P.O. Box 15645 Las Vegas, Nevada 89114-5645Small BusinessGroup Certificate Of CoverageTHIS CERTIFICATE CONTAINS A DEDUCTIBLEUmentsThis Certificate including Attachment A Benefit Scheduleand any other Attachments, Endorsements, Riders orAmendments to it, your Enrollment Form, healthstatements, Insured identification card and all otherapplications received by SHL are all part of your SHLmembership package. Please read them carefully and keepthem in a safe place. Words that are capitalized aredefined in Section 15. - Glossary.This Small Business Group Health Insurance Certificateof Coverage ("Certificate") contains the terms underwhich Sierra Health and Life Insurance Company, Inc.("SHL") agrees to insure Eligible Employees and theirEligible Family Members of the Policyholder ("Group")and to make benefit payments for certain healthcareservices.SHL and Group have agreed to all of the terms of thisCertificate, and the Certificate has been incorporated byreference into the Group Enrollment Agreement (“GEA”)entered into by SHL and Group.Please carefully review your Certificate and yourAttachment B, Services Requiring Prior Authorization, todetermine which services require Prior Authorizationunder the Plan. Failure of the Insured to comply with therequirements of SHL’s Managed Care Program and thePrior Authorization process will result in a reduction ofbenefits.This Certificate and your attached Attachment A BenefitSchedule tell you about your benefits, rights and duties asan SHL Insured. They also tell you about SHL’s duties toyou.Form No. SHLSBCERT(2014)Page 141NVSHLCE SB COC 2014
Table of ContentsSECTION 1. Eligibility, Enrollment and Effective Date. 4SECTION 2. Termination . 5SECTION 3. Continuation of Coverage . 6SECTION 4. Managed Care Program . 11SECTION 5. Obtaining Covered Services . 12SECTION 6. Covered Services . 13SECTION 7. Exclusions . 22SECTION 8. Limitations . 26SECTION 9. Coordination of Benefits (COB). 26SECTION 10. Subrogation . 28SECTION 11. Premium Payments and Rate Changes . 29SECTION 12. General Provisions . 29SECTION 13. Claims Provisions . 32SECTION 14. Appeals Procedures . 33SECTION 15. Glossary . 39Attachment A, Benefit ScheduleAttachment B, Services Requiring Prior AuthorizationEndorsements, if applicableRiders, if applicableForm No. SHLSBCERT(2014)Page 241NVSHLCE SB COC 2014
The Department of Business and IndustryState of NevadaDivision Of InsuranceTelephone NumbersforConsumers of HealthcareHours of operation for the Division:Monday through Friday from 8 a.m. until 5 p.m., Pacific Standard Time (PST)The Division is closed during state holidays.Contact information for the Division:Carson City Office:Phone: (775) 687-0700Fax:(775) 687-07871818 East College Pkwy., Suite 103Carson City, NV 89706Las Vegas Office:Phone: (702) 486-4009Fax:(702) 486-40072501 East Sahara Ave., Suite 302Las Vegas, NV 89104The Division also provides a toll-free number for consumers residing outside of the above areas:1-800-992-0900 Please listen to the greeting and select the appropriate prompt.If you have any questions regarding your health care coverage, please contact SHL’s Member Services Department atthe following:Address:Sierra Health and Life Insurance Company, Inc.Attn: Member Services DepartmentP.O. Box 15645Las Vegas, NV 89114-5645Phone: (Monday – Friday from 8:00 a.m. until 5:00 p.m., Pacific Standard Time):(702) 242-7700 or 1-800-888-2264Form No. SHLSBCERT(2014)Page 341NVSHLCE SB COC 2014
Certificate of CoverageSECTION 1.satisfied all of the requirements of (a) or (b) below:a. The child must be covered as a Dependent underthis Plan before reaching the limiting age, andproof of incapacity and dependency must begiven to SHL by the Subscriber within thirty-one(31) days of the child reaching the limiting age;orb. The handicap started before the child reached thelimiting age, but the Subscriber was covered byanother health insurance carrier that covered thechild as a handicapped Dependent prior to theSubscriber applying for coverage with SHL.Eligibility, Enrollment andEffective DateSubscribers and Dependents who meet the followingcriteria are eligible for coverage under this Certificate.1.1Who Is EligibleSubscriber. To be eligible to enroll as a Subscriber,an employee must:A. Be a bona fide employee of the Group; andB. Meet the following criteria; Be employed full-time; Be actively at work; Work at least the minimum number of hoursper week indicated by the Group in itsAttachment A to the Group EnrollmentAgreement (GEA); Meet the