Dear COHO Plan Member:
As part of our continuing effort to enhance and improve our employee benefits, COHO
Benefits of CTSI provides the group healthcare benefits described in this Plan
Description. The Plan includes Medical/Vision/Pharmacy and Dental coverage. It also
provides information regarding eligibility, coverage exclusions, termination of coverage,
claims procedures, COBRA options and other pertinent Plan information.
COHO Benefits of CTSI is self-funded, which means we provide our own coverage rather
than purchasing coverage from an insurance company. This also means that the success
of our Plan is dependent on wise utilization of health care services by our members. We
are confident that our employee group can work with us to enable all members to enjoy
the security provided by this comprehensive healthcare plan.
Please familiarize yourself with the provisions of the Plan so that you may make informed,
educated decisions regarding your healthcare.
In an effort to secure cost-effective, quality care for our members, we have contracted
with healthcare providers on the Samaritan Health Services Provider Network. Most
benefits for services rendered by these doctors and hospitals are payable at 80%. Services
from providers not in the Samaritan Health Services Provider Network are payable at
40%. Therefore, using the network doctors and hospitals will save you money as well as
provide the Plan with much-needed discounts.
If you need assistance locating a doctor or have questions as to whether your physician is
in the network, please call Samaritan Health Services at 800.832.4580 or your employers
Thank you for partnering with COHO Benefits Plan Administration in working toward
our common goal: Continuation of comprehensive healthcare benefits through a fiscally
sound Plan. Please do not hesitate to contact the COHO Benefits of the CTSI Plan
Administration staff at 996-5882 if you have any questions or require additional
The group's benefits described herein are in effect as of January 1st, 2010.
The deductible, co-pay, out-of-pocket amounts and pharmacy benefits are effective as of
January 1st of each calendar year.
COHO BENEFITS OF THE CTSI PLAN ADMINISTRATION
TABLE OF CONTENTS
General Plan Information ........................................................................................................... 2
Utilization Management Program ............................................................................................... 4
Definitions .................................................................................................................................. 6
Deductibles, Copays and Out of Pocket Maximums ................................................................. 10
Group Schedule of Benefits ..................................................................................................... 13
Special Restrictions for Pre-Existing Conditions ....................................................................... 22
Medical Services Exclusions .................................................................................................... 23
General Healthcare Coverage Exclusions ................................................................................ 26
Prescription Drug Program ....................................................................................................... 28
Eligibility and Effective Dates ................................................................................................... 30
Coordination of Benefits ........................................................................................................... 35
Third Party Recovery................................................................................................................ 41
Termination of Coverage .......................................................................................................... 43
Extension of Coverage ............................................................................................................. 44
Extension of Benefits ............................................................................................................... 45
Continuation of Coverage Option (COBRA) ............................................................................. 46
Claims Procedures ................................................................................................................... 49
Statement of Rights of Employees ........................................................................................... 50
Funding Sources and Uses ...................................................................................................... 51
Administrative Provisions ......................................................................................................... 52
COHO PLAN DOCUMENT JAN 2010 1
GENERAL PLAN INFORMATION
Name of Plan: COHO Benefits of CTSI
Plan Sponsor: Confederated Tribes of Siletz Indians
Address: c/o Chinook Winds Casino Resort
1777 NW 44th
Lincoln City, Oregon 97367
Business Phone Number: (541) 996-5882
Participating Employer(s): Confederated Tribes of Siletz Indians
Chinook Winds Casino Resort
Chinook Winds Casino Resort – Hotel
Chinook Winds Golf Resort
Siletz Tribal Gaming Commission
Siletz Tribal Business Corporation
Plan Sponsor ID Number (EIN): 93-0714057
Plan/Group Number: 501
Plan Year: January 1 through December 31
Plan Benefits: Medical coverage
Fiduciaries (Titles): Confederated Tribes of Siletz Indians
Address: c/o Chinook Winds Casino Resort
1777 NW 44th
Lincoln City, Oregon 97367
(Legal process may be served upon the Plan Sponsor
or a Fiduciary)
Designated Legal Agent: Confederated Tribes of Siletz Indians
Address: P.O. Box 549
Siletz, OR 97380
Claims Processing Unit: Samaritan Health Services
Address: P. O. Box 1310
Corvallis, OR 97339
COHO PLAN DOCUMENT JAN 2010 2
How COHO Plan Members Can Control the Cost of Quality Health Care
As a consumer of Healthcare services, your choices and decisions directly affect the quality and
quantity of healthcare benefits. In recent years the cost of medical and pharmaceutical services has
increased drastically. However, quality health care is still available at a reasonable cost to employees
and their dependents.
The following are suggestions provided to help you reduce your out-of-pocket expenses:
Healthy Living Practices
Take good care of yourself to reduce current and future medical expenses. Good diet, exercise, healthy
living choices, preventive care and self-education all contribute to a healthy lifestyle. We all expect and
are entitled to quality healthcare. With medical costs increasing each year, all Plan members must
make a determined effort to secure quality care at the most reasonable cost.
Using Network providers will reduce your out-of-pocket cost for all medical services.
Second Surgical Opinions
Consider obtaining a second opinion prior to surgery to confirm the diagnosis and discuss alternatives to
having surgery. Second surgical opinions are covered at 80% with no deductible.
Whenever possible, use outpatient facilities for approved elective surgeries and pre-admission x-ray and
Weekend Hospital Admissions
Except in emergency situations, try to avoid being admitted to the hospital on Friday or Saturday.
Home Health Care
Question your doctor about the appropriateness of home health care post-outpatient surgery. It is
generally less expensive than a hospital stay.
Asking your physician to prescribe generic and/or formulary brand name (rather than non formulary
brand-name) drugs can reduce drug costs. In addition, obtaining 90 days supplies of maintenance
medications will reduce your cost of medication, thus extending the life of your annual pharmacy benefit.
Review Your Bills
Review your medical bills carefully and compare them to your Explanation of Benefits (EOB). Obtain
itemized billings. Discuss cost efficiency with your physician.
Make certain that you advise the Plan Administrator of all health care coverage you carry. If necessary,
the administrator will assist you in filing claims.
Your everyday healthcare choices are essential in helping to maintain a quality group healthcare
Plan. The Plan is dedicated to continuing to provide comprehensive insurance coverage to our
COHO PLAN DOCUMENT JAN 2010 3
UTILIZATION MANAGEMENT PROGRAM
Benefits provided by the Plan under the Medical Schedule of Benefits are subject to compliance with
the requirements of the Utilization Management Program as described below and in any packet of
information distributed by the Utilization Management Organization. These requirements are designed
to encourage Covered Persons to obtain quality medical care while utilizing the most cost-efficient
Prior Authorization List
Prior authorization is required for the following medical services and surgical procedures from:
Samaritan Health Services
Inpatient Admissions, with exception of maternity delivery services
Emergency Admissions, notification required within 48 hours
o Tonsillectomy and Adenoidectomy
o Laminectomy, with or without fusion
o Reconstructive surgery – regardless of place of service
o Gastric bypass surgery
o Circumcision for non-newborns
o Sleep study
o Allergy Testing
Artificial limbs and eyes
Inpatient rehabilitative services
Cardiac rehabilitation – Phase 2 (short-term outpatient)
Chemotherapy and Dialysis
Magnetic Resonance Angiography - MRAs
Pain management clinics – hospital based outpatient only
Skilled nursing facility services
Home health services
Medical equipment, including insulin pumps, oxygen and oxygen supplies, and any durable medical
equipment over $1,000 or rental over three months
Any services that could be considered cosmetic or experimental.
Residential and Inpatient Treatment for chemical dependency and mental health.
Genetic testing except standard prenatal testing with includes Cystic Fibrosis where indicated.
Prior to obtaining the services listed above, authorization must be obtained. A hospital or physician who
is a contracted provider may request pre-authorization by phone at the number identified above. The
request will be reviewed and the Covered Person will be notified of the number of approved hospital
days for the requested admission.
COHO PLAN DOCUMENT JAN 2010 4
If services are received from a non-contracted provider, the member is responsible to make
certain the compliance procedures of this program are completed. To minimize the risk of reduced
benefits, an Employee should contact Samaritan Health Services to make sure that the hospital or
attending physician has initiated the necessary pre-authorization process. Member may initiate the
necessary pre-authorization procedure with Samaritan, knowing that attending physicians and hospital
must also contact Samaritan. Members will be held responsible for pre-authorization completion
for services obtained from non contracted facilities and physicians.
Emergency hospitalizations must be communicated within 48 hours of occurrence, and followed
by the filing of any necessary forms. An emergency hospitalization must be supported by the attending
Physician’s statement describing the nature of the emergency, relative clinical information about the
patient’s condition and why hospital confinement was immediately necessary.
Penalty for Non-Compliance
If the pre-authorization requirements are not completed by the Member for non-contracted
facilities or providers, an additional $200 deductible will be imposed.
Any additional share of expenses which becomes the Covered Person’s responsibility for failure to
comply with these requirements will not be considered eligible medical expenses, and will not apply to
any deductible, coinsurance or out of pocket maximums of the Plan.
Prior authorization is not a guarantee of coverage. The prior authorization program is designed
ONLY to determine whether or not a proposed course of treatment is medically necessary and
appropriate. Benefits under the Plan will depend upon the person’s eligibility for coverage and the Plan’s
limitations and exclusions.
The Utilization Management Program also includes services for the management of potentially
catastrophic claims. Case management will assist in coordination of care. In conjunction with these
services, the Plan Sponsor reserves the right to monitor health care and modify Plan benefits to assure
that high-quality medical care is provided in the most cost-effective settings.
COHO PLAN DOCUMENT JAN 2010 5
Accidental Injury - Any accidental bodily injury which occurs while an individual is covered under the
Plan and which is caused by external forces under unexpected circumstances and which does not arise
out of or in the course of the employment of a Covered Person.
Ambulatory Surgical Center (Outpatient Facility) - Any public or private establishment which complies
with all licensing and other legal requirements and is operating lawfully in the jurisdiction where it is
located; with an organized medical staff of Physicians; with permanent facilities that are equipped and
operated primarily for the purpose of performing surgical procedures; with continuous Physician services
and registered professional nursing services whenever a patient is in the facility; and which does not
provide services or other accommodations for patients to stay overnight.
Birthing Center - A special room in a Hospital that exists to provide delivery and pre-natal and
post-natal care with minimum medical intervention or a free-standing Outpatient facility which:
is in compliance with licensing and other legal requirements in the jurisdiction where it is located;
is engaged mainly in providing a comprehensive birth service program to persons who are considered
normal low-risk patients;
has organized facilities for birth services on its premises;
provides birth services, which are performed by or under the direction of a Physician specializing in
obstetrics and gynecology;
has 24-hour-a-day registered nursing services;
maintains daily clinical records.
Note: This Plan does not cover expenses related to home birth
Business Travel - The period of time when a Plan Member is performing duties related to his/her usual
job, away from his/her standard workplace location.
Fiduciary - Any person who has binding authorization to make decisions regarding Plan policies,
interpretations, practices or procedures. A Fiduciary will thus include, but not be limited to, the Plan
Administrator, officers and directors of the Plan Sponsor, group benefits committee members and any
Formulary (Prescription Plan) – A list of prescription medications compiled by a third party payor of
safe, effective therapeutic drugs specifically covered by this Plan.
Home Health Care Agency - An agency or organization which:
is primarily engaged in and duly licensed, if such licensing is required by the appropriate licensing
authority, to provide skilled nursing services and other therapeutic services;
has policies established by a professional group associated with the agency or organization which
includes at least one registered graduate nurse (R.N.) to govern the services provided;
provides for full-time supervision of such services by a Physician or by a registered graduate nurse;
maintains a complete medical record on each patient;
COHO PLAN DOCUMENT JAN 2010 6
has a full-time administrator.
In rural areas where there are no agencies which meet the above requirements or areas in which the
available agencies do not meet the needs of the community, the services of visiting nurses may be
substituted for the services of an agency.
Hospice - An entity providing a coordinated set of services rendered at home, in Outpatient settings or
in institutional settings for Covered Persons suffering from a condition that has a terminal prognosis. A
Hospice must have an interdisciplinary group of personnel which includes at least one Physician and one
registered graduate nurse, and which maintains central clinical records on all patients. A Hospice must
meet the standards of the National Hospice Organization (NHO) and applicable state licensing
Hospital - An institution which is accredited as a hospital under the Hospital Accreditation Program of
the Joint Commission on the Accreditation of Hospitals and which:
complies with all licensing and other legal requirements and is operating lawfully in the jurisdiction where
it is located;
is primarily engaged in providing medical treatment to sick and injured persons as registered bed
patients and maintains permanent facilities for five or more such patients;
is operated under the supervision of a staff of Physicians;
continuously provides 24-hour-a-day nursing service by registered graduate nurses;
maintains a daily medical record for each patient;
maintains facilities for diagnosis of injury or disease;
maintains permanent facilities for major surgical operations on its premises; and
is not, other than incidentally, a place of rest, for custodial care, for the aged, for drug addicts or
alcoholics, for the care of senile persons, a nursing home, a hotel, a school or a similar institution.
