1.0 PLAN YEAR

Risk pooling is a continuous system following the calendar year for reporting, reimbursements, dues, plan payments, fees and all other purposes unless otherwise specified. Membership, and coverage, may begin or terminate at any time and will be accounted to the nearest month of participation. Adjustments to dues, plan payments, fees will be targeted for annual review but may occur at any time for any reason.

 

2.0 PLAN DESCRIPTION

A co-operative has been organized whose membership shares the intermediate risks and costs of healthcare expenses via pooling. • The Co-operative provides catastrophic re-insurance health benefits for the Members In Good Standing. The benefit must include all qualified healthcare costs, as commonly included in a basic health policy and defined as deductible medical costs in the Internal Revenue Code of the United States Code as amended and all covered Tribal healthcare benefits and expenses. This would exclude vision and dental care as commonly covered by vision and dental plans as well as travel, meals, and other peripheral medical costs. The Plan must pay 100% of all covered costs after the Maximum Out of Pocket has been met. The Co-operative will pay the premiums for this catastrophic re-insurance coverage from membership dues.• The Plan will establish a capital reserve for covering healthcare costs of those Members In Good Standing and their qualified dependents. The reserve should be equivalent to 25% of the sum of the Maximum Out of Pocket costs of all current catastrophic healthcare plans purchased for the members by the Co-operative. The remaining 75% is to be

covered by re-insurance and a performance bond. The Co-operative will establish a series of reserve accounts to

provide necessary liquidity for immediate cash requirements while returning a moderate income to offset operating  costs:

- A minimum of 15% of the reserve may be held in federally insured depository accounts administered by a licensed CPA fiduciary. All of these funds must be covered by the deposit insurance.

- A maximum of 60% of the reserve may be held in low-risk treasury notes, commercial paper, or equivalent securities.

- A maximum of 40% of the reserve may be invested in bonds and debt securities rated AAA investment grade by Standard & Poor's rating agency.

- A maximum of 25% of the reserve may be invested in AA+ rated equity securities with liberal cash dividend policies and practices.

- A maximum of 5% of the reserve may be held in emerging markets generally understood to be either poverty

stricken or third world by the IMF and whose governments are recognized by the United States Government as legitimate and responsible. These funds, if any, must be used for cultivating small businesses through non-profit micro-loan facilities or effectively educating the underprivileged population. Less than 15% of these funds may be used for administrative costs and all of these funds should be retrievable.

• The Co-operative will offer assistance to members in establishing tax advantaged options for funding their

healthcare costs and retirement planning through qualified third-party providers:

- Health Reimbursement Arrangement (HRA) accounts from their employers to provide employer defined potentially aggregating benefits including dues, plan payments and fees.

- Health Saving Accounts (HSA) to cover qualified plan Maximum Out of Pocket costs.

- Flexible Spending Arrangements (FSA) from employers to provide employer defined non-aggregating benefits. - Individual Retirement Accounts (IRA) for pre-tax contributions taxable at distribution. - Roth IRA (RIRA) for non-taxable returns on investments. - Various other options consistent with plan objectives.

- Each member, with their dependents, may have an individualized plan as selected from options added to the basic plan through supplements and or waivers.

 

2.1 Plan Options

2.1.1 Core Elements

Members will receive catastrophic health Plans with a common Maximum Out of Pocket established by plan

administrators. Members will select personalized coverage plans from the menu of coverage options which may include waivers for specific conditions.

 

Members Monthly Plan Payments will include:

a. The cost for the catastrophic re-insurance health plan.

b. The member's share of projected operating costs adjusted for prior period variances. c. The member's contribution to the sharing pool as underwritten for selected coverage. d. A 5% margin for co-operative debt elimination and/or charitable activities.

 

The Co-operative may assist members with negotiating service pricing terms for cash payments. Effective negotiations are subject to Co-operative involvement prior to service. Members are always responsible for selecting service providers that comply with reasonable and customary service

rates. Divergence from reasonable and customary as defined by the catastrophe Plan may be covered by the HRA or

the HSA as written into the plan but will not be covered from Co-operative assets and may need to be covered with out-of-plan, (after tax) funds.

