ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼11: ) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 ACCESS TO RECORDS AND CONFIDENTIALITY 10 DEFINITIONS OF TERMS USED 10 SERVICES NOT COVERED 13 DISPUTES AND COMPLAINTS 16 DETERMINATION OF COVERAGE 16 COMPLAINTS 16 CONDITIONS 19 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 COORDINATION OF BENEFITS 19 MEDICARE AND THIS CONTRACT 22 EFFECTIVE DATE AND ELIGIBILITY 22 EFFECTIVE DATE 22 ELIGIBILITY 23 CHANGES IN COVERAGE 24 TERMINATION 24 VOLUNTARY TERMINATION 24 INVOLUNTARY TERMINATION 24 TERMINATION FOR CAUSE 24 CLAIMS PROVISIONS 25 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 3 contracts
Samples: www.healthpartners.com, www.healthpartners.com, www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼11: ) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 7 STEP THERAPY OVERRIDE PROCESS 8 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 8 PRIOR AUTHORIZATION OF SERVICES 9 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 DISPUTES AND COMPLAINTS 16 15 DETERMINATION OF COVERAGE 16 15 COMPLAINTS 16 15 CONDITIONS 19 18 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 18 COORDINATION OF BENEFITS 19 19 MEDICARE AND THIS CONTRACT 22 EFFECTIVE DATE AND ELIGIBILITY 22 EFFECTIVE DATE 22 22 ELIGIBILITY 23 23 CHANGES IN COVERAGE 24 23 TERMINATION 24 VOLUNTARY TERMINATION 24 24 INVOLUNTARY TERMINATION 24 24 TERMINATION FOR CAUSE 24 CLAIMS PROVISIONS 25 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 2 contracts
Samples: www.healthpartners.com, www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼11: ) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 7 STEP THERAPY OVERRIDE PROCESS 8 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 8 PRIOR AUTHORIZATION OF SERVICES 9 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 DISPUTES AND COMPLAINTS 16 15 DETERMINATION OF COVERAGE 16 15 COMPLAINTS 16 15 CONDITIONS 19 18 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 18 COORDINATION OF BENEFITS 19 19 MEDICARE AND THIS CONTRACT 22 21 EFFECTIVE DATE AND ELIGIBILITY 22 EFFECTIVE DATE 22 ELIGIBILITY 22 ELIGIBILITY 23 CHANGES IN COVERAGE 24 23 TERMINATION 23 VOLUNTARY TERMINATION 24 INVOLUNTARY TERMINATION 24 VOLUNTARY TERMINATION 24 INVOLUNTARY TERMINATION 24 TERMINATION FOR CAUSE 24 CLAIMS PROVISIONS 25 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 2 contracts
Samples: www.healthpartners.com, www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼11: ) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 ACCESS TO RECORDS AND CONFIDENTIALITY 10 DEFINITIONS OF TERMS USED 10 SERVICES NOT COVERED 13 DISPUTES AND COMPLAINTS 16 DETERMINATION OF COVERAGE 16 COMPLAINTS 16 CONDITIONS 19 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 COORDINATION OF BENEFITS 19 MEDICARE AND THIS CONTRACT 22 EFFECTIVE DATE AND ELIGIBILITY 22 EFFECTIVE DATE 22 ELIGIBILITY 23 CHANGES IN COVERAGE 24 TERMINATION 24 VOLUNTARY TERMINATION 24 INVOLUNTARY TERMINATION 24 TERMINATION FOR CAUSE 24 CLAIMS PROVISIONS 25 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 2 contracts
Samples: www.healthpartners.com, www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo Xxxxxx xxx wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼112k6s¼: 711) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad Xxxx Xxxxxx (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 (ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 7 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 8 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 8 PRIOR AUTHORIZATION OF SERVICES 8 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 12 DISPUTES AND COMPLAINTS 16 15 DETERMINATION OF COVERAGE 16 15 COMPLAINTS 16 15 CONDITIONS 19 18 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 18 COORDINATION OF BENEFITS 19 18 MEDICARE AND THIS CONTRACT 22 21 EFFECTIVE DATE AND ELIGIBILITY 22 21 EFFECTIVE DATE 22 21 ELIGIBILITY 23 21 CHANGES IN COVERAGE 24 22 TERMINATION 24 22 VOLUNTARY TERMINATION 24 23 INVOLUNTARY TERMINATION 24 23 TERMINATION FOR CAUSE 24 23 CLAIMS PROVISIONS 25 AMENDMENT(S) 24 BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 1 contract