However, the requirement for major surgical facilities will be waived for:
a psychiatric health facility properly licensed to operate as such in the State of Oregon; and
a facility operated primarily for the treatment of alcoholism or chemical dependency, which is accredited
by the Joint Commission on Accreditation of Healthcare Organizations.
Medically Necessary - Services and supplies which are:
reasonably required for the treatment or management of a health disorder as defined by physician
review; (see Physician definition, Page 8)
commonly and customarily recognized by Physicians as appropriate in the treatment or management of
a health condition; including services and supplies for preventive conditions;
services which are educational, experimental or custodial in nature are not defined as medically
COHO PLAN DOCUMENT JAN 2010 7
With respect to Inpatient services and supplies, "Medically Necessary” further means that the health
condition requires a degree and frequency of services and treatment which can be provided ONLY on an
Mid Wife – A licensed professional midwife certified by the state of practice, who assists in the delivery
Note: This plan does not cover expenses related to home birth.
Physician - A legally licensed doctor of medicine (M.D.) or doctor of osteopathy (D.O.), and any other
licensed health care provider that state law requires be recognized as a physician, who is practicing
within the scope of their license.
(NOTE: The term “Physician” shall not include interns, residents, fellows or others enrolled in a
residency training program. Also, for purposes of certifying Total Disability, a Physician will include
ONLY an M.D. or a D.O.)
Pregnancy - Childbirth, miscarriage or complications arising therefrom incurred only by a covered
Employee or the covered spouse of an Employee.
Relative - A spouse, or a parent, brother, sister, or child of the Employee or of the Employee's spouse.
Semi-Private Room Charge - The standard charge by a facility for semi-private room and board
accommodations, or the applicable coverage percentage of the lowest charge by the facility for single
bed room and board accommodations where the facility does not provide any semi-private
Sickness - Sickness shall mean bodily illness or disease (other than mental health conditions), and
congenital abnormalities of a covered newborn child diagnosed by a physician.
Skilled Nursing Facility - An institution which is duly licensed as a convalescent hospital, extended
care facility, skilled nursing facility, or intermediate care facility and is operated in accordance with the
governing laws and regulations;
is primarily engaged in providing accommodations and skilled nursing care 24 hours-a-day for
is under the full-time supervision of a Physician or a registered graduate nurse;
admits patients only upon the recommendation of an authorized admitting physician, maintains complete
medical records, and has available at all times the services of a Physician;
has established methods and procedures for the dispensing and administering of drugs;
has an effective utilization review plan;
is approved and licensed by Medicare;
has a written transfer agreement in effect with one or more Hospitals; and
is not, other than incidentally, a nursing home, a hotel, a school or a similar institution, a place
of rest, for custodial care, for the aged, for drug addicts, for alcoholics, for the care of mentally
ill or persons with nervous disorders, or for the care of senile persons.
COHO PLAN DOCUMENT JAN 2010 8
Total Disability or Totally Disabled - With reference to an Employee, it is disability resulting solely
from a sickness, injury or pregnancy which prevents Employee from engaging in any employment or
occupation for which he is or becomes qualified by reason of education, training, or experience.
Employee may not, in fact, be engaged in any employment or occupation for wage or profit and be
considered Totally Disabled.
For a Dependent, defined as that which prevents Dependent from engaging in substantially all the
normal activities of a person in good health of like age and gender.
A Covered Person must also be under the care of a Physician (M.D. or D.O.) in order to be Totally
Disabled for benefit purposes.
Urgent Care Facility - A freestanding facility which is engaged primarily in providing minor emergency
and episodic medical care and which has:
a board-certified Physician, a registered nurse (R.N.) and a registered X-ray technician in attendance at
has x-ray and laboratory equipment and a life support system.
An Urgent Care Facility does not include a clinic located at, operated in conjunction with, or in any way
made a part of a regular Hospital.
Usual, Customary and Reasonable - A charge made by a provider which does not exceed the general
level of charges made by other providers in the area or community who have similar experience and
training for the treatment of health conditions comparable in severity and nature to the health condition
being treated. The term “area” as it would apply to any particular service, medicine, or supply means a
county or such greater area as is necessary to obtain a representative cross section of the level of
(NOTE: With regard to charges made by a provider of service participating in the COHO Plan's provider
network, Usual, Customary and Reasonable shall mean the rates negotiated between the network and
the Plan Sponsor.)
Visiting Nurses - Professionals qualified by education at an accredited school of nursing,
licensed by the State of Oregon to practice nursing and employed by a hospital or social service
agency to perform public health services and specifically to visit sick persons in a community.
COHO PLAN DOCUMENT JAN 2010 9
A Deductible is an amount that a Covered Person must contribute toward payment of eligible medical
expenses. Deductible amounts apply to all services covered under this plan, with the exception of
primary care provider office visits and preventative care services. Effective January 1 of each
calendar year the Annual Deductibles will be:
Annual Deductible, per person, per Calendar Year $300; Non-Network $600
Maximum Deductible, per family, per Calendar Year $600; Non-Network $1,200
If a total of $600 in eligible medical expenses is incurred collectively by covered members of a family
during a Calendar Year, and is applied toward the In-Network Calendar Year Deductibles, the Deductible
is satisfied for the family. For these purposes a "family” will include a covered Employee and his/her
If a member reaches the deductible amount for In Network and then seeks services from an Out Of
Network provider, the accumulated In Network deductible will apply towards the Out of Network
Out of Network deductibles do accumulate towards In Network deductibles
COHO PLAN DOCUMENT JAN 2010 10
COINSURANCE AND COPAY SCHEDULES
Coinsurance - Coinsurance is the amount that members are responsible to pay (after deductibles are
satisfied and in addition to copays) after the Plan has made payment to allowable and/or usual and
customary amounts. Coinsurance amounts vary by network utilization and service.
Co-pay - An amount a Covered Person must pay for a prescription drug purchase or In-Network medical
services. Co-pays do not apply to the Out-of-Pocket maximums or deductibles. The co-pays are as
Retail, $12 generic, $30 formulary, $45 non formulary (30 day supply)
Mail order, $30 generic, $75 formulary, $112.50 non formulary (90 day supply)
Medical Office Visits: $25/visit PCP
$35/visit Specialist (subject to deductible)
Urgent Care Centers
Immediate Care Centers $35/visit (subject to deductible)
Emergency Room Use: $150 visit/unless admitted same day (subject to deductible)
In-Patient Stays: $100 day, up to maximum of $500 per admission (subject to deductible)
COHO PLAN DOCUMENT JAN 2010 11
OUT OF POCKET MAXIMUMS
Out of pocket (OOP) maximums are amounts paid by the member. Once the member has paid the
maximum amount, the Plan will pay all further covered services at 100% of usual and customary fee
levels, not to exceed contracted rates. Coinsurance amounts are accumulated toward OOP
maximum amounts on a calendar year basis. Members are still responsible for copays after
OOP maximums are reached.
Out of Pocket Maximum Amount:
In Network: Individual $3,500 / Family $7,500
Out of Network: Individual $7,500 / Family $22,500
If a member reaches the out of pocket maximum for In-Network services and then seeks services from
an out of network provider, the accumulated in-network OOP will apply towards the out of network OOP
maximum amount. Out of network amounts will apply towards in network maximums.
Those covered medical services with specific benefit maximums (e.g. Chiropractic care, Physical
Therapy) are not eligible for any addition benefit after OOP maximums are met.
The following charges do not accumulate toward the out of pocket maximum:
1. Deductibles and copayments
2. Charges not covered at all by the Plan
3. Prior Authorization penalties
4. Prescription copayments
5. Dental and routine vision expenses.
COHO PLAN DOCUMENT JAN 2010 12
COHO BENEFITS OF CTSI
GROUP SCHEDULE OF BENEFITS
This section is a listing of those medical services, supplies and conditions which are covered by the
Except as otherwise noted below, covered medical expenses are the Usual, Customary and Reasonable
charges for services listed below and which are incurred by a Covered Person - subject to the
Definitions, Limitations and Exclusions and all other provisions of the Plan Document. In general,
services and supplies must be approved by a Physician and must be Medically Necessary for the care
and treatment of a covered Sickness, Accidental Injury, Pregnancy or other covered health care
For benefit purposes medical expenses shall be deemed to be incurred on the latest of the following
the date a purchase is contracted; or
the date delivery is made; or
the actual date a service is rendered.
If any covered medical service is provided during the course of a PCP or Specialist office visit or during
inpatient or outpatient treatment, benefits will be paid at the respective levels. Reference lab costs will be
paid at the same level as the referring physician.
DEDUCTIBLE AMOUNTS APPLY TO ALL COVERED SERVICES,
WITH THE EXCEPTION OF PRIMARY CARE OFFICE VISITS AND PREVENTIVE CARE SERVICES.
The maximum payable for all eligible medical expenses for each Covered Person shall not exceed the
Maximum Plan Benefit shown below which applies to all periods a person is covered under the Plan.
Any lesser Maximum Benefits or Maximum Allowances are also applicable to all periods a person is
covered under the Plan. Other maximums may apply to specific periods, conditions or types or levels of
MAXIMUM LIFETIME PLAN BENEFIT $ 1,000,000
Acquired Immune Deficiency Syndrome (AIDS) and HIV-Related Conditions - Coverage for the
diagnosis and treatment of acquired immune deficiency syndrome (AIDS) and HIV-related conditions.
Chiropractic-type Care Calendar Year Maximum Allowance
(limited to a maximum of $20 per visit) 20 visits
Durable Medical Equipment (Lifetime maximum) $ 10,000
Home Health Care/Skilled Nurse Facility
Calendar Year Maximum Benefit $ 5,000
COHO PLAN DOCUMENT JAN 2010 13
Calendar Year Maximum Benefit $ 2,000
Out of State Service 40%
Out of state (Oregon) services will be reimbursed at forty percent regardless of
the type of provider status. Usual and customary reimbursement and medical
necessity will apply.
IN NETWORK OUT OF NETWORK
Alcoholism - see "Mental Health/Substance Abuse”
Allergy Testing and Injections – Testing subject to prior authorization 80% 40%
Ambulance - Benefits determination based upon Emergent/Non-Emergent provided services.
Professional licensed ambulance service which is Medically Necessary and when used to transport the
Covered Person from the place where they are injured or stricken by a sickness to the nearest facility
where treatment can be given. Ambulance services provided out of the state of Oregon will be paid
at sixty percent.
Outpatient Surgery – See Prior Authorization Requirements 80% 40%
Anesthesia - Anesthetics and services of a Physician or registered nurse anesthetist for the
administration of anesthesia.
Blood transfusions - Blood and blood plasma (if not replaced by or for the patient), including blood
processing and administration services.
Business Travel – Approved period of time when member is performing job related duties away from
standard workplace location. Paid as In Network, Subject to In Network Deductibles.
Physician Office/Urgent Care $25 co-pay then 80%
Emergency Room - Deductible $150 co-pay then 80%
Ambulance – Deductible 80%
Chemical Dependency - see "Mental Health/Substance Abuse"
Chemotherapy 80% 40%
Chiropractic Care - Manipulation to anatomically correct vertebral disorders such as incomplete
dislocation, off centering, misalignment, misplacement, fixation, abnormal spacing, sprain or strain.
Limited to 20 visits per calendar year, maximum payment per visit is $20. Subject to deductible.
COHO PLAN DOCUMENT JAN 2010 14
IN NETWORK OUT OF NETWORK
Contraception - Prescription devices which must be inserted, injected or implanted by a Physician, such
as intrauterine devices (IUDs) and Norplant, etc.
Dietary Counseling - Dietary counseling for dietary control when such counseling has been determined
to be Medically Necessary for the treatment of morbid obesity and has been prescribed by a Physician.
Diagnostic Services - Diagnostic laboratory and x-ray expense, including charges for electro-
cardiograms, ectroencephalograms, pneumoencephalograms, basal metabolism tests, or similar
diagnostic tests generally approved by Physicians throughout the United States which are
related/appropriate to diagnosis and standards of medical care. 80% 40%
Diagnostic services obtained during a primary care office visit are covered at 100% after copayment.
Drug or Substance Abuse - see “Mental Health/Substance Abuse”
Durable Medical Equipment - Durable medical equipment is an item which can withstand repeated
use, is primarily used to serve a medical purpose, is generally not useful to a person in the absence of
illness, injury, or disease and is appropriate for use in the patient’s home. Coverage provides for rental
up to the purchase price only. Lifetime Maximum Benefit - $10,000
NOTE : The Plan will not cover deluxe equipment with mechanical features, such as motor driven
wheelchairs and chair lifts, devices and equipment used for environmental control or to enhance the
environmental setting, such as air conditioners, portable whirlpool pumps, etc.
Emergency Room Care - Expenses incurred for emergency care. Copays are waived if admitted
inpatient from emergency room. Copay applies to each visit. Claims are reviewed by the Utilization
Management Organization. If it is determined that the visit was of a non-emergent nature, benefits will
be paid at a lesser level. Out of Area Emergency Room care will be paid as in network after
medical review determines the service was medically necessary and emergent.