 

2.1.2 Plan A

If the Member is an employee: The Member's employer may establish an HRA sufficient to cover the Members Monthly Plan Payment at a minimum. HRA funds in excess of projected Monthly Plan Payment may be used to reimburse other qualified healthcare costs. An HSA may be established to cover any difference between total members costs plus the Plan Maximum Out of Pocket and the funded HRA. After the Maximum Out of Pocket has been met then all qualified medical costs will be eligible for coverage from the first dollar with no additional out of pocket costs. If the Member is an employer/sole proprietor:

 

The Member will pay the minimum Monthly Plan Payment. A HSA may be funded to cover the Maximum Out of

Pocket. All qualified medical costs are eligible to be covered from the first dollar after the Maximum Out of Pocket has been met.

 

2.1.3 Plan B

The Member's employer may establish, fund, and vest an HRA for a covered employee to cover the members Monthly

Plan Payment and any qualifying healthcare costs not covered by the Plan as defined by the individual's plan selections. An HSA may be established and funded to the amount of the plan Maximum Out of Pocket. Qualified plan costs will be reimbursed as specified from the HSA or HRA. After reaching the Maximum Out of Pocket, the plan will reimburse an agreed upon percentage of qualified eligible costs. All out of pocket expenses and other qualified but non-covered costs will be reimbursed from the HRA/HSA.

 

2.1.4 Plan C

The Member will pay the minimum Monthly Plan Payment. The Member will pay all qualified plan Maximum Out of

Pocket costs as incurred and submit all documentation for plan verification. After reaching the Maximum Out of Pocket

the plan will reimburse a predetermined percentage of incurred qualified eligible costs after verification. Any other healthcare costs not covered by the plan selections are the responsibility of the member.

 

Note:

Once a Member has selected their plan options, the Member may not change plans except at the beginning of a new

fiscal year. The Risk Pool administrator will notify you of the deadline for making plan design changes for the new plan year.

 

3.0 PLAN MAXIMUMS

3.1 Member Annual Maximum Out of Pocket

3.1.1 Individual

$5,000 Maximum Out of Pocket for eligible medical and pharmacy services. This Maximum Out of Pocket applies to each individual whether an individual member or an individual family member. There is no Maximum Out of Pocket limit if a member does not comply with disease management program(s).

 

3.1.2 Couple or Two Party

$10,000 Maximum Out of Pocket for eligible medical and pharmacy services. The Maximum Out of Pocket of $5,000

applies to each individual. There is no Maximum Out of Pocket if a member does not comply with disease management program(s).

 

3.1.3 Family

$10,000 Maximum Out of Pocket for eligible medical and pharmacy services. The Maximum Out of Pocket of $5,000

applies to each individual until the Family Maximum of $10,000 is reached. There is no Maximum Out of Pocket if a member does not comply with disease management program(s).

 

3.1.4 Plans for Singles, Couples, and Families

There is no Maximum Out of Pocket if the member fails to comply with the pharmacy intervention or disease

management program. All prescriptions shall be filled with named generic products if available, unless an exception

has been granted due to a verifiable medical reason. To request an exception, the member or provider may contact the Healthcare Management Administrator. If an exception has not been granted and a prescription is filled with non-generic products, the difference paid will not be eligible or applied to the Maximum Out of Pocket and the member will also be responsible for the entire cost of the non-generic product. These additional costs will not apply towards the Maximum Out of Pocket.

 

3.1.5 Health Plan with HSA Qualifying Option

Members pay for all pharmacy costs until the Maximum Out of Pocket has been met by the combination of both covered

medical and pharmacy benefits. After the Maximum Out of Pocket has been met, any other qualified expenses are now

eligible for reimbursement. Unless there is a verifiable medical reason, the Maximum Out of Pocket amount of each

eligible prescription will not apply if member does not comply with a disease management or prescription intervention program. The Maximum Out of Pocket will not be considered met if the member does not comply with the pharmacy intervention or disease management program. All prescriptions shall be filled with named generic products if available, unless an exception has been granted due to a verifiable medical reason. To request an exception, the member or provider may contact the Healthcare Management Administrator. If an exception has not been granted and a prescription is filled with non-generic products, these additional costs will not apply towards the Maximum

 

Out of Pocket.

