Summary Plan Description Choice Plus Definity HRA Plan for by slappypappy126

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									    Summary Plan Description
   Choice Plus Definity HRA Plan
                        for
Fort Bend Independent School District

                Group Number: 706484
             Effective Date: January 1, 2009
Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                    Table of Contents                                                                8. Hospital - Inpatient Stay ...................................................................... 14
                                                                                                                     9. Injections received in a Physician's Office........................................ 15
                                                                                                                     10. Maternity Services............................................................................... 15
                                                                                                                     11. Mental Health and Substance Abuse Services - Outpatient......... 16
                                                                                                                     12. Mental Health and Substance Abuse Services - Inpatient and
Introduction....................................................... 1                                                Intermediate............................................................................................... 17
How to Use this Document.......................................................................1                     13. Ostomy Supplies................................................................................. 19
Information about Defined Terms ...........................................................1                         14. Outpatient Surgery, Diagnostic and Therapeutic Services ........... 19
Your Contribution to the Benefit Costs...................................................1                           15. Physician's Office Services ................................................................ 22
Customer Service and Claims Submittal ..................................................1                            16. Professional Fees for Surgical and Medical Services ..................... 23
                                                                                                                     17. Prosthetic Devices.............................................................................. 23
Section 1: What's Covered--Benefits ................. 3                                                              18. Reconstructive Procedures................................................................ 24
Accessing Benefits .......................................................................................3          19. Rehabilitation Services - Outpatient Therapy ................................ 25
Copayment....................................................................................................4       20. Skilled Nursing Facility/Inpatient Rehabilitation Facility
Eligible Expenses.........................................................................................4          Services ....................................................................................................... 26
Notification Requirements .........................................................................4                 21. Spinal Treatment................................................................................. 27
Payment Information ..................................................................................6              22. Temporomandibular Joint Dysfunction (TMJ).............................. 28
Annual Deductible.......................................................................................6            23. Thrombosis Stockings ....................................................................... 28
Out-of-Pocket Maximum ...........................................................................6                   24. Transplantation Services.................................................................... 29
Lifetime Maximum Benefit ........................................................................6                   25. Urgent Care Center Services ............................................................. 32
Benefit Information.....................................................................................7
1. Ambulance Services - Emergency only ................................................7                             Section 2: What's Not Covered--Exclusions ... 33
2. Dental Services - Accident only ............................................................7                     How We Use Headings in this Section.................................................. 33
3. Durable Medical Equipment..................................................................9                      We Do not Pay Benefits for Exclusions................................................ 33
4. Emergency Health Services................................................................. 11                     A. Alternative Treatments ....................................................................... 33
5. Eye Examinations................................................................................. 11              B. Comfort or Convenience .................................................................... 33
6. Home Health Care ............................................................................... 12               C. Dental .................................................................................................... 34
7. Hospice Care......................................................................................... 13          D. Drugs..................................................................................................... 34
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                                                                 i                                                                                         (Table of Contents)
E. Experimental, Investigational or Unproven Services..................... 35                                             Dependent.................................................................................................. 48
F. Foot Care............................................................................................... 35            When to Enroll and When Coverage Begins........................................ 50
G. Medical Supplies and Appliances...................................................... 35                               Initial Enrollment Period ......................................................................... 50
H. Mental Health/Substance Abuse ...................................................... 35                                Open Enrollment Period ......................................................................... 50
I. Nutrition................................................................................................. 36          New Eligible Persons ............................................................................... 50
J. Physical Appearance ............................................................................. 37                   Adding New Dependents ........................................................................ 51
K. Preexisting Conditions........................................................................ 37                      Family Status Change ............................................................................... 52
L. Providers ............................................................................................... 38           Late Enrollees............................................................................................ 53
M. Reproduction....................................................................................... 39                 Late Entrants ............................................................................................. 53
N. Services Provided under Another Plan............................................ 39
O. Transplants........................................................................................... 39              Section 5: How to File a Claim........................ 54
P. Travel ..................................................................................................... 40        If You Receive Covered Health Services from a Network
Q. Vision and Hearing ............................................................................. 40                    Provider ...................................................................................................... 54
R. All Other Exclusions........................................................................... 40                     Filing a Claim for Benefits....................................................................... 54

Section 3: Description of Network and                                                                                     Section 6: Questions, Complaints and
Non-Network Benefits .................................... 43                                                              Appeals............................................................. 57
Network Benefits...................................................................................... 43                 What to Do First....................................................................................... 57
Non-Network Benefits ............................................................................ 45                      How to Appeal a Claim Decision........................................................... 57
Emergency Health Services..................................................................... 46                         Appeal Process .......................................................................................... 58
                                                                                                                          Appeals Determinations........................................................................... 58
Section 4: When Coverage Begins................... 47                                                                     Urgent Claim Appeals that Require Immediate Action ...................... 58
How to Enroll ........................................................................................... 47
If You Are Hospitalized When Your Coverage Begins ...................... 47                                               Section 7: Coordination of Benefits................. 60
If You Are Eligible for Medicare ........................................................... 47                           Benefits When You Have Coverage under More than One Plan...... 60
Who is Eligible for Coverage.................................................................. 48                         When Coordination of Benefits Applies ............................................... 60
Eligible Person .......................................................................................... 48             Definitions ................................................................................................. 60

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                                                                     ii                                                                                        (Table of Contents)
Order of Benefit Determination Rules.................................................. 61                              Section 9: General Legal Provisions ................ 74
Effect on the Benefits of this Plan......................................................... 63                        Plan Document ......................................................................................... 74
Right to Receive and Release Needed Information............................. 64                                        Relationship with Providers .................................................................... 74
Payments Made ......................................................................................... 64             Your Relationship with Providers .......................................................... 74
Right of Recovery ..................................................................................... 64             Incentives to Providers ............................................................................ 75
                                                                                                                       Incentives to You...................................................................................... 75
Section 8: When Coverage Ends ..................... 65                                                                 Interpretation of Benefits ........................................................................ 75
General Information about When Coverage Ends ............................. 65                                          Administrative Services ............................................................................ 75
Events Ending Your Coverage............................................................... 67                          Amendments to the Plan ......................................................................... 76
The Entire Plan Ends............................................................................... 67                 Clerical Error ............................................................................................. 76
You Are No Longer Eligible................................................................... 67                       Information and Records......................................................................... 76
The Plan Administrator Receives Notice to End Coverage............... 67                                               Examination of Covered Persons........................................................... 77
Participant Retires or Is Pensioned........................................................ 67                         Workers' Compensation not Affected ................................................... 77
Other Events Ending Your Coverage ................................................... 68                               Medicare Eligibility ................................................................................... 77
Fraud, Misrepresentation or False Information ................................... 68                                   Subrogation and Reimbursement ........................................................... 77
Material Violation ..................................................................................... 68            Refund of Overpayments ........................................................................ 79
Improper Use of Medical ID card ......................................................... 68                           Limitation of Action................................................................................. 79
Failure to Pay............................................................................................. 68
Threatening Behavior............................................................................... 68                 Section 10: Glossary of Defined Terms ........... 80
Coverage for a Handicapped Child........................................................ 69
Continuation of Coverage ....................................................................... 69
Continuation Coverage under Federal Law (COBRA) ....................... 69
Qualifying Events for Continuation Coverage under Federal
Law (COBRA)........................................................................................... 70
Notification Requirements and Election Period for
Continuation Coverage under Federal Law (COBRA) ....................... 70
Terminating Events for Continuation Coverage under Federal
Law (COBRA)........................................................................................... 71

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                                                                 iii                                                                                      (Table of Contents)
                                                                            Information about Defined Terms
                                           Introduction                     Because this Summary Plan Description is a legal document, we
                                                                            want to give you information about the document that will help you
                                                                            understand it. Certain capitalized words have special meanings. We
                                                                            have defined these words in (Section 10: Glossary of Defined
We are pleased to provide you with this Summary Plan Description.           Terms). You can refer to Section 10 as you read this document to
This Summary Plan Description describes your Benefits, as well as           have a clearer understanding of your Summary Plan Description.
your rights and responsibilities, under the Plan.
                                                                            When we use the words "we," "us," and "our" in this document, we
                                                                            are referring to the Plan Sponsor. When we use the words "you" and
How to Use this Document                                                    "your" we are referring to people who are Covered Persons as the
We encourage you to read your Summary Plan Description and any              term is defined in (Section 10: Glossary of Defined Terms).
attached Riders and/or Amendments carefully.
We especially encourage you to review the Benefit limitations of this       Your Contribution to the Benefit Costs
Summary Plan Description by reading (Section 1: What's Covered--            The Plan may require the Participant to contribute to the cost of
Benefits) and (Section 2: What's Not Covered--Exclusions). You              coverage. Contact your benefits representative for information about
should also carefully read (Section 9: General Legal Provisions) to         any part of this cost you may be responsible for paying.
better understand how this Summary Plan Description and your
Benefits work. You should call the Claims Administrator if you have
questions about the limits of the coverage available to you.                Customer Service and Claims Submittal
                                                                            Please make note of the following information that contains Claims
Many of the sections of the Summary Plan Description are related to         Administrator department names and telephone numbers.
other sections of the document. You may not have all of the
information you need by reading just one section. We also encourage         Customer Service Representative (questions regarding Coverage
you to keep your Summary Plan Description and any attachments in            or procedures): As shown on your medical ID card.
a safe place for your future reference.
                                                                            Prior Notification: As shown on your medical ID card.
Please be aware that your Physician does not have a copy of your
Summary Plan Description and is not responsible for knowing or              Mental Health/Substance Abuse Services Designee: As shown
communicating your Benefits.                                                on your medical ID card.




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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        1                                                                      (Introduction)
Claims Submittal Address:


                 United HealthCare Insurance Company
                                P.O. Box 30555
                      Salt Lake City, Utah 84130-0555


Requests for Review of Denied Claims and Notice of
Complaints:


Name and Address For Submitting Requests:
                 United HealthCare Insurance Company
                                P.O. Box 30432
                      Salt Lake City, Utah 84130-0432


     Members may now submit a Medical Claim Appeal on-line.
1.    Log in to Myuhc.com.
2.     Click on the “Claim Center” link.
3. Complete the “Customer Issue Submission Form” (instructions
for completing the form/submitting information is included).




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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        2                                                          (Introduction)
                                                                                 You must show your medical identification card (ID card) every
                  Section 1:                                                     time you request health care services from a Network provider. If
                                                                                 you do not show your medical ID card, Network providers have no

    What's Covered--Benefits                                                     way of knowing that you are enrolled under the Plan. As a result,
                                                                                 they may bill you for the entire cost of the services you receive. For
                                                                                 details about when Network Benefits apply, see (Section 3:
                                                                                 Description of Network and Non-Network Benefits).

                 This section provides you with information about:               Benefits are available only if all of the following are true:
                 • Accessing Benefits.
                                                                                 •   Covered Health Services are received while the Plan is in effect.
                 •    Copayments and Eligible Expenses.
                                                                                 •   Covered Health Services are received prior to the date that any
                 •    Annual Deductible, Out-of-Pocket Maximum                       of the individual termination conditions listed in (Section 8:
                      and Lifetime Maximum Benefit.                                  When Coverage Ends) occurs.
                 •    Covered Health Services. We pay Benefits for the           •   The person who receives Covered Health Services is a Covered
                      Covered Health Services described in this section              Person and meets all eligibility requirements specified in the
                      unless they are listed as not covered in (Section 2:           Plan.
                      What's Not Covered--Exclusions).
                                                                                 Depending on the geographic area and the service you receive, you
                 •    Covered Health Services that require you or your           may have access through the Claims Administrator's Shared Savings
                      provider to notify the Claims Administrator                Program to Non-Network providers who have agreed to discount
                      before you receive them. Network providers are             their charges for Covered Health Services. If you receive Covered
                      responsible for notifying the Claims                       Health Services from these providers, and if your Copayment is
                      Administrator before they provide certain health           expressed as a percentage of Eligible Expenses for Non-Network
                      services to you. You are responsible for notifying         Benefits, that percentage will remain the same as it is when you
                      the Claims Administrator before you receive                receive Covered Health Services from Non-Network providers who
                      certain health services from a Non-Network                 have not agreed to discount their charges; however, the total that
                      provider.                                                  you owe may be less when you receive Covered Health Services
                                                                                 from Shared Savings Program providers than from other Non-
                                                                                 Network providers, because the Eligible Expenses may be a lesser
Accessing Benefits                                                               amount.
You can choose to receive either Network Benefits or Non-Network
Benefits. In most cases, you must see a Network Physician to obtain
Network Benefits.



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             3                                           (Section 1: What's Covered--Benefits)
Copayment                                                                   Claims Administrator before they provide these services to you.
                                                                            There are some Network Benefits, however, for which you are
Copayment is the amount you pay each time you receive certain
                                                                            responsible for notifying the Claims Administrator.
Covered Health Services. For a complete definition of Copayment,
see (Section 10: Glossary of Defined Terms). Copayment amounts
are listed on the following pages next to the description for each          When you choose to receive certain Covered Health
Covered Health Service. Please note that when Copayments are                Services from Non-Network providers, you are
calculated as a percentage (rather than as a set dollar amount) the         responsible for notifying the Claims Administrator
percentage is based on Eligible Expenses.
                                                                            before you receive these Covered Health Services.

Eligible Expenses                                                           Services for which you must provide prior notification appear in this
Eligible Expenses for Covered Health Services, incurred while the           section under the Must You Notify the Claims Administrator? column in
Plan is in effect, are determined by us or by our designee. Our             the table labeled Benefit Information.
designee is the Claims Administrator. For a complete definition of
Eligible Expenses that describes how payment is determined, see             To notify the Claims Administrator, call the telephone number on
(Section 10: Glossary of Defined Terms).                                    your medical ID card.

We have delegated to the Claims Administrator the discretion and            When you choose to receive services from Non-Network providers,
authority to initially determine on our behalf whether a treatment or       we urge you to confirm with the Claims Administrator that the
supply is a Covered Health Service and how the Eligible Expense             services you plan to receive are Covered Health Services, even if not
will be determined and otherwise covered under the Plan.                    indicated in the Must You Notify the Claims Administrator? column.
                                                                            That is because in some instances, certain procedures may not meet
When you receive Covered Health Services from Network                       the definition of a Covered Health Service and therefore are
providers, you are not responsible for any difference between the           excluded. In other instances, the same procedure may meet the
Eligible Expenses and the amount the provider bills. When you               definition of Covered Health Services. By calling before you receive
receive Covered Health Services from Non-Network providers, you             treatment, you can check to see if the service is subject to limitations
are responsible for paying, directly to the Non-Network provider,           or exclusions such as:
any difference between the amount the provider bills you and the
amount we will pay for Eligible Expenses.                                   •   The Cosmetic Procedures exclusion. Examples of procedures
                                                                                that may or may not be considered Cosmetic include: breast
                                                                                reduction and reconstruction (except for after cancer surgery
Notification Requirements                                                       when it is always considered a Covered Health Service); vein
Prior notification is required before you receive certain Covered               stripping, ligation and sclerotherapy, and upper lid
Health Services. Network providers are responsible for notifying the            blepharoplasty.


Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        4                                          (Section 1: What's Covered--Benefits)
•   The Experimental, Investigational or Unproven Services
    exclusion.
•   Any other limitation or exclusion of the Plan.
Special Note Regarding Medicare
If you are enrolled for Medicare on a primary basis (Medicare pays
before we pay Benefits under the Plan), the notification
requirements described in this Summary Plan Description do not
apply to you. Since Medicare is the primary payer, we will pay as
secondary payer as described in (Section 7: Coordination of
Benefits). You are not required to notify the Claims Administrator
before receiving Covered Health Services.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        5   (Section 1: What's Covered--Benefits)
Payment Information
    Payment Term                           Description                                                  Amounts

 Annual                    The amount you pay for Covered                                               Network
                           Health Services before you are eligible      $2,000 per Covered Person per calendar year, not to exceed $4,000 for all
 Deductible                to receive Benefits. For a complete                               Covered Persons in a family.
                           definition of Annual Deductible, see
                           (Section 10: Glossary of Defined
                           Terms).
                                                                                                     Non-Network
                           The Network Deductible and the               $4,000 per Covered Person per calendar year, not to exceed $8,000 for all
                           Non-Network Deductible do not                                     Covered Persons in a family.
                           cross-apply.

 Out-of-                   The maximum you pay, out of your                                             Network
                           pocket, in a calendar year for               $3,500 per Covered Person per calendar year, not to exceed $7,000 for all
 Pocket                    Copayments. For a complete definition                             Covered Persons in a family.
 Maximum                   of Out-of-Pocket Maximum, see                 The Out-of-Pocket Maximum does not include the Annual Deductible.
                           (Section 10: Glossary of Defined
                           Terms).
                                                                                                     Non-Network
                                                                        $7,000 per Covered Person per calendar year, not to exceed $14,000 for all
                                                                                             Covered Persons in a family.
                                                                         The Out-of-Pocket Maximum does not include the Annual Deductible.


 Lifetime                  The maximum amount we will pay for                                Network and Non-Network
                           Benefits during the entire period of                              $2,000,000 per Covered Person.
 Maximum                   time you are enrolled under the Plan.
 Benefit                   For a complete definition of Lifetime
                           Maximum Benefit, see (Section 10:
                           Glossary of Defined Terms).




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          6                                            (Section 1: What's Covered--Benefits)
Benefit Information
                               Description of                                   Must         Your Copayment              Does            Do You Need
                           Covered Health Service                               You             Amount                Copayment         to Meet Annual
                                                                              Notify the      % Copayments are        Help Meet           Deductible?
                                                                               Claims        based on a percent of   Out-of-Pocket
                                                                                               Eligible Expenses
                                                                            Administrator?                            Maximum?

 1. Ambulance Services - Emergency only                                       Network
 Emergency ambulance transportation by a licensed ambulance                      No               Ground                 Yes                   Yes
 service to the nearest Hospital where Emergency Health Services                               Transportation:
 can be performed.                                                                                 20%

                                                                                             Air Transportation:
                                                                                                   20%
                                                                            Non-Network
                                                                                 No              Same as               Same as              Same as
                                                                                                 Network               Network              Network


 2. Dental Services - Accident only                                           Network
 Dental services when all of the following are true:                             Yes                20%                  Yes                   Yes

 •   Treatment is necessary because of accidental damage.
 •   Dental services are received from a Doctor of Dental Surgery,
     "D.D.S." or Doctor of Medical Dentistry, "D.M.D.".
 •   The dental damage is severe enough that initial contact with a
     Physician or dentist occurred within 72 hours of the accident.
 Benefits are available only for treatment of a sound, natural tooth.       Non-Network
 The Physician or dentist must certify that the injured tooth was:               Yes             Same as               Same as              Same as
                                                                                                 Network               Network              Network
 •   A virgin or unrestored tooth, or


Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        7                                               (Section 1: What's Covered--Benefits)
                               Description of                                     Must         Your Copayment              Does            Do You Need
                           Covered Health Service                                 You             Amount                Copayment         to Meet Annual
                                                                                Notify the      % Copayments are        Help Meet           Deductible?
                                                                                 Claims        based on a percent of   Out-of-Pocket
                                                                                                 Eligible Expenses
                                                                              Administrator?                            Maximum?

 •   A tooth that has no decay, no filling on more than two surfaces,
     no gum disease associated with bone loss, no root canal therapy,
     is not a dental implant and functions normally in chewing and
     speech.
 Dental services for final treatment to repair the damage must be
 both of the following:

 •   Started within three months of the accident.
 •   Completed within 12 months of the accident.
 Please note that dental damage that occurs as a result of normal
 activities of daily living or extraordinary use of the teeth is not
 considered an "accident". Benefits are not available for repairs to
 teeth that are injured as a result of such activities.
 Benefits will not be paid for under this Plan for charges incurred for
 or in connection with treatment to teeth, malocclusion, the nerves or
 roots of the teeth, gingival tissue or alveolar processes, EXCEPT,
 benefits will be payable for charges incurred:

     •    For treatment required because of accidental bodily Injury
          sustained while covered under this Plan to sound natural
          teeth. Such expenses must be incurred within six (6) months
          of the date of the accident. This exception shall not in any
          event be deemed to include charges for treatment for the
          repair or replacement of a denture;

     •    For extraction of impacted wisdom teeth.



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          8                                               (Section 1: What's Covered--Benefits)
                               Description of                                    Must         Your Copayment              Does            Do You Need
                           Covered Health Service                                You             Amount                Copayment         to Meet Annual
                                                                               Notify the      % Copayments are        Help Meet           Deductible?
                                                                                Claims        based on a percent of   Out-of-Pocket
                                                                                                Eligible Expenses
                                                                             Administrator?                            Maximum?
                  Notify the Claims Administrator
 Please remember that you must notify the Claims Administrator as
 soon as possible, but at least five business days before follow-up
 (post-Emergency) treatment begins. (You do not have to provide
 notification before the initial Emergency treatment.) If you do not
 notify the Claims Administrator, Benefits will be reduced by $500;
 however, the reduction in Benefits will not exceed Eligible Expenses
 for the Covered Health Services.

 3. Durable Medical Equipment                                                  Network
 Durable Medical Equipment that meets each of the following                  Yes, for items          20%                  Yes                   Yes
 criteria:                                                                    more than
                                                                                $1,000.
 •   Ordered or provided by a Physician for outpatient use.                  Non-Network
 •   Used for medical purposes.                                              Yes, for items          50%                  Yes                   Yes
 •   Not of use to a person in the absence of a disease or disability.        more than
                                                                                $1,000.
 If more than one piece of Durable Medical Equipment can meet
 your functional needs, Benefits are available only for the most
 cost-effective piece of equipment.
 Examples of Durable Medical Equipment include:

 •   Equipment to assist mobility, such as a standard wheelchair.
 •   A standard Hospital-type bed.
 •   Oxygen and the rental of equipment to administer oxygen
     (including tubing, connectors and masks).



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         9                                               (Section 1: What's Covered--Benefits)
                               Description of                                  Must         Your Copayment              Does            Do You Need
                           Covered Health Service                              You             Amount                Copayment         to Meet Annual
                                                                             Notify the      % Copayments are        Help Meet           Deductible?
                                                                              Claims        based on a percent of   Out-of-Pocket
                                                                                              Eligible Expenses
                                                                           Administrator?                            Maximum?

 •   Delivery pumps for tube feedings (including tubing and
     connectors).
 •   Braces, including necessary adjustments to shoes to
     accommodate braces. Braces that stabilize an Injured body part
     and braces to treat curvature of the spine are considered Durable
     Medical Equipment and are a Covered Health Service. Braces
     that straighten or change the shape of a body part are orthotic
     devices, and are excluded from coverage. Dental braces are
     excluded from coverage.
 •  Mechanical equipment necessary for the treatment of chronic or
    acute respiratory failure (except that air-conditioners,
    humidifiers, dehumidifiers, air purifiers and filters, and personal
    comfort items are excluded from coverage).
 We and the Claims Administrator will decide if the equipment
 should be purchased or rented. To receive Network Benefits, you
 must purchase or rent the Durable Medical Equipment from the
 vendor the Claims Administrator identifies.
                    Notify the Claims Administrator
 Please remember that you must notify the Claims Administrator
 before obtaining any single item of Durable Medical Equipment that
 costs more than $1,000 (either purchase price or cumulative rental of
 a single item). If you do not notify the Claims Administrator,
 Benefits will be reduced by $500.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          10                                           (Section 1: What's Covered--Benefits)
                               Description of                                       Must         Your Copayment              Does            Do You Need
                           Covered Health Service                                   You             Amount                Copayment         to Meet Annual
                                                                                  Notify the      % Copayments are        Help Meet           Deductible?
                                                                                   Claims        based on a percent of   Out-of-Pocket
                                                                                                   Eligible Expenses
                                                                                Administrator?                            Maximum?

