maintained within a Hospital solely for the care and treatment of patients who are critically ill.This also includes what is referred to as a"coronary care unit'or an"acute care unit."It has:facilities for special nursing care not available in regular rooms and wards of the Hospital;special life saving equipment which is immediately available at all times;at least two beds for the accommodation of the critically ill;and at least one registered nurse(R.N.)in continuous and constant attendance 24 hours a day. Late Enrollee means a Plan Participant who enrolls under the Plan other than during the first 31-day period in which the individual is eligible to enroll under the Plan or during a Special Enrollment Period. Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations.Lifetime is understood to mean while covered under this Plan.Under no circumstances does Lifetime mean during the lifetime of the Covered Person. Medical Care Facility means a Hospital,a facility that treats one or more specific ailments or any type of Skilled Nursing Facility. Medical Emergency means a sudden onset of a condition with acute symptoms requiring immediate medical care and includes such conditions as heart attacks,cardiovascular accidents,poisonings,loss of consciousness or respiration,convulsions or other such acute medical conditions. Medically or Dentally Necessary care and treatment is recommended or approved by a Physician or Dentist; is consistent with the patient's condition or accepted standards of good medical practice;is medically proven to be effective treatment of the condition;is not performed mainly for the convenience of the patient or provider of medical services;and is the most appropriate level of services which can be safely provided to the patient All of these criteria must be met;merely because a Physician recommends or approves certain care does not mean that it is Medically Necessary. The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary. Jeffe(son Cowq 42 July I,2015 Medicare is the Health Insurance For The Aged and Disabled program under Title XVIII of the Social Security Act,as amended. Mental Disorder means any disease or condition,regardless of whether the cause is organic,that is classified as a Mental Disorder in the current edition of International Classification of Diseases,published by the U.S. Department of Health and Human Services or is listed in the current edition ofDiagnosdc and Statistical Manual of Mental Disorders,published by the American Psychiatric Association. No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents. Outpatient Care and/or Services is treatment including services,supplies and medicines provided and used at a Hospital under the direction of a Physician to a person not admitted as a registered bed patient;or services rendered in a Physician's office,laboratory or X-ray facility,an Outpatient Surgical Center,or the patient's home. Outpatient Surgical Center is a licensed facility that is used mainly for performing outpatient surgery,has a staff of Physicians,has continuous Physician and nursing care by registered nurses(R.N.$)and does not provide for overnight stays. Partial Hospitalization is an outpatient program specifically designed for the diagnosis or active treatment of a Mental Disorder or Substance Abuse when there is reasonable expectation for improvement or when it is necessary to maintain a patient's functional level and prevent relapse;this program shall be administered in a psychiatric facility which is accredited by the Joint Commission on Accreditation of Health Care Organizations and shall be licensed to provide partial hospitalization services,if required,by the state in which the facility is providing these services.Treatment lasts less than 24 hours,but more than four hours,a day and no charge is made for room and board. Pharmacy means a licensed establishment where covered Prescription Drugs are filled and dispensed by a pharmacist licensed under the laws of the state where he or she practices. Physician means a Doctor of Medicine(M.D.),Doctor of Osteopathy(D.O.),Optometrist(O.D),Doctor of Podiatry(D.P.M.),Doctor of Chiropractic(D.C.),Audiologist,Certified Nurse Anesthetist,Licensed Professional Counselor,Licensed Professional Physical Therapist,Master of Social Work(M.S.W.),Midwife, Occupational Therapist,Doctor of Dental Surgery(D.D.S.),Physiotherapist,Psychiatrist,Psychologist (Ph.D.),Speech Language Pathologist and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license. Plan means Jefferson County Health Plan,which is a benefits plan for certain Employees of Jefferson County and is described in this document. Plan of Care.A description of the goals,outcomes,prognosis,and proposed interventions for a Covered Person, including criteria for discharge and the optimal duration and frequency of therapeutic interventions. Plan Participant is any Employee,Retiree or Dependent who is covered under this Plan. Plan Year is the 12-month period beginning on July 1 and ending on June 30.. Pregnancy is childbirth and conditions associated with Pregnancy,including complications. Prescription Drug means any of the following:a Food and Drug Administration-approved drug or medicine which,under federal law,is required to bear the legend: "Caution:federal law prohibits dispensing without prescription"; injectable insulin;hypodermic needles or syringes,but only when dispensed upon a written prescription of a licensed Physician.Such drug must be Medically Necessary in the treatment of a Sickness or Injury. Jefferson Cmmty 43 July 1,2015 Retired Employee is a former Active Employee of the Employer who was retired while employed by the Employer under the formal written plan of the Employer and elects to contribute to the Plan the contribution required from the Retired Employee. Sickness is a person's Illness,disease or Pregnancy(including complications). Skilled Nursing Facility is a facility that fully meets all of these tests: (1) It is licensed to provide professional nursing services on an inpatient basis to persons convalescing from Injury or Sickness.The service must be rendered by a registered nurse(R.N.) or by a licensed practical nurse(L.P.N.)under the direction of a registered nurse. Services to help restore patients to self-care in essential daily living activities must be provided. (2) Its services are provided for compensation and under the full-time supervision of a Physician. (3) It provides 24 hour per day nursing services by licensed nurses,under the direction of a full-time registered nurse. (4) It maintains a complete medical record on each patient. (5) It has an effective utilization review plan. (6) It is not other than incidentally,a place for rest,the aged,drug addicts,alcoholics,the mentally disabled,Custodial or educational care or care of Mental Disorders;and (7) It is approved and licensed by Medicare. This term also applies to charges incurred in a facility referring to itself as an extended care facility, convalescent nursing home,rehabilitation hospital,long-term acute care facility or any other similar nomenclature. Spinal Manipulation/Chiropractic Care means skeletal adjustments,manipulation or other treatment in connection with the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human body.Such treatment is done by a Physician to remove nerve interference resulting from,or related to,distortion,misalignment or subluxation of,or in,the vertebral column. Substance Abuse is regular excessive compulsive drinking of alcohol and/or physical habitual dependence on drugs.This does not include dependence on tobacco and ordinary caffeine-containing drinks. Total Disability(Totally Disabled)means:In the case of a Dependent child,the complete inability as a result of Injury or Sickness to perform the normal activities of a person of like age and sex in good health. Jefferson County 44 ',. July I,2015 PLAN EXCLUSIONS Note:All exclusions related to Prescription Drugs are shown in the Prescription Drug Plan. Note:All exclusions related to Dental are shown in the Dental Plan. Note:All exclusions related to Vision are shown in the Vision Plan. For all Medical Benefits shown in the Schedule of Benefits,a charge for the following is not covered: (1) Coding Guidelines.Charges for inappropriate coding in accordance to the industry standard guidelines in effect. (2) Complications of non-covered treatments.Care,services or treatment required as a result of complications from a treatment not covered under the Plan are not covered. (3) Counseling.Care and treatment for marital or premarital counseling, Note:Counseling and other confidential assistance maybe available through the Employee Assistance Program offered by Sapphire Resource Connection, as stated in Medical Benefits section ofthis Plan (4) Custodial care.Services or supplies provided mainly as a rest cure,maintenance or Custodial Care,except as specifically stated as a benefit under this Plan. (5) Educational or vocational testing.Services for educational or vocational testing or training, except as specifically stated as a benefit under this Plan. (6) Excess charges.The part of an expense for care and treatment of an Injury or Sickness that is in excess of the Allowable Charge. (7) Exercise programs.Exercise programs for treatment of any condition,except for Physician-supervised cardiac rehabilitation,occupational or physical therapy covered by this Plan. (8) Experimental or not Medically Necessary.Care and treatment that is either Experimental/ Investigational or not Medically Necessary. (9) Eye care.Radial keratotomy or other eye surgery to correct refractive disorders.Also,routine eye examinations,including refractions,lenses for the eyes and exams for their fitting,except as stated as a specific benefit of this Plan.This exclusion does not apply to aphakic patients and soft lenses or sclera shells intended for use as comes]bandages. (10) Foreign Travel. Care,treatment or supplies out ofthe U.S.if travel is for the sole purpose of obtaining medical services. (11) Government coverage.Care,treatment or supplies furnished by a program or agency funded by any government.This does not apply to Medicaid or when otherwise prohibited by law. (12) Hair loss.Care and treatment for hair loss including wigs,hair transplants or any drug that promises hair growth,whether or not prescribed by a Physician,except for wigs after chemotherapy. (13) Hearing aids and exams.Charges for services or supplies in connection with hearing aids or exams for their fitting. (14) Hospital employees.Professional services billed by a Physician or nurse who is an employee of a Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service. Jefferson Canty 45 July 1,2015 (15) Illegal Acts. Charges for services received as a result of an Illness or Injury occurring directly,or indirectly as a result of the Covered Person engaging in,or attempting to engage in a"serious criminal act",a riot or public disturbance;and for which the Covered Person is convicted,pleads guilty,enters an Alford plea,or enters a plea bargain agreement,including but not limited to a suspended sentence or deferred prosecution.For the purposes of this exclusion,the term"serious criminal act"shall mean any act or series of acts by the Covered Person,or by the Covered Person in concert with another or others,for which,if prosecuted as a criminal offense,a sentence to a term of imprisonment in excess of one year could be imposed.This exclusion does not apply if the injury resulted from an act of domestic violence or a medical(including both physical and mental health)condition. (16) Impotence.Care,treatment,services,supplies or medication in connection with treatment for impotence. (17) Infertility.Care,supplies,services and treatment for infertility,artificial insemination,or in vitro fertilization (18) Mailing or Sales Tax.Charges for mailing,shipping,handling,conveyance and sales tax. (19) No charge.Care and treatment for which there would not have been a charge if no coverage had been in force. (20) Non-emergency Hospital admissions.Care and treatment billed by a Hospital