Emergent $150 co-pay then 80% SAME
Non-Emergent $150 co-pay then 60% 40%
Hearing Aids and Examinations - One (1) hearing exam every calendar year and one (1) hearing aid
every three (3) years. 80% 40%
IN NETWORK OUT OF NETWORK
Home Health Care/Skilled Nursing Facility - Services and supplies as listed herein which are
furnished by a Home Health Care Agency or a skilled nursing facility to a Covered Person under the
care of a Physician and which are furnished in accordance with a home health care or skilled nursing
facility plan which is established and periodically reviewed by the attending Physician. The attending
Physician must certify that the proper treatment of the Sickness or Accidental Injury would require
confinement as a resident Inpatient in a Hospital in the absence of the services and supplies provided as
part of the home health care of skilled nursing facility plan.
The Plan will pay up to $5,000 in a Calendar Year for home health care services and supplies and/or
Medically Necessary confinement to a Skilled Nursing Facility.
COHO PLAN DOCUMENT JAN 2010 15
Covered Home Health Care Agency expenses will include visits by any of the following professionals:
a registered graduate nurse (R.N.) or a licensed practical nurse (L.P.N.) on a part-time intermittent
home health aides under the supervision of an R.N. on a part-time or intermittent basis;
physical, occupational and speech therapists.
Covered Home Health Care Agency or skilled nursing facility expenses will also include medical
supplies, drugs and medicines prescribed by a Physician and laboratory services, but only to the extent
that such charges would have been covered if the patient had remained in the Hospital.
Hospice Care - The charges made by a Hospice, facility or agency for care of a Covered Person with a
terminal prognosis (life expectancy of six months or less), limited to a lifetime maximum benefit of
$5,000. Eligible Expenses include charges for:
Hospice facility services and supplies rendered by a licensed agency and/or facility on an Inpatient
nursing care by a registered graduate nurse, a licensed practical nurse, a vocational nurse or a public
health nurse who is under the direct supervision of a registered nurse or licensed social worker;
medical supplies, including drugs and biologicals and the use of medical appliances;
services, supplies and treatments deemed Medically Necessary and ordered by a Physician.
IN NETWORK OUT OF NETWORK
Hospital Services - the charges made by a Hospital for daily room and board, limited to the Semi-
Private Room Charge of the Hospital of confinement or three (3) times the Semi-Private Room Charge
for confinement to an Intensive Care Unit; and ancillary services and supplies excluding items not
medically necessary or supplied for personal comfort only. Subject to Deductibles
$100 copay per day/$500 max per admission then 80% 40%
Outpatient charges made by a Hospital for ancillary services and supplies provided on an Outpatient
basis. Subject to Deductibles 80% 40%
Immunizations - see “Preventive Care” on page 18.
Drugs - Inpatient - Medicines that are dispensed and administered to a Covered Person during an
Inpatient confinement. 80% 40%
Drugs - Outpatient - The charges for the following which are purchased at a licensed pharmacy:
drugs and medicines which are lawfully obtainable ONLY upon the written prescription of a Physician,
including oral contraceptives; injectable insulin, including syringes and/or needles for insulin
COHO PLAN DOCUMENT JAN 2010 16
The Co-pay requirement (see "Prescription Drug Program” on page 28) is applied to each prescription
purchase (i.e., the request for each separate drug or medication issued by a Physician, and each
authorized refill of such request).
IN NETWORK OUT OF NETWORK
Medical Eye Coverage: Benefits will include services related to the diagnosis and treatment of ocular,
neurologic and/or systemic disease of the eye. Services covered include but are not limited to the
treatment of eye disease and injuries, prescription of therapeutic drugs and other procedures
such as removal of foreign bodies. A licensed ophthalmologist or optometrist, within the appropriate
scope of practice, must provide services. 80% 40%
Medical Supplies - Medical supplies must be medically necessary and include things such as casts,
splints, trusses, cervical collars, surgical dressing, colostomy bags and related supplies, catheters and
cardiac pacemakers. Supplies for personal comfort only are not covered. 80% 40%
Mental Health/Substance Abuse - For Plan purposes, a mental health condition will include
schizophrenic disorders, paranoid disorders, affective disorders (depression, mania, manic-depressive
illness), anxiety disorders, somatoform disorders, personality disorders, and disorders of infancy,
childhood and adolescence EXCEPT for those conditions which are expressly excluded in the list of
Medical Services Exclusions beginning on page 23 (i.e., childhood learning and behavior disorders,
hypnotherapy, marriage and family Counseling, sex Counseling, sex therapy and vocational testing and
training). 80% 40%
Newborn Care - Hospital services rendered during the birth confinement of a covered newborn
child/children. The Plan may not, under Federal law, restrict any hospital length of stay in connection
with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less
than 96 hours following a cesarean section. Federal law does allow the attending physician, after
consulting with the mother, to discharge earlier. This plan does not cover expenses related to home
Nursing Services/Private Duty - The charges made by a registered graduate nurse (R.N.), licensed
vocational nurse (L.V.N.) or licensed practical nurse (L.P.N.) for private duty nursing services when
Medically Necessary and prescribed in writing by the attending Physician or surgeon specifically as to
duration and type.
Oxygen - Oxygen and services and/or supplies for the administration of oxygen. Covered as
Durable medical equipment (Page 15). 80% 40%
Pap Smear - see “Preventive Care” on page 18.
Physical/Occupational Therapy – 80% 40%
Professional services of a licensed physical therapist, when specifically prescribed by a Physician or
surgeon as to type and duration, but only to the extent that the therapy is for improvement of bodily
function. Improvement in function must be documented on a continuous basis. Combined coverage for
physical/occupational and speech therapy is limited to a maximum benefit of $2,000 per Calendar
COHO PLAN DOCUMENT JAN 2010 17
Physician Services - Medical and surgical treatment by a Physician (M.D. or D. 0.), including office,
home or Hospital visits, clinic care and consultations. “Routine Office and/or PCP" shall be defined as
General Practice, Family Practice, Internal Medicine, Pediatrician, Obstetrician, Gynecologist, Nurse
Practitioner and Physician Assistant office visits. All other office visits shall be considered “non-routine
office and/or specialist" visits. Specialist visits are subject to deductibles.
IN NETWORK OUT OF NETWORK
PCP Office Visit $25 copay then 100% 40%
Specialist Office Visit (subject to deductible) $35 copay then 80% 40%
Pregnancy - Pregnancy expenses of a covered Employee or covered Dependent (spouse only) are
covered to the same extent as any Sickness. Coverage will not include expenses incurred by a
surrogate mother. This plan does not cover expenses related to home birth.
PCP Office Visit $25 copay then100% 40%
Specialist Office Visit (subject to deductible) $35 copay then 80% 40%
Pregnancy Testing - The charges for pregnancy testing for an Employee or a covered Dependent
Lab Only Charges 80% 40%
Preventive Care - The Plan will cover the following "preventive” measures. The deductible and copay
will not apply to these listed Preventive Care Measures. Payment will not exceed usual and customary
fees nor contract rates.
a routine annual preventive physical examination for a Covered Person, including medically
appropriate lab tests and x-rays.
Calendar year maximum benefit is $750.00 100% 40%
Medically appropriate preventive lab, x-rays or diagnostic testing over the $750 annual limit
Deductible 100% 40%
the following immunizations, not subject to $750.00 maximum: 100% 40%
Acellular pertussis with tetanus (DTaP)
Diphtheria, tetanus and pertussis (DTP)
Influenza (seasonal and non-seasonal)
Measles, mumps, rubella (MMR)
Pediatric tetanus (DT)
polio (oral or injectable)
Tetanus Immune Globulin
Tetramune (Hibitis and DTP)
screening mammograms are included in $750 calendar benefit– subject to following
limitations: Age 35-39 One routine mammogram, Age 40 and over, one routine mammogram per
COHO PLAN DOCUMENT JAN 2010 18
IN NETWORK OUT OF NETWORK
calendar year. Non-routine mammogram for medical diagnosis not subject to these frequency
limitations or benefit levels. 100% 40%
routine immunizations for covered school-age children; 100% 40%
(not subject to $750 benefit maximum)
annual Pap smear; pelvic exam and breast exam – included in $750 calendar benefit
well child care, up to age 6 (including routine Physician exams and related diagnostic services).
(not subject to $750 benefit maximum)
Prosthetics - Artificial limbs or eyes which are lost/removed or inoperative due to wear while the
Covered Person is covered under the Plan. The Plan will also cover a contact lens or hard lens for each
eye if necessary after cataract surgery. 80% 40%
Radiation Therapy - Radium and radioactive isotope therapy. 80% 40%
Rehabilitation Services – 80% 40%
Inpatient rehabilitation services. 30 day calendar year maximum benefits. See Prior Authorization list.
Respiratory Therapy - Professional services of a licensed respiratory therapist, when specifically
prescribed by a Physician or surgeon as to type and duration, but only to the extent that the therapy is
for improvement of bodily function. Improvement in function must be documented on a continuous
basis. 80% 40%
Second Surgical Opinion – Not Subject to Deductible 80% 80%
The Usual, Customary and Reasonable fees of a Physician for a second surgical opinion consultation
when rendered within one (1) month of the surgeon's recommendation for surgery. The Physician
rendering the second opinion regarding the Medical Necessity of proposed surgery must be qualified to
render such a service, either through experience, specialist training or education, or similar criteria, and
must not be affiliated in any way with the Physician who will be performing the actual surgery.
Skilled Nursing Facility/Home Health Care – 80% 40%
Medically Necessary room and board (limited to the Semi-Private Room Charge of the facility) and
ancillary services and supplies which are provided by a Skilled Nursing Facility but only when
is for the same condition causing the preceding confinement;
commences within 14 days of discharge from such prior confinement;
is one during which a Physician consults with the Covered Person at least once each 7 days.
The Plan will pay up to $5,000 in a Calendar Year for combined home health care services and
supplies and/or Medically Necessary confinement to a Skilled Nursing Facility.
COHO PLAN DOCUMENT JAN 2010 19
IN NETWORK OUT OF NETWORK
Sleep Apnea – 80% 40%
Treatment of sleep apnea is covered. Sleep studies and other diagnostic testing are covered. Other
types of sleep disorders are not covered. Subject to Prior Authorization.
Smoking cessation - Smoking cessation aids are covered if prescribed by a treating physician.
See Pharmacy Benefits section on page 28. Office visits are also covered at primary or specialty benefit
Specialists - Professionals who specialize in a particular practice or branch of medicine (i.e.,
orthopedics, cardiology, nephrology). Subject to Deductibles.
Specialist Office Visit $35 copay then 80% 40%
Speech Therapy - Services by a qualified speech therapist to restore or rehabilitate any speech loss or
impairment caused by Accidental Injury or Sickness except a mental, emotional or nervous disorder. In
the case of a congenital defect that can be corrected or improved with surgery, expenses will be
considered only if incurred after surgery for the defect. Combined coverage with physical/occupational
and speech therapy. Calendar year benefit $2,000 – Subject to Deductibles
Specialist Office Visit $35 copay then 80% 40%
Out Patient Hospital 80% 40%
Sterilization Procedures - Surgical procedures for the purpose of sterilization (i.e., a vasectomy for a
male or a tubal ligation for a female). Subject to Deductibles
Office Surgery 80% 40%
Out Patient Hospital 80% 40%
Substance Abuse/Mental Health – 80% 40%
For Plan purposes, “Substance abuse” is physical and/or emotional dependence on legal prescription or
street drugs, legal prescription or street narcotics, alcohol or other documented addictive substances to
a debilitating degree. It does not include tobacco dependence or dependence on ordinary drinks
In addition to other providers who are covered under the Plan. For substance abuse care, a Covered
Person may also use approved providers referred by the Siletz Tribal alcohol and drug program.
Temporomandibular Joint Dysfunction – This plan does not cover expenses related to the
Transplants - Transplants are covered as any other sickness but are subject to the following conditions:
All transplant procedures and activity requires pre-authorization by Samaritan Health Services; coverage
is limited to procedures which are Medically Necessary and listed below:
COHO PLAN DOCUMENT JAN 2010 20
Liver (limited to eligible recipients through the age of 20)
the procedure must be in conformance with accepted medical practice;
the treatment must not be experimental or investigational;
the recipient of the transplant must have been covered by the Plan for (1) at least twenty-four
consecutive months prior to the procedure, or (2) since birth;
expenses incurred for the transplantation of artificial, animal, or other non-human body organs will not be
the Plan will pay up to $5,000, as part of the recipient's claim, for a donor’s expenses if the recipient is
eligible for coverage at the time of the transplant.
IN NETWORK OUT OF NETWORK
Urgent Care Facilities - Facilities which are equipped and operate mainly to render treatment for
sudden onset of illness or injury.
$35 copay then 100% 40%
Vision Care - Vision benefits are administered by VSP. VSP network providers must be used to ensure
maximum benefit. Covered services include:
Exam - every 12 months
Lenses - every 12 months (single vision, lined bifocal and lined trifocal lenses)
Frames - every 24 months (up to $120, with a 20% discount off any out of pocket costs)
Contacts - every 12 months (including fitting and evaluation up to $105). If Contacts are chosen,
member will be eligible for a frame 12 months from the date the contacts were obtained.
Prescription Glasses - one time $25.00 for lenses and/or frames
Contacts - No co-pay
Non-network providers: If services are obtained from a non-network provider, co-pays still apply.
Lesser benefit levels will apply, resulting in higher out-of-pocket costs. Payment in full is required
at time of appointment. Member then submits claim directly to VSP for partial reimbursement.