 4. Emergency Health Services                                                     Network
 Services that are required to stabilize or initiate treatment in an                 No                 20%                  Yes                   Yes
 Emergency. Emergency Health Services must be received on an
 outpatient basis at a Hospital or Alternate Facility.
 You will find more information about Benefits for Emergency
 Health Services in (Section 3: Description of Network and Non-             Non-Network
 Network Benefits).                                                          Yes, but only           Same as               Same as              Same as
                                                                            for an Inpatient         Network               Network              Network
                                                                                  Stay.
                  Notify the Claims Administrator
 Please remember that if you are admitted to a non-Network
 Hospital as a result of an Emergency, you must notify the Claims
 Administrator within one business day or the same day of admission,
 or as soon as reasonably possible. If you don't notify the Claims
 Administrator as required, your Benefits will be reduced as described
 below under Hospital - Inpatient Stay.

 5. Eye Examinations                                                              Network
 Eye examinations due to medical condition or Injury received from a                 No                 20%                  Yes                   Yes
 health care provider in the provider's office.
 Please note that Benefits are not available for routine vision
 examinations, including refractive examinations, or for charges            Non-Network
 connected to the purchase or fitting of eyeglasses or contact lenses                No                 50%                  Yes                   Yes
 EXCEPT, hearing aids or glasses due to medical condition or injury
 that caused the patient to require a hearing aid or glasses are covered
 under medical.



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           11                                               (Section 1: What's Covered--Benefits)
                               Description of                                   Must         Your Copayment              Does            Do You Need
                           Covered Health Service                               You             Amount                Copayment         to Meet Annual
                                                                              Notify the      % Copayments are        Help Meet           Deductible?
                                                                               Claims        based on a percent of   Out-of-Pocket
                                                                                               Eligible Expenses
                                                                            Administrator?                            Maximum?

 6. Home Health Care                                                            Network
 Services received from a Home Health Agency that are both of the                 No                20%                  Yes                   Yes
 following:

 •   Ordered by a Physician.
 •   Provided by or supervised by a registered nurse in your home.
 Benefits are available only when the Home Health Agency services           Non-Network
 are provided on a part-time, intermittent schedule and when skilled              Yes               50%                  Yes                   Yes
 care is required.
 Skilled care is skilled nursing, skilled teaching, and skilled
 rehabilitation services when all of the following are true:

 •   It must be delivered or supervised by licensed technical or
     professional medical personnel in order to obtain the specified
     medical outcome, and provide for the safety of the patient.
 •   It is ordered by a Physician.
 •   It is not delivered for the purpose of assisting with activities of
     daily living, including but not limited to dressing, feeding,
     bathing or transferring from a bed to a chair.
 •   It requires clinical training in order to be delivered safely and
     effectively.
 •   It is not Custodial Care.
 We and the Claims Administrator will decide if skilled care is
 required by reviewing both the skilled nature of the service and the



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           12                                           (Section 1: What's Covered--Benefits)
                               Description of                                   Must         Your Copayment              Does            Do You Need
                           Covered Health Service                               You             Amount                Copayment         to Meet Annual
                                                                              Notify the      % Copayments are        Help Meet           Deductible?
                                                                               Claims        based on a percent of   Out-of-Pocket
                                                                                               Eligible Expenses
                                                                            Administrator?                            Maximum?
 need for Physician-directed medical management. A service will not
 be determined to be "skilled" simply because there is not an available
 caregiver.
                   Notify the Claims Administrator
 Please remember that for Non-Network Benefits you must notify
 the Claims Administrator five business days before receiving
 services. If you do not notify the Claims Administrator, Benefits will
 be reduced by $500; however, the reduction in Benefits will not
 exceed Eligible Expenses for the Covered Health Service.

 7. Hospice Care                                                                Network
 Hospice care that is recommended by a Physician. Hospice care is an              No                20%                  Yes                   Yes
 integrated program that provides comfort and support services for
 the terminally ill. Hospice care includes physical and psychological
 care for the terminally ill person, and short-term grief counseling for
 immediate family members. Benefits are available when hospice care
 is received from a licensed hospice agency.
 Please contact the Claims Administrator for more information
 regarding guidelines for hospice care. You can contact the Claims          Non-Network
 Administrator at the telephone number on your medical ID card.                   Yes               50%                  Yes                   Yes

                   Notify the Claims Administrator
 Please remember that for Non-Network Benefits you must notify
 the Claims Administrator five business days before receiving
 services. If you do not notify the Claims Administrator, Benefits will
 be reduced by $500; however, the reduction in Benefits will not
 exceed Eligible Expenses for the Covered Health Service.



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                                                                           13                                           (Section 1: What's Covered--Benefits)
                               Description of                                     Must         Your Copayment              Does            Do You Need
                           Covered Health Service                                 You             Amount                Copayment         to Meet Annual
                                                                                Notify the      % Copayments are        Help Meet           Deductible?
                                                                                 Claims        based on a percent of   Out-of-Pocket
                                                                                                 Eligible Expenses
                                                                              Administrator?                            Maximum?

 8. Hospital - Inpatient Stay                                                     Network
 Inpatient Stay in a Hospital. Benefits are available for:                          No                20%                  Yes                   Yes

 •   Services and supplies received during the Inpatient Stay.
 •   Room and board in a Semi-private Room (a room with two or
     more beds).
 Benefits for Physician services are described under Professional Fees for
 Surgical and Medical Services.
                Notify the Claims Administrator
 Please remember that for Non-Network Benefits you must notify                Non-Network
 the Claims Administrator as follows:                                               Yes               50%                  Yes                   Yes

 •   For elective admissions: five business days before admission.
 •   For non-elective admissions: within one business day or the
     same day of admission.
 •   For Emergency admissions: within one business day or the
     same day of admission, or as soon as is reasonably possible.
 If you do not notify the Claims Administrator, Benefits will be
 reduced by $500; however, the reduction in Benefits will not exceed
 Eligible Expenses for the Covered Health Service.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             14                                           (Section 1: What's Covered--Benefits)
                               Description of                                  Must         Your Copayment              Does            Do You Need
                           Covered Health Service                              You             Amount                Copayment         to Meet Annual
                                                                             Notify the      % Copayments are        Help Meet           Deductible?
                                                                              Claims        based on a percent of   Out-of-Pocket
                                                                                              Eligible Expenses
                                                                           Administrator?                            Maximum?

 9. Injections received in a Physician's                                       Network
                                                                                 No                20%                  Yes                   Yes
 Office
 Benefits are available for injections received in a Physician's office
 when no other health service is received, for example allergy
 immunotherapy.
 If the injection received in a Physician's office is less than the
 Copayment Amount then only the cost of the injection applies.

                                                                           Non-Network
                                                                                 No         50% per injection           Yes                   Yes


 10. Maternity Services                                                        Network
 Benefits for Pregnancy will be paid at the same level as Benefits for           No         Same as Physician's Office Services, Professional Fees,
 any other condition, Sickness or Injury. This includes all maternity-                       Hospital-Inpatient Stay, Outpatient Diagnostic and
 related medical services for prenatal care, postnatal care, delivery,                                      Therapeutic Services.
 and any related complications.
 There are special prenatal programs to help during Pregnancy. They
 are completely voluntary and there is no extra cost for participating
 in the programs. To sign up, you should notify the Claims
 Administrator during the first trimester, but no later than one month
 prior to the anticipated childbirth.
 We will pay Benefits for an Inpatient Stay of at least:

 •   48 hours for the mother and newborn child following



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          15                                           (Section 1: What's Covered--Benefits)
                               Description of                                 Must            Your Copayment              Does            Do You Need
                           Covered Health Service                             You                Amount                Copayment         to Meet Annual
                                                                            Notify the         % Copayments are        Help Meet           Deductible?
                                                                             Claims           based on a percent of   Out-of-Pocket
                                                                                                Eligible Expenses
                                                                          Administrator?                               Maximum?
     a normal vaginal delivery.
 •   96 hours for the mother and newborn child following
     a cesarean section delivery.
 If the mother agrees, the attending provider may discharge the
 mother and/or the newborn child earlier than these minimum time
 frames.
                  Notify the Claims Administrator
 Please remember that for Non-Network Benefits you must notify            Non-Network
 the Claims Administrator as soon as reasonably possible if the           Yes, if Inpatient   Same as Physician's Office Services, Professional Fees,
 Inpatient Stay for the mother and/or the newborn will be more than        Stay exceeds        Hospital-Inpatient Stay, Outpatient Diagnostic and
 the time frames described. If you do not notify the Claims                time frames.                       Therapeutic Services.
 Administrator that the Inpatient Stay will be extended, your Benefits
 for the extended stay will be reduced by $500; however, the
 reduction in Benefits will not exceed Eligible Expenses for the
 Covered Health Service.

 11. Mental Health and Substance Abuse                                        Network
                                                                            No, unless               20%                  Yes                   Yes
 Services - Outpatient                                                     psychological
 Mental Health Services and Substance Abuse Services received on an       testing services
 outpatient basis in a provider's office or at an Alternate Facility,        are being
 including:                                                                  rendered.

 •   Mental health, substance abuse and chemical dependency
     evaluations and assessment.
 •   Diagnosis.



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                                                                         16                                              (Section 1: What's Covered--Benefits)
                               Description of                                   Must           Your Copayment              Does            Do You Need
                           Covered Health Service                               You               Amount                Copayment         to Meet Annual
                                                                              Notify the        % Copayments are        Help Meet           Deductible?
                                                                               Claims          based on a percent of   Out-of-Pocket
                                                                                                 Eligible Expenses
                                                                            Administrator?                              Maximum?

 •   Treatment planning.
 •   Referral services.
 •   Medication management.
 •   Short-term individual, family and group therapeutic services
     (including intensive outpatient therapy).
 •   Crisis intervention.
 For Network Benefits, referrals to a Mental Health/Substance               Non-Network
 Abuse provider are at the sole discretion of the Mental                      No, unless              50%                  Yes                   Yes
 Health/Substance Abuse Designee, who is responsible for                     psychological
 coordinating all of your care. Contact the Mental Health/Substance         testing services
 Abuse Designee at 1-800-864-9427 regarding Network Benefits for               are being
 outpatient Mental Health and Substance Abuse Services.                        rendered.
                       Authorization Required
 Pre-Certification required for psychological testing services in excess
 of $500 prior to psychological testing services being rendered.

 12. Mental Health and Substance Abuse                                          Network
                                                                       You must call                  20%                  Yes                   Yes
 Services - Inpatient and Intermediate                                  the Mental
 Mental Health Services and Substance Abuse Services received on an       Health/
 inpatient or intermediate care basis in a Hospital or an Alternate      Substance
 Facility. Benefits include detoxification from abusive chemicals or  Abuse Designee
 substances that is limited to physical detoxification when necessary  to receive the
 to protect your physical health and well-being.                          Benefits.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           17                                             (Section 1: What's Covered--Benefits)
                               Description of                                   Must          Your Copayment              Does            Do You Need
                           Covered Health Service                               You              Amount                Copayment         to Meet Annual
                                                                              Notify the       % Copayments are        Help Meet           Deductible?
                                                                               Claims         based on a percent of   Out-of-Pocket
                                                                                                Eligible Expenses
                                                                            Administrator?                             Maximum?
 The Mental Health/Substance Abuse Designee, who will authorize
 the services, will determine the appropriate setting for the treatment.    Non-Network
 If an Inpatient Stay is required, it is covered on a Semi-private Room      You must call           50%                  Yes                   Yes
 basis. At the discretion of the Mental Health/Substance Abuse                the Mental
 Designee, two sessions of intermediate care (such as partial                   Health/
 hospitalization) may be substituted for one inpatient day.                    Substance
                                                                            Abuse Designee
 Network Benefits for Mental Health Services and Substance Abuse             to receive the
 Services must be provided by or under the direction of the Mental              Benefits.
 Health/Substance Abuse Designee. For Network Benefits, referrals
 to a Mental Health/Substance Abuse provider are at the sole
 discretion of the Mental Health/Substance Abuse Designee, who is
 responsible for coordinating all of your care. Contact the Mental
 Health/Substance Abuse Designee regarding Benefits for
 inpatient/intermediate Mental Health Services and Substance Abuse
 Services.
 Any combination of Network and Non-Network Benefits for
 Mental Health Services is limited to 28 days per lifetime.
 Benefits for Substance Abuse Services are limited to 3 series of
 treatment per lifetime.
                       Authorization Required
 Please remember that you must call and get authorization to receive
 these Benefits in advance of any treatment through the Mental
 Health/Substance Abuse Designee. The Mental Health/Substance
 Abuse Designee phone number appears on your medical ID card.
 Without authorization, Benefits will be reduced by $500.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           18                                            (Section 1: What's Covered--Benefits)
                               Description of                                     Must         Your Copayment              Does            Do You Need
                           Covered Health Service                                 You             Amount                Copayment         to Meet Annual
                                                                                Notify the      % Copayments are        Help Meet           Deductible?
                                                                                 Claims        based on a percent of   Out-of-Pocket
                                                                                                 Eligible Expenses
                                                                              Administrator?                            Maximum?

 13. Ostomy Supplies                                                              Network
 Benefits for ostomy supplies include only the following:                           No                20%                  Yes                   Yes

 •   Pouches, face plates and belts.
 •   Irrigation sleeves, bags and catheters.
 •   Skin barriers.
 Benefits are not available for gauze, adhesive, adhesive remover,            Non-Network
 deodorant, pouch covers, or other items not listed above.                          No                50%                  Yes                   Yes



 14. Outpatient Surgery, Diagnostic and
 Therapeutic Services
 Outpatient Surgery                                                               Network
 Covered Health Services received on an outpatient basis at a                       No                20%                  Yes                   Yes
 Hospital or Alternate Facility including:

 •   Benefits under this section include only the facility charge and
     the charge for required Hospital-based professional services,
     supplies and equipment. Benefits for the surgeon fees related to
     outpatient surgery are described under Professional Fees for Surgical
     and Medical Services.
                                                                              Non-Network
 When these services are performed in a Physician's office, Benefits                No                50%                  Yes                   Yes
 are described under Physician's Office Services below.



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             19                                           (Section 1: What's Covered--Benefits)
                               Description of                                   Must         Your Copayment              Does            Do You Need
                           Covered Health Service                               You             Amount                Copayment         to Meet Annual
                                                                              Notify the      % Copayments are        Help Meet           Deductible?
                                                                               Claims        based on a percent of   Out-of-Pocket
                                                                                               Eligible Expenses
                                                                            Administrator?                            Maximum?

 Outpatient Diagnostic Services                                                 Network
                                                                                               For lab and
 Covered Health Services received on an outpatient basis at a                     No
                                                                                               radiology/
 Hospital or Alternate Facility including:                                                       X-ray:
 •   Lab and radiology/X-ray.                                                                       20%                   Yes                  Yes
 •   Mammography testing.
 Benefits under this section include the facility charge, the charge for                         For
 required services, supplies and equipment, and all related                       No         mammography
 professional fees.                                                                            testing:
 When these services are performed in a Physician's office, Benefits                                20%                   Yes                  Yes
 are described under Physician's Office Services below.

                                                                                  No
                                                                                                 For
                                                                                             Colonoscopy:
                                                                                                 0% with             Not Applicable             No
                                                                                               diagnosis of
                                                                                             routine/wellness
                                                                                                  codings
                                                                                                20% with                  Yes                  Yes
                                                                                             diagnosis related
                                                                                                 to illness
                                                                            Non-Network
 This section does not include Benefits for CT scans, Pet scans,                  No             50%                      Yes                  Yes
 MRIs, or nuclear medicine, which are described immediately below.                           No Benefits for



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           20                                           (Section 1: What's Covered--Benefits)
                               Description of                                     Must         Your Copayment              Does            Do You Need
                           Covered Health Service                                 You             Amount                Copayment         to Meet Annual
                                                                                Notify the      % Copayments are        Help Meet           Deductible?
                                                                                 Claims        based on a percent of   Out-of-Pocket
                                                                                                 Eligible Expenses
                                                                              Administrator?                            Maximum?
                                                                                               preventive care.
 Outpatient Diagnostic/Therapeutic Services - CT                                  Network
 Scans, Pet Scans, MRI and Nuclear Medicine                                         No                20%                  Yes                   Yes

 Covered Health Services for CT scans, Pet scans, MRI, and nuclear
 medicine received on an outpatient basis at a Hospital or Alternate
 Facility.
                                                                              Non-Network
 Benefits under this section include the facility charge, the charge for            No                50%                  Yes                   Yes
 required services, supplies and equipment, and all related
 professional fees.

 Outpatient Therapeutic Treatments                                                Network
                                                                                    No                20%                  Yes                   Yes
 Covered Health Services for therapeutic treatments received on an
 outpatient basis at a Hospital or Alternate Facility, including dialysis,
 intravenous chemotherapy or other intravenous infusion therapy,
 and other treatments not listed above.
 Benefits under this section include the facility charge, the charge for      Non-Network
 required services, supplies and equipment, and all related                         No                50%                  Yes                   Yes
 professional fees.
 When these services are performed in a Physician's office, Benefits
 are described under Physician's Office Services below.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             21                                           (Section 1: What's Covered--Benefits)
                               Description of                                Must           Your Copayment              Does             Do You Need
                           Covered Health Service                            You               Amount                Copayment          to Meet Annual
                                                                           Notify the        % Copayments are        Help Meet            Deductible?
                                                                            Claims          based on a percent of   Out-of-Pocket
                                                                                              Eligible Expenses
                                                                         Administrator?                              Maximum?

 15. Physician's Office Services                                             Network
 Covered Health Services for preventive medical care.                          No                   0%              Not Applicable              No
 Preventive medical care includes:

 •   Preventive medical care.
 •   Voluntary family planning.
 •   Well-baby and well-child care.
 •   Routine physical examinations.
 •   Vision and hearing screenings. (Vision screenings do not include
     refractive examinations to detect vision impairment.)
 • Immunizations.
 • HIB Vaccinations for children under age 6.
 Network Benefits are limited to $500 per calendar year.
                                                                         Non-Network
                                                                         No Benefits for    No Benefits for         No Benefits for     No Benefits for
                                                                         preventive care.   preventive care.        preventive care.    preventive care.

 Covered Health Services for the diagnosis and treatment of a
 Sickness or Injury received in a Physician's office.                        Network
                                                                               No                  20%                    Yes                  Yes




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        22                                              (Section 1: What's Covered--Benefits)
                               Description of                                  Must         Your Copayment              Does            Do You Need
                           Covered Health Service                              You             Amount                Copayment         to Meet Annual
                                                                             Notify the      % Copayments are        Help Meet           Deductible?
                                                                              Claims        based on a percent of   Out-of-Pocket
                                                                                              Eligible Expenses
                                                                           Administrator?                            Maximum?
                                                                           Non-Network
                                                                                 No                50%                  Yes                   Yes


 16. Professional Fees for Surgical and                                        Network
                                                                                 No                20%                  Yes                   Yes
 Medical Services
 Professional fees for surgical procedures and other medical care
 received in a Hospital, Skilled Nursing Facility, Inpatient
 Rehabilitation Facility or Alternate Facility, or for Physician house
 calls.
 When these services are performed in a Physician's office, Benefits
 are described under Physician's Office Services above.                    Non-Network
                                                                                 No                50%                  Yes                   Yes


 17. Prosthetic Devices                                                        Network
 External prosthetic devices that replace a limb or an external body             No                20%                  Yes                   Yes
 part, limited to:

 •   Artificial arms, legs, feet and hands.
 •   Artificial eyes, ears and noses.
 •  Breast prosthesis as required by the Women's Health and Cancer
    Rights Act of 1998. Benefits include mastectomy bras and
    lymphedema stockings for the arm.
 Wigs are covered for hair replacement for loss from disease process
 and/or hair loss related to treatment of a disease process. There is a
 $400 lifetime maximum on this benefit.



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          23                                           (Section 1: What's Covered--Benefits)
                               Description of                                Must         Your Copayment              Does            Do You Need
                           Covered Health Service                            You             Amount                Copayment         to Meet Annual
                                                                           Notify the      % Copayments are        Help Meet           Deductible?
                                                                            Claims        based on a percent of   Out-of-Pocket
                                                                                            Eligible Expenses
                                                                         Administrator?                            Maximum?
 If more than one prosthetic device can meet your functional needs,
 Benefits are available only for the most cost-effective prosthetic      Non-Network
 device.                                                                       No                50%                  Yes                   Yes

 The prosthetic device must be ordered or provided by, or under the
 direction of a Physician.

 18. Reconstructive Procedures                                               Network
 Services for reconstructive procedures, when a physical impairment            No         Same as Physician's Office Services, Professional Fees,
 exists and the primary purpose of the procedure is to improve or                          Hospital-Inpatient Stay, Outpatient Diagnostic and
 restore physiologic function. Reconstructive procedures include                             Therapeutic Services, and Prosthetic Devices.
 surgery or other procedures which are associated with an Injury,
 Sickness or Congenital Anomaly. The fact that physical appearance
 may change or improve as a result of a reconstructive procedure
 does not classify such surgery as a Cosmetic Procedure when a
 physical impairment exists, and the surgery restores or improves
 function.
 Cosmetic Procedures are excluded from coverage. Procedures that
 correct an anatomical Congenital Anomaly without improving or           Non-Network
 restoring physiologic function are considered Cosmetic Procedures.            Yes        Same as Physician's Office Services, Professional Fees,
 The fact that a Covered Person may suffer psychological                                   Hospital-Inpatient Stay, Outpatient Diagnostic and
 consequences or socially avoidant behavior as a result of an Injury,                        Therapeutic Services, and Prosthetic Devices.
 Sickness or Congenital Anomaly does not classify surgery or other
 procedures done to relieve such consequences or behavior as a
 reconstructive procedure.
 Please note that Benefits for reconstructive procedures include
 breast reconstruction following a mastectomy, and reconstruction of



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        24                                           (Section 1: What's Covered--Benefits)
                               Description of                                   Must         Your Copayment              Does            Do You Need
                           Covered Health Service                               You             Amount                Copayment         to Meet Annual
                                                                              Notify the      % Copayments are        Help Meet           Deductible?
                                                                               Claims        based on a percent of   Out-of-Pocket
                                                                                               Eligible Expenses
                                                                            Administrator?                            Maximum?
 the non-affected breast to achieve symmetry. Other services required
 by the Women's Health and Cancer Rights Act of 1998, including
 breast prostheses and treatment of complications, are provided in
 the same manner and at the same level as those for any other
 Covered Health Service. You can contact the Claims Administrator
 at the telephone number on your medical ID card for more
 information about Benefits for mastectomy-related services.
                   Notify the Claims Administrator
 Please remember that for Non-Network Benefits you must notify
 the Claims Administrator five business days before receiving
 services. When you provide notification, the Claims Administrator
 can verify that the service is a reconstructive procedure rather than a
 Cosmetic Procedure. Cosmetic Procedures are always excluded from
 coverage. If you do not notify the Claims Administrator, Benefits for
 reconstructive procedures will be reduced by $500; however, the
 reduction in Benefits will not exceed Eligible Expenses for the
 Covered Health Service.

