Changes to Your Membership Information

Current information about you helps us serve you better. Have you recently changed your

• Name?
• Marital status? (Married, divorced, death of spouse)
• Family status? (Birth, death, adoption)
• Address?
• Medical coverage? (Changed to another plan)
• Employment status? (New job)

If there has been a change in your employer or personal information, let us know. You will need to work with your employer to complete a GVHP Membership Application and Change Form. (Your company's Human Resource department can usually help you.) Or, you can work with the GVHP Customer Services team to make any necessary address changes. Remember, we want to stay in touch with you. Up-to-date information helps us communicate better with our members.

Dependents need to be added within 30 days from the date of eligibility. The "date of eligibility" means the date on which a person can get benefits or services. Here are some GVHP time frames for adding new dependents:

• Newborns -- 30 days from date of birth
• New spouse -- 30 days from date of marriage
• Newly adopted child -- 30 days from formal date of adoption (that is, the date of adoption that appears on court papers)

Check with your employer, too. Your employer might have some other rules for adding new dependents.

There is other important information that might have changed. Have you:

• Moved out of the service area?
• Had a dependent turn 19?
• Had a dependent leave school or drop credits?

If you moved out of the service area, you may still be eligible for GVHP benefits. If you wish to continue your coverage, call the GVHP Customer Service team at 616-949-2410. You must complete an Out-of-Area Waiver Form. For more information see the Out-of-Area Waiver section.

GVHP coverage for children normally ends at age 19. This means your son or daughter is covered until the end of the calendar year he or she turns 19 or as specifically noted in your employers eligibility rules. Some employer groups offer dependent coverage to full-time students who are between the ages of 19 and 25 years of age. Check with your employer to find out if you have student coverage and the age requirement. We also verify student and dependent coverage. For further details, see Special Situations: Proof of Eligibility in this section.

Family dependents who do not have the student option, may choose either their COBRA option or the GVHP conversion plan. For more information, see Group or Individual Conversion Privilege and Your Rights under the Health Insurance Portability and Accountability Act in this section.

Special Situations: Proof of Eligibility

There are certain eligibility conditions that GVHP looks at from time to time. These are called "special situations." They include the following:

• Student Verification
• Disabled Dependent
• Incapacitated Dependent Status

Here are some of the things we look for when reviewing eligibility for "special conditions:"

1. Is the dependent attending school full-time?
2. Is the school a recognized college or university? Or, is it a recognized trade or secondary school?
3. Does the dependent meet the requirements as described by the Internal Revenue Code (IRS) to maintain dependent status?
4. Is the dependent unmarried?
5. Does the dependent live at home?
6. Is the dependent unable to support himself or herself?

These are just a few things we ask. Each "special situation" has certain conditions. We do this to make sure the person is "eligible." We want to make sure your dependent can receive care

For more information, see your Certificate of Coverage, Article IV: Eligibility Requirements. Also, look at your riders, or call your Customer Service team at 616-949-2410.

Out-of-Area Waiver

To be a GVHP member, you must live or work in the GHVP service area. If you live "out-of-area", you still may be eligible. This means you could still receive services and benefits at your GVHP Family Practice Office. (For more information about the GVHP service area, see the section called GVHP Service Area.)

The following are "out-of-area" conditions that may mean you can continue your GVHP coverage:

1. You must work in the GVHP service area.
2. You must also meet the eligibility rules of your employer and the GVHP Certificate of Coverage.
3. You must be able to come in-area for all covered services. Emergency care is, however, covered out-of-area.

What do you need to do if you live "out-of-area", and actively work in the service area, are not a conversion retiree, and want to continue your GVHP coverage? Just complete an Out-of-Area Waiver form. When you sign this form you are saying you understand GVHP services are only available in the GVHP service area. You agree to come "in-area" for routine medical care. Out-of-area medical emergencies are covered if out-of-the area.