applicable waiting period indicated bythe Group in its Attachment A to the GEA; Enroll during an enrollment period; and Work for an employer that meets the MinimumEmployer Contribution Percentage for theapplicable coverage as set forth in theAttachment A to the GEA.The actively at work requirement will not apply toindividuals covered under Group’s prior welfarebenefit plan on the date of that plan’s discontinuance,provided that this Certificate is initially effective nomore than sixty (60) days after the prior plan’sdiscontinuance. All other requirements will apply tosuch individuals.Dependent. To be eligible to enroll as a Dependent, anindividual must be one of the following: A Subscriber’s legal spouse or a legal spousefor whom a court has ordered coverage. Aregistered domestic partner. A child by birth. Adopted child. Stepchild.Minor child for whom a court has orderedcoverage. Child being Placed for Adoptionwith the Subscriber. A child for whom a courthas appointed the Subscriber or theSubscriber’s spouse the legal guardian.The definition of Dependent is subject to the followingconditions and limitations: A Dependent includes any child listed aboveunder the limiting age of 26. A Dependent includes a Dependent child whois incapable of self-sustaining employmentdue to mental or physical handicap, chieflydependent upon the Subscriber for economicsupport and maintenance, and who hasForm No. SHLSBCERT(2014)SHL may require proof of continuing incapacity anddependency, but not more often than once a year after the firsttwo (2) years beyond the date when the child reaches thelimiting age. SHL’s determination of eligibility is final.Evidence of any court order needed to prove eligibility mustbe given to SHL.1.2Who Is Not EligibleEligible Dependent does not include: A foster child. A child placed in the Subscriber's home other than foradoption. A grandchild. Any other person not defined in Section 22.214.171.124Changes In Eligibility StatusIt is the Subscriber's responsibility to give SHL written noticewithin thirty-one (31) days of changes which affect hisDependent’s eligibility. Changes include, but are not limitedto: Reaching the limiting age. Ceasing to satisfy the mental or physical handicaprequirements. Death. Divorce. Any other event which affects a Dependent’s eligibility.If the Subscriber fails to give notice which would haveresulted in termination of coverage, SHL shall have the rightto terminate coverage in accordance with the GroupEnrollment Agreement.1.4EnrollmentEligible Employees and Eligible Family Members must enrollduring one of the Enrollment Periods described below orwithin thirty-one (31) days of first becoming eligible in orderto have coverage under this Plan.Page 441NVSHLCE SB COC 2014
Certificate of Coverage1.Initial Enrollment Period. An Initial EnrollmentPeriod is the period of time during which anEligible Employee and Eligible Family Membermay enroll under this Plan as shown in the GEAsigned by the Group.2.Subscriber's newborn natural child is covered for the firstthirty-one (31) days from birth. Coverage continues afterthirty-one (31) days only if the Subscriber enrolls thechild as a Dependent and pays the premium within sixty(60) days of the date of birth.2.Group Open Enrollment Period. An OpenEnrollment Period of at least thirty-one (31) daysmay be held at least once a year allowing EligibleEmployees and Eligible Family Members to enrollunder this Plan without giving evidence of goodhealth.3.An adopted child is covered for the first thirty-one (31)days from birth only if the adoption has been legallycompleted before the child’s birth. A child Placed forAdoption at any other age is covered for the first thirtyone (31) days after the Placement for Adoption.3.Special Enrollment Period. A SpecialEnrollment Period allows a Special Enrollee toenroll for coverage under this Plan upon a SpecialEnrollment Event as defined herein during aperiod of at least thirty-one (31) days followingthe Special Enrollment Event.4.Right to Deny Application. SHL can denymembership to any person who: Violates or has violated any provision of theSHL Certificate. Misrepresents and/or fails to disclose amaterial fact which would affect coverageunder this Plan. Fails to follow SHL rules. Fails to make a premium payment.5.1.5Right to Deny Application for Renewal. As acondition of Group’s renewal under this Plan,SHL may require Group to exclude a Subscriberand/or Dependent who committed fraud upon SHLor misrepresented and/or failed to disclose