 19. Rehabilitation Services - Outpatient                                       Network
                                                                                  No                20%                  Yes                   Yes
 Therapy
 Short-term outpatient rehabilitation services for:

 •   Physical therapy.
 •   Occupational therapy.
 •   Speech therapy.
 •   Pulmonary rehabilitation therapy.


Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           25                                           (Section 1: What's Covered--Benefits)
                               Description of                                Must         Your Copayment              Does            Do You Need
                           Covered Health Service                            You             Amount                Copayment         to Meet Annual
                                                                           Notify the      % Copayments are        Help Meet           Deductible?
                                                                            Claims        based on a percent of   Out-of-Pocket
                                                                                            Eligible Expenses
                                                                         Administrator?                            Maximum?

 •   Cardiac rehabilitation therapy.
 Rehabilitation services must be performed by a licensed therapy         Non-Network
 provider, under the direction of a Physician.                                 No                50%                  Yes                   Yes
 Benefits are available only for rehabilitation services that are
 expected to result in significant physical improvement in your
 condition within two months of the start of treatment.
 Please note that we will pay Benefits for speech therapy only when
 the speech impediment or speech dysfunction results from Injury,
 stroke or a Congenital Anomaly which requires surgery.

 20. Skilled Nursing Facility/Inpatient                                      Network
                                                                               No                20%                  Yes                   Yes
 Rehabilitation Facility Services
 Services for an Inpatient Stay in a Skilled Nursing Facility or
 Inpatient Rehabilitation Facility. Benefits are available for:

 •   Services and supplies received during the Inpatient Stay.
 •   Room and board in a Semi-private Room (a room with two or
     more beds) if available.
 Please note that Benefits are available only for the care and
 treatment of an Injury or Sickness that would have otherwise
 required an Inpatient Stay in a Hospital.
                Notify the Claims Administrator
 Please remember that for Non-Network Benefits you must notify           Non-Network
 the Claims Administrator as follows:                                          Yes               50%                  Yes                   Yes



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        26                                           (Section 1: What's Covered--Benefits)
                               Description of                                  Must         Your Copayment              Does            Do You Need
                           Covered Health Service                              You             Amount                Copayment         to Meet Annual
                                                                             Notify the      % Copayments are        Help Meet           Deductible?
                                                                              Claims        based on a percent of   Out-of-Pocket
                                                                                              Eligible Expenses
                                                                           Administrator?                            Maximum?

 •   For elective admissions: five business days before admission.
 •   For non-elective admission: within one business day or the same
     day of admission.
 •   For Emergency admissions: within one business day or the same
     day of admission, or as soon as is reasonably possible.
 If you do not notify the Claims Administrator, Benefits will be
 reduced by $500; however, the reduction in Benefits will not exceed
 Eligible Expenses for the Covered Health Service.

 21. Spinal Treatment                                                          Network
 Benefits for Spinal Treatment when provided by a Spinal Treatment               No                20%                  Yes                   Yes
 provider in the provider's office.
 Benefits include diagnosis and related services and are limited to one
 visit and treatment per day.                                              Non-Network
 Any combination of Network and Non-Network Benefits for Spinal                  No                50%                  Yes                   Yes
 Treatment is limited to $1,040 per calendar year billed by a
 chiropractor (limit does not include X-rays). X-rays billed by a
 chiropractor are limited to 2 sets per calendar year.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          27                                           (Section 1: What's Covered--Benefits)
                               Description of                                Must         Your Copayment              Does            Do You Need
                           Covered Health Service                            You             Amount                Copayment         to Meet Annual
                                                                           Notify the      % Copayments are        Help Meet           Deductible?
                                                                            Claims        based on a percent of   Out-of-Pocket
                                                                                            Eligible Expenses
                                                                         Administrator?                            Maximum?

 22. Temporomandibular Joint                                                 Network
                                                                               No         Same as Physician's Office Services, Professional Fees,
 Dysfunction (TMJ)                                                                         Hospital-Inpatient Stay, and Outpatient Diagnostic
 Covered Health Services for diagnostic and surgical treatment of                                      and Therapeutic Services.
 conditions affecting the temporomandibular joint when provided by
 or under the direction of a Physician. Benefits include necessary
 diagnostic or surgical treatment required as a result of accident,
 trauma, congenial abnormality, developmental abnormality, or
 orpathology.
 Services for the evaluation and treatment of temporomandibular          Non-Network
 joint syndrome (TMJ), whether the services are considered to be               No         Same as Physician's Office Services, Professional Fees,
 medical or dental in nature, including oral appliances. Upper and                         Hospital-Inpatient Stay, and Outpatient Diagnostic
 lower jawbone surgery. Orthognathic surgery, jaw alignment and                                        and Therapeutic Services.
 treatment for the temporomandibular joint.

 23. Thrombosis Stockings                                                    Network
 Thrombosis stockings are covered with a Physician’s prescription.             No                20%                  Yes                   Yes
 Limit will be 1 pair per 6 months.

                                                                         Non-Network
                                                                               No                50%                  Yes                   Yes




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        28                                           (Section 1: What's Covered--Benefits)
                               Description of                                    Must           Your Copayment              Does             Do You Need
                           Covered Health Service                                You               Amount                Copayment          to Meet Annual
                                                                               Notify the        % Copayments are        Help Meet            Deductible?
                                                                                Claims          based on a percent of   Out-of-Pocket
                                                                                                  Eligible Expenses
                                                                             Administrator?                              Maximum?

 24. Transplantation Services                                                    Network
 Covered Health Services for the following organ and tissue                        Yes                 20%                    Yes                  Yes
 transplants when ordered by a Physician. Transplantation services
 must be received at a Designated Facility. Transplant services
 rendered at programs that do not participate in the URN transplant
 network or transplant access program are not eligible for coverage
 under this Plan. Benefits are available for the transplants listed below
 when the transplant meets the definition of a Covered Health
 Service, and is not an Experimental, Investigational or Unproven
 Service:

 •   Bone marrow transplants (either from you or from a compatible           Non-Network
     donor) and peripheral stem cell transplants, with or without high       Non-Network        Non-Network             Non-Network         Non-Network
     dose chemotherapy. Not all bone marrow transplants meet the             Benefits are not   Benefits are not        Benefits are not    Benefits are not
     definition of a Covered Health Service.                                    available.         available.              available.          available.
 •   Heart transplants.
 •   Heart/lung transplants.
 •   Lung transplants.
 •   Kidney transplants.
 •   Kidney/pancreas transplants.
 •   Liver transplants.
 •   Liver/small bowel transplants.
 •   Pancreas transplants.
 •   Small bowel transplants.



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                            29                                              (Section 1: What's Covered--Benefits)
                               Description of                                   Must         Your Copayment              Does            Do You Need
                           Covered Health Service                               You             Amount                Copayment         to Meet Annual
                                                                              Notify the      % Copayments are        Help Meet           Deductible?
                                                                               Claims        based on a percent of   Out-of-Pocket
                                                                                               Eligible Expenses
                                                                            Administrator?                            Maximum?

 Benefits are also available for cornea transplants that are provided by
 a Network Physician at a Network Hospital. We do not require that
 cornea transplants be performed at a Designated Facility. For cornea
 transplants, Benefits will be paid at the same level as Professional
 Fees, Outpatient Surgery, Diagnostic and Therapeutic Services, and
 Inpatient Hospital rather than as described in this Section
 "Transplantation Services".
 Organ or tissue transplants or multiple organ transplants other than
 those listed above are excluded from coverage.
 Under the Plan there are specific guidelines regarding Benefits for
 transplant services. Contact the Claims Administrator at the
 telephone number on your medical ID card for information about
 these guidelines.
                     Transportation and Lodging
 The Claims Administrator will assist the patient and family with
 travel and lodging arrangements when services are received from a
 Designated Facility. Expenses for travel, lodging and meals for the
 transplant recipient and a companion are available under this Plan as
 follows:

 •   Transportation of the patient and one companion who is
     traveling on the same day(s) to and/or from the site of the
     transplant for the purposes of an evaluation, the transplant
     procedure or necessary post-discharge follow-up.
 •   Eligible Expenses for lodging and meals for the patient (while
     not confined) and one companion. Benefits are paid at a per


Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           30                                           (Section 1: What's Covered--Benefits)
                               Description of                                 Must         Your Copayment              Does            Do You Need
                           Covered Health Service                             You             Amount                Copayment         to Meet Annual
                                                                            Notify the      % Copayments are        Help Meet           Deductible?
                                                                             Claims        based on a percent of   Out-of-Pocket
                                                                                             Eligible Expenses
                                                                          Administrator?                            Maximum?
     diem rate of $100.
 •   Travel and lodging expenses are only available if the transplant
     recipient resides more than 50 miles from the Designated
     Facility.
 •   If the patient is an Enrolled Dependent minor child, the
     transportation expenses of two companions will be covered and
     lodging and meal expenses will be reimbursed up to the $100 per
     diem rate.
 There is a combined overall lifetime maximum Benefit of $10,000
 per Covered Person for all transportation, lodging and meal
 expenses incurred by the transplant recipient and companion(s) and
 reimbursed under this Plan in connection with all transplant
 procedures.
                   Notify the Claims Administrator
 You must notify the Claims Administrator as soon as the possibility
 of a transplant arises (and before the time a pre-transplantation
 evaluation is performed at a transplant center). If you do not notify
 the Claims Administrator, and if the transplantation services are not
 performed at a Designated Facility, Benefits will be reduced by $500;
 however the reduction in Benefits will not exceed Eligible Expenses
 for the Covered Health Service.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         31                                           (Section 1: What's Covered--Benefits)
                               Description of                                     Must         Your Copayment              Does            Do You Need
                           Covered Health Service                                 You             Amount                Copayment         to Meet Annual
                                                                                Notify the      % Copayments are        Help Meet           Deductible?
                                                                                 Claims        based on a percent of   Out-of-Pocket
                                                                                                 Eligible Expenses
                                                                              Administrator?                            Maximum?

 25. Urgent Care Center Services                                                  Network
 Covered Health Services received at an Urgent Care Center. When                    No                20%                  Yes                   Yes
 services to treat urgent health care needs are provided in a
 Physician's office, Benefits are available as described under Physician's
 Office Services earlier in this section.

                                                                              Non-Network
                                                                                    No                50%                  Yes                   Yes




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             32                                           (Section 1: What's Covered--Benefits)
                                                                               The services, treatments, items or supplies listed in this section are
                         Section 2:                                            not Covered Health Services, except as may be specifically provided
                                                                               for in (Section 1: What's Covered--Benefits).

              What's Not Covered--
                                                                               A. Alternative Treatments
                       Exclusions                                              1. Acupressure and acupuncture.
                                                                               2. Aroma therapy.
                                                                               3. Hypnotism.
                 This section contains information about:                      4. Massage Therapy.
                 • How headings are used in this section.                      5. Rolfing.
                 •    Medical services that are not covered. We call           6. Biofeedback including behavior modification therapy and
                      these Exclusions. It is important for you to know           hypnotic training.
                      what services and supplies are not covered under         7. Other forms of alternative treatment as defined by the Office of
                      the Plan.                                                   Alternative Medicine of the National Institutes of Health.

                                                                               B. Comfort or Convenience
How We Use Headings in this Section                                            1. Television.
To help you find specific exclusions more easily, we use headings.
The headings group services, treatments, items, or supplies that fall          2. Telephone calls and/or telephone consultation. Telephone
into a similar category. Actual exclusions appear underneath                      consultations with a licensed mental health provider (while the
headings. A heading does not create, define, modify, limit or expand              participant is out of state) are limited to three per calendar year.
an exclusion. All exclusions in this section apply to you.                     3. Beauty/Barber service.
                                                                               4. Guest service.
                                                                               5. Supplies, equipment and similar incidental services and supplies
We Do not Pay Benefits for Exclusions                                             for personal comfort, even if obtained upon the
We will not pay Benefits for any of the services, treatments, items or            recommendation of a Physician. Examples include:
supplies described in this section, even if either of the following are
true:                                                                               ⎯ Air conditioners.
                                                                                    ⎯ Air purifiers and filters.
•   It is recommended or prescribed by a Physician.                                 ⎯ Batteries and battery chargers.
•   It is the only available treatment for your condition.                          ⎯ Blood pressure kits.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          33                                       (Section 2: What's Not Covered--Exclusions)
    ⎯ Dehumidifiers.                                                          5. Dental X-rays, supplies and appliances and all associated
                                                                                 expenses, including hospitalizations and anesthesia. The only
    ⎯ Escalators or elevators.
                                                                                 exceptions to this are for any of the following:
    ⎯ Exercise cycles.
                                                                                 ⎯ Transplant preparation.
    ⎯ Humidifiers.
                                                                                 ⎯ Initiation of immunosuppressives.
    ⎯ Hypo-allergenic pillows.
                                                                                 ⎯ The direct treatment of acute traumatic Injury, cancer or
    ⎯ Mattresses.                                                                   cleft palate.
    ⎯ Motorized transportation equipment.                                     6. Treatment of congenitally missing, malpositioned, or super
    ⎯ Saunas.                                                                    numerary teeth, even if part of a Congenital Anomaly
    ⎯ Steam baths.                                                            EXCEPT, benefits will be payable for charges incurred:

    ⎯ Swimming pools.                                                            •   For treatment required because of accidental bodily Injury
                                                                                     sustained while covered under this Plan to sound natural
    ⎯ Water beds.                                                                    teeth. Such expenses must be incurred within six (6) months
   ⎯ Water purifiers.                                                                of the date of the accident. This exception shall not in any
6. Devices and computers to assist in communication and speech.                      event be deemed to include charges for treatment of the
                                                                                     repair or replacement of a denture;
C. Dental                                                                        •   For extraction of impacted wisdom teeth; and
1. Dental care except as described in (Section 1: What's Covered--               •   For Hospital and associated professional fees (other than
   Benefits) under the heading Dental Services - Accident Only.                      surgeon and assistant surgeon) in connection with a dental
                                                                                     procedure which must be performed at a facility due to
2. Preventive care, diagnosis, treatment of or in connection with
                                                                                     documented medical necessity.
   the teeth, malocclusion, the nerves or roots of the teeth, gingival
   tissue or alveolar processes. Examples include all of the
   following:                                                                 D. Drugs
    ⎯ Extraction, restoration and replacement of teeth.                       1. Prescription drug products for outpatient use that are filled by a
                                                                                 prescription order or refill.
    ⎯ Medical or surgical treatments of dental conditions.
                                                                              2. Non-injectable medications given in a Physician's office except
   ⎯ Services to improve dental clinical outcomes.                               as required in an Emergency.
3. Dental implants.                                                           3. Medicine or drugs which are in Food and Drug Administration
4. Dental braces.                                                                Phase I, II, or III testing.
                                                                              4. Over the counter drugs and treatments.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         34                                     (Section 2: What's Not Covered--Exclusions)
E. Experimental, Investigational or                                            performed; or for treatment of corns, calluses or toenails, unless at
                                                                               least part of the nail root is removed; or purchase of orthopedic
Unproven Services                                                              shoes or other devices for support of the feet.
Experimental, Investigational and Unproven Services are excluded.
The fact that an Experimental, Investigational or Unproven Service,            G. Medical Supplies and Appliances
treatment, device or pharmacological regimen is the only available
treatment for a particular condition will not result in Benefits if the        1. Devices used specifically as safety items or to affect performance
procedure is considered to be Experimental, Investigational or                    in sports-related activities.
Unproven in the treatment of that particular condition.                        2. Prescribed or non-prescribed medical supplies. Examples
                                                                                  include:
Benefits will not be paid for charges in connection with
                                                                                   ⎯ Ace bandages.
Experimental or Investigational surgery or treatment not considered
reasonable and necessary as so classified by the Health Care                       ⎯ Gauze and dressings.
Financing Administration of the United States of Health and Human                  ⎯ Syringes.
Services.
                                                                                  ⎯ Diabetic test strips.
                                                                               3. Orthotic appliances that straighten or re-shape a body part
F. Foot Care                                                                      (including cranial banding and some types of braces).
1. Routine foot care (including the cutting or removal of corns and            4. Tubings and masks are not covered except when used with
   calluses).                                                                     Durable Medical Equipment (as described in Section 1: What's
                                                                                  Covered--Benefits).
2 Nail trimming, cutting, or debriding.
3. Hygienic and preventive maintenance foot care. Examples
   include the following:                                                      H. Mental Health/Substance Abuse
                                                                               1. Services performed in connection with conditions not classified
    ⎯ Cleaning and soaking the feet.
                                                                                  in the current edition of the Diagnostic and Statistical Manual of
    ⎯ Applying skin creams in order to maintain skin tone.                        the American Psychiatric Association.
    ⎯ Other services that are performed when there is not a                    2. Mental Health Services and Substance Abuse Services that
         localized illness, Injury or symptom involving the foot.                 extend beyond the period necessary for short-term evaluation,
4. Treatment of flat feet.                                                        diagnosis, treatment or crisis intervention.
5. Treatment of subluxation of the foot.                                       3. Mental Health Services as treatment for insomnia and other
6. Shoe orthotics except one per lifetime in lieu of surgery.                     sleep disorders, neurological disorders and other disorders with a
                                                                                  known physical basis.
Benefits will not be paid for charges resulting from weak, unstable
or flat feet or bunions, unless an open cutting operation is
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          35                                     (Section 2: What's Not Covered--Exclusions)
4. Treatment for conduct and impulse control disorders,                         The Mental Health/Substance Abuse Designee may consult with
   personality disorders, paraphilias and other Mental Illnesses that           professional clinical consultants, peer review committees or
   will not substantially improve beyond the current level of                   other appropriate sources for recommendations and information
   functioning, or that are not subject to favorable modification or            regarding whether a service or supply meets any of these criteria.
   management according to prevailing national standards of                  8. Benefits will not be paid for charges resulting from any
   clinical practice, as reasonably determined by the Mental                    intentionally self-inflicted Injury, while sane or insane, in excess
   Health/Substance Abuse Designee.                                             of the $10,000 lifetime maximum benefit.
5. Services utilizing methadone treatment as maintenance,
   L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or their                 I. Nutrition
   equivalents.
                                                                             1. Megavitamins, vitamins, minerals, and nutrition based therapy.
6. Treatment provided in connection with or to comply with
   involuntary commitments, police detentions and other similar              2. Recreational therapy, educational services and supplies, non-
   arrangements, unless authorized by the Mental                                medical self-care or training or enrollment in a health, athletic or
   Health/Substance Abuse Designee.                                             similar club, except as specifically mentioned as a Covered
                                                                                Expense under the Plan;
7. Services or supplies for the diagnosis or treatment of Mental
   Illness, nervous or emotional disorders including alcoholism or           3. Nutritional counseling for either individuals or groups;
   substance abuse disorders in excess of the maximums shown in                 EXCEPT, dietetic education or self-management training for
   the Benefit Information section of your Summary Plan                         management of diabetes. Diabetes self-management means:
   Description that, in the reasonable judgment of the Mental                   a. Training provided after the initial diagnosis of diabetes in the
   Health/Substance Abuse Designee, are any of the following:                       care and management of that condition, including nutritional
                                                                                    counseling and proper use of diabetic equipment and
    ⎯ Not consistent with prevailing national standards of clinical
                                                                                    diabetic supplies.
      practice for the treatment of such conditions.
                                                                                b. Additional training authorized on the diagnosis of a health
    ⎯ Not consistent with prevailing professional research                          care practitioner of a significant change in the Covered
      demonstrating that the services or supplies will have a                       Person’s symptoms or condition of diabetes that requires
      measurable and beneficial health outcome.                                     changes in the Covered Person’s self-management regime.
    ⎯ Typically do not result in outcomes demonstrably better than              c. Periodic or episodic continuing education training when
      other available treatment alternatives that are less intensive                prescribed by an appropriate health care practitioner as
      or more cost effective.                                                       warranted by the development of new techniques and
    ⎯ Not consistent with the Mental Health/Substance Abuse                         treatment for diabetes.
      Designee's level of care guidelines or best practices as               4. Enteral feedings and other nutritional and electrolyte
      modified from time to time.                                               supplements, including infant formula and donor breast milk.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        36                                     (Section 2: What's Not Covered--Exclusions)
J. Physical Appearance                                                       6. Wigs regardless of the reason for the hair loss except for wigs
                                                                                required as a result of a disease process.
1. Cosmetic Procedures (including cosmetic surgery) except as
   specifically listed as an Eligible Expense. See the definition in
   (Section 10: Glossary of Defined Terms). Examples include:                    Note:
    ⎯ Services or supplies which constitute personal comfort or                  The Plan shall not be responsible for the reimbursement for
      beautification items (including wigs, except as provided for               services or treatment of complications that result from any
      oncology patients or hair prosthesis) except as specifically               cosmetic surgery, procedure or treatment.
      listed as an Eligible Expense.
    ⎯ Pharmacological regimens, nutritional procedures or
                                                                             K. Preexisting Conditions
      treatments.                                                            Unless otherwise specifically included, healthcare benefits will not be
                                                                             paid under this plan for charges for any pre-existing conditions.
    ⎯ Scar or tattoo removal or revision procedures (such as
      salabrasion, chemosurgery and other such skin abrasion                 The effective date determines when the ninety (90) day Pre-Existing
      procedures).                                                           Condition look-back period begins and when the twelve (12)
                                                                             month/eighteen (18) month Pre-Existing Condition exclusion
   ⎯ Skin abrasion procedures performed as a treatment for acne.             period begins and ends.
2. Replacement of an existing breast implant if the earlier breast
   implant was performed as a Cosmetic Procedure.                            Eligible Persons will not be entitled to reimbursement for eligible
   Note: Replacement of an existing breast implant is considered             medical expenses that are incurred as a result of an Injury or
   reconstructive if the initial breast implant followed mastectomy.         Sickness or a related Injury or Sickness for which the Eligible Person
   See Reconstructive Procedures in (Section 1: What's Covered--             has consulted with a Physician, received any medical care, treatment
   Benefits).                                                                services, medications, or prescriptions within the ninety (90) day
                                                                             period immediately preceding the effective date of this coverage,
   Injuries or illnesses related to breast implants performed as a           until the first of one (1) of the following events occurs:
   cosmetic procedure.
                                                                             Coverage for that condition will be provided on:
3. Physical conditioning programs such as athletic training, body-
   building, exercise, fitness, flexibility, and diversion or general
   motivation.                                                               1. Ninety (90) consecutive days ending after the date the coverage
                                                                                is effective for the Eligible Person (employee or dependent) and
4. Weight loss programs whether or not they are under medical                   during which period the Eligible Person has not consulted a
   supervision. Weight loss programs for medical reasons are also               physician with respect to such Injury or Sickness or related
   excluded.                                                                    condition.
5. Cosmetic hair loss treatment.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        37                                     (Section 2: What's Not Covered--Exclusions)
2. After an Eligible Person (employee or dependent) has been                     8   Military coverage;
    continuously enrolled in the Plan concurrently for three hundred             9   Indian Health Service;
    sixty-five (365) consecutive days.                                           10  State risk pool;
To receive benefits for a Pre-Existing Condition, a LATE                         11  Any other state-sponsored arrangement for individuals
ENROLLEE must go ninety (90) consecutive days after the                              unable to get coverage otherwise.
coverage is effective without consulting a Physician, receiving
medical care, treatment, services, medications or prescriptions for              If you do not have a significant break in coverage between the
the Pre-Existing Condition.                                                      termination date of your prior creditable coverage and your
                                                                                 effective date under this Plan, you may submit a certificate of
Exceptions                                                                       creditable coverage or other statement from your prior coverage
The Pre-Existing Condition Exclusion Limitation will not apply to:               that shows the length of time you were covered and your
    1 Eligible Persons (employees or dependents) that have been                  termination date. A significant break in coverage is more than
        covered since the Plan’s original effective date, or                     sixty-three (63) continuous days. Once we receive the certificate
    2 Eligible Persons (employees or dependents) that were                       or statement, we will give you credit for each day of prior
        covered by the prior plan and would not be subject to an                 creditable coverage against the twelve (12) month exclusion
        exclusion or reduction of benefits of the prior plan’s pre-              period and will not be subject to any limitations under the Plan
        existing condition exclusion limitation.                                 solely because a condition, Injury, or illness is pre-existing.
Pregnancy will not be considered a Pre-Existing Condition.
                                                                              L. Providers
If you had creditable coverage prior to your effective date under this        1. Treatment or care rendered by a Physician, R.N., L.P.N.,
Plan, you may be able to receive credit for part or all of the pre-              licensed or certified practitioner, who is related by blood or
existing exclusion period described in the previous paragraph,                   marriage to the Covered Person, including spouse, brother,
Creditable coverage includes:                                                    sister, parent or child. This includes any service the provider may
                                                                                 perform on himself or herself.
    1 A group health plan;
                                                                              2. Treatment or care provided by any person who ordinarily resides
    2 Health insurance (insurance or reimbursement) provided in
                                                                                 with the Covered Person.
        group or individual market;
                                                                              3. Services provided at a free-standing or Hospital-based diagnostic
    3 A governmental plan;
                                                                                 facility without an order written by a Physician or other provider.
    4 A church plan;                                                             Services that are self-directed to a free-standing or Hospital-
    5 Medicare;                                                                  based diagnostic facility. Services ordered by a Physician or other
    6 Medicaid;                                                                  provider who is an employee or representative of a free-standing
    7 TRICARE (formerly CHAMPUS);                                                or Hospital-based diagnostic facility, when that Physician or
                                                                                 other provider:
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         38                                     (Section 2: What's Not Covered--Exclusions)
    ⎯ Has not been actively involved in your medical care prior to            10. Birth Control devices or medication (other than oral
      ordering the service, or                                                    contraceptives, as covered under the Prescription Drug
                                                                                  Program) including their insertion and removal.
    ⎯ Is not actively involved in your medical care after the service
       is received.
    This exclusion does not apply to mammography testing.                     N. Services Provided under Another Plan
                                                                              1. Health services for which other coverage is required by federal,
M. Reproduction                                                                  state or local law to be purchased or provided through other
                                                                                 arrangements. This includes, but is not limited to, coverage
1. Health services and associated expenses for infertility treatments.           required by workers' compensation, no-fault auto insurance, or
2. Surrogate parenting.                                                          similar legislation.
3. The surgical reversal of elective sterilization, or sex                    2. Health services resulting from an Injury, illness or disability
   transformations or treatment of sexual dysfunctions of                        reimbursement which could have been available if pursued under
   inadequacy which includes implants and related hormone                        the Worker’s Compensation Act or by any form of insurance
   therapy and for non-prescriptive contraceptives.                              available by the employer whether or not the employer is a
4. Health services and associated expenses for elective abortion.                subscriber or non subscriber in an Worker’s Compensation
5. Fetal reduction surgery.                                                      program; except as specifically listed as an Eligible Expense.
6. Health services associated with the use of non-surgical or drug-           3. Health services for treatment of military service-related
   induced Pregnancy termination.                                                disabilities, when you are legally entitled to other coverage and
                                                                                 facilities are reasonably available to you.
7. Related to or in connection with infertility, including but not
   limited to, infertility studies, procedures to restore or enhance          4. Health services while on active military duty.
   fertility, artificial insemination, in-vitro fertilization and/or
   artificial reproduction procedures.                                        O. Transplants
8. For hormonal disorders, male or female, resulting in a treatment           1. Health services for organ and tissue transplants, except those
   program of periodic rapid assays of reproductive hormones (e.g.               described in (Section 1: What's Covered--Benefits).
   estradiol, lutenizing hormone, Follicle Stimulation (FSH),                 2. Health services connected with the removal of an organ or tissue
   progesterone, and androgens; gonadotropic stimulation) given in               from you for purposes of a transplant to another person. (Donor
   a sequential manner requiring laboratory tests to evaluate the                costs for removal are payable for a transplant through the organ
   effect of such stimulation; reproductive organ                                recipient's Benefits under the Plan).
   ultrasounds/echogram or biopsies following gonadotopin
                                                                              3. Health services for transplants involving mechanical or animal
   stimulation and follow-up office visits, not including diagnoses
                                                                                 organs.
   of menopausal conditions.
9. Norplant.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         39                                     (Section 2: What's Not Covered--Exclusions)
4. Transplant services rendered at programs that do not participate          4. Eye exercise therapy, visual training or vision therapy for the
   in the URN transplant network or transplant access program are               correction of vision.
   not eligible for coverage under the Plan.                                 5. Surgery that is intended to allow you to see better without
5. Any solid organ transplant that is performed as a treatment for              glasses or other vision correction including radial
   cancer.                                                                      keratotomy/Keratoplasty when the primary purpose is to correct
6. Transplantation or implantation of non-human, artificial or                  myopia (nearsightedness), hyperopia (farsightedness) or
   mechanical organs, or any part thereof.                                      astigmatism (blurring).
7. Travel or accommodations, whether or not recommended by a                 6. Routine vision examinations, including refractive examinations.
   Physician other than those eligible under Covered Transplant              7. Eyeglasses or contact lenses are covered if required as the result
   Services.                                                                    of cataract surgery performed while the person is covered under
8. Any multiple organ transplant not listed as a Covered Health                 the Plan.
   Service under the heading Transplantation Health Services in
   (Section 1: What's Covered--Benefits).                                    R. All Other Exclusions
                                                                             1. Health services and supplies that do not meet the definition of a
P. Travel                                                                       Covered Health Service - see the definition in (Section 10:
1. Health services provided in a foreign country, unless required as            Glossary of Defined Terms).
   Emergency Health Services.                                                2. Physical, psychiatric or psychological exams, testing,
2. Travel or transportation expenses, even though prescribed by a               (psychological testing in excess of $500 that is not authorized
   Physician. Some travel expenses related to covered                           and that is not medically necessary), vaccinations, immunizations
   transplantation services may be reimbursed at our discretion.                or treatments that are otherwise covered under the Plan when:
3. Incurred as a result of travel outside of the United States or its           ⎯ Required solely for purposes of career, education, sports or
   territories specifically to receive medical treatment.                         camp, travel, employment, insurance or marriage.
                                                                                ⎯ Related to judicial or administrative proceedings or orders.
Q. Vision and Hearing                                                           ⎯ Conducted for purposes of medical research.
1. Purchase or replacement cost of hearing aids, eye glasses or                 ⎯ Required to obtain or maintain a license of any type.
   contact lenses EXCEPT, hearing aids or eye glasses due to a
   medical condition or injury that caused the patient to require a          3. Health services received as a result of war, any act of war, or any
   hearing aid or eye glasses are covered under medical.                        type of military conduct, whether declared or undeclared or
                                                                                caused during service in the armed forces of any country.
2. Fitting charge for hearing aids, eye glasses or contact lenses.
                                                                                ⎯ Services rendered by a Hospital or facility operated by the
3. Routine hearing test (except as provided for newborns).
                                                                                  United States Government or any authorized agency of the
                                                                                  United States Government, or furnished at the expense of
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        40                                   (Section 2: What's Not Covered--Exclusions)
           such government or agency; except for expenses incurred              17. Psychosurgery.
           due to services provided for a Non-Military connected                18. Treatment of benign gynecomastia (abnormal breast
           disability.                                                              enlargement in males).
4.    Health services received after the date your coverage under the           19. Medical and surgical treatment of excessive sweating
      Plan ends, including health services for medical conditions                   (hyperhidrosis).
      arising before the date your coverage under the Plan ends.
                                                                                20. Medical and surgical treatment for snoring, except when
5.    Health services for which you have no legal responsibility to pay,            provided as a part of treatment for documented obstructive
      or for which a charge would not ordinarily be made in the                     sleep apnea.
      absence of coverage under the Plan.                                       21. Oral appliances for snoring.
6.    In the event that a Non-Network provider waives Copayments                22. Speech therapy except as required for treatment of a speech
      and/or the Annual Deductible for a particular health service, no              impediment or speech dysfunction that results from Injury,
      Benefits are provided for the health service for which the                    stroke, or a Congenital Anomaly which requires surgery.
      Copayments and/or Annual Deductible are waived.
                                                                                23. Any charges for missed appointments, room or facility
7.    Charges in excess of Eligible Expenses or in excess of any
                                                                                    reservations, completion of claim forms or record processing.
      specified limitation.
                                                                                24. Any charge for services, supplies or equipment advertised by the
      ⎯ Charges in excess of the Usual and customary charge, as                     provider as free.
          determined by fees and expenses charged by most Hospitals
                                                                                25. Any charges prohibited by federal anti-kickback or self-referral
          located in the same area and by most Physicians of similar
                                                                                    statutes.
          training or experience located in the same area.
                                                                                26. Nicotine skin patches.
8.    Non-surgical treatment of obesity, including morbid obesity for
      services or supplies rendered to any member for treatment of              27. Smoking cessation.
      obesity or for weight reduction.                                          28. Charges Incurred in connection with services and supplies which
9.    Surgical treatment of obesity including severe morbid obesity                 are not medically necessary for the treatment of a covered
      (with a BMI greater than 35).                                                 Accidental Injury or illness and/or are not recommended and
                                                                                    approved by a Physician.
10.   Growth hormone therapy.
                                                                                29. Housekeeping or custodial care.
11.   Sex transformation operations.
                                                                                30. Charges in excess of the usual and customary charge as
12.   Custodial Care.
                                                                                    determined by fees and expenses charged by most Hospitals
13.   Domiciliary care.                                                             located in the same area and by most Physicians of similar
14.   Private duty nursing.                                                         training experience located in the same area.
15.   Respite care.                                                             31. Training services or educational training problems.
16.   Rest cures.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           41                                     (Section 2: What's Not Covered--Exclusions)
32. Charges Incurred in connection with an Eligible Person’s                  41. Lymphoedema therapy unless performed by a licensed Physician
    participation in a riot or insurrection.                                      in lymphoedema therapy.
33. Services not actually rendered.                                           42. Charges resulting from or occurring during the commission of a
34. Charges Incurred as a result of or in connection with the                     crime or while engaged in an illegal occupation, felonious act or
    diagnosis or treatment of a learning disability, learning                     aggravated assault.
    impairment or behavioral problem(s), by any name called,
    whether or not associated with manifest mental disorders or
    other disturbances, except for charges incurred for attention
    deficit disorder diagnosed in a neurological capacity, by a
    Physician trained to recognize and treat such disorder. This
    excludes, but is not limited to charges for remedial education or
    training: Educational Therapy (including therapeutic training
    exercises and multi-sensory teaching techniques); periodic
    achievement tests; tutoring; rental or purchase of books, tools,
    equipment, implements, or supplies of any kind; travel,
    recreational activities; or any other services rendered on an
    Inpatient or Outpatient basis for or in connection with such
    conditions; however, this exclusion shall not apply to charges
    incurred for medically necessary office visits to a medical doctor
    and/or laboratory examinations required for medication checks
    as a result of taking a medication prescribed for or in connection
    with such condition(s).
35. Charges due to pregnancy of a dependent other than a
    dependent spouse.
36. Marriage counseling or sex therapy.
37. Influenza Vaccination.
38. Employer mandated immunizations.
39. Care or treatment furnished by a Christian Science practitioner;
    homeopath; marriage, family or child(ren) counselor; or
    naturopath.
40. Any services or supplies, unless otherwise covered under Eligible
    Expenses.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         42                                     (Section 2: What's Not Covered--Exclusions)
                                                                             Comparison of Network and Non-Network Benefits
                      Section 3:                                                Benefits
                                                                                                        Network
                                                                                                A higher level of
                                                                                                                                  Non-Network
                                                                                                                             A lower level of
        Description of Network                                                                  Benefits means less
                                                                                                cost to you. See
                                                                                                                             Benefits means more
                                                                                                                             cost to you. See

             and Non-Network                                                                    (Section 1: What's
                                                                                                Covered--Benefits).
                                                                                                                             (Section 1: What's
                                                                                                                             Covered--Benefits).

                       Benefits                                               Who Should
                                                                              Notify the
                                                                                                Network providers
                                                                                                handle notification for
                                                                                                                             You must notify the
                                                                                                                             Claims Administrator
                                                                                Claims          you. However, there          for certain Covered
                                                                             Administrator      are exceptions. See          Health Services.
                                                                               for Care         (Section 1: What's           Failure to notify
                  This section includes information about:                   Coordination
                                                                                                Covered--Benefits),          results in reduced
                  • Network Benefits.                                                           under the Must You           Benefits or no
                  •   Non-Network Benefits.                                                     Notify the Claims            Benefits. See (Section
                                                                                                Administrator? column.       1: What's Covered--
                  •   Emergency Health Services.
                                                                                                                             Benefits), under the
                                                                                                                             Must You Notify the
Network Benefits                                                                                                             Claims Administrator?
                                                                                                                             column.
Network Benefits are paid at a higher level than Non-Network
Benefits. Network Benefits are payable for Covered Health Services            Who Should        Not required. We pay         You must file claims.
which are either of the following:                                            File Claims       Network providers            See (Section 5: How
                                                                                                directly.                    to File a Claim).
•   Provided by or under the direction of a Network Physician or
    other Network provider in the Physician's office or at a Network          Outpatient        Emergency Health Services are always paid as
    facility.                                                                 Emergency         a Network Benefit (paid the same whether you
                                                                             Health Services    are in or out of the Network). That means that
•   Emergency Health Services.
                                                                                                if you seek Emergency care at a Non-Network
                                                                                                facility, you are not required to meet the
                                                                                                Annual Deductible or to pay any difference
                                                                                                between Eligible Expenses and the amount the
                                                                                                provider bills.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        43                   (Section 3: Description of Network and Non-Network Benefits)
Provider Network                                                             CoordinationSM process and to provide you with information about
The Claims Administrator arranges for health care providers to               additional services that are available to you, such as disease
participate in a Network. Network providers are independent                  management programs, health education, pre-admission counseling
practitioners. They are not our employees or employees of the                and patient advocacy.
Claims Administrator. It is your responsibility to select your
                                                                             If you receive certain Covered Health Services from a Network
provider.
                                                                             provider, you must notify the Claims Administrator. The Covered
The credentialing process confirms public information about the              Health Services for which notification is required is shown in
providers' licenses and other credentials, but does not assure the           (Section 1: What's Covered--Benefits). When you notify the Claims
quality of the services provided.                                            Administrator, you will receive the Care Coordination services
                                                                             described above.
You will be given a directory of Network providers. However,
before obtaining services you should always verify the Network               Designated Facilities and Other Providers
status of a provider. A provider's status may change. You can verify         If you have a medical condition that the Claims Administrator
the provider's status by calling the Claims Administrator.                   believes needs special services, they may direct you to a Designated
It is possible that you might not be able to obtain services from a          Facility or other provider chosen by them. If you require certain
particular Network provider. The network of providers is subject to          complex Covered Health Services for which expertise is limited, the
change. Or you might find that a particular Network provider may             Claims Administrator may direct you to a Non-Network facility or
not be accepting new patients. If a provider leaves the Network or is        provider.
otherwise not available to you, you must choose another Network              In both cases, Network Benefits will only be paid if your Covered
provider to get Network Benefits.                                            Health Services for that condition are provided by or arranged by
Do not assume that a Network provider's agreement includes all               the Designated Facility or other provider chosen by the Claims
Covered Health Services. Some Network providers contract to                  Administrator.
provide only certain Covered Health Services, but not all Covered            You or your Network Physician must notify the Claims
Health Services. Some Network providers choose to be a Network               Administrator of special service needs (including, but not limited to,
provider for only some products. Refer to your provider directory or         transplants or cancer treatment) that might warrant referral to a
contact the Claims Administrator for assistance.                             Designated Facility or Non-Network facility or provider. If you do
                                                                             not notify the Claims Administrator in advance, and if you receive
Care CoordinationSM                                                          services from a Non-Network facility (regardless of whether it is a
Your Network Physician is required to notify the Claims                      Designated Facility) or other Non-Network provider, Network
Administrator regarding certain proposed or scheduled health                 Benefits will not be paid. Non-Network Benefits may be available if
services. When your Network Physician notifies the Claims                    the special needs services you receive are Covered Health Services
Administrator, they will work together to implement the Care                 for which Benefits are provided under the Plan.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        44                  (Section 3: Description of Network and Non-Network Benefits)
Health Services from Non-Network Providers Paid as                           •   Provided by Non-Network providers.
Network Benefits                                                             •   Provided under the direction of a Non-Network Physician, at a
If specific Covered Health Services are not available from a Network             Non-Network facility or program.
provider, you may be eligible for Network Benefits when Covered
Health Services are received from Non-Network providers. In this             Depending on the geographic area and the service you receive, you
situation, your Network Physician will notify the Claims                     may have access through the Claim's Administrator's Shared Savings
Administrator, and they will work with you and your Network                  Program to providers who have agreed to discount their charges for
Physician to coordinate care through a Non-Network provider.                 Covered Health Services. If you receive Covered Health Services
                                                                             from these providers, and if your Copayment is expressed as a
When you receive Covered Health Services through a Network                   percentage of Eligible Expenses for Non-Network Benefits, that
Physician, we will pay Network Benefits for those Covered Health             percentage will remain the same as it is when you receive Covered
Services, even if one or more of those Covered Health Services is            Health Services from Non-Network providers who have not agreed
received from a Non-Network provider.                                        to discount their charges; however, the total that you owe may be
                                                                             less when you receive Covered Health Services from Shared Savings
Limitations on Selection of Providers                                        Program providers than from other Non-Network providers,
If the Claims Administrator determines that you are using health             because the Eligible Expense may be a lesser amount.
care services in a harmful or abusive manner, or with harmful
frequency, your selection of Network providers may be limited. If            Notification Requirement
this happens, you may be required to select a single Network                 You must notify the Claims Administrator before getting certain
Physician to provide and coordinate all future Covered Health                Covered Health Services from Non-Network providers. The details
Services.                                                                    are shown in the Must You Notify the Claims Administrator? column in
                                                                             (Section 1: What's Covered--Benefits). If you fail to notify the
If you do not make a selection within 30 days of the date we notify
                                                                             Claims Administrator, Benefits are reduced or denied.
you, the Claims Administrator will select a single Network Physician
for you.                                                                     Prior notification does not mean Benefits are payable in all cases.
                                                                             Coverage depends on the Covered Health Services that are actually
If you fail to use the selected Network Physician, Covered Health
                                                                             given, your eligibility status, and any benefit limitations.
Services will be paid as Non-Network Benefits.
                                                                             Care Coordination SM
Non-Network Benefits                                                         When you notify the Claims Administrator as described above, they
Non-Network Benefits are paid at a lower level than Network                  will work to implement the Care CoordinationSM process and to
Benefits. Non-Network Benefits are payable for Covered Health                provide you with information about additional services that are
Services which are either of the following:                                  available to you, such as disease management programs, health
                                                                             education, pre-admission counseling and patient advocacy.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        45                  (Section 3: Description of Network and Non-Network Benefits)
Emergency Health Services
We provide Benefits for Emergency Health Services when required
for stabilization and initiation of treatment as provided by or under
the direction of a Physician.
Network Benefits are paid for Emergency Health Services, even if
the services are provided by a Non-Network provider.
If you are confined in a Non-Network Hospital after you receive
Emergency Health Services, the Claims Administrator must be
notified within one business day or on the same day of admission if
reasonably possible. The Claims Administrator may elect to transfer
you to a Network Hospital as soon as it is medically appropriate to
do so. If you choose to stay in the Non-Network Hospital after the
date the Claims Administrator decides a transfer is medically
appropriate, Non-Network Benefits may be available if the
continued stay is determined to be a Covered Health Service.




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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        46      (Section 3: Description of Network and Non-Network Benefits)
                                                                             Inpatient Stay as long as you receive Covered Health Services in
                     Section 4:                                              accordance with the terms of the Plan.
                                                                             You should notify the Claims Administrator within 48 hours of the
          When Coverage Begins                                               day your coverage begins, or as soon as is reasonably possible.
                                                                             Network Benefits are available only if you receive Covered Health
                                                                             Services from Network Providers.

                  This section includes information about:
                  • How to enroll.                                           If You Are Eligible for Medicare
                                                                             Your Benefits under the Plan may be reduced if you are eligible for
                  •   If you are hospitalized when this coverage             Medicare but do not enroll in and maintain coverage under both
                      begins.                                                Medicare Part A and Part B.
                  •   Who is eligible for coverage.
                                                                             Your Benefits under the Plan may also be reduced if you are
                  •   When to enroll.                                        enrolled in a Medicare Advantage (Medicare Part C) plan but fail to
                  •   When coverage begins.                                  follow the rules of that plan. Please see Medicare Eligibility in (Section
                                                                             9: General Legal Provisions) for more information about how
                                                                             Medicare may affect your Benefits.
How to Enroll
To enroll, the Eligible Person must complete an enrollment form.
The Plan Administrator or its designee will give the necessary forms
to you, along with instructions about submitting your enrollment
form and any required contribution for coverage. We will not
provide Benefits for health services that you receive before your
effective date of coverage.


If You Are Hospitalized When Your
Coverage Begins
If you are an inpatient in a Hospital, Skilled Nursing Facility or
Inpatient Rehabilitation Facility on the day your coverage begins, we
will pay Benefits for Covered Health Services related to that

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        47                                                (Section 4: When Coverage Begins)
Who is Eligible for Coverage
            Who                                                   Description                                         Who Determines Eligibility

 Eligible                      Eligible Person usually refers to an employee of ours who meets the             We determine who is eligible to enroll
                               eligibility rules. When an Eligible Person actually enrolls, we refer to that   under the Plan.
 Person                        person as a Participant. For a complete definition of Eligible Person and
                               Participant, see (Section 10: Glossary of Defined Terms).
                               If both spouses are Eligible Persons under the Plan, each may enroll as a
                               Participant or be covered as an Enrolled Dependent of the other, but
                               not both.
                               Except as we have described in (Section 4: When Coverage Begins),
                               Eligible Persons may not enroll.

