NCH HEALTHCARE SYSTEM CHOICE HEALTH PLAN

NCH Healthcare System Choice Health Plan - PD/SPD Group #2003020 - January 1, 2012

PLAN DOCUMENTSUMMARY PLAN DESCRIPTION

for the

NCH HEALTHCARE SYSTEMCHOICE HEALTH PLAN

This booklet describes the Plan Benefitsin effect as of January 1, 2012

The Plan has been established for the benefit ofEligible employees and their dependents of:

NCH HEALTHCARE SYSTEMCHOICE HEALTH PLAN

Claims Processed By:

ALLEGIANCE BENEFIT PLAN MANAGEMENT, INC.2806 South Garfield Street

PO Box 3018Missoula, MT 59806-3018

Missoula Area Phone Number: (406) 721-2222Toll-Free Number: (800) 877-1122

iNCH