See separate VSP documentation for additional information.
Well Child Care - see “Preventive Care” on page 18.
COHO PLAN DOCUMENT JAN 2010 21
SPECIAL RESTRICTIONS FOR PRE-EXISTING CONDITIONS
NOTE: This provision applies to services of all Covered Providers - including Siletz Clinic.
A pre-existing condition will not be covered until the individual has been on the plan for twelve (12)
consecutive months after their effective date of coverage. HOWEVER, for an individual who is a late
enrollee, the pre-existing condition limitation will apply until he/she has been covered under the Plan for
eighteen (18) consecutive months. See the “Annual Enrollment” provision in the Eligibility and
Effective Dates section on page 31 for identification of individuals who are “late enrollees” and are
subject to this restriction.
For these purposes, a pre-existing condition is an illness or injury for which medical advice, diagnosis,
care or treatment was recommended or received (“treatment” includes taking drugs or medicines) during
the six (6) months before the Covered Person's enrollment date. An individual's enrollment date is his
first day of Plan coverage, or, if earlier (new employee), the first day of the waiting period for such
coverage. A Pregnancy will not be considered a pre-existing condition, regardless of the date of
conception, diagnosis, or first treatment. Genetic information is not a pre-existing condition in the
absence of a diagnosis of a condition related to the genetic information.
NOTES: The pre-existing condition limitation will not apply to an adopted child or a newborn who is
acquired by the Employee while he is covered under the Plan and is enrolled in a timely manner when
the child is first eligible (see Eligibility and Effective Dates section on page 31). For these purposes, an
“adopted child” is any person under the age of 19 as of the date of adoption or placement for adoption.
Placement for adoption means the assumption and retention by the Employee of the legal obligation for
the total or partial support of a child to be adopted. Placement ends whenever the legal support
For Plan members who enroll under the re-hire provision, the pre-existing condition limitations will only
apply to the extent it did when the member left the Plan. If the waiting period had previously been
satisfied, no additional waiting period will be imposed. If it had been partially satisfied, then the balance
would still need to be completed. This provision only applies to reinstatement status and not to plan
members with previous plan participation who are treated as new employees for enrollment purposes.
The pre-existing time limits may be reduced or waived if an individual had prior coverage. See
"Allowance for Prior Creditable Coverage” in the Eligibility and Effective Dates section on page 35 for
These pre-existing condition limitations are intended to comply with at least the minimum requirements
of the Health Insurance Portability and Accountability Act of 1996 (H.R. 3103).
COHO PLAN DOCUMENT JAN 2010 22
MEDICAL SERVICES EXCLUSIONS
Except as specifically stated otherwise, no benefits shall be payable for:
Abortion - Elective abortion unless the mother's life would be endangered if the Pregnancy were
allowed to continue to term. Complications arising out of an abortion, however, are covered as any other
Air Purification Units, etc. - Air conditioners and electric heating units.
Blood - Whole blood or plasma when donated or otherwise replaced by or on behalf of the patient.
Childhood Disorders - Treatment of learning disorders, behavioral problems, mental retardation,
hyperkinetic syndrome, or autism of childhood, unless directly related to a recognized medical/mental
Cosmetic Surgery - Any surgery, service, drug or supply designed to improve the appearance of an
individual by alteration of a physical characteristic which is within the broad range of normal but which
may be considered unpleasant or unsightly in the absence of diagnosed medical condition, except when:
necessitated by a non-occupational Accidental Injury which occurs while the patient is covered by the
Plan and then only for Eligible Expenses incurred within six months from the date of the accident; or
surgery is performed for all stages of reconstruction of a breast on a past or current mastectomy which
was Medically Necessary; surgery and reconstruction of the other breast to produce a symmetrical
appearance; prostheses; and treatment of physical complications of a mastectomy, including
lymphedema. These benefits are subject to the same deductibles and coinsurance as other medical and
surgical benefits. Intended to comply with the Women’s Health and Cancer Rights Act of 1998 (WHCRA)
necessary to correct a congenital abnormality in a child covered continuously under the Plan from birth.
Counseling, Etc. - Hypnotherapy, marriage or family counseling; treatment of learning disorders,
behavioral problems, mental retardation, hyperkinelic syndrome, or autism of childhood, vocational
testing, evaluation or counseling; or therapy or Counseling for sexual dysfunctions or inadequacies.
Custodial Care - Care or confinement primarily for the purpose of meeting personal needs which could
be rendered at home or by persons without professional skills or training.
Dental Care - Care or treatment on or to the teeth, alveolar processes, gingival tissue, or for
malocclusion will not be covered medical expenses except for:
excision of tumors, cysts or abscess and infection beyond tooth and gums, or
the repair or alleviation of damage to natural teeth caused solely by Accidental Injury sustained while
covered hereunder and provided such treatment is rendered within six months after such accident; or
Hospital room and board and necessary ancillary Hospital services associated with the above, also
including hospital services for patient’s of young age, mental or developmental impairment; extensive
dental work or tumor removal that cannot be completed in an office setting due to patient medical
condition and when the patient has another serious medical condition that may complicate the dental
COHO PLAN DOCUMENT JAN 2010 23
Diagnostic Hospital Admissions - Confinement in a Hospital that is for diagnostic purposes only, when
such diagnostic services could be performed in an Outpatient setting.
Exercise Equipment/Health Clubs - Exercising equipment, vibratory equipment, swimming or therapy
pools. Enrollment in health, athletic or similar clubs.
Family Planning - Services or supplies related to family planning, other than contraceptive devices or
medications or sterilization procedures.
Foot Care (routine) – Routine foot care is defined as treatment of corns, calluses, toenails, hypertrophy
of foot skin or toenails. Coverage for routine foot care is limited to those persons with diagnosed
diabetes or peripheral-vascular disease. Treatment of ingrown toenails and other medical conditions of
the foot are covered to the same extent as other medical conditions.
Expenses incurred for appliances, orthotics, orthopedic shoes and supports, except in the case of
diagnosed diabetes or peripheral-vascular disease.
Genetic Counseling or Testing - Guidance provided by a medical professional to individuals with an
increased risk of having offspring with a specific genetic disorder and that includes providing information
and advice concerning the probability of producing offspring with the disorder, prenatal diagnostic tests
and available treatments.
Impregnation - Artificial insemination, in-vitro fertilization, G.I.F.T. (Gameti Intrafallopian Transfer) or
any type of artificial impregnation procedure, whether or not any such procedure is successful.
Infertility - Services or Charges related to or in connection with fertility studies, sterility studies, or
procedures to restore or enhance fertility.
Marriage and Family Counseling - Counseling for the purpose of resolving family or marital difficulties.
Nicotine Addiction - Nicotine withdrawal programs, facilities or supplies. However, prescriptions for
smoking cessation aids are covered if prescribed by a physician.
Non-Prescription Drugs - Drugs which can be purchased over-the-counter and without a Physician's
written prescription, except for insulin and syringes for the administration of insulin. See the Pharmacy
benefits section for specific exceptions.
Not Medically Necessary/Not Physician Prescribed - Any services or supplies which are (1) not
Medically Necessary, and (2) not incurred on the advice of a Physician. See Pre-authorization
Obesity – see “Weight Control" on page 25.
Occupational and other Therapy - Occupational therapy (except during an Inpatient Hospital
confinement or as included in Home Health Care or Skilled Nursing Facility services), vocational,
educational, recreational, art, dance, or music therapy.
Personal Comfort or Convenience Items - Services or supplies provided for personal comfort and not
necessary for treatment of a covered Sickness, Accidental Injury, or Pregnancy including, but not limited
to, the purchase or rental of telephones, televisions, orthopedic mattresses, allergy-free pillows, blankets
and/or mattress covers, wigs, non-prescription drugs and medicines, non-hospital adjustable beds,
COHO PLAN DOCUMENT JAN 2010 24
waterbeds, motorized transportation equipment, elevators, escalators, professional medical equipment
(such as blood pressure kits) or supplies or attachments to such equipment.
Pre-existing Conditions - see Special Restrictions for Pre-existing Conditions on page 22.
Preventive or Routine Care - Routine exams, physicals or anything not ordered by a Physician or not
Medically Necessary for treatment of Sickness, Accidental Injury or Pregnancy, except as may be
specifically included in the list of Covered Medical Expenses. Examples include ODOT exams, pre-
employment exams, etc.
Self-Procured Services - Charges for services rendered to a Covered Person who is not under the
regular care of a Physician and for services, supplies or treatment, including any period of hospital
confinement, which were/are not recommended, approved and certified as necessary and reasonable by
a Physician, except as may be specifically included in the list of Covered Medical Expenses.
Sex Change Procedures, Services or Supplies - Sex change counseling, treatment, services or
supplies related to sex change surgery or any resulting complications.
Sex Counseling or Treatment - Treatment, therapy or counseling for sexual dysfunctions or
inadequacies which are not related to organic disease.
Sleep Disorders – with the exception of sleep apnea
Sterilization Reversal Surgery - Reconstruction (reversal) of prior elective sterilization procedures.
Vision Surgery for Correction of Refractive Error - The Plan does not cover vision procedures whose
purpose is the correction of refractive error, such as radial keratotomy. See VSP Vision Plan for
Vocational Testing or Training
Testing and/or training for educational purposes or to assist an individual in pursuing a trade or
Weight Control - Services or supplies for obesity, weight reduction or dietary control, except when
provided for treatment of morbid obesity or diabetes.
COHO PLAN DOCUMENT JAN 2010 25
GENERAL HEALTH CARE COVERAGE EXCLUSIONS
The following exclusions apply to all health benefits and no benefits shall be payable under this Health
Care Coverage for:
Any confinement of a Covered Person in a public or private institution as the result of a court order.
Any injury resulting from or occurring during the Covered Person's commission or attempt to commit an
aggravated assault or felony, or any injury resulting from a Covered Person being involved in illegal
activities or an illegal occupation.
Drugs in Testing Phases
Medicines or drugs which are in the Food and Drug Administration Phases I, II or III testing.
Charges in excess of the Usual, Customary and Reasonable fees for services or supplies provided.
Services or supplies which are specifically listed by the American Medical Association having no medical
value or which are considered experimental or investigational in nature as determined by the Food and
Drug Administration and the American Medical Association's Council on Medical Specialty Societies.
Treatments which are not parts of generally accepted health care services.
Charges made for the completion or photocopying of claim forms or for providing supplemental
Services furnished the Covered Person in any veterans hospital, military hospital, institution or facility
operated by the United States government (except for treatment of non-service related disease or
sickness), or by any state government or any agency or instrumentality of such government, for which
the Covered Person has no legal obligation to pay.
Claims which are not filed with the Contract Administrator for handling within the twelve (12) months
after the date the expenses are incurred, except in the absence of legal capacity of the Claimant.
Charges for treatment of any Injury sustained or illness contracted while in the military service of any
Expenses incurred for failure to keep a scheduled appointment.
No Charge / No Legal Requirement to Pay
Services for which no charge is made or for which a Covered Person is not required to pay, or is not
billed or would not have been billed in the absence of coverage under this Plan. This exclusion does not
apply to benefits or coverage which is available through the Medical Assistance Act (Medicaid).
Not Listed Services or Supplies
Any services, care or supplies not specifically listed in the Plan Document as Eligible Expenses are NOT
covered under the Plan.
COHO PLAN DOCUMENT JAN 2010 26
Nuclear Energy Release
Any injury or illness resulting from the non-therapeutic release of nuclear energy.
Services or supplies for which a Covered Person’s entitled (or could have been entitled if proper
application had been made) to have reimbursed by or furnished by any plan, authority or law of any
government, governmental agency (Federal or State, Dominion or Province or any political subdivision
Outside United States
Charges incurred outside of the United States if the Covered Person traveled to such a location for the
sole purpose of obtaining such services, drugs or supplies.
Services/supplies for which the Covered Person is eligible for benefits under the plan that this Plan
Relative or Household Member Caregivers
Any service rendered to a Covered Person by a Relative or anyone who customarily lives in the Covered
Charges for treatment of Injury where it is determined that the Covered Person was involved in a
motorcycle accident while not wearing a helmet or in an automobile accident while not wearing a seat
Shipping and Handling
Any charges for shipping, handling, postage, interest or financing charges.
Advice or consultation given by or through any form of telecommunication.
Third Party Liabilities
Any expenses caused by any third party when payment for such expenses has been paid (or will be
paid) by the third party or the third party's insurance company. See section entitled Third Party
Recovery on page 41 for further information.
Travel, whether or not recommended by a Physician.
Veterans Hospital - see “Government-Operated Facilities”.
War or Active Duty
Health conditions resulting from insurrection, war (declared or undeclared) or any act of war and any
complications therefrom, or service in the armed forces of any country.
Any condition for which the Covered Person has or had a right to compensation under any Workers'
Compensation or occupational disease law or any other legislation of similar purpose.
Any condition, which arise from or is sustained in the course of any occupation or employment for
compensation, profit or gain.
COHO PLAN DOCUMENT JAN 2010 27
PRESCRIPTION DRUG PROGRAM
Outpatient prescription drugs can be obtained from a pharmacy in the HealthTrans Pharmaceutical
Network or any other licensed pharmacy. Plan members who are enrolled in any federally recognized
Indian tribe may be able to obtain services from the Siletz Community Health Clinic Pharmacy.