 Dependent                     Dependent refers to the Participant's spouse (wife or husband) and              We determine who qualifies as a
                               children. When a Dependent actually enrolls, we refer to that person as         Dependent.
                               an Enrolled Dependent. For a complete definition of Dependent and
                               Enrolled Dependent, see (Section 10: Glossary of Defined Terms).                Dependent children coverage starts at
                                                                                                               birth and includes unmarried children and
                               Dependents of an Eligible Person may not enroll unless the Eligible             grandchildren covered on Income Tax.
                               Person is also covered under the Plan.                                          Children are covered up to age 25
                               If both parents of a Dependent child are enrolled as a Participant, only        regardless of student status.
                               one parent may enroll the child as a Dependent.
                               Except as we have described in (Section 4: When Coverage Begins),
                               Dependents may not enroll.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                                48                                           (Section 4: When Coverage Begins)
            Who                                                   Description                                Who Determines Eligibility
                               A dependent will be eligible to participate in the Plan on or within thirty
                               (30) days of the later of:
                               a. the date the Employee is eligible for coverage under the Plan, if on
                               that date the Employee is covered by the Plan and has made any
                               necessary contributions to the Employer; or
                               b. the date the Employee gains an eligible Dependent, if on that date the
                               Employee is covered by the Plan and has made any necessary
                               contributions to the Employer.
                               It is the responsibility of the employee to notify the Fort Bend ISD
                               Benefits Office in writing to terminate coverage for a dependent that is
                               no longer an Eligible Dependent as defined in this Plan. Notice may be
                               sent to the Fort Bend ISD Benefits Office at: 16431 Lexington
                               Boulevard, Suite 214, Sugar Land, Texas 77479, by fax at (281) 634-1431
                               or (281) 634-1711, or by e-mail to Benefits@fortbend.k12.tx.us. Your
                               deductions for medical coverage will not be adjusted unless, and until
                               you notify the Fort Bend ISD Benefits Office in writing regarding a
                               change in status within the same month of the change. Also, you will
                               forfeit all deductions that may have been reduced had you provided
                               timely written notice of a status change.
                               The District reserves the right to audit all dependents on the plan
                               to confirm their eligibility. Failure to provide such proof shall
                               result in the employee being financially responsible for all health
                               care benefits provided to the dependent.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                                49                                  (Section 4: When Coverage Begins)
When to Enroll and When Coverage Begins
              When to Enroll                                        Who Can Enroll                                   Begin Date

 Initial Enrollment                            Eligible Persons may enroll themselves and their   Coverage begins on the date identified by the
                                               eligible Dependents.                               Plan Administrator, if the Plan Administrator
 Period                                                                                           receives the completed enrollment form and
 The Initial Enrollment Period is the                                                             any required contribution for coverage within
 first period of time when Eligible                                                               30 days of the date the Eligible Person becomes
 Persons can enroll.                                                                              eligible to enroll.

 Open Enrollment                               Eligible Persons may enroll themselves and their   The Plan Administrator determines the Open
                                               eligible Dependents.                               Enrollment Period. Coverage begins on the
 Period                                                                                           date identified by the Plan Administrator if the
                                                                                                  Plan Administrator receives the completed
                                                                                                  enrollment form and any required contribution
                                                                                                  within 30 days of the date the Eligible Person
                                                                                                  becomes eligible to enroll.

 New Eligible Persons                          New Eligible Persons may enroll themselves and     Full-time hourly employees:
                                               their eligible Dependents.
                                                                                                  Coverage begins on the first day of the
                                                                                                  following month coinciding with or next
                                                                                                  following the completion of a 90 day waiting
                                                                                                  period if the Plan Administrator receives the
                                                                                                  properly completed enrollment form and any
                                                                                                  required contribution for coverage within 30
                                                                                                  days of the date the new Eligible Person
                                                                                                  becomes eligible to enroll and if the Participant
                                                                                                  pays any required contribution to the Plan
                                                                                                  Administrator for Coverage.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             50                                        (Section 4: When Coverage Begins)
              When to Enroll                                        Who Can Enroll                                     Begin Date

                                                                                                   All other active employees participating in the
                                                                                                   Teachers Retirement System (TRS):
                                                                                                   Coverage begins on the first day of the
                                                                                                   following month if the Plan Administrator
                                                                                                   receives the properly completed enrollment
                                                                                                   form and any required contribution for
                                                                                                   coverage within 30 days of the date of hire if
                                                                                                   the new Eligible Person becomes eligible to
                                                                                                   enroll and if the Participant pays any required
                                                                                                   contribution to the Plan Administrator for
                                                                                                   Coverage.

 Adding New                                    Participants may enroll only the Dependents who     Coverage begins on the date of the event if the
                                               join their family because of any of the following   Plan Administrator received the completed
 Dependents                                    events:                                             enrollment form and any required contribution
                                                                                                   for coverage within 30 days of the event that
                                               •    Birth. A claim for maternity expenses is not   makes the new Dependent eligible.
                                                    considered as enrollment of a newborn.
                                                                                                   In no event will the Dependent's coverage
                                               •    Legal guardianship.                            begin before the Employee's coverage.
                                               •    Court or administrative order.                 If you acquire a newborn child(ren), an
                                               •    Marriage.                                      enrollment form for the newborn child(ren) for
                                                                                                   dependent coverage must be completed and
                                                                                                   sent to the Benefits Department within 30 days
                                                                                                   of the birth. Coverage for the newborn will be
                                                                                                   effective on the date of birth, if the child(ren) is
                                                                                                   enrolled within the first thirty (30) days,
                                                                                                   otherwise the child(ren) will not be covered.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             51                                          (Section 4: When Coverage Begins)
              When to Enroll                                        Who Can Enroll                                       Begin Date

                                               During the plan year, certain Family Status Changes
 Family Status Change                          as defined by CFR 1.125 will permit an employee to
                                                                                                      Event Takes Place (for example, a birth or
                                                                                                      marriage). Coverage begins on the date of the
                                               add/or drop eligible dependent(s) other than during    event if the Plan Administrator receives the
                                               open enrollment. A family status qualifying event
                                                                                                      completed enrollment form and any required
                                               permits the employee to add or drop dependents on      contribution within 30 days of the event.
                                               the benefit plan, but is not considered a qualifying
                                               event for benefit plan changes. Only those             It is the responsibility of the employee to notify
                                               dependents affected by the Family Status Change        the Fort Bend ISD Benefits Office in writing to
                                               may be added or dropped on/off the Plan. Forms         terminate coverage for a member and/or
                                               must be completed and documentation must be            Dependent that is no longer an Eligible
                                               submitted to the Insurance/Benefits Department         Member/Dependent as defined in this Plan.
                                               within thirty (30) days of the event:                  Notice may be sent to the Fort Bend ISD
                                               1.marriage;                                            Benefits Office at 16431 Lexington Boulevard,
                                                                                                      Suite 214, Sugar Land, Texas 77479, by fax at
                                                                                                      (281) 634-1431 or (281) 634-1711, or by email
                                               2.divorce;                                             to Benefits@fortbend.k12.tx.us. Your
                                                                                                      deductions for medical coverage will not be
                                               3.employee gains an eligible Dependent                 adjusted unless, and until you notify the Fort
                                               (note: includes grandchildren);                        Bend ISD Benefits Office in writing regarding a
                                                                                                      change in status within the same month of the
                                                                                                      change. Also, you will forfeit all deductions
                                               4.death;
                                                                                                      that may have been reduced had you provided
                                                                                                      timely written notice of a status change.
                                               5.loss/gain of spouse’s employment;
                                                                                                      Coverage begins on the first day of the
                                                                                                      following month if the Plan Administrator
                                               6.employment status change from full-time              received the properly completed enrollment
                                               to part-time;                                          form and required contribution for coverage
                                                                                                      within 30 days of the event.
                                               7. employment status change from part-time
                                               to full-time;                                          Coverage ends on the last day of the month in
                                                                                                      which the change occurs if the Plan



Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             52                                            (Section 4: When Coverage Begins)
              When to Enroll                                        Who Can Enroll                                      Begin Date

                                               8.unpaid leave of absence;                              Administrator received the properly completed
                                                                                                       change forms within 30 days of the event.
                                               9.significant change* in the cost or coverage of your
                                               spouse’s health plan;

                                               10.loss of coverage.

                                               *Significant change means the cost of the employee
                                               and/or spouse’s health coverage increases or
                                               decreases by at least 25%.

 Late Enrollees                                An Eligible Person or Dependent who does not            Coverage begins on the date identified by the
                                               enroll for coverage under the Plan when he or she is    Plan Administrator after the Plan Administrator
                                               first eligible, and who does not enroll during the      receives the completed enrollment form and
                                               Initial Enrollment Period, Open Enrollment Period,      any required contribution for coverage.
                                               or a special enrollment period as described above.


 Late Entrants
 Late entrants will only be accepted for coverage during the Plan’s annual open enrollment, or within thirty (30) days of a Family Status change.
 A late enrollment is any enrollment that occurs after the Individual’s initial enrollment date if the individual was not covered on the District’s
 prior plan. Coverage for these late entrants will be effective:

     •    Full-time employees – First of the month after your completed paperwork is received in the Insurance/Benefits Department.

     •    Full-time hourly employees – First of the month after a 90 day waiting period.
 The Pre-existing Condition Limitation Exclusion will apply if the Late Entrant does not present a certificate of creditable coverage for the
 previous eighteen (18) months.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             53                                            (Section 4: When Coverage Begins)
                                                                             format that contains all of the information required, as described
                                Section 5:                                   below.
                                                                             You must submit a request for payment of Benefits within 90 days
                      How to File a Claim                                    after the date of service. If you do not provide this information to
                                                                             the Claims Administrator within one year of the date of service,
                                                                             Benefits for that health service will be denied or reduced, in our or
                                                                             the Claims Administrator's discretion. This time limit does not apply
                  This section provides you with information about:          if you are legally incapacitated. If your claim relates to an Inpatient
                  • How and when to file a claim.                            Stay, the date of service is the date your Inpatient Stay ends.

                  •   If you receive Covered Health Services from a          If a Participant provides written authorization to allow direct
                      Network provider, you do not have to file a            payment to a provider, all or a portion of any Eligible Expenses due
                      claim. We pay these providers directly.                to a provider may be paid directly to the provider instead of being
                                                                             paid to the Participant. We will not reimburse third parties who have
                  •   If you receive Covered Health Services from a          purchased or been assigned benefits by Physicians or other
                      Non-Network provider, you are responsible for          providers.
                      filing a claim.
                                                                             Required Information
If You Receive Covered Health Services                                       When you request payment of Benefits from us, you must provide
                                                                             all of the following information:
from a Network Provider
We pay Network providers directly for your Covered Health                    A.   Participant's name and address.
Services. If a Network provider bills you for any Covered Health             B.   The patient's name, age and relationship to the Participant.
Service, contact the Claims Administrator. However, you are
responsible for meeting the Annual Deductible and for paying                 C.   The member number stated on your medical ID card.
Copayments to a Network provider at the time of service, or when             D.   An itemized bill from your provider that includes the following:
you receive a bill from the provider.                                             ⎯ Patient Diagnosis
                                                                                  ⎯ Date of service
Filing a Claim for Benefits                                                       ⎯ Procedure Code(s) and descriptions of service(s) rendered
When you receive Covered Health Services from a Non-Network                     ⎯ Provider of service (Name, Address and Tax Identification
provider, you are responsible for requesting payment from us                       Number)
through the Claims Administrator. You must file the claim in a               E. The date the Injury or Sickness began.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        54                                                   (Section 5: How to File a Claim)
F. A statement indicating either that you are, or you are not,               Once notified of the extension you then have 45 days to provide this
   enrolled for coverage under any other health insurance plan or            information. If all of the needed information is received within the
   program. If you are enrolled for other coverage you must include          45 day time frame and the claim is denied, the Claims Administrator
   the name of the other carrier(s).                                         will notify you of the denial within 15 days after the information is
                                                                             received. If you do not provide the needed information within the
Payment of Benefits                                                          45 day period, your claim will be denied.
Through the Claims Administrator, we will make a benefit                     A denial notice will explain the reason for denial, refer to the part of
determination as set forth below.                                            the Plan on which the denial is based, and provide the claim appeal
You may not assign your Benefits under the Plan to a Non-Network             procedures.
provider without our consent. The Claims Administrator may,
however, in their discretion, pay a Non-Network provider directly
                                                                             Pre-service Claims
for services rendered to you.                                                Pre-service claims are those claims that require notification or
                                                                             approval prior to receiving medical care. If your claim was a pre-
The Claims Administrator will notify you if additional information is
                                                                             service claim, and was submitted properly with all needed
needed to process the claim. The Claims Administrator may request
                                                                             information, you will receive written notice of the claim decision
a one time extension not longer than 15 days and will pend your
                                                                             from the Claims Administrator within 15 days of receipt of the
claim until all information is received. Once you are notified of the
                                                                             claim. If you filed a pre-service claim improperly, the Claims
extension or missing information, you then have at least 45 days to
                                                                             Administrator will notify you of the improper filing and how to
provide this information.
                                                                             correct it within 5 days after the pre-service claim was received. If
                                                                             additional information is needed to process the pre-service claim, the
Benefit Determinations                                                       Claims Administrator will notify you of the information needed
Post-service Claims                                                          within 15 days after the claim was received, and may request a one
                                                                             time extension not longer than 15 days and pend your claim until all
Post-service claims are those claims that are filed for payment of           information is received. Once notified of the extension you then
benefits after medical care has been received. If your post-service          have 45 days to provide this information. If all of the needed
claim is denied, you will receive a written notice from the Claims           information is received within the 45 day time frame, the Claims
Administrator within 30 days of receipt of the claim, as long as all         Administrator will notify you of the determination within 15 days
needed information was provided with the claim. The Claims                   after the information is received. If you do not provide the needed
Administrator will notify you within this 30 day period if additional        information within the 45 days period, your claim will be denied. A
information is needed to process the claim, and may request a one            denial notice will explain the reason for denial, refer to the part of
time extension not longer than 15 days and pend your claim until all         the Plan on which the denial is based, and provide the claim appeal
information is received.                                                     procedures.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        55                                                  (Section 5: How to File a Claim)
Urgent Claims that Require Immediate Action                                    A denial notice will explain the reason for denial, refer to the part of
Urgent claims are those claims that require notification or a benefit          the Plan on which the denial is based, and provide the claim appeal
determination prior to receiving medical care, where a delay in                procedures.
treatment could seriously jeopardize your life or health or the ability
to regain maximum function or, in the opinion of a Physician with              Concurrent Care Claims
knowledge of your medical condition could cause severe pain. In                If an on-going course of treatment was previously approved for a
these situations:                                                              specific period of time or number of treatments, and your request to
                                                                               extend the treatment is an urgent claim as defined above, your
•   You will receive notice of the benefit determination in writing or         request will be decided within 24 hours, provided your request is
    electronically within 72 hours after the Claims Administrator              made at least 24 hours prior to the end of the approved treatment.
    receives all necessary information, taking into account the                The Claims Administrator will make a determination on your request
    seriousness of your condition.                                             for the extended treatment within 24 hours from receipt of your
•   Notice of denial may be oral with a written or electronic                  request.
    confirmation to follow within 3 days.
                                                                               If your request for extended treatment is not made at least 24 hours
If you filed an urgent claim improperly, the Claims Administrator              prior to the end of the approved treatment, the request will be
will notify you of the improper filing and how to correct it within 24         treated as an urgent claim and decided according to the timeframes
hours after the urgent claim was received. If additional information           described above. If an on-going course of treatment was previously
is needed to process the claim, the Claims Administrator will notify           approved for a specific period of time or number of treatments, and
you of the information needed within 24 hours after the claim was              you request to extend treatment in a non-urgent circumstance, your
received. You then have 48 hours to provide the requested                      request will be considered a new claim and decided according to
information.                                                                   post-service or pre-service timeframes, whichever applies.
You will be notified of a benefit determination no later than 48
hours after:

•   The Claims Administrator's receipt of the requested information;
    or
•   The end of the 48-hour period within which you were to provide
    the additional information, if the information is not received
    within that time.



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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          56                                                  (Section 5: How to File a Claim)
                                                                              writing. However, if you are not satisfied with a benefit
                       Section 6:                                             determination as described in (Section 5: How to File a Claim) you
                                                                              may appeal it as described below, without first informally contacting

           Questions, Complaints                                              Customer Service. If you first informally contact Customer Service
                                                                              and later wish to request a formal appeal in writing, you should
                                                                              contact Customer Service and request an appeal. If you request a
                     and Appeals                                              formal appeal, a Customer Service representative will provide you
                                                                              with the appropriate address of the Claims Administrator.
                                                                              If you are appealing an urgent care claim denial, please refer to the
                                                                              "Urgent Claim Appeals that Require Immediate Action" section
                  This section provides you with information to help          below and contact Customer Service immediately.
                  you with the following:
                  • You have a question or concern about Covered              The Customer Service telephone number is shown on your medical
                     Health Services or your Benefits.                        ID card. Customer Service representatives are available to take your
                                                                              call.
                  •   You have a Complaint.
                  •   How to handle an appeal that requires immediate
                      action.                                                 How to Appeal a Claim Decision
                  •   You are notified that a claim has been denied           If you disagree with a pre-service or post-service claim
                      because it has been determined that a service or        determination after following the above steps, you can contact the
                      supply is excluded under the Plan and you wish          Claims Administrator in writing to formally request an appeal.
                      to appeal such determination.                           Your request should include:

To resolve a question or appeal, just follow these steps:                     •   The patient's name and the identification number from the
                                                                                  medical ID card.

What to Do First                                                              •   The date(s) of medical service(s).
If your question or concern is about a benefit determination, you             •   The provider's name.
may informally contact Customer Service before requesting a formal            •   The reason you believe the claim should be paid.
appeal.
                                                                              •   Any documentation or other written information to support
If the Customer Service representative cannot resolve the issue to                your request for claim payment.
your satisfaction over the phone, you may submit your question in

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         57                                   (Section 6: Questions, Complaints and Appeals)
Your first appeal request must be submitted to the Claims                      from receipt of a request for appeal of a denied claim. The second
Administrator within 180 days after you receive the claim denial.              level appeal will be conducted and you will be notified by the Plan
                                                                               Administrator of the decision within 30 days from receipt of a
                                                                               request for review of the first level appeal decision.
Appeal Process
A qualified individual who was not involved in the decision being              For procedures associated with urgent claims, see "Urgent Claim
appealed will be appointed to decide the appeal. If your appeal is             Appeals that Require Immediate Action" below.
related to clinical matters, the review will be done in consultation           If you are not satisfied with the first level appeal decision of the
with a health care professional with appropriate expertise in the field        Claims Administrator, you have the right to request a second level
who was not involved in the prior determination. The Claims                    appeal from us as the Plan Administrator. Your second level appeal
Administrator (first level appeals) and the Plan Administrator                 request must be submitted to the Plan Administrator in writing
(second level appeals) may consult with, or seek the participation of,         within 60 days from receipt of the first level appeal decision.
medical experts as part of the appeal resolution process. You
consent to this referral and the sharing of pertinent medical claim            The Plan Administrator has the exclusive right to interpret and
information. Upon request and free of charge, you have the right to            administer the Plan, and these decisions are conclusive and binding.
reasonable access to and copies of, all documents, records, and other
information relevant to your claim for benefits.                               Please note that the decision of the Plan Administrator is based only
                                                                               on whether or not Benefits are available under the Plan for the
                                                                               proposed treatment or procedure. The Plan Administrator does not
Appeals Determinations                                                         determine whether the pending health service is necessary or
                                                                               appropriate is between you and your Physician.
Pre-service and Post-service Claim Appeals
You will be provided written or electronic notification of decision
on your appeal as follows:
                                                                               Urgent Claim Appeals that Require
For appeals of pre-service claims, (as defined in Section 5: How to            Immediate Action
File a Claim), the first level appeal will be conducted and you will be        Your appeal may require immediate action if a delay in treatment
notified by the Claims Administrator of the decision within 15 days            could significantly increase the risk to your health or the ability to
from receipt of a request for appeal of a denied claim. The second             regain maximum function or cause severe pain. In these urgent
level appeal will be conducted and you will be notified by the Plan            situations:
Administrator of the decision within 15 days from receipt of a
request for review of the first level appeal decision.                         The appeal does not need to be submitted in writing. You or your
                                                                               Physician should call the Claims Administrator as soon as possible.
For appeals of post-service claims (as defined in Section 5: How to            The Claims Administrator will provide you with a written or
File a Claim), the first level appeal will be conducted and you will be        electronic determination within 72 hours following receipt by the
notified by the Claims Administrator of the decision within 30 days
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          58                                    (Section 6: Questions, Complaints and Appeals)
Claims Administrator of your request for review of the
determination taking into account the seriousness of your condition.
For urgent claim appeals, the Plan Administrator has delegated to
the Claims Administrator the exclusive right to interpret and
administer the provisions of the Plan. The Claims Administrator's
decisions are conclusive and binding.