The Out-of-Area Waiver form does not apply to students or members who are "temporarily absent." Students are covered under the student option or a student rider from the GVHP service area. "Temporarily absent" means that you will not be outside the GVHP service area for a period of time greater than ninety (90) consecutive days.

If you have any questions about the requirements for an Out-of-Area Waiver, please call the GVHP Customer Service Team at 616-949-2410.

Other Insurance Coverage

You may have other insurance that gives you the same or similar benefits as GVHP. If you do, it is important that GVHP knows this. Some examples of other insurance include Blue Cross and Blue Shield, Medicare or Medicaid. WorkerÕs compensation and auto no-fault insurance can give coverage.

You can give us information about your other insurance when you complete the GVHP Membership Application and Change Form. You can also give us this information when you visit your Family Practice Office. (See Checking-In for Your Appointment.) Or, you can call your GVHP Customer Service team at 616-949-2410 to let us know about other insurance coverage. It is important we know about other insurance coverage. It helps us coordinate your benefits. (See Coordination of Benefits and Subrogation in the next section.)

For Auto No-Fault insurance, there are a few things you should know. This is also true for Worker's Compensation. We would like to share this with you.

You must have Auto No-Fault insurance if you own a car in the State of Michigan. If you are in a car accident, GVHP might cover your medical care. GVHP covers your medical care if we are "primary." This means we pay first when your car insurance does not cover medical care. This is called "coordinated coverage." However, you could have a policy with medical benefits. If you do, your car insurance is primary. This means it covers your medical care. We call this "uncoordinated coverage." Your car insurance might also cover other medical expenses. This is good because GVHP might not cover all your expenses. GVHP follows State of Michigan requirements for covering medical care due to car accidents. For more information, see your Certificate of Coverage, Article IV: Auto No-Fault and Worker Compensation.

Your GVHP Certificate of Coverage does not, however, cover services for work-related injuries. These are usually covered under your employer. Please report all work-related injuries to your employer. If GVHP takes care of you during your illness or injury, we can ask for payment from your employer's Worker's Compensation plan. GVHP also follows State of Michigan requirements for medical care due to work accidents. For more information, see your Certificate of Coverage, Article IV: Auto No-Fault and Worker Compensation. See information about Subrogation in the next section of your handbook.

Coordination of Benefits and Subrogation

Coordination of Benefits (COB) is a process of applying benefits when there are two or more insurance plans. This is done so benefits from all sources do not go over 100% of what is covered. It means benefits are not "duplicated." That is, only one "benefit" will ever be paid. So, under COB, you never get more benefits than what one insurance plan would pay.

When you are covered by two GVHP policies, you have dual membership. When GVHP and another insurance plan cover you, you have dual coverage. Benefits are usually "coordinated" for both situations. However, each plan must be "effective" on the date the service is given. This means you must be covered or eligible to receive benefits under the insurance plan.

If you are covered by two or more plans, all of them could pay for the same service. This would not be correct. Nor is this the intent of coverage. Then, who really should pay? Let's learn a little more about COB.

COB requires that one plan pay first. But, which plan should? Here are some general rules about who pays first:

• If you are the subscriber, GVHP pays first FOR YOUR HEALTH EXPENSES. This means GVHP is PRIMARY. Remember that you are the subscriber if you are the one who pays the premium.
• If you are covered under your spouse's plan, this plan pays second or is SECONDARY.
• If you have children, in Michigan, the birthday rule is used to figure out who is primary. This means that the plan of the spouse who has the earliest birthday in the year pays first on the children. For example, if your birthday falls in July but your spouse's falls in September, your plan is primary.

When GVHP is secondary, we coordinate benefits. However, there are a few things to remember about secondary coverage.

