Yearly curriculum inventory report by budget programs areas

THE INDEMNITY HEALTH
BENEFITS PLAN
THE UNIVERSITY SYSTEM OF GEORGIA
Plan Design Effective January 1, 2004 Booklet Revised July 2004

RESOURCE CONTACTS

Should you have questions regarding your indemnity health benefits plan, please contact the appropriate resource(s) identified below:

For Questions About

Please Contact

Claims/Coverage Provided by Campus Human Resources/

the Plan

Personnel Office

Location
Your Institution

Participating Providers For information regarding the
participating providers in: (1) the BCBSGA Participating Physician Network (within the
State of Georgia) or
(2) the BCBS National Participating Provider Network (outside of the State of
Georgia) Pre-certification for Specific
Outpatient/All Inpatient Hospital Services

Blue Cross Blue Shield of Georgia
Blue Cross Blue Shield of Georgia
Blue Cross Blue Shield Association Customer Service
UNICARE

1-800-424-8950 TDD/404-842-8073
1-800-424-8950 TDD/404-842-8073
1-800-810 BLUE (2583)
1-800-233-5765 TDD/1-800-368-4424

MEDCALL For emergency room referral and for medical information from a registered nurse, 24-hours a day,
seven days a week.

UNICARE

1-800-785-0006 TDD/1-800-368-4424

Disease State Management UNICARE Program

1-800-790-2507 TDD/1-800-368-4424

Organ and Tissue Transplant UNICARE Program

1-800-828-6518 TDD/1-800-368-4424

Pharmacy Benefit Program Express Scripts, Inc.

1-877-650-9341 TDD/1-800-842-5754

HIPAA Coverage

Secretary

U.S. Department of Health and Human Services Office of Civil Rights, Region IV 61 Forsyth St. SW, Suite 3B70 Atlanta, GA 30303-8909 404-562-7886 (metro Atlanta) 1-866-627-7748 (outside of metro Atlanta)

University System of Georgia health benefits website: www.usg.edu/admin/humres/benefits/health/

TABLE OF CONTENTS

1 YOUR INDEMNITY HEALTH BENEFITS PLAN

1 Introduction

2 Benefits at a Glance

11 Who Can Enroll

11 How to Enroll

11 Dependent Coverage

12 When Employee Coverage Begins

13 When Dependent Coverage Begins

13 Adding or Deleting Dependents

14

Full-Time Student Verification Process for Dependents Between the Ages of 19-25

14

Change of Full-Time Student Status Upon Attainment of Age 26

15 USG Open Enrollment Period

15 The Cost of Your Healthcare Coverage

15 Qualifying Events for Changes in Healthcare Plan Coverage

17 Continuation of Healthcare Coverage into Retirement

17 USG Retiree Annual Change Period

18 Qualifying Events for Changes in Retiree Healthcare Plan Coverage

19 Permissible USG Retiree Healthcare Plan Changes

19 The Annual Deductible

19 The Maximum Annual Out-Of-Pocket Limit (Stop Loss)

20 Maximum Lifetime Benefit

21 Administrative Agents/Business Associates

21 HOW YOUR INDEMNITY HEALTH BENEFITS PLAN WORKS
22 The Participating Physician Program-BCBSGA Participating Physician Program (Within the State of Georgia)
23 The National Participating Provider Network-BCBS National Participating Provider Network (Outside the State of Georgia)
24 Wellness Care/Preventive Healthcare 24 Treatment of Diseases of the Eye 25 BlueChoice Vision Program 25 Hospital Inpatient Care Diagnostic Related Group (DRG) Rates 26 Second Medical Option for Elective Surgery 26 Medical Utilization Management Review Program 28 Maternity and Newborn Infant Nursery Care Benefits 29 Newborn's and Mother's Health Protection Act of 1996 29 Women's Health and Cancer Rights Act of 1998 29 Pre-Certification for Certain Outpatient Procedures/Diagnostic Tests 31 Medical Case Management 31 Extended Care Facility 32 Home Healthcare Services 32 Durable Medical Equipment (DME)

33 Hospice Care Services

34 Disease State Management Program (DSM)

35 MedCall Program

36 Organ and Tissue Transplant Program

36 Covered Expenses

39 Mental Health and Substance Abuse Treatment

40 Mental Health Sustance Abuse Service Providers

40

BCBSGA Prudent Buyer Program (Within the State of Georgia)

40

BCBS National Participating Provider Network (Outside the State of Georgia)

41 Pharmacy Benefit Management (PBM) Program

43 Expenses the Indemnity Healthcare Plan Does Not Cover (Exclusions)

45 When Your Indemnity Healthcare Plan Coverage Ends

46 When Your Indemnity Healthcare Plan Coverage for Your Eligible and Covered

Dependent(s) Ends

47 Coverage For Active Employees Age 65 or Over

47 Coverage After Retirement

48 Extended Healthcare Coverage for Dependents After the Death of a Covered Employee

48 Filing Paper Claims/Use of Physician Who Is Not A Member of the Indemnity

Healthcare Programs or Network

48

Use of a Non-Participating Provider Within the State of Georgia

49

Use of a Non-Participating Provider Outside of the State of Georgia

49

General Information Required to File a Claim

50 Filing Paper Claims/Foreign Claims While Traveling Abroad

51 Denial of a Medical Claim by BCBSGA

51 Appealing a Denied Claim

52 Assignment of Benefits

52 Subrogation

52 ADMINISTRATIVE INFORMATION

52 Coordination of Benefits (COB)

55 Your COBRA Rights

57 Health Insurance Portability and Accountability Act (HIPAA)

Notice of Privacy Practices

63

Consent for Authorization for Use/Release of Health Information Form

65 Future of the Plan

65 Employment Rights Not Implied

65 Glossary of Terms

69 LEGISLATION PASSED BY THE 2004 GEORGIA GENERAL ASSEMBLY AND SIGNED BY THE GOVERNOR

BOR Indemnity Health Benefits Plan Summary Document
YOUR INDEMNITY HEALTH BENEFITS PLAN
INTRODUCTION
This booklet describes the Board of Regents Indemnity Health Benefits Plan (the plan), available to employees and retirees of the University System of Georgia (the System), effective January 1, 2004.
Your health benefits plan is designed with two important goals in mind. The primary purpose of the healthcare plan is to provide you and your family with access to medical care in the event of an illness or serious injury. Your indemnity healthcare plan will offset member costs for medically necessary treatment of covered illnesses and/or injuries.
The second goal of the health benefits plan is to encourage covered members and their families to take an active role in decisions regarding their healthcare. That involvement begins with reading this booklet and with learning how the indemnity healthcare plan works. It is your responsibility to make efficient use of the coverage provided by the plan. Should you have questions regarding your benefits, as presented in this booklet, please contact your campus Human Resources/Personnel Office, or, the appropriate vendor. Vendors are listed on the inside front cover of this plan summary document.

Indemnity Plan Design - Effective January 1, 2004

1

Booklet Revised July 2004

BENEFITS AT A GLANCE

Provided for your information is a summary of selected benefits that are available to you and your family under the plan:

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Maximum Lifetime Benefits (Medical & Pharmacy Benefits Combined) Annual Deductible
Individual Family (3 or more covered members)

$2 Million
$300 $900

Maximum Annual Out-of-Pocket Limit (Stop Loss)
Individual Family

$2,000 $4,000

Annual deductibles, annual maximum out-ofpocket limits (stop loss), and annual visit limitations, will be based upon a January 1 - December 31 plan year.

Member co-payments for prescription drugs do not apply toward the annual deductible or toward the maximum annual out-of-pocket (stop loss) limit.

Pre-Existing Conditions

Member costs incurred for balance billing will not apply toward the annual deductible or toward the maximum annual out-of-pocket (stop loss) limit. None

Physician Services Provided In An Office Setting

80% of UCR charges for non-surgical services; subject to deductible.

Physician Office Visit

For treatment of illness or injury

Wellness Care/Preventive Healthcare
Physical Exam, Mammogram, Pap Smear, Prostate Exam/PSA, Well-baby Care and Immunizations, Adult Immunizations, Routine Eye Exams, Routine Hearing Exams

$500 per person per plan year; paid at 100% of UCR; not subject to deductible.
The maximum wellness benefit that a covered member may receive is $500 per person per plan year, regardless of the network affiliation
of the provider.

Indemnity Plan Design - Effective January 1, 2004

2

Booklet Revised - July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Laboratory Services

80% of UCR charges; subject to deductible.

(Exclusive of Wellness Care/Preventive Healthcare)

Laboratory, X-ray, Allergy Testing, Injectable Medications, and Diagnostic Tests

Injectable medications that are provided in a physician's office may be covered under medical benefits.

Pre-certification for diagnostic testing may be required by UNICARE.

Maternity Care

90% of UCR charges; subject to deductible.

(Prenatal, Delivery and Postnatal)

Outpatient Surgery

90% of UCR charges; subject to deductible.

Pre-certification may be required by UNICARE.

Allergy Testing, Shots and Serum

80% of UCR charges; subject to deductible.

Second Surgical Opinions (Elective Surgery)

100% of UCR charges; not subject to deductible.

Treatment of TMJ

80% of UCR charges; subject to deductible.

(Temporomandibular Joint Disorders)

Lifetime benefit limit of $1,000.

For diagnostic testing & non-surgical treatment

Pre-certification may be required by UNICARE.

Indemnity Plan Design - Effective January 1, 2004

3

Booklet Revised - July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Inpatient Hospital Services
Physician Services Physician Care/Surgery
Physician services may include surgery, anesthesiology, pathology, radiology, and/or maternity care/delivery.
Pre-certification is required by UNICARE.

90% of UCR charges for surgeon, subject to deductible.
80% of UCR charges for anesthesiologist, pathologist, or radiologist services/consultations; subject to deductible.
Some surgeons and/or some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists
and/or radiologists) providing services may not be part of the BCBSGA Participating Physician Program/BCBS National Participating Provider Network.

Failure to access these BCBS programs or networks will result in the member being
subject to balance billing.

Hospital Services Other Than Those For Emergency Room Care
Inpatient Care (Includes inpatient short term rehabilitation services)
Pre-certification is required by UNICARE.

In-State Hospitals 90% of contracted DRG rate; limited to semi-
private room rate; subject to deductible.
Out-of-State Hospitals 90% of UCR charges for service area; limited
to semi-private room rate; subject to deductible.

The use of a non-BCBS National Participating Provider Network facility, outside of Georgia,
will result in benefit coverage at 90% of contracted State of Georgia DRG rate; subject
to deductible and balance billing.

Maternity Care (Delivery)

90% of contracted DRG rate; subject to deductible.

Indemnity Plan Design - Effective January 1, 2004

4

Booklet Revised - July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Laboratory Services

90% of UCR charges; subject to deductible.

X-ray, Laboratory Work, Diagnostic Testing. Provided in conjunction with the treatment of an illness or injury.

Pre-certification for diagnostic testing may be required by UNICARE.

Hospice Care

90% of UCR charges; subject to deductible.

Pre-certification is required by UNICARE.

Outpatient Hospital/Facility Services
Physician Services Physician Care/Surgery
Physician services may include surgery, anesthesiology, pathology, radiology, and/or maternity care.
Pre-certification may be required by UNICARE.

90% of UCR charges for surgeon; subject to deductible.
80% of UCR charges for anesthesiologist, pathologist, or radiologist services/consultations; subject to deductible.
Some surgeons and/or some hospital-based physicians (examples: emergency room physicians, anesthesiologists, pathologists
and/or radiologists) providing services may not be a part of the BCBSGA Participating Physician Program/BCBS National Participating Provider Network.

Failure to access these BCBS programs or networks will result in the member being
subject to balance billing.

Indemnity Plan Design - Effective January 1, 2004

5

Booklet Revised July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Facility Selected by a Treating Physician which is a Plan Approved Facility
Treatment/care provided in an outpatient setting may require precertification by UNICARE.

90% of UCR charges in a Plan approved facility; subject to deductible.
Failure to use a Plan approved facility will result in the member being subject to balance
billing.
For identification of a Plan approved facility, within the State of Georgia, please contact BCBSGA Customer Services at 1-800-424-8950/TDD 404-842-8073.

For identification of a Plan approved facility, outside the State of Georgia, please contact BCBS Customer Service at 1-800-810-BLUE
(2583).

Care in a Hospital Emergency Room (ER)
For treatment of an emergency medical condition or injury

Surgical Services: 90% of UCR charges, if referred by MedCall;
subject to deductible.
80% of UCR charges, if not referred by MedCall; subject to deductible.

Non-Surgical Services: 80% of UCR charges, if referred by MedCall;
subject to deductible.

70% of UCR charges, if not referred by MedCall; subject to deductible.

Laboratory Services

80% of UCR charges; subject to deductible.

X-ray, Laboratory Work, Diagnostic Testing. Provided in conjunction with treatment of an illness or injury.

Pre-certification for diagnostic testing may be required by UNICARE.

Indemnity Plan Design - Effective January 1, 2004

6

Booklet Revised July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Urgent Care Services

80% of UCR charges; subject to deductible.

Extended Care Facility

90% of UCR charges; subject to deductible.

Pre-certification is required by UNICARE.

Home Nursing Care
Pre-certification is required by UNICARE.

90% of UCR charges; subject to deductible. No plan year limit.

Home Hyperalimentation
Pre-certification is required by UNICARE.

90% of UCR charges; subject to deductible. No lifetime benefit limit.

Hospice Care

90% of UCR charges; subject to deductible.

Pre-certification is required by UNICARE.

Cochlear Implants

90% of UCR charges; subject to deductible.

Pre-certification is required by UNICARE.

Ambulance Services
Land or air ambulance for medically necessary emergency transportation only

80% of UCR charges; subject to deductible; subject to balance billing for non-
participating/non-covered providers of ambulance services.

Durable Medical Equipment (DME) Rental or Purchase

80% of UCR charges; subject to deductible.

Plan may require approved Letter of Medical Necessity and Pre-certification may be required by UNICARE.

Vendor: UNICARE

Indemnity Plan Design - Effective January 1, 2004

7

Booklet Revised July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Outpatient Short Term Rehabilitation Services
Pre-certification may be required by UNICARE.

80% of UCR charges; subject to deductible.
Physical, speech, cardiac and occupational therapies are limited to 40 visits per incident
type per plan year.

Limited Medical Coverage for Dental/ Oral Care
Surgical Extraction of Impacted Teeth
Medical benefits are not available for partially erupted teeth.

90% of UCR charges for surgeon; subject to deductible.

Dental/Oral Care
Not covered; other than accidental injury to natural teeth.

80% of UCR charges; subject to deductible; subject to balance billing if services are not
rendered by a network provider.
Network providers may not be available for all covered services.

Disease State Management (DSM) Program Services
Asthma, Diabetes, Oncology, and Congestive Heart Failure
Pre-certification is required by UNICARE.
Vendor: UNICARE

100% of vendor negotiated rates; not subject to deductible.
To receive plan benefits coverage, participation in the appropriate DSM program is required.

Indemnity Plan Design - Effective January 1, 2004

8

Booklet Revised - July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Pharmacy Benefits Manager Vendor: Express Scripts, Inc.

3-Tier Co-payment Structure For Up To A 30-Day Supply
Generic: $10 member co-payment Preferred Brand Name: $25 member
co-payment Non-Preferred Brand Name: 20% co-payment
of non-preferred name brand drug cost, with minimum member co-payment of
$40/maximum member co-payment of $100.

Quarterly Out-of-Pocket Maximums For Use of Generic and Preferred Brand
Medications

Employee

$450 per quarter

Employee + Child $900 per quarter

Employee + Spouse $900 per quarter

Family

$1,350 per quarter

A quarter will consist of three consecutive months as designated below:

1st Quarter - January through March 2nd Quarter - April through June
3rd Quarter - July through September 4th Quarter - October through December

Indemnity Plan Design - Effective January 1, 2004

9

Booklet Revised July 2004

SELECTED PLAN FEATURES AND COVERED SERVICES

PLAN PROVISIONS AND BENEFITS

Mental Health and Substance Abuse
Pre-certification is required by UNICARE.
Vendor: BCBSGA Prudent Buyer Program (within the State of Georgia) and BCBS National Participating Provider Network (outside the State of Georgia)

Inpatient 90% of UCR charges, subject to deductible. Maximum benefit coverage of 60 days per person per plan year; 90 days per person per
lifetime.
Outpatient 80% of UCR charges; subject to deductible. Maximum benefit coverage of 20 visits per
person per plan year.