3.2 Plan Year Maximums

30 days inpatient treatment for alcoholism and substance abuse in any six month period. $2,000 for outpatient treatment for alcoholism and substance abuse. $900 for up to 30 outpatient visits for mental health conditions other than those biologically based. $8,000 for Durable Medical Equipment. $2,500 for treatment of Temporomandibular Joint Syndrome (TMJ).

 

3.3 Lifetime Maximums

• 90 days inpatient treatment for alcoholism and substance abuse.

• $25,000 for procurement for single or multiple transplant organs.

• $8,000 for transportation and lodging costs related to an organ transplant (per transplant occurrence).

 

4.0 COVERED DAILY HOSPITAL ROOM, BOARD AND MEDICAL SERVICES

The medically necessary daily charge made by the hospital for the most common semi-private accommodations when

medically necessary and pre-authorized by the plan's Healthcare Management Company.

 

4.1 Covered Miscellaneous Hospital Services

Medically necessary charges for:

• Use of an ambulance to the closest treatment facility.

• Charges for services of a physician or related provider. • Blood and blood plasma, and the administration of it.

• Other medically necessary services and supplies provided for the patients use during the stay, if charged for by the

hospital, extended care facility, or acute rehabilitation facility.

• Diagnostic and therapeutic services of a hospital. • Durable medical equipment when pre-authorized.

 

4.2 Covered Surgical Services

Covered surgical charges for surgery performed in a hospital or in a doctor's office, clinic, or ambulatory surgical

facility includes:

• Fees for surgical procedures performed by a physician.

• Fees for an assistant surgeon (M.D., Physician's Assistant or the equivalent), if medically necessary and

pre-authorized before surgery is performed.

• Fees for anesthesia.

 

4.3 Covered Anesthesia Services

Anesthetics, oxygen, and their administration by a qualified professional.

 

4.4 Covered Preventive Services

You are responsible for payments of all treatments until you meet your Maximum Out of Pocket. However, we want all of

our members to be in the best health possible and we offer the ability to receive, for example, annual check-ups at highly discounted rates.

 

4.5 Covered Out-of-Hospital Care and Other Covered Charges

a. Medically necessary charges by physicians or related providers. 

b. Blood and blood plasma, and it's administration.

c. Chemotherapy.

d. Optometric services for the diagnosis or treatment of a medical condition or disease (e.g. glaucoma) or for an injury

to the eye. Coverage also includes the cost of eyeglasses or contact lenses required because of an eye injury or cataract surgery.

e. Hearing testing for covered children (newborns up to 1 year old) and if necessary, hearing aids and their fitting

up to age 8.

e. Non-dental services needed because of injury to teeth unless injury to the teeth or their surrounding tissue or structure is caused by chewing; for surgical removal of impacted or partially impacted teeth; for removal of tumors or cysts; or for drainage of an abscess or cyst. Non-dental services and supplies provided for a jaw condition if needed because of an injury, medically necessary surgery or treatment of TMJ (temporomandibular joint syndrome) up to the annual maximum and subject to pre-authorization. f. Services and supplies provided in conjunction with sinus surgery if medically necessary and pre-authorized. A second opinion is required if repeat surgery is needed. 

g. Insulin pumps and glucometers. (Diabetic test strips, lancets, and medically necessary related supplies are covered under the Prescription Drug Plan.

h. Medically necessary outpatient speech (which is not already provided or covered by a school system) occupational, and physical therapy that is prescribed by a physician. Visits are limited to 10 visits per medical occurrence. To be an eligible expense, visits above the 10-visit limit must be pre-authorized before receiving services. The Plan does not cover additional visits for the same problem which are not pre-authorized and approved. (The patient is limited to 10 visits per medical occurrence even if the 10 visits extend over two plan years.)

i. Necessary private-duty nursing when part of a written home healthcare treatment plan and provided by a nurse

affiliated with a certified home healthcare agency. (The plan does not cover nursing care if the nurse resides in the

member's home or is a member of the participant's immediate family.) Subject to the annual maximum, initial rental or purchase, at the Plan's option, of medically necessary durable medical equipment; such as crutches, braces, wheelchairs, and other prostheses needed for the treatment of a disease, illness, or injury. Repairs or replacements of prostheses and other equipment must also be considered medically necessary for the patient's condition and will be consistent with current equipment. The Plan will not cover equipment prescribed solely for convenience or because it is the most recent model. Personal comfort or convenience items, including items and supplies related to the use of durable medical equipment (e.g., batteries, battery chargers, AC/DC adapter plugs, etc.), are not covered by the Plan. For covered services provided by approved IHCPO providers, practitioners and nurses acting within the scope of their license.