• Under the Michigan COB Act, a health maintenance organization (HMO) does not have to pay claims or benefits if it did not authorize them.
• If a service or benefit was not covered by GVHP but is under the primary plan, we would not pay it.
• When coordinating benefits, Grand Valley Health Plan does not duplicate benefits. This means Grand Valley Health Plan will not pay more on a claim as a secondary payer than what GVHP would originally have paid for the claim. This is even true when your primary insurance may have already paid for some of the claim. Here is an example of this. If your primary insurance paid 50% on a claim and your GVHP benefit as a secondary insurer is also at 50%. Grand Valley Health Plan would not pay anything additional on the claim. You would still be responsible for the remaining balance.

DonÕt be disappointed if all of your plans together do not pay the total amount of the original bill. Having more than one insurance does not always mean that you will not have any out-of-pocket expenses. This means your bills still may not be covered at 100 percent.

There are a few times when someone might have three plans in effect at the same time. This is common for people who become Medicare eligible. So, how is this handled? Here is a general "rule of thumb." If you are Medicare eligible and your spouse is actively employed at a company of 20 or more employees, GVHP is primary. Federal law requires this. Medicare is then secondary. Benefits from the other plan are third.

For more information about how GVHP coordinates benefit, see your Certificate of Coverage, Article IV: Coordination of Benefits. Or, call your GVHP Customer Service team at (616) 949-2410.

Subrogation is a legal term. It means to replace one person for another when a rightful claim is due from the other person or party. This other person or party could be covered by other insurance. Or, a lawsuit might be settled. GVHP has the right to recover the money for the claim from the other source.

Here's another way to look at subrogation. GVHP pays for or provides a medical service or benefit. We then learn the claim was due to another person or party's fault. For example, you were hurt while fixing something in your home. Your homeowner's insurance might pay for your medical care. Or, your child hurts himself or herself while playing at school. The school has general liability insurance to cover the cost of care.

Or, you are injured on the job. Your employer's Worker Compensation plan might cover the cost of your medical bills. For these or similar situations, GVHP has the right to recover its medical costs.

As a GVHP member, you agree to cooperate with the subrogation process. Subrogation can save health care dollars by making the responsible person or party pay.

For more information about subrogation, see your Certificate of Coverage, Article IV: Subrogation. Or, call your GVHP Customer Service team at (616) 949-2410.

Termination of Membership

Your membership may end for a number of reasons. Your employer may cancel its contract with GVHP. Or, you or your dependent may become ineligible for membership. This could happen due to divorce. The marriage of a dependent child can end membership. Also, when a child reaches the age of 19, membership can end. Becoming an emancipated minor can also end membership. (An emancipated minor is a child being declared by a court of law to be an "adult." The court has said the child is able to handle his or her own affairs.) If membership ends for one of these reasons, this is called "termination without cause."

You may also lose your membership for other reasons. It could end due to you not paying your premium. It could end because you did not let GVHP subrogate your rights of recovery. It could end because you were not able to establish a satisfactory physician-patient relationship. It could end for refusing to follow medical advice or treatment plan. It could end for intentionally submitting false information, or committing fraudulent acts to obtain benefits. This is called "termination for cause."

For more information, see also your Certificate of Coverage, Article IV: General Provisions, Termination.

Group or Individual Conversion Privilege

If you lose your job, you can still be covered by GHVP, or, if your child is no longer eligible, he or she can still be a GVHP member. When this happens, you then have the option to change to the GVHP conversion plan. The GVHP conversion plan offers you the basic GVHP medical benefits. There are no riders, however.

There are a few times when you might not be accepted for the conversion option. For example, if you do not live in the service area, you are not eligible for this plan. If you lose your job due to "gross misconduct," you could not get this option. If you fail to pay your premium, you would not be accepted for this option. You also are not eligible if you commit fraudulent acts with your health insurance. It is important to remember you must elect and make your first premium payment for Conversion within 30 days of your group coverage termination date with Grand Valley Health Plan.