The co-pays for prescriptions are:
Retail/30 day supply – Generic $12, Formulary $30, Non Formulary $45
Retail/90 day supply – Generic $30, Formulary $75, Non Formulary $112.50
Available at participating retail pharmacies only
Mail Order/90 day supply – Generic $30, Formulary $75, Non Formulary $112.50
Effective January 1, of each year, there will be an annual (Calendar Year) maximum benefit under the
plan of $5,000 per individual.
MAIL ORDER -Mail order prescriptions are strongly suggested as a means to reduce cost. Three month
supplies (90 days) can be obtain through the mail order program for the cost of two and one half months
copay. HealthTrans mail order forms can be obtained through your employer benefit coordinators.
FORMULARY – Effective January 1, 2006, the Plan is utilizing a preferred drug formulary. The
formulary is a list of preferred prescription medications compiled by HealthTrans, which are effective
therapeutic drugs specifically covered by this Plan. You can obtain copies of the formulary through your
employer’s Benefits Department or by calling the Plan administrative offices at 541.996.5882
90 DAY RETAIL – Participating retail pharmacy (obtain list from your employer benefit coordinator) will
dispense 90 day supplies of maintenance/long term use medications. Appropriate prescriptions are
necessary. Utilization of the 90 day retail options will reduce out of pocket costs (see copay structure
STOP SMOKING MEDICATIONS - Over the counter aids – Zero Copay – up to six times per calendar
year. Prescription aids – standard copay based on medication – up to two times per year
SPECIALTY MEDICATIONS - 30 day supply limit, lesser of $250 or 20% coinsurance. Prior
Authorization Required. Request Specialty Medication list from Benefits staff.
QUANTITY LIMITS - Maximum amount of one medication you can receive at one time. Prior authorized
override for higher quantities may be obtained. Request Quantity Limit list from Benefit staff.
STEP THERAPY - The practice of beginning drug therapy with the most safe and cost-effective
medications and stepping up to other more risky and costly therapy, only if necessary. Effected drug
classes are for High Blood Pressure, Heartburn and GERD, Pain Therapy and Allergies. Request
documentation from Benefits staff. Exceptions are available.
GENERIC INCENTIVE - The Plan will pay 100% of the cost for an initial 90 day supply of generic
medication when you switch from a brand name medication, if medically appropriate per your physician.
TABLET SPLITTING - Voluntary program whereby you can achieve 50% savings on certain medication
approved by the FDA for tablet splitting.
COHO PLAN DOCUMENT JAN 2010 28
OUT OF NETWORK PHARMACY
When prescription drugs are not purchased at the Siletz Clinic Pharmacy or at a HealthTrans network
pharmacy, the Covered Person must pay for the prescription at the time of purchase and then submit a
prescription receipt with a complete claim form to HealthTrans for reimbursement. The Plan will then
pay the claim according to the coverages and limitations of the Plan and deduct the appropriate co-pay.
PHARMACY EXCLUSIONS – These items are not covered
1. Items not requiring a prescription by law (Over the Counter, OTC).
2. Biological serum and immunization agents.
3. Vitamins – with the exception of pre-natal vitamins
4. Anorexants – except in the case of morbid obesity.
5. Fertility Drugs.
PHARMACY EXCEPTIONS -
Approved Over the Counter (OTC) items – As prescribed by an authorized prescriber.
Accumulates to annual maximum benefit. No copay due from member.
1. APAP 80mg Chewable – 30%.
2. APAP16/5ml Elixir – 120ml.
3. APAP 325mg – 24’s.
4. Dimetapp elixir – 120ml.
5. Guaitenesin DM – 15ml & 120ml.
6. Hydrocortisone cream 1% - 30mg.
7. Pediacare Children’s Cough Syrup – 120ml.
8. Hedicuicides – All Nx & Rid sprays.
9. Sodium Chloride Nasal Drops
10. Tolfnanais Power – 80gm.
11. Tolfnanais Cream 15gm.
12. Bee Sting Kits.
13. OTC Smoking cessation aids/prescription needed, up to six times per year.
14. Claritin OTC
15. Prilosec OTC
COHO PLAN DOCUMENT JAN 2010 29
ELIGIBILITY AND EFFECTIVE DATES
Eligibility Requirements - Employees
Individuals who are eligible to participate in the Health Care Coverages as “Employees” will include:
individuals who are in active employment for the Employer, performing all Customary duties of their
occupation at their usual place of employment and regularly scheduled to work at least 30 hours of work
per week; and/or be employed in a benefits eligible employment class (Full Time, Part Time Regular,
selected professional employees who are regularly scheduled to work at least twenty (20) hours
per week for the Employer, when Plan coverage is a condition of employment.
An Employee shall be deemed in "active employment" on each day of a regular paid vacation or on a
regular non-working day, provided they were actively at work on the last preceding regular working day.
Refer to page 46 Extension of Coverage section(s) for instances when these eligibility requirements
may be waived or modified.
Eligibility Requirements - Dependents
An eligible Dependent of an Employee is as follows. Birth certificates or other legal documents are
required prior to adding dependents to the Plan:
A spouse must have met all requirements of a valid marriage contract in the state of residence,
or the marriage must be a recognized tribal marriage. A marriage license or tribal certification of the
marriage is required prior to adding a spouse to the Plan. In no instance will a covered spouse include
a "common law” spouse.
any unmarried child under age 19 who is financially dependent upon the Employee for support. For
these purposes a “child” will include: (1) an Employee's natural child, (2) a stepchild through legal
marriage, and (3) a child placed under the legal guardianship of the Employee. In addition, and in order
to comply with OBRA 1993: Public Law 10366, a “child” will include an adopted child as defined by the
law, whether or not the adoption has become final, and a child for whom the Employee or covered
Dependent spouse is required to provide coverage due to a Medical Child Support Order (MCSO) which
is determined by the Plan Sponsor in accordance with its written procedures (which are incorporated
herein by reference) to be a Qualified Medical Child Support Order. Upon receipt of an MCSO, the Plan
Administrator will promptly inform the Employee and each child who is the subject of the MCSO of its
receipt of the order and will explain (in writing) the Plan's procedures for determining if the order is a
QMCSO. Within a reasonable time, the Plan Administrator will decide whether the MCSO is qualified
and will notify the Employee and the child(ren) of its determination.
Coverage cannot be discontinued for any child who is enrolled to comply with a QMCS0 unless the
Employee submits written evidence that the child support order is no longer in effect.
an unmarried student age 19 or over but less than 25, if such child meets the requirements of the
preceding paragraph, except age, and is in full-time school attendance at a qualified educational
As used herein the term “qualified educational institution” will mean high schools, junior colleges or other
two-year colleges granting two-year degrees; universities or colleges granting four-year degrees or post-
graduate degrees; proprietary schools such as business colleges, professional schools, trade and
technical schools - which are established as other than evening schools exclusively.
COHO PLAN DOCUMENT JAN 2010 30
Full-time school attendance” means 12 units or more per semester in all of the above except for
proprietary schools. In a proprietary school, “full-time school attendance" will mean a minimum of 25
hours of classroom attendance per week on a five-day week schedule.
Cessation of full-time school attendance will terminate Dependent status with respect to the student
EXCEPT that, if cessation is due to school vacation, Dependent status will terminate on the date the
school reconvenes if attendance does not resume.
Dependent coverage can not exceed or differ from the coverage level elected by the employee.
An eligible Dependent does not include:
a spouse who is legally separated or divorced from the Employee, unless Employee is required to
provide coverage due to court order or decree, in which case such spouse must have met all
requirements of a valid separation or divorce contract in the state granting such separation or divorce;
any person who is on active duty in a military service;
any person who resides outside of the United States;
any person who is not a resident of the same Country as the Employee;
any person who is eligible and has enrolled as an Employee under the Plan;
any person who is covered as a Dependent of another Employee under the Plan.
Effective Date- Employees
This Plan provides contributory coverage (Employee may pay a portion of the premium cost). An eligible
Employee's coverage is effective, subject to timely enrollment, upon completion of a waiting period as
documented in your employer personnel policies:
Confederated Tribes of Siletz Indians/Siletz Tribal Gaming Commission/Siletz Tribal Business
To the first of the month following thirty (30) days of continuous active employment
Chinook Winds Casino Resort/Hotel/Golf Resort
To the first of the month following ninety (90) days of continuous active employment; or
To the first day of the month following thirty (30) days of continuous active employment
If Employee fails to enroll within 31 days after completion of the waiting period, Employee will be
effective only in accordance with the Annual Enrollment or Special Enrollment Rights provisions below.
NOTE: If a CTSI part-time employee changes from part-time to full-time status and has completed at
least thirty (30) days of continuous active employment, such Employee's coverage will be effective on
the first of the month after the date of the change in status. For Chinook Winds part-time employees,
the same conditions will apply except the continuous employment provision will be 90 days.
If the waiting period has not been completed in full prior to the date of the status change, such employee
will receive credit toward the waiting period requirement for the number of continuous days worked in
COHO PLAN DOCUMENT JAN 2010 31
Transfer of Employment between Participating Employers: If an employee transfers employment
between any participating employers, coverage under the plan will terminate as described in former
employer’s personnel policies. After return to active employment status with the new employer (within
one week of termination), eligible employee will not be subject to additional enrollment waiting periods.
Eligible employee will receive credit for any waiting periods accumulated or satisfied prior to transfer.
Pre-existing condition limitations will only apply to the extent it did prior to transfer. If the Pre-existing
condition waiting period had previously been satisfied, no additional waiting period will be imposed.
Refer to page 46, Extension of Coverage section(s) for instances when these eligibility requirements
may be waived or modified.
Effective Date - Dependents
This Plan provides contributory coverage for eligible Dependents (i.e., Employee pays at least a portion
of the cost of coverage). Dependents who are eligible and enrolled concurrently with the Employee will
be effective on the Employee's effective date. Dependents not enrolled when Employee is initially
eligible or acquired later may become covered only if the Employee makes written application for
coverage for such Dependents in a form furnished for that purpose. If application is made:
on, before, or within 31 days of the date of employee eligibility, the Dependent(s) shall be effective on
the date of employee eligibility; or
after 31 days beyond the date of initial employee eligibility, Dependent(s) will be effective only in
accordance with the Annual Enrollment or Special Enrollment Rights provisions below.
A Dependent's coverage will not become effective prior to the Employee's effective date.
Newborn / Adopted Children
Newborn or adoptive child(ren) must be enrolled within 31 days of birth (or adoptive placement) in
order for coverage under the Plan to become effective on the date of birth (placement). After 31 days,
the Annual Enrollment or Special Enrollment Rights provisions below will apply.
A spouse (see page 31 for eligibility requirements) must be enrolled within 31 days of the date of
marriage in order for coverage under the Plan to become effective on the date of marriage. After 31
days, the Biannual Enrollment or Special Enrollment rights provisions below will apply.
Each Plan Year, an annual enrollment will be held for eligible Employees and their eligible Dependents
who did not enroll in the Health Care Coverages of the Plan when initially eligible for coverage. The
effective date of coverage for annual enrollment will be January 1 . Individuals enrolling during such
enrollment period will become covered on the first day of the month following such election but any such
individual will be considered a late enrollee and may be subject to a longer pre-existing condition period -
see Special Restrictions for Pre-existing Conditions section on page 22.
Special Enrollment Rights
An individual who enrolls in accordance with this “Special Enrollment Rights” provision is not a “late
enrollee” as that term may apply to the pre-existing condition limitations (see Special Restrictions for
Pre-existing Conditions section on page 22 for a special 18-month waiting period that may be included
for late enrollees).
Initial Declination Due to Other Coverage - An individual who did not enroll in the Plan when first eligible,
will be allowed to apply for coverage under the Plan at a later date if:
COHO PLAN DOCUMENT JAN 2010 32
they were covered under another group health plan or other health insurance arrangement at the time
coverage was initially offered;
if Employer required it, the Employee stated in writing at the time initial enrollment was offered that other
coverage was the reason for declining enrollment in the Plan;
the individual lost the other coverage as a result of a certain event, such as loss of eligibility for
coverage, expiration of COBRA continuation coverage, termination of employment or reduction in the
number of hours of employment, or because employer contributions towards such coverage were
the Employee requested Plan enrollment within thirty (30) days of termination of the other coverage.
If the above conditions are met, Plan coverage will be effective on the first day of the first calendar
month that begins after the date on which the Plan received the completed application.
Medicaid and/or CHIP - In addition, special enrollment rights apply to the the following:
The employee’s or dependent’s Medicaid of CHIP coverage is terminated as a result of loss of eligibility,
or the employee of dependent becomes eligible for a premium assistance subsidy under Medicaid or
Reinstatement - defined as those instances when Regulatory Agency or Termination Review board
reinstates termed employees to active status. Employee will be re-enrolled retro-active to term date
upon appropriate notification to Plan Administrative staff.
If an Employee is rehired and returns to an eligible status (working 30 + hours per week) within six (6)
months after Termination of Coverage under this Plan, such rehire shall have coverage, with timely
completion of enrollment forms, (for employee and any Dependents who are eligible by definition)
Chinook Winds Resort employess: on the first of the month following 90 days employment.
