Church Activity Medical Assistance Handbook - Deseret Mutual by jianghongl

VIEWS: 34 PAGES: 18

									General Information
Disclaimer
Key Points to Know
Church Activity Contact Information
Eligibility
How Assistance Is Funded
Maximum Amount Payable
How to Request Medical & Dental Assistance
Medical
Ambulance
Diagnostic X-rays & Lab Tests
Emergency Room
Exams & Consultations
Extended Care Facility
Eyewear (Glasses or Contact Lenses)
Hospital — Inpatient
Medical Equipment (Durable)
Medical Supplies
Prescription Drugs
Private Duty Nursing
Prosthetics & Appliances
Surgery — Outpatient Services
Surgery & Anesthesia
Therapy
Transportation
Dental
Alternative Procedures
Anesthesia
Diagnostic Procedures
Endodontic Procedures
Oral Surgery
Orthodontic Procedures
Outpatient Hospitalization
Prosthodontic Procedures
Restorative Procedures
How to Request Death & Dismemberment Assistance
Dismemberment
Death
How to Determine Payment Status
Prior Approval
Pre-existing Conditions
Coordination of Benefits
Legal Notice
Appeals
Subrogation
Definitions
Exclusions




                                                  DESERET MUTUAL
                                                  BENEFIT ADMINISTRATORS



                   150 Social Hall Avenue, Suite 170 • P.O. Box 45530
                            Salt Lake City, Utah 84145-0530
      Telephone: 1-801-578-5600 • Toll Free: 1-800-777-3622 • Fax: 1-801-578-5907
                                                                           B57.11/12
                                       Table of Contents
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
      Disclaimer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
      Key Points to Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
      Church Activity Contact Information . . . . . . . . . . . . . . . . . . . . . . 4
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
How Assistance Is Funded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Maximum Amount Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
How to Request Medical & Dental Assistance . . . . . . . . . . . . . . . . . . . 5
Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
      Ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
      Diagnostic X-rays & Lab Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
      Emergency Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
      Exams & Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
      Extended Care Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
      Eyewear (Glasses or Contact Lenses). . . . . . . . . . . . . . . . . . . . . . . . 9
      Hospital — Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
      Medical Equipment (Durable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
      Medical Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
      Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
      Private Duty Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
      Prosthetics & Appliances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
      Surgery — Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
      Surgery & Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
      Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
      Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13   General Information
      Alternative Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
                                                                                                                Church Activity Medical Assistance (CAMA) is administered by
                                                                                                                Deseret Mutual Benefit Administrators (“Deseret Mutual”) and provides
      Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
                                                                                                                limited medical, dental, and certain death and dismemberment
      Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14              payments for individuals who have an accident or a qualified sickness as
                                                                                                                a result of being involved (either as participants or spectators) in an
      Endodontic Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15               activity of The Church of Jesus Christ of Latter-day Saints (“Church”)
                                                                                                                or associated local ecclesiastic units in the United States or Canada.
      Oral Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15       Church activities include, but aren’t limited to:

      Orthodontic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15               •   Church or temple cleaning and maintenance
                                                                                                                •   Church meetings
      Outpatient Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
                                                                                                                •   General or stake conferences
      Prosthodontic Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16                •   Girls’ camps
      Restorative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16             •   Officially-organized sports programs
                                                                                                                •   Road shows or pageants
How to Request Death & Dismemberment Assistance . . . . . . . . . . . . 17
                                                                                                                •   Scouting activities (Cub Scouts, Boy Scouts, Varsity, and Venture)
      Dismemberment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17            •   Seminary and institute activities
      Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17    •   Temple attendance
                                                                                                                •   Volunteer or welfare assignments
How to Determine Payment Status . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
                                                                                                                •   Ward or stake activities
Prior Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18         •   Youth conferences or treks


                                                                                                                Disclaimer
Pre-existing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Coordination of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
                                                                                                                CAMA is not and does not meet the qualifications of being a no-fault
Legal Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
                                                                                                                insurance, liability insurance, or workers’ compensation fund. Rather, it
Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19    is a gratuitous, benevolent program for individuals who have an accident
                                                                                                                or qualified sickness while participating in certain church activities of
Subrogation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20      the Church and may assist with out-of-pocket expenses in a secondary
                                                                                                                position. It is not a liability insurance carrier for the Church, its
Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20     property, or its members. CAMA is not intended to pay all expenses
                                                                                                                associated with an accident or qualified sickness. Payment is considered
                                                                                                                based on the information provided in this handbook.
                                                                                                                                                    1
Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Key Points to Know                                                                  The Church recommends that people involved in Church activities
                                                                                    protect themselves by carrying reasonable amounts of liability
Church Activity Medical Assistance (CAMA) provides limited but                      insurance, such as homeowners insurance, auto insurance, etc.
valuable assistance when medical, life insurance, or other coverage is not          Everyone participating in an activity must maintain at least the
available. Some key points to understand include:                                   minimum coverage required by law.

1. CAMA is not insurance. It’s a limited discretionary gratuity                 4. Assistance for accidents while traveling is limited. Travel-related
   assistance program administered by Deseret Mutual on behalf of the              activities are eligible for discretionary assistance when
   Church. It’s designed to help local leaders as they help members of             transportation is an integral part of the Church activity.
   their congregations who are injured during Church activities. This
   includes help with medical treatment and coordination of benefits                Travel-related injuries are not eligible for assistance when
   from traditional insurers. Payment made by CAMA is limited by                    transportation is for:
   the rules described in this handbook.
                                                                                    •   routine travel to and from meetings or activities (for examples,
2. CAMA is not liability insurance. Church members and leaders                          transportation to attend sacrament meeting, stake or general
   should continue to protect themselves by carrying adequate liability                 conference, Young Men / Young Women activities, etc.)
   or casualty insurance through their own automobile, homeowners,
   renters, boat, recreational vehicle, or other insurance providers.               •   routine travel in preparation for a Church calling or assignment