UNICARE may approve up to 50 visits per year under the following conditions: (1) in lieu
of inpatient treatment; or (2) immediately following hospital confinement for the same
condition.

Failure to access these BCBS programs or networks will result in the member being
subject to balance billing.

Organ and Tissue Transplants
The UNICARE Centers of Expertise Programs direct patients to network heart, liver, lung and bone marrow transplant specialists.
Prior approval is required by UNICARE.

90% of vendor network rate at a UNICARE contracted transplant center; subject to
deductible and to separate $100 hospital deductible.
The lifetime benefit limit for expenses related to a donor search, when using a UNICARE
contracted transplant Center, is $10,000.

Vendor: UNICARE

60% of UCR charges at a non-contracted UNICARE transplant center; subject to deductible, to separate $100 hospital
deductible, and to balance billing.

There will be no donor search benefit provided if an individual uses a noncontracted UNICARE transplant center.

Lifetime benefit limit of $500,000.

Indemnity Plan Design - Effective January 1, 2004 10
Booklet Revised - July 2004

WHO CAN ENROLL
If you are employed by the University System of Georgia for at least 20 hours per week on a regular basis, you are eligible for coverage under the indemnity healthcare plan beginning your first day at work. If you are a member of the Corps of Instruction (teaching faculty) under contract on at least a regular half-time basis, you are eligible for coverage beginning the first day of the month in which you are required to be at work.
HOW TO ENROLL
You must complete an indemnity health benefits plan enrollment form to apply for healthcare coverage. You may obtain this form from your campus Human Resources/Personnel Office. The completed enrollment form must include the legal names and birth dates of all eligible dependents.
The indemnity healthcare plan provides four levels of coverage:

Single

Employee + Child Employee + Spouse

Family

Employee Only

Employee + One Dependent Child

Employee + Spouse

Employee + Two or More Dependents
(Spouse and/or Children)

DEPENDENT COVERAGE

When an employee elects "Employee + Child", "Employee + Spouse", or "Family" coverage, his/her eligible dependents may be covered by the healthcare plan selected. Eligible dependents of an employee include:

Legal spouse;

Unmarried, natural and adopted children under age 19; or to age 26, if verification of fulltime student status at an accredited school is provided;

Unmarried step-children under age 19 who depend on the employee for support and maintenance and who live with the employee in a normal parent-child relationship; or to age 26, who depend on the employee for support and who can provide written verification of fulltime student status at an accredited school;

Unmarried children for whom, as a result of a legal separation or divorce, the employee is legally responsible, even though they may not live with the employee;

Children for whom the covered employee is the permanent legal guardian if: A court has named the employee as the child's permanent guardian; and

Indemnity Plan Design - Effective January 1, 2004 11
Booklet Revised - July 2004

The child lives in the employee's home in a normal parent-child relationship; and The child is dependent on the employee for support.
Unmarried, disabled children beyond the age limit if: They are unable to support themselves; and They depend on the employee for support; and The condition existed prior to age 19 (or age 26, if they become incapacitated while a full-time student); and Proof of incapacity is furnished within 31 days of the child's 19th birthday (or age 26, if they become incapacitated while a full-time student).
If you have a dependent(s) employed by the University System of Georgia, and your dependent(s) is participating in any University System of Georgia healthcare plan, you may not cover that dependent(s) under your "employee + child", "employee + spouse", or "family" coverage.
If your spouse is employed by the University System of Georgia, but he/she does not elect to participate in an available healthcare plan, you may cover him/her under your "employee + spouse" or "family" coverage.
If both a husband and wife are benefits-eligible employees of the University System of Georgia, only one may elect to provide coverage for the other spouse and/or dependents.
WHEN EMPLOYEE COVERAGE BEGINS
If you enroll in healthcare coverage on your first day of employment, you will be covered by the plan as of:
Your employment date; or The first of the month following your date of employment.
As an employee of the University System of Georgia, you have 31 days from your effective date of employment to enroll for coverage in a healthcare plan. If you enroll in a healthcare plan within 31 days of your employment date, you will be covered by the plan as of:
The date you enroll; or The first of the month following your date of employment.
You will have the opportunity to determine when you wish to have your coverage begin; but, in either instance, you will be required to pay for a full month of coverage. It is important that you enroll within 31 days of your date of employment. You will not be permitted to enroll in an available healthcare plan again until the next University System of Georgia open enrollment period.
Indemnity Plan Design - Effective January 1, 2004 12
Booklet Revised - July 2004

Open enrollment is generally held during the fall of each calendar year. Healthcare plan elections made during an open enrollment period will become effective at the beginning of a new plan year. The plan year for the University System of Georgia is currently a calendar year (January 1 December 31).
If you are absent from work, due to illness or injury, on the date that your healthcare plan coverage is to be effective, participation in the plan will begin on the first day that you return to active work. Active work is defined as performing all regular and assigned duties at one's normal or required work location.
WHEN DEPENDENT COVERAGE BEGINS
An eligible dependent will become covered on:
The first day that he/she becomes eligible; or The first of the month following his/her date of eligibility.
You will be required to ensure that your dependents, including newborns, are enrolled under your plan coverage within 31 days following his/her eligibility date. You should contact your campus Human Resources/Personnel Office to convey all appropriate information.
An eligible newborn is covered at birth. A dependent, other than a newborn, who is confined to a hospital or other institution when his/her coverage would normally begin, will be covered upon his/her discharge.
If you enroll your dependents within 31 days following their eligibility date, their coverage will begin on:
The date you apply for coverage; or The first of the month following the date in which you apply for coverage.
You will have the opportunity to determine when you wish to have your dependent's coverage begin; but, in either instance, you will be required to pay for a full month of coverage. It is important that you enroll your dependents within 31 days of their becoming eligible for coverage. You will not be permitted to enroll your dependents in an available healthcare plan again until the next University System of Georgia open enrollment period.
ADDING OR DELETING DEPENDENTS
When you experience some form of a qualifying event, you will need to contact your campus Human Resources/Personnel Office to complete a change form to add or to delete a dependent. Some examples of "qualifying events" include: (A) a change in employment status for you or your spouse; (B) a change in marital status; and (C) the birth or adoption of a child (including stepchildren and legally placed foster children). There are other examples of qualifying events.
Indemnity Plan Design - Effective January 1, 2004 13
Booklet Revised - July 2004

Change forms must be completed with your campus Human Resources/Personnel Office within 31 days of a qualifying event. Failure to comply with this time requirement will prohibit you from changing your coverage until the next University System of Georgia open enrollment period.
Full-Time Student Verification Process for Dependents Between the Ages 19-25
Ninety (90) days prior to a dependent reaching his/her nineteenth (19) birthday, Blue Cross Blue Shield of Georgia (BCBSGA) will mail a letter to the contract holder requesting that he/she provide verification of his/her dependent's full-time student status.
The contract holder will be required to submit documentation of full-time student status to the institutional Human Resources/Personnel Office where he/she is employed. Examples of required documentation include a student registration schedule, a student enrollment tuition receipt, or a student enrollment confirmation letter from the dependent's school. To ensure continuous coverage, the contract holder must provide the required documentation to his/her employing institution, prior to his/her dependent attaining age 19.
Upon receipt of the required documentation, the employing institution will make the necessary adjustments to the dependent's healthcare coverage. Should a contract holder fail to provide the requisite documentation to his/her employing institution, coverage for the student dependent will be terminated. It will be the contact holder's responsibility to notify his/her campus Human Resources/Personnel Office when the member, or his/her covered dependent(s), are no longer eligible for University System of Georgia healthcare coverage. Such notification is required for the member and his/her covered dependent(s) to be eligible to participate in COBRA healthcare coverage.
Each year ninety days prior to the dependent's birthday, BCBSGA will mail the contract holder an annual letter requiring verification of full-time student status for his/her dependents that are between the ages of 19 and 25.
Change of Full-Time Student Status Upon Attainment of Age 26
Your indemnity healthcare plan will provide coverage for your full-time student dependent until he/she attains age 26. On a dependent's 26th birthday, his/her indemnity healthcare coverage will terminate. For information regarding your dependent's ability to continue healthcare coverage, please see page 55 for the section entitled, Your COBRA Rights.
Indemnity Plan Design - Effective January 1, 2004 14
Booklet Revised - July 2004

USG OPEN ENROLLMENT PERIOD
Open enrollment is generally held during the fall of each calendar year. A University System open enrollment period covers a 30 calendar-day time frame. Your Human Resources/Personnel Office will advise you of the specific dates for your campus open enrollment period.
Healthcare plan elections made during an open enrollment period will become effective at the beginning of a new plan year. The plan year for the University System of Georgia is currently a calendar year (January 1 December 31).
During an open enrollment period, an active and eligible employee may elect to (1) enroll in a healthcare plan; (2) drop healthcare coverage; (3) participate in a different healthcare plan option; and/or (4) change his/her level of coverage (i.e. single, employee + child, employee + spouse, or family). Members who have COBRA coverage will have the same open enrollment period and options.
THE COST OF YOUR HEALTHCARE COVERAGE
The University System of Georgia contributes a majority of the cost associated with your health benefit plan coverage. Information regarding employer/employee healthcare plan contribution rates is shared with your campus Human Resources/Personnel Office. The costs associated with providing various healthcare plan options to employees, retirees and dependents of the University System of Georgia changes periodically. Your campus Human Resources/Personnel Office will notify you of any changes in plan costs and in employer/employee contribution rates. Your premium will depend upon the level of coverage (single, employee + child, employee + spouse, or family) that you select. The healthcare plan premium contribution for active, eligible employees will be paid with pre-tax dollars.
QUALIFYING EVENTS FOR CHANGES IN HEALTHCARE PLAN COVERAGE
Because your share of the cost for healthcare plan premiums is paid with pre-tax dollars, the Internal Revenue Services (IRS) has established strict rules regarding the operation of your healthcare plan. IRS rules state that the choices made by a covered member during an annual open enrollment period must remain in effect for the entire plan year (January 1 through December 31.) The only exception permitted under IRS rules is when a covered member has a qualifying event.
If you have a qualifying event, you may add, change, or discontinue healthcare coverage. Appropriate documentation, specific to the qualifying event, must be presented to your campus Human Resources/Personnel Office before a change in healthcare plan coverage will be granted or approved. Some examples of qualifying events include:
A change in your marital status;
Indemnity Plan Design - Effective January 1, 2004 15
Booklet Revised - July 2004

The birth or adoption of a child (including stepchildren and legally placed foster children);
The death of a covered dependent;
A change in the employment status of a covered member, his/her spouse, or his/her covered dependent(s), that affects eligibility for coverage under a cafeteria or other qualified healthcare plan;
The loss of eligibility status by a covered dependent;
A campus approved leave of absence without pay (maximum of 12 months);
You and/or your spouse being called to full-time active military service/duty;
Losing or gaining healthcare coverage eligibility under Medicare or Medicaid;
A change in residence to a location outside of a healthcare plan's service area;
Healthcare plan election choices made by spouses with different employers in which the employers have different healthcare plan years (Please see the example below); or
Example:
You work for the University System of Georgia (USG) and have a January 1 December 31 health benefits plan year. Your spouse works for XYZ employer. XYZ has an October 1 September 30 health benefits plan year. Both employer health benefits plans are qualified healthcare plans.
You have "single" healthcare coverage with the University System of Georgia. Your spouse, employed by XYZ, discontinues his/her healthcare coverage with XYZ effective September 30. September 30 is the end of employer XYZ's plan year. You wish to add your spouse, employed by XYZ, under your healthcare plan with the University System of Georgia, effective October 1. You request to make this change to avoid a break in healthcare coverage for your spouse.
Your spouse, employed by XYZ, conveys to XYZ that he/she will no longer participate in XYZ's healthcare plan effective October 1. Under IRS regulations, the University System of Georgia may permit you to change your election from "single" to "employee+ spouse" effective October 1. The spouse, employed by XYZ, must provide documentation or certification to the USG that he/she has lost healthcare coverage with XYZ.
Qualified Medical Child Support Order (QMCSO)
A court-ordered qualified medical child support order (QMCSO) results from a divorce, legal separation, annulment, or change in legal custody. A QMCSO requires that you, your spouse, former spouse, or another individual provide healthcare coverage for enrolled
Indemnity Plan Design - Effective January 1, 2004 16
Booklet Revised - July 2004

dependent(s) that have been approved by the court. The court order and effective date of healthcare plan coverage for court-designated enrolled dependent(s) must be presented to your campus Human Resources/Personnel Office within 90 days of the court's decision.
PLEASE NOTE: For each of the qualifying events identified above, you must file a timely request with your campus Human Resources/Personnel Office to add or change healthcare coverage. For instances other than a qualified medical child support order (QMCSO), "timely" means within 31 days of the event that qualified one for a change in healthcare coverage (i.e., employment, loss of coverage, marriage, birth or adoption, etc.) A QMCSO must be presented to your Human Resources/Personnel Office within 90 days of the court's decision.
A failure to complete a change form within 31 days of a qualifying event will prohibit you from making coverage changes until the next University System open enrollment period. Unless otherwise noted, the effective date for changes in healthcare coverage will be the first day of the month following institutional approval.
CONTINUATION OF HEALTHCARE COVERAGE INTO RETIREMENT
A University System of Georgia retiree, who, upon his/her separation from employment with the University System of Georgia, meets the criteria for retirement as set forth in Section 802.0902 (Definition of a Retiree/Eligibility for Retirement) of The Policy Manual, shall remain eligible to continue as a member of one of the System's group health benefits plans. The level of healthcare coverage that one may take into retirement will be the level of coverage that he/she had immediately prior to retirement.
USG RETIREE ANNUAL CHANGE PERIOD
The USG retiree annual change period is generally held during the fall of each calendar year. The USG retiree annual change period will coincide with the same 30 calendar-day time frame designated as the USG open enrollment period for active, eligible employees. The institutional Human Resources/Personnel Office, from which an individual retires, will advise the retiree of the specific dates for his/her annual change period.
A retiree will not be permitted to participate in the annual change period unless he/she elected to take healthcare coverage into retirement at the time of his/her separation from employment with the University System of Georgia.
During an annual retiree change period, an eligible retired employee may elect to: (1) drop or discontinue healthcare coverage; (2) participate in a different healthcare plan option; and/or (3) reduce his/her level of coverage. During the annual change period, a retiree shall not be permitted to add healthcare coverage, or, increase the level of coverage that he/she took into retirement, unless it is the result of one of four (4) qualifying events.
Indemnity Plan Design - Effective January 1, 2004 17
Booklet Revised - July 2004

Following institutional approval, any change in retiree healthcare coverage will become effective within 31 days of the qualifying event; not at the beginning of the next plan year.
QUALIFYING EVENTS FOR CHANGES IN RETIREE HEALTHCARE PLAN COVERAGE
A USG retiree will be permitted to make a change in the level of healthcare coverage that he/she took into retirement, if he/she has a qualifying event. The change in retiree healthcare coverage must be consistent with the qualifying event. A retiree will be required to provide the proper documentation to justify a requested benefits coverage change to the institutional Human Resources/Personnel Office from which he/she retired. A retiree must request a coverage change within 31 days of the qualifying event.
Appropriate documentation, specific to the qualifying event, must be presented to your campus Human Resources/Personnel Office before a change in healthcare plan coverage will be granted or approved.
There will be only four (4) instances of a qualifying event that a University System of Georgia institution may consider in granting a change in the level of healthcare coverage for a USG retiree. They are:
(1) Becoming eligible for Medicare; (2) The addition of a dependent(s) because of marriage, birth, adoption or a Qualified
Medical Child Support Order (QMSCO); (3) The loss of a dependent's health benefit coverage through a change in a spouse's group
coverage, through COBRA coverage, through Medicare, or through Medicaid; and (4) A change in a spouse's employment status that affects coverage eligibility under a
qualified health plan.
A Qualified Medical Child Support Order (QMSCO) is a court-ordered remedy resulting from a divorce, legal separation, annulment, or change in legal custody. A QMSCO requires that an individual provide healthcare coverage for an enrolled dependent(s) that has been approved by the court. The court order and effective date of healthcare plan coverage for a court-designated enrolled dependent(s) must be presented to the institutional Human Resources/Personnel Office from which an individual retired, within 90 days of the court's decision.
PLEASE NOTE: For each of the four (4) qualifying events that are identified above, one must file a timely request with the Human Resources/Personnel Office from which he/she retired. For instances other than a qualified medical child support order (QMCSO), "timely" means within 31 days of the qualifying event. A QMCSO must be presented to the appropriate Human Resources/Personnel Office within 90 days of the court's decision.
A failure to complete a change form within 31 days of a qualifying event will prohibit one from making such changes. Unless otherwise noted, the effective date for changes in healthcare coverage will be the first day of the month following the institution's approval.
Indemnity Plan Design - Effective January 1, 2004 18
Booklet Revised - July 2004