CTSI/STGC/STBC employees: on the first of the month following date of rehire employment.
Military Assignment (return from)
Employees who return to employment after active duty service as a member of the United States
Reserves or National Guard will be reinstated to coverage under the Plan (for themselves and any
Dependents who were covered prior to the military assignment) immediately upon resumption of active
employment. Neither the waiting period requirement nor any Plan limitations with reference to pre-
existing conditions will apply. This provision is intended to comply with Federal law and, if it is in conflict
or incomplete in any way, Federal law will prevail.
Transfer of Coverage
If a husband and wife are both Employees and are covered as Employees under this Plan and one of
them terminates, the terminating spouse and any of his/her eligible and enrolled Dependents will be
permitted to immediately enroll under the remaining Employee's coverage without having to provide
evidence of good health. Such new coverage shall be deemed a continuation of prior coverage and
shall not operate to reduce or increase any coverage to which the person was entitled while enrolled as
the Employee or the Dependent of the terminated Employee. In order to transfer coverage to the
remaining employee a new application must be submitted on a timely basis. This transfer of coverage
provision is applicable to the dependent(s) of non married employees with documentation that both
employees are biological or legally adoptive parents of dependent(s).
COHO PLAN DOCUMENT JAN 2010 33
If a dependent who is covered under the Plan becomes an employee and meets the eligibility criteria of
the medical plan, they will be enrolled as a new plan member immediately. If termination from the Plan
occurs, and they still qualify as a dependent of an employee on the Plan, the dependent will be permitted
to immediately enroll as, that employee’s dependent again. In order to re-enroll as a dependent, the
employee’s enrollment documents must be updated, and a written request to add the dependent must
be submitted on a timely basis.
For all transfers to be considered timely, required documentation must be submitted no later than the
end of the month following the month in which the transfer criteria occurred.
Allowance for Prior “Creditable Coverage”
An individual (Employee or Dependent) who transfers to this Plan from another plan of "creditable
coverage” within 63-days (i.e., with not more than 63 days of non-coverage, not counting any days
applied toward waiting period requirements), has a right to demonstrate “creditable coverage” and to
request a certificate of creditable coverage from the prior health plan(s). This Plan will help any such
individual in obtaining such certificate(s). An individual also has the right to demonstrate creditable
coverage through the presentation of documentation or other means where a certificate of creditable
coverage cannot be obtained from the prior health plan(s).
If the prior coverage is determined to be "creditable coverage”, the Plan enrollee will be credited with
time covered under such prior plan(s) toward the time limits of this Plan's pre-existing condition limitation
or other time-covered requirements that may apply to Plan coverages.
"Creditable coverage” includes those coverages identified in H.R. 3103, such as coverage under a group
health plan (including a governmental or church plan), individual health insurance coverage, Medicare
(other than coverage solely under sec. 1928), Medicaid, military-sponsored health care, a State health
benefits risk pool, the Federal Employees Health Benefit Program, a public health plan as defined in
regulations and any health benefit plan of the Peace Corps Act.
COHO PLAN DOCUMENT JAN 2010 34
COORDINATION OF BENEFITS (COB)
Benefits provided under the Plan are subject to an industry-standard Coordination of Benefits (COB)
Briefly, the intent of COB is to avoid a duplication of benefits when an individual has coverage under
more than one plan, such as often occurs when both a husband and wife are employed. In such an
instance, the two (or more) plans will determine, between them, who will provide benefits on a “primary”
basis and who will provide “secondary” benefits.
For COB purposes an "Other Plan” will include:
group, blanket or franchise insurance coverage;
group automobile insurance;
any coverage under labor-management trusteed plans, union welfare plans, employer or professional
organization plans, or employee benefit organization plans;
any coverage under government programs including Medicare (Titles XVIII and XIX of the Social
Security Act as enacted of thereafter amended), CHAMPUS/CHAMPVA, and any coverage required or
provided by a statute. For purposes of implementing this provision, eligibility alone will constitute
any group coverage sponsored by or provided through a school or other educational institution.
To assure prompt claims handling, Claimants with more than one plan of coverage should be certain to
provide other coverage details (name of carrier, claims-paying address, policy no., etc.) when filing
1. COORDINATION OF THIS GROUP CONTRACT’S BENEFITS WITH OTHER BENEFITSS
This Coordination of Benefits (COB) section applies when a Member has health care coverage under
more than one Plan. The term “Plan” is defined below for the purposes of this COB section. The order of
benefit determination rules govern the order in which each Plan will pay a claim for benefits. The Plan
that pays first is called the Primary plan. The Primary plan must pay benefits in accordance with its
policy terms without regard to the possibility that another Plan may cover some expenses. The Plan that
pays after the Primary plan is the Secondary plan. The Secondary plan may reduce the benefits it pays
so that payments from all Plans do not exceed 100% of the total Allowable expense.
2. DEFINITIONS RELATING TO COORDINATION OF BENEFITS
Plan means any of the following that provides benefits or Services for medical, pharmacy, routine vision or dental
treatment. If separate contracts are used to provide coordinated coverage for members of a group, the separate
contracts are considered parts of the same plan and there is no COB among those separate contracts.
1. Plan includes: group insurance contracts, health maintenance organization (HMO) contracts, closed panel
plans or other forms of group or group-type coverage (whether insured or uninsured); medical care components
of group long-term care contracts, such as skilled nursing care; and Medicare or any other federal
governmental plan, as permitted by law.
2. Plan does not include: hospital indemnity coverage or other fixed indemnity coverage; accident only coverage;
specified disease or specified accident coverage; school accident type coverage; benefits for non-medical
COHO PLAN DOCUMENT JAN 2010 35
components of group long-term care policies; Medicare supplement policies; Medicaid policies; or coverage
under other federal governmental plans, unless permitted by law.
Each contract for coverage listed under 2.1 and 2.2 above is a separate Plan. If a Plan has two parts
and COB rules apply only to one of the two, each of the parts is treated as a separate Plan.
This plan means, as used in this COB section, the part of this contract to which this COB section applies
and which may be reduced because of the benefits of other plans. Any other part of this contract
providing health care benefits is separate from This plan. A contract may apply one COB provision to
certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another
COB provision to coordinate other benefits.
The order of benefit determination rules listed in Section 3 determine whether This plan is a Primary plan
or Secondary plan when a Member has health care coverage under more than one Plan.
When This plan is primary, We determine payment for Our benefits first before those of any other Plan
without considering any other Plan’s benefits. When This plan is secondary, We determine Our benefits
after those of another Plan and may reduce the benefits We pay so that all Plan benefits do not exceed
100% of the total Allowable expense.
Allowable expense means a health care expense, including deductibles, coinsurance and copayments,
that is covered at least in part by any Plan covering a Member. When a Plan provides benefits in the
form of Services, the reasonable cash value of each Service will be considered an Allowable expense
and a benefit paid. An expense that is not covered by any Plan covering a Member is not an Allowable
expense. In addition, any expense that a provider by law or in accordance with a contractual agreement
is prohibited from charging a Member is not an Allowable expense.
The following are examples of expenses that are NOT Allowable expenses:
1. The difference between the cost of a semi-private hospital room and a private hospital room is not an
Allowable expense, unless one of the Plans provides coverage for private hospital room expenses.
2. If You are covered by two or more Plans that compute their benefit payments on the basis of usual
and customary fees or relative value schedule reimbursement methodology or other similar
reimbursement methodology, any amount in excess of the highest reimbursement amount for a
specific benefit is not an Allowable expense.
3. If You are covered by two or more Plans that provide benefits or Services on the basis of negotiated
fees, an amount in excess of the highest of the negotiated fees is not an Allowable expense.
4. If You are covered by one Plan that calculates its benefits or Services on the basis of usual and
customary fees or relative value schedule reimbursement methodology or other similar
reimbursement methodology and another Plan that provides its benefits or Services on the basis of
negotiated fees, the Primary plan’s payment arrangement shall be the Allowable expense for all
Plans. However, if the provider has contracted with the Secondary plan to provide the benefit or
Service for a specific negotiated fee or payment amount that is different than the Primary plan’s
payment arrangement and if the provider’s contract permits, the negotiated fee or payment shall be
the Allowable expense used by the Secondary plan to determine its benefits.
COHO PLAN DOCUMENT JAN 2010 36
5. The amount of any benefit reduction by the Primary plan because You have failed to comply with the
Plan provisions is not an Allowable expense. Examples of these types of plan provisions include
second surgical opinions, precertification of admissions, and preferred provider arrangements.
Closed panel plan
A Closed panel plan is a Plan that provides health care benefits to Members primarily in the form of
Services through a panel of providers that have contracted with or are employed by the Plan, and that
excludes coverage for Services provided by other providers, except in cases of emergency or referral by
a panel member. If the primary plan is a closed panel plan and the secondary plan is not a closed panel
plan, the secondary plan shall pay or provide benefits as if it were the primary plan when a covered
person uses a non-panel provider, except for emergency services or authorized referrals that are paid or
provided by the primary plan.
A Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree,
is the parent with whom the Dependent child resides more than one half of the calendar year excluding
any temporary visitation.
3. ORDER OF BENEFIT DETERMINATION RULES
When a Member is covered by two or more Plans, the rules for determining the order of benefit
payments are as follows:
A. The Primary plan pays or provides its benefits according to its terms of coverage and without regard
to the benefits of any other Plan.
1. Except as provided in Paragraph (2) below, a Plan that does not contain a COB provision that is
consistent with the State of Oregon’s COB regulations is always primary unless the provisions of
both Plans state that the complying plan is primary.
2. Coverage that is obtained by virtue of membership in a group that is designed to supplement a
part of a basic package of benefits and provides that this supplementary coverage shall be
excess to any other parts of the Plan provided by the contract holder. Examples of these types of
situations are major medical coverages that are superimposed over base plan hospital and
surgical benefits, and insurance type coverages that are written in connection with a Closed
panel plan to provide out-of-network benefits.
C. A Plan may consider the benefits paid or provided by another Plan in calculating payment of its
benefits only when it is secondary to that other Plan.
D. Each Plan determines its order of benefits using the first of the following rules that apply. Rules are
applied in a sequential order:
1. Non-Dependent or Dependent. The Plan that covers a Member other than as a Dependent, for
example as an employee, Subscriber or retiree is the Primary plan and the Plan that covers the
Member as a Dependent is the Secondary plan. However, if the Member is a Medicare
beneficiary and, as a result of federal law, Medicare is secondary to the Plan covering the
Member as a Dependent; and primary to the Plan covering the Member as other than a
Dependent (e.g. a retired employee); then the order of benefits between the two Plans is
reversed so that the Plan covering the Member as an employee, subscriber or retiree is the
Secondary plan and the other Plan is the Primary plan.
COHO PLAN DOCUMENT JAN 2010 37
2. Dependent Child Covered Under More Than One Plan. Unless there is a court decree stating
otherwise, when a Member is a Dependent child and is covered by more than one Plan the order
of benefits is determined as follows:
a) For a Dependent child whose parents are married or are living together, whether or not they
have ever been married:
i. The Plan of the parent whose birthday falls earlier in the calendar year is the Primary
ii. If both parents have the same birthday, the Plan that has covered the parent the longest
is the Primary plan.
b) For a Dependent child whose parents are divorced or separated or not living together,
whether or not they have ever been married:
i. If a court decree states that one of the parents is responsible for the Dependent child’s
health care expenses or health care coverage and the Plan of that parent has actual
knowledge of those terms, that Plan is primary. If the parent with responsibility has no
health care coverage for the Dependent child’s health care expenses, but that parent’s
spouse does, that parent’s spouse’s Plan is the primary Plan. This rule applies to plan
years commencing after the Plan is given notice of the court decree;
ii. If a court decree states that both parents are responsible for the Dependent child’s health
care expenses or health care coverage, the provisions of Subparagraph (a) above shall
determine the order of benefits;
iii. If a court decree states that the parents have joint custody without specifying that one
parent has responsibility for the health care expenses or health care coverage of the
Dependent child, the provisions of Subparagraph (a) above shall determine the order of
iv. If there is no court decree allocating responsibility for the Dependent child’s health care
expenses or health care coverage, the order of benefits for the Dependent child are as
The Plan covering the Custodial parent, first;
The Plan covering the spouse of the Custodial parent, second;
The Plan covering the non-custodial parent, third; and then
The Plan covering the Dependent spouse of the non-custodial parent, last.
c) For a Dependent child covered under more than one Plan of individuals who are not the
parents of the Dependent child, the provisions of Subparagraph (a) or (b) above shall
determine the order of benefits as if those individuals were the parents of the Dependent
3. Active Employee or Retired or Laid-off Employee. The Plan that covers a Member as an active
employee, that is, an employee who is neither laid off nor retired, is the Primary plan. The Plan
covering that same Member as a retired or laid-off employee is the Secondary plan. The same
would hold true if a Member is a Dependent of an active employee and that same person is a
Dependent of a retired or laid-off employee. If the other Plan does not have this rule, and as a
result, the Plans do not agree on the order of benefits, this rule is ignored. This rule does not
apply if the rule labeled D(1) can determine the order of benefits.