You may choose to elect the conversion option when there is no other coverage available to you. It is important to know you may also be eligible for coverage under COBRA when you lose coverage under your group health plan. This is the Consolidated Omnibus Budget Reconciliation Act of 1985, also known as COBRA. This is a federal law. It extends coverage for you and your dependents under certain circumstances. For more information about COBRA, see your Rights Under HIPAA below. For more information about your conversion option, call the GVHP Customer Service team at (616) 949-2410.

Your Rights Under the Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act of 1996 is also known as HIPAA. It is a federal law. It gives you the right to "carry" health coverage with you. The Michigan Patient Protection Act also assures you of this right.

What does it mean to "carry" your health coverage? Your health coverage is "portable." That is it goes with you from job to job. It means you will get "credit" for coverage. For example, you might take a job where your health plan has a "waiting period." This means if you have a "pre-existing" medical condition, you have to wait to be covered by your new plan. Under HIPAA, you can get coverage sooner. You receive "credit" for the time you had coverage under your old plan. This is applied to your new plan's waiting period. Often it means you have no "waiting period."

GVHP does not have any "pre-existing" clauses on group or conversion coverage. When you choose GVHP, you are eligible for coverage on the date your employer says you are. If you have coverage on an individual policy a "pre-existing" clause may be in affect.

How else does HIPAA work? Under HIPAA, you receive a Certificate of Creditable Coverage when you leave your job. This tells you and your next plan how long you had health insurance. You then receive "credit" for coverage that happened without a break of 63 days or more. Any pre-existing condition before the break in coverage of 63 days would, however, not be credited.

HIPAA does not mean you can carry over your current health benefits. It does not mean you can take your current plan with you.

HIPAA also extends COBRA coverage for certain situations. If you work for a company with 20 or more employees, you have COBRA rights. If you work for a company with less than 20 employees, you may not be eligible for COBRA.

So, what is COBRA? The Consolidated Omnibus Budget Reconciliation Act of 1985 is also known as COBRA. This is a federal law. You and your dependents have certain rights under this law.

You and your dependents are eligible for the option of extending you health coverage under your current plan. Certain "qualifying events" must happen. A "qualifying event" means one of the following:

• Voluntary or involuntary loss of employment. Loss of a job for "gross misconduct" is not included.
• Reduction in hours of employment or coverage
• Becoming eligible for Medicare
• Divorce or legal separation
• Death of covered employee
• Loss of "dependent child" status
• Retirees covered by retirement company plan filing for bankruptcy under Title 11

When one of these events happens, COBRA gives you the option to continue your benefits. It also "extends" the time period for coverage. You must be eligible on the day of the qualifying event. The following are the periods of extended coverage under COBRA:

In the case of individuals who qualify for Social Security Disability, special rules apply. Coverage is extended an additional eleven (11) months. Those individuals are eligible for twenty-nine (29) months of coverage under COBRA.

You learn of your COBRA rights when you receive an initial notice. This is done at the time you are first hired. When you leave your job, you will again receive a "special notice." Your employer has thirty (30) days from the date of your "qualifying event" to notify the plan administrator. Once the plan administrator learns of the "event," it has fourteen (14) days to let you know. You have sixty (60) days to elect coverage under COBRA. You have forty-five (45) days after telling your employer or plan administrator to make your COBRA payment.

PLEASE NOTE: GVHP WILL ONLY GIVE YOU CARE ON A FEE-FOR-SERVICE BASIS UNTIL YOU MAKE YOUR COBRA PAYMENT. YOU WILL BE PAID BACK FOR THESE SERVICES, ONCE YOU HAVE ELECTED AND MADE YOUR COBRA PAYMENT.

Your employer usually handles you and your dependents' COBRA rights. Call your Human Resource department to learn more. Ask for information about how to obtain COBRA. You may also call your GVHP Customer Service team at (616) 949-2410.

Your Rights Under the Employers Retirement Income Security Act (ERISA)

As a member of a group health plan, you have certain other rights and protections. These come to you through The Employers Retirement Income Security Act of 1974. This federal law is also known as ERISA. ERISA covers what employers must do for the pension, health and welfare benefits of their employees. You can learn more about your rights under ERISA. Your Certificate of Coverage gives you more information. See Appendix A of your certificate. Please take the time to look over this very important information.

Your Rights Under Other Laws

Certain federal laws also give you rights or benefits. State laws also give you certain benefits. These laws require that GVHP and other managed care organizations meet certain conditions. They also say we must cover certain services. GVHP wants you to know that we follow the conditions of these laws. Sometimes these laws say we must tell you about benefit changes. We tell you about new laws or changes to your benefits through our member publication, HealthLine. You may also be informed by letter.

Here is some brief information about recent laws that affect your health care coverage.

Women's Health & Cancer Act of 1998

This is a federal law. It requires health plans that cover mastectomies (surgery for removal of the breast due to malignant breast tumors) to also cover other aspects of treatment. The following services must be covered:

• Reconstruction of the breast on which a mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and any physical complications resulting from the mastectomy, including lymphedemas (swelling and fluid retention of the lymph nodes)

The law states that an appropriate care plan will be determined. This plan will be done in consultation between the GVHP member and her physician. Coverage is, of course, subject to any applicable copayments consistent with your GHVP certificate and riders. The law became effective for plan years beginning on or after October 21, 1998.

Newborns & Mothers Health Protection Act of 1996.

This is a federal law. It requires certain lengths of stay for mothers and newborns. These are:

• 48-hour length of stay for normal vaginal deliveries (NSVDs)
• 96-hour length of stay for caesarian section (C-sections) deliveries

The required length of stay is for both mother and child. This means that a newborn child's hospital stay could be longer than his or her mother's stay. Or, the mother's stay could be longer than the child's. The attending physician may decide, after discussion with and agreement by the mother, to discharge mother and baby earlier than the required length of stay.

GVHP has never assigned length of stays. We have always worked with the attending physician (doctor who delivered your baby), and allowed length of stays as ordered by the doctor. We want you to know that we do meet the requirements of this law.

Well Woman Examination and Routine Gynecological Care.

This law allows a female member to directly go to an obstetrician/gynecologist (OB/GYN) for an annual well- woman examination and routine gynecological care. An OB/GYN is a medical specialist in the areas of pregnancy, labor, delivery, and after-care as well as female illnesses and conditions. An annual well-woman examination means a visit for a health exam or physical. Routine gynecological care means a pap, pelvic and breast examination. Both of these are annual benefits.

In summary, this law allows:

• A female member may have an annual well woman visit and/or routine gynecological exam with an OB/GYN.
• This visit does not need a referral (authorization) if the visit is with an in-network (GVHP OB/GYN Panel) OB/GYN.
• The visit needs a referral (authorization) if the visit is not with an in-network OB/GYN.

For a listing of the GVHP OB/GYN Panel, call your GVHP Family Practice Office or your GVHP Customer Service team at 616-949-2410.

Diabetes Mandate Bill

This law began April 1, 2001. This law ensures that all diabetics have some coverage for their diabetic medical supplies through their insurance company. Grand Valley Health Plan will provide coverage for diabetic medical equipment supplies such as blood glucose monitors, test strips, and lancets. This equipment will be covered under your Durable Medical Equipment benefit after a 50 percent copayment under your base Certificate of Coverage.

There are a few things to keep in mind in order to be eligible for this coverage.

• Grand Valley Health Plan does require that you have regularly scheduled appointments at your GVHP Family Practice Office for your diabetic care along with participating in the Diabetic Disease State Management Program at your GVHP Family Practice Office. If you have questions about the program, please contact your GVHP Family Practice Office.
• Grand Valley Health Plan also requires that all supplies are ordered and obtained through your GVHP Family Practice Office. When you are in need of supplies simply contact your GVHP Family Practice Office and they will make the necessary arrangements.

If you have any questions about these specific laws, please contact your GVHP Family Practice Office or your GVHP Customer Service Team at 616-949-2410.