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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        59                       (Section 6: Questions, Complaints and Appeals)
                                                                             Definitions
                    Section 7:                                               For purposes of this section, terms are defined as follows:

      Coordination of Benefits                                               1. "Coverage Plan" is any of the following that provides benefits or
                                                                                services for medical or dental care or treatment. However, if
                                                                                separate contracts are used to provide coordinated coverage for
                                                                                members of a group, the separate contracts are considered parts
                                                                                of the same Coverage Plan and there is no COB among those
                  This section provides you with information about:
                                                                                separate contracts.
                  • What you need to know when you have coverage
                     under more than one plan.                                  a. "Coverage Plan" includes: group insurance, closed panel or
                                                                                    other forms of group or group-type coverage (whether
                  •   Definitions specific to Coordination of Benefit               insured or uninsured); medical care components of group
                      rules.                                                        long-term care contracts, such as skilled nursing care;
                  •   Order of payment rules.                                       medical, no-fault, or personal injury protection (PIP) benefits
                                                                                    under group or individual automobile contracts; medical
                                                                                    benefits coverage under homeowner's insurance; and
Benefits When You Have Coverage under                                               Medicare or other governmental benefits, as permitted by
                                                                                    law.
More than One Plan                                                              b. "Coverage Plan" does not include: individual or family
This section describes how Benefits under the Plan will be
                                                                                    insurance; closed panel or other individual coverage (except
coordinated with those of any other plan that provides benefits to
                                                                                    for group-type coverage); school accident type coverage;
you.
                                                                                    benefits for non-medical components of group long-term
                                                                                    care policies; Medicare supplement policies, Medicaid policies
                                                                                    and coverage under other governmental plans, unless
When Coordination of Benefits Applies                                               permitted by law.
This coordination of benefits (COB) provision applies when a person
has health care coverage under more than one benefit plan.                          Each contract for coverage under a. or b. above is a separate
                                                                                    Coverage Plan. If a Coverage Plan has two parts and COB
The order of benefit determination rules described in this section                  rules apply only to one of the two, each of the parts is treated
determine which Coverage Plan will pay as the Primary Coverage                      as a separate Coverage Plan.
Plan. The Primary Coverage Plan that pays first pays without regard          2. The order of benefit determination rules determine whether this
to the possibility that another Coverage Plan may cover some                    Coverage Plan is a "Primary Coverage Plan" or "Secondary
expenses. A Secondary Coverage Plan pays after the Primary                      Coverage Plan" when compared to another Coverage Plan
Coverage Plan and may reduce the benefits it pays.                              covering the person.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        60                                          (Section 7: Coordination of Benefits)
   When this Coverage Plan is primary, its benefits are determined                    an amount in excess of the highest of the negotiated fees is
   before those of any other Coverage Plan and without considering                    not an Allowable Expense.
   any other Coverage Plan's benefits. When this Coverage Plan is                 d. If a person is covered by one Coverage Plan that calculates its
   secondary, its benefits are determined after those of another                      benefits or services on the basis of usual and customary fees
   Coverage Plan and may be reduced because of the Primary                            and another Coverage Plan that provides its benefits or
   Coverage Plan's benefits.                                                          services on the basis of negotiated fees, the Primary Coverage
3. "Allowable Expense" means a health care service or expense,                        Plan's payment arrangements shall be the Allowable Expense
   including deductibles and copayments, that is covered at least in                  for all Coverage Plans.
   part by any of the Coverage Plans covering the person. When a                  e. The amount a benefit is reduced by the Primary Coverage
   Coverage Plan provides benefits in the form of services, (for                      Plan because a Covered Person does not comply with the
   example an HMO) the reasonable cash value of each service will                     Coverage Plan provisions. Examples of these provisions are
   be considered an Allowable Expense and a benefit paid. An                          second surgical opinions, precertification of admissions, and
   expense or service that is not covered by any of the Coverage                      preferred provider arrangements.
   Plans is not an Allowable Expense. Dental care, routine vision              4. "Closed Panel Plan" is a Coverage Plan that provides health
   care, outpatient prescription drugs, and hearing aids are examples             benefits to Covered Persons primarily in the form of services
   of expenses or services that are not Allowable Expenses under                  through a panel of providers that have contracted with or are
   the Plan. The following are additional examples of expenses or                 employed by the Coverage Plan, and that limits or excludes
   services that are not Allowable Expenses:                                      benefits for services provided by other providers, except in cases
   a. If a Covered Person is confined in a private Hospital room,                 of emergency or referral by a panel member.
       the difference between the cost of a Semi-private Room in               5. "Custodial Parent" means a parent awarded custody by a court
       the Hospital and the private room, (unless the patient's stay in           decree. In the absence of a court decree, it is the parent with
       a private Hospital room is medically necessary in terms of                 whom the child resides more than one half of the calendar year
       accepted medical practice, or one of the Coverage Plans                    without regard to any temporary visitation.
       routinely provides coverage for Hospital private rooms) is not
       an Allowable Expense.
   b. If a person is covered by two or more Coverage Plans that
                                                                               Order of Benefit Determination Rules
       compute their benefit payments on the basis of usual and                When two or more Coverage Plans pay benefits, the rules for
       customary fees, any amount in excess of the highest of the              determining the order of payment are as follows:
       usual and customary fees for a specific benefit is not an
                                                                               A. The Primary Coverage Plan pays or provides its benefits as if the
       Allowable Expense.
                                                                                  Secondary Coverage Plan or Coverage Plans did not exist.
   c. If a person is covered by two or more Coverage Plans that
                                                                               B. A Coverage Plan that does not contain a coordination of benefits
       provide benefits or services on the basis of negotiated fees,
                                                                                  provision that is consistent with this provision is always primary.
                                                                                  There is one exception: coverage that is obtained by virtue of
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          61                                          (Section 7: Coordination of Benefits)
   membership in a group that is designed to supplement a part of a             b. If the specific terms of a court decree state that one of
   basic package of benefits may provide that the supplementary                     the parents is responsible for the child's health care
   coverage shall be excess to any other parts of the Coverage Plan                 expenses or health care coverage and the Coverage Plan
   provided by the contract holder. Examples of these types of                      of that parent has actual knowledge of those terms, that
   situations are major medical coverages that are superimposed                     Coverage Plan is primary. This rule applies to claim
   over base Coverage Plan Hospital and surgical benefits, and                      determination periods or plan years commencing after the
   insurance type coverages that are written in connection with a                   Coverage Plan is given notice of the court decree.
   closed panel Coverage Plan to provide out-of-network benefits.               c. If the parents are not married, or are separated (whether
C. A Coverage Plan may consider the benefits paid or provided by                    or not they ever have been married) or are divorced, the
   another Coverage Plan in determining its benefits only when it is                order of benefits is:
   secondary to that other Coverage Plan.                                           1) The Coverage Plan of the custodial parent;
D. The first of the following rules that describes which Coverage                   2) The Coverage Plan of the spouse of the custodial
   Plan pays its benefits before another Coverage Plan is the rule to                    parent;
   use.                                                                             3) The Coverage Plan of the noncustodial parent; and
   1. Non-Dependent or Dependent. The Coverage Plan that                                 then
        covers the person other than as a dependent, for example as                 4) The Coverage Plan of the spouse of the noncustodial
        an employee, member, subscriber or retiree is primary and the                    parent.
        Coverage Plan that covers the person as a dependent is
        secondary. However, if the person is a Medicare beneficiary          3. Active or inactive employee. The Coverage Plan that covers a
        and, as a result of federal law, Medicare is secondary to the           person as an employee who is neither laid off nor retired is
        Coverage Plan covering the person as a dependent; and                   primary. The same would hold true if a person is a dependent
        primary to the Coverage Plan covering the person as other               of a person covered as a retiree and an employee. If the other
        than a dependent (e.g. a retired employee); then the order of           Coverage Plan does not have this rule, and if, as a result, the
        benefits between the two Coverage Plans is reversed so that             Coverage Plans do not agree on the order of benefits, this
        the Coverage Plan covering the person as an employee,                   rule is ignored. Coverage provided an individual as a retired
        member, subscriber or retiree is secondary and the other                worker and as a dependent of an actively working spouse will
        Coverage Plan is primary.                                               be determined under the rule labeled D(1).
   2. Child Covered Under More Than One Coverage Plan. The                   4. Continuation coverage. If a person whose coverage is
        order of benefits when a child is covered by more than one              provided under a right of continuation provided by federal or
        Coverage Plan is:                                                       state law also is covered under another Coverage Plan, the
                                                                                Coverage Plan covering the person as an employee, member,
        a. The Primary Coverage Plan is the Coverage Plan of the                subscriber or retiree (or as that person's dependent) is
            male person.                                                        primary, and the continuation coverage is secondary. If the

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        62                                          (Section 7: Coordination of Benefits)
       other Coverage Plan does not have this rule, and if, as a             B. If a Covered Person is enrolled in two or more closed panel
       result, the Coverage Plans do not agree on the order of                  Coverage Plans and if, for any reason, including the provision of
       benefits, this rule is ignored.                                          service by a non-panel provider, benefits are not payable by one
   5. Longer or shorter length of coverage. The Coverage Plan that              closed panel Coverage Plan, COB shall not apply between that
       covered the person as an employee, member, subscriber or                 Coverage Plan and other closed panel Coverage Plans.
       retiree longer is primary.                                            C. This Coverage Plan reduces its benefits as described below for
   6. If the preceding rules do not determine the Primary Coverage              Covered Persons who are eligible for Medicare when Medicare
       Plan, the Allowable Expenses shall be shared equally between             would be the Primary Coverage Plan.
       the Coverage Plans meeting the definition of Coverage Plan               Medicare benefits are determined as if the full amount that would
       under this provision. In addition, this Coverage Plan will not           have been payable under Medicare was actually paid under
       pay more than it would have paid had it been primary.                    Medicare, even if:
E. A group or individual automobile contract that provides medical,
   no-fault or personal injury protection benefits or a homeowner's             •   The person is entitled but not enrolled for Medicare.
   policy that provides medical benefits coverage shall provide                     Medicare benefits are determined as if the person were
   primary coverage.                                                                covered under Medicare Parts A and B.
                                                                                •   The person is enrolled in a Medicare Advantage (Medicare
Effect on the Benefits of this Plan                                                 Part C) plan and receives non-covered services because the
A. When this Coverage Plan is secondary, it may reduce its benefits                 person did not follow all rules of that plan. Medicare benefits
   by the total amount of benefits paid or provided by all Coverage                 are determined as if the services were covered under
   Plans Primary to this Coverage Plan. As each claim is submitted,                 Medicare Parts A and B.
   this Coverage Plan will:                                                     •   The person receives services from a provider who has elected
   1. Determine its obligation to pay or provide benefits under its                 to opt-out of Medicare. Medicare benefits are determined as
        contract;                                                                   if the services were covered under Medicare Parts A and B
   2. Determine the difference between the benefit payments that                    and the provider had agreed to limit charges to the amount of
        this Coverage Plan would have paid had it been the Primary                  charges allowed under Medicare rules.
        Coverage Plan and the benefit payments paid or provided by              •   The services are provided in any facility that is not eligible for
        all Coverage Plans Primary to this Coverage Plan.                           Medicare reimbursements, including a Veterans
   If there is a difference, this Coverage Plan will pay that amount.               Administration facility, facility of the Uniformed Services, or
   Benefits paid or provided by this Coverage Plan plus those of                    other facility of the federal government. Medicare benefits are
   Coverage Plans primary to this Coverage Plan may be less than                    determined as if the services were provided by a facility that is
   100 percent of total Allowable Expenses.                                         eligible for reimbursement under Medicare.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        63                                             (Section 7: Coordination of Benefits)
    •   The person is enrolled under a plan with a Medicare Medical          Right of Recovery
        Savings Account. Medicare benefits are determined as if the          If the amount of the payments we made is more than we should have
        person were covered under Medicare Parts A and B.                    paid under this COB provision, we may recover the excess from one
                                                                             or more of the persons we have paid or for whom we have paid; or
                                                                             any other person or organization that may be responsible for the
                                                                             benefits or services provided for you. The "amount of the payments
Right to Receive and Release Needed                                          made" includes the reasonable cash value of any benefits provided in
                                                                             the form of services.
Information
Certain facts about health care coverage and services are needed to
apply these COB rules and to determine benefits payable under this
Coverage Plan and other Coverage Plans. The Plan Administrator
may get the facts it needs from, or give them to, other organizations
or persons for the purpose of applying these rules and determining
benefits payable under this Coverage Plan and other Coverage Plans
covering the person claiming benefits.
The Plan Administrator need not tell, or get the consent of, any
person to do this. Each person claiming benefits under this Coverage
Plan must give us any facts we need to apply those rules and
determine benefits payable. If you do not provide us the information
we need to apply these rules and determine the Benefits payable, your
claim for Benefits will be denied.


Payments Made
A payment made under another Coverage Plan may include an
amount that should have been paid under this Coverage Plan. If it
does, we may pay that amount to the organization that made the
payment. That amount will then be treated as though it were a benefit
paid under this Coverage Plan. We will not have to pay that amount
again. The term "payment made" includes providing benefits in the
form of services, in which case "payment made" means reasonable
cash value of the benefits provided in the form of services.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        64                                             (Section 7: Coordination of Benefits)
                         Section 8:                                           General Information about When
                                                                              Coverage Ends
               When Coverage Ends                                             We may discontinue this Benefit plan and/or all similar benefit plans
                                                                              at any time.
                                                                              Your entitlement to Benefits automatically ends on the date that
                  This section provides you with information about all        coverage ends, even if you are hospitalized or are otherwise receiving
                  of the following:                                           medical treatment on that date.
                  • Events that cause coverage to end.                        When your coverage ends, we will still pay claims for Covered
                  •   Continuation of Benefits During Approved                Health Services that you received before your coverage ended.
                      Leave of Absence                                        However, once your coverage ends, we do not provide Benefits for
                                                                              health services that you receive for medical conditions that occurred
                  •   The date your coverage ends.                            before your coverage ended, even if the underlying medical
                  •   Continuation of coverage under federal law              condition occurred before your coverage ended.
                      (COBRA).
                                                                              An Enrolled Dependent's coverage ends on the date the
                                                                              Participant's coverage ends.
                                                                              It is the responsibility of the Employee to notify the Fort Bend ISD
                                                                              Benefits Office in writing to terminate coverage for a Dependent
                                                                              that is no longer an Eligible Dependent as defined in This Plan.
                                                                              Notice may be sent to the Fort Bend ISD Benefits Office at: 16431
                                                                              Lexington Boulevard, Suite 214, Sugar Land, Texas 77479, by fax at
                                                                              (281) 634-1431 or (281) 634-1711, or by email to
                                                                              Benefits@fortbend.k12.tx.us. Your deductions for medical coverage
                                                                              will not be adjusted unless, and until you notify the Fort Bend ISD
                                                                              Benefits Office in writing regarding a change in status within the
                                                                              same month of the change. Also, you will forfeit all deductions that
                                                                              may have been reduced had you provided timely written notice of a
                                                                              status change.



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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         65                                                (Section 8: When Coverage Ends)
The district reserves the right to audit all dependents on the                  Participant Death: Participant's coverage, and all Dependents
plan to confirm their eligibility. Failure to provide such proof                covered by the Participant, will end at Midnight on the last day of
shall result in the Employee being financially responsible for                  the month in which the change occurred under the guidelines of
all health care benefits provided to the dependent.                             Family Status Change as defined by CFR 1.125.
Except as provided in the Continuation of Coverage section, and                 Dependent Death: Upon the death of a covered Dependent, the
except as provided below, Employee's coverage will terminate on the             deceased Dependent's coverage ends at Midnight on the date of
earliest of the following dates:                                                death; however, under the guidelines of Family Status Change as
         a. on the fifteenth (15th) or the thirtieth (30th) of the month        defined by CFR 1.125, the change in coverage will be effective the
following the Employee's receipt of last paycheck;                              first of the month following the change.
         b. the end of the period for which the Employee fails to
remit required contributions for his health Care Benefits when due;
         c. the date the Plan is changed to end coverage for the class
to which the Employee belongs;
         d. on the day in which the Employee ceases to belong to a
class for which coverage is provided; or
         e. on the termination date of the Plan.

Except as provided in the Continuation of Coverage section, a
Dependent that reaches the maximum age of 25 (regardless of
student status), coverage will terminate on the earliest of the
following dates:
          a. the last day of the month in which Dependent child loses
eligibiliy; or
          b. on the day in which the Employee's coverage terminates.




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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           66                                                (Section 8: When Coverage Ends)
Events Ending Your Coverage
Coverage ends on the earliest of the dates specified in the following table:
               Ending Event                                                                 What Happens

 The Entire Plan Ends                           Your coverage ends on the date the Plan ends. We are responsible for notifying you that your
                                                coverage has ended.

 You Are No Longer                              Your coverage ends on the date you are no longer eligible to be a Participant or Enrolled Dependent.
                                                Please refer to (Section 10: Glossary of Defined Terms) for a more complete definition of the terms
 Eligible                                       "Eligible Person", "Participant", "Dependent" and "Enrolled Dependent".

 The Plan Administrator                         Your coverage ends on the date the Plan Administrator receives written notice from us instructing the
                                                Plan Administrator to end your coverage, or the date requested in the notice, if later.
 Receives Notice to End
 Coverage
 Participant Retires or                         Your coverage ends the date the Participant is retired or pensioned under the Plan. We are
                                                responsible for providing written notice to the Plan Administrator to end your coverage.
 Is Pensioned
                                                This provision applies unless we designate a specific coverage classification for retired or pensioned
                                                persons, and only if the Participant continues to meet any applicable eligibility requirements. We can
                                                provide you with specific information about what coverage is available for retirees.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                            67                                               (Section 8: When Coverage Ends)
Other Events Ending Your Coverage
When any of the following happen, we will provide written notice to the Participant that coverage has ended on the date the Plan Administrator
identifies in the notice:
                   Ending Event                                                                  What Happens

 Fraud, Misrepresentation                               Fraud or misrepresentation, or because the Participant knowingly gave us false material
                                                        information. Examples include false information relating to another person's eligibility or status
 or False Information                                   as a Dependent. We have the right to demand that you pay back all Benefits we paid to you, or
                                                        paid in your name, during the time you were incorrectly covered under the Plan.

 Material Violation                                     There was a material violation of the terms of the Plan.

 Improper Use of Medical                                You permitted an unauthorized person to use your medical ID card, or you used another
                                                        person's card.
 ID card
 Failure to Pay                                         You failed to pay a required contribution.

 Threatening Behavior                                   You committed acts of physical or verbal abuse that pose a threat to our staff, the Claims
                                                        Administrator's staff, a provider, or other Covered Persons.




Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             68                                                (Section 8: When Coverage Ends)
                                                                              Continuation of Benefits during
Coverage for a Handicapped Child                                              Approved Leave of Absence:
Coverage for an unmarried Enrolled Dependent child who is not
able to be self-supporting because of mental retardation or a physical        Employees on an Approved Leave of Absence will be allowed to
handicap will not end just because the child has reached a certain            continue under the Plan based on the Fort Bend Independent
age. We will extend the coverage for that child beyond the limiting           School District Board Policy.
age if both of the following are true regarding the Enrolled
Dependent child:
                                                                              Continuation of Coverage
•   Is not able to be self-supporting because of mental retardation           If your coverage ends under the Plan, you may be entitled to elect
    or physical handicap.                                                     continuation coverage (coverage that continues on in some form) in
•   Depends mainly on the Participant for support.                            accordance with federal law.
Coverage will continue as long as the Enrolled Dependent is                   Continuation coverage under COBRA (the federal Consolidated
incapacitated and dependent unless coverage is otherwise terminated           Omnibus Budget Reconciliation Act) is available only to Plans that
in accordance with the terms of the Plan.                                     are subject to the terms of COBRA. You can contact your Plan
                                                                              Administrator to determine if we are subject to the provisions of
We will ask you to furnish the Plan Administrator with proof of the           COBRA.
child's incapacity and dependency within 30 days of the date
coverage would otherwise have ended because the child reached a               If you selected continuation coverage under a prior plan which was
certain age. Before the Plan Administrator agrees to this extension           then replaced by coverage under this Plan, continuation coverage
of coverage for the child, the Plan Administrator may require that a          will end as scheduled under the prior plan or in accordance with the
Physician chosen by us examine the child. We will pay for that                terminating events listed below, whichever is earlier.
examination.
The Plan Administrator may continue to ask you for proof that the             Continuation Coverage under Federal
child continues to meet these conditions of incapacity and
dependency. Such proof might include medical examinations at our              Law (COBRA)
expense. However, we will not ask for this information more than              Much of the language in this section comes from the federal law that
once a year.                                                                  governs continuation coverage. You should call your Plan
                                                                              Administrator if you have questions about your right to continue
If you do not provide proof of the child's incapacity and dependency          coverage.
within 30 days of the Plan Administrator's request as described
above, coverage for that child will end.                                      In order to be eligible for continuation coverage under federal law,
                                                                              you must meet the definition of a "Qualified Beneficiary". A
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         69                                            (Section 8: When Coverage Ends)
Qualified Beneficiary is any of the following persons who was                   D.   Divorce or legal separation of the Participant.
covered under the Plan on the day before a qualifying event:                    E.   Loss of eligibility by an Enrolled Dependent who is a child.
                                                                                F.   Entitlement of the Participant to Medicare benefits.
•   A Participant.
                                                                                G.   The Plan Sponsor's commencement of a bankruptcy under Title
•   A Participant's Enrolled Dependent, including with respect to                    11, United States Code. This is also a qualifying event for any
    the Participant's children, a child born to the Participant during a             retired Participant and his or her Enrolled Dependents if there is
    period of continuation coverage under federal law.                               a substantial elimination of coverage within one year before or
•   A Participant's former spouse.                                                   after the date the bankruptcy was filed.