PERMISSIBLE USG RETIREE HEALTHCARE PLAN CHANGES
Please be reminded that retiree healthcare premiums are not paid with pre-tax dollars. Therefore, a retiree may reduce his/her healthcare coverage, or, discontinue his/her healthcare coverage at any time during the plan year. If you wish to reduce your healthcare coverage, or, if you wish to discontinue your healthcare coverage, please submit your request in writing to the Human Resource/Personnel Office from which you retired.
Please be reminded that if you reduce your level of healthcare coverage, you will not be permitted to increase your coverage at a later date, without establishing one of the four (4) qualifying events previously identified. As a retiree, if you elect to discontinue your healthcare coverage, you will not be permitted to re-enroll at a later date.
THE ANNUAL DEDUCTIBLE
The annual deductible is an amount of money that you will be required to pay each plan year (January 1 December 31) for covered benefit expenses, before the plan will begin to pay for its portion of covered charges. The maximum annual deductible that a covered member, under the indemnity plan, will pay is $300 for individual coverage and $900 for family coverage. The family deductible can be met through any combination of covered medical expenses incurred by three or more covered members within a household. Member co-payments for prescription drugs will not apply toward the annual deductible for the indemnity healthcare plan. Member costs incurred for balance billing will not apply toward the annual deductible or toward the annual maximum out-of-pocket limits (stop loss).
THE MAXIMUM ANNUAL OUT-OF-POCKET LIMIT (Stop Loss)
The indemnity plan provides for a member's protection if his/her out-of-pocket covered expenses reach a certain limit during a plan year. The annual out-of-pocket limit is $2,000 for individual coverage and $4,000 for family coverage.
If your individual or family out-of-pocket covered expenses reach these respective limits during the plan year, the plan will pay for 100% of the covered expenses that you and/or your family incur for the remainder of the plan year.
Just as with the family annual deductible, the family maximum annual out-of-pocket limit can be met through any combination of covered medical expenses incurred by three or more covered members within a household. The family out-of-pocket limit can be met without each family member meeting a separate, individual out-of-pocket limit; however, the total out-of-pocket amount must equal $4,000.
Indemnity Plan Design - Effective January 1, 2004 19
Booklet Revised - July 2004

The maximum annual out-of-pocket limit includes any plan deductible or the member's portion that he/she is required to pay for medical benefits. The maximum annual out-of-pocket limit for medical benefits excludes:
Expenses for medical services that are not covered by the indemnity plan (page 43); Expenses for medical services in which the member fails to comply with the Medical
Utilization Review Program requirements (pages 26-28); Expenses for covered medical services that exceed the usual, customary and reasonable
(UCR) contracted amounts (page 22); Expenses for medical services exceeding other plan limits; Expenses for incurred medical and pharmacy services that exceed the maximum lifetime
benefit of $2 million; Expenses for medical services that are not paid by the University System of Georgia
indemnity plan because of a coordination of benefits (COB) with any other plan(s) that covers you and/or your dependents (page 52); Balance billing costs incurred by a member for his/her use of a non-participating physician (pages 23-24); and Member co-payments for prescription drugs (pages 41-43).
MAXIMUM LIFETIME BENEFIT
The maximum lifetime medical and pharmacy benefits the indemnity healthcare plan will pay is $2,000,000 per person.
Covered charges incurred by a covered member for TMJ, organ and tissue transplant services, and mental health/substance abuse treatments have separate annual maximum and/or separate maximum lifetime benefits. The annual and/or lifetime maximum amount for TMJ, organ and tissue transplants, and/or mental health/substance abuse treatment is included in the $2,000,000 maximum lifetime medical benefit.
There is a separate lifetime limit of $1,000 for the diagnostic testing and non-surgical treatment of Temporomandibular Joint Disorders (TMJ) or orofacial pain. Covered medical benefits include diagnosis, x-ray, splinting, physical therapy, and subsequent follow-up treatments.
Organ and Tissue Transplant services have a maximum lifetime benefit limit of $500,000. The lifetime benefit limit for expenses related to the donor search for an individual who uses a UNICARE contracted transplant center is $10,000. This donor search benefit is included in the $500,000 Organ and Tissue Transplant maximum lifetime benefit. Prior approval by UNICARE is required.
There are annual and lifetime maximum benefit limits for both inpatient and outpatient Mental Health and Substance Abuse treatment services.
Indemnity Plan Design - Effective January 1, 2004 20
Booklet Revised - July 2004

Inpatient: Maximum benefit coverage of 60 days per person per plan year; 90 days per person per lifetime; pre-certification by UNICARE is required.
Outpatient: Maximum benefit coverage of 20 visits per person per plan year. UNICARE may approve up to 50 visits per plan year under the following conditions: (1) in lieu of inpatient treatment; or (2) immediately following a hospital confinement for the same condition.
ADMINISTRATIVE AGENTS/BUSINESS ASSOCIATES
The current administrative agents/business associates for the University System of Georgia indemnity healthcare plan include:
(A) WellPoint/Blue Cross Blue Shield of Georgia Provides customer service; and Provides claims administration services. BCBSGA Participating Physician Program Provides the network of medical providers within the State of Georgia.
(B) Blue Cross Blue Shield Association BCBS National Participating Provider Network Provides the network of medical providers, hospitals, and facilities outside of the State of Georgia.
(C) WellPoint/UNICARE Provides pre-certification for specific outpatient and all inpatient hospital services; Provides case management services; Provides access and education regarding disease state management programs (diabetes, asthma, congestive heart failure, and oncology); Provides access for organ and tissue transplant network Centers of Expertise; and Provides access to MedCall member services. Provides mental health medical review.
(D) Express Scripts Provides pharmacy benefit program services.
HOW YOUR INDEMNITY HEALTHCARE BENEFITS PLAN WORKS
The indemnity healthcare plan covers only eligible charges that are:
Medically necessary: A service or treatment that, in the judgment of the indemnity healthcare plan, is both appropriate and consistent with a medical diagnosis. To meet the plan's criteria for medical necessity, any service or treatment must be widely accepted professionally within the United States as effective, appropriate, and essential. The treatment or service must be based on recognized standards of the healthcare specialty involved. The treatment or service may not be experimental in nature; educational; or primarily for research or investigations.
Indemnity Plan Design - Effective January 1, 2004 21
Booklet Revised - July 2004

Prescribed by a physician: A physician is defined to include a doctor of medicine, a doctor of osteopathy, a doctor of dental surgery, a doctor of dental medicine, or a doctor of podiatric medicine. A physician must be legally licensed by the Composite Board of the State of Georgia (or a similar board in any other state) to practice medicine and/or perform surgery.
The following professionals are considered to be covered providers under the plan, when acting within the scope of their licenses and when rending services as defined by the plan. These professionals include optometrists, clinical psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors.
Within UCR: Usual, customary and reasonable (UCR) as set by BCBSGA/BCBS. Each term has a specific meaning:
Usual: The fee which a physician most frequently charges for the procedure performed;
Customary: A fee based upon a competitive profile of the usual fees received as reimbursement by similar physicians in a given geographic areas for the procedure performed; and
Reasonable: A fee which differs from usual or customary fees because of unusual circumstances or complications occurs in which require additional time, skill and experience.
The indemnity healthcare plan will pay up to the usual fee, not to exceed the customary fee, unless special circumstances or complications occur. If special circumstances or complications occur, the plan may consider the reasonable fee.
Diagnostic Related Group (DRG) rates: The Georgia Department of Community Health (DCH) negotiated direct contracts with the majority of acute care hospitals located within the State of Georgia. These direct contracts established the rates that would be paid for medical services associated with hospital inpatient care. Payment for services is based upon a negotiated Diagnostic Related Group (DRG) rate. DRG rates are, therefore, based upon the specific diagnosis and type of treatment provided for the patient.
Covered by the indemnity healthcare plan: There are certain medical treatments, services and expenses that are not covered by the plan. Such is the case with the University System of Georgia indemnity healthcare plan. A number of these are identified in this booklet.
THE PARTICIPATING PHYSICIAN PROGRAM
BCBSGA Participating Physician Program (Within the State of Georgia)
The Participating Physician Program helps reduce your out-of-pocket indemnity plan medical expenses for covered physician services. This program, established by Blue Cross Blue Shield of Georgia (BCBSGA), is a voluntary, statewide arrangement between BCBSGA and physicians that are eligible to practice in Georgia.
Indemnity Plan Design - Effective January 1, 2004 22
Booklet Revised - July 2004

Each participating physician must agree to accept the indemnity plan's established UCR fee limit as the maximum payment amount for his/her professional services. This means that once you have met your deductible, you will pay only for your appropriate portion of covered medical charges.
THE NATIONAL PARTICIPATING PROVIDER NETWORK
BCBS National Participating Provider Network (Outside of the State of Georgia)
The Blue Cross Blue Shield (BCBS) National Participating Provider Network is a network that is similar in scope to the existing BCBSGA Participating Physician Program. With this network, the providers have contracted with their local Blue Cross Blue Shield plan in the state where the provider practices.
Within the BCBS National Participating Provider Network, physicians and facilities have agreed to accept the "allowable charge" as the maximum payment for their services. "Allowable charge" will be based upon the contracted rate that a national participating provider has agreed to accept from the local BCBS plan in the state where the services are rendered.
Healthcare plan participants, who access either the BCBS National Participating Provider Network or the BCBSGA Participating Physician Program, will not be subject to balance billing. In addition, a participating physician will prepare and file all of your medical claims for you. Plan benefits are paid directly to participating physicians. Failure to access these BCBS programs or networks will result in the member being subject to balance billing.
Physicians who are eligible to participate in the BCBSGA/BCBS programs are those who meet the definition of physician as identified earlier in this booklet.
It is always your choice to select and use either a participating physician or a non-participating physician. Please be informed that many non-participating physicians will not file your medical claims for you. Please, also, be informed that a non-participating physician has not signed an agreement with BCBSGA/BCBS to accept the indemnity plan's UCR/allowable charge fee limit as the maximum payment amount for his/her professional services.
This means that you may be subject to balance billing. Member costs incurred for balance billing will not apply toward the annual deductible or toward the annual maximum out-ofpocket limits (stop loss).
To determine if your physician is a BCBSGA/BCBS participating provider, please ask him or her. When visiting a new physician, or when being referred to a specialist, it is wise to check in advance to see if he/she is a BCBSGA/BCBS participating physician. Information regarding the physicians who participate in BCBSGA Georgia network may be determined by contacting the BCBSGA Customer Service at 1-800-424-8950 or TDD 404-842-8073. To determine if your physician or facility located outside of Georgia is in the BCBS National Provider Network, please contact BCBS Association Customer Service at 1-800-810-BLUE (2583).
Indemnity Plan Design - Effective January 1, 2004 23
Booklet Revised - July 2004

These telephone numbers are listed on your indemnity plan identification card. You may also obtain this information by accessing the University System of Georgia website at www.usg.edu/admin/humres/benefits/health/.
PLEASE NOTE: The University System of Georgia indemnity healthcare plan does not have the legal authority to intervene when a non-participating provider balance bills the member. Therefore, the healthcare plan cannot reduce or eliminate balance billed amounts. The healthcare plan will not make additional payments above the plan allowed benefit limits.
WELLNESS CARE/PREVENTIVE HEALTHCARE
The indemnity plan will provide wellness benefits of up to $500 per person per plan year. The wellness benefit is paid at 100% of UCR and is not subject to a member deductible. Charges for wellness services in excess of the annual $500 maximum level benefit are not eligible for reimbursement under any other category of plan coverage. Wellness care/preventive healthcare services include:
Routine physical exams; Routine mammograms; Pap smears; Prostate exams/PSA; Well-baby care and immunizations; Adult immunizations; Routine eye exams (either an ophthalmologist or an optometrist may provide wellness vision
care services); and Routine hearing exams.
Under this benefit, well-baby care includes routine physical exams, immunizations, x-rays, laboratory tests, and other tests billed by the attending physician for services rendered in his/her office.
Treatment of suspected/identified illnesses or injuries and allergy injections are not covered by the wellness benefit.
TREATMENT OF DISEASES OF THE EYE
The indemnity plan design includes coverage for the treatment of diseases of the eye. Under Georgia statute, a plan design that provides benefits coverage for the treatment of diseases of the eye must include optometrists as providers for vision care services.
Ophthalmologists are medical doctors (MD); are licensed to perform eye-related surgical procedures; and are involved with the treatment of vision-related conditions and diseases of the
Indemnity Plan Design - Effective January 1, 2004 24
Booklet Revised - July 2004

eye. An optometrist may perform vision care services involving the treatment of diseases of the eye that are non-surgical in nature.
To assist you in understanding the difference between the types of services that an optometrist may render as compared to those that an ophthalmologist may render, please consider the following example. An optometrist may provide vision care services that would be employed to diagnose a cataract, but he/she would not be able to perform corrective cataract surgery. An ophthalmologist, as a licensed medical doctor, would be able to perform corrective cataract surgery.
The purchase of eyewear (glasses/contact lenses) is not a covered benefit under the wellness/preventive care program.
BlueChoice Vision Program
Blue Cross Blue Shield of Georgia (BCBSGA) has established a member-discounted vision care services contract with LensCrafters (excluding LensCrafters Optiques) and with a number of independent optometrists throughout the State of Georgia, called the BlueChoice Vision Program. By using this program you will save costs for vision exams, contact lenses, and eyeglasses. To receive the discounted rate, please present your member identification card to any participating BlueChoice Vision provider.
For a listing of the BlueChoice Vision participating providers, please contact the BCBSGA customer service unit at 1-800-424-8950/TDD 404-842-8073 or visit the University System of Georgia website at www.usg.edu/admin/humres/benefits/health/. Please be informed that the BlueChoice Vision Program is a vision services discount program, not an employee benefit. This program is subject to change or termination at anytime.
HOSPITAL INPATIENT CARE DIAGNOSTIC RELATED GROUP (DRG) RATES
In the latter part of 1999, the Georgia Department of Community Health (DCH) negotiated direct contracts with the majority of acute care hospitals located within the State of Georgia. These direct contracts established the rates that would be paid for medical services associated with hospital inpatient care. Payment for services is based upon a negotiated Diagnostic Related Group (DRG) rate. DRG rates are, therefore, based upon the specific diagnosis and type of treatment provided for the patient.
When this initial contract was executed, there were in excess of 160 State of Georgia acute care hospitals that agreed to accept the DRG rate structure proposed by DCH. The number of State of Georgia DRG-contracted hospitals may change. Each hospital maintains an individual contract with the Department of Community Health.
As a cautionary note, please be informed that any State of Georgia acute care hospital may choose to terminate its respective DRG contract with DCH. We encourage you to check with
Indemnity Plan Design - Effective January 1, 2004 25
Booklet Revised - July 2004

your hospital, prior to admission, and determine if it continues to maintain its DRG contract with the Department of Community Health. If your hospital does not participate in the direct contract with the Department of Community Health, hospital inpatient services will process under UCR.
SECOND MEDICAL OPINION FOR ELECTIVE SURGERY
A member is permitted to obtain a second medical opinion for an elective surgery. The indemnity plan will cover 100% of UCR charges for a second medical opinion. The charges for the second physician's consultation services are not subject to a deductible. Please be reminded that an elective surgery must be deemed to be medically necessary by UNICARE to receive plan benefits.
Decisions regarding an elective surgery will continue to be the joint responsibility of the member and his/her physician. Please be informed that the plan will not provide benefits coverage for inpatient hospital consultations associated with an elective surgery.
MEDICAL UTILIZATION MANAGEMENT REVIEW PROGRAM
The Medical Utilization Management Review program, provided by UNICARE, is comprised of three components. These components are integrated to ensure that the highest degree of patient care is provided during every stage of treatment for an illness or injury: Pre-certification Review:
Specific Outpatient Medical Procedures - To access benefits coverage for specific outpatient medical procedures/diagnostic testing, UNICARE must determine if: (1) the procedure is medically necessary; and/or (2) if an appropriate and alternative treatment is available. For the specific listing of outpatient procedures that require UNICARE pre-certification, please review the section entitled, "Pre-certification for Certain Outpatient Procedures/Diagnostic Tests", located on pages 29-31.
Outpatient pre-certification review is not required for covered retirees/covered spouses of retirees who have Medicare Part B. In this instance, Medicare Part B would provide primary coverage and the University System of Georgia indemnity healthcare plan would provide secondary coverage.
Inpatient Hospital Admissions - To access benefits coverage for inpatient hospital admissions, UNICARE must determine if: (1) the procedure and/or admission is medically necessary; and/or (2) if an appropriate and alternative treatment is available.
For an inpatient hospital admission, a pre-certification review is not required for covered retirees/covered spouses of retirees who have Medicare Part A. In this instance, Medicare Part A would provide primary coverage and the University System of Georgia indemnity healthcare plan would provide secondary coverage.
Indemnity Plan Design - Effective January 1, 2004 26
Booklet Revised - July 2004