COHO PLAN DOCUMENT JAN 2010 38
4. COBRA or State Continuation Coverage. If a Member whose coverage is provided pursuant to
COBRA or under a right of continuation provided by state or other federal law is covered under
another Plan, the Plan covering the Member as an employee, subscriber or retiree or covering
the Member as a Dependent of an employee, Subscriber or retiree is the Primary plan and the
COBRA or state or other federal continuation coverage is the Secondary plan. If the other Plan
does not have this rule, and as a result, the Plans do not agree on the order of benefits, this rule
is ignored. This rule does not apply if the rule labeled D(1) can determine the order of benefits.
5. Longer or Shorter Length of Coverage. The Plan that covered the Member as an employee,
Subscriber or retiree longer is the Primary plan and the Plan that covered the Member the
shorter period of time is the Secondary plan.
6. If the preceding rules do not determine the order of benefits, the Allowable expenses shall be
shared equally between the Plans meeting the definition of Plan. In addition, This plan will not
pay more than We would have paid had We been the Primary plan.
4. EFFECT ON THE BENEFITS OF THIS PLAN
When This plan is secondary, We may reduce Our benefits so that the total benefits paid or provided by
all Plans during a plan year are not more than the total Allowable expenses. In determining the amount
to be paid for any claim, the Secondary plan will calculate the benefits it would have paid in the absence
of other health care coverage and apply that calculated amount to any Allowable expense under its Plan
that is unpaid by the Primary plan. The Secondary plan may then reduce its payment by the amount so
that, when combined with the amount paid by the Primary plan, the total benefits paid or provided by all
Plans for the claim do not exceed the total Allowable expense for that claim. In addition, the Secondary
plan shall credit to its plan deductible any amounts it would have credited to its deductible in the absence
of other health care coverage.
If a Member is enrolled in two or more Closed panel plans and if, for any reason, including the provision
of Services by a non-panel provider, benefits are not payable by one Closed panel plan, COB shall not
apply between that Plan and other Closed panel plans.
5. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION
Certain facts about health care coverage and Services are needed to apply this COB section and to
determine benefits payable under This plan and other Plans. We may get the facts We need from, or
give them to, other organizations or persons for the purpose of applying this section and determining
benefits payable under This plan and other Plans covering a Member claiming benefits. We need not
tell, or get the consent of, any person to do this. Each Member claiming benefits under This plan must
give Us any facts We need to apply this section and determine benefits payable.
6. FACILITY OF PAYMENT
A payment made under another Plan may include an amount that should have been paid under This
plan. If it does, We may pay that amount to the organization that made that payment. That amount will
then be treated as though it were a benefit paid under This 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 the reasonable cash value of the benefits provided in the form of Services.
7. RIGHT OF RECOVERY
If the amount of the payments made by Us is more than We should have paid under this COB section,
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 the
COHO PLAN DOCUMENT JAN 2010 39
Member. The “amount of the payments made” includes the reasonable cash value of any benefits
provided in the form of Services.
COB Provisions With Respect to Medicare
In accordance with the Tax Equity Fiscal Responsibility Act of 1982 TEFRA - P.L. 97-248) and the
Deficit Reduction Act (DEFRA - P. L. 98-369), an active Employee or spouse, who has attained age 65
and is eligible for Medicare, may elect or reject medical coverage under This Plan, If such person elects
medical coverage under This Plan, the benefits of This Plan shall generally be determined before any
benefits provided by Medicare (i.e., This Plan will pay its benefits first and then the claims may be
submitted to Medicare for consideration). Covered Persons should be certain to enroll in Medicare
coverage in a timely manner to assure maximum coverage.
There may be an instance when, in accordance with Federal law, This Plan may assume a secondary
position to Medicare (i.e., Medicare will determine its liability first). If this should occur, This Plan
reserves the right to assume the secondary carrier position and benefits will be determined in
accordance with the Coordination of Benefits provision above. When This Plan may lawfully assume
a secondary position and an Employee or Dependent becomes eligible for the program of benefits
provided under Medicare, he is deemed to be covered by both Medicare parts “A” and "B" for all
purposes under this Plan. An Employee or Dependent is considered to be covered by Medicare on the
earliest date any coverage under Medicare could have been effective to him had he applied for Medicare
in a timely manner.
NOTE: If a Medicare-eligible Employee rejects coverage under the Plan, no Plan coverage will be
available for any of his Dependents.
COHO PLAN DOCUMENT JAN 2010 40
THIRD PARTY RECOVERY PROVISION
Right of Subrogation and Refund
This provision applies when a covered person incurs medical, dental or vision expenses for injuries or
illnesses that may be caused by the act or omission of a third party. In such circumstances, the covered
person or beneficiary may have a claim against that third party, or insurer, for payment of the medical,
dental or vision expenses.
Accepting benefits under the Plan for those incurred medical, dental or vision expenses automatically
assigns to the Plan any rights the covered person or beneficiary may have to recover payments from
any third party or insurer. This subrogation right allows the Plan to pursue any claim which the covered
person or beneficiary has against any third party, or insurer, whether or not the covered person or
beneficiary chooses to pursue that claim. The Plan may make a claim directly against the third party or
insurer, but in any event, the Plan has a lien on any amount recovered by the covered person or
beneficiary, whether or not designated as payment for medical expenses. This lien shall remain in effect
until the Plan is repaid in full.
The covered person:
· Automatically assigns to the Plan his or her rights against any third party or insurer when this provision
· Must repay to the Plan the benefits paid on his or her behalf out of the recovery made from the third
party or insurer.
For any amount subject to subrogation or refund, the covered person or beneficiary agrees to recognize
the Plan’s right to subrogation and refund. These rights provide the Plan with a priority over any funds
paid by a third party to a covered person relative to the injury or illness, including a priority over any
claim for non-medical, dental or vision attorney fees, or other costs and expenses.
Notwithstanding its priority to funds, the Plan's subrogation and refund rights, as well as the rights
assigned to it, are limited to the extent to which the Plan has made, or will make, payment for medical,
dental or vision expenses, as well as any costs and fees associated with the enforcement of its rights
under the Plan.
When a right of recovery exists, the covered person or beneficiary will execute and deliver all required
instruments and papers as well as doing whatever else is needed to secure the Plan’s right of
subrogation as a condition to having the Plan make payments. In addition, the covered person or
beneficiary will do nothing to prejudice the right of the Plan to subrogate. This right of refund also applies
when a covered person recovers under an uninsured or underinsured motorist plan (which will be treated
as Third Party coverage when reimbursement or subrogation is in order), homeowner's plan, renter's
plan, medical malpractice plan or any liability plan. The Plan Administrator has a right to request reports
on and approve of all settlements.
Recovery means money paid to the covered person or beneficiary by way of judgment, settlement, or
otherwise to compensate for losses caused by the injuries or illness, whether or not said losses reflect
medical, dental or vision expenses covered by the Plan. The right of refund also applies when a covered
person recovers under an uninsured or underinsured motorist plan, homeowner’s plan, renter’s plan,
medical malpractice plan or any liability plan.
Subrogation means the Plan’s right to pursue the covered person’s claims for medical, dental or vision
COHO PLAN DOCUMENT JAN 2010 41
against the third party.
Refund means repayment to the Plan for medical, dental or vision benefits that it has paid for care and
treatment of the injury or illness.
Assignment of Rights as a Condition to the Plan Making Payment
The covered person must assign to the Plan his or her rights to any recovery arising out of or related to
any act or omission which caused or contributed to the injury or illness for which such benefits are to be
COHO PLAN DOCUMENT JAN 2010 42
TERMINATION OF COVERAGE
Employee Coverage Termination
An Employee's coverage under the Health Care Coverages of the Plan shall terminate upon the earliest
of the following:
At midnight of the day when employee’s termination or ineligibility occurs;
termination of the Plan;
termination of participation in the Plan by the Employer;
the date the Employee becomes a full-time member of the armed forces of any country.
For active duty in the military services of the United States such date will be the date of active duty on
his/her “activation Orders.” However, if the U.S. active duty call-up is for less than 30 days and is then
extended, Plan coverage will continue until 12:00 midnight on the 30th day of active duty;
the date on which the covered Employee leaves or is dismissed from the employment of the Employer or
ceases to be eligible or engaged in active employment for the required number of hours as specified in
Eligibility and Effective Dates section - except when coverage is extended under the terms of any
employer based personnel policies.
Dependent Coverage Termination
A Dependent's coverage under the Health Care Coverages of the Plan shall terminate upon the earliest
of the following:
termination of the Plan;
termination of the coverage of the Employee, except when Employee's coverage terminates solely due
to Employee's exhaustion of his Maximum Plan Benefit (see Medical Schedule of Benefits);
the date of the Dependent's entry into the armed forces of any country;
the day the Covered Person no longer satisfies the Plan definition of Dependent, except when coverage
is extended under the terms of the provision entitled Extension of Coverage for Handicapped Dependent
the date of expiration of the period for which the Employee last made the required contribution for such
coverage, if Dependent's coverage is provided on a contributory basis (i.e., Employee shares in the
See section entitled Continuation of Coverage Option (COBRA) on page 46.
COHO PLAN DOCUMENT JAN 2010 43
EXTENSION(S) OF COVERAGE
Extension of Coverage for Handicapped Dependent Children
If an already covered Dependent child attains the age which would otherwise terminate his status as a
if on the day immediately prior to the attainment of such age the child was a covered Dependent under
the Plan; and
at the time of attainment of such age the child is incapable of self-sustaining employment by reason of
mental retardation or physical handicap or disability which commenced prior to the attainment of such
such child is primarily dependent upon the Employee for support and maintenance;
then such child's status as a "Dependent” shall not terminate solely by reason of his having attained the
specified age and he shall continue to be considered a covered Dependent under the Plan so long as he
remains in such condition, and otherwise conforms to the definition of “Dependent.”
The Employee must submit to the Contract Administrator proof of the child's incapacity within thirty-one
(31) days of the child's attainment of such age, and thereafter as may be required, but not more
frequently than once a year after the two-year period following the child's attainment of such age.
COHO PLAN DOCUMENT JAN 2010 44
EXTENSION OF BENEFITS
Extension of Coverage During Absence From Work
If an Employee fails to continue in active employment due to sickness, injury, maternity leave, or
approved leave of absence, the Employee may be permitted to continue Health Care Coverages for
himself and his Dependents, though Employee will be required to continue payment of employee cost of
coverage during such absence. However, any such plan of extended coverage offered by the Employer
must be written (see Employer personnel policies or any employee handbook prepared by the Employer)
and must be administered on a basis which precludes individual selection.
CTSI Headstart Plan members exception: Employees of the CTSI Headstart Program are exempt
from the Extension policy described above. During those months that the program is not active, benefits
will continue as if the program was active. Dependent coverage premiums remain the responsibility of
Any such extended coverage which is offered by the Employer and elected by the Employee shall
automatically and immediately cease on the earliest of the following dates:
the date the person becomes covered under any other group plan for benefits of a type similar to that
provided by this Plan;
the date of expiration of the period for which the last contribution was paid, if such contribution is
the date of termination of this Plan.
See section entitled Continuation of Coverage Option (COBRA), on page 46.
COHO PLAN DOCUMENT JAN 2010 45
CONTINUATION OF COVERAGE OPTION (COBRA)
In order to comply with the Consolidated Omnibus Budget Reconciliation Act of 1985, the Plan includes
a Continuation of Coverage Option which is available to certain Covered Persons whose Health Care
Coverage(s) under the Plan would otherwise terminate. This provision is intended to comply with that
This continuation shall run concurrently with any continuation period which may be mandated by state
NOTE: The COBRA option is also intended to comply with the Health Insurance Portability and
Accountability Act of 1996.
Definitions - When capitalized in this COBRA section, the following items will have the meanings shown
Qualified Beneficiary - A covered Employee or a Dependent of a covered Employee who was a
Covered Person on the date preceding the date on which the Qualifying Event occurred and whose
Participating Employer, in the Calendar Year prior to the Calendar Year of the Qualifying Event,
employed at least 20 employees on a typical business day (i.e., had 20 or more employees on at least
50% of its working days).
On or after January 1, 1997, a Qualified Beneficiary includes one or more children born to or placed for
adoption with a covered Employee during the period of COBRA continued coverage.
Qualifying Event - Any one of the following events which would result in the loss of coverage under the
Plan (see NOTE):
the death of the covered Employee;
the termination of employment of the covered Employee (other than by the Employee's gross
reduction in a covered Employee's hours of employment to an ineligible status;
the divorce or legal separation of the covered Employee from the Employee's spouse;
the Employee's coverage termination due to his becoming entitled to Medicare benefits;
the cessation of covered Dependent coverage by operation of Plan Document provision.
While an individual may incur more than one Qualifying Event, the length of continued coverage will
never exceed 36 months from the date of the first Qualifying Event.
NOTE: A Qualifying Event will also occur on the date an Employee's FMLA leave terminates, whether
or not the Employee continued Plan coverage during the leave for himself or his eligible Dependents.
For these purposes, an FMLA leave is ONLY a leave granted by the Employer in accordance with the
Family and Medical Leave Act of 1993 and, for these purposes, the date of termination of such leave
will NOT be affected by any state or local laws that may require the Employer to provide coverage for
longer than the FMLA requirements.