Qualifying Events for Continuation                                              Notification Requirements and Election
Coverage under Federal Law (COBRA)                                              Period for Continuation Coverage under
If the coverage of a Qualified Beneficiary would ordinarily terminate           Federal Law (COBRA)
due to one of the following qualifying events, then the Qualified
Beneficiary is entitled to continue coverage. The Qualified                     Notification Requirements for Qualifying Event
Beneficiary is entitled to elect the same coverage that she or he had           The Participant or other Qualified Beneficiary must notify the Plan
on the day before the qualifying event.                                         Administrator within 60 days of the latest of the date of the
                                                                                following events:
The qualifying events with respect to an employee who is a Qualified
Beneficiary are:                                                                •    The Participant's divorce or legal separation, or an Enrolled
A. Termination of employment, for any reason other than gross                        Dependent's loss of eligibility as an Enrolled Dependent.
   misconduct.                                                                  •    The date the Qualified Beneficiary would lose coverage under
                                                                                     the Plan.
B. Reduction in the Participant's hours of employment.
                                                                                •    The date on which the Qualified Beneficiary is informed of his
With respect to a Participant's spouse or dependent child who is a                   or her obligation to provide notice and the procedures for
Qualified Beneficiary, the qualifying events are:                                    providing such notice.
A. Termination of the Participant's employment (for reasons other               The Participant or other Qualified Beneficiary must also notify the
   than the Participant's gross misconduct).                                    Plan Administrator when a second qualifying event occurs, which
                                                                                may extend continuation coverage.
B. Reduction in the Participant's hours of employment.
                                                                                If the Participant or other Qualified Beneficiary fails to notify the
C. Death of the Participant.                                                    Plan Administrator of these events within the 60 day period, the

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           70                                                 (Section 8: When Coverage Ends)
Plan Administrator is not obligated to provide continued coverage            The Trade Act of 2002 amended COBRA to provide for a special
to the affected Qualified Beneficiary. If a Participant is continuing        second 60-day COBRA election period for certain Participants who
coverage under federal law, the Participant must notify the Plan             have experienced a termination or reduction of hours and who lose
Administrator within 60 days of the birth of a child.                        group health plan coverage as a result. The special second COBRA
                                                                             election period is available only to a very limited group of
Notification Requirements for Disability                                     individuals: those who are receiving trade adjustment assistance
Determination or Change in Disability Status                                 (TAA) or 'alternative trade adjustment assistance' under a federal law
                                                                             called the Trade Act of 1974. These Participants are entitled to a
The Participant or other Qualified Beneficiary must notify the Plan
                                                                             second opportunity to elect COBRA coverage for themselves and
Administrator as described under "Terminating Events for
                                                                             certain family members (if they did not already elect COBRA
Continuation Coverage under Federal Law (COBRA)," subsection A
                                                                             coverage), but only within a limited period of 60 days from the first
below.
                                                                             day of the month when an individual begins receiving TAA (or
The notice requirements will be satisfied by providing written notice        would be eligible to receive TAA but for the requirement that
to the Plan Administrator at the address stated in Attachment II to          unemployment benefits be exhausted) and only during the six
this Summary Plan Description. The contents of the notice must be            months immediately after their group health plan coverage ended.
such that the Plan Administrator is able to determine the covered
                                                                             If a Participant qualifies or may qualify for assistance under the
employee and qualified beneficiary or beneficiaries, the qualifying
                                                                             Trade Act of 1974, he or she should contact the Plan Administrator
event or disability, and the date on which the qualifying event
                                                                             for additional information. The Participant must contact the Plan
occurred.
                                                                             Administrator promptly after qualifying for assistance under the
None of the above notice requirements will be enforced if the                Trade Act of 1974 or the Participant will lose his or her special
Participant or other Qualified Beneficiary is not informed of his or         COBRA rights. COBRA coverage elected during the special second
her obligations to provide such notice.                                      election period is not retroactive to the date that Plan coverage was
                                                                             lost, but begins on the first day of the special second election period.
After providing notice to the Plan Administrator, the Qualified
Beneficiary shall receive the continuation coverage and election
notice. Continuation coverage must be elected by the later of 60 days        Terminating Events for Continuation
after the qualifying event occurs; or 60 days after the Qualified
Beneficiary receives notice of the continuation right from the Plan          Coverage under Federal Law (COBRA)
COBRA Administrator.                                                         Continuation under the Plan will end on the earliest of the following
                                                                             dates:
The Qualified Beneficiary's initial premium due to the Plan
Administrator must be paid on or before the 45th day after electing          A. Eighteen months from the date of the qualifying event, if the
continuation.                                                                   Qualified Beneficiary's coverage would have ended because the

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        71                                                (Section 8: When Coverage Ends)
    Participant's employment was terminated or hours were reduced                  or loss of eligibility by an Enrolled Dependent who is a child (i.e.
    (i.e., qualifying event A.).                                                   qualifying events C., D., or E.).
    If a Qualified Beneficiary is determined to have been disabled              C. With respect to Qualified Beneficiaries, and to the extent that
    under the Social Security Act at anytime within the first 60 days of           the Participant was entitled to Medicare prior to the qualifying
    continuation coverage for qualifying event A. then the Qualified               event:
    Beneficiary may elect an additional eleven months of                            ⎯ Eighteen months from the date of the Participant's
    continuation coverage (for a total of twenty-nine months of                       termination of employment or work hours being reduced; or
    continued coverage) subject to the following conditions:
                                                                                   ⎯ Thirty-six months from the date of the Participant's
    ⎯ Notice of such disability must be provided within the latest                     Medicare entitlement, if a second qualifying event (that was
      of 60 days after:                                                                due to either the Participant's termination of employment or
      ♦ the determination of the disability; or                                        the Participant's work hours being reduced) occurs prior to
      ♦ the date of the qualifying event; or                                           the expiration of the eighteen months.
      ♦ the date the Qualified Beneficiary would lose coverage                  D. With respect to Qualified Beneficiaries, and to the extent that the
          under the Plan; and                                                      Participant became entitled to Medicare subsequent to the
      ♦ in no event later than the end of the first eighteen                       qualifying event:
          months.                                                                  ⎯ Thirty-six months from the date of the Participant's
    ⎯ The Qualified Beneficiary must agree to pay any increase in                       termination from employment or work hours being reduced
      the required premium for the additional eleven months.                            (first qualifying event) if:
                                                                                        ♦ the Participant's Medicare entitlement occurs within the
   ⎯ If the Qualified Beneficiary who is entitled to the eleven
                                                                                             eighteen month continuation period; and
       months of coverage has non-disabled family members who
       are also Qualified Beneficiaries, then those non-disabled                        ♦ if, absent the first qualifying event, the Medicare
       Qualified Beneficiaries are also entitled to the additional                           entitlement would have resulted in a loss of coverage for
       eleven months of continuation coverage.                                               the Qualified Beneficiary under the group health plan.
   Notice of any final determination that the Qualified Beneficiary             E. The date coverage terminates under the Plan for failure to make
   is no longer disabled must be provided within 30 days of such                   timely payment of the premium.
   determination. Thereafter, continuation coverage may be                      F. The date, after electing continuation coverage, that coverage is
   terminated on the first day of the month that begins more than                  first obtained under any other group health plan. If such
   30 days after the date of that determination.                                   coverage contains a limitation or exclusion with respect to any
B. Thirty-six months from the date of the qualifying event for an                  pre-existing condition, continuation shall end on the date such
   Enrolled Dependent whose coverage ended because of the death                    limitation or exclusion ends. The other group health coverage
   of the Participant, divorce or legal separation of the Participant,             shall be primary for all health services except those health

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           72                                                (Section 8: When Coverage Ends)
   services that are subject to the pre-existing condition limitation
   or exclusion.
G. The date, after electing continuation coverage, that the Qualified
   Beneficiary first becomes entitled to Medicare, except that this
   shall not apply in the event that coverage was terminated
   because the Plan Sponsor filed for bankruptcy, (i.e. qualifying
   event G.). If the Qualified Beneficiary was entitled to
   continuation because the Plan Sponsor filed for bankruptcy, (i.e.
   qualifying event G.) and the retired Participant dies during the
   continuation period, then the other Qualified Beneficiaries shall
   be entitled to continue coverage for thirty-six months from the
   date of the Participant's death.
H. The date the entire Plan ends.
I. The date coverage would otherwise terminate under the Plan as
   described in this section under the heading Events Ending Your
   Coverage.




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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        73                                    (Section 8: When Coverage Ends)
                                                                             have any other relationship with Network providers such as
                   Section 9:                                                principal-agent or joint venture. Neither we nor the Claims
                                                                             Administrator are liable for any act or omission of any provider.

     General Legal Provisions                                                The Claims Administrator is not considered to be an employer of
                                                                             the Plan Administrator for any purpose with respect to the
                                                                             administration or provision of benefits under this Plan.
                                                                             We and the Plan Administrator are solely responsible for all of the
                  This section provides you with information about:          following:
                  • General legal provisions concerning your Plan.
                                                                             •   Enrollment and classification changes (including classification
                                                                                 changes resulting in your enrollment or the termination of your
Plan Document                                                                    coverage).
This Summary Plan Description presents an overview of your
Benefits. In the event of any discrepancy between this Summary               •   The timely payment of Benefits.
Plan Description and the official Plan Document, the Plan                    •   Notifying you of the termination or modifications to the Plan.
Document shall govern.
                                                                             Your Relationship with Providers
Relationship with Providers                                                  The relationship between you and any provider is that of provider
The relationships between us, the Claims Administrator, and                  and patient.
Network providers are solely contractual relationships between               •   You are responsible for choosing your own provider.
independent contractors. Network providers are not our agents or
employees. Nor are they agents or employees of the Claims                    •   You must decide if any provider treating you is right for you.
Administrator. Neither we nor any of our employees are agents or                 This includes Network providers you choose and providers to
employees of Network providers.                                                  whom you have been referred.
                                                                             •   You must decide with your provider what care you should
We do not provide health care services or supplies, nor do we                    receive.
practice medicine. Instead, we pay Benefits. Network providers are
independent practitioners who run their own offices and facilities.          •   Your provider is solely responsible for the quality of the services
The credentialing process confirms public information about the                  provided to you.
providers' licenses and other credentials, but does not assure the
quality of the services provided. Network providers are not our              The relationship between you and us is that of employer and
employees or employees of the Claims Administrator; nor do we                employee, Dependent or other classification as defined in the Plan.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        74                                             (Section 9: General Legal Provisions)
Incentives to Providers                                                      programs or certain disease management programs. The decision
                                                                             about whether or not to participate is yours alone but we
The Claims Administrator pays Network providers through various
                                                                             recommend that you discuss participating in such programs with
types of contractual arrangements, some of which may include
                                                                             your Physician. These incentives are not Benefits and do not alter or
financial incentives to promote the delivery of health care in a cost
                                                                             affect your Benefits. Contact the Claims Administrator if you have
efficient and effective manner. These financial incentives are not
                                                                             any questions.
intended to affect your access to health care.
Examples of financial incentives for Network providers are:                  Interpretation of Benefits
                                                                             We and the Claims Administrator have sole and exclusive discretion
•   Bonuses for performance based on factors that may include                to do all of the following:
    quality, member satisfaction, and/or cost effectiveness.
•   Capitation - a group of Network providers receives a monthly             •   Interpret Benefits under the Plan.
    payment for each Covered Person who selects a Network                    •   Interpret the other terms, conditions, limitations and exclusions
    provider within the group to perform or coordinate certain                   of the Plan, including this Summary Plan Description and any
    health services. The Network providers receive this monthly                  Riders and Amendments.
    payment regardless of whether the cost of providing or
    arranging to provide the Covered Person's health care is less            •   Make factual determinations related to the Plan and its Benefits.
    than or more than the payment.
                                                                             We and the Claims Administrator may delegate this discretionary
The methods used to pay specific Network providers may vary.                 authority to other persons or entities who provide services in regard
From time to time, the payment method may change. If you have                to the administration of the Plan.
questions about whether your Network provider's contract includes
                                                                             In certain circumstances, for purposes of overall cost savings or
any financial incentives, we encourage you to discuss those questions
                                                                             efficiency, we may, in our sole discretion, offer Benefits for services
with your provider. You may also contact the Claims Administrator
                                                                             that would otherwise not be Covered Health Services. The fact that
at the telephone number on your medical ID card. They can advise
                                                                             we do so in any particular case shall not in any way be deemed to
whether your Network provider is paid by any financial incentive,
                                                                             require us to do so in other similar cases.
including those listed above; however, the specific terms of the
contract, including rates of payment, are confidential and cannot be
disclosed.                                                                   Administrative Services
                                                                             We may, in our sole discretion, arrange for various persons or
Incentives to You                                                            entities to provide administrative services in regard to the Plan, such
                                                                             as claims processing. The identity of the service providers and the
Sometimes the Claims Administrator may offer coupons or other
                                                                             nature of the services they provide may be changed from time to
incentives to encourage you to participate in various wellness
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        75                                             (Section 9: General Legal Provisions)
time in our sole discretion. We are not required to give you prior             providing misinformation on eligibility or Benefit coverages or
notice of any such change, nor are we required to obtain your                  entitlements. It is your responsibility to confirm the accuracy of
approval. You must cooperate with those persons or entities in the             statements made by us or our designees, including the Claims
performance of their responsibilities.                                         Administrator, in accordance with the terms of this Summary Plan
                                                                               Description and other Plan documents.

Amendments to the Plan
We reserve the right, in our sole discretion and without your                  Information and Records
approval, to change, interpret, modify, withdraw or add Benefits or            At times we or the Claims Administrator may need additional
terminate the Plan. Plan Amendments and Riders are effective on                information from you. You agree to furnish us and/or the Claims
the date we specify.                                                           Administrator with all information and proofs that we may
                                                                               reasonably require regarding any matters pertaining to the Plan. If
Any provision of the Plan which, on its effective date, is in conflict         you do not provide this information when we request it we may
with the requirements of federal statutes or regulations, or applicable        delay or deny payment of your Benefits.
state law provisions (of the jurisdiction in which the Plan is
delivered) is hereby amended to conform to the minimum                         By accepting Benefits under the Plan, you authorize and direct any
requirements of such statutes and regulations.                                 person or institution that has provided services to you to furnish us
                                                                               or the Claims Administrator with all information or copies of
Any change or amendment to or termination of the Plan, its benefits            records relating to the services provided to you. We or the Claims
or its terms and conditions, in whole or in part, shall be made solely         Administrator have the right to request this information at any
in a written amendment (in the case of a change or amendment) or               reasonable time. This applies to all Covered Persons, including
in a written resolution (in the case of a termination), whether                Enrolled Dependents whether or not they have signed the
prospective or retroactive, to the Plan, in accordance with the                Participant's enrollment form. We and the Claims Administrator
procedures established by us. Covered Persons will receive notice of           agree that such information and records will be considered
any material modification to the Plan. No one has the authority to             confidential.
make any oral modification to the Summary Plan Description.
                                                                               We and the Claims Administrator have the right to release any and
Changes in Health Care Benefits will be effective for all Employees            all records concerning health care services which are necessary to
in Active Service (and inactive due to a disability) on the effective          implement and administer the terms of the Plan, for appropriate
date that the Plan is amended.                                                 medical review or quality assessment, or as we are required to do by
                                                                               law or regulation. During and after the term of the Plan, we, the
                                                                               Claims Administrator, and our related entities may use and transfer
Clerical Error                                                                 the information gathered under the Plan for research and analytic
If a clerical error or other mistake occurs, that error does not create        purposes.
a right to Benefits. These errors include, but are not limited to,
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          76                                             (Section 9: General Legal Provisions)
For complete listings of your medical records or billing statements          If you are eligible for or enrolled in Medicare, please
we recommend that you contact your health care provider. Providers           read the following information carefully.
may charge you reasonable fees to cover their costs for providing
records or completing requested forms.                                       If you are eligible for Medicare on a primary basis (Medicare pays
                                                                             before Benefits under the Plan), you should enroll for and maintain
If you request medical forms or records from us, we also may charge          coverage under both Medicare Part A and Part B. If you do not
you reasonable fees to cover costs for completing the forms or               enroll and maintain that coverage, and if we are the secondary payer
providing the records.                                                       as described in (Section 7: Coordination of Benefits), we will pay
In some cases, we or the Claims Administrator will designate other           Benefits under the Plan as if you were covered under both Medicare
persons or entities to request records or information from or related        Part A and Part B. As a result, you will be responsible for the costs
to you, and to release those records as necessary. Such designees            that Medicare would have paid and you will incur a larger out-of-
have the same rights to this information as the Plan Administrator.          pocket cost.
                                                                             If you are enrolled in a Medicare Advantage (Medicare Part C) plan
                                                                             on a primary basis (Medicare pays before Benefits under the Plan),
Examination of Covered Persons                                               you should follow all rules of that plan that require you to seek
In the event of a question or dispute regarding your right to                services from that plan's participating providers. When we are the
Benefits, we may require that a Network Physician of our choice              secondary payer, we will pay any Benefits available to you under the
examine you at our expense.                                                  Plan as if you had followed all rules of the Medicare Advantage plan.
                                                                             You will be responsible for any additional costs or reduced Benefits
                                                                             that result from your failure to follow these rules, and you will incur
Workers' Compensation not Affected                                           a larger out-of-pocket cost.
Benefits provided under the Plan do not substitute for and do not
affect any requirements for coverage by workers' compensation
insurance.                                                                   Subrogation and Reimbursement
                                                                             Subrogation is the substitution of one person or entity in the place
                                                                             of another with reference to a lawful claim, demand or right.
Medicare Eligibility                                                         Immediately upon paying or providing any Benefit, we shall be
Benefits under the Plan are not intended to supplement any                   subrogated to and shall succeed to all rights of recovery, under any
coverage provided by Medicare. Nevertheless, in some                         legal theory of any type, for the reasonable value of any services and
circumstances Covered Persons who are eligible for or enrolled in            Benefits we provided to you, from any or all of the following listed
Medicare may also be enrolled under the Plan.                                below.
                                                                             In addition to any subrogation rights and in consideration of the
                                                                             coverage provided by this Plan, we shall also have an independent
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        77                                          (Section 9: General Legal Provisions)
right to be reimbursed by you for the reasonable value of any                       ⎯ obtaining our consent or our agents' consent before releasing
services and Benefits we provide to you, from any or all of the                       any party from liability or payment of medical expenses.
following listed below:
                                                                                •   That failure to cooperate in this manner shall be deemed a
                                                                                    breach of contract, and may result in the termination of health
•   Third parties, including any person alleged to have caused you to
                                                                                    benefits or the instigation of legal action against you.
    suffer injuries or damages.
                                                                                •   That we have the sole authority and discretion to resolve all
•   Your employer.
                                                                                    disputes regarding the interpretation of the language stated
•   Any person or entity who is or may be obligated to provide                      herein.
    benefits or payments to you, including benefits or payments for
                                                                                •   That no court costs or attorneys' fees may be deducted from our
    underinsured or uninsured motorist protection, no-fault or
                                                                                    recovery without our express written consent; any so-called
    traditional auto insurance, medical payment coverage (auto,
                                                                                    "Fund Doctrine" or "Common Fund Doctrine" or "Attorney's
    homeowners or otherwise), workers' compensation coverage,
                                                                                    Fund Doctrine" shall not defeat this right, and we are not
    other insurance carriers or third party administrators.
                                                                                    required to participate in or pay court costs or attorneys' fees to
•   Any person or entity who is liable for payment to you on any                    the attorney hired by you to pursue your damage/personal injury
    equitable or legal liability theory.                                            claim.
These third parties and persons or entities are collectively referred to        •   That regardless of whether you have been fully compensated or
as "Third Parties".                                                                 made whole, we may collect from you the proceeds of any full or
                                                                                    partial recovery that you or your legal representative obtain,
You agree as follows:                                                               whether in the form of a settlement (either before or after any
                                                                                    determination of liability) or judgment, with such proceeds
•   That you will cooperate with us in protecting our legal and                     available for collection to include any and all amounts earmarked
    equitable rights to subrogation and reimbursement, including,                   as non-economic damage settlement or judgment.
    but not limited to:
                                                                                •   That benefits paid by us may also be considered to be benefits
    ⎯ providing any relevant information requested by us,                           advanced.
    ⎯ signing and/or delivering such documents as we or our                     •   That you agree that if you receive any payment from any
      agents reasonably request to secure the subrogation and                       potentially responsible party as a result of an Injury or illness,
      reimbursement claim,                                                          whether by settlement (either before or after any determination
    ⎯ responding to requests for information about any accidents                    of liability), or judgment, you will serve as a constructive trustee
      or injuries,                                                                  over the funds, and failure to hold such funds in trust will be
                                                                                    deemed as a breach of your duties hereunder.
    ⎯ making court appearances, and


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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           78                                             (Section 9: General Legal Provisions)
•   That you or an authorized agent, such as your attorney, must              •   All or some of the expenses were not paid by the Covered
    hold any funds due and owing us, as stated herein, separately and             Person or did not legally have to be paid by the Covered Person.
    alone, and failure to hold funds as such will be deemed as a              •   All or some of the payment we made exceeded the Benefits
    breach of contract, and may result in the termination of health               under the Plan.
    benefits or the instigation of legal action against you.
•   That we may set off from any future benefits otherwise provided           The refund equals the amount we paid in excess of the amount we
    by us the value of benefits paid or advanced under this section           should have paid under the Plan. If the refund is due from another
    to the extent not recovered by us.                                        person or organization, the Covered Person agrees to help us get the
                                                                              refund when requested.
•   That you will not accept any settlement that does not fully
    compensate or reimburse us without our written approval, nor              If the Covered Person, or any other person or organization that was
    will you do anything to prejudice our rights under this provision.        paid, does not promptly refund the full amount, we may reduce the
•   That you will assign to us all rights of recovery against Third           amount of any future Benefits that are payable under the Plan. The
    Parties, to the extent of the reasonable value of services and            reductions will equal the amount of the required refund. We may
    Benefits we provided, plus reasonable costs of collection.                have other rights in addition to the right to reduce future benefits.
•   That our rights will be considered as the first priority claim
    against Third Parties, including tortfeasors for whom you are             Limitation of Action
    seeking recovery, to be paid before any other of your claims are          If you want to bring a legal action against us or the Claims
    paid.                                                                     Administrator you must do so within three years from the expiration
•   That we may, at our option, take necessary and appropriate                of the time period in which a request for reimbursement must be
    action to preserve our rights under these subrogation provisions,         submitted or you lose any rights to bring such an action against us or
    including filing suit in your name, which does not obligate us in         the Claims Administrator.
    any way to pay you part of any recovery we might obtain.
                                                                              You cannot bring any legal action against us or the Claims
•   That we shall not be obligated in any way to pursue this right            Administrator for any other reason unless you first complete all the
    independently or on your behalf.                                          steps in the appeal process described in this document. After
                                                                              completing that process, if you want to bring a legal action against us
Refund of Overpayments                                                        or the Claims Administrator you must do so within three years of
If we pay Benefits for expenses incurred on account of a Covered              the date you are notified of our final decision on your appeal, or you
Person, that Covered Person, or any other person or organization              lose any rights to bring such an action against us or the Claims
that was paid, must make a refund to us if either of the following            Administrator.
apply:


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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         79                                             (Section 9: General Legal Provisions)
                                                                              Annual Deductible - the amount you must pay for Covered Health
                               Section 10:                                    Services in a calendar year before we will begin paying for Benefits
                                                                              in that calendar year unless otherwise specified in the Benefit

                      Glossary of Defined                                     Summary.
                                                                              Benefits - your right to payment for Covered Health Services that
                                   Terms                                      are available under the Plan. Your right to Benefits is subject to the
                                                                              terms, conditions, limitations and exclusions of the Plan, including
                                                                              this Summary Plan Description and any attached Riders and
                                                                              Amendments.
                  This section:                                               Claims Administrator - the company (including its affiliates) that
                  • Defines the terms used throughout this Summary            provides certain claim administration services for the Plan.
                     Plan Description.
                                                                              Congenital Anomaly - a physical developmental defect that is
                  •   Is not intended to describe Benefits.                   present at birth, and is identified within the first twelve months of
                                                                              birth.
Alternate Facility - a health care facility that is not a Hospital and
that provides one or more of the following services on an outpatient          Continuous Creditable Coverage - health care coverage under any
basis, as permitted by law:                                                   of the types of plans listed below, during which there was no break
                                                                              in coverage of 63 consecutive days or more:
•   Surgical services.
                                                                              •   A group health plan.
•   Emergency Health Services.
                                                                              •   Health insurance coverage.
•   Rehabilitative, laboratory, diagnostic or therapeutic services.
                                                                              •   Medicare.
An Alternate Facility may also provide Mental Health Services or              •   Medicaid.
Substance Abuse Services on an outpatient or inpatient basis.
                                                                              •   Medical and dental care for members and certain former
                                                                                  members of the uniformed services, and for their dependents.
Amendment - any attached written description of additional or
alternative provisions to the Plan. Amendments are effective only             •   A medical care program of the Indian Health Services Program
when signed by us or the Plan Administrator. Amendments are                       or a tribal organization.
subject to all conditions, limitations and exclusions of the Plan,            •   A state health benefits risk pool.
except for those that are specifically amended.                               •   The Federal Employees Health Benefits Program.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                         80                                          (Section 10: Glossary of Defined Terms)
•   Any public health benefit program provided by a state, county,           Custodial Care - services that:
    or other political subdivision of a state.
                                                                             •   Are non-health related services, such as assistance in activities of
•   The State Children's Health Insurance Program (S-CHIP).
                                                                                 daily living (including but not limited to feeding, dressing,
•   Health plans established and maintained by foreign governments               bathing, transferring and ambulating); or
    or political subdivisions and by the U.S. government.
                                                                             •   Are health-related services which do not seek to cure, or which
•   Any health coverage provided by a governmental entity.                       are provided during periods when the medical condition of the
•   A health benefit plan under the Peace Corps Act.                             patient who requires the service is not changing; or
                                                                             •   Do not require continued administration by trained medical
A waiting period for health care coverage will be included in the
                                                                                 personnel in order to be delivered safely and effectively.
period of time counted as Continuous Creditable Coverage.
                                                                             Dependent - the Participant's legal spouse or an unmarried
Copayment - the charge you are required to pay for certain Covered
                                                                             dependent child of the Participant or the Participant's spouse. The
Health Services. A Copayment may be either a set dollar amount or
                                                                             term child includes any of the following:
a percentage of Eligible Expenses.
Cosmetic Procedures - procedures or services that change or                  •   A natural child.
improve appearance without significantly improving physiological             •   A stepchild.
function, as determined by the Claims Administrator on our behalf.
                                                                             •   A child for whom legal guardianship has been awarded to the
Covered Health Service(s) -those health services provided for the                Participant or the Participant's spouse.
purpose of preventing, diagnosing or treating a Sickness, Injury,            •   Grandchildren covered by Income Tax.
Mental Illness, substance abuse, or their symptoms.
                                                                             The definition of Dependent is subject to the following condition
A Covered Health Service is a health care service or supply                  and limitation:
described in (Section 1: What's Covered--Benefits) as a Covered
Health Service, which is not excluded under (Section 2: What's Not           •   A Dependent includes any unmarried dependent child under 25
Covered--Exclusions).                                                            years of age.
Covered Person - either the Participant or an Enrolled Dependent,            The Participant must reimburse us for any Benefits that we pay for a
but this term applies only while the person is enrolled under the            child at a time when the child did not satisfy these conditions.
Plan. References to "you" and "your" throughout this Summary Plan
Description are references to a Covered Person.                              A Dependent also includes a child for whom health care coverage is
                                                                             required through a 'Qualified Medical Child Support Order' or other
                                                                             court or administrative order. We are responsible for determining if