for non-Medical Emergency admissions on a Friday or a Saturday.This does not apply if surgery is performed within 24 hours of admission. (21) No obligation to pay.Charges incurred for which the Plan has no legal obligation to pay. (22) No Physician recommendation.Care,treatment,services or supplies not recommended and approved by a Physician;or treatment,services or supplies when the Covered Person is not under the regular care of a Physician.Regular care means ongoing medical supervision or treatment which is appropriate care for the Injury or Sickness. (23) Nutritional Supplements. (24) Obesity.Care and treatment of obesity,weight loss or dietary control whether or not it is,in any case,a part of the treatment plan for another Sickness.Medically Necessary surgical and non- surgical charges for Morbid Obesity will be covered as specifically stated as a benefit under this Plan. (25) Occupational Injury. Care and treatment of an Injury or Sickness that is occupational—that is, arises from work for wage or profit and for which the Plan participant is eligible to receive benefits under any Workers'Compensation or occupational disease law.This exclusion will apply if the Plan participant was eligible to receive such benefits and failed to properly file a claim for such benefits or to comply with any other provision of the law to obtain such benefits. (26) Personal comfort items.Personal comfort items,patient convenience items,or other equipment, such as,but not limited to,air conditioners,air-purification units,humidifiers,electric heating units,orthopedic mattresses,blood pressure instruments,scales,elastic bandages or stockings, nonprescription drugs and medicines,and first-aid supplies and nonhospital adjustable beds. (27) Plan design excludes.Charges excluded by the Plan design as mentioned in this document. (28) Private duty nursing.Charges in connection with care,treatment or services of a private duty nurse. Jefferson County 46 July 1,2015 (29) Replacement braces.Replacement of braces of the leg,arm,back,neck,or artificial arms or legs, unless there is sufficient change in the Covered Person's physical condition to make the original device no longer functional. (30) Routine care.Charges for routine or periodic examinations,screening examinations,evaluation procedures,preventive medical care,or treatment or services not directly related to the diagnosis or treatment of a specific Injury,Sickness or Pregnancy-related condition which is known or reasonably suspected,unless such care is specifically covered in the Schedule of Benefits. (31) Routine foot care.Treatment of weak,strained,flat,unstable or unbalanced feet,metatarsalgia or bunions(except open cutting operations),and treatment of corns,calluses or toenails(unless needed in treatment of a metabolic or peripheral-vascular disease or when deemed Medically Necessary). (32) Self-Inflicted.Any loss due to an intentionally self-inflicted Injury.This exclusion does not apply if the Injury resulted from an act of domestic violence or a medical(including both physical and mental health)condition. (33) Services before or after coverage.Care,treatment or supplies for which a charge was incurred before a person was Covered under this Plan or after coverage ceased under this Plan. (34) Sex changes.Care,services or treatment for non-congenital transsexualism,gender dysphoria or sexual reassignment or change.This exclusion includes medications,implants,hormone therapy, surgery,medical or psychiatric treatment. (35) Sleep disorders.Care and treatment for sleep disorders unless deemed Medically Necessary. (36) Surgical sterilization reversal.Care and treatment for reversal of surgical sterilization. (37) Temporomandibular Joint Syndrome.All diagnostic and treatment services related to the treatment of jaw joint problems including temporomandibular joint(TMJ)syndrome. (38) Travel or accommodations.Charges for travel or accommodations,whether or not recommended by a Physician,except for ambulance charges as defined as a covered expense,or as specifically stated as a benefit under this Plan. (39) War.Any loss that is due to a declared or undeclared act of war. Jefferson County 47 July I,2015 PRESCRIPTION DRUG BENEFITS As administered by Navitus The Coordination of Benefits provisions will not apply to prescriptions purchased at a participating pharmacy. Pharmacy Drug Charge Participating pharmacies have contracted with the Plan to charge Covered Persons reduced fees for covered Prescription Drugs. Navitus Health Solutions is the administrator of the pharmacy drug plan. Copayments The copayment is applied to each covered pharmacy drug charge and is shown in the Schedule of Benefits. The copayment amount is not a covered charge under the medical Plan. Any one pharmacy prescription is limited to a 34-day supply. If a drug is purchased from a non-participating pharmacy,or a participating pharmacy when the Covered Person's ID card is not used,the Covered Person will be required to pay 100%at the point of sale,no discount will be given,and the Covered Person must submit the prescription receipt to Navitus for reimbursement less any applicable copayment as shown in the Schedule of Benefits. At select participating pharmacies,the Covered Person will be able to obtain a 90-day supply,per prescription, at the same copayment level as the mail order benefit(as shown in the Schedule of Benefits).For additional information or a current list of these select participating pharmacies,please contact Navitus at Toll-free 866- 333-2757. Mail Order Drug Benefit Option The mail order drug benefit option is available for maintenance medications(those that are taken for long periods of time,such as drugs sometimes prescribed for heart disease,high blood pressure,asthma,etc.). Because of volume buying,the mail order pharmacy is able to offer Covered Persons significant savings on their prescriptions.The mail order pharmacy is subject to change.Please contact Navitus for more information concerning the mail order pharmacy. Copayments The copayment is applied to each covered mail order drug charge and is shown in the Schedule of Benefits. The copayment amount is not a covered charge under the medical Plan. Any one mail order prescription is limited to a 90 day supply. Specialty Pharmacy Program Specialty medications are high-cost injectables,infused,oral,or inhaled medications prescribed in the treatment of chronic disease conditions(e.g.,Chronic Kidney Disease,Crohn's Disease,Multiple Sclerosis,or Osteoarthritis).This Plan offers a program for specialty medications that can provide Coveted Persons with greater convenience,including express delivery,follow-up care calls,expert counseling,and superior service. All prescriptions are subject to the terms, limitations, and exclusions as set forth this Plan. Please contact Navitus for more information concerning the Specialty Pharmacy Program. Covered Prescription Drugs Note:Some quantity limitations and/or prior outhorhations may be required. Jefferson County 48 July 1,2015 (1) All drugs prescribed by a Physician that require a prescription either by federal or state law,but excludes any drugs stated as not covered under this Plan. (2) All compounded prescriptions containing at least one prescription ingredient in a therapeutic quantity. (3) Insulin and other diabetic supplies,when prescribed by a Physician. (4) Contraceptives,when prescribed by a Physician,including but not limited to orals,transdermals, devices,and injectables.Contraceptive benefits for intrauterine devices(IUDs)and implants, when prescribed by a Physician,are covered under the Medical Benefit of this Plan. (5) Electrolytes. (6) Migraine products. Limit of 2 Imitrex kits per copayment. (7) Drugs for the treatment of Attention Deficit Disorder. (8) Retin A,Differin or Accutane through age 24;thereafter prior authorization is required. Limits To This Benefit This benefit applies only when a Covered Person incurs a covered Prescription Drug charge.The covered drug charge for any one prescription will be limited to: (1) Refills only up to the number of times specified by a Physician. (2) Refills up to one year from the date of order by a Physician. Expenses Not Covered This benefit will not cover a charge for any of the following: (1) Administration.Any charge for the administration of a covered Prescription Drug. (2) Appetite suppressants. A charge for appetite suppressants,dietary supplements or vitamin supplements.Certain benefits may be available under the Medical Benefits of this Plan for the treatment ofMorbid Obesity. (3) Consumed on premises.Any drug or medicine that is consumed or administered at the place where it is dispensed (4) Devices.Devices of any type,even though such devices may require a prescription.These include (but are not limited to)therapeutic devices,blood glucose monitoring machines,insulin pumps and supplies,artificial appliances,braces,support garments,or any similar device. These may be considered Covered Charges under the Medical Bents section of this Plan. (5) Drugs used for cosmetic purposes.Charges for drugs used for cosmetic purposes,such as anabolic steroids,or medications for hair growth or removal. (6) ExperimentaL Experimental drugs and medicines,even though a charge is made to the Covered Person. (7) FDA.Any drug not approved by the Food and Drug Administration. (8) Growth hormones.Charges for drugs to enhance physical growth or athletic performance or appearance. Jefferson County 49 July 1,2015 (9) Immunization.Immunization agents or biological sera (10) Impotence.A charge for impotence medication. (11) Infertility.A charge for infertility medication. (12) Injectable supplies.A charge for hypodermic syringes and/or needles(other than for insulin). (13) Inpatient medication.A drug or medicine that is to be taken by the Covered Person,in whole or in part,while Hospital confined.This includes being confined in any institution that has a facility for the dispensing of drugs and medicines on its premises. (14) Investigational.A drug or medicine labeled:"Caution-limited by federal law to investigational use". (15) Medical exclusions.A charge excluded under Medical Plan Exclusions. (16) No charge.A charge for Prescription Drugs which may be properly received without charge under local,state or federal programs. (17) Non-legend drags.A charge for FDA-approved drugs that are prescribed for non-FDA-approved uses. (18) No prescription.A drug or medicine that can legally be bought without a written prescription. This does not apply to injectable insulin or diabetic supplies. (19) Refills.Any refill that is requested more than one year after the prescription was written or any refill that is more than the number of refills ordered by the Physician. (20) Smoking cessation.A charge for Prescription Drugs for smoking cessation. These may be considered Covered Charges under the Medical Benefits section of this Plan (21) Vitamins.A charge for legend or non-legend vitamins. HOW TO SUBMIT PHARMACY CLAIMS When obtaining a prescription,a Plan Participant should show his or her JPT/Jefferson County Identification card to the pharmacist. Participating Pharmacies may submit claims on a Plan Participant's behalf. If the pharmacy provider is unable to submit the claim,the Plan Participant should request a receipt. To assist Navitus in processing a claim,the following information must be provided when submitting the claim for processing: — A copy of the receipt — Group name and number (Jefferson County Group 000 1174) — Employee's name and Identification Number — Provider Billing Identification Number Name of patient The prescribing Physician The prescription name An itemization for each separate prescription The date of purchase Jefferson County 50 July I,2015 WHERE TO SUBMIT PHARMACY CLAIMS For proscription claims questions or to obtain a claim form please calk Navitus Health Solutions-toll-free 1 (866)333-2757 or access www.ebms.com Please submit prescription claim forms to: Navitus Health Solutions Operations Division—Claims P.O.Box 999 Appleton,WI 54912-1999 Or fax ALL information to 1 (920)735-5313 or toll free 1 (855)668-8550 Jefferson Carry 51 July 1,2015 VISION CARE BENEFITS Vision care benefits apply when vision care charges are incurred by a Covered Person for services that are recommended and approved by a Physician or Optometrist. BENEFIT PAYMENT Benefit payment for a Covered Person will be made as described in the Schedule of Benefits. VISION CARE CHARGES Vision care charges are the Allowable Charges for the vision care services and supplies shown in the Schedule of Benefits.Benefits for these charges are payable up to the maximum benefit amounts shown in the Schedule of Benefits for each vision care service or supply. LIMITS No benefits will be payable for the following: (1) Before covered.Care,treatment or supplies for which a charge was incurred before a person was covered under this Plan. (2) Services or materials not listed as Covered Charges. (3) Excluded.Charges excluded or limited by the Plan design as stated in this document. (4) Eye examinations required by an employer as a condition of employment,or which the employer is required to provide by virtue of a labor agreement,or those required by a governmental body. (5) Health plan.Any charges that are covered under a health plan that reimburses a greater amount than this Plan. (6) No prescription.Charges for lenses ordered without a prescription. (7) Orthoptics.Charges for orthoptics(eye muscle exercises). (g) Suagh>sses.Charges for safety goggles,including prescription type. (9) Training.Charges for vision training or subnormal vision aids. (10) Visual analysis which does not include refraction. (11) A visual analysis or vision aids provided as a result of an Injury while employed for wage or profit or Sickness covered by a Workers'Compensation Act or similar law. Jefferson County 52 July I,2015 DENTAL BENEFITS This benefit applies when covered dental charges are incurred by a person while covered under this Plan. BENEFIT PAYMENT Each Calendar Year benefits will be paid to a Covered Person for the dental charges.Payment will be made at the rate shown under Dental Percentage Payable in the Schedule of Benefits.No benefits will be paid in excess of the Maximum Benefit Amount. MAXIMUM BENEFIT AMOUNT The Maximum dental benefit amount is shown in the Schedule of Benefits. DENTAL CHARGES Dental charges are the Allowable Charges made by a Dentist or other Physician for necessary care,appliances or other dental material listed as a covered dental service. A dental charge is incurred on the date the service or supply for which it is made is performed or furnished. However,there are times when one overall charge is made for all or part of a course of treatment.In this case, the Claims Administrator will apportion that overall charge to each of the separate visits or treatments.The pro rata charge will be considered to be incurred as each visit or treatment is completed. COVERED DENTAL SERVICES Class A Services: Preventive and Diagnostic Dental Procedures The limits on Class A services are for routine services. If dental need is present,this Plan will consider for reimbursement services performed more frequently than the limits shown. (1) Routine oral exams.This includes the cleaning and scaling of teeth.Limit of one exam per Covered Person every six months. (2) One bitewing x-ray series every six months. (3) One full mouth x-ray every 36 months. (4) One fluoride treatment for covered Dependent children under age 14 each Calendar Year. (5) Space maintainers for covered Dependent children under age 14 to replace primary teeth. (6) Emergency palliative treatment for pain. (7) Sealants on the occlusal surface of a permanent posterior tooth for Dependent children under age 14. Class B Services: Basic Dental Procedures (1) Dental x-rays not included in Class A. (2) Oral surgery.Oral surgery includes,but is not limited to,removal of teeth,preparation of the mouth for dentures and removal of tooth-generated cysts. (3) Periodontics(gum treatments). Jefferson County 53 July 1,2015 (4) Endodontics(root canals). (5) Extractions.This service includes local anesthesia and routine postoperative care. (6) Recementing bridges,crowns or inlays. (7) Fillings,other than gold. (g) General anesthetics,upon demonstration of Medical Necessity. (9) Antibiotic drugs. Class C Services: Major Dental Procedures (1) Gold restorations,including inlays,onlays and foil fillings.The cost of gold restorations in excess of the cost for amalgam,synthetic porcelain or plastic materials will be included only when the teeth must be restored with gold. (2) Installation of crowns. (3) Installing precision attachments for removable dentures. (4) Installing partial,full or removable dentures to replace one or more natural teeth.This service also includes all adjustments made during 12 months following the installation. (5) Addition of clasp or rest to existing partial removable dentures. (6) Initial installation of fixed bridgework to replace one or more natural teeth. (7) Repair of crowns,bridgework and removable dentures. (S) Rebasing or relining of removable dentures. (9) Replacing an existing removable partial or full denture or fixed bridgework;adding teeth to an existing removable partial denture;or adding teeth to existing bridgework to replace newly extracted natural teeth.However,this item will apply only if one of these tests is met: (a) The existing denture or bridgework was installed at least five years prior to its replacement and cannot currently be made serviceable. (b) The existing denture is of an immediate temporary nature.Further,replacement by permanent dentures is required and must take place within six months from the date the temporary denture was installed. EXCLUSIONS A charge for the following is not covered: (1) Administrative costs.Administrative costs of completing claim forms or reports or for providing dental records. (2) Broken appointments.Charges for broken or missed dental appointments. (3) Cosmetic. Services or supplies which are primarily cosmetic in nature. (4) Crowns.Crowns for teeth that are restorable by other means or for the purpose of Periodontal Splinting. Jefferson County 54 July 1,2015 (8) Excluded under Medical.Services that are excluded under Medical Plan Exclusions. (6) Hygiene.Oral hygiene,plaque control programs or dietary instructions. (7) Implants.Implants,including any appliances and/or crowns and the surgical insertion or removal of implants. (8) Medical services.Services that,to any extent,are payable under any medical expense benefits of the Plan. (9) No listing.Services which are not included in the list of covered dental services. (10) Orthodontia.Orthodontic treatment and orthognathic surgery. (11) Personalization.Personalization of dentures. (12) Replacement.Replacement of lost or stolen appliances. (13) Splinting.Crowns,fillings or appliances that are used to connect(splint)teeth,or change or after the way the teeth meet,including altering the vertical dimension,restoring the bite(occlusion)or are cosmetic. Jefferson County 55 July I,2015 HOW TO SUBMIT CLAIMS When services are received from a health care provider,a Plan Participant should show his or her JPT/Jefferson County Identification card to the provider. Participating Providers may submit claims on a Plan Participant's behalf. If it is necessary for a Plan Participant to submit a claim,he or she should request an itemized bill which includes procedure(CPT)and diagnostic(ICD-9)codes from his or her health care provider. To assist the Claims Administrator in processing the claim,the following information must be provided when submitting the claim for processing: — A copy of the itemized bill — Group name and number(Jefferson County Group 0001174) — Provider Billing Identification Number — Employee's name and Identification Number — Name of patient — Name,address,telephone number of the provider of care — Date of service(s) — Place of service — Amount billed Note. A Plan Participant can obtain a claim form from the Plan Administrator or the Claims Administrator. Claim forms are also available at httr://www.ebms.com. WHERE TO SUBMIT CLAIMS Employee Benefit Management Services, Inc., is the Claims Administrator. Claims for expenses should be submitted to the Claims Administrator at the address below: Employee Benefit Management Services,Inc. P.O.Box 21367 Billings,Montana 59104 (406)245-3575 or(800)777-3575 WHEN CLAIMS SHOULD BE FILED Claims should be filed with the Claims Administrator within 365 days of the date charges for the service were incurred.Benefits are based on the Plan's provisions at the time the charges were incurred.Claims filed later than that date will be declined. The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim.If not,more information may be requested from the Covered Person.The Plan reserves the right to have a Plan Participant seek a second medical opinion. CLAIMS PROCEDURE A Claim means a request for a Plan benefit,made by a Plan Participant or by an authorized representative of a Plan Participant that complies with the Plan's reasonable procedures for filing benefit Claims.A Claim for benefits is not a Claim that has been previously submitted,denied,appealed,and re-denied upon appeal. A"Claim"is a Post-Service Claim under the terms of the Plan.A Post-Service Claim means a Claim for covered medical services that have already been received by the Plan Participant. All questions regarding Claims should be directed to the Claims Administrator.All claims will be considered for payment according to the Plan's terms and conditions,limitations and exclusions,and industry standard guidelines in effect at the time charges were incurred.The Plan may,when appropriate or when required by Jefferson County 56 July 1,2015 law,consult with relevant health care professionals and access professional industry resources in making decisions about claims involving specialized medical knowledge or judgment.The Plan Administrator shall have full responsibility to adjudicate all claims and to provide a full and fair review of the initial claim determination in accordance with the following Claims review procedure. A Claim will not be deemed submitted until it is received by the Claims Administrator. For the purposes of this section,Claimant means the Plan Participant or the Plan Participant's authorized representative.A Claimant may appoint an authorized representative to act upon his or her behalf with respect to the Claim.Contact the Claims Administrator for information on the Plan's procedures for authorized representatives.A Claimant does not include a healthcare provider simply by virtue of an assignment of benefits. An Adverse Benefit Determination shall mean a denial,reduction,or termination of,or a failure to provide or make payment(in whole or in part)for,a benefit.An inquiry regarding eligibility or benefits without a Claim for benefits is not a Claim and,therefore,cannot be appealed. Initial Benefit Determination The Initial Benefit Determination on a Post-Service Claim will be made within 30 days of the Claim Administrator's receipt of the Claim.If the Claims Administrator requires an extension due to circumstances beyond the Plan's control,the Claims Administrator will notify the Claimant of the reason for the delay within the initial 30-day period.A benefit determination on the Claim will be made within 15 days of the date the notice of the delay was provided to the Claimant. if additional information is necessary to process the Claim, the Claims Administrator will request the additional information from the Claimant within the initial 30-day period.The Claimant must submit the requested information within 45 days of receipt of the request from the Claims Administrator.Failure to submit the requested information within the 45-day period may result in a denial of the Claim or a reduction in benefits.A benefit determination on the Claim will be made within 15 days of the Plan's receipt of the additional information. Notice of Adverse Benefit Determination The Plan shall provide written or electronic notice of the determination on a Claim in a manner meant to be understood