Notification - An Employee or Qualified Beneficiary must notify the Employer's Benefits Office or the
Plan Administrator within 60 days of the Qualifying Event in event of divorce, legal separation, or
Dependent child becoming ineligible.
COHO PLAN DOCUMENT JAN 2010 46
The Employer or Plan Administrator must notify Qualified Beneficiaries of their Continuation of Coverage
rights within 14 days after receiving notice of a Qualifying Event. Notice mailed to Qualified Beneficiary's
last known address will be considered adequate. Notice to a spouse is treated as notification to all other
Qualified Beneficiaries residing with spouse at the time notice is made.
Election and Election Period - Continuation of Coverage may be elected during the period beginning
on the date coverage would otherwise terminate due to a Qualifying Event and ending on the later of the
sixty (60) days after coverage ends due to a Qualifying Event;
sixty (60) days after the notice of the Continuation of Coverage Option rights is sent.
Each individual who would otherwise lose coverage is entitled to make an individual election which would
allow one to elect continued coverage even if others in the same family have declined or, if optional
benefits were available, an eligible Employee and his/her Dependents could elect different coverage(s).
Effective Date of Coverage - Continuation of Coverage, if elected within the period allowed for such
election, is effective retroactively to the date coverage would otherwise have terminated due to the
Qualifying Event and Qualified Beneficiary will be retroactively charged for coverage accordingly.
Level of Benefits - Continuation of Coverage elected hereunder will be equivalent to coverage provided
to a similarly situated person to whom a Qualifying Event has not occurred. If coverage is modified to
similarly situated Employees, the same modification will apply to Qualified Beneficiaries.
Also, Qualified Beneficiaries will be allowed to change their coverage upon the birth or adoption of a new
child, in the same manner and to the same extent that such changes are allowed for active Employees.
Cost of Continuation of Coverage - The cost of coverage may be paid in monthly installments and
such cost will not exceed 102% of the Plan's full cost of coverage, during the same period, for a similarly
situated Covered Person to whom a Qualifying Event has not occurred. The "full cost" includes any part
of the cost which may be paid by the Employer. Retroactive premiums must be paid by the Qualified
Beneficiary to the Plan within 45 days of election of Continuation of Coverage.
NOTE: For Qualified Beneficiaries who reside in a state with a health insurance premium program (by
whatever name it may be called), the state may pay the cost of COBRA coverage for a Qualified
Beneficiary who is eligible for health care benefits from the state through a program for the
medically-indigent or due to a certain disability(ies). Contact the Employer's personnel offices for
Termination of Continuation of Coverage - Coverage under this provision will terminate on the earlier
the end of thirty-six (36) months if the Qualifying Event is death of the covered Employee, divorce or
separation, Employee's entitlement to Medicare, or a Dependent child who no longer qualifies as a
the end of eighteen (18) months if the Qualifying Event is employment termination or reduction of hours
to non-eligible status. HOWEVER, a Qualified Beneficiary who is determined under Title 11 or Title XVI
of the Social Security Act to have been disabled at the time of termination or within the 60 days
thereafter (i.e., at the time of the Qualifying Event or at any time during the first 60 days of COBRA
coverage) may notify the Plan Sponsor of such disablement before the end of the 18-month period and
extend the continued coverage for 11 months (i.e., from 18 to 29 months) or until the Qualified
COHO PLAN DOCUMENT JAN 2010 47
Beneficiary is no longer disabled, if earlier. This 11-month extension option will also be available to
family members of the disabled Qualified Beneficiary. The cost of such extended coverage may be
150% of the full cost of an active enrollee's coverage for months 19 through 29;
the termination of all Employer- provided group health plans;
the failure to make timely premium payments to the Plan (coverage may be terminated if the beneficiary
is more than 30 days delinquent in paying his/her premium);
the date the Qualified Beneficiary becomes covered under another group health plan (whether or not as
an employee). However, if the new coverage contains any exclusion or limitation with respect to any
pre-existing condition of the Qualified Beneficiary and such exclusion or limitation is not prohibited by
H.R. 3103 (the federal Health Insurance Portability and Accountability Act of 1996), then such other
coverage will not end the continuation coverage period;
the date the Qualified Beneficiary becomes entitled to Medicare benefits.
COHO PLAN DOCUMENT JAN 2010 48
Proof of Loss
Written proof covering the details of loss for which a health care claim is made must be furnished to the
Contract Administrator (Claims Processing Unit) within ninety (90) days after the date of such loss.
Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it can be
shown that it was not reasonably possible to give proof within such time, provided such proof is
furnished as soon as reasonably possible and, in no event except in the absence of legal capacity of the
Claimant, later than twelve (12) months from the date on which covered charges were incurred.
Claims should be submitted as soon as possible after expenses are incurred to the following claims
processing unit’s address:
Samaritan Health Services
Attn: Claims Department
P. O. Box 1310
Corvallis, OR 97339
Assignments to Providers
All Eligible Expenses reimbursable under the Health Care Coverages of the Plan will be paid to the
covered Employee except that (1) assignments of benefits to Hospitals, Physicians or other providers of
service will be honored and (2) at the Plan's option and unless the Covered Person requests otherwise
in writing no later than the time for filing proof of loss, the Plan may pay benefits directly to providers of
Benefits due to any network provider will be considered “assigned" to such provider and will be paid
directly to such provider, whether or not a written assignment of benefits was executed.
Claim Denials and Member Appeal/Grievance Procedures
If the claims processing unit determines that a claim should be wholly or partially denied, the Claimant
will be given written notification of such denial. This notice will include:
the reason(s) for the denial;
specific reference to the Plan provision(s) on which the denial is based.
A Claimant may request a review of his claim, provided such request is filed in writing to the claims
processing unit (at the address shown above) within 60 days after the date his claim is denied. If the
claimant desires, the appeal may be filed directly with the Plan Administrator for delivery directly to the
Group Benefits Committee.
At such time as the Claimant requests a review of the denied claim, they may review any pertinent
documents and should submit issues and comments in writing to Samaritan Health Services, or the Plan
Administrator who will make all information available to the Group Benefits Committee.
The Group Benefits Committee will make a decision with regard to such claim not later than 60 days
after the receipt of the request for review, unless special circumstances require an extension of time. If
such an extension is required, written notice of the extension will be furnished to the Claimant prior to
the end of the initial 60 day period. The extension notice will explain the special circumstances requiring
an extension and the date the Committee expects to render the final decision.
The decision on review will be in writing, will include the specific reason(s) for the decision and will
reference the pertinent provisions on which the decision is based. If the claimant is not satisfied with the
determination of the Group Benefits Committee, he/she may appeal to the Tribal Court as the final
COHO PLAN DOCUMENT JAN 2010 49
STATEMENT OF RIGHTS OF EMPLOYEES
A participant in this Plan is entitled to certain rights and protections under this Plan. These rights and
protections are intended to comply with the intent of the Employee Retirement Income Security Act of
1974 (ERISA). The rights are:
to examine, without charge, at the Contract Administrator's office or at the Plan Sponsor's office, all Plan
documents, insurance contracts, and copies of all documents filed by the Plan with the U.S. Dept. of
Labor, such as Annual Reports and Plan Descriptions;
to obtain copies of all Plan documents and other Plan information upon written request to the Plan
Sponsor or the Contract Administrator. A reasonable charge may be made for the copies;
to receive a summary of the Plan's annual financial report which the Plan Sponsor furnishes to each
to file suit in Tribal Court if any materials requested are not received within 30 days of the request
unless notified that the materials were not sent because of matters beyond the control of the Plan
Sponsor or Contract Administrator. The court may require the Plan Sponsor to pay up to $110 for
each day of delay.
In addition to creating rights for Plan participants, this Plan imposes duties upon the people who are
responsible for the operation of the Plan (the Fiduciaries). Fiduciaries have a duty to operate the Plan
prudently and in the interest of Plan participants and beneficiaries. Fiduciaries who violate these duties
may be removed.
No one, including the Employer, may fire a Plan participant or discriminate against him to prevent him
from obtaining a welfare benefit or exercising rights under this plan.
If a participant is improperly denied a welfare benefit in whole or in part, he has the right to file suit in
Tribal Court. If Plan Fiduciaries are misusing the Plan's money, a participant shall have the right to file
suit in a Tribal Court or request assistance from the U.S. Department of Labor. If successful in such
lawsuit, the Court may, if it so decides, require the other party to pay his legal costs, including attorney's
Any questions about this Statement of Rights under this Plan should be brought to the attention of the
Employer, the Contract Administrator or the Plan Sponsor.
COHO PLAN DOCUMENT JAN 2010 50
FUNDING - SOURCES AND USES
The Health Care Coverage(s) afforded to an Employee by this Plan may require Employee contribution
(see Eligibility and Effective Dates section on page 31) but shall be at least partially funded by the
Employer. If an Employee elects to enroll Dependent(s) under the Plan, the Employee may be
responsible for payment of all or a portion of the Dependent contributions suitable to cover such
enrollment. For active Employees, the Employer shall deduct such costs on a regular basis from the
Employee's pre-tax wages or salary.
The Employer shall make contributions to the Plan for the Health Care Coverage(s) of Employees and
may contribute to the cost of Dependent coverage. These contributions and those paid by Employee, if
any, shall be placed in a special account or accounts administered by the Contract Administrator.
Plan Funded Benefits
The contributions will be applied to provide the benefits under the Plan.
Contributions may be used to purchase insurance coverage(s) to ensure that the Plan will meet its
self-funded Health Care Coverage obligations. The policy(ies) may be reviewed upon request submitted
to the Contract Administrator and/or the Plan Administrator. The Contract Administrator and/or Plan
Administrator are also available to answer any questions about the coverages.
Contributions will also be used to pay administrative expenses of the Plan in accordance with the terms
and conditions of an administration agreement between the Plan Sponsor and the Contract
Any premium or other taxes which may be imposed by any state or other taxing authority and which are
applicable to the coverages of the Plan shall be paid by the Plan Sponsor.
COHO PLAN DOCUMENT JAN 2010 51
Amendment or Termination of the Plan
The Plan Sponsor expects the Plan to be permanent, but since future conditions affecting the Plan
Sponsor or Employer(s) cannot be anticipated or foreseen, the Plan Sponsor must necessarily and does
hereby reserve the right:
to determine and/or waive eligibility for benefits or to construe the terms of the Plan;
to alter or postpone the method of payment of any benefit: and
to make any modifications or amendments to the Plan as are necessary or appropriate to
qualify or maintain the Plan as a plan meeting the requirements of the applicable sections of the
Internal Revenue Code or ERISA; and
to amend any provision of these administrative provisions, and
to terminate, suspend, withdraw, amend, modify or waive the Plan in whole or in part at any time.
Gender and Number
Except when otherwise indicated by the context, any masculine terminology shall also include the
feminine (and vice-versa) and any term in the singular shall also include the plural (and vice-versa).
No Employee, Dependent or other beneficiary shall have any right or claim to benefits from the Plan,
except as specified herein. Any dispute as to benefits under this Plan shall be resolved by the Plan
Sponsor under and pursuant to the Plan Document. No action may be brought for benefits provided by
the Plan or an amendment or modification thereof, or to enforce any right thereunder, until after the
claim has been submitted to and determined by the Plan and then action may only be brought within one
year after the date of such decision.
Misuse of Identification Card
If an Employee or covered Dependent permits any person who is not a covered member of the family
unit to use any identification card issued or fails to report a lost or stolen card, the Plan Sponsor may
give Employee written notice that his (and his family's) coverage will be terminated at the end of 31 days
from the date written notice is given.
Physical Examination and Autopsy
The Plan, at its own expense, shall have the right and opportunity to have a Physician of its choice
examine the Covered Person when and as often as it may reasonably require during the pendency of
any claim, and to make an autopsy in case of death, where it is not forbidden by law.
Rights Against the Plan Sponsor or Employer
Neither the establishment of the Plan, nor any modification thereof, nor any distributions hereunder, shall
be construed as giving to any Employee or any person any legal or equitable rights against the Plan
Sponsor, its shareholders, directors, or officers, or as giving any person the right to be retained in the
employ of the Employer.
The Plan Sponsor shall be substituted for all rights of an Employee to recover attorney fees against any
adverse party. Employees shall do nothing to prejudice such rights of the Plan Sponsor and further they
agree to do all acts necessary to preserve and take advantage of such rights. If payment has been
COHO PLAN DOCUMENT JAN 2010 52
made by the Plan in such instances and if the adverse party reimburses the Employee directly, the Plan
shall have the right to recover such payment from an Employee.
Type of Plan
This is an employee welfare benefit plan whose purpose is to provide certain welfare benefits for eligible
Employees of the Employer(s), their eligible Dependents, and Qualified Beneficiaries under COBRA.
If this Plan is subject to the terms of any collective bargaining agreement or if it is a multiple-employer
plan, a complete list of the employers and/or bargaining units participating in the Plan may be obtained
upon written request to the Plan Sponsor, and is available for examination by Covered Person and
beneficiaries at the office of the Plan Sponsor. Covered Persons and beneficiaries may receive from the
Plan Sponsor, upon written request, information as to whether a particular Employer or employee
organization is participating in the Plan and, if the Employer or organization is participating, the address
of such entity.
COHO PLAN DOCUMENT JAN 2010 53