Samples: www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U . 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) λ 0 (Amharic) 8n·8nø>: Õ ô,p LL ôC4 L2L 0 ff Õp0õ 0ßn á0ñqxŃ Õ40g 20ßn á0þeEŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 9 FùVØ4 nVsìnb : øÜ n2ø Dጥ0 FÜø 0-000-000-0000. ( æ8 p 2k6s7¼118 4 2nሳW7ø11: ) £µ¬µÅ¥ ภчæчÅ¥ (Thai) Á¦¥Á&¥น: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Áaч»u¡ภчæчÅ¥»uч¤ч&aæ&ч&'ª¥Á®¨&°µ£µ¬µÅ¢¦¸ чеภчæчÅ¢&¸ æ & 0-000-000-0000. (TTY: 711) unD xxX (Karen) ymol.ymo;= ymol)ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. wvXmbl)vXmphR eDwrHRb)ohM) vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ȒơƑĐřș ȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ębee áxx’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXXTTY: 001000) Deitsch Xeitsch (Pennsylvanian DutcxDxxxx) Xxxx du Deitsch Waxx xx Xeitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ÞS ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ ᪥ᮏㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Ȫǐ¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã ǓȬǐ Ǿȡ `Þ ÞS @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION ENROLLEE IXXXXMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 4 BENEFITS CHART 4 CHANGES IN BENEFITS 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 9 PRIOR AUTHORIZATION OF SERVICES 9 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 DISPUTES AND COMPLAINTS 16 DETERMINATION OF COVERAGE 16 16 COMPLAINTS 16 CONDITIONS 19 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 19 COORDINATION OF BENEFITS 19 19 MEDICARE AND THIS CONTRACT 22 EFFECTIVE DATE AND ELIGIBILITY 22 EFFECTIVE DATE 22 22 ELIGIBILITY 23 23 CHANGES IN COVERAGE 24 TERMINATION 24 VOLUNTARY TERMINATION 24 24 INVOLUNTARY TERMINATION 24 24 TERMINATION FOR CAUSE 24 CLAIMS PROVISIONS 25 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the available ax xxe start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 1 contract
Samples: www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo Xxxxxx xxx wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼112k6s¼: 711) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad Xxxx Xxxxxx (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 (ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 7 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 8 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 8 PRIOR AUTHORIZATION OF SERVICES 8 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 12 DISPUTES AND COMPLAINTS 16 15 DETERMINATION OF COVERAGE 16 15 COMPLAINTS 16 15 CONDITIONS 19 18 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 18 COORDINATION OF BENEFITS 19 18 MEDICARE AND THIS CONTRACT 22 21 EFFECTIVE DATE AND ELIGIBILITY 22 21 EFFECTIVE DATE 22 21 ELIGIBILITY 23 21 CHANGES IN COVERAGE 24 22 TERMINATION 24 22 VOLUNTARY TERMINATION 24 22 INVOLUNTARY TERMINATION 24 23 TERMINATION FOR CAUSE 24 23 CLAIMS PROVISIONS 25 23 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 1 contract
Samples: www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼11: ) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 4 BENEFITS CHART 4 CHANGES IN BENEFITS 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 9 PRIOR AUTHORIZATION OF SERVICES 9 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 DISPUTES AND COMPLAINTS 16 DETERMINATION OF COVERAGE 16 16 COMPLAINTS 16 CONDITIONS 19 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 19 COORDINATION OF BENEFITS 19 19 MEDICARE AND THIS CONTRACT 22 EFFECTIVE DATE AND ELIGIBILITY 22 EFFECTIVE DATE 22 22 ELIGIBILITY 23 23 CHANGES IN COVERAGE 24 TERMINATION 24 VOLUNTARY TERMINATION 24 24 INVOLUNTARY TERMINATION 24 24 TERMINATION FOR CAUSE 24 CLAIMS PROVISIONS 25 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 1 contract
