PRE-EXISTING CONDITIONS EXCLUSION PERIOD

A Pre-existing Condition is any Condition related to a physical or mental Condition, regardless of the cause of the Condition, for which medical advice, diagnosis, care, or treatment was recommended or received during the six-month period immediately preceding:

1. The first day of the Participant’s Waiting Period, typically the date full-time employment begins, for persons who enroll during their Initial Enrollment Period; or

2. The Eftective Date of the Participant’s Coverage under this Group Health Plan for persons who enroll during the Special Enrollment Period and the Annual Enrollment Period.

A Pre-existing Condition does not include:

1. pregnancy;

2. Genetic Information in the absence of a diagnosis of the Condition;

3. routine follow-up care of breast cancer after the person was determined to be free of breast cancer; or

4. Conditions arising from domestic violence.

Genetic Information means information about genes, gene products, and inherited characteristics that may derive from the individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories, and direct analysis of genes or chromosomes.

There is no coverage under this Group Health Plan for services or supplies to treat a Pre-existing Condition, or Conditions arising from a Pre-existing Condition, until the Participant has been continuously covered under this Group Health Plan for a 12-month period. This 12-month Pre-existing Condition Exclusionary Period begins on the first day of the Waiting Period for persons who enroll during the Initial Enrollment Period; or the Participant’s Effective Date of coverage under this Group Health Plan for persons who enroll during the Special Enrollment Period and the Annual Enrollment Period. This exclusion period also applies to any Prescription Drug that is prescribed in connection with a Pre-existing Condition.

All Employees and Dependents enrolled subsequent to the Effective Date of this Group Health Plan will be subject to the Pre-existing Conditions exclusion period, except for newborn or Adopted Dependents who are properly enrolled in accordance with this Group Health Plan or Participants who enroll during their 30 day initial enrollment period. However, credit will be given for the time an eligible Participant or Dependent was covered under previous Creditable Coverage if the previous Creditable Coverage was continuous to a date not more than 62 days prior to the Participant’s:

1. first day of the Waiting Period (i.e., first day of employment) for individuals applying for coverage during his or her Initial Enrollment Period; or

2. the Effective Date of coverage under this Group Health Plan for individuals applying for coverage during a Special or Annual Enrollment Period.

If there was a break in coverage of 63 days or more, no credit will be given for prior Creditable Coverage.

Creditable Coverage is any of the following health care coverages under which an individual may have been previously covered:

1. a group health plan;

2. health insurance coverage;

3. Part A and Part B of Title XVIII of the Social Security Act (Medicare);

4. Title XIX of the Social Security Act (Medicaid, other than coverage consisting ..solely of benefits under Section 1928 of the program for distribution of pediatric vaccines);

5. Chapter 55 of Title 10, United States Code (medical and dental care for members and certain former members of the uniformed services and their dependents);

6. a medical care program of the Indian Health Services or of a tribal organization;

7. a State health benefits risk pool (FCHA);

8. a health plan offered under chapter 89 of Title 5, United States Code;

9. a public health plan; and

10. a health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. 2504[E]).

Prior health insurers and/or group health plans are required to provide a certification of Creditable Coverage to the Participant upon termination of his or her coverage.

This Pre-existing Conditions exclusion period applies to each Participant unless the Participant:

1. was covered under the Trust’s group medical plan on the date immediately preceding the Effective Date of this Group Health Plan; and

2. enrolled under this Group Health Plan during the Initial Enrollment Period prior to the Effective Date of this Group Health Plan.

Well Child Care

Health care services and supplies furnished to a Participant who is a Dependent child which are Physician-delivered or Physician-supervised may be Covered Services. Such Covered Services include:

1. periodic examinations, which include a history, physical examinations, developmental assessment and anticipatory guidance necessary to monitor the normal growth and development of a child;

2. oral and/or injectable immunizations; and

3. laboratory tests normally performed for a well child.

These Covered Services must be provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics.

These benefits will be limited to periodic visits to age 17 and will not be subject to the Calendar Year Deductible. Benefits will be paid at the Coinsurance percentage of the Allowed Amount set forth in the Schedule of Benefits.

Annual Adult Preventive Physical Exam

For participating providers only, an annual adult preventive physical exam and related tests, including gynecological exams, may be Covered Services up to the maximum set forth in the Schedule of Benefits. Benefits will not be subject to the Calendar Year Deductible and will be reimbursed at 100% of your plans’ Schedule amount when a participating provider is used, after the copayment has been satisfied. For non-participating providers, this service is covered after the deductible is satisfied, and will be reimbursed at the co-insurance rate (subject to the allowance).

Mammogram Screening Services
The best protection is Early Detection!

Cancer is a word that sends shivers through most of us - particularly if our loved ones or we have battled this dreaded disease. Today, one in eight women develop breast cancer over her lifetime. That is an astounding statistic. Luckily, with early detection and prompt medical care, the breast cancer survival rate is up to 96 percent.

However, it shouldn't take a breast cancer scare to prompt action. Every woman should be aware of the risk - a risk that increases dramatically with age.

That is why the Diocese of Palm Beach offers coverage of routine and diagnostic mammograms for covered employees and their dependents under the Diocesan medical plans. Following are the details of those benefits.

• Routine and diagnostic mammograms are covered under preventive health benefits.

• Routine and diagnostic mammograms are not subject to the deductible, coinsurance or co-payment. Benefits are processed at 100%, if you use participating providers.

• Benefits paid for routine and diagnostic mammograms do not accumulate toward the adult calendar year maximum for preventive services.

• Services must be obtained in a medical office, medical treatment facility or through a health testing service that uses radiological equipment registered with the appropriate Florida regulatory agency (or those of another state) for diagnostic purposes or breast cancer screening

• Obtain a prescription from your physician for a routine or diagnostic mammogram, then contact Blue Cross’s Customer Service Department at 800-345-3885 to confirm that a provider is participating in your medical plan’s network.

The following mammogram screening services are Covered Services when furnished to a Participant:

1. a baseline mammogram for any woman who is 35 years of age or older, but younger than 40 years of age;

2. a mammogram every two years for any woman who is 40 years of age or older, but younger than 50 years of age, or more frequently based upon a Physician's recommendation;

3. a mammogram every year for any woman who is 50 years of age or older; or

4. one or more mammograms a year, based upon a Physician's recommendation, for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before age 30.

Except for mammograms done more frequently than every two years for women 40 years of age or older, but younger than 50 years of age, benefits are payable when, with or without a prescription from a Physician, the Participant obtains a mammogram in a medical office, medical treatment facility or through a health testing service that uses radiological equipment registered with the Department of Health and Rehabilitative Services for breast cancer screening. Benefits are not subject to the Calendar Year Deductible and Coinsurance requirements of the Group Health Plan.

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Sandy Maulden
Benefits Assistant
(561) 775-9574
E-Mail:smaulden@diocesepb.org