Continued Inpatient Hospital/Medical Facility Confinement Review - During an approved hospital/medical facility confinement, UNICARE will monitor a patient's progress by consulting with his/her attending physician. UNICARE will consult with the attending physician to ensure that the recommended treatment plan is consistent with medical benefits covered by the healthcare plan design. UNICARE will, also, review and render decisions for requests to extend periods of inpatient hospital/medical facility confinement.
Available Alternative Medical Services/Care Review Process - UNICARE will identify patients for whom early discharge from a hospital/medical facility to a home healthcare environment is appropriate. UNICARE will identify a provider, from a nationwide network of contracted home healthcare agencies, to provide necessary services/care for the patient. Home healthcare agency treatment plans for the patient will be monitored by UNICARE.
Under the Medical Utilization Management Review program, UNICARE must review all of the following:
Hospital confinements, including emergency room admissions and surgery; Inpatient psychiatric or substance abuse treatment, including transitions to lower levels of
care; Certain outpatient procedures and diagnostic testing; Organ and tissue transplants; Confinement in an extended care facility (following or in lieu of an inpatient hospital stay); Home healthcare; Hospice care; Home hyperalimentation; and Private duty nursing.
The Medical Utilization Management Review program ensures that you and your family receive medically necessary treatment. The program also assists you in avoiding unnecessary expenses.
Should you elect to receive home healthcare, hospice care, or private duty nursing; or should you be confined in an extended care facility without the prior approval of UNICARE, no plan benefits will be paid.
PLEASE NOTE:
Blue Cross Blue Shield of Georgia (BCBSGA) Participating Physician Program When a member uses a BCBSGA participating physician, the medical provider is responsible for obtaining the required pre-certification from UNICARE for a hospital confinement or for a prescribed outpatient procedure/diagnostic test.
Blue Cross Blue Shield (BCBS) National Participating Provider/Non-Participating Physician
When a member uses a BCBS National Participating Provider, or a non-participating physician, it is the member's responsibility to obtain the necessary pre-certification from UNICARE for a hospital confinement or for a prescribed outpatient procedure/diagnostic test.
Indemnity Plan Design - Effective January 1, 2004 27
Booklet Revised - July 2004

PLEASE NOTE: (continued)
The member must contact UNICARE at least 48 hours prior to his/her scheduled medical procedure, unless the procedure is an emergency.
If a member fails to comply with Medical Utilization Management Review requirements, a $200 penalty may be assessed for each respective inpatient and outpatient procedure. The $200 penalty will not apply to a member's annual deductible or maximum annual out-of-pocket limit. In addition, a member's benefit coverage may be denied for any treatment that he/she receives that is not deemed to be medically necessary, including charges for inpatient days in a hospital that exceed the number of days allowed through the pre-certification process. (The specific outpatient procedures/diagnostic tests that require pre-certification are identified on pages 2931.)
The final decision regarding the appropriate level of medical treatment for you and your family continues to be the joint responsibility of you and your physician. The Medical Utilization Management Review program is designed to evaluate medical alternatives. It is not designed, nor intended, to practice medicine. The review process does not replace the medical advice of your physician; the review process ensures that you are aware of all medical options before you receive care.
The Medical Utilization Management Review program ensures that you and your family receive medically necessary treatment. The program also assists you in avoiding unnecessary expenses.
Should you elect to receive home healthcare, hospice care, or private duty nursing services, without the prior approval of UNICARE, no plan benefits will be paid.
MATERNITY AND NEWBORN INFANT NURSERY CARE BENEFITS
After meeting your deductible, the plan will pay 90% of UCR for all covered charges associated with prenatal, delivery, and postnatal maternity care. The plan will pay for 90% of the contracted DRG rates for covered hospital charges.
Upon the birth of a newborn, the covered newborn begins to establish his/her own individual hospital charges. The covered newborn will not be required to establish a separate and individual deductible, unless the covered newborn continues to be hospitalized after the discharge of the mother. Covered charges, incurred by the newborn, will be paid by the healthcare plan at the appropriate benefit level.
Maternity care benefits are provided for a covered employee; a covered spouse; and/or a covered, unmarried dependent female child. Maternity care benefits are covered for licensed birthing centers and for services provided by a certified nurse midwife.
Indemnity Plan Design - Effective January 1, 2004 28
Booklet Revised - July 2004

NEWBORN'S AND MOTHER'S HEALTH PROTECTION ACT OF 1996
Congress has passed the Newborns' and Mothers' Health Protection Act of 1996. This federal statute created a minimum length of inpatient hospital care that must be provided for mothers and newborns having healthcare coverage under a group or individual healthcare plan. The respective University System of Georgia healthcare plans comply with this federal mandate. The minimum length of inpatient care will vary depending upon the medical condition of the mother. The minimum length of stay following a normal vaginal delivery is 48 hours and the minimum of length of stay following a cesarean section is 96 hours. If the attending physician, in consultation with the mother, decides to discharge the mother and/or newborn prior to the mandated minimum stay, the hospital confinement requirements will not apply.
WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998
Congress has passed the Women's Health and Cancer Rights Act of 1998. This federal statute requires that group health insurance plans provide its participants with certain benefits for reconstructive surgery and/or complications related to a mastectomy. The respective University System of Georgia healthcare plans comply with this federal mandate. The federal statute requires that a group healthcare plan provide coverage for:
Reconstruction of the breast on which the mastectomy has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications at all stages of the mastectomy,
including lymphedemas.
The attending physician and the patient will discuss an appropriate medical treatment plan that may be shared with UNICARE. The recommended treatment plan may be reviewed and approved by UNICARE. Benefits coverage will be subject to the same deductible and coinsurance provisions that apply to the other medical and/or surgical benefits of this healthcare plan.
PRE-CERTIFICATION FOR CERTAIN OUTPATIENT PROCEDURES/DIAGNOSTIC TESTS (PLAN YEAR 2004)
Certain outpatient procedures and diagnostic tests will require pre-certification. When your physician recommends an outpatient procedure, please ask that your doctor provide you with the CPT code for that procedure.
You may then contact the UNICARE Medical Utilization Management Review program (1-800233-5765/TDD 1-800-368-4424) or the BCBSGA Customer Service unit (1-800-424-8950/TDD 404-842-8073) to determine whether pre-certification is required.
If a procedure requires pre-certification, you must call the Medical Utilization Management Review program at least 48 hours prior to the scheduled procedure, unless the procedure is an
Indemnity Plan Design - Effective January 1, 2004 29
Booklet Revised - July 2004

emergency. Outpatient pre-certification review is not required for covered retirees/covered spouses of retirees who have Medicare Part B. The following medical CPT procedure categories require pre-certification:
CAT or CT Scans (computerized axial tomographies), except brain and spine 70480 through 70482; 70490 through 70492; 71250; 71260; 71270; 71275; 72192 through 72194; 73200 through 73202; 73700 through 73702; 74150; 74160; 74170; 76375; 76380
Colonoscopies 45378 through 45385
Endoscopies 43234; 43235; 43239
Esophageal Surgeries 43280; 43289; 43324 through 43326
Laparoscopies and/or Peritoneoscopies 49320; 49329; 58578; 58550; 58551; 58660 through 58662; 58679
MRAs (magnetic resonance angiographies) 70544 through 70549; 71555; 72159; 73225; 73725; 74185; 72198
MRIs (magnetic resonance imaging) 70336; 70540 through 70543; 70551 through 70553; 71550 through 71552; 72141; 72142; 72146 through 72149; 72156 through 72158; 72195 through 72197; 73218 through 73223; 73718 through 73723; 74181 through 74183; 75552 through 75556; 76093; 76094; 76400; 76375
Nasal Surgeries 30400 through 30520; 30620; 30930
Pet Scans 78608; 78609; 78459; 78491; 78492; 78810
Sleep Studies 95805 through 95808; 95810; 95811
Uvulopalatopharynogoplasties 42120; 42140; 42145; 42299; 42950
PLEASE NOTE:
Blue Cross Blue Shield of Georgia (BCBSGA) Participating Physician Program When a member uses a BCBSGA participating physician, the medical provider is responsible for obtaining the required pre-certification from UNICARE for this outpatient procedures/diagnostic tests.
Indemnity Plan Design - Effective January 1, 2004 30
Booklet Revised - July 2004

PLEASE NOTE: (continued)
Blue Cross Blue Shield (BCBS) National Participating Provider /Non Participating Physician
When a member uses a BCBS National Participating Provider or a non-participating physician, it is the member's responsibility to obtain the necessary pre-certification from UNICARE for these prescribed outpatient procedure/diagnostic tests.
The member must contact UNICARE at least 48 hours prior to his/her scheduled medical procedure, unless the procedure is an emergency.
If a member fails to comply with Medical Utilization Management Review requirements, a $200 penalty may be assessed for each respective inpatient and outpatient procedure. The $200 penalty will not apply to a member's annual deductible or maximum annual out-of-pocket limit. In addition, a member's benefit coverage may be denied for any treatment that he/she receives that is not deemed to be medically necessary.
The final decision regarding the appropriate level of medical treatment for you and your family continues to be the joint responsibility of you and your physician. The Medical Utilization Management Review program is designed to evaluate medical alternatives.
It is not designed, nor intended, to practice medicine. The review process does not replace the medical advice of your physician; the review process ensures that you are aware of all medical options before you receive care.
MEDICAL CASE MANAGEMENT
The Medical Case Management program, administered by UNICARE, is designed to assist with the complexities and costs of a catastrophic illness or injury. This program employs early intervention strategies to identify such cases. The program provides continuous medical case management from hospitalization through discharge and recovery.
UNICARE physicians, case managers and rehabilitation specialists work with a patient's attending physician to facilitate the most appropriate medical treatment and setting. The Medical Case Management program is automatically activated by UNICARE when a member experiences a catastrophic illness or injury.
EXTENDED CARE FACILITY
After meeting your deductible, the plan will pay for 90% of covered charges for extended care facility services. UNICARE must review and pre-certify all extended care facility services.
An extended care facility is a skilled nursing facility qualified to receive Medicare payments, or one that operates in accordance with local laws under the full-time supervision of a licensed nurse or doctor.
Indemnity Plan Design - Effective January 1, 2004 31
Booklet Revised - July 2004

It must provide room and board and 24-hour-a-day skilled nursing care of sick and injured persons, at the patient's expense, during the convalescent stage of an injury or illness.
Extended care facilities do not include institutions operated primarily for the care of the aged; treatment of mental disease; drug addiction; alcoholism; or educational or custodial care.
HOME HEALTHCARE SERVICES
After meeting your deductible, the plan will pay for 90% of covered charges for home healthcare services. UNICARE must review and pre-certify all home healthcare services.
Home healthcare services that are covered include:
Visits for part-time or occasional nursing care provided by an appropriate home healthcare professional;
Short term rehabilitation services. Your benefit provides for: physical, speech, cardiac and occupational therapies that are limited to a maximum of 40 visits per incident type per plan year. To receive a benefit for speech therapy, there must be a medically diagnosed condition of inability to speak/loss of speech due to illness, surgery, or birth defect. Services must be provided by a qualified speech therapist.
Medical supplies, prescribed medications, and laboratory services, if such services would have been provided in a hospital; and
Nutritional counseling that is provided or supervised by a registered nurse (RN).
Home healthcare services that are not covered include:
Services or supplies that are not included in a UNICARE-approved home healthcare plan; Custodial care; Services provided by a family member; and Services or supplies that are experimental in nature.
DURABLE MEDICAL EQUIPMENT (DME)
To receive benefit coverage for durable medical equipment (DME), it must serve to improve or maintain a patient's mobility and/or function. DME must be consistent with the patient's physical disorder. The equipment must be prescribed by an attending physician and must be appropriate for in-home use. Examples of DME include wheelchairs or hospital-type beds. DME must meet the following criteria:
It must be able to withstand repeated use; It is must be manufactured solely to serve a medical purpose; It must not be merely for comfort or convenience; and It must be useful for an ill or injured patient.
Indemnity Plan Design - Effective January 1, 2004 32
Booklet Revised - July 2004

The plan coverage for DME is based on UCR charges for basic equipment. The benefit for deluxe equipment, including prosthesis, will be limited to the UCR fee for the basic version of that specific type of equipment. The indemnity healthcare plan will determine whether DME should be rented or purchased. Approved rental fees will not be permitted to exceed the cost of purchasing the DME.
Based upon a physician's prescription for DME, you and/or your physician will be required to contact UNICARE. UNICARE will determine if the recommended DME meets the plan criteria for medical necessity and/or requires pre-certification. UNICARE will make such decisions on a case-by-case basis. Please contact UNICARE at 1-800-233-5765/TDD 1-800-368-4424.
Some of the DME items that are not covered by the indemnity healthcare plan include, but are not limited to:
Air conditioners, humidifiers, dehumidifiers or purifiers; Motor-driven chairs or beds, when standard equipment is adequate; The rental or purchase of equipment if a member is in a hospital/facility; Pools, spas, and whirlpools; Electric stair chairs or elevator chairs; Physical fitness, exercise or ultraviolet-tanning equipment; Foot care devices including arch supports, orthopedic or corrective/custom made shoes; Heating pads, hot water bottles, home enema equipment, or rubber gloves; Electric toothbrushes; and Home supplies, such as first aid items.
HOSPICE CARE SERVICES
A hospice program provides for the care and counseling of terminally ill patients and their families. After meeting your deductible, the plan will pay for 90% of covered charges for hospice care services. UNICARE must review and pre-certify all hospice care services. Hospice care services that are covered include:
Semi-private room and board;
Local ambulance or special transport service between the terminally ill patient's home and the hospice facility;
Medical supplies, prescribed medications, and laboratory services;
Dietary counseling by a licensed nutritionist or dietician;
Physical, respiratory or speech therapy;
Homemaker services for a maximum of seven (7) days;
Part-time nursing care by a registered nurse (RN) or a licensed practical nurse (LPN);
Indemnity Plan Design - Effective January 1, 2004 33
Booklet Revised - July 2004

Counseling services for the patient, or for the family learning to cope with a terminally ill patient. Counseling services will be for no longer than six months; and
Assistance with the identification and access to available community resources;
Hospice care services that are not covered include:
Funeral arrangements; Financial or legal counseling; Counseling by clergy or any volunteer group; Care furnished by family member or someone who lives in the terminally ill patient's
home; Private duty nursing; and Volunteer services or services normally free of charge.
DISEASE STATE MANAGEMENT PROGRAM
The Disease State Management (DSM) program, administered by UNICARE, provides educational assistance to members with chronic disease. The DSM program is voluntary and strictly confidential. The program assists participants with managing their chronic medical condition by providing educational information and intervention strategies.
Program participants are encouraged to work with their personal "case manager" and their attending physician to prevent potential side effects and complications from the chronic disease. The case manager is an experienced registered nurse (RN) who, with guidance from the treating physician, provides patients with informational resources to improve their quality of life.
The DSM program includes participant information regarding Diabetes, Asthma, Oncology and Congestive Heart Failure. Through participation in a DSM program, a member will become knowledgeable about his/her chronic disease, his/her physician-prescribed medical treatment plan, and the means to assist with managing/monitoring his/her chronic condition. The goals of the DSM programs are to: (1) improve member recognition of chronic disease warning signals; (2) improve early detection and management of symptoms; (3) promote optimal use of medical therapy; and (4) improve patient compliance with prescribed treatment plans.
UNICARE will identify members, who may be appropriate candidates, to participate in this voluntary program through various means. These means may include, but not be limited to, the following:
A candidate's medical history and related claims experience; A review of emergency room treatment/hospitalization claims experience and/or pre-
certification reviews by UNICARE; Referral by MedCall of a member to the DSM program; and Member inquiries regarding access and participation in the DSM program.
Indemnity Plan Design - Effective January 1, 2004 34
Booklet Revised - July 2004