 

14. Services provided by our approved Turtle Healing Band Centers and providers including contraceptive implants and

removal and Depo-Provera injections.

 

15. Radioactive isotope therapy.

 

16. Radiotherapy

 

17. Charges for the following services and supplies qualify as covered home healthcare charges but only to the extent

that the charges are pre-authorized as medically necessary and received during convalescence in the covered

member's home:

a. Skilled nursing care provided or supervised by a registered nurse, affiliated with a certified home

healthcare agency.

b. Home health aide services (mainly patient care).

c. Physician ordered physical, occupational, speech, and respiratory therapy.

d. Medical social services by a licensed medical or psychiatric social worker who is supervised by a physician. e. Covered medical supplies and equipment. f. Hospice care provided in the home. 

 

The following charges do not qualify as covered home healthcare charges:

a. Charges for services rendered by the Member, a member of the family, or by any person who resides in the

Member's home. The Member's family consists of the Member, the Member's spouse, children, brothers, sisters, and parents of either the Member or the Member's spouse.

b. Charges for custodial care.

 

18. The Plan covers charges for the following non-experimental organ transplant services approved by the

Food and drug Administration:

a. Heart

b. Lung

c. Bone marrow and stem cell transplants for certain conditions;

d. Kidney

e. Pancreas

f. Liver

g. Cornea.

 

Benefits are payable for recipients covered by the Plan except for a limit on organ procurement fees. Covered charges include, but are not limited to:

a. Pre-transplant evaluation;

b. Organ procurement/listing fees, surgical, storage, and transportation costs incurred or directly related to the

donation of the organ used in one of the organ transplant procedures described above. The maximum lifetime

benefit for eligible procurement services will not exceed $25,000 per person;

c. Inpatient expenses and medication.

d. All professional fees.

e. Reasonable transportation costs (mileage reimbursement based on the IRS allowable reimbursement for

medical related travel) to and from the site of the organ transplant procedure. Expenses are covered for the organ transplant recipient and a companion for the procedure only.

f. Necessary and reasonable lodging for the organ transplant recipient and a companion incurred at the site of the

covered organ transplant procedure during the transplant benefit period.

g. Medically necessary follow-up care.

 

19. HPV (human papilomavirus) screening, when medically necessary to aid in a diagnosis after a borderline

Pap smear; In compliance with the Women's Health and Cancer Rights Act, if a member receives benefits in

connection with a mastectomy, the Plan covers the following services:

a. Reconstruction of the breast on which the mastectomy was performed.

b. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

c. Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.

 

20. Coverage for reconstructive services needed because of either an accident or a child's (under the age of 18) birth defect.

 

21. Coverage for covered chiropractic treatments and services, subject to review for medically necessary and treatment effectiveness. A second opinion may be necessary.

 

22. Coverage for prenatal care, delivery, and postpartum examinations. Blood tests and pap smears performed during

the prenatal exam or postpartum checkup are also considered covered charges. In compliance with Newborns' and Mothers' Health Protection Act of 1996, the Plan provides the following maternity health benefits.

a. A minimum of 48 hours of inpatient care for a mother and her covered newborn following a vaginal delivery and a

minimum of 96 hours of inpatient care following a delivery by cesarean section.

b. However, if the treating physician determines through standardized medical criteria that the entire stay is not

necessary, and the patient and the doctor agree that the member can go home, the Plan is not required to pay for the entire 48 or 96 hour hospital stay. 

c. Regardless of the length of the hospital stay, the Plan will cover one follow-up home visit to verify the condition

of both the member and the newborn. One home visit will be covered even if the mother and/or child are hospitalized for the entire 48 or 96 hours.