by the Claimant.If a Claim is denied in whole or in part,notice will include the following: (1) Specific reason(s)for the denial. (2) Reference to the specific Plan provisions on which the denial was based. (3) Description of any additional information necessary for the Claimant to perfect the Claim and an explanation of why such information is necessary. (4) Description of the Plan's Claims review procedures and the time limits applicable to such procedures. (5) Statement that the Claimant is entitled to receive,upon request and free of charge,reasonable access to,and copies of,all documents,records,and other information relevant to the Claim. If applicable: (6) Any internal rule,guideline,protocol,or other similar criterion that was relied upon in making the determination on the Claim(or a statement that such a rule,guideline,protocol,or criterion was relied upon in making the Adverse Benefit Determination and that a copy will be provided free of charge to the Claimant upon request). (7) If the Adverse Benefit Determination is based on the Medical Necessity or Experimental or Investigational exclusion or similar such exclusion,an explanation of the scientific or clinical judgment for the detemtination applying the terms of the Plan to the Claim,or a statement that such explanation will be provided free of charge,upon request. Jefferson County 57 Jury I,2015 (8) Identification of medical or vocational experts,whose advice was obtained on behalf of the Plan in connection with a Claim. If the Claimant does not understand the reason for the Adverse Benefit Determination,the Claimant should contact the Claims Administrator at the address or telephone number printed on the Notice of Determination. Claims Review Procedure-General A Claimant may appeal an Adverse Benefit Determination.The Plan offers a two-level review procedure to provide the Claimant with a full and fair review of the Adverse Benefit Determination. The Plan will provide for a review that does not give deference to the previous Adverse Benefit Determination and that is conducted by either an appropriate Plan representative or the Claims Administrator on the Plan's behalf,who is neither the individual who made the Initial Benefit Determination,nor a subordinate of that individual.The review will take into account all comments,documents,records and other information submitted by the Claimant related to the claim,without regard as to whether this information was submitted or considered in the Initial Benefit Determination. If the Adverse Benefit Determination was based in whole or in part upon medical judgment,including determinations on whether a particular treatment,drug,or other item is Experimental and/or Investigational,or not Medically Necessary,the Plan Administrator or its designee will consult with a health care professional who has the appropriate training and experience in the applicable field of medicine;was not consulted in the Initial Benefit Determination;and is not the subordinate of the initial decision-maker.The Plan may consult with vocational or other experts regarding the Initial Benefit Determination. The Plan Administrator will provide free of charge upon request by the Claimant,reasonable access to and copies of,documents,records,and other information as described in Items 5 through 8 under"Notice of Adverse Benefit Determination". First Level of Claims Review The written request for review must be submitted within 180 days of the Claimant's receipt of notice of an Adverse Benefit Determination.The Claimant should include in the appeal letter:his or her name,ID number, group health plan name,and a statement of why the Claimant disagrees with the Adverse Benefit Determination.The Claimant may include any additional supporting information,even if not initially submitted with the Claim. The appeal should be addressed to: Plan Administrator %Employee Benefit Management Services,Inc.(EBMS) P.O.Box 21367 Billings,Montana 59104 Attn:Claims Appeals An appeal will not be deemed submitted until it is received by the Plan Administrator or its designee. Failure to appeal the initial Adverse Benefit Determination within the 180 day period will render that determination final. The first level of review will be performed by the Claims Administrator on the Plan's behalf.The Claims Administrator will review the information initially received and any additional information provided by the Claimant,and determine if the Initial Benefit Determination was appropriate based upon the terms and conditions of the Plan and other relevant information.The Claims Administrator will send a written or electronic Notice of Determination to the Claimant within 30 days of the receipt of the appeal. Jefferson County 58 July 1,2015 Second Level of Claims Review If the Claimant does not agree with the Claims Administrator's determination from the first level review,the Claimant may submit a second level appeal in writing within 60 days of the Claimant's receipt of the Notice of Determination from the first level of review,along with any additional supporting information to: Plan Administrator % Employee Benefit Management Services,Inc.(EBMS) P.O.Box 21367 Billings,Montana 59104 Attn:Claims Appeals An appeal will not be deemed submitted until it is received by the Plan Administrator or its designee. Failure to appeal the determination from the first level of review within the 60 day period will render that determination final The second level of review will be done by the Plan Administrator.The Plan Administrator will review the information initially received and any additional information provided by the Claimant,and make a determination on the appeal based upon the terms and conditions of the Plan and other relevant information. The Plan Administrator will send a written or electronic Notice of Determination for the second level of review to the Claimant within 30 days of receipt of the appeal.The determination by the Plan Administrator upon review will be final,binding,and conclusive and will be afforded the maximum deference permitted by law. If upon review, the Adverse Benefit Determination remains the same and the Claimant still does not agree with the determination, the Claimant has the right to bring an action for benefits. Before fling a lawsuit,the Claimant must exhaust both levels of review as described in this section.A legal action to obtain benefrtr must be commenced within one(1)year of the date of the notice of the Plan Administrator's determination on the second level of review. Jefferson County 59 July 1,2015 COORDINATION OF BENEFITS Coordination of the benefit plans.The Plan's Coordination of Benefits provision sets forth rules for the order of payment of Covered Charges when two or more plans—including Medicare—are paying.The Plan has adopted the order of benefits as set forth in the National Association of Insurance Commissioners(NAIL) Model COB Regulations,as amended. When a Covered Person is covered by this Plan and another plan,or the Covered Person's Spouse is covered by this Plan and by another plan,or the couple's Covered children are covered under two or more plans the plans will coordinate benefits when a claim is received.All references to Spouse will also be applicable to a Domestic Partner, unless otherwise indicated The plan that pays first according to the rules will pay as if there were no other plan involved.The secondary and subsequent plans will pay the balance due up to 100%of the total Allowable Charges. Benefit plan.This provision will coordinate the medical and dental benefits of a benefit plan.The term benefit plan means this Plan or any one of the following plans: (1) Group or nongroup insurance contracts and subscriber contracts; (2) Uninsured arrangements of group or group-type coverage; (3) Group and nongroup coverage through closed panel plans; (4) Group-type contracts; (5) The medical components of long-term care contracts,such as skilled nursing care; (6) Medicare or other government benefits,as permitted by law.This does not include Medicaid,or a government plan that by law,provides benefits that are in excess of those of any private insurance plan or other non-governmental plan. (7) The medical benefits coverage in automobile"no-fault"and traditional automobile"fault"type contracts; The term benefit plan does not include hospital indemnity,accident only,specified disease,school accident or non-medical long-term care coverage. Allowable Charge(s).For a charge to be allowable it must be a usual,customary,and reasonable charge and at least part of it must be covered under this Plan.(See"Allowable Charge"in the Defined Terms section.) In the case of HMO(Health Maintenance Organization)or other in-network only plans:This Plan will not consider any charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also,when an HMO or network plan is primary and the Covered Person does not use an HMO or network provider,this Plan will not consider as an Allowable Charge any charge that would have been covered by the HMO or network plan had the Covered Person used the services of an HMO or network provider. In the case of service type plans where services are provided as benefits,the reasonable cash value of each service will be the Allowable Charge. Automobile limitations.When any medical benefits coverage is available under vehicle insurance,the Plan shall pay excess benefits only,without reimbursement for vehicle plan deductibles. Benefit plan payment order.When two or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules: (A) Plans that do not have a coordination provision,or one like it,will pay first.Plans with such a provision will be considered after those without one. (B) Plans with a coordination provision will pay their benefits up to the Allowable Charge. Jefferson County 60 July I,2015 The first rule that describes which plan is primary is the rule that applies: (1) The benefits of the plan which covers the person directly(that is,as a Member/Employee,Retiree,or subscriber)("Plan A")are determined before those of the plan which covers the person as a Dependent("Plan B"). For Qualified Beneficiaries,coordination is determined based on the person's status prior to the Qualifying Event Special rule. If.(i)the person covered directly is a Medicare beneficiary,and(ii) Medicare is secondary to Plan B,and(iii)Medicare is primary to Plan A(for example,if the person is retired),THEN Plan B will pay first (2) Unless there is a court decree stating otherwise for a Dependent child up to age 19,when a child is covered as a Dependent by more than one plan the order of benefits is determined as follows: When a child is covered as a Dependent and the parents are married or living together,these rules will apply: • The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined before those of the benefit plan of the parent whose birthday falls later in that year; • If both parents have the same birthday,the benefits of the benefit plan which has covered the parent for the longer time are determined before those of the benefit plan which covers the other parent. When a child's parents are divorced,legally separated or not living together,whether or not they have ever been married,these rules will apply: • A court decree may state which parent is financially responsible for medical and dental benefits of the child.In this case,the benefit plan of that parent will be considered before other plans that cover the child as a Dependent.If the financially responsible parent has no health care coverage for the Dependent child,but that parent's spouse does,the plan of that parent's spouse is the primary plan.This rule applies beginning the first of the month after the plan is given notice of the court decree. • A court decree may state both parents will be responsible for the Dependent child's health care expenses.In this case,the plans covering the child shall follow order of benefit determination rules outlined above when the parents are married or living together(as detailed above); • If the specific terms of the court decree state that the parents shall share