Should you desire additional information or should you wish to participate in one of the DSM programs, please call UNICARE at 1-800-790-2507/TDD 1-800-368-4424.
MEDCALL PROGRAM
MedCall is a toll-free, 24-hours a day, seven days a week, medical information service available to you and your covered family members. Whenever you or your family members experience a troubling health symptom, you may speak directly with a registered nurse. Nurse counselors are available to answer questions regarding medical procedures, health symptoms or prescription medications.
Nurse professionals are available to assist you with member referrals to appropriate healthcare providers, to self-help agencies, and/or to hospital emergency rooms/urgent care facilities, as necessary. The toll-free MedCall telephone number is 1-800-785-0006/TDD 1-800-368-4424. Hospital Emergency Room Care - MedCall nurses have the authority to issue hospital emergency room referrals. Emergency room referrals by MedCall will result in a higher level of benefit coverage for the member. If an emergency room referral is obtained from MedCall, the level of benefit coverage for surgical services will be 90% and the level of benefit coverage for non-surgical services will be 80%.
If an emergency room referral is not obtained from MedCall, the level of benefit coverage for surgical services will be 80% and the level of benefit coverage for non-surgical services will be 70%. If a member is admitted to the hospital following emergency room care, he/she will receive the higher level of benefit coverage.
If a member is admitted to a hospital, he/she must contact UNICARE within 48 hours after the admission. The toll-free telephone number for UNICARE is 1-800-233-5765/TDD 1-800-3684424. Failure to contact UNICARE within 48 hours may result in a $200 member penalty.
The use of MedCall is voluntary. You must decide what level of medical care is appropriate under emergency conditions. If you believe that you and/or your family member are facing a life-threatening situation, please act responsibly. Please go to the nearest medical facility or please call 911, if available in your area. If possible, we encourage you to contact MedCall to obtain timely emergency medical assistance.
The MedCall audio library is a medical information service/resource that is available to our plan participants. The audio library, developed by healthcare experts, provides extensive medical information on a variety of health-related topics. You may wish to access the audio library for information on a specific medical condition. Please call the MedCall toll-free telephone number at anytime, day or night. Should you have additional questions regarding the medical information that you receive, you may transfer to a registered nurse and discuss the medical topic in greater detail. Please be reminded that the audio library should not be used as a substitute for your physician's professional assistance.
The MedCall audio library information is available on the University System of Georgia website at www.usg.edu/admin/humres/benefits/health/. The resource link is Healthwise Knowledgebase.
Indemnity Plan Design - Effective January 1, 2004 35
Booklet Revised - July 2004

ORGAN AND TISSUE TRANSPLANT PROGRAM
The UNICARE Centers of Expertise Program for organ and tissue transplant services is a national network of credentialed medical providers. Providers are invited to participant in this program based on compliance with established standards of clinical expertise. The Centers of Expertise Program directs patients to network heart, liver, lung, and bone marrow transplant specialists.
The organ and tissue transplant program uses literature-based protocols. These protocols guide UNICARE physicians and members of the UNICARE transplant panel in the completion of medical review determinations. Each member who participates in the Organ and Tissue Transplant program will have a Transplant Coordinator. The Transplant Coordinator will introduce the patient to the program; explain the program procedures; and assist the patient with the coordination of any needed home care services. The program provides for patient access to a specialty-matched physician reconsideration process.
The UNICARE Centers of Expertise Program for organ and tissue transplant services provide members with a higher level of benefit coverage. Participants in this program will receive benefit coverage at 90% of the network rate if a UNICARE contracted transplant center is used. There will be an additional and separate $100 hospital deductible required from the member, if this benefit is used.
The lifetime benefit limit for expenses related to the donor search for an individual who uses a UNICARE contracted transplant center is $10,000. This donor search benefit is included in the $500,000 Organ and Tissue Transplant maximum lifetime benefit. Prior approval by UNICARE is required.
Please be advised that organ and tissue transplants are covered at 60% of UCR charges at a noncontracted UNICARE transplant center. There will be an additional and separate $100 hospital deductible required from the member, if this benefit is used. There is no benefit coverage for expenses related to the donor search when using a non-contracted UNICARE transplant center. The member will, also, be subject to balance billing.
Should you desire additional information, or should you wish to participate in the UNICARE Centers for Expertise Organ and Tissue Transplant program, please call UNICARE at 1-800828-6518/TDD 1-800-368-4424.
The lifetime maximum benefit limit for the Organ and Tissue Transplant program is $500,000.
COVERED EXPENSES
Please be reminded that certain covered expenses will require a pre-certification by UNICARE. Other covered expenses may require pre-certification from UNICARE. Please refer to the "Benefits At A Glance" section located on page 2 of this booklet.
Indemnity Plan Design - Effective January 1, 2004 36
Booklet Revised - July 2004

Inpatient Hospital and Physician Services 90%
After meeting your deductible, the plan will pay for 90% of the contracted DRG rates for covered inpatient hospital services rendered within the State of Georgia and for 90% of UCR charges for inpatient hospital services rendered outside the State of Georgia. Covered inpatient hospital services include:
Semi-private room and board;
Observation room stays of less than 24 hours;
Charges for intensive care unit (ICU), cardiac care unit (CCU), or other similar accommodations;
Laboratory charges, including x-rays and diagnostic testing/examinations;
Physician charges for a surgical or obstetrical procedure;
Sterilization procedures, but not reversals;
Registered nurse (RN) charges for skilled nursing care, including private duty nursing; and
Organ and tissue transplants are covered at 90% of the vendor network rate at a UNICARE contracted transplant center. There will be an additional and separate $100 hospital deductible required from the member, if this benefit is used. The lifetime benefit limit for expenses related to the donor search for members who use a UNICARE transplant center is $10,000.
Please be advised that organ and tissue transplants are covered at 60% of UCR charges at a non-contracted UNICARE transplant center. There will be an additional and separate $100 hospital deductible required from the member, if this benefit is used. There is no benefit coverage for expenses related to the donor search when using a non-contracted UNICARE transplant center. The member will, also, be subject to balance billing.
Inpatient Hospital and Physician Services 80%
After meeting your deductible, the plan will pay for 80% of UCR charges for:
Anesthesiologist, pathologist, or radiologist services/consultations; and
Pre-admission testing, if performed within a seven-day period prior to a scheduled hospital confinement.
Outpatient Hospital/Facility Services 90%
After meeting your deductible, the plan will pay for 90% of UCR covered charges for:
Indemnity Plan Design - Effective January 1, 2004 37
Booklet Revised - July 2004

Emergency room surgical services, if a referral to the emergency room is obtained from MedCall;
Physician charges for surgical procedures;
Surgical charges associated with the removal of impacted teeth;
Cochlear implants;
Outpatient surgical facility selected by a treating physician which is a Plan approved facility;
Treatment provided in an extended care facility;
Home hyperalimentation;
Treatment provided through a home nursing care program; and
Services provided through a hospice care program.
Outpatient Hospital/Facility Services 80%
After meeting your deductible, the plan will pay for 80% of UCR charges for:
Physician charges for services/consultations rendered by an anesthesiologist, pathologist, or radiologist;
Emergency room non-surgical services, if a referral to the emergency room is obtained from MedCall;
Laboratory charges, including x-rays and diagnostic testing/examinations;
Ambulance service for medically necessary emergency transportation, to the nearest facility providing the required treatment; and
Outpatient short-term rehabilitation services. Your benefit provides for: physical, speech, cardiac and occupational therapies that are limited to a maximum of 40 visits per incident type per plan year. To receive a benefit for speech therapy, there must be a medically diagnosed condition of inability to speak/loss of speech due to illness, surgery, or birth defect. Services must be provided by a qualified speech therapist.
Physician Services Provided in an Office Setting 100%
The plan will pay for 100% of UCR charges for:
Wellness care/preventive healthcare (limited to $500 per person per plan year); and
Indemnity Plan Design - Effective January 1, 2004 38
Booklet Revised - July 2004

Second surgical opinions for elective surgery.
Physician Services Provided in an Office Setting 90%
After meeting your deductible, the plan will pay for 90% of UCR charges for:
Outpatient surgery provided in a physician office setting;
Removal of impacted teeth, other than partially erupted teeth; and
Maternity care (prenatal and postnatal).
Physician Services Provided in an Office Setting 80%
After meeting your deductible, the plan will pay for 80% of UCR charges for:
A physician's office visit for non-surgical services;
Laboratory charges, including x-rays and diagnostic testing/examinations (exclusive of wellness care/preventive healthcare);
Allergy testing, shots and serum;
Diagnostic testing and non-surgical treatment of temporomandibular joint disorders (TMJ); and
Expenses incurred for rental or purchase of durable medical equipment (DME) or supplies, if medically necessary.
MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
After meeting your deductible, the plan will pay for 90% of covered charges for inpatient mental health and substance abuse treatment services. The plan provides for maximum benefit coverage of 60 days per person per plan year; 90 days per person per lifetime. Care and treatment must be provided in a UNICARE approved hospital. Pre-certification for inpatient mental health and substance abuse treatment services by UNICARE is required
After meeting your deductible, the plan will pay for 80% of covered charges for outpatient mental health and substance abuse treatment services. The plan provides for maximum benefit coverage of 20 visits per person per plan year. UNICARE may approve up to 50 visits per person per plan year under the following conditions: (1) in lieu of inpatient treatment; or (2) immediately following a hospital confinement for the same condition.
Physician services provided for the treatment of Attention Deficit Disorder (ADD) will apply towards the outpatient mental health visit limitation of 20 visits per plan year.
Indemnity Plan Design - Effective January 1, 2004 39
Booklet Revised - July 2004

Mental health and substance abuse treatment services must be medically necessary and must be provided by a qualified professional. A qualified professional is a licensed psychiatrist; a licensed clinical psychologist; a licensed clinical social worker; a licensed professional counselor; and/or a licensed marriage and family therapist. The plan design will provide benefits coverage for treatment services provided by a qualified professional that relate to psychiatric or substance abuse diagnoses.
A UNICARE approved hospital means a hospital, an outpatient treatment facility, or a residential treatment facility. A convalescent nursing home is not deemed to be a UNICARE approved hospital under this specific plan benefit. A residential treatment facility is an institution that is established and operated in compliance with applicable state statutes. A residential treatment facility provides for the treatment of psychiatric conditions, alcoholism, chemical dependency, or drug addiction. The facility must provide room and board; evaluation and diagnosis; counseling; and referral/orientation to specialized community resources. A residential treatment facility must maintain a written, specific regimen requiring full-time residence and participation by the patient.
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICE PROVIDERS
BCBSGA Prudent Buyer Program (Within the State of Georgia)
One of the features that are included in the indemnity healthcare plan to help reduce your out-ofpocket costs is the BCBSGA Prudent Buyer Program. Similar to the BCBSGA Participating Physician Program, this program provides a network of mental health facilities that have agreed to accept the indemnity plan's established UCR fee limit as the maximum payment for the professional treatment services that are provided within the State of Georgia. The BCBSGA Prudent Buyer Program applies to both inpatient and outpatient mental health facility treatment services.
BCBS National Participating Provider Network (Outside the State of Georgia)
The BCBS National Participating Provider Network is a network that is similar in scope to the existing BCBSGA Prudent Buyer Program. With this network, the providers have contracted with their local Blue Cross Blue Shield plan in the state where the provider practices.
Within the BCBS National Participating Provider Network, physicians and facilities have agreed to accept the "allowable charge" as the maximum payment for their services. "Allowable charge" will be based upon the contracted rate that a national participating provider has agreed to accept from the local BCBS plan in the state where the services are rendered. The BCBS National Participating Provider Network applies to both inpatient and outpatient mental health facility treatment services.
Indemnity Plan Design - Effective January 1, 2004 40
Booklet Revised - July 2004

Healthcare plan participants, who access either the BCBSGA Prudent Buyer Program, or the BCBS National Participating Provider Network, will not be subject to balance billing.
It is always your choice to select or use a mental health facility that is or that is not a part of the BCBSGA Prudent Buyer Program or the BCBS National Participating Provider Network. Please be informed that if you select a mental health facility that is not a participant in these BCBS networks or programs, you may be subject to balance billing for mental health and substance abuse treatment services that are provided. Member costs incurred for balance billing will not apply toward the annual deductible or toward the annual maximum out-of-pocket limits (stop loss).
To determine if a mental health facility is a member of the BCBSGA Prudent Buyer Program or of the BCBS National Participating Provider Network, please ask the facility administrator. It is wise to check with the mental health facility in advance of receiving treatment services.
Information regarding the physicians/facilities that participate in BCBSGA Prudent Buyer network (within the State of Georgia) may be determined by contacting the BCBSGA Customer Service at 1-800-424-8950 or TDD 404-842-8073. To determine if your out of state physician or facility is in the BCBS National Provider Network, please contact BCBS Association Customer Service at 1-800-810-BLUE (2583). These telephone numbers are listed on your indemnity plan identification card. You may also obtain this information by accessing the University System of Georgia website at www.usg.edu/admin/humres/benefits/health/.
PLEASE NOTE:
The University System of Georgia indemnity healthcare plan does not have the legal authority to intervene when a non-participating provider balance bills the member. Therefore, the healthcare plan cannot reduce or eliminate balance billed amounts. The healthcare plan will not make additional payments above the plan allowed benefit limits.
PHARMACY BENEFIT MANAGEMENT (PBM) PROGRAM
Express Scripts, Inc., has been chosen to administer the prescription drug benefit program for the self-insured healthcare plans of the University System of Georgia. The prescription drug benefit program was designed to offer clinical effectiveness, choice and flexibility. The pharmacy benefit plan was developed after extensive review, analyses, and recommendations of a national panel of physicians and pharmacists.
The University System of Georgia has implemented a three-tiered pharmacy benefit plan. Your three-tiered pharmacy plan includes generic drugs, preferred brand name drugs, and nonpreferred brand name drugs. Each tier has it's own individual co-payment. Your co-payment will vary based on the specific medication that you and your physician select. The use of generic prescription medications, whenever available, is the most cost effective option for a member.
Indemnity Plan Design - Effective January 1, 2004 41
Booklet Revised - July 2004

PRESCRIPTION DRUG CO-PAYMENTS

Co-Payment For
Generic Drugs Preferred Brand Name Drugs Non-Preferred Brand Name Drugs

Participating Retail Pharmacy 30-Day Supply $10.00 $25.00
20% with a $40.00 minimum and a $100.00 maximum

Your indemnity healthcare plan includes a quarterly out-of-pocket maximum for members who obtain generic and preferred brand name prescription medications. The co-payments for these prescription medications will apply toward your quarterly out-of-pocket maximum. The following quarterly out-of-pocket maximum amounts (stop loss) will apply:

QUARTERLY OUT-OF-POCKET MAXIMUMS

Employee

$450 per quarter

Employee + Child (2 covered members) Employee + Spouse (2 covered members) Family (3 or more covered members)

$900 per quarter $900 per quarter $1,350 per quarter

Upon a member reaching his/her quarterly out-of-pocket maximum, his/her prescription drug copayments will be waived for any additional generic and preferred brand name medications for the remainder of that quarter. Member co-payments will resume at the beginning of the next calendar quarter and will be charged until the plan thresholds are reached for that quarter. A quarter will consist of three consecutive months as designated below:

1st quarter - January through March 2nd quarter - April through June
3rd quarter - July through September 4th quarter - October through December

Co-payments for non-preferred brand name medications will not apply to the quarterly outof-pocket maximum benefit.

Prescription drug co-payments do NOT apply to the University System of Georgia medical annual deductible or to the medical maximum annual out-of-pocket limits (stop loss).