 

23. Benefits are payable for inpatient and outpatient treatment for mental and nervous conditions as well as alcohol and substance abuse by a qualified, licensed provider, when pre-authorized. The prescription drug program covers most outpatient prescription drugs. Medically necessary, covered medications that are prescribed and administered during an approved confinement are payable under the Plan. Diabetic and cardiac education. The Plan covers education sessions received within four months of the

original diagnosis. An additional four to five education sessions will be covered if/when a diabetic moves from Type II diabetes (diet controlled) to Type I (insulin dependent).

Ossatron lithotripsy procedure (extracorporeal shock wave treatment for chronic Proximal Plantar Fasciititis) requires pre-authorization or a second opinion. The Plan covers facility and physician charges associated with this procedure if the procedure is pre-authorized and conservative treatments have been tried for six months and failed to resolve the problem. Conservative treatments include icing and anti-inflammatory prescriptions, nutritional and natural supplements.

 

5.0 DESCRIPTION OF PLAN LIMITATIONS AND EXCLUSIONS

5.1 Exclusions

The Plan does not pay any benefits for the following services or supplies:

 

a. Provided before the member was covered by the HealthCare Plan or after coverage ends.

 

b. Not medically necessary Provided without a provider or practitioners prescription, recommendation, or approval.

Services which are experimental in nature or pharmaceutical drugs that are not approved by the Food and Drug

Administration (FDA) or covered by the Plan. 

 

c. Excess costs above the Plan's accepted maximums. Provided in connection with custodial care. Covered by or as a benefit under Medicare, Medicaid, or any other plan or insurance. Which would not have been billed if benefits were not available. For which the Member is not legally required to pay. For which the Risk Pool cannot legally provide benefits. 

 

d. Services for illness or injury sustained while working for pay or profit that are paid under a Workers Compensation plan or any other insurance coverage. 

 

e. For an injury or illness caused by a war, by participation in a riot, or while committing a felony. Provided by a family or member of Member's household. This exclusion does not apply if the family or household member is the only licensed healthcare provider in the local area and is acting within the normal scope of the licensed healthcare provider's employment. 

 

f. General, routine health exams if over 19 years of age (including routine annual physicals or employment-related physicals). Screenings for HIV or hepatitis.

 

16. Charges for food, food substitutes, food supplements including infant formulas and vitamins which are purchased

for consumption on an outpatient basis, (excluding formula for the treatment of phenylketonuria (PKU) and prescribed prenatal vitamins).

 

17. Over-the-counter drugs or supplies, which are available over the counter if they are not prescribed (other excluded

drugs and pharmaceutical products are listed under (52);

 

18. Minoxidil in any of its forms;

 

19. Personal comfort or convenience items, including TVs and telephone usage while hospitalized, sauna and whirlpool

devices, and items and supplies related to the use of durable medical equipment (e.g., batteries, battery charges, AC/DC adapter plugs, blood pressure cuffs, etc.).

 

20. Exercise equipment and club membership.

 

21. Whirlpool or aqua massage or massage therapy.

 

22. Reconstruction of an external part of the body for cosmetic reasons or to correct a developmental defect, unless services are needed because of an accident or a birth defect (for a child under age 18).

 

23. Enhancements designed to facilitate personal lifestyle choices, including services and supplies intended mainly to

improve personal performance or appearance or provided primarily to beautify.

 

24. Weight control treatments, including surgical or non-surgical, whether inpatient or outpatient, including weight-control pharmaceutical drugs.

 

25. Any eye care service or supply provided for diagnosis or treatment of astigmatism, myopia, hyperopia, or presbyopia,

including eye examinations and surgery.

 

26. Eyeglasses, contact lenses, and their fitting, except when needed because of medical necessity (e.g., an injury to the

eye or following cataract surgery).

 

27. Audiology (hearing) tests, unless prescribed by a physician and medically necessary.

 

28. The fitting or cost of a hearing aid.

 

29. Dental treatment except as needed because of an injury to teeth, because it is needed to treat a condition of the jaw (e.g., TMJ), or because it is necessary to surgically remove an impacted tooth, tumor, or cyst, or to drain an abscess or cyst.