3. CAMA provides secondary assistance. That means it provides                       •   personal acts of service
   payment after any other insurance coverage. For more information,
   see Coordination of Benefits on page 19.                                     5. Personal functions or events do not qualify for assistance. This
                                                                                   includes weddings, receptions, family reunions, and other personal
    The Church recommends that injured persons seek insurance                      gatherings held at the Church meetinghouses or other Church property.
    coverage from personal, employer, or government-sponsored
    programs. Injured persons are responsible to use all of the benefits        6. Only certain missionaries are eligible for CAMA. Full-time senior
    available to them.                                                             missionaries (couples and single sisters who are 40 and older), Church-
                                                                                   service missionaries, and other Church volunteers are eligible.
    If a person’s insurance coverage requires them to seek care from a
    specific source to be eligible for benefits, that source must be used for       Full-time missionaries who are younger than 40 aren’t eligible. These
    this program to consider payment of related out-of-pocket expenses.             missionaries should be referred to the Missionary Medical Program.
    If a person loses their insurance coverage because they didn’t follow
    the rules, this program won’t pay for services. If a person doesn’t         7. Accidents that occur during Scouting activities sponsored by the
    have insurance coverage with network providers, he or she should               Primary or Young Men organizations and that require medical,
    use Deseret Mutual network providers.                                          dental, or other related services are paid regardless of fault (unless
                                                                                   otherwise excluded). Because of this, wards or branches aren’t
    CAMA will pay up to $15,000 for medical services, or death or                  expected to purchase the optional BSA Council Accident and
    dismemberment losses. This eliminates the need for wards or                    Sickness Insurance Plan. To get a verification form as proof of
    branches to carry sports, camp, or trip accident insurance.                    available CAMA benefits, please contact Deseret Mutual (see pages
                                                                                   5 and 6).
                                     2                                                                               3
8. For Scouting activities involving Church Scout units, Boy Scouts                    Maximum Amount Payable
   of America provides liability insurance to the Church and
   registered leaders. To maintain eligibility for this coverage, we                   For medical and dental services, the maximum amount is $15,000 per
   strongly encourage all Scouts, committee members, and adult                         person per accident. This pays for expenses that either exceed or aren’t
   Scouting leaders to properly register.                                              covered by other available sources. You must submit a valid Church

Church Activity Contact Information
                                                                                       Activity Medical Assistance Request Form in a timely manner.

                                                                                       The maximum assistance period is three years, beginning on the date of
                                                                                       the accident and ending 36 months later or when the maximum amount
To contact Deseret Mutual:                                                             has been exhausted, whichever comes first.


                                                                                       How to Request Medical & Dental Assistance
        Salt Lake City area . . . . . . . . . . . . . . . . . 1-801-578-5600
        Toll free. . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-777-3622
        Fax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-801-578-5907   Medical and dental payments from this program are secondary to
        Email . . . . . . . . . . . . . . . . . . . churchactivity@dmba.com            benefits provided by other available insurance coverage. You must first
        Website. . . . . . . . . . . . . . www.dmba.com/churchactivity                 submit all bills to the primary insurance carrier before CAMA will
                                                                                       provide assistance.
Or write us at:
                                                                                       Expenses that aren’t submitted within 12 months of the date of service
                   Deseret Mutual Benefit Administrators                               won’t be eligible for payment. To get assistance, you are responsible to
                  Attn: Church Activity Medical Assistance                             provide the needed information.
                              P.O. Box 45530
                      Salt Lake City, Utah 84145-0530                                  To request assistance, you must provide the following information (if
                                                                                       you don’t submit this information, payment will be delayed):

Eligibility                                                                            1. Send us a properly completed Church Activity Medical Assistance
                                                                                          Request Form signed by the patient or legal guardian and the
All individuals associated with a ward or branch in the United States or                  bishop/branch president. Only one form is necessary for each
Canada who are injured during an eligible Church activity may receive                     accident per person.
assistance. (U.S. territories and international areas aren’t included.
Contact the area office when outside the U.S. or Canada.)                              2. When you receive medical care, give your doctor or hospital your
                                                                                          personal insurance information. When you’re approved to receive

How Assistance Is Funded
                                                                                          CAMA payments, give the doctor or hospital your assigned Deseret
                                                                                          Mutual identification number (DMID) and Deseret Mutual’s address
                                                                                          and telephone number so providers can bill us directly.
CAMA is paid from the general funds of the Church. To maintain the
cost effectiveness of the program, it employs exclusions, maximum                      3. If the provider won’t submit a secondary bill, send us an itemized
allowable limits, and assistance limitations.                                             claim form from the provider and your insurance company’s
                                                                                          Explanation of Benefits (EOB) showing what they paid.
                                            4                                                                              5
4. Prescription drug reimbursement requests must include itemized                      Payment for eligible charges are:
   receipts listing the pharmacy name and address, patient name,
   purchase date, prescription number, and charge.                                     •   subject to exclusions

5. To request payment for crowns, periapical X-rays must be submitted                  •   based on maximum allowable limits as determined by CAMA (see
   with the claim form.                                                                    page 24)

You are responsible to pay charges for solely cosmetic purposes or                     •   based on procedures related directly to an eligible injury or qualified
services that exceed maximum allowable limits. For an explanation of                       sickness
maximum allowable limits, see page 24.
                                                                                       •   based on the service date (rather than the date the accident or
We’ll send a Church Activity Medical Assistance Request Form to the                        qualified sickness occurred)
bishop or branch president when ward or branch leadership call Deseret
Mutual at:                                                                             •   based on whether the treatment is medically necessary

        Salt Lake City area . . . . . . . . . . . . . . . . . 1-801-578-5600           To make the most of available assistance, we encourage you to use
        Toll free. . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-777-3622    network providers and to get prior approval when receiving treatment.