If a member purchases a preferred brand name prescription drug that is not indicated as "Brand Necessary", and there is a generic alternative available; only the $10 generic member co-payment will be applied to the quarterly maximum out-of-pocket member

Indemnity Plan Design - Effective January 1, 2004 42
Booklet Revised - July 2004

pharmacy benefit. The difference in cost between the generic alternative and the preferred brand name medication will not apply to the quarterly maximum out-of-pocket member pharmacy benefit.
Prescription drug co-payments covered by the healthcare plan, will not be changed or overridden on an individual basis.
There are two Express Scripts resources available to assist you, your pharmacist, and/or your physician with questions regarding the University System of Georgia pharmacy benefit program. You may contact Express Scripts, 24-hours a day, seven days a week, by calling the toll free customer service telephone number at 1-877-650-9341/TDD 1-800-842-5754.
You may also obtain information by going to the University System of Georgia website address at www.usg.edu/admin/humres/benefits/health/.
Among the types of information that are available on the University System of Georgia website are the location of Express Scripts participating network pharmacies within the State of Georgia; the 2004 Georgia Preferred Drug List; and the Board of Regents Member handbook which describes your prescription drug benefit plan. Please be reminded that prescription drug member co-payments will not apply to your medical healthcare plan annual deductible or out-of-pocket maximum.
There will be no Coordination of Benefits (COB) for allowed pharmacy charges between the Board of Regents pharmacy plan and any other pharmacy/medical plan in which the member may be enrolled.
The member's maximum lifetime benefit of $2 million includes services provided for both medical care/treatment, as well as, pharmacy benefits.
EXPENSES THE INDEMNITY HEALTHCARE PLAN DOES NOT COVER (Exclusions)
Some of the medical services, supplies or treatments that are not covered by the indemnity healthcare plan include, but are not limited to:
Those that exceed the usual, customary and reasonable (UCR) limit for covered charges;
Those that are not medically necessary;
Those that could have been provided in a more cost-effective manner, without affecting the patient's good health. (Example: Incurring hospital charges for a Friday or Saturday inpatient hospital admission, unless the weekend admission was deemed medically necessary by UNICARE);
Those that are provided by an immediate family member or household resident;
Indemnity Plan Design - Effective January 1, 2004 43
Booklet Revised - July 2004

Those that are not recommended/approved by an attending physician;
Those that were received prior to being eligible for plan participation and coverage;
Those that may be covered by state or federal programs, such as items covered by Workers' Compensation or Medicare;
Those charges incurred by a member from his/her physician for failure to keep a scheduled appointment;
Those that are for the medical/surgical management of weight loss or for gastric-restrictive procedures associated with the correction of obesity;
Those that are for fitness/exercise programs;
Those that are to correct a speech deficiency or to improve a habitual speech disorder;
Those that are associated with cosmetic surgery, except for charges related to accidental injury, corrective surgery for congenital anomalies, and/or reconstructive surgeries following a mastectomy;
Those for hair transplants, hair pieces or wigs;
Those for hearing aids;
Those for foot orthotics and/or foot inserts;
Those that are incurred, directly or indirectly, from participating in an insurrection, a war, or the service in the armed forces of any country;
Those that are custodial in nature;
Those that are investigational/experimental in nature;
Those for hypnotherapy;
Those for infertility drugs or artificial insemination agents;
Those associated with any type of infertility treatment/procedures; including, but not limited to, artificial insemination, invitro-fertilization, embryo transfer processes, and/or reversal sterilization;
Those for the treatment of sexual dysfunction or inadequacies, including the treatment for impotency (except male organic erectile dysfunction);
Indemnity Plan Design - Effective January 1, 2004 44
Booklet Revised - July 2004

Those for a sex transformation; Those for acupuncture therapy; Those for child, career, social adjustment, financial, pastoral or marriage counseling; Those for therapy for conditions related to hyper-kinetic syndromes, learning disabilities,
behavioral problems, mental retardation or speech disorders; Those that are not provided by a legally licensed physician. The medical services and/or
treatment provided must be within the scope of the physician's license; Those that are provided by a chiropractor; Those for nutritional supplements; Those for smoking cessation programs; Those for dental work, dental X-rays, or dentures, unless the procedure resulted from
accidental injury to natural teeth sustained while covered under the plan; and Those for radial keratotomy; and/or for the surgical correction of nearsightedness,
astigmatism, or any other correction of vision due to a refractive problem.
WHEN YOUR INDEMNITY HEALTHCARE PLAN COVERAGE ENDS
Your coverage, under the indemnity healthcare plan, will end on the last day of the month in which: You are no longer eligible to participate in the plan; You elect to withdraw from the plan during an open enrollment period; Your employment is terminated, except due to death; You fail to make any required employee contribution; or The indemnity healthcare plan is terminated. Please be reminded that you may continue with your coverage under the indemnity healthcare plan, if you are on a campus-approved leave of absence.
Indemnity Plan Design - Effective January 1, 2004 45
Booklet Revised - July 2004

Blue Cross Blue Shield of Georgia will issue a Certificate of Creditable Coverage to a member when his/her indemnity healthcare plan coverage ends. This Certificate of Creditable Coverage may be presented to a new employer to demonstrate proof of previous healthcare plan coverage. The BCBSGA Certificate of Creditable Coverage affords compliance with specific provisions of the federal Health Insurance Portability and Accountability Act (HIPAA).
WHEN INDEMNITY HEALTHCARE PLAN COVERAGE FOR YOUR ELIGIBLE AND COVERED DEPENDENT(S) ENDS
Your indemnity healthcare plan will provide coverage for your full-time student dependent until he/she attains age 26. On a dependent's 26th birthday, his/her indemnity healthcare coverage will terminate. Healthcare coverage extended to your eligible covered dependents (other than full-time students) will end on the last day of the month in which:
Your dependent(s) ceases to be eligible;
You are no longer eligible to participate in the plan;
Your dependent(s) becomes eligible for coverage under the plan, as a University System of Georgia employee;
You elect to withdraw from the plan during an open enrollment period;
Your employment is terminated;
You elect to reduce your level of benefit coverage: (1) from "family" coverage to "employee + child" coverage, to "employee + spouse" coverage, or to "single" coverage; or (2) from "employee + child" coverage or "employee + spouse" coverage to "single" coverage;
You fail to make any required employee contribution; or
The plan is terminated.
If your indemnity healthcare plan coverage ends, you and/or your dependents may be eligible for an extension of coverage under the special provisions of the plan. Please see the section entitled, "Coverage After Retirement", located on page 47, or the section entitled, "Extended Coverage for Your Dependents After Your Death", located on page 48 of this booklet.
Indemnity Plan Design - Effective January 1, 2004 46
Booklet Revised - July 2004

COVERAGE FOR ACTIVE EMPLOYEES AGE 65 OR OVER
If a member continues to work past the age of 65, he/she may be eligible to access healthcare coverage under both the indemnity healthcare plan and under Medicare Part A. If a member meets the eligibility requirements for participation in Medicare Part A, he/she should apply for these benefits with Social Security.
For an active employee who is age 65 and older, the indemnity plan will continue to provide primary healthcare coverage. If the member has enrolled in Medicare Part A, secondary healthcare coverage may be available under Medicare.
If an employee has a spouse who is age 65 or older, the spouse should apply for Medicare Part A and Part B, when eligible.
COVERAGE AFTER RETIREMENT
When a member retires from active service with the University System of Georgia, participation in the indemnity healthcare plan may be continued into retirement if the member complies with the requirements as prescribed by the Board of Regents Policy Manual. A member who enters retirement may continue with the same level (single, employee + child, employee + spouse, or family) of healthcare coverage that he/she had immediately prior to retirement. On page 17 of this booklet, information is provided regarding the USG Retiree Annual Change Period.
Continued participation in the healthcare plan is voluntary. You will continue to pay your employee portion of the monthly premium. The institution from which you retired will continue to pay the employer's share of your monthly premium. The costs of healthcare plan premiums for employees, retirees and dependents of the University System of Georgia changes periodically. Your campus Human Resources/Personnel Office will notify you of any changes in plan costs and in employer/employee contribution rates.
If you carry "employee + child" healthcare coverage or "employee + spouse" healthcare coverage or "family" healthcare coverage into retirement, and you predecease your spouse, your covered dependents will be permitted to continue their healthcare coverage. Healthcare coverage for the spouse will continue until his/her death or remarriage. Coverage for dependent children would continue until they ceased to be eligible.
When a retired member of the University System of Georgia reaches age 65, it is strongly recommended that he/she apply for Medicare Part A and Part B. If a member meets the eligibility requirements for participation under both Medicare Part A and B, he/she should apply for these benefits with Social Security. If you are covered by both Medicare and the indemnity healthcare plan, your Medicare coverage will be primary. Your indemnity plan coverage will be secondary.
If an employee has a spouse who is age 65 or older, the spouse should apply for Medicare Part A and Part B, when eligible.
Indemnity Plan Design - Effective January 1, 2004 47
Booklet Revised - July 2004

EXTENDED HEALTHCARE COVERAGE FOR DEPENDENTS AFTER THE DEATH OF A COVERED EMPLOYEE
(A) Deceased University System of Georgia Employee With A Minimum of Ten Years of Service
A dependent, of an active employee who dies while in active service or in retirement, may remain as a participant of the indemnity plan under the following conditions:
The deceased employee must have had at least ten years of continuous service in a benefits eligible position with the University System of Georgia; or
The deceased employee must have had ten years of continuous service with the State of Georgia. The final two years of State of Georgia continuous service must have been with the University System of Georgia in a benefits eligible position.
The University System of Georgia will continue to pay the employer portion of healthcare plan premiums until the dependent ceases to be eligible. Healthcare coverage for a deceased member's spouse will continue until his/her death or remarriage.
(B) Deceased University System of Georgia Employee With Less Than Ten Years of Service
A dependent, of an active employee who dies with less than ten years of service, may remain as a participant in the indemnity healthcare plan for no more than 24 consecutive months after the death of the employee. The University System of Georgia will pay the employer portion of the healthcare plan premiums for this 24 month period. After this 24-month period, a dependent may elect to continue his/her healthcare coverage through COBRA. For information regarding Your COBRA Rights, please see page 55 of this booklet.
FILING PAPER CLAIMS/USE OF A PHYSICIAN WHO IS NOT A MEMBER OF THE INDEMNITY HEALTHCARE
PROGRAMS OR NETWORK
USE OF NON-PARTICIPATING PROVIDER WITHIN THE STATE OF GEORGIA
If you receive medical care from a physician who is not a member of the BCBSGA Participating Physician Program within the State of Georgia, you will have one year from the date that such service was rendered to file a paper claim and receive reimbursement for covered charges.
Claims for such medical services provided within the State of Georgia should be submitted to: Blue Cross Blue Shield of Georgia Post Office Box 7728 Columbus, GA 31908-7728 Telephone: 1-800-424-8950/TDD 404-842-8073
Indemnity Plan Design - Effective January 1, 2004 48
Booklet Revised - July 2004

Claims forms for medical services rendered within the State of Georgia are available and may be obtained from your campus Human Resources/Personnel Office, from the BCBSGA Customer Service department, or via electronic format from the University System of Georgia website, www.usg.edu/admin/humres/benefits/health/.
USE OF NON-PARTICIPATING PROVIDER OUTSIDE OF THE STATE OF GEORGIA
If you receive medical care from a medical provider outside of Georgia, who is not a member of the BCBS National Provider Network, you will have to contact BCBSGA Customer Service for assistance. Claims for medical services provided outside of the State of Georgia must be filed and submitted to the local Blue Cross Blue Shield plan in the state where the services are rendered. To obtain the name, mailing address and claim form for the local Blue Cross Blue Shield plan, please contact BCBSGA Customer Service at 1-800-424-8950/TDD 404-842-8073 for assistance.
You will have one year from the date that such service was rendered to file a paper claim and receive reimbursement for covered charges.
Failure to submit an out-of-state medical claim(s) to a local Blue Cross Blue Shield plan may result in the delayed processing of your benefits. If incorrect benefits are applied to your claim, reimbursement for incurred medical expenses will be further delayed.
GENERAL INFORMATION REQUIRED TO FILE A CLAIM
To process your medical claim, the following information is required regardless of the provider. Plan benefits will be paid upon receipt of: (1) a completed claim form; and (2) provider documentation of medical treatment and/or services. The claim form must be filled out in its entirety. Any missing information may cause a delay in processing your reimbursement. The following information must be included on the claim form:
Name of the contract holder; contract number; and group number, exactly as it appears on your member identification card;
Provider documentation of medical treatment/services and detailed diagnosis; and
A copy of the provider's billing statement indicating:
The name of the patient; The type of treatment or services rendered; The date and charges for treatment or services; and The signature of the provider.
Please retain a copy of all claim forms and bills for your records.
Indemnity Plan Design - Effective January 1, 2004 49
Booklet Revised - July 2004

Claims forms are available and may be obtained from your campus Human Resources/Personnel Office, from the BCBSGA Customer Service department, or via electronic format from the University System of Georgia website, www.usg.edu/admin/humres/benefits/health/.
PLEASE NOTE:
The following do not meet the supporting documentation required for filing a paper claim: (1) a provider billing statement that reflects a "balance due" amount; (2) a cash receipt issued to a member from a provider; and/or (3) a canceled check reflecting a member's payment for provider services.
FILING PAPER CLAIMS/FOREIGN CLAIMS WHILE TRAVELING ABROAD
If a member receives medical care while traveling outside of the United States, he/she will be required to pay the provider at the time that medical services are rendered. The member will have one year from the date that the medical services were rendered to file a paper claim and receive reimbursement for covered charges. Claims should be submitted to:
Blue Cross Blue Shield of Georgia Post Office Box 7728 Columbus, GA 31908-7728 Telephone: 1-800-424-8950/TDD 404-842-8073
Plan benefits will be paid upon receipt of: (1) a completed claim form; and (2) an itemized bill for medical treatment and/or services. The member will be required to have the itemized bill translated into English prior to submitting a paper claim to BCBSGA. To expedite the processing of such claims, BCBSGA requests that the billed amount be converted to an equivalent United States currency rate.
The claim form must be filled out in its entirety. Any missing information may cause a delay in processing your reimbursement.
PLEASE NOTE:
An explanation of benefit (EOB) form and reimbursement for covered medical treatment/services will be mailed to a member's United States mailing address. BCBSGA will not mail this type of information to any address outside of the United States.
Please be reminded that the member must pay for provider services rendered outside of the United States. BCBSGA will not reimburse a non-United States healthcare provider.
Indemnity Plan Design - Effective January 1, 2004 50
Booklet Revised - July 2004

DENIAL OF A MEDICAL CLAIM BY BCBSGA
If a member has a medical claim that is denied by BCBSGA, he/she will receive written notification from BCBSGA. The denial notice will include:
The specific reason(s) for the denial; A reference to the plan provision(s) that supports the denial by BCBSGA; The clarification of information required from the member/provider to complete the
processing of the claim; and An explanation regarding the necessity for providing additional information.
If a time extension to process a claim is required by BCBSGA, the member will be notified in writing and provided with an explanation for the reason for the extension.
APPEALING A DENIED CLAIM
A member has a right to express concerns about a denied claim and to expect an unbiased resolution of his/her issues. BCBSGA is an important informational resource that should be initially contacted to answer member inquiries and to confirm the types of coverage that have been adopted/implemented for the indemnity healthcare plan.
If a medical claim is denied, the member may appeal this decision to BCBSGA within 60 days of the date that the claim was denied.
1. Please contact the BCBSGA Customer Service department at 1-800-424-8950/TDD 404842-8073. Please share your concerns regarding a denied medical claim with the BCBSGA customer service representative. When discussing a claim, please provide the following information:
Contract holder name and identification number; Patient name and address; Provider name and address (hospital and/or physician); Date/dates of service; and Type of service received.
2. You have the right to submit a written inquiry regarding your denied medical claim. Written inquiries should be directed to:
Blue Cross Blue Shield of Georgia Post Office Box 7728 Columbus, GA 31908-7728
3. You should receive a written response from BCBSGA regarding your initial written inquiry within 30 calendar days.
Indemnity Plan Design - Effective January 1, 2004 51
Booklet Revised - July 2004