This exclusion includes orthodontic services, caps, crowns, prosthesis and removal, care or alignment of the teeth

because of an injury to the teeth (or their surrounding tissue or structure) caused by chewing, and periodontal disease.

 

30. Routine foot care, except medically necessary orthotic devices.

 

31. Transportation or lodging, except as provided under ambulance, organ transplant benefits or Medical Tourism.

 

32. Religious counseling and marital counseling.

 

33. Treatment for compulsive gambling.

 

34. Family group therapy (e.g., parent/child relationships).

 

35. The use of CPAP's (Continuous Positive Airway Pressure) when used solely to control behavior problems or to resolve

behavioral issues.

 

36. Recreational or educational therapy and other forms of non-medical self care, unless provided as a part of

Plan-approved diabetic or cardiac education or rehabilitative care. This includes learning disability therapy and treatment normally provided through other mandated programs.

 

37. Wigs used for hair loss resulting from any medical condition.

 

38. Artificial insemination, invitro fertilization, pharmacy fertility agents or treatment or drugs to reverse a sterilization procedure.

 

39. Chelation therapy that is not determined to be medically necessary (such as treatment of heavy metals).

 

40. Laetrile use in any form.

 

41. Biofeedback, massage therapy and pain management therapy/treatment, unless prescribed by an

approved provider.

 

42. Treatment of drugs prescribed in connection with milieu or milieu therapy.

 

43. Services or drugs related to sex transformations.

 

44. Charges covered by automobile, homeowners or other insurance that provides related coverage while the policy is

in effect.

 

45. Ergonomic or other home or work site evaluations.

 

46. Construction, remodeling or the structural alteration of a residence to accommodate the access to, mobility in or use of the residence.

 

47. Genetic testing that is used as a predetermination or predictor of a future medical condition is not considered medically necessary and is not covered when performed in connection with the treatment or mitigation of an existing medical condition.

 

48. Charges for smoking cessation classes, drugs, or other treatment.

 

49. Speech, occupational, or physical therapy that is in excess of the Plan's benefit maximums without a doctor's

prescription and pre-authorization.

 

50. Charges for missed medical appointments.

 

51. The cost of a second procedure/surgery if it can be determined that the procedure must be redone and is necessary because physician instructions were not followed. The Member would be responsible for all of the cost of the second procedure and the cost of the second procedure/surgery also would not apply to the individual's annual Maximum Out of Pocket limit.

 

52. The following drugs and pharmaceutical products are excluded unless otherwise noted:

a. Therapeutic devices or appliances, hypodermic needles (excluding those used for administration of insulin), syringes,

support garments, and other non-medical substances regardless of intended use

b. Any over-the-counter medication without a prescription

c. Blood products

d. Experimental medications

e. Diabetic monitors (are covered under the medical portion of the plan as Durable Medical Equipment)

f. Contraceptive jellies, creams, foams, and devices

g. Cosmetic medications, including hair loss medications

 

We will pay benefits for incurred charges as provided for under the Plan. In the event that treatment for medical care

and/or services are provided for which benefits are not otherwise payable under the Plan, the Plan, at its option, will

consider the payment of benefits under the Plan for charges incurred for such care and/or services. Benefits, if any, shall be paid only as determined by the Plan.

 

5.2 Pre-existing Condition Waiting Period

Children enrolled under age 19 who have been without healthcare coverage for six months or longer will have a six

month pre-existing condition waiting period for medical services. Children under age 19 who have been enrolled in a health plan for the past twelve (12) months will not have pre-existing condition waiting period.

 

5.3 Termination of Benefits

All coverage and benefits provided by the Risk Pool will terminate when any of the following apply:

• The member fails to make monthly plan payments in accordance with the set terms.

• The member no longer meets all eligibility requirements.

• The member has knowingly made any false or fraudulent statement of a material fact with reference to any application for the risk pool or statement relating to eligibility for the risk pool.