joint custody,without stating that one of the parents is responsible for the health care expenses of the child,the plans covering the child shall follow the order of benefit determination rules outlined above when a child is covered as a Dependent and the parents are married or living together. If there is no court decree allocating responsibility for the Dependent child's health care expenses,the order of benefits are as follows: 10 The plan covering the custodial parent, 2id The plan covering the spouse of the custodial parent, 3'd The plan covering the non-custodial parent,and The plan covering the spouse of the noncustodial parent. Jefferson County 61 July 1,2015 When a child is covered as a Dependent under more than one plan of individuals who are not the parents of the child,the order of benefits shall be determined as if those individuals were parents of the child. Unless specifically stated otherwise,court order and custody provisions apply up to age 19 for any Dependent child. For a Dependent child who has coverage under either or both parents'plans and also has his or her own coverage as a dependent under a spouse's plan,Rule(5)applies. If the Dependent child's coverage under the spouse's plan began on the same date as the Dependent child's coverage under either or both parents'plans,the birthday rule shall apply to the Dependent child's parents and the Dependent child's spouse. (3) The benefits of a benefit plan which covers a person as a Member/Employee who is neither laid off nor retired or as a Dependent of a Member/Employee who is neither laid off nor retired are determined before those of a plan which covers that person as a laid-off or Retired Member/Employee.This rule does not apply if Rule(1)can be used to detemtine the order of benefits If the other benefit plan does not have this rule,and if,as a result,the plans do not agree on the order of benefits,this rule does not apply. (4) The benefits of a benefit plan which covers a person as a Member/Employee who is neither laid off nor retired or a Dependent of a Member/Employee who is neither laid off nor retired are determined before those of a plan which covers the person as a COBRA beneficiary.This rule does not apply if Rule(1)can be used to determine the order of benefits. (5) If there is still a conflict after these rules have been applied,the benefit plan which has covered the patient for the longer time will be considered first. When there is a conflict in coordination of benefit rules,the Plan will never pay more than 500/9 of Allowable Charges when paying secondary. (C) Medicare will pay primary,secondary or last to the extent stated in federal law.When Medicare is to be the primary payer,this Plan will base its payment upon benefits that would have been paid by Medicare under Parts A and B,regardless of whether or not the person was enrolled under both of these parts.The Plan reserves the right to coordinate benefits with respect to Medicare Part D. (D) If a Plan Participant is under a disability extension from a previous benefit plan,that benefit plan will pay first and this Plan will pay second. (E) The Plan will pay primary to Tricare to the extent required by federal law. Claims determination period.Benefits will be coordinated on a Calendar Year or Plan Year basis,as shown in the Schedule of Benefits section.This is called the claims determination period. Right to receive or release necessary information.To make this provision work,this Plan may give or obtain needed information from another insurer or any other organization or person.This information may be given or obtained without the consent of or notice to any other person.A Covered Person will give this Plan the information it asks for about other plans and their payment of Allowable Charges. Facility of payment.This Plan may repay other plans for benefits paid that the Plan Administrator determines it should have paid.That repayment will count as a valid payment under this Plan. Right of recovery.This Plan may pay benefits that should be paid by another benefit plan.In this case this Plan may recover the amount paid from the other benefit plan or the Covered Person.That repayment will count as a valid payment under the other benefit plan. Further,this Plan may pay benefits that are later found to be greater than the Allowable Charge.In this case, this Plan may recover the amount of the overpayment from the source to which it was paid. Jeff[ cowty 62 July I,2015 TRIRD PARTY RECOVERY Defined Terms "Covered Person"means anyone covered under the Plan,including but not limited to minor dependents and deceased Covered Persons.Covered Person shall include the parents,trustee,guardian,heir,personal representative or other representative of a Covered Person,regardless of applicable law and whether or not such representative has access or control of the Recovery. "Recover,""Recovered,""Recovery"means all monies recovered by way of judgment,settlement, reimbursement,or otherwise to compensate for any loss related to any Injury,Sickness,condition,and/or accident where a Third Party is or may be responsible. "Recovery"includes,but is not limited to,recoveries for medical or dental expenses,attorneys'fees,costs and expenses,pain and suffering,loss of consortium, wrongful death,wages and/or any other recovery of any form of damages or compensation whatsoever. "Subrogation"means the Plan's right to exercise the Covered Person's rights to Recover or pursue Recovery from a Third Party who is liable to the Covered Person for expenses for which the Plan has paid or may agree to pay benefits. "Third Party"means any third party including but not limited to another person,any business entity,insurance policy or any other policy or plan,including but not limited to uninsured or underinsured coverage,self- insured coverage,no-fault coverage,automobile coverage,premises liability(homeowners or business), umbrella policy. Right to Reimbursement To the extent that the Plan has paid benefits to or on behalf of a Covered Person,the Plan has a right of reimbursement of such benefits and is entitled to subrogation as provided herein,against a judgment or recovery received by the Covered Person from a Third Party found liable for a wrongful act or omission that caused the Injury or Sickness necessitating benefit payments. If a Covered Person intends to institute an action for damages against a Third Party,the Covered Person shall give the Plan reasonable notice of the Covered Person's intention to institute the action.Reasonable notice shall include information reasonably calculated to inform the Plan of the facts giving rise to the Third Party action and of any potential Recovery. The Covered Person may request that the Plan pay a proportionate share of the reasonable costs of the Third Party action,including attorney fees. The Plan may elect not to participate in the costs of the action. If such an election is made,the Plan waives 50"/0 of any subrogation rights granted to the Plan through this provision. The Covered Person shall take no action through settlement or otherwise which prejudices the rights and interests of the Plan,and shall cooperate fully with the Plan and its agents,regarding the Plan's rights under this section. Jefferson Comity 63 Jdy I,2015 COBRA CONTINUATION COVERAGE Introduction The right to COBRA Continuation Coverage was created by a federal law,the Consolidated Omnibus Budget Reconciliation Act of 1985,as amended("COBRA71.COBRA Continuation Coverage can become available to you and other members of your family when group health coverage would otherwise end. You should check with your Employer to see if COBRA applies to you and your Dependents. You may have other options available to you when you lose group health coverage. For example,you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace,you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally,you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible(such as a spouse's plan),even if that plan generally doesn't accept late enrollees. What is COBRA Continuation Covera¢e? "COBRA Continuation Coverage"is a continuation of Plan coverage when coverage otherwise would end because of a life event known as a"Qualifying Event." After a Qualifying Event,COBRA Continuation Coverage must be offered to each person who is a"Qualified Beneficiary." You,your spouse,and your dependent children could become Qualified Beneficiaries if coverage under the Plan is lost because of the Qualifying Event. Under the Plan,Qualified Beneficiaries who elect COBRA Continuation Coverage must pay for COBRA Continuation Coverage. Life insurance,Accidental death and dismemberment benefits and weekly income or long-term disability benefits(if a part of your Employer's plan)are not considered for continuation under COBRA. Domestic Partners and Children of a covered Member's Domestic Partner,who otherwise satisfy the Eligibility requirements set forth in the Eligibility provision and are covered under this Plan,will also be offered the opportunity to make an independent election to receive COBRA Continuation Coverage. All references to Spouse will also be applicable to a Domestic Partner,unless otherwise indicated If you are a Covered Member,you will become a Qualified Beneficiary if you lose your coverage under the Plan due to one of the following Qualifying Events: • Your hours of employment are reduced;or • Your employment ends for any reason other than your gross misconduct. If you are the Spouse of a Covered Member,you will become a Qualified Beneficiary if you lose your coverage under the Plan due to one of the following Qualifying Events: • Your Spouse dies; • Your Spouse's hours of employment are reduced; • Your Spouse's employment ends for any reason other than his or her gross misconduct; • Your Spouse becomes entitled to Medicare benefits(under Part A,Part B,or both);or • You become divorced or legally separated from your Spouse. Note: Medicare entitlement means that you are eligible for and enrolled in Medicare. Your Dependent children will become Qualified Beneficiaries if they lose coverage under the Plan due to one of the following Qualifying Events: • The parent-covered Member dies; • The gent-covered Member's hours of employment are reduced; • The parent-covered Member's employment ends for any reason other than his or her gross misconduct; • The parent-covered Member becomes entitled to Medicare benefits(Part A,Part B,or both); • The parents become divorced or legally separated;or • The child is no longer eligible for coverage under the plan as a"Dependent child." Jefferson County 64 July I,2015 If this Plan provides retiree health coverage,sometimes,filing a proceeding in bankruptcy under Title 11 of the United States Code can be a Qualifying Event. If a proceeding in bankruptcy is filed with respect to the Employer,and that bankruptcy results in the loss of coverage of any retired Member covered under the Plan, the retired Member will become a Qualified Beneficiary with respect to the bankruptcy. The retired Member's Spouse,surviving Spouse,and Dependent children also will become Qualified Beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA Continuation Coverage available? The Plan will offer COBRA Continuation Coverage to Qualified Beneficiaries only after the Plan Administrator has been notified that a Qualifying Event has occurred. When the Qualifying Event is the end of employment,reduction of hours of employment,death of the Covered Member,commencement of proceeding in bankruptcy with respect to the Employer,or the Covered Member's becoming entitled to Medicare benefits(under Part A,Part B,or both),the Plan Administrator must be notified of the Qualifying Event. For all other qualifying events(divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child),you must notify the Plan Administrator within 60 days after the Qualifying Event occurs. You must provide this notice in writing to: Joint Powers Trust aka Montana Joint Powers Trust Plan Administrator P.O.Box 21367 Billings,MT 59104 (406)245-3575 Notice must be postmarked,if mailed,or dated,if