Send the completed Church Activity Medical Assistance Request Form to:                 1. Always receive care from network providers

        Fax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-801-578-5907       •   If you have health insurance, you should use network providers
        Email . . . . . . . . . . . . . . . . . . . churchactivity@dmba.com                    available through your insurance. You can further reduce costs if
                                                                                               the provider is also contracted with Deseret Mutual. To identify
                                                                                               Deseret Mutual network providers, call 1-800-777-3622 or visit
                             Deseret Mutual
                                                                                               www.dmba.com/churchactivity. If you lose coverage because you
                Attn: Church Activity Medical Assistance
                                                                                               didn’t use network providers, this program won’t pay for
                             P.O. Box 45530
                                                                                               services.
                       Salt Lake City, Utah 84145


Medical
                                                                                               CAMA will pay up to the program’s maximum allowable limits
                                                                                               or your remaining responsibility after your primary insurance
                                                                                               makes payment, whichever is less. It won’t pay more than 100%
To be eligible for assistance, services must:                                                  of the maximum allowable limit as determined by CAMA. In
                                                                                               other words, you may be responsible for amounts exceeding the
                                                                                               maximum allowable limits.
•   be the direct result of an accident or qualified sickness suffered as a
    result of participating in a Church activity
                                                                                           •   If you don’t have health insurance, we strongly recommend
                                                                                               you use Deseret Mutual network providers. To do this, call
•   begin within 90 days of the original accident or onset of the
                                                                                               1-800-777-3622 or visit www.dmba.com/churchactivity. If you
    qualified sickness
                                                                                               don’t use network providers, you may be responsible for amounts
                                                                                               exceeding CAMA’s maximum allowable limits.
                                            6                                                                               7
2. When required, get prior approval for services                             All payments are subject to the maximum allowable limits
                                                                                           determined by Deseret Mutual.

                                                                              Exams & Consultations
   •   If you have health insurance, you should follow any
       preauthorization guidelines for that insurance before receiving
       treatment. If you lose coverage because you didn’t follow the
       rules of a personal health plan, this program won’t pay for            CAMA pays for physician services related to the injury or qualified
       services.                                                              sickness. It doesn’t pay for well-care visits, routine physical exams,
                                                                              or physical check-ups.

                                                                              Extended Care Facility
   •   If you don’t have health insurance, you should get prior
       approval from CAMA for major medical services before
       receiving treatment (see Prior Approval on page 18). If you don’t
       get prior approval, you may be responsible for amounts not paid        CAMA pays for up to 60 days of room and board expenses incurred
       by the program.                                                        while confined in an extended care facility if the care:
Payment for the following services is subject to the maximum                  •   is for the treatment of an injury or qualified sickness directly
allowable limits determined by Deseret Mutual:                                    associated with being involved in a Church activity


   Ambulance
                                                                              •   commences within five days after discharge from a hospital
                                                                              •   is recommended by a physician, and

   When medically necessary, CAMA will pay for licensed ambulance             •   is for the purpose of convalescing from bodily injury rather than
   services to the nearest medical facility that is equipped to furnish the       for custodial care
   appropriate care.                                                          CAMA will also pay for services in an extended care facility if it is
                                                                              used in place of a more expensive extended hospital stay. We
   Diagnostic X-rays & Lab Tests                                              strongly recommend you get prior approval.


   You must get prior approval from CAMA for major radiology
                                                                              Eyewear (Glasses or Contact Lenses)
   services like MRIs. Your health insurance may also require
                                                                              CAMA will pay expenses for glasses or contact lenses only if their
   preauthorization.
                                                                              use is necessary because of eye surgery (one time only per surgery).

   Emergency Room                                                             Hospital — Inpatient
   If an emergency room visit results in an inpatient hospital stay, you      CAMA will pay for:
   may have to preauthorize with your health insurance as soon as
                                                                              •   semi-private room and board accommodations
   possible. See Hospital — Inpatient on page 9.
                                                                              •   services and materials
   If you receive follow-up care at the emergency room, you will likely       •   intensive care unit services
   be billed for another emergency room visit. Since emergency room
   charges are generally more expensive, we recommend you receive             Patients with no insurance coverage should call CAMA for prior
                                                                              approval. See the definition of “hospital” on page 23.

                                    8                                                                            9
   follow-up care at a doctor’s office.
All payments are subject to the maximum allowable limits                  All payments are subject to the maximum allowable limits
             determined by Deseret Mutual.                                             determined by Deseret Mutual.

Medical Equipment (Durable)                                               Prescription Drugs

Durable medical equipment includes items such as wheelchairs,             CAMA reimburses for the purchase of prescription drugs if they are
crutches, and hospital-type beds or other medical equipment needed        required because of an injury or qualified sickness. Additionally,
for medical reasons because of an injury or qualified sickness.           they must be:
                                                                          •   approved by the Food and Drug Administration
If the equipment costs less than $300 to rent or buy or is required for
                                                                          •   only attainable with a physician’s prescription
less than three months, you don’t need to get prior approval or a
prescription from your physician.                                         •   purchased from a licensed pharmacist

If the equipment costs over $300, is required for more than three
                                                                          Private Duty Nursing
months, and you don’t have health insurance, you must get prior
approval and a prescription before buying the equipment. If you
have health insurance that covers durable medical equipment, your         Services must be performed by a licensed Registered Nurse or
insurance will also require a prescription, including the anticipated     Licensed Practical Nurse.


                                                                          Prosthetics & Appliances
length of time the equipment will be medically necessary.

CAMA will pay for rental of the equipment up to the purchase price
or the maximum allowable, whichever is less.                              CAMA pays for artificial limbs and eyes, trusses, braces, or other
                                                                          medical appliances when their use is necessary because of surgery.
You are responsible for any expenses associated with the                  To be eligible for payment, you must have a prescription from your
maintenance and upkeep of the medical equipment, whether the              physician. Fitting, adjustment, and repair services may also be
equipment is purchased or rented.                                         eligible for payment. Expenses for replacement because of normal
                                                                          wear and tear are eligible for payment, but replacements of lost items
                                                                          are not. Time limitations apply on replacing certain items.
When you no longer need the equipment, you must return it to the

                                                                          Surgery — Outpatient Services
vendor if it was rented. If it was purchased, you may donate it to a
medical charity.

                                                                          If you don’t have other health insurance, you must call CAMA for

Medical Supplies
                                                                          prior approval.


                                                                          Surgery & Anesthesia
To be eligible for payment, medical supplies must be prescribed by a
physician. Payments aren’t available for over-the-counter supplies.       If you don’t have other health insurance, you must call CAMA for
                                                                          prior approval.
                               10                                                                        11
All payments are subject to the maximum allowable limits                   Dental
             determined by Deseret Mutual.