Samples: www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 ≑㚵⊁ˤ婳农暣 0-000-000-0000. (TTY: 711) Français (French) ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U . 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo Xxxxxx xxx wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) λ 0 (Amharic) 8n·8nø>: Õ ô,p LL ôC4 L2L 0 ff Õp0õ 0ßn á0ñqxŃ Õ40g 20ßn á0þeEŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 9 FùVØ4 nVsìnb : øÜ n2ø Dጥ0 FÜø 0-000-000-0000. ( æ8 p 2k6s7¼118 4 2nሳWø: 711) £µ¬µÅ¥ ภчæчÅ¥ (Thai) Á¦¥Á&¥น: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Áaч»u¡ภчæчÅ¥»uч¤ч&aæ&ч&'ª¥Á®¨&°µ£µ¬µÅ¢¦¸ чеภчæчÅ¢&¸ æ & 0-000-000-0000. (TTY: 711) unD xxX (Karen) ymol.ymo;= ymol)ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. wvXmbl)vXmphR eDwrHRb)ohM) vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad Xxxx Xxxxxx (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ębee áxx’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXXTTY: 001000) Deitsch Xeitsch (Pennsylvanian DutcxDxxxx) Xxxx du Deitsch Waxx xx Xeitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ÞS ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ ᪥ᮏㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Ȫǐ¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã ǓȬǐ Ǿȡ `Þ ÞS @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 (ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION ENROLLEE IXXXXMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 7 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 8 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 8 PRIOR AUTHORIZATION OF SERVICES 8 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 12 DISPUTES AND COMPLAINTS 16 15 DETERMINATION OF COVERAGE 16 15 COMPLAINTS 16 15 CONDITIONS 19 18 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 18 COORDINATION OF BENEFITS 19 18 MEDICARE AND THIS CONTRACT 22 21 EFFECTIVE DATE AND ELIGIBILITY 22 21 EFFECTIVE DATE 22 21 ELIGIBILITY 23 21 CHANGES IN COVERAGE 24 22 TERMINATION 24 22 VOLUNTARY TERMINATION 24 23 INVOLUNTARY TERMINATION 24 23 TERMINATION FOR CAUSE 24 23 CLAIMS PROVISIONS 25 AMENDMENT(S) 24 BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the available ax xxe start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
Appears in 1 contract
Samples: www.healthpartners.com
ATENCIÓN. si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 0-000-000-0000. (TTY: 711) ƐƞƗƞƕƞƖ (Laotian) ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞ ƊǙ ƞƋƩƖǚ ƞƐƞƗƞ ƕƞƖ, ƀƞƋƌǑƕƀƞƋƅǙ ƖƆƩƘǘ ƙƇǚ ƞƋƐƞƗƞ, ƫƇƆǞƌƩƗǐ ǟƂǙ ƞ, ƪƒǙ ƋƒƐǚ ƙƒƬƘǚ ƊǙ ƞƋ. ƫƊƔ 0-000-000-0000. (TTY: 711) Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb xxx koj. Xx xxx 0-000-000-0000. (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, xxxxxx Xxxxx kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 0-000-000-0000. (TTY: 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch xx xx trợ xxxx xxx miễn phí xxxx xxx bạn. Gọi số 0-000-000-0000. (TTY: 711) ΔϳΑέόϟ (Arabic)ήϓϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)0-000-000-0000 ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁ˤ ATTENTION: Si vous parlez français, des services d’aide 婳农暣 0-000-000-0000. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 0-000-000-0000. (ATS: 711) Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 0-000-000-0000. (телетайп: 711) 䞲ῃ㠊 (Korean) 㨰㢌a 䚐ạ㛨⪰ ㇠㟝䚌㐐⏈ ᷱ㟤S 㛬㛨 㫴㠄 ㉐⽸㏘⪰ ⱨ⨀⦐ 㢨㟝䚌㐘 ㍌ 㢼㏩⏼␘U 0-000-000-0000. (TTY: 711) Af Soomaali (Somali) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo bilaash ah. Fadlan soo Xxxxxx xxx wac 0-000-000-0000. (TTY: 711) Tagalog (Tagalog) PAUNAWA: Kung nagsasalita xx xx Tagalog, maaari kang gumamit ng mga serbisyo ng tulong xx xxxx nang walang bayad. Tumawag sa 0-000-000-0000. (TTY: 711) Oromiffa (Cushite [Oromo]) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 0-000-000-0000. (TTY: 711) Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 0-000-000-0000. (TTY: 711) 0 (Amharic) 8n·>: Õ ô,p LL 0 ff Õp0õ 0ßn á0ñqxŃ [Ģ CØùʽp kÅ÷ìkº£Ł ·Ü k2¼ DČ0 ÚܼY 0-000-000-0000. ( æ8 p 2k6s7¼112k6s¼: 711) £µ¬µÅ¥ (Thai) Á¦¥: µ»¡£µ¬µÅ¥»µ¤µ¦Ä¦µ¦nª¥Á®¨°µ£µ¬µÅ¢¦¸ æ 0-000-000-0000. (TTY: 711) unD (Karen) ymol.ymo;= erh>uwdR unD usdmtCd< erRM> usdmtw>rRpXRvX wvXmbl.vXmphR eDwrHRb.ohM. vuDRId; 0-000-000-0000. (TTY: 711) ελληνικά (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 0-000-000-0000. (TTY: 711) ȓîŷ Ƅ (Mon-Khmer, Cambodian) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚ éřǯžŻ ŴƤȓîŷ Ƅ, ȒơƑĐșřȇ ŻȓŧŚéŴƤ ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ Ś éɇ ĆȄ Ƅ ŏȄƄơȽŬŐ 0-000-000-0000. (TTY: 711) Diné Bizaad Xxxx Xxxxxx (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bxx xxá’ánída’áwo’dę´ę´’, t’áá jiik’eh, éí ná hóló˛ , koj˛i’ hódíílnih 0-000-000-0000. (XXX: 001) Deitsch (Pennsylvanian Dutcx) Xxxx du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 0-000-000-0000. (TTY: 711) Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 0-000-000-0000. (TTY: 711) Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 0-000-000-0000. (TTY: 711) Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 0-000-000-0000. (TTY: 711) Ǒ¡ȣ (Hindi) Úȡ Ʌ: Ǒ ] Ǒ¡ȣ Ȫȯ ¡ɇ Ȫ ]ȯ ͧf ǕÝ Ʌ ȡȡ ¡ȡȡ ȯȡfȲ `Þ ¡ɇ@ 0-000-000-0000. (TTY: 711) ᪥ᮏ ㄒ (Japanese) ὀព㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ ↓ᩱࡢゝㄒᨭࢆࡈ⏝࠸ࡓࡔࡅࡲࡍࠋ0-000-000-0000 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 0-000-000-0000. (TTY: 711) ȯȡȣ (Nepali) Úȡ ǑǕ¡Ȫ :Q ȡ^ɍȯ ȯȡȣ Ȫã¡Ǖ Û ȯ ȡ^ɍȪ Ǔǔà ȡȡ ¡ȡȡ ȡ¡Ǿ ǓȬã Ǿȡ `Þ @ Ȫ Ǖ¡Ȫ Q 0-000-000-0000 (ǑǑȡ^: 711) Srpsko-hrvatski (Serbo-Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 0-000-000-0000. (TTY: 711) Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 0-000-000-0000. (TTY: 711) ȤK^hSj (Gujarati) ɅIWh: Ks S\p ȤK^hSj Zs_Sh es, Ss iW:ɃƣD [hch deh] dpahB S\h^h \hN° ;X_ƞV Jp. YsW D^s 0-000-000-0000. (TTY: 711) Adamawa (Fulfulde, Sudanic) MAANDO: To a waawi Adamawa, e xxxxx xxxxxxxx-ma to ekkitaaki wolde caahu. Noddu 0-000-000-0000. (TTY: 711) ϭΩέ˵ (Urdu) ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ؏ϳ٫ فΗϟϭΑ ϭΩέ ̟ έ̳ :έΩέΑΧ .(TTY: 711) 0-000-000-0000 ؐϳή̯ ϝΎ̯ ل ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ Українська (Ukranian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 0-000-000-0000. (телетайп: 711) TABLE OF CONTENTS Section Page ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY 1 IMPORTANT ENRXXXXE INFORMATION FOR NETWORK SERVICES 1 ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES 2 TERMS AND CONDITIONS OF USE OF THIS CONTRACT 2 INTRODUCTION TO THE MEMBERSHIP CONTRACT 3 MEMBERSHIP CONTRACT 3 3 IDENTIFICATION CARD 3 ASSIGNMENT OF BENEFITS 3 3 ENROLLMENT PAYMENTS 3 BENEFITS 3 3 BENEFITS CHART 4 CHANGES IN BENEFITS 4 4 AMENDMENTS TO THIS CONTRACT 4 CONFLICT WITH EXISTING LAW 4 4 HOW TO USE THE NETWORK 4 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES 8 STEP THERAPY OVERRIDE PROCESS 8 7 UNAUTHORIZED PROVIDER SERVICES 8 CareCheck® (Applicable to Non-Network Benefits only) 9 8 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 8 PRIOR AUTHORIZATION OF SERVICES 8 ACCESS TO RECORDS AND CONFIDENTIALITY 10 9 DEFINITIONS OF TERMS USED 10 9 SERVICES NOT COVERED 13 12 DISPUTES AND COMPLAINTS 16 15 DETERMINATION OF COVERAGE 16 15 COMPLAINTS 16 15 CONDITIONS 19 18 RIGHTS OF REIMBURSEMENT AND SUBROGATION 19 18 COORDINATION OF BENEFITS 19 18 MEDICARE AND THIS CONTRACT 22 20 EFFECTIVE DATE AND ELIGIBILITY 22 21 EFFECTIVE DATE 22 21 ELIGIBILITY 23 21 CHANGES IN COVERAGE 24 22 TERMINATION 24 22 VOLUNTARY TERMINATION 24 22 INVOLUNTARY TERMINATION 24 22 TERMINATION FOR CAUSE 24 23 CLAIMS PROVISIONS 25 23 AMENDMENT(S) BENEFITS CHART HEALTHPARTNERS MISSION TO IMPROVE HEALTH AND WELL-BEING IN PARTNERSHIP WITH OUR MEMBERSM PATIENTS AND COMMUNITY ABOUT GROUP HEALTH PLAN, INC., HEALTHPARTNERS, INC. and HEALTHPARTNERS INSURANCE COMPANY Group Health Plan, Inc. (GHI). GHI is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). GHI underwrites the HMO Benefits described in this Contract. GHI is a part of the HealthPartners family of related organizations. When used in this Contract, “we”, “us” or “our” has the same meaning as “GHI” and its related organizations. HealthPartners, Inc. (HealthPartners). HealthPartners is a non-profit corporation which is licensed by the State of Minnesota as a Health Maintenance Organization (HMO). HealthPartners administers the HealthPartners Benefits described in this Contract. HealthPartners