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Hospitalization (per day) Regular Inpatient Stay - a maximwn of 100 days per confmement ICU/CCU - a maximwn of 30 days per confinement Mental Illness - a maximwn of 30 days per confmement Alcohol and Substance Abuse - a maximwn of 30 days per confmement Convalescent Facility - confinement must begin within three (3) days of a hospitalization stay of at least three (3) days. A maximwn of sixty (60) days per confinement. Limitation/Exclusion Specific to Hospitalization and Surgery Benefits of the Plan Benefits not provided for injury or sickness of a covered person, which results directly or indirectly, wholly or partly, ftom pre-existing conditions until covered under the plan for 6 continuous months. Refer to the definition of "pre- existing condition" in the Administration section. Emergency Ambulance Services! Not currently offered Maximum payable for Ground Ambulance: $750 per occurrence. Maximum payable for Air Ambulance: $5,000 per occurrence. Hospice Care (Inpatient and Outpatient); Maximum of $25,000 payable per lifetimeINot currently offered MentaI/NervouslNot currently offered Inpatient and Residential limited to 7 days per calendar year. Day treatment limited to 14 days per calendar year. Outpatient limited to 26 individual or group visits per calendar year. Intensive Outpatient accumulates to the 26 outpatient visit limit per calendar year. Medication checks are not included in the 26 outpatient visit limit per calendar year Vision Care Benefit Discounts on frames, lenses, contact lenses and eye examinations are available ftom national providers such as Pearle Vision, Sears Optical, JCPenney Optical and Target Optical. To find a participating provider, go to Vision One's website at www.colemanagedvision.com, plan number: 46907 or call (800) 804-4384. Survivor Benefit Dependent coverage continues - premium ftee - following an insured employee's death for up to 18 months. Health Insurance Portability and Accountability Act of 1996 (HIP AA) HIP AA provides individuals certain rights and protection relating to healthcare coverage. Federal law gives the plan sponsor of non-Federal governmental plans the right to exempt the plan in whole or in part ftom requirements of Title I except for the creditable coverage certificate requirements. TML IEBP has opted out of HIP AA and is exempt trom the Title I HIP AA requirements. Title I: BENEFIT PAYABLE High Standard $500 $1,000 $250 $250 $250 $200 $400 $100 $100 $100 Refers to creditable coverage, restrictions on pre-existing conditions, special enrollments, non-discrimination based on Health Status Factors, Newborns' and Mothers' Health Protection Act, Mental Health Protection Act, Mental Health Parity Act and Women's Health and Cancer Rights Act; Has an exemption option for self-funded, non-federal, governmental plans. . . Title II: Effective April 14, 2003, Administrative Simplification guidelines have been mandated. The administrative simplification process includes standards for electronic transactions and code sets, national identifiers (for employers, health plan and providers), Security and Electronic Signature Standards (final rule was published February 20,2003) and Standards for Privacy of Individually Identifiable Health Information (Privacy Rule); . A self-funded, non-federal, governmental health plan cannot exempt itself ftom the Title II requirement. Privacy of Your Health Information TML Intergovernmental Employee Benefits Pool will provide information regarding Privacy and Confidentiality guidelines. Each Covered Individual will receive a letter upon annual enrollment, regarding the Privacy and Confidentiality procedure guidelines. TML Intergovernmental Employee Benefits Pool maintains procedures to protect the privacy and confidentiality of personal health information. If personal health information is requested, the Covered Individual will be required to sign a . C:\Documents and Settings\ganderson\Loca1 Settings\Terq>orary Internet Files\OLK5\EarlyRetdoc