amaterial fact which affected his coverage underthis Plan.Effective Date of CoverageBefore coverage can become effective, SHL mustreceive and accept premium payments and anEnrollment Form for the person applying to become anInsured.When a person applies to become an Insured on orbefore the date he is eligible, coverage starts as shownin the GEA signed by Group.1.If a person applies to be an Insured within thirtyone (31) days of the date he is first eligible toapply, coverage starts on the first day of thecalendar month following the month when theEnrollment Form is received by SHL.Form No. SHLSBCERT(2014)Coverage continues after the applicable thirty-one (31)day period only if the Subscriber enrolls the child as aDependent and pays any premium within sixty (60) daysfollowing the placement of the child in the Subscriber’shome. In the event adoption proceedings are terminated,coverage of a child Placed for Adoption ends on the datethe adoption proceedings are terminated.4.If a court has ordered Subscriber to cover his or her legalspouse or unmarried minor child, that person will becovered for the first thirty-one (31) days following thedate of the court order. Coverage continues after thirtyone (31) days if the Subscriber enrolls the Dependent andpays any Dependent’s premium. A copy of the courtorder must be given to SHL.5.For a Special Enrollee, the Effective Date of Coverage ison the first day of the calendar month after an EnrollmentForm is received, unless otherwise specified in the GEA.6.When a person applies to become an Insured during theOpen Enrollment Period, coverage starts on the first dayof the calendar month following the Open EnrollmentPeriod.Subscriber must give SHL a copy of the certified birthcertificate, decree of adoption, or certificate of Placement forAdoption for coverage to continue after thirty-one (31) daysfor newborn and adopted children.Subscriber must give SHL a copy of the certified marriagecertificate or any other required documents before coveragecan be effective for other Eligible Family Members.SECTION 2.TerminationThis section tells you under what conditions your coverageunder this Plan will terminate and the date that the coveragewill end. In the event an Insured’s coverage is terminatedpursuant to Sections 2.1 and 2.2 below, the coverage of hisDependents will also be terminated.Page 541NVSHLCE SB COC 2014
Certificate of Coverage2.1Termination by SHLSHL may terminate coverage under this Plan at thetimes shown for any one or more of the followingreasons: Failure to maintain eligibility requirements as setforth in Section 1.On the first day of the month that a contributionwas due and not received by SHL.With thirty (30) days written notice, if the Insuredallows his or any other Insured's SHL ID Card tobe used by any other person, or uses anotherperson's SHL ID Card. The Insured will be liableto SHL for all costs incurred as a result of themisuse of the SHL ID Card.If the Insured performs an act or practice thatconstitutes fraud, or makes any intentionalmisrepresentation of material fact, as prohibitedby the terms of coverage, SHL has the right torescind coverage and declare coverage under thePlan null and void as of the original Effective Dateof Coverage and refund any applicable premium.Thirty (30) days written notice shall be providedto the Insured prior to any rescission of coverage.An Insured has the right to appeal any suchrescission.In the case of a Small Group Insured, wheninformation provided to SHL by a Small GroupInsured in his Enrollment Form is determined tobe untrue, inaccurate, or incomplete, in lieu oftermination of coverage, SHL shall have the rightto retroactively increase past premium paymentsto the maximum rate allowed that would havebeen billed if such untrue, inaccurate, orincomplete information had not been provided. Ifthe revised premium rate is not received by SHLwithin thirty (30) days of the letter of notification,coverage will be terminated as of the paid-to-date.Subject to Section 3., Continuation of Coverage,on the last day of the calendar month (or sooner, ifprovided in the GEA)
Form No. SHLSBCERT(2014) Page 1 41NVSHLCE_SB_COC_2014 P.O. Box 15645 Las Vegas, Nevada 89114-5645 Small Business Group Certificate Of Coverage THIS CERTIFICATE CONTAINS A DEDUCTIBLE Uments This Small Business Group Health Insurance Certificate of Coverage ("Certificate") contains the terms under which Sierra Health and Life Insurance Company, Inc. ("SHL") agrees to insure Eligible Employees ...