is the parent company of a family of related organizations and provides administrative services for Group Health Plan, Inc. HealthPartners Insurance Company. HealthPartners Insurance Company is the insurance company underwriting the Non- Network Medical Expense Benefits described in this Contract. HealthPartners Insurance Company is a part of the HealthPartners family of related organizations. The comprehensive HMO coverage described in this Contract and Benefits Chart may not cover all your health care expenses. Read this Contract carefully to determine which expenses are covered. The laws of the State of Minnesota provide members of an HMO, certain legal rights, including the following: IMPORTANT ENROLLEE INFORMATION FOR NETWORK SERVICES: • COVERED SERVICES. These are network services provided by participating network providers or authorized by those providers. This Contract fully defines what services are covered and describes procedures you must follow to obtain coverage. • PROVIDERS. Enrolling with us does not guarantee services by a particular provider on the list of network providers. When a provider is no longer part of the network, you must choose among remaining Network providers. • EMERGENCY SERVICES. Emergency services from providers outside the network will be covered if proper procedures are followed. Read this Contract for the procedures, benefits and limitations associated with emergency care from network and non-network providers. • EXCLUSIONS. Certain services or medical or dental supplies are not covered. Read this Contract for a detailed explanation of all exclusions. • CANCELLATION. Your coverage may be cancelled by you or us only under certain conditions. Read this Contract for the reasons for cancellation of coverage. • NEWBORN COVERAGE. If your health plan provides for dependents coverage, a newborn infant is covered from birth. We will not automatically know of the newborn’s birth or that you would like coverage under your plan. You should notify us of the newborn’s birth and that you would like coverage. If your Contract requires an additional enrollment payment for each dependent, we are entitled to all enrollment payments due from the time of the infant’s birth until the time you notify us of the birth. We may withhold payment of any health benefits for the newborn infant until any enrollment payments you owe are paid. • PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT. Enrolling with us does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is avaixxxxe at the start of the Contract year. ENROLLEE BILL OF RIGHTS FOR NETWORK SERVICES • Enrollees have the right to available and accessible services including emergency services 24 hours a day and seven days a week. • Enrollees have the right to be informed of health problems, and to receive information regarding treatment alternatives and risks which is sufficient to assure informed choice. • Enrollees have the right to refuse treatment, and the right to privacy of medical or dental and financial records maintained by us and our health care providers, in accordance with existing law. • Enrollees have the right to file a complaint with us and the Commissioner of Health and the right to initiate a legal proceeding when experiencing a problem with us or our health care providers. • Enrollees have the right to a grace period of 31 days for each enrollment payment due, when falling due after the first enrollment payment, during which period this contract shall continue in force. If you are a recipient of the advance payment of the premium tax credit, you have a 3-month grace period, as described in the “Termination” section under subsection “Termination for Cause”. • Medicare enrollees have the right to voluntarily disenroll from coverage and the right not to be requested or encouraged to disenroll, except in circumstances specified in federal law. • Medicare enrollees have the right to a clear description of nursing home and home care benefits covered by us.
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Samples: www.healthpartners.com