Therapy                                                                    To be eligible for assistance, services must:

                                                                           •   be the direct result of an accident suffered while participating in a
CAMA pays for the following categories of therapy, up to 25                    Church activity
medically necessary visits per category each accident year.
Additional visits are subject to medical necessity review and prior        •   commence within 90 days of the original accident
approval:
                                                                           Payment for eligible charges are:
•   physical/occupational therapy
                                                                           •   subject to exclusions
•   vertebral column rehabilitation
                                                                           •   based on procedures related directly to an eligible injury
•   speech therapy (This applies to restorative therapy only. You
                                                                           •   based on the service date (rather than the date the accident occurred)
    must get prior approval to be eligible for payment.)
                                                                           To make the most of the assistance available, we encourage you to use
If the services relate to the same diagnosis and the same part of the      network providers and to get prior approval when receiving treatment:
body, visits for physical or occupational therapy or vertebral column
rehabilitation will be counted together. If they are for different parts   1. Always receive care from network providers
of the body, they will be counted separately. For example, if your
back and leg are injured, you would be eligible for 25 visits for your         •   If you have dental insurance, you should use network providers
back and 25 visits for your leg.                                                   available through your insurance. You can further reduce costs if
                                                                                   the provider is also contracted with Deseret Mutual. To identify

Transportation
                                                                                   Deseret Mutual network providers, call 1-800-777-3622 or visit
                                                                                   www.dmba.com/churchactivity. If you lose coverage because you
                                                                                   didn’t use dental plan network providers, this program won’t
                                                                                   pay for services.
To be eligible for payment, you must get prior approval.
                                                                                   CAMA will pay up to the program’s maximum allowable limits
CAMA will pay for the least expensive, reasonable form of                          or your remaining responsibility after the primary insurance
transportation for the patient to and from the nearest medical                     makes payment, whichever is less. It won’t pay more than 100%
facility that is equipped to furnish the appropriate care.                         of the maximum allowable limit as determined by CAMA. In
                                                                                   other words, you may be responsible for amounts exceeding the
If traveling by automobile, CAMA will pay the IRS standard                         maximum allowable limits.
mileage rate for eligible medical travel after the first 200 miles.
                                                                               •   If you don’t have dental insurance, we strongly recommend
For more information about payment for ambulance services, see                     you use Deseret Mutual network providers. To do this, call
Ambulance on page 8.                                                               1-800-777-3622 or visit www.dmba.com/churchactivity. If you

                                12                                                                              13
                                                                               All payments are subject to the maximum allowable limits
                                                                                            determined by Deseret Mutual.
       don’t use network providers, you may be responsible for amounts
       exceeding CAMA’s maximum allowable limits.

2. When required, get prior approval for services                              Endodontic Procedures

   •   If you have dental insurance, you should follow any                     Pulpal and root canal therapy is eligible for payment. However, the
       preauthorization guidelines for that insurance before receiving         fees for bases or pulp caps are not.


                                                                               Oral Surgery
       treatment. If you lose coverage because you didn’t follow the rules
       of a personal dental plan, this program won’t pay for services.

   •   If you don’t have dental insurance, you should get prior approval
                                                                               Extractions and other oral surgeries are paid for based on the
       with CAMA for major dental services before receiving treatment
                                                                               following guidelines:
       (see Prior Approval on page 18). If you don’t get prior approval, you
       may still be responsible for amounts not paid by CAMA.                  •   routine post-operative visits are considered part of the total
                                                                                   surgical procedure
Payment for the following services is subject to the maximum
                                                                               •   payments aren’t available for oral surgery or other related
allowable limits determined by Deseret Mutual:
                                                                                   expenses for tooth transplants

   Alternative Procedures
                                                                               •   re-implanting teeth that have been “knocked out” is eligible


   Sometimes there is more than one way to treat a particular dental           Orthodontic Procedures
   problem. CAMA pays for the least expensive treatment when the
   results meet acceptable dental standards.                                   Services must be for the direct result of an injury suffered while

   Anesthesia
                                                                               participating in a Church-sponsored and supervised activity. You
                                                                               must get prior approval from CAMA because not all charges may be
                                                                               eligible for payment.


                                                                               Outpatient Hospitalization
   CAMA pays for general anesthesia expenses when used as a part of oral
   surgery or for an approved outpatient hospitalization (see page 15).

   Local, regional, block, conscious, or relative analgesia are normally       Outpatient hospital services for dental treatment are eligible if:
   included in the cost of a complete procedure. CAMA won’t pay for
   anesthesia if it is billed separately.                                      •   a medical problem exists that must be monitored in connection
                                                                                   with general anesthesia and surgical procedures
   CAMA doesn’t pay for hypnosis and relative anesthesia.

   Diagnostic Procedures
                                                                               •   general anesthesia is required because of extended work on
                                                                                   children younger than five years of age

                                                                               •   dental or surgical procedures are performed on a patient who has
   You must get prior approval from CAMA for major services because                a mental handicap (such as Downs Syndrome) or a sensory
   not all charges may be eligible for payment.                                    handicap (such as deafness or blindness)
                                    14                                                                         15
All payments are subject to the maximum allowable limits               How to Request Death & Dismemberment Assistance
             determined by Deseret Mutual.