emailed or hand-delivered on or before the 60th day following the Qualifying Event. How is COBRA Continuation Coverage provided? Once the Plan Administrator receives notice that a Qualifying Event has occurred,COBRA Continuation Coverage will be offered to each of the Qualified Beneficiaries. Each Qualified Beneficiary will have an independent right to elect COBRA Continuation Coverage. Covered Members may elect COBRA Continuation Coverage on behalf of their Spouses,and parents may elect COBRA Continuation Coverage on behalf of their children. In the event that the COBRA Administrator determines that the individual is not entitled to COBRA Continuation Coverage,the COBRA Administrator will provide to the individual an explanation as to why he or she is not entitled to COBRA Continuation Coverage. How long does COBRA Continuation Coverage Iaat? COBRA Continuation Coverage is a temporary continuation of coverage that generally last for 18 months due to the employment termination or reduction of hours of work. Certain Qualifying Events,or a second Qualifying Event during the initial period of coverage,may permit a Qualified Beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA Continuation Coverage can be extended, discussed below. If the Qualifying Event is the death of the Covered Member(or former Member),the Covered Member's(or former Member's)becoming entitled to Medicare benefits(under Part A, Part B,or both),your divorce or legal separation,or a Dependent child's losing eligibility as a Dependent child,COBRA Continuation Coverage can last for up to a total of 36 months. Jefferson coumy 65 July 1,2015 Medicare extension of COBRA Continuation Coverage If you(as the Covered Member)become entitled to Medicare benefits,your Spouse and dependents may be entitled to an extension of the 18 month period of COBRA Continuation Coverage. If you first become entitled to Medicare benefits,and later experience a termination or employment or a reduction of hours,then the maximum coverage period for Qualified Beneficiaries other than you ends on the later of(i)36 months after the date you became entitled to Medicare benefits,and(ii) 18 months(or 29 months if there is a disability extension)after the date of the termination or reduction of hours. For example,if you become entitled to Medicare 8 months before the date on which your employment terminates,COBRA Continuation Coverage for your Spouse and children can last up to 36 months after the date of your Medicare entitlement. If the first Qualifying Event is your termination of employment or a reduction of hours of employment,and you then became entitled to Medicare benefits less than 18 months after the first Qualifying Event,Qualified Beneficiaries other than you are not entitled to an extension of the l8 month period, Disability extension of 18-mouth period of COBRA Continuation Coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration (SSA)to be disabled and you notify the Plan Administrator as set forth herein,you and your entire family may be entitled to receive up to an additional 1 l months of COBRA Continuation Coverage,for a total maximum of 29 months. The disability would have to have started at some time before the 61P day of COBRA Continuation Coverage and must last at least until the end of the 18-month period of COBRA Continuation Coverage. An extra fee will be charged for this extended COBRA Continuation Coverage. Notice of the disability determination must be provided in writing to the Plan Administrator by the date that is 60 days after the latest of: • The date of the disability determination by the SSA; • The date on which a Qualifying Event occurs; • The date on which the Qualified Beneficiary loses(or would lose)coverage under the Plan as a result of the Qualifying Event;or • The date on which the Qualified Beneficiary is informed,through the furnishing of the Plan's Summary Plan Description of both the responsibility to provide the notice and the Plan's procedures for providing such notice to the Plan Administrator. In any event,this notice must be furnished before the end of the first 18 months of Continuation Coverage. The notice must include the name of the Qualified Beneficiary determined to be disabled by the SSA and the date of the determination. A copy of SSA's Notice of Award Letter must be provided within 30 days after the deadline to provide the notice. You must provide this notice m: Joint Powers Trust aka Montana Joint Powers Trust Plan Administrator P.O.Box 21367 Billings,MT 59104 (406)245-3575 Jefferson County 66 July I,2015 Second Qualifying Event extension of 18-month period of COBRA Continuation Coverage If your family experiences another Qualifying Event while receiving 18 months of COBRA Continuation Coverage,the Spouse and Dependent children in your family can get up to 18 additional months of COBRA Continuation Coverage,for a maximum of 36 months,if the Plan Administrator is properly notified about the second Qualifying Event. This extension may be available to the Spouse and any Dependent children receiving COBRA Continuation Coverage if the covered Member or former Member dies,becomes entitled to Medicare benefits(under Part A,Part B,or both),or gets divorced or legally separated,or if the Dependent child stops being eligible under the Plan as a Dependent child. This extension is only available if the second Qualifying Event would have caused the Spouse or Dependent child to lose coverage under the Plan had the first Qualifying Event not occurred. Notice of a second Qualifying Event must be provided in writing to the Plan Administrator by the date that is 60 days after the latest of • The date on which the relevant Qualifying Event occurs; • The date on which the Qualified Beneficiary loses(or would lose)coverage under the Plan as a result of the Qualifying Event;or • The date on which the Qualifying Beneficiary is informed,through the furnishing of the Plan's Summary Plan Description,of both the responsibility to provide the notice and the Plan's procedures for providing such notice to the Plan Administrator. The notice must include the name of the Qualified Beneficiary experiencing the second Qualifying Event,a description of the event and the date of the event. If the extension of coverage is due to a divorce or legal separation,a copy of the decree of divorce or legal separation must be provided within 30 days after the deadline to provide the notice. You must provide this notice to: Joint Powers Trust aka Montana Joint Powers Trust Plan Administrator P.O.Box 21367 Billings,MT 59104 (406)245-3575 Does COBRA Continuation Coverage ever end earlier than the maximum periods above? COBRA Continuation Coverage also may end before the end of the maximum period on the earliest of the following dates: • The date your Employer ceases to provide a group health plan to any Employee; • The date on which coverage ceases by reason of the Qualified Beneficiary's failure to make timely payment of any required premium; • The date that the Qualified Beneficiary first becomes,after the date of election,covered under any other group health plan(as an Employee or otherwise),or entitled to either Medicare Part A or Part B (whichever comes first),except as stated under COBRA's special bankruptcy rules; • The first day of the month that begins more than 30 days after the date of the SSA's determination that the Qualified Beneficiary is no longer disabled,but in no event before the end of the maximum coverage period that applied without taking into consideration the disability extension;or • On the same basis that the Plan can terminate for cause the coverage of a similarly situated non- COBRA participant. Jeffe Caumty 67 July 1,2015 How Do I Pay for COBRA Continuation Coverue? Once COBRA Continuation Coverage is elected,you must pay for the cost of the initial period of coverage within 45 days. Payments are then due on the first day of each month to continue coverage for that month. If a payment is not received and/or post-marked within 30 days of the due date,COBRA Continuation Coverage will be canceled and will not be reinstated. Are There Other Covera¢e Options Besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA Continuation Coverage,there may be other coverage options for you and your family through the Health Insurance Marketplace,Medicaid,or other group health plan coverage options (such as a spouse's plan)through what is called a"special enrollment period." Some of these options may cost less than COBRA continuation Coverage. You can learn more about many of these options at www.healthcare.gov. Additional Information Additional information about the Plan and COBRA Continuation Coverage is available from the Plan Administrator or the COBRA Administrator: Joint Powers Trost aka Montana Joint Powers Trust Employee Benefit Management Services,Inc. Plan Administrator COBRA Administrator P.O.Box 21367 P.O.Box 21367 Billings,MT 59104 Billings,MT 59104 (406)245-3575 (406)245-3575 or(800)777-3575 For more information about your rights under the Employee Retirement Income Security Act(ERISA), including COBRA,the Patient Protection and Affordable Care Act,and other laws affecting group health plans,contact the nearest Regional or District Office of the U.S.Department of Labor's Employee Benefits Security Administration(EBSA)in your area or visit www.dol.eov/ebsa.(Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website). For more information about the Marketplace,visit www.HealthCare.eov. Current Addresses To protect your family's rights,let the Plan Administrator(who is identified above)know about any changes in the addresses of family members.You should also keep a copy,for your records,of any notices you send to the Plan Administrator. Jefferson County 68 July 1,2015 COBRA CONTINUATION COVERAGE FOR RETIRED EMPLOYEES AND/OR THEIR DEPENDENTS COBRA Continuation Coverage will not be available to those Retired Employees that elected,at the time of retirement,to continue coverage under the terms of the Plan as a Redred Employee.However,the following COBRA Continuation Coverage may apply to a Retired Employee's Qualified Benef eiarles. Introduction The right to COBRA Continuation Coverage was created by a federal law,the Consolidated Omnibus Budget Reconciliation Act of 1985,as amended("COBRA').COBRA Continuation Coverage can become available to you and other members of your family when group health coverage would otherwise end. You should check with your Employer to see if COBRA applies to you and your Dependents. You may have other options available to you when you lose group health coverage. For example,you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace,you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally,you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible(such as a spouse's plan),even if that plan generally doesn't accept late enrollees. What is COBRA Continuation Coverage? "COBRA Continuation Coverage"is a continuation of Plan coverage when coverage otherwise would end because of a life event known as a"Qualifying Event" After a Qualifying Event,COBRA Continuation Coverage must be offered to each person who is a"Qualified Beneficiary." You,your spouse,and your dependent children could become Qualified Beneficiaries if coverage under the Plan is lost because of the Qualifying Event Under the Plan,Qualified Beneficiaries who elect COBRA Continuation Coverage must pay for COBRA Continuation Coverage. Life insurance,Accidental death and dismemberment benefits and weekly income or long-term disability benefits(if a part of your Employer's plan)are not considered for continuation under COBRA. Domestic Partners and Children of a covered Member's Domestic Partner,who otherwise satisfy the Eligibility requirements set forth in the Eligibility provision and are covered under this Plan,will also be offered the opportunity to make an independent election to receive COBRA Continuation Coverage. All references to Spouse will also be applicable to a Domestic Partner,unless otherwise indicated If you are a Covered Member,you will become a Qualified