• The member knowingly presents or causes to be presented a false or fraudulent claim by;

a. Submitting any proof in support of such a claim for the payment of a loss upon the risk pool,

 

b. Prepares, makes, or subscribes a false or fraudulent account, certificate, affidavit or Proof of Loss, or other document or writing, with the intent of presenting or suing in support of such a claim. If for any reason we make payment under this policy in error, we may recover the amount we paid. Unless specifically listed, coverage or exclusions are subject to interpretation of the Risk Pool and the member's recourse is limited to the appeal and legal action provisions of this plan.

 

6.0 OTHER PLAN PROVISIONS AND REQUIREMENTS

 

6.1 Non-insurance™Disclaimer

This Plan coverage is NOT AN INSURANCE PRODUCT.

 

6.2 Voluntary Contribution

Participants voluntarily contribute assessed fees and payments, a portion of an overall participation assessment, as

agreed to a shared-risk pool owned by the sponsor organization with no guaranty of ever receiving any benefits or consideration of any kind in return. Contributions are irrevocably gifted to the sponsor organization freely and without undue influence or duress of any kind to use as they see fit at any time or in any place for any reason.

 

6.3 Shared-Risk Pool

The shared-risk pool is intended as a potential safety net for the Plan and may be used for any charitable purpose,

including charitably covering unexpected costs of unforeseen healthcare needs. It is also an opportunity for members to donate to the sponsor. A limited portion of reserves in excess of forecast assessed needs of the Plan may be transferred

to and used in other qualified charitable programs either sponsored by the Plan sponsor or by another qualified

charitable organization. The sponsor may also determine that their requested assessment was excessive and offer to return a portion of the contributed funds to donors reducing their deductible contribution for the period.

 

6.4 Other Products

Other products, as the Plan member determines, may be purchased and integrated with this plan but no such

requirement exists. Opportunities to mitigate or reduce risks to and of the member may be offered through third party

vendors and those products may include insurance or additional coverage but they are in no way associated with this plan and there is not, nor will there be any requirements to, or unfounded adjustment of participation requirements for purchasing or participating in any peripheral coverage or healthcare solutions.

 

6.5 Separate and Distinct

This Plan is a functional portion of a comprehensive program promoting improved Quality-of-Life initiatives. There may

be several opportunities to learn of and enroll in other plans, systems, associations, and endeavors both related and unrelated to the overall Quality-of-Life Program. This Plan is separate and distinct from any other product or service.

 

6.6 HRA's and HSA's

Established HSA's provide tax advantaged fund to cover qualified costs and is integral for optimization of this Plan.

Contact your financial advisor or Financial institution for eligibility.

 

7.0 PLAN ADMINISTRATION

The Governing Board retains the right to change the Plan's design, modify coverages and change contributions or

funding mechanisms at any time it deems necessary, with appropriate notice. The Board, or other fiduciary designated,

shall have authority to make a determination with respect to such issues or such provisions, subject to judicial review by a court of appropriate jurisdiction. The information contained in this document and its interpretation by the Board's designee supersedes all verbal representations of the Plan's provisions.

The Board has delegated certain tasks to its designees. When Members participate in the Risk Pool, they are agreeing

that the Risk Pool or its designees may collect the information it needs from providers in order to make benefit

determinations or payments. Providers are expected to provide needed medical and claim information to comply with this provision. It also means the Risk Pool or its designees have the right to deal directly with providers to ensure that fiduciary responsibilities are being properly carried out to achieve maximum efficiency and effectiveness. The Risk Pool may, without the consent of or notice to any person, release to or obtain from any other person or organization any information which it deems necessary to determine if a Plan provision applies. Any claimant under this Plan shall furnish to the Risk Pool the necessary information as may be needed to implement this provision. Sharing information will help those providers to better evaluate and direct care. It will also allow them to provide advice to the Risk Pool as deemed reasonable in the management of the Plan and for the benefit of Plan participants. The Risk Pool will not provide personal or medical information for commercial or marketing purposes to

outside vendors.

 

7.1 Medically Necessary Treatment

The Risk Pool reserves the right to determine if a service or supply is medically necessary. Many services will be

reviewed for appropriateness and medical necessity before the services are rendered, through the pre-authorization

process. Other services, such as emergency care, the use of air ambulances and private duty nursing, may be reviewed after treatment is provided.

 

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