Prosthodontic Procedures                                               If you don’t submit your assistance request form within 12 months from
                                                                       the accident date, it won’t be eligible for payment. You are responsible
                                                                       to provide the information needed to process your assistance request.
CAMA pays for crowns, implant supported crowns, veneers, bridges,
onlays, inlays, and partial and complete dentures based on the         To request assistance, you must provide the following information (if
following guidelines:                                                  don’t submit this information, payment my be delayed):

•   CAMA won’t make separate payment for tooth preparation,
                                                                           Dismemberment
    temporary restorations, pulp caps, cement bases, impressions,
    analgesia, or local anesthesia. These procedures are normally
    included in the cost of a complete prosthodontic procedure
                                                                           •   A properly completed Church Activity Medical Assistance Request
                                                                               Form, signed by the patient or legal guardian and the
•   You must submit periapical X-rays for all prosthodontic
                                                                               bishop/branch president. Only one form is necessary for each
    procedures except complete dentures
                                                                               accident per person

                                                                           •   A statement from the physician indicating the details of the
Restorative Procedures
                                                                               dismemberment

                                                                           •   All related medical bills. These will be paid according to the
CAMA pays for amalgam, porcelain, composite, resin, and metal                  information outlined in the medical section (pages 8 to 12)
restorations based on the following guidelines:

•   CAMA will pay for only one restoration per tooth surface, no           Death
    matter how many restorations are placed on the surface
                                                                           •   A properly completed Church Activity Medical Assistance Request
•   CAMA won’t make separate payment for tooth preparation,                    Form, signed by the legal representative, or spouse and the
    temporary restorations, pulp caps, cement bases, impressions,              bishop/branch president. Include a copy of the certified death
    analgesia, or local anesthesia. These procedures are normally              certificate if available
    included in the cost of a complete restorative procedure with a
    single charge                                                      The Church Activity Medical Assistance Request Form will be sent to the
                                                                       bishop or branch president when ward or branch leadership calls Deseret
                                                                       Mutual at:
•   Composite, resin, or acrylic restorations in posterior teeth are
    considered optional dentistry. CAMA will pay the cost of an                Salt Lake City. . . . . . . . . . . . . . . . . . . . . 1-801-578-5600
    amalgam restoration
                                                                               Toll Free . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-777-3622


                               16                                                                                17
Send the completed Church Activity Medical Assistance Request forms to:                Pre-existing Conditions
        Fax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-801-578-5907   A pre-existing condition is a bodily injury or sickness for which notable
        Email . . . . . . . . . . . . . . . . . . . churchactivity@dmba.com            signs or symptoms have been manifest within six months, or a diagnosis
                                                                                       made or treatment given within 12 months before the Church-related
                             Deseret Mutual                                            accident. For the purposes of this program, conditions that are
                Attn: Church Activity Medical Assistance                               considered pre-existing aren’t eligible for assistance.


                                                                                       Coordination of Benefits
                             P.O. Box 45530
                       Salt Lake City, Utah 84145


How to Determine Payment Status
                                                                                       Assistance from this program is secondary to benefits provided by group
                                                                                       or individual policies, prepaid health plans, health maintenance
                                                                                       organizations (HMOs), medical service contracts, excess insurance
After we review your Church Activity Medical Assistance Request Form                   policies, Medicare, account-based plans (such as Health Savings
and enroll you in the program, we will send you a letter that includes                 Accounts or similar plans) or employee or employer trusts.
your Deseret Mutual Identification Number (DMID). This number is
used to identify you when seeking care from medical or dental providers                If your insurance coverage requires you to seek care from a specific
or when contacting Deseret Mutual.                                                     source to be eligible for benefits, you must use that source for this
                                                                                       program to help with any related expenses. If you lose coverage because
You may also use the DMID to view payment of expenses online. To do                    you didn’t follow the rules of a personal health plan or use network
this, go to www.dmba.com/churchactivity and create a login ID,                         providers, this program won’t pay for services.
password, and security protocol. You can view bills you’ve submitted to

                                                                                       Legal Notice
CAMA for payment by entering your login ID and password in the
appropriate fields. If you have any questions about how to create a login
ID, please contact CAMA (see contact information below).
                                                                                       This handbook provides you with an explanation of the assistance

Prior Approval
                                                                                       available through Church Activity Medical Assistance. It does not
                                                                                       constitute a legal contract between you and Deseret Mutual or you and
                                                                                       The Church of Jesus Christ of Latter-day Saints.
Prior approval is a service provided by CAMA to answer questions that
                                                                                       Appeals
bishops, branch presidents, or patients may have about this program.
We review the proposed care for necessity, efficiency, and quality. We
then give some guidelines to follow to make sure you receive the
                                                                                       Appeals on assistance determinations must be made within 12 months of
maximum assistance available. If you don’t have personal health
                                                                                       the original time of processing or determination. Appeals must be
insurance, you must coordinate your care with CAMA.
                                                                                       submitted in writing and addressed to:
To get prior approval, call or email CAMA at:                                                                     Deseret Mutual
                                                                                                         Church Activity Medical Assistance
        Salt Lake City area . . . . . . . . . . . . . . . . . 1-801-578-5600
                                                                                                          Attention: Management Review
        Toll free. . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-777-3622                               P.O. Box 45530
        Email . . . . . . . . . . . . . . . . . . . churchactivity@dmba.com                                 Salt Lake City, Utah 84145
                                           18                                                                             19
Subrogation                                                                Acute: Having rapid onset, severe symptoms, and a short course;
                                                                              opposite of chronic

                                                                           Affidavit: A statement written and sworn to in the presence of
If an injury is the liability of another party and you have the right to
recover damages, you must reimburse CAMA for any amount it has paid
after you recover damages from the third party.                                someone authorized to administer an oath, such as a notary public

CAMA will be reimbursed:                                                   Appeal: A formal complaint you make when you want us to reconsider
                                                                              a decision

                                                                           Appliance: A dental device, removable or fixed, used to provide
•   first

•   from any claim against the third party, the third party’s liability       function or therapeutic healing effect. A fixed appliance is
    insurance carrier, or your underinsured or uninsured motorist             cemented to the teeth or attached by adhesive materials. A
    insurance carrier                                                         prosthetic appliance is used to replace one or more missing teeth

•   whether the recovery is obtained by settlement, judgment, or from      Chronic: Showing little change or slow progression and long
    any other source                                                          continuance of symptoms; opposite of acute

•   regardless of how the settlement is allocated by the third party or    Contracted Facilities: Hospitals, labs, and other health-care
    insurance carrier                                                         facilities that have contracted to provide services to participants

•   regardless of whether the settlement is considered to have recovered   Contracted Providers: Physicians, specialists, and other providers of
    full compensation or damages                                              health-care services who have contracted to provide services to
                                                                              participants