Beneficiary if you lose your coverage under the Plan due to one of the following Qualifying Events: • Your hours of employment are reduced;or • Your employment ends for any reason other than your gross misconduct If you are the Spouse of a Covered Member,you will become a Qualified Beneficiary if you lose your coverage under the Plan due to one of the following Qualifying Events: • Your Spouse dies; • Your Spouse's hours of employment are reduced; • Your Spouse's employment ends for any reason other than his or her gross misconduct; • Your Spouse becomes entitled to Medicare benefits(under Part A,Part B,or both);or • You become divorced or legally separated from your Spouse. Note: Medicare entitlement means that you are eligible for and enrolled in Medicare. Jefferson Co ty 69 July I,2015 Your Dependent children will become Qualified Beneficiaries if they lose coverage under the Plan due to one of the following Qualifying Events: • The parent-covered Member dies; • The parent-covered Member's hours of employment are reduced; • The parent-covered Member's employment ends for any reason other than his or her gross misconduct; • The parent-covered Member becomes entitled to Medicare benefits(Part A,Part B,or both); • The parents become divorced or legally separated;or • The child is no longer eligible for coverage under the plan as a"Dependent child." If this Plan provides retiree health coverage,sometimes,filing a proceeding in bankruptcy under Title l I of the United States Code can be a Qualifying Event. If a proceeding in bankruptcy is filed with respect to the Employer,and that bankruptcy results in the loss of coverage of any retired Member covered under the Plan, the retired Member will become a Qualified Beneficiary with respect to the bankruptcy. The retired Member's Spouse,surviving Spouse,and Dependent children also will become Qualified Beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA Continuation Coverage available? The Plan will offer COBRA Continuation Coverage to Qualified Beneficiaries only after the Plan Administrator has been notified that a Qualifying Event has occurred. When the Qualifying Event is the end of employment,reduction of hours of employment,death of the Covered Member,commencement of proceeding in bankruptcy with respect to the Employer,or the Covered Member's becoming entitled to Medicare benefits(under Part A,Part B,or both),the Plan Administrator must be notified of the Qualifying Event. For all other qualifying events(divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child),you must notify the Plan Administrator within 60 days after the Qualifying Event occurs. You must provide this notice in writing to: Joint Powers Trust aka Montana Joint Powers Trust Plan Administrator P.O.Box 21367 Billings,MT 59104 (406)245-3575 Notice must be postmarked,if mailed,or dated,if emailed or hand-delivered on or before the 60s'day following the Qualifying Event. How is COBRA Continuation Coverage provided? Once the Plan Administrator receives notice that a Qualifying Event has occurred,COBRA Continuation Coverage will be offered to each of the Qualified Beneficiaries. Each Qualified Beneficiary will have an independent right to elect COBRA Continuation Coverage. Covered Members may elect COBRA Continuation Coverage on behalf of their Spouses,and parents may elect COBRA Continuation Coverage on behalf of their children. In the event that the COBRA Administrator determines that the individual is not entitled to COBRA Continuation Coverage,the COBRA Administrator will provide to the individual an explanation as to why he or she is not entitled to COBRA Continuation Coverage. How bog does COBRA Continuation Coverage last? COBRA Continuation Coverage is a temporary continuation of coverage that generally last for 18 months due to the employment termination or reduction of hours of work. Certain Qualifying Events,or a second Qualifying Evert during the initial period of coverage,may permit a Qualified Beneficiary to receive a maximum of 36 months of coverage. Jefferson County 70 July 1,2013 There are also ways in which this 18-month period of COBRA Continuation Coverage can be extended, discussed below. If the Qualifying Event is the death of the Covered Member(or former Member),the Covered Member's(or former Member's)becoming entitled to Medicare benefits(under Part A,Part B,or both),your divorce or legal separation,or a Dependent child's losing eligibility as a Dependent child,COBRA Continuation Coverage can last for up to a total of 36 months. Medicare extension of COBRA Continuation Coverage If you(as the Covered Member)become entitled to Medicare benefits,your Spouse and dependents may be entitled to an extension of the 18 month period of COBRA Continuation Coverage. If you first become entitled to Medicare benefits,and later experience a termination or employment or a reduction of hours,then the maximum coverage period for Qualified Beneficiaries other than you ends on the later of(i)36 months after the date you became entitled to Medicare benefits,and(ii) 18 months(or 29 months if there is a disability extension)after the date of the termination or reduction of hours. For example,if you become entitled to Medicare 8 months before the date on which your employment terminates,COBRA Continuation Coverage for your Spouse and children can last up to 36 months after the date of your Medicare entitlement. If the first Qualifying Event is your termination of employment or a reduction of hours of employment,and you then became entitled to Medicare benefits less than 18 months after the first Qualifying Event,Qualified Beneficiaries other than you are not entitled to an extension of the 18 month period. Disability extension of 18-month period of COBRA Continuation Coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration (SSA)to be disabled and you notify the Plan Administrator as set forth herein,you and your entire family may be entitled to receive up to an additional 11 months of COBRA Continuation Coverage,for a total maximum o£29 months. The disability would have to have started at some time before the 60'day of COBRA Continuation Coverage and must last at least until the end of the 18-month period of COBRA Continuation Coverage. An extra fee will be charged for this extended COBRA Continuation Coverage. Notice of the disability determination must be provided in writing to the Plan Administrator by the date that is 60 days after the latest of • The date of the disability determination by the SSA; • The date on which a Qualifying Event occurs; • The date on which the Qualified Beneficiary loses(or would lose)coverage under the Plan as a result of the Qualifying Event;or • The date on which the Qualified Beneficiary is informed,through the furnishing of the Plan's Summary Plan Description of both the responsibility to provide the notice and the Plan's procedures for providing such notice to the Plan Administrator. In any event,this notice must be furnished before the end of the first 18 months of Continuation Coverage. The notice must include the name of the Qualified Beneficiary determined to be disabled by the SSA and the date of the determination. A copy of SSA's Notice of Award Letter must be provided within 30 days after the deadline to provide the notice. You must provide this notice to: Joint Powers Trust aka Montana Joint Powers Trust Plan Administrator P.O.Box 21367 Billings,MT 59104 (406)245-3575 Jefferson county 71 Jury I,2015 Second Qualifying Event extension of 18-month period of COBRA Continuation Coverage if your family experiences another Qualifying Event while receiving 18 months of COBRA Continuation Coverage,the Spouse and Dependent children in your family can get up to 18 additional months of COBRA Continuation Coverage,for a maximum of 36 months,if the Plan Administrator is properly notified about the second Qualifying Event. This extension may be available to the Spouse and any Dependent children receiving COBRA Continuation Coverage if the covered Member or former Member dies,becomes entitled to Medicare benefits(under Part A,Part B,or both),or gets divorced or legally separated,or if the Dependent child stops being eligible under the Plan as a Dependent child. This extension is only available if the second Qualifying Event would have caused the Spouse or Dependent child to lose coverage under the Plan had the first Qualifying Event not occurred. Notice of a second Qualifying Event must be provided in writing to the Plan Administrator by the date that is 60 days after the latest of: • The date on which the relevant Qualifying Event occurs; • The date on which the Qualified Beneficiary loses(or would lose)coverage under the Plan as a result of the Qualifying Event;or • The date on which the Qualifying Beneficiary is informed,through the furnishing of the Plan's Summary Plan Description,of both the responsibility to provide the notice and the Plan's procedures for providing such notice to the Plan Administrator. The notice must include the name of the Qualified Beneficiary experiencing the second Qualifying Event,a description of the event and the date of the event. If the extension of coverage is due to a divorce or legal separation,a copy of the decree of divorce or legal separation must be provided within 30 days after the deadline to provide the notice. You must provide this notice to: Joint Powers Trust aka Montana Joint Powers Trust Plan Administrator P.O.Box 21367 Billings,MT 59104 (406)245-3575 Does COBRA Continuation Coverage ever end earlier than the maximum periods above? COBRA Continuation Coverage also may end before the end of the maximum period on the earliest of the following dates: • The date your Employer ceases to provide a group health plan to any Employee; • The date on which coverage ceases by reason of the Qualified Beneficiary's failure to make timely payment of any required premium; • The date that the Qualified Beneficiary first becomes,after the date of election,covered under any other group health plan(as an Employee or otherwise),or entitled to either Medicare Part A or Part B (whichever comes first),except as stated under COBRA's special bankruptcy rules; • The first day of the month that begins more than 30 days after the date of the SSA's determination that the Qualified Beneficiary is no longer disabled,but in no event before the end of maximum coverage period that applied without taking into consideration the disability extension;or • On the same basis that the Plan can terminate for cause the coverage of a similarly situated non- COBRA participant. Jefferson County 72 ley 1,2015 How Do I Pay for COBRA Continuation Coverage? Once COBRA Continuation Coverage is elected,you must pay for the cost of the initial period of coverage within 45 days. Payments are then due on the first day of each month to continue coverage for that month. If a payment is not received and/or post-marked within 30 days of the due date,COBRA Continuation Coverage will be canceled and will not be reinstated. Are There Other Coverage Options Besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA Continuation Coverage,there may be other coverage options for you and your family through the Health Insurance Marketplace,Medicaid,or other group health plan coverage options (such as a spouse's plan)through what is called a"special enrollment period." Some of these options may cost less than COBRA continuation Coverage. You can learn more about many of these options at www.healthcare.gov. Additional Information Additional information about the Plan and COBRA Continuation Coverage is available fmm the Plan Administrator or the COBRA Administrator: Joint Powers Trust aka Montana Joint Powers Trust Employee Benefit Management Services,Inc. Plan Administrator COBRA Administrator P.O.Box 21367 P.O.Box 21367 Billings,MT 59104 Billings,MT 59104 (406)245-3575 (406)245-3575 or(800)777-3575 For more information about your rights under the Employee Retirement Income Security Act(ERISA), including COBRA,the Patient Protection and Affordable Care Act,and other laws affecting group health plans,contact the nearest Regional or District Office of the U.S.Department of Labor's Employee Benefits Security Administration(EBSA)in your area or visit www.dol.rtov/ebsa.(Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website). For more information about the Marketplace,visit www.HealthCare.2ov. Current Addresses To protect your family's rights,let the Plan Administrator(who is identified above)know about any changes in the addresses of family members.You should also keep a copy,for your records,of any notices you send to the Plan Administrator. Jefferson County 73 July 1,2015 RESPONSIBILITIES FOR PLAN ADMINISTRATION PLAN ADMINISTRATOR. The Joint Powers Trust also known as Montana Joint Powers Trust is the Plan Administrator. The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies, interpretations,practices,and procedures. It is the express intent of this Plan that the Plan Administrator shall have maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan,to make determinations regarding issues which relate to eligibility for benefits,to decide disputes which may arise relative to a Plan Participant's rights,and to decide questions of Plan interpretation and those of fact relating to the Plan.The decisions of the Plan Administrator will be final and binding on all interested parties. DUTIES OF THE PLAN ADMINISTRATOR. (1) To administer the Plan in accordance with its terms. (2) To interpret the Plan,including the right to remedy possible ambiguities,inconsistencies or omissions. (3) To decide disputes which may arise relative to a Plan Participant's rights. (4) To prescribe procedures for filing a claim for benefits and to review claim denials. (S) To keep and maintain the Plan documents and all other records pertaining to the Plan. (6) To appoint a Claims Administrator to pay claims. (7) To delegate to any person or entity such powers,duties and responsibilities as it deems appropriate. CLAIMS ADMINISTRATOR IS NOT A FIDUCIARY.A Claims Administrator is not a fiduciary under the Plan by virtue of paying claims in accordance with the Plan's rules as established by the Plan Administrator. PLAN IS NOT AN EMPLOYMENT CONTRACT The Plan is not to be construed as a contract for or of employment. CLERICAL ERROR Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly terminated.An equitable adjustment of contributions will be made when the error or delay is discovered. If,due to a clerical error,an overpayment occurs in a Plan reimbursement amount,the Plan retains a contractual right to the overpayment.The person or institution receiving the overpayment will be required to return the incorrect amount of money. In the case of a Plan Participant,if it is requested,the amount of overpayment will be deducted from future benefits payable. AMENDING AND TERMINATING THE PLAN If the Plan is terminated,the rights of the Plan Participants are limited to expenses incurred before termination. The Employer intends to maintain this Plan indefinitely;however,it reserves the right,at any time,to suspend or terminate the Plan in whole or in part. The Plan Administrator reserves the right,at any time,to amend, suspend or terminate the Plan in whole or in part, in compliance with the following provisions: (1) Amendments shall be by a resolution of the Trustees or other similar governing body of the Joint Powers Trust also known as Montana Joint Powers Trust or by the written approval of an authorized officer of the Joint Powers Trust also known as Montana Joint Powers Trust. Jetrer County 74 July 1,2015 (2) Termination shall be by a resolution of the Trustees or other similar governing body of the Joint Powers Trust also known as Montana Joint Powers Trust or by the written approval of an authorized officer of the Joint Powers Trust also known as Montana Joint Powers Trust STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (THE-PRIVACY STANDARDS")ISSUED PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996,AS AMENDED(HIPAA) Disclosure of Summary Health Information to the Plan Administrator and Plan Sponsor In accordance with the Privacy Standards,the Plan may disclose Summary Health Information to the Plan Administrator and/or the Plan Sponsor,if the Plan Administrator or the Plan Sponsor requests the Summary Health Information for the purpose of(a)obtaining premium bids from health plans for providing health insurance coverage under this Plan or(b)modifying,amending or terminating the Plan. "Summary Health Information"may be individually identifiable health information and it summarizes the claims history,claims expenses or the type of claims experienced by individuals in the plan,but it excludes all identifiers that must be removed for the information to be&-identified,except that it may contain geographic information to the extent that it is aggregated by five-digit zip code. Disclosure of Protected Health Information(PHI)to the Plan Administrator for Plan Administration Purposes "Protected Health Information" (PHI) means individually identifiable health information, created or received by a health care provider,health plan, employer, or health care clearinghouse; and relates to the past,present,or fixture physical or mental health condition of an individual;the provision of health care to an individual;or the past, present,or future payment for the provision of health care to an individual; and is transmitted or maintained in any form or medium. In order that the Plan Administrator may receive and use PHI for Plan Administration purposes,the Plan Administrator agrees to: (1) Not use or further disclose PHI other than as permitted or required by the Plan Documents or as Required by Law(as defined in the Privacy Standards); (2) Ensure that any agents,including a subcontractor,to whom the Plan Administrator provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Administrator with respect to such PHI; (3) Not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Administrator,except pursuant to an authorization which meets the requirements of the Privacy Standards; (4) Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which the Plan Administrator becomes aware; (5) Make available PHI in accordance with Section 164.524 of the Privacy Standards(45 CFR 164524); (6) Make available PHI for amendment and incorporate any amendments to PHI in accordance with Section 164.526 of the Privacy Standards(45 CFR 164.526); (7) Make available the information required to provide an accounting of disclosures in accordance with Section 164.528 of the Privacy Standards(45 CFR 164.528); (8) Make its internal practices,books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of the U.S.Department of Health and Human Services("HHS'), or any other officer or employee of HHS to whom the authority involved has been delegated,for hrfasm couay 75 July t,2015 purposes of determining compliance by the Plan with Part 164,Subpart E,of the Privacy Standards (45 CFR 164.500 of seq); (9) If feasible,return or destroy all PHI received from the Plan that the Plan Administrator still maintains in any form and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made,except that,if such return or destruction is not feasible,limit further uses and disclosures to those purposes that make the return or destruction of the PHI infeasible;and (10) Ensure that adequate separation between the Plan and the Plan Administrator,as required in Section 164.504(f)(2Xiii)of the Privacy Standards(45 CFR 164.504(f)(2Xiii)),is established as follows: (a) The following employees,or classes of employees,or other persons under control of the Plan Administrator,shall be given access to the PHI to be disclosed: Joint Powers Trust also known as Montana Joint Powers Trust Trustees (b) The access to and use of PHI by the individuals described in subsection(a)above shall be restricted to the Plan Administration functions that the Plan Administrator performs for the Plan (c) In the event any of the individuals described in subsection(a)above do not comply with the provisions of the Plan Documents relating to use and disclosure of PHI,the Plan Administrator shall impose reasonable sanctions as necessary,in its discretion,to ensure that no further non-compliance occurs.Such sanctions shall be imposed progressively(for example,an oral warning,a written warning,time off without pay and termination),if appropriate,and shall be imposed so that they are commensurate with the severity of the violation "Plan Administration"activities are limited to activities that would meet the definition of payment or health care operations,but do not include finmctions to modify,amend or terminate the Plan or solicit bids from prospective issuers. "Plan Administration'functions include quality assurance,claims processing,auditing,monitoring and management of carve-out plans,such as vision and dental. It does not include any employment-related functions or functions in connection with any other benefit or benefit plans. The Plan shall disclose PHI to the Plan Administrator only upon receipt of a certification by the Plan Administrator that(a)the Plan Documents have been amended to incorporate the above provisions and(b)the Plan Administrator agrees to comply with such provisions. Disclosure of Certain Enrollment Information to the Plan Administrator and the Plan Sponsor Pursuant to Section 164.504(1)(IXiii)of the Privacy Standards(45 CFR 164.504(t)(lXiii)),the Plan may disclose to the Plan Administrator and/or the Plan Sponsor information on whether an individual is participating in the Plan or is enrolled in or has disenrolled from a health insurance issuer or health maintenance organization offered by the Plan to the Plan Administrator. Disclosure of PHI to Obtain Stop-bss or Excess Loss Coverage The Plan Administrator hereby authorizes and directs the Plan,through the Plan Administrator or the Claims Administrator,to disclose PHI to stop-loss carriers,excess loss carriers or managing general underwriters(MGUs) for underwriting and other purposes in order to obtain and maintain stop-loss or excess loss coverage related to benefit claims under the Plan Such disclosures shall be made in accordance with the Privacy Standards and any applicable Business Associate Agreemem(s). Other Disclosures and Uses of PHI With respect to all other uses and disclosures of PHI,the Plan shall comply with the Privacy Standards Jefferson County 76 July 1,2015 STANDARDS FOR SECURITY OF ELECTRONIC PROTECTED HEALTH INFORMATION (THE"PRIVACY STANDARDS")ISSUED PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996,AS AMENDED(HIPAA) Disclosure of Electronic Protected Health Information("Electronic PHI")to the Plan Sponsor for Plan Administration Functions To enable the Plan Sponsor to receive and use Electronic PHI for Plan Administration Functions(as defined in 45 CFR§ 164.504(a)),the Plan Sponsor agrees to: • Implement administrative,physical,and technical safeguards that reasonably and appropriately protect the confidentiality, integrity,and availability of the Electronic PHI that it creates,receives,maintains, or transmits on behalf of the Plan; • Ensure that adequate separation between the Plan and the Plan Sponsor,as required in 45 CFR § 164.504(f)(2xiii),is supported by reasonable and appropriate security measures. • Ensure that any agent,including a subcontractor,to whom the Plan Sponsor provides Electronic PHI created,received,maintained,or transmitted on behalf of the Plan,agrees to implement reasonable and appropriate security measures to protect the Electronic PHI;and • Report to the Plan any security incident of which it becomes aware. Jetrewn County 77 July 1.2015 GENERAL PLAN INFORMATION PLAN NAME Jefferson County Health Plan PLAN EFFECTIVE DATE:September 1,2006 PLAN YEAR ENDS:June 30 EMPLOYER/PLAN SPONSOR INFORMATION Jefferson County P.O.Box H Boulder,MT 59632-0249 (406)2254020 PLAN ADMINISTRATOR Joint Powers Trust also known as Montana Joint Powers Trust P.O.Box 21367 Billings,Montana 59104 (406)245-3575 CLAIMS ADMINISTRATOR Employee Benefit Management Services,Inc. P.O.Box 21367 Billings,Montana 59104 (406)245-3575 Jefferson County 78 July 1,2015