4. Following the review process by BCBSGA, a member may submit a final appeal to the plan administrator. The plan administrator will not accept any member appeal until the entire BCBSGA process has been completed. The member will be required to provide the plan administrator with all supporting documentation presented at the respective levels of the BCBSGA appeal process. The plan administrator will render a final decision.
ASSIGNMENT OF BENEFITS
The process of assignment of benefits permits a member to have his/her plan benefits paid directly to a provider (physician/hospital) for medical treatment/services that have been rendered. Healthcare benefits are automatically paid to:
Physicians participating in the BCBSGA Participating Physician Program and physicians, hospitals and facilities participating in the BCBS National Participating Provider Network;
Mental health hospitals participating in the BCBSGA Prudent Buyer Program and the physicians, hospitals and facilities participating in the BCBS National Participating Provider Network;
State of Georgia DRG contracted hospitals; and Centers of Expertise participating in the UNICARE national Organ and Tissue
Transplant program.
SUBROGATION
The indemnity healthcare plan includes a subrogation clause. If a covered member incurs medical expenses for an injury or illness involving alleged negligence/misconduct of another party, BCBSGA may have a claim against the other party for payment of a covered member's medical bills. BCBSGA can seek to recover the cost of a member's medical treatment/services incurred by the plan for such expenses. BCBSGA can seek recovery of associated medical costs from either the member or from a third party. The member will be responsible for providing BCBSGA with any information or assistance needed to enforce this provision.
ADMINISTRATIVE INFORMATION
COORDINATION OF BENEFITS (COB)
A number of healthcare plan members and enrolled dependents may be covered under another healthcare plan that provides medical benefits on a group-insurance basis. If you are such a member, you should be informed about the indemnity plan's provision for "Coordination of Benefits (COB)".
The indemnity plan's COB provision stipulates that, when there is multiple coverage by two or more group-insurance medical benefit plans, reimbursement by the Board of Regents indemnity plan will not exceed 100% of the covered charges incurred. Covered charges do not include member penalties assessed for plan non-compliance.
Indemnity Plan Design - Effective January 1, 2004 52
Booklet Revised - July 2004

The COB provision applies to any group-insurance medical benefit plan. Examples would include governmental programs, such as Medicare; or the employer of a spouse who offers group-insurance medical benefits. COB does not apply to an individual policy for healthcare coverage, for which the member pays the total premium directly to the insurer.
To administer the COB provision, it must be determined which group-insurance medical plan is deemed to have "primary" coverage. The primary plan will be required to initially process and pay any covered medical claims. This generally means that the primary plan will pay for the majority of the costs associated with such claims. Any other group-insurance medical plan(s) is deemed to have "secondary" coverage responsibilities.
The decision regarding which group-insurance medical plan is "primary", is made as follows:
1. A plan without a Coordination of Benefits (COB) provision is primary over a plan with COB provision.
2. A group-insurance medical plan that covers an individual as an active or retired employee is primary over a group-insurance medical plan that covers an individual as a dependent.
An exception to this policy is:
An institution has a retiree of the University System of Georgia (USG). The USG retiree has healthcare coverage with: (1) the University System of Georgia; (2) Medicare; and (3) is covered as a dependent under his/her spouse's active group healthcare plan. In this case, the spouse's healthcare plan coverage is primary; Medicare coverage is secondary; and the retiree's USG healthcare plan has the third or tertiary level of responsibility.
3. For children, the healthcare plan of the parent whose birthday occurs earlier in the calendar year is deemed to be primary. If both parents' birthdays occur on the same day, the healthcare plan that has insured the parent for the longest period of time is primary. If one of the plans does not have the parent birthday rule, the father's healthcare plan is primary.
4. For children of separated or divorced parents: (A) When a court decree has determined that one parent has financial responsibility for medical, dental or other healthcare expenses of a child, the healthcare plan of the parent with court-decreed financial responsibility is primary to any other plan covering the child (regardless of which parent has custody).
(B) When a court decree states that the parents will share joint custody, without specifying which parent has financial responsibilities for medical or dental care expenses of a child, the plan providing primary coverage for the child, will follow the sequence of benefit determination rules presented below:
1. The healthcare plan of the parent whose birthday occurs earlier in the calendar year is primary;
Indemnity Plan Design - Effective January 1, 2004 53
Booklet Revised - July 2004

2. When both parents' birthdays occurs on the same day, the healthcare plan that has insured the parent for the longest period of time is primary; and
3. If one of the plans does not have the parent birthday rule, the father's healthcare plan is primary.
(C) In the absence of court-decreed financial responsibility:
1. For healthcare plans that cover a child of separated or divorced parents who have not remarried, the healthcare plan of the parent with custody is deemed to be primary.
2. For healthcare plans that cover a child of remarried parent(s):
The healthcare plan of the remarried parent, with custody, is deemed to be primary;
The healthcare plan of the step-parent is deemed to be secondary; and The healthcare plan of the biological parent, without custody, is deemed to
have the third level of healthcare payment responsibility.
5. The healthcare plan that covers an insured individual as an active employee is primary over a healthcare plan that covers a retiree or laid-off employee. The same process is true for an active employee covered by his/her employer's group-insurance medical plan who is also covered as a dependent under a retiree's/laid-off employee's group-insurance medical plan. An active employee's healthcare plan will have primary coverage responsibilities.
Benefits under the Board of Regents indemnity healthcare plan will also be coordinated with benefits provided by the federal Medicare program. If a member has both USG indemnity healthcare coverage and Medicare coverage, COB procedures will be established as follows:
If you are covered under the indemnity healthcare plan as an active employee or as the spouse of an active employee, the USG indemnity plan will be primary. Your BCBSGA Participating Physician Program and your BCBS National Participating Provider Network will file medical claims with the USG indemnity plan initially and then, with Medicare. In many cases, your healthcare provider will file your medical claims with the USG indemnity healthcare plan and Medicare simultaneously.
If you are covered under the USG indemnity healthcare plan as a retiree or as the spouse of a USG retiree, and you are age 65 or older, Medicare will be primary.
If you return to active employment with another employer after you reach age 65 and you are covered by the new employer's group-insurance healthcare plan, then: (1) your new employer's healthcare plan will be primary; (2) Medicare coverage will be secondary; and (3) the USG healthcare plan will be considered to have a third or tertiary coverage responsibilities.
Indemnity Plan Design - Effective January 1, 2004 54
Booklet Revised - July 2004

YOUR COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), you or your covered dependents have the option of continuing healthcare coverage under the University System of Georgia indemnity healthcare plan. Terms, conditions, and costs for healthcare coverage are identified below. If your coverage is continued under COBRA, UNICARE must continue to review and approve all medical treatment/services that are provided for you and your covered dependents. You will be required to comply with all plan requirements to receive covered benefits.
You may elect COBRA coverage under the following conditions:
Coverage for you and your covered dependents can be continued for up to 18 months if:
You terminate your employment with the University System of Georgia, for reasons other than gross misconduct; or
You have a reduction in your work commitment to less than half time. To be eligible for benefits coverage, you must be employed by the University System of Georgia for at least 20 hours per week on a regular basis.
There are changes in family circumstances that would permit a covered dependent to extend his/her COBRA coverage from an initial 18-month eligibility period up to a maximum of a 36-month eligibility period. Presented below are the conditions that would permit this extension of COBRA healthcare coverage for up to 36 months.
Coverage may be provided for your spouse and dependents, if you die; Coverage may be provided for your spouse and dependents, if you legally separate or
divorce; Coverage may be provided for your child, when the child is no longer an eligible
dependent under the indemnity healthcare plan; or, Coverage may be provided for your spouse and dependents when you become Medicare
eligible, usually at age 65.
Under certain conditions, COBRA healthcare coverage may be granted for a period of 29 months:
A covered member of your family is disabled at the time of the loss of your healthcare coverage.
Under certain conditions, COBRA healthcare coverage may be extended from an initial 18month eligibility period to a 29-month eligibility period:
A covered member of your family becomes disabled while you are receiving COBRA healthcare benefits.
Indemnity Plan Design - Effective January 1, 2004 55
Booklet Revised - July 2004

If the indemnity healthcare plan continues to provide coverage for any period of time after a COBRA qualifying event occurs, such time will be counted against the 18, 29, or 36 months of COBRA eligibility.
The cost for COBRA healthcare coverage will be the combined employer and employee premium contribution amounts, plus an additional 2% administrative fee. The member cost for COBRA healthcare coverage would, therefore, be 102% of the total indemnity healthcare premiums. The employee/employer premium costs for the indemnity healthcare plan changes periodically. As changes in premiums for the indemnity plan change, costs for COBRA healthcare coverage will change accordingly.
COBRA healthcare premiums must be paid to your campus Human Resources/Personnel Office. A member must make an election for COBRA healthcare coverage within 60 days (after the date of the COBRA continuation notice) of his/her loss of University System of Georgia healthcare coverage.
The member must submit his/her initial premium payment within 45 days of election of COBRA coverage or COBRA healthcare continuation rights will be forfeited. A member will be required to remit all premiums to his/her institution from the date of his/her initial loss of University System of Georgia healthcare coverage.
Thereafter, the member will be responsible for remitting monthly premiums to his/her campus Human Resources/Personnel Office, consistent with an institutionally determined schedule of payment.
PLEASE NOTE:
It is the member's responsibility to notify his/her campus Human Resources/Personnel Office when the member or his/her covered dependent(s) are no longer eligible for University System of Georgia healthcare coverage. Such notification is required for the member and his/her covered dependents to be eligible to participate in COBRA healthcare coverage.
It is, also, the member's responsibility to notify his/her campus Human Resources/Personnel Office when there is a change in the member's or in the member's covered dependents' COBRA eligibility status.
COBRA healthcare coverage will end prior to the end of the 18-month, 29-month or 36-month maximum eligibility participation period if:
A COBRA-covered disabled family member, who recovers from his/her disability; after the initial 18-month eligibility period and prior to the conclusion of the 29-month COBRA eligibility period;
The member fails to remit his/her required COBRA healthcare premium within the institutionally approved schedule for payment; or
The University System of Georgia healthcare plan is terminated.
Indemnity Plan Design - Effective January 1, 2004 56
Booklet Revised - July 2004

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
NOTICE OF PRIVACY PRACTICES
The broad mission and extensive scope of operations of the Board of Regents of the University System of Georgia, including the constituent colleges and universities of the University System of Georgia (collectively, the "Board"), necessitates that the Board collect, maintain, and, where necessary, disseminate health information regarding the Board's students, employees, volunteers, and others. For example, the Board collects medical information through its various medical and dental hospitals, clinics, and infirmaries; through the administration of its various medical and life insurance programs; and through its various environmental health and safety programs. The Board protects the confidentiality of individually identifiable health information that is in its possession. Such health information, which is protected from unauthorized disclosure by Board policies and by state and federal law, is referred to as "protected health information," or "PHI."
PHI is defined as any individually identifiable health information regarding the medical/dental history, the mental or physical condition, or the medical treatment of an employee, a student, or a patient. Examples of PHI include patient name, address, telephone and/or fax number, electronic mail address, social security number or other patient identification number, date of birth, date of treatment, medical treatment records, medical enrollment records, or medical claims records.
The Board will follow the practices that are described in its Notice of Privacy Practices ("Notice"). The Board reserves the right to change the terms of its Notice and of its privacy policies, and to make the new terms applicable to all PHI that it maintains. Before the Board makes an important change to its privacy policies, it will promptly revise its Notice and post a new Notice in conspicuous locations.
Permitted Uses and Disclosures of PHI
The following categories describe the different ways in which the Board may use or disclose your PHI. We include some examples that should help you better understand each category.
The Board may receive, use, or disclose your PHI to administer your health and dental benefits plan. Please be informed that the Board, under certain conditions and circumstances, may use or disclose your PHI without obtaining your prior written authorization. An example of this would be when the Board is required to do so by law.
For Treatment. The Board may use and disclose PHI as it relates to the provision, coordination, or management of medical treatment that you receive. The disclosure of PHI may be shared among the respective healthcare providers who are involved with your treatment and medical care. For example, if your primary care physician needs to use/disclose your PHI to a specialist, with whom he/she consults regarding your condition, this would be permitted.
Indemnity Plan Design - Effective January 1, 2004 57
Booklet Revised - July 2004

For Payment. The Board may use and disclose PHI to bill and collect payment for healthcare services and items that you receive. The Board may transmit PHI to verify that you are eligible for healthcare and/or dental benefits. The Board may be required to disclose PHI to its business associates, such as its claims processing vendor, to assist in the processing of your health and dental claims. The Board may disclose PHI to other healthcare providers and health plans for the payment of services that are rendered to you or to your covered family members by such providers or health plans.
For Healthcare Operations. The Board may use and disclose PHI as part of its business operations. As an example, the Board may require a healthcare vendor partner (referred to as a "business associate") to survey and assess constituent satisfaction with healthcare plan design/coverage. Constituent survey results assist the Board in evaluating quality of care issues and in identifying areas for needed healthcare plan improvements. Business associates are required to agree to protect the confidentiality of your individually identifiable health information.
The Board may disclose PHI to ensure compliance with applicable laws. The Board may disclose PHI to healthcare/dental providers and health/dental plans to assist them with their required credentialing and peer review activities. The Board may disclose PHI to assist in the detection of healthcare fraud and abuse. Please be reminded that the lists of examples that are provided are not intended to be either exhaustive, or exclusive.
As Required by Law and Law Enforcement. The Board must disclose PHI when required to do so by applicable law. The Board must disclose PHI when ordered to do so in a judicial or administrative proceeding. The Board must disclose PHI to assist law enforcement personnel with the identification/location of a suspect, fugitive, material witness, or missing person. The Board must disclose PHI to comply with a law enforcement search warrant, a coroner's request for information during his/her investigation, or for other law enforcement purposes.
For Public Health Activities and Public Health Risks. The Board may disclose PHI to government agencies that are responsible for public health activities and to government agencies that are responsible for minimizing exposure to public health risks. The Board may disclose PHI to government agencies that maintain vital records, such as births and deaths. Additional examples in which the Board may disclose PHI, as it relates to public health activities, include assisting in the prevention and control of disease; reporting incidents of child abuse or neglect; reporting incidents of abuse, neglect, or domestic violence; reporting reactions to medications or product defects; notifying an individual who may have been exposed to a communicable disease; or, notifying an individual who may be at risk of contracting or spreading a disease or condition.
For Health Oversight Activities. The Board may disclose PHI to a government agency that is authorized by law to conduct health oversight activities. Examples in which the Board may disclose PHI, as it relates to health oversight activities, include assisting with audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions
Indemnity Plan Design - Effective January 1, 2004 58
Booklet Revised - July 2004

or activities that are necessary to monitor healthcare systems, government programs, and compliance with civil rights laws.
Coroners, Medical Examiners, and Funeral Directors. The Board may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent; for determining a cause of death; or, otherwise as necessary, to enable these parties to carry out their duties consistent with applicable law.
Organ, Eye, and Tissue Donation. The Board may release PHI to organ procurement organizations to facilitate organ, eye, and tissue donation and transplantation.
Research. Under certain circumstances, the Board may use and disclose PHI for medical research purposes.
To Avoid a Serious Threat to Health or Safety. The Board may use and disclose PHI to law enforcement personnel or other appropriate persons. The Board may use and disclose PHI to prevent or lessen a serious threat to the health or safety of a person or the public.
Specialized Government Functions. The Board may use and disclose PHI for military personnel and veterans, under certain conditions, and if required by the appropriate authorities. The Board may use and disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities. The Board may use and disclose PHI for the provision of protective services for the President of the United States, other authorized persons, or foreign heads of state. The Board may use and disclose PHI to conduct special investigations.
Workers' Compensation. The Board may disclose PHI for worker's compensation and similar programs. These programs provide benefits for work-related injuries or illnesses.
Appointment Reminders/Health Related Benefits and Services. The Board and/or its business associates may use and disclose your PHI to various other business associates that may contact you to remind you of a healthcare or dental appointment. The Board may use and disclose your PHI to business associates that will inform you of treatment program options, or, of other health related benefits/services such as disease state management programs.
Disclosures for HIPAA Compliance Investigations. The Board must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the "Secretary") when so requested. The Secretary may make such a request of the Board to investigate its compliance with privacy regulations of the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA").
Indemnity Plan Design - Effective January 1, 2004 59
Booklet Revised - July 2004