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        81                                          (Section 10: Glossary of Defined Terms)
an order meets the criteria of a Qualified Medical Child Support             •   When Covered Health Services are received from Non-Network
Order.                                                                           providers as a result of an Emergency or as otherwise arranged
                                                                                 through the Claims Administrator, Eligible Expenses are billed
A Dependent does not include anyone who is also enrolled as a
                                                                                 charges unless a lower amount is negotiated.
Participant. No one can be a Dependent of more than one
Participant.                                                                 For Non-Network Benefits, Eligible Expenses are based on either of
                                                                             the following:
Designated Facility - a facility that has entered into an agreement
on behalf of the facility and its affiliated staff with the Claims
                                                                             •   When Covered Health Services are received from Non-Network
Administrator or with an organization contracting on its behalf to
                                                                                 providers, Eligible Expenses are determined, at the Claims
render Covered Health Services for the treatment of specified
                                                                                 Administrator's discretion, based on:
diseases or conditions. A Designated Facility may or may not be
located within your geographic area.                                             ⎯ Available data resources of competitive fees in that
                                                                                   geographic area.
Durable Medical Equipment - medical equipment that is all of the
                                                                                 ⎯ Fee(s) that are negotiated with the provider.
following:
                                                                                 ⎯ 50% of the billed charge.
•   Can withstand repeated use.                                                  ⎯ A fee schedule that the Claims Administrator develops.
•   Is not disposable.                                                       •   When Covered Health Services are received from Network
•   Is used to serve a medical purpose with respect to treatment of a            providers, Eligible Expenses are the contracted fee(s) with that
    Sickness, Injury or their symptoms.                                          provider.
•   Is not useful to a person in the absence of a Sickness, Injury or        Eligible Expenses are determined solely in accordance with the
    their symptoms.                                                          Claims Administrator's reimbursement policy guidelines. The
•   Is appropriate for use in the home.                                      reimbursement policy guidelines are developed, in the Claims
                                                                             Administrator's discretion, following evaluation and validation of all
Eligible Expenses - for Covered Health Services incurred while the           provider billings in accordance with one or more of the following
Plan is in effect, Eligible Expenses are determined as stated below:         methodologies:
For Network Benefits, Eligible Expenses are based on either of the
                                                                             •   As indicated in the most recent edition of the Current
following:
                                                                                 Procedural Terminology (CPT), a publication of the American
                                                                                 Medical Association, and/or the Centers for Medicare and
•   When Covered Health Services are received from Network
                                                                                 Medicaid Services (CMS).
    providers, Eligible Expenses are the contracted fee(s) with that
    provider.                                                                •   As reported by recognized professionals or publications.

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        82                                          (Section 10: Glossary of Defined Terms)
•   As used for Medicare.                                                      •   Subject to review and approval by any institutional review board
•   As determined by medical staff and outside medical consultants                 for the proposed use.
    pursuant to other appropriate source or determination that the             •   The subject of an ongoing clinical trial that meets the definition
    Claims Administrator accepts.                                                  of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations,
                                                                                   regardless of whether the trial is actually subject to FDA
Eligible Person – an active employee of the Plan Sponsor who is                    oversight.
contributing to the Teachers Retirement System (TRS).
                                                                               If you have a life-threatening Sickness or condition (one which is
Emergency - a serious medical condition or symptom resulting                   likely to cause death within one year of the request for treatment) we
from Injury, Sickness or Mental Illness which is both of the                   may, in our discretion, determine that an Experimental or
following:                                                                     Investigational Service meets the definition of a Covered Health
                                                                               Service for that Sickness or condition. For this to take place, we
•   Arises suddenly.                                                           must determine that the procedure or treatment is promising, but
•   In the judgment of a reasonable person, requires immediate care            unproven, and that the service uses a specific research protocol that
    and treatment, received within 24 hours of onset, to avoid                 meets standards equivalent to those defined by the National
    jeopardy to life or health.                                                Institutes of Health.
Emergency Health Services - health care services and supplies                  Family Status Change - is a material change in family member(s)
necessary for the treatment of an Emergency.                                   status under which one has no control that affects eligibility for
                                                                               medical benefits as defined in CFR 1.125. The Federal government
Enrolled Dependent - a Dependent who is properly enrolled under                uses examples of qualifying events such as: marriage, divorce,
the Plan.                                                                      employee gains an eligible Dependent (i.e.birth, death, loss/gain of
Experimental or Investigational Services - medical, surgical,                  employment, employment status change from full-time to part-time
diagnostic, psychiatric, substance abuse or other health care services,        or employment status change from part-time to full-time, unpaid
technologies, supplies, treatments, procedures, drug therapies or              leave of absence, and a significant change in the cost or coverage of
devices that, at the time we make a determination regarding coverage           your spouse's health plan (significant change means the cost of the
in a particular case, are determined to be any of the following:               employee and/or spouse's health coverage increases or decreases by
                                                                               at least 25%).
•   Not approved by the U.S. Food and Drug Administration                      Home Health Agency - a program or organization authorized by
    (FDA) to be lawfully marketed for the proposed use and not                 law to provide health care services in the home.
    identified in the American Hospital Formulary Service or the
    United States Pharmacopoeia Dispensing Information as                      Hospital - an institution, operated as required by law, that is both of
    appropriate for the proposed use.                                          the following:

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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          83                                          (Section 10: Glossary of Defined Terms)
•   Is primarily engaged in providing health services, on an inpatient         •   Within 30 days of the date a new Eligible Person first becomes
    basis, for the acute care and treatment of injured or sick                     eligible.
    individuals. Care is provided through medical, diagnostic and              Lifetime Maximum Benefit - the maximum amount that we will
    surgical facilities, by or under the supervision of a staff of             pay for Benefits during the entire period of time that you are
    Physicians.                                                                enrolled under the Plan. When the Lifetime Maximum Benefit
•   Has 24 hour nursing services.                                              applies, it is described in (Section 1: What's Covered--Benefits).

A Hospital is not primarily a place for rest, custodial care or care of        Medicare - Parts A, B, C and D of the insurance program
the aged and is not a nursing home, convalescent home or similar               established by Title XVIII, United States Social Security Act, as
institution.                                                                   amended by 42 U.S.C. Sections 1394, et seq. and as later amended.

Initial Enrollment Period - the initial period of time, as                     Mental Health Services - Covered Health Services for the
determined by the Plan Administrator, during which Eligible                    diagnosis and treatment of Mental Illnesses. The fact that a
Persons may enroll themselves and their Dependents under the Plan.             condition is listed in the current Diagnostic and Statistical Manual of
                                                                               the American Psychiatric Association does not mean that treatment
Injury - bodily damage other than Sickness, including all related              for the condition is a Covered Health Service.
conditions and recurrent symptoms.
                                                                               Mental Health/Substance Abuse Designee - the organization or
Inpatient Rehabilitation Facility - a Hospital (or a special unit of           individual, designated by the Claims Administrator, that provides or
a Hospital that is designated as an Inpatient Rehabilitation Facility)         arranges Mental Health Services and Substance Abuse Services for
that provides rehabilitation health services (physical therapy,                which Benefits are available under the Plan.
occupational therapy and/or speech therapy) on an inpatient basis,
as authorized by law.                                                          Mental Illness - those mental health or psychiatric diagnostic
                                                                               categories that are listed in the current Diagnostic and Statistical
Inpatient Stay - an uninterrupted confinement, following formal                Manual of the American Psychiatric Association, unless those
admission to a Hospital, Skilled Nursing Facility or Inpatient                 services are specifically excluded under the Plan.
Rehabilitation Facility.
                                                                               Network - when used to describe a provider of health care services,
Late Enrollee - an Eligible Person or Dependent who enrolls for                this means a provider that has a participation agreement in effect
coverage under the Plan at a time other than the following:                    (either directly or indirectly) with the Claims Administrator or with
                                                                               their affiliate to participate in the Claims Administrator's Network;
•   During the Initial Enrollment Period.                                      however, this does not include those providers who have agreed to
•   During an Open Enrollment Period.                                          discount their charges for Covered Health Services by way of their
                                                                               participation in the Shared Savings Program. The Claims
•   During a special enrollment period as described in Section 4.              Administrator's affiliates are those entities affiliated with them
                                                                               through common ownership or control with the Claims
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          84                                        (Section 10: Glossary of Defined Terms)
Administrator or with its ultimate corporate parent, including direct        Copayments for some Covered Health Services will never apply to
and indirect subsidiaries.                                                   the Out-of-Pocket Maximum, as specified in (Section 1: What's
                                                                             Covered--Benefits) and those Benefits will never be payable at 100%
A provider may enter into an agreement to provide only certain               even when the Out-of-Pocket Maximum is reached.
Covered Health Services, but not all Covered Health Services, or to
be a Network provider for only some of the Claims Administrator's            The following costs will never apply to the Out-of-Pocket
products. In this case, the provider will be a Network provider for          Maximum:
the Covered Health Services and products included in the
participation agreement, and a Non-Network provider for other                •   Any charges for non-Covered Health Services;
Covered Health Services and products. The participation status of            •   Copayments for Covered Health Services available by an
providers will change from time to time.                                         optional Rider.
Network Benefits - Benefits for Covered Health Services that are             •   The amount of any reduced Benefits if you do not notify the
provided by (or directed by) a Network Physician or other Network                Claims Administrator as described in (Section 1: What's
provider in the provider's office or at a Network or Non-Network                 Covered--Benefits) under the Must You Notify the Claims
facility.                                                                        Administrator? column.
Non-Network Benefits - Benefits for Covered Health Services that             •   Charges that exceed Eligible Expenses.
are provided by or directed by a Non-Network Physician either at a           •   Any Copayments for Covered Health Services in (Section 1:
Network facility or at a Non-Network facility.                                   What's Covered--Benefits) that do not apply to the Out-of-
                                                                                 Pocket Maximum.
Open Enrollment Period - a period of time that follows the Initial
Enrollment Period during which Eligible Persons may enroll                   •   The Annual Deductible.
themselves and Dependents under the Plan, as determined by us.               Even when the Out-of-Pocket Maximum has been reached, you will
Out-of-Pocket Maximum - the maximum amount of Copayments                     still be required to pay:
you pay every calendar year. If you use both Network Benefits and
Non-Network Benefits, two separate Out-of-Pocket Maximums                    •   Any charges for non-Covered Health Services.
apply. Once you reach the Out-of-Pocket Maximum for Network                  •   Charges that exceed Eligible Expenses.
Benefits, Benefits for those Covered Health Services that apply to
                                                                             •   The amount of any reduced Benefits if you do not notify the
the Out-of-Pocket Maximum are payable at 100% of Eligible
                                                                                 Claims Administrator as described in (Section 1: What's
Expenses during the rest of that calendar year. Once you reach Out-
                                                                                 Covered--Benefits) under the Must You Notify the Claims
of-Pocket Maximum for Non-Network Benefits, Benefits for those
                                                                                 Administrator? column.
Covered Health Services that apply to the Out-of-Pocket Maximum
are payable at 100% of Eligible Expenses during the rest of that             •   Copayments for Covered Health Services available by an
calendar year.                                                                   optional Rider.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        85                                          (Section 10: Glossary of Defined Terms)
•   Copayments for Covered Health Services in (Section 1: What's                there is not a diagnosis of a condition related to the genetic
    Covered--Benefits) that are subject to Copayments that do not               information.
    apply to the Out-of-Pocket Maximum.
                                                                                Pregnancy - includes all of the following:
Participant - an Eligible Person who is properly enrolled under the
Plan. The Participant is the person (who is not a Dependent) on                 •   Prenatal care.
whose behalf the Plan is established.                                           •   Postnatal care.
                                                                                •   Childbirth.
Physician - any Doctor of Medicine, "M.D.", or Doctor of
Osteopathy, "D.O.", who is properly licensed and qualified by law.              •   Any complications associated with Pregnancy.

Please Note: Any podiatrist, dentist, psychologist, chiropractor,               Rider - any attached written description of additional Covered
optometrist, or other provider who acts within the scope of his or              Health Services not described in this Summary Plan Description.
her license will be considered on the same basis as a Physician. The            Riders are effective only when signed by us and are subject to all
fact that we describe a provider as a Physician does not mean that              conditions, limitations and exclusions of the Plan except for those
Benefits for services from that provider are available to you under             that are specifically amended in the Rider.
the Plan.
                                                                                Semi-private Room - a room with two or more beds. When an
Plan – Choice Plus Plan for Fort Bend Independent School                        Inpatient Stay in a Semi-private Room is a Covered Health Service,
District.                                                                       the difference in cost between a Semi-private Room and a private
                                                                                room is a Benefit only when a private room is necessary in terms of
Plan Administrator - is Fort Bend Independent School District.                  accepted medical practice, or when a Semi-private Room is not
Plan Sponsor - Fort Bend Independent School District. References                available.
to "we", "us", and "our" throughout the Summary Plan Description                Shared Savings Program - the Shared Savings Program provides
refer to the Plan Sponsor.                                                      access to discounts from the provider's charges when services are
Preexisting Condition - an Injury or Sickness that is identified by             rendered by those Non-Network providers that participate in that
the Plan Administrator as having been diagnosed or treated, or for              program. The Claims Administrator will use the Shared Savings
which prescription medications or drugs were prescribed or taken                Program to pay claims when doing so will lower Eligible Expenses.
within the three month period ending on the person's enrollment                 The Claims Administrator does not credential the Shared Savings
date. (The enrollment date is the date the person became covered                Program providers and the Shared Savings Program providers are
under the Plan or, if earlier, the first day of any waiting period under        not Network providers. Accordingly, Benefits for Covered Health
the Plan.) A Preexisting Condition does not include Pregnancy.                  Services provided by Shared Savings Program providers will be paid
Genetic information is not an indicator of a Preexisting Condition, if          at the Non-Network Benefit level (except in situations when
                                                                                Benefits for Covered Health Services provided by Non-Network
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                           86                                          (Section 10: Glossary of Defined Terms)
providers are payable at Network Benefit levels, as in the case of             •   Well-conducted randomized controlled trials. (Two or more
Emergency Health Services). When the Claims Administrator uses                     treatments are compared to each other, and the patient is not
the Shared Savings Program to pay a claim, patient responsibility is               allowed to choose which treatment is received.)
limited to Copayments calculated on the contracted rate paid to the
                                                                               •   Well-conducted cohort studies. (Patients who receive study
provider, in addition to any required Annual Deductible.
                                                                                   treatment are compared to a group of patients who receive
Sickness - physical illness, disease or Pregnancy. The term Sickness               standard therapy. The comparison group must be nearly identical
as used in this Summary Plan Description does not include Mental                   to the study treatment group.)
Illness or substance abuse, regardless of the cause or origin of the
                                                                               Decisions about whether to cover new technologies, procedures and
Mental Illness or substance abuse.
                                                                               treatments will be consistent with conclusions of prevailing medical
Skilled Nursing Facility - a Hospital or nursing facility that is              research, based on well-conducted randomized trials or cohort
licensed and operated as required by law.                                      studies, as described.

Spinal Treatment - detection or correction (by manual or                       If you have a life-threatening Sickness or condition (one that is likely
mechanical means) of subluxation(s) in the body to remove nerve                to cause death within one year of the request for treatment) we and
interference or its effects. The interference must be the result of, or        the Claims Administrator may, in our discretion, determine that an
related to, distortion, misalignment or subluxation of, or in, the             Unproven Service meets the definition of a Covered Health Service
vertebral column.                                                              for that Sickness or condition. For this to take place, we and the
                                                                               Claims Administrator must determine that the procedure or
Substance Abuse Services - Covered Health Services for the                     treatment is promising, but unproven, and that the service uses a
diagnosis and treatment of alcoholism and substance abuse disorders            specific research protocol that meets standards equivalent to those
that are listed in the current Diagnostic and Statistical Manual of the        defined by the National Institutes of Health.
American Psychiatric Association, unless those services are
specifically excluded. The fact that a disorder is listed in the               Urgent Care Center - a facility, other than a Hospital, that provides
Diagnostic and Statistical Manual of the American Psychiatric                  Covered Health Services that are required to prevent serious
Association does not mean that treatment of the disorder is a                  deterioration of your health, and that are required as a result of an
Covered Health Service.                                                        unforeseen Sickness, Injury, or the onset of acute or severe
                                                                               symptoms.
Unproven Services - services that are not consistent with
conclusions of prevailing medical research which demonstrate that
the health service has a beneficial effect on health outcomes and that
are not based on trials that meet either of the following designs.



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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                          87                                          (Section 10: Glossary of Defined Terms)
                                           Riders, Amendments, Notices


Attachment I

Notice of Amendment of the Fort Bend ISD
Summary Plan Description For Fort Bend
Independent School District
                                                                            are required for any other Covered Health Service. Limitations on
                                              Attachment                    Benefits are the same as for any other Covered Health Service.


                                                       I                    Statement of Rights under the
                                                                            Newborns' and Mothers' Health
                                                                            Protection Act
                                                                            Group health plans and health insurance issuers may not, under
Women's Health and Cancer Rights Act                                        federal law, restrict Benefits for any Hospital length of stay in
                                                                            connection with childbirth for the mother or newborn child to less
of 1998                                                                     than 48 hours following a vaginal delivery, or less than 96 hours
As required by the Women's Health and Cancer Rights Act of 1998,            following a cesarean section. However, federal law does not prohibit
we provide Benefits under the Plan for mastectomy, including                the mother's or newborn's attending provider, after consulting with
reconstruction and surgery to achieve symmetry between the breasts,         the mother, from discharging the mother or her newborn earlier
prostheses, and complications resulting from a mastectomy                   than 48 hours (or 96 hours as applicable). In any case, plans and
(including lymphedema).                                                     issuers may not, under federal law, require that a provider obtain
If you are receiving Benefits in connection with a mastectomy,              authorization from the Plan or the insurance issuer for prescribing a
Benefits are also provided for the following Covered Health                 length of stay not in excess of 48 hours (or 96 hours).
Services, as you determine appropriate with your attending
Physician:

•   All stages of reconstruction of the breast on which the
    mastectomy was performed;
•   Surgery and reconstruction of the other breast to produce a
    symmetrical appearance; and
•   Prostheses and treatment of physical complications of the
    mastectomy, including lymphedema.
The amount you must pay for such Covered Health Services
(including Copayments and any Annual Deductible) are the same as


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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                        I
(Attachment I)
                                                                                      Information (PHI) is individually identifiable health information
                 Notice of                                                            related to your condition, services provided to you, or payments
                                                                                      made for your care, which is created or received by a health plan, a

   Amendment of the Fort                                                              health care clearinghouse, or a health care provider that
                                                                                      electronically transmits such information. Electronic Protected
                                                                                      Health Information (ePHI) is PHI that is maintained or transmitted
  Bend ISD Summary Plan                                                               in electronic form. The Plan and Fort Bend Independent School
                                                                                      District will reasonably and appropriately safeguard ePHI created,
 Description For Fort Bend                                                            received, maintained, or transmitted to or by Fort Bend Independent
                                                                                      School District on behalf of the Plan.

       Independent School                                                             The Plan and Fort Bend Independent School District are separate
                                                                                      and independent legal entities, which exchange information to
                   District                                                           coordinate your Plan coverage. In order to receive ePHI from the
                                                                                      Plan, Fort Bend Independent School District agrees that it will:

                                                                                      •   Implement administrative, physical, and technical safeguards that
(Attach this Notice to your Summary Plan Description)                                     reasonably and appropriately protect the confidentiality,
                                                                                          integrity, and availability of the ePHI that Fort Bend
For: All Employees participating in TRS                                                   Independent School District creates, receives, maintains, or
                                                                                          transmits on behalf of the Plan;
Your Summary Plan Description is amended on April 20, 2005.
                                                                                      •   Ensure that access to, and use and disclosure of ePHI by the
                                                                                          employees or classes of employees described in this Plan
     Fort Bend ISD Summary Plan Description, (SPD) Plan                                   Document is supported by reasonable and appropriate security
                       Document                                                           measures;

      Security of Electronic Protected Health Information                             •   Ensure that any agent, including a subcontractor, to whom Fort
                                                                                          Bend Independent School District provides this information
Under the federal security regulations enacted pursuant to the                            agrees to implement reasonable and appropriate security
Health Insurance Portability and Accountability Act of 1996                               measures to protect the information; and
(HIPAA), your health plans are required to safeguard the
confidentiality and ensure the integrity and availability of your                     •   Report to the Plan any security incident of which Fort Bend
Electronic Protected Health Information (ePHI). Protected Health                          Independent School District becomes aware.
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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                              II
(Notice of Amendment of the Fort Bend ISD Summary Plan Description For Fort Bend Independent School District)
Only employees designated by the Director of Risk Management
under the control of Fort Bend Independent School District may
have access to ePHI. Such employees may only have access to, and
use and disclose, ePHI for purposes of the plan administrative
functions described in this Plan Document Fort Bend Independent
School District performs for the Plan.

If you believe your rights under HIPAA have been violated, you
have the right to file a complaint with the Plan or with the Secretary
of the U.S. Department of Health and Human Services. Fort Bend
Independent School District has provided a mechanism for
resolving issues of noncompliance by employees described above
who have access to ePHI.

Employees may find additional information on their rights
under HIPPA and PHI by visiting
www.fortbend.k12.tx.us/departments/benefits or by contacting the
Benefits’ Office at 281-634-1418.

All other terms, provisions and conditions shown in your Summary
Plan Description will continue to apply.




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Choice Plus Plan for Fort Bend Independent School District - 01/01/09
                                                                             III
(Notice of Amendment of the Fort Bend ISD Summary Plan Description For Fort Bend Independent School District)
666362 - 12/02/2008

								
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