                                                                           Coordination of Benefits: The process of combining medical (or
Your acceptance of CAMA gives Deseret Mutual the right to subrogate.
You must provide any information CAMA requests for subrogation
purposes. If you don’t, you may be responsible for reimbursing all costs      dental) benefits of two or more plans to assure maximum benefits
and expenses paid by CAMA for the injury or qualified sickness.               without paying more in benefits than the actual charges incurred

                                                                           Church Activity Medical Assistance Request Form: A form that
Definitions                                                                   is made available to ecclesiastical leaders (bishops and branch
                                                                              presidents) when an individual wants to request Church Activity
Accident: An unpremeditated event of violent and external means               Medical Assistance. The form is to be completed by the patient or
   that happens suddenly, without intention or design, is unexpected,         guardian and bishop or branch president (or counselor if the bishop
   unusual, unforeseen, is identifiable as to time and place, and is not      is not available). If a bishop or branch president or members of his
   the result of sickness                                                     immediate family have an accident or qualified sickness as a direct
                                                                              result of being involved in a Church activity, the stake president
Accident Date: The calendar day the Church activity accident occurred         must complete the bishop/branch president section of the form

Accident Year: Twelve months from the date of the accident                 Congenital: A condition that is present at birth


                                    20                                                                        21
Dentist: A person licensed to practice dentistry according to the laws       Extended Care Facility: An institution, or distinct part thereof, that
   and regulations in the locality where the services are rendered              is licensed according to state or local law, and is operated primarily
                                                                                for the purpose of providing skilled nursing care and treatment to
Deseret Mutual Identification Number (DMID): A number that                      individuals convalescing from injury or sickness as an inpatient. It
   Deseret Mutual assigns to you as a secure means for accessing your           also:
   information
                                                                                 •   has organized facilities for medical treatment and provides 24-
Durable Medical Equipment: Equipment that can be used in the                         hour nursing service under the full-time supervision of a
   home and is needed for medical reasons. A person normally needs                   physician or a registered nurse
   this kind of equipment only when injured. Examples of durable
                                                                                 •   maintains daily clinical records on each patient and has
   medical equipment include wheelchairs or hospital beds
                                                                                     physician services available under an established agreement
Eligible Charges / Expenses: Expenses incurred for treatment of                  •   has transfer arrangements with one or more hospitals, a
    injury that are:                                                                 utilization review plan in effect, and operational policies
                                                                                     developed with the advice and review of a professional group,
    •   medically necessary for the care and treatment of the injury                 including at least one physician

                                                                             Full-time Missionary: An individual who is called by the Church
        sustained while in a Church activity and that are incurred on
        the recommendation and while under the continuous care of a
        licensed physician or practitioner                                       and provides more than 32 hours per week of service to fulfill a
                                                                                 missionary purpose

                                                                             Hospital: A facility that is licensed as a hospital and is operating
    •   not in excess of the maximum allowable charges as defined by
        Deseret Mutual for the services performed or the materials
        furnished                                                               within the scope of this license

                                                                             Hospital Emergency Room: Hospital facility that provides treatment
    •   not excluded from payment or otherwise excluded by the terms            for urgent medical needs that may or may not be life-threatening at
        of the program                                                          that particular time

    •   incurred for one or more of the services or materials specified in   Hospitalization: Admittance to and confinement as a patient in a
        the program                                                             hospital upon the recommendation of a physician

    •   incurred during a period of eligibility in the program               Illness: A bodily disorder, disease, pregnancy, mental or emotional
                                                                                 infirmity, or all sickness that is a result of the same cause or a related
    Eligible charges are incurred on the date the service is performed or        cause

                                                                             Incurred Charges: Charges incurred on the date the service is
    the purchase is made

Estate: All assets owned by an individual at death that are to be
                                                                                 performed or purchase is made
   distributed according to the individual’s will or by a court that         Injury: Harm or hurt. It may be caused by oneself (such as a hamstring
   determines the distribution of the assets between heirs and/or                injury) or by an external agent (such as frostbite). For assistance
   creditors                                                                     purposes, see the program provisions and exclusions

                                   22                                                                             23
Inpatient Care: Health care that you get when you are admitted to a           Personal Function: An event or activity that is not sponsored by an
   hospital, skilled nursing facility, or rehabilitation facility                ecclesiastical unit of the Church, but that is for personal, family, or
                                                                                 other non-Church purposes regardless of whether or not the activity
Liability Insurance: Insurance coverage to protect against claims                occurs on Church property

                                                                              Physician: A person who has been educated, trained, and licensed as a
   alleging that one’s negligence or inappropriate action resulted in
   injury
                                                                                 physician to practice the art and science of medicine according to the
Maximum Allowable Limits: The maximum dollar amount CAMA
                                                                                 laws and regulations in the locality where the services are rendered
  will pay for a defined medical or dental procedure as set forth under       Plan Provider: “Provider” is a general term for doctors, health-care
  contract provisions and/or market practice                                     professionals, hospitals, and health-care facilities that are licensed or

Medical Equipment: A prosthesis, appliance, or device that is
                                                                                 certified by Medicare and by the state to provide health-care
                                                                                 services. A plan provider is a provider that is contracted with
   primarily and customarily used to serve a medical purpose and                 Deseret Mutual to provide services to participants

                                                                              Pre-existing Condition: A bodily injury or sickness for which
   generally is not useful to a person in the absence of injury or sickness

Medically Necessary: Services or supplies that are proper and                    notable signs or symptoms have been manifest within six months, or
   needed for a legitimate diagnosis or a cost-efficient treatment of your       a diagnosis made or treatment given within 12 months before the
   medical condition; are used for the diagnosis, direct care, and               accident date

                                                                              Prior Approval: A vital process to make sure your care is medically
   treatment of your medical condition; meet the standards of good
   medical practice in the local community; and aren’t mainly for the
                                                                                 appropriate and to give you guidelines for what services are eligible
   convenience of you or your doctor
                                                                                 for assistance before you commit to the costs. Prior approval is
No-fault: This refers to the type of payment or coverage that is made
                                                                                 required for certain services
   available by entities when someone is hurt or injured, regardless of       Qualified Sickness: An acute illness beginning during and connected
   who caused the hurt or injury                                                 with participation in a Church activity. A qualified sickness must

Non-contracted Facilities: Hospitals, labs, and other health-care
                                                                                 have required first aid, urgent care, or unscheduled medically
                                                                                 necessary treatment during the activity or within 24 hours after the
   facilities that have not contracted with Deseret Mutual to provide            end of the activity. Examples include, but are not limited to,
   services to participants                                                      dehydration, altitude sickness, food poisoning, heat exhaustion, and
                                                                                 heat stroke. Sickness and disease such as cold, flu, measles, etc., are
Non-contracted Providers: Physicians, specialists, and other                     not qualified sicknesses and aren’t eligible for assistance (see
   providers of health-care services who have not contracted with                exclusions 3.8 and 3.9 on page 29)

                                                                              Qualified Sickness Date: The calendar day the qualified sickness began
   Deseret Mutual to provide services to participants

Non-routine Travel: Travel required to fulfill a specific assignment or       Routine Preparation: Preparation for a calling or responsibility that
   calling and that doesn’t occur on a regular basis                             is done regularly or on a normal basis. This includes, but is not

Personal Acts of Service: A task or activity not done because of a
                                                                                 limited to, lesson or talk preparation, meeting preparation or
                                                                                 development, etc.

                                                                              Service Date: The date medical or dental treatment begins
   Church calling or assignment, but because of a personal desire to
   help others
                                   24                                                                             25
Skilled Nursing Facility: An institution, or part of an institution,             1.8 Care or treatment not furnished and/or prescribed by a dentist
    that is licensed according to state or local law, and is operated            1.9 Expenses or treatments that exceed maximum allowable charges
    primarily for the purpose of providing skilled nursing care and              1.10 Expenses for personalized restorations or specialized techniques
    treatment to individuals convalescing from injury or illness as an                that exceed standard costs for dental procedures
    inpatient                                                                    1.11 Unfinished dental work
Surgical Center: Any licensed public or private establishment:
                                                                                 1.12 Lost or stolen dentures, bridges, or appliances
                                                                                 1.13 Appliances, restorations, or treatment other than full dentures, whose
      •     with an organized medical staff of physicians                             primary purpose is to alter vertical dimension or restore occlusion
                                                                                 1.14 Protective athletic mouthguards or habit-control appliances, such
      •     with permanent facilities equipped and operated primarily for             as nightguards or finger-sucking appliances
            the purpose of performing surgical procedures                        1.15 Fluoride rinse, toothpaste, toothbrush, or other products or
      •     with continuous physician services whenever a patient is in the           supplies intended for home use
            facility                                                             1.16 Dental treatments or procedures that are:
                                                                                      • considered dental research
      •     that doesn’t provide services or other accommodations for                 • investigative/experimental technology
            patients to stay overnight                                                • not recognized by the U. S. dental profession as usual and/or
Treatment: Care provided under the direction of a physician                                common

Verification Form: A form provided to ecclesiastical units (wards or
                                                                                      • determined by CAMA not to be usual and/or common dental
                                                                                           practice
   branches) that outlines what CAMA will provide for those who                       • illegal
   have an accident or qualified sickness as a direct result of being                 That a dentist might prescribe, order, recommend, or approve
   involved in a Church activity. This form doesn’t provide, verify, or               services or dental equipment doesn’t, of itself, make it an allowable
   confirm liability insurance coverage by CAMA                                       expense, even though it is not specifically listed as an exclusion.
                                                                                      Investigative/experimental technology means a treatment, procedure,
Exclusions
                                                                                      facility, equipment, drug, device, or supply that doesn’t, as determined
                                                                                      by CAMA on a case-by-case basis, meet all of this criteria:
Assistance is not available for charges that do not meet the definition of            • The technology has final approval from all appropriate
eligible as previously defined, and in addition, any charges for:                          governmental regulatory bodies, if applicable

Dental Care
                                                                                      • The technology is available in significant number outside the
                                                                                           clinical trial or research setting
1.1       Filling out claim forms                                                     • The available research about the technology is substantial.
1.2       Failure to keep a scheduled dentist visit                                        For program purposes, substantial means sufficient to allow
1.3       Study models or photos                                                           CAMA to conclude the technology:
1.4       Surgery, dentistry, or orthodontics that are performed primarily for             — is both necessary and appropriate for your treatment
          cosmetic or non-therapeutic purposes, including teeth whitening                  — is safe and efficacious
1.5       General anesthesia other than for oral surgery, unless otherwise                 — more likely than not will be beneficial to your health
          provided for by the program                                                      — is generally recognized as appropriate by the regional
1.6       Expenses for educational programs, plaque control, myofunctional                       dental community as a whole
          therapy and oral hygiene or dietary instruction                                  Procedures or treatments falling in these categories continue to
1.7       Services or supplies not furnished and/or prescribed by a dentist,               be excluded from CAMA until they are specifically included
          (for example, denturist services)
                                       26                                                                            27
Diagnostic & Experimental Services                                             3.4   Injury or qualified sickness sustained during routine preparation of
2.1   Care, treatment, diagnostic procedures, or operations which are:               a Church assignment in your home or places other than the
      • considered medical research                                                  meetinghouse
      • investigative/experimental technology                                  3.5   Injury or qualified sickness sustained while a full-time missionary
      • not recognized by the U.S. medical profession as usual and/or                in the mission field, including travel to and from
           common                                                              3.6   Injury or qualified sickness sustained while performing personal
      • determined by CAMA not to be usual and/or common                             acts of service
           medical practice                                                    3.7   Injury or qualified sickness sustained during use of any type of
      • illegal                                                                      recreational vehicle or animal, such as all-terrain vehicles,
      That a physician might prescribe, order, recommend, or approve                 motorcycles, snow mobiles, boats, horses, etc., except when used
      services or medical equipment doesn’t, of itself, make it an allowable         as part of a Church activity involving such vehicles or animals
      expense, even though it is not specifically listed as an exclusion.      3.8   Routine bacterial or viral infection or illness. Examples include,
      “Investigative/experimental technology” means treatment,                       but are not limited to, bronchitis, common cold, conjunctivitis,
      procedure, facility, equipment, drug, device, or supply that doesn’t,          ear pain, flu, fungal infections, meningitis, pneumonia, sinusitis,
      as determined by CAMA on a case-by-case basis, meet all of the                 sore throat, strep throat, or tonsillitis
      following criteria:                                                      3.9   Bodily disorder, condition, treatment, disease, or mental or
      • The technology must have final approval from all appropriate                 emotional infirmity that is not the direct result of being involved
           governmental regulatory bodies, if applicable                             in a Church activity. Examples include, but are not limited to,
      • The technology must be available in significant number                       abdominal pain, acne, anger, anxiety, appendicitis, asthma,
           outside the clinical trial or research setting                            depression, diabetes, ear problems, heart disease, hernia,
      • The available research about the technology must be                          hypoglycemia, ingrown toenail, kidney stones, pregnancy, skin
           substantial. For the purposes of CAMA, “substantial” means                rash, or sleep disorders
                                                                               Government/War
           sufficient to allow CAMA to conclude the technology:
           — is both medically necessary and appropriate for your
                                                                               4.1   Services furnished by a hospital or facility owned or operated by
                treatment
                                                                                     the United States Government or any agency thereof; any charges
           — is safe and efficacious
                                                                                     for services, treatments, or supplies furnished by or for the United
           — more likely than not will be beneficial to your health
                                                                                     States Government or any agency thereof; individuals
           — must be generally recognized as appropriate by the
                                                                                     participating in government-entitled programs, such as veterans
                regional medical community as a whole
                                                                               4.2   Services covered, or that could have been covered, by any
           Procedures, care, treatment, or operations falling in the
                                                                                     governmental plan had you complied with the requirements of the
           categories described herein continue to be excluded from
                                                                                     plan, including but not limited to Medicare
           CAMA until actual experience clearly defines them as non-
                                                                               4.3   Injury sustained from war or act of war or service in the military
           experimental and they are specifically included in CAMA
General
                                                                                     forces of any country at war, declared or undeclared. (This
                                                                                     exclusion doesn’t apply while you are actively engaged in pursuing
3.1   Expenses where there was no initial loss within 90 days of the                 a specific assignment given and authorized by the Church that
      accident or qualified sickness                                                 requires you to either reside or travel outside of your country of
3.2   Expenses incurred more than 36 months from the date of the                     residence, except for routine commuting to and from work. Your
      accident or qualified sickness                                                 spouse is also exempt from this provision if he/she travels or
3.3   Assistance requested more than 12 months after the service date                resides with you while pursuing such an assignment)
      or accident or qualified sickness date

                                    28                                                                            29
Insurance/Workers’ Compensation                                                    chairs with a lifting mechanism or function, spa memberships,
5.1   Services which a third party, the liability insurance of the third           vision devices, whirlpools, or modifications associated with
      party, underinsured motorist, or uninsured motorist insurance pays           activities of daily living, homes, or vehicles
                                                                             Medical Necessity/Cosmetic
      or is obligated to pay
5.2   Services covered, or that could have been covered, by any group or
                                                                             8.1   Care, treatment, or operations that aren’t clearly a medical
      individual medical policy, prepaid health plan, health maintenance
                                                                                   necessity
      organization, medical service contract, excess insurance policy,
                                                                             8.2   Care, treatment, or operations for convenience, contentment, or
      account-based plans (such as Health Savings Accounts or similar
                                                                                   other nontherapeutic purposes
      plans), Medicare, or employee or employer trust
                                                                             8.3   Care or treatment of mental or emotional conditions unless caused
5.3   Services covered, or that could have been covered, by applicable
                                                                                   by an accident that is a direct result of being involved in a Church
      Workers’ Compensation statutes
                                                                                   activity
5.4   Services or materials covered or that could have been covered by
                                                                             8.4   Pain clinics
      insurance required or provided by any statute had you complied
                                                                             8.5   Services or supplies not furnished and/or prescribed by a physician
      with the statutory requirements, including but not limited to no-
                                                                             8.6   Care or treatment not furnished and/or prescribed by a physician
                                                                             Miscellaneous
      fault insurance
Legal Exclusions
                                                                             9.1   Services of any practitioner of the healing arts who:
6.1. Services that you’re not, in the absence of this assistance, legally
                                                                                   • ordinarily resides in the same household with you
     obligated to pay
                                                                                   • has legal responsibility for your financial support and
6.2. Care, treatment, operations, or prescription drugs incurred after
                                                                                       maintenance
     termination of assistance
                                                                             9.2   Catastrophic events defined as earthquake, fire, terrorist attack, or
6.3. Complications resulting from excluded services
                                                                                   any other accidental occurrence in one event or a group of related
6.4. Services provided as a result of a court order or for other legal
                                                                                   events that happens within seven days or less and results in death,
     proceedings
                                                                                   serious physical injury, or qualified sickness to 50 or more eligible
6.5. Person committing a crime who will benefit from the crime or
                                                                                   people
     person that cannot be a beneficiary or recipient of assistance
                                                                             9.3   Injury sustained while you were intoxicated or under the influence
     because of a law or statute
                                                                                   of any narcotic unless administered on the advice of a physician
6.6. Injury sustained during participation in or attempt at committing
                                                                             9.4   Pre-existing or congenital conditions
     an assault or felony
                                                                             9.5   Expenses or treatments that exceed maximum allowable limits
                                                                             Vision
6.7. Suicide or self-inflicted injuries, while sane or insane
6.8. Services not specified as eligible for assistance
Medical Equipment                                                            10.1 Eye examinations or refractions for the correction of vision,
                                                                                  eye/visual training, and for the purchase of fitting of glasses or
7.1   Multipurpose equipment or facilities, including related
                                                                                  contact lenses, unless otherwise provided for by the terms of the
      appurtenances, controls, accessories, or modifications thereof.
                                                                                  program
      This includes but is not limited to buildings, motor vehicles, air
      conditioning, air filtration units, whirlpool baths, exercise
      equipment or machines, vibrating chairs and beds, etc. Also,
      certain medical equipment, including air filtration systems,
      dehumidifiers, exercise equipment, heating lamps or pads,
      humidifiers, non-prescription braces or orthotics, learning devices,

                                   30                                                                           31

								
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