Uses and Disclosures of Your PHI to Which You Have An Opportunity to Object
You have the opportunity to object to certain categories of uses and disclosures of PHI that the Board may make:
Patient Directories. Unless you object, the Board may use some of your PHI to maintain a directory of individuals in its hospitals or provider facilities. This information may include your name, your location in the facility, your general condition (e.g. fair, stable, etc.), and your religious affiliation. Religious affiliation may be disclosed to members of the clergy. Except for religious affiliation, the information that is maintained in a patient directory may be disclosed to other persons who request such information by referring to your name.
Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care. Unless you object, the Board may disclose your PHI to a family member, another relative, a friend, or another person whom you have identified as being involved with your healthcare, or, responsible for the payment of your healthcare. The Board may also notify these individuals concerning your location or condition.
Fundraising Activities. Unless you object, the Board may disclose your PHI to contact you for fundraising efforts to support the Board, its related foundations, and/or its cooperative organizations.
Such disclosure would be limited to personal contact information, such as your name, address and telephone number. The money raised in connection with these fundraising activities would be used to expand and support the provision of healthcare and related services to the community.
If you object to the use of your PHI in any, or all, of the three instances identified above, please notify your campus or facility privacy officer, in writing.
Other Uses and Disclosures of Your PHI For Which Authorization Is Required
Certain uses and disclosures of your PHI will be made only with your written authorization. Please be advised that there are some limitations with regard to your right to object to a decision to use or disclose your PHI.
Regulatory Requirements. The Board is required, by law, to maintain the privacy of your PHI, to provide individuals with notice of the Board's legal duties and PHI privacy practices, and to abide by the terms described in this Notice. The Board reserves the right to change the terms of its Notice and of its privacy policies, and to make the new terms applicable to all PHI that it maintains. Before the Board makes an important change to its privacy policies, it will promptly revise its Notice and post a new Notice in conspicuous locations. You have the following rights regarding your PHI.
Indemnity Plan Design - Effective January 1, 2004 60
Booklet Revised - July 2004

You may request that the Board restrict the use and disclosure of your PHI. The Board is not required to agree to any restrictions that you request, but if the Board does so, it will be bound by the restrictions to which it agrees, except in emergency situations.
You have the right to request that communications of PHI to you from the Board be made by a particular means or at particular locations. For instance, you might request that communications be made at your work address, or by electronic mail, rather than by regular US postal mail. Your request must be made in writing. Your request must be sent to the privacy officer on your campus or facility. The Board will accommodate your reasonable requests without requiring you to provide a reason for your request.
Generally, you have the right to inspect and copy your PHI that the Board maintains, provided that you make your request in writing to the privacy officer on your campus or your facility. Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), the Board will inform you of the extent to which your request has, or, has not been granted. In some cases, the Board may provide you with a summary of the PHI that you request, if you agree in advance to a summary of such information and to any associated fees. If you request copies of your PHI, or agree to a summary of your PHI, the Board may impose a reasonable fee to cover copying, postage, and related costs.
If the Board denies access to your PHI, it will explain the basis for the denial. The Board will explain your opportunity to have your request and the denial reviewed by a licensed healthcare professional (who was not involved in the initial denial decision).
This healthcare professional will be designated as a reviewing official. If the Board does not maintain the PHI that you request, but it knows where your requested PHI is located; it will advise you how to redirect your request.
If you believe that your PHI maintained by the Board contains an error or needs to be updated, you have the right to request that the Board correct or supplement your PHI. Your request must be made in writing to the privacy officer on your campus or in your facility. Your written request must explain why you desire an amendment to your PHI.
Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), the Board will inform you of the extent to which your request has, or, has not been granted. The Board generally can deny your request, if your request for PHI: (i) is not created by the Board, (ii) is not part of the records the Board maintains, (iii) is not subject to being inspected by you, or (iv) is accurate and complete.
If your request is denied, the Board will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial, (ii) if you do not file a statement of disagreement, to submit a request that any future disclosures of the relevant PHI be made with a copy of your request and the Board's denial attached, and (iii) complain about the denial.
Indemnity Plan Design - Effective January 1, 2004 61
Booklet Revised - July 2004

You generally have the right to request and receive a list of the disclosures of your PHI that the Board has made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made prior to April 14, 2003).
The list will not include disclosure for which you have provided a written authorization, and will not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations, (ii) made to you, (iii) for the Board's patient directory or to persons involved in your healthcare, (iv) for national security or intelligence purposes, or (v) to correctional institutions or law enforcement officials.
You should submit any such request to the privacy officer on your campus or in your facility. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), the Board will respond to you regarding the status of your request. The Board will provide the list to you at no charge. If you, however, make more than one request in a year, you will be charged a fee for each additional request. You have the right to receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically. This notice may be found at the Board website address, www.usg.edu/admin/legal. To obtain a paper copy of this notice, please contact your campus or facility privacy officer.
You may complain to the Board if you believe your privacy rights, with respect to your PHI, have been violated by contacting the privacy officer on your campus or in your facility. Your must submit a written complaint. The Board will in no manner penalize you or retaliate against you for filing a complaint regarding the Board's privacy practices. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services. You may contact the Secretary by calling 1-866-627-7748 (outside of metropolitan Atlanta) or (404) 562-7886 (in metropolitan Atlanta).
If you have any questions about this notice, please contact the Human Resources office on your campus or in your facility. For additional information, please contact the privacy officer on your campus or facility.
Effective Date: April 14, 2003 PLEASE NOTE: On the following page you will find the CONSENT FOR AUTHORIZATION FOR USE/RELEASE OF HEALTH INFORMATION form. This form provides a spouse or another person/class of persons (organization) with the authority to act on behalf of another member. A signed authorization form provides access to PHI (protected health information) for an individual/organization other than the contract holder.
Should you need to access PHI for another individual, we ask that you photocopy this form and submit the completed form to your campus Human Resource/Personnel Office. Your institutional Human Resource/Personnel Office will forward a copy to the vendor (Business Associate/Agent) associated with your request.
Should you have any questions regarding the use of this form, please contact your campus Human Resource/Personnel Office for assistance.
Indemnity Plan Design - Effective January 1, 2004 62
Booklet Revised - July 2004

CONSENT FOR AUTHORIZATION FOR USE/RELEASE OF HEALTH INFORMATION
This authorization form applies only to the release and disclosure of protected health information (PHI). This authorization is not for treatment or intended for any other purpose.
By signing this form, I authorize my college, my university, my facility, or the University System office and Business Associates/Agents to use, release, or disclose the protected health information described below to:
Name and address of person/organization to whom information may be sent: ______________________________________________________________________________
Transmit this information on or about (information will not be resent absent reauthorization): ___/___/___.
This authorization expires upon fulfillment of this request unless special circumstances apply.
Purpose for disclosure:___________________________________________________________
I authorize the following information to be sent to the address above:
____ Copies of all medical records for the period ___/___/___ to ___/___/___.
____ Copies of information described below for period ___/___/___ to ___/___/___.
____ History and Physical Examination ____ Lab Reports ____ Reports From Physicians
____ Other (specify) ____________________________________________________________
I understand that this information may include any history of acquired immunodeficiency (AIDS); sexually transmitted diseases (STD); human immunodeficiency virus (HIV) infection; behavioral health services/psychiatric care; treatment for alcohol and/or drug abuse; or similar conditions.
Please include on a separate piece of paper any other special instructions or limitations.
I understand that there may be information in these records that I would not wish to be released. I have been provided with a copy of my college, university, facility, or University System policies and procedures for HIPAA Compliance and any changes thereto which may be associated with this authorization. I have been provided an opportunity to discuss any concerns I may have about the use or misuse of my health information with my institutional or facility privacy officer or other appropriate personnel.
Indemnity Plan Design - Effective January 1, 2004 63
Booklet Revised - July 2004

I understand that my institution or facility, the University System of Georgia, or the Board of Regents of the University System of Georgia assumes no responsibility for the use or misuse by others of my health information disclosed under this authorization. I release the Board of Regents of the University System of Georgia and its agents and employees from all legal liability that may arise from this authorization.

Name (please print): ____________________________________________________________

Address:______________________________________________________________________

Telephone: (____)_____________________

Fax: (____)__________________________

Group No.: __________________________

Group Name:________________________

Member ID Number: __________________

Social Security Number:________________

Signed:_______________________________________________________________________ Date of Birth:___________________________ Date this Authorization Executed:________

If the signature above is not that of the person whose medical records are authorized to be released, I am acting for the person whose medical records are being authorized for release:

My relationship to such person is:__________________________________________________ Signed:_______________________________________________________________________

The person whose medical records are hereby authorized for release or that person's representative may revoke this authorization by notifying in writing the privacy officer at the person's university, college or facility. Federal law states that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on obtaining this authorization if such conditioning is otherwise prohibited by the Health Insurance Portability and Accountability Act of 1996. Federal law also requires a statement that there is a potential for the protected health information released under this authorization to be subject to redisclosure by the recipient.

FORM CREATED 29 JAN 03

Indemnity Plan Design - Effective January 1, 2004 64
Booklet Revised - July 2004

FUTURE OF THE PLAN
The Board of Regents of the University System of Georgia is the plan sponsor for the selfinsured indemnity healthcare plan. While the University System of Georgia expects the indemnity healthcare plan to remain in effect, the University System of Georgia reserves the right to change the plan, or any benefit under the plan, from time to time; or to discontinue the plan, or any benefit under the plan, at any time.
EMPLOYMENT RIGHTS NOT IMPLIED
Your participation in the indemnity healthcare plan is not a contract of employment - it does not guarantee you continued employment with the University System of Georgia. Nor does it limit the University System of Georgia's right to discharge you, without regard to the effect that your discharge would have on your rights under the indemnity healthcare plan. If you quit or if you are discharged, you have no right to future benefits from the plan except as specifically provided in this booklet and the benefit plan document.
GLOSSARY OF TERMS
This section of your health plan booklet provides terminology and phrases used throughout this document.
Acute Care Care provided when such services are medically necessary and immediately required as a result of a sudden onset of illness or injury.
Balance Billing The dollar amount charged by a provider that is in excess of the plan's allowed amount for medical care or treatment. Amounts that are balance billed by a provider are the member's responsibility. Member costs incurred for balance billing will not apply toward the annual deductible or toward the annual maximum out-of-pocket limits (stop loss).
Coinsurance Coinsurance is the portion of the covered allowed charges that a member must pay, after he/she has met the appropriate deductible. If a healthcare plan covers 80% of the cost for a particular benefit, the member would be responsible for the remaining 20% of covered charges. The 20% of allowed charges, paid by the member, is deemed to be the coinsurance amount.
Contract Year A period of one year commencing on the effective date (or renewal date) of a healthcare plan contract and ending at 12:00 midnight on the last day of the one year period. The contract year for the University System of Georgia begins on January 1 and concludes on December 31.
Indemnity Plan Design - Effective January 1, 2004 65
Booklet Revised - July 2004

Co-payment A co-payment is a fixed dollar amount that a member must pay for a particular service or item, such as a member co-payment for a prescription medication.
Covered Charges The portion of a member's billed charges for medical treatment, services, or supplies that will be reimbursed by the healthcare plan.
Custodial Care Custodial care is any type of care, including room and board, that: (a) does not require the skills of a professional or technical healthcare provider; (b) is not furnished by, nor is under the supervision of, such a professional or technical healthcare provider; (c) does not, otherwise, meet the requirements of a post-hospital skilled nursing facility care; or (d) is a level of care, such that a member has reached his/her maximum level of physical or mental function, and is not likely to make further significant improvements. Custodial care includes, but is not limited to, any type of care in which the primary purpose of care is to attend to the member's activities of daily living. Such care does not entail, nor require, the continuing attention or observation by trained medical or paramedical healthcare providers. Generally, care is considered custodial, if it can be provided by an untrained adult with little or no supervision.
Deductible A deductible is a fixed dollar amount that a member must pay out-of-pocket, each plan year, before the healthcare plan will begin to pay for covered benefits.
Emergency Care Emergency care is medical care that is provided for a sudden, severe, and/or unexpected illness/injury. If such care/treatment were not provided immediately, the results could be life threatening or could result in permanent impairment of bodily functions.
Explanation of Benefits (EOB) An Explanation of Benefits (EOB) is an itemized statement of member-incurred medical charges. An EOB will identify paid or denied provider charges following the processing of a filed healthcare claim.
Hospice Care Hospice care is a form of medical care that is provided for a patient who has been physiciancertified as being terminally ill. Hospice care may be rendered in an inpatient or outpatient setting. The life expectancy of a hospice patient is generally deemed to be six months or less.
Indemnity Plan An indemnity plan is a type of healthcare plan that provides major medical coverage, including diagnosis and/or treatment of illness, injury or medical conditions. This type of healthcare plan allows a member the greatest flexibility in the selection of healthcare providers. The current claims administrator for the University System of Georgia's indemnity plan is Blue Cross Blue Shield of Georgia.
Indemnity Plan Design - Effective January 1, 2004 66
Booklet Revised - July 2004

Inpatient A member, who is admitted to a hospital for medical treatment or services, and for whom, a room and board charge is paid. To be considered as inpatient, a hospital confinement must be for a period of at least 24 hours.
Lifetime Maximum Benefit The lifetime maximum benefit is $2,000,000. The lifetime maximum benefit reflects a cumulative total of all covered medical and pharmacy charges paid by the healthcare plan. Please be reminded that the lifetime maximum benefit for a USG covered member includes all covered charges paid by current and previous University System of Georgia indemnity/PPO healthcare plan contracts.
Medical Utilization Management Medical Utilization Management is a program that is administered by UNICARE for all inpatient, and for specific outpatient, medical/surgical treatments and diagnostic tests. To access benefits coverage, UNICARE must determine if: (1) a procedure is medically necessary; and/or (2) if an appropriate and alternative treatment is available. For additional information, please see page 26 of this booklet.
Medically Necessary A service or treatment, which in the judgment of the indemnity healthcare plan, is both appropriate and consistent with a medical diagnosis. To meet the plan's criteria for medical necessity, any service or treatment must be widely accepted professionally within the United States as effective, appropriate, and essential. The treatment or service must be based on recognized standards of the healthcare specialty involved. The medically necessary treatment or service may not be experimental in nature; educational; or primarily for research or investigations.
Mental Health Disorders Mental health disorders include mental disorders, mental illnesses, psychiatric illnesses, mental conditions, psychiatric conditions and/or drug, alcohol or chemical dependency. Mental health disorders may be organic; non-organic; biological; non-biological; genetic; of chemical origin; of non-chemical origin; irrespective of cause, basis or inducement.
Non-Covered Charges Services that are not covered by the healthcare benefit plan design.
Outpatient A member who receives treatment from a hospital, urgent care facility or outpatient facility and is released to return home following treatment. To be considered as outpatient, treatment received in a facility must be for a period of less than 24 hours.
Indemnity Plan Design - Effective January 1, 2004 67
Booklet Revised - July 2004

Out-of-Pocket Limit (Stop Loss) An out-of-pocket limit is the maximum amount of healthcare plan expenses that a member will be required to pay during a plan year. Out-of-pocket expenses include member deductibles and member co-insurance payments required on an annual plan year basis. Once a member reaches his/her out-of-pocket limit, the healthcare plan will pay for 100% of covered expenses for the remainder of the plan year. Member costs incurred for balance billing will not apply toward the annual deductible or toward the annual maximum out-of-pocket limits (stop loss). PHI (Personal Health Information) Personal health information, which is protected from unauthorized disclosure by Board of Regents, by state statute, and by federal law, is referred to as "protected health information," or "PHI." PHI is defined as any individually identifiable health information regarding the medical/dental history, the mental or physical condition, or the medical treatment of an employee, a student, or a patient. Examples of PHI include patient name, address, telephone and/or fax number, electronic mail address, social security number or other patient identification number, date of birth, date of treatment, medical treatment records, medical enrollment records, or medical claims records. Provider A provider is a licensed medical doctor, a plan-approved healthcare professional, and/or a hospital/medical facility. Disclaimer: This booklet summarizes your indemnity healthcare plan. It is not intended to cover all the details of the indemnity healthcare plan. This booklet is not a contract and the benefits that are described can be terminated or amended by the University System of Georgia in its sole discretion. Should any questions arise, the master contract and the contract of the administration are the final authorities in determining benefits.
Indemnity Plan Design - Effective January 1, 2004 68
Booklet Revised - July 2004

LEGISLATION PASSED BY THE 2004 GEORGIA GENERAL ASSEMBLY AND SIGNED BY THE GOVERNOR
There was no legislation passed by the 2004 session of the Georgia General Assembly that will impact the Board of Regents Indemnity Health Benefits Plan Summary Document. Disclaimer: This information is provided for informational purposes only and no warranty is provided for accuracy. Members should consult legal counsel regarding legal rights and responsibilities. Revised 6-17-04
Indemnity Plan Design - Effective January 1, 2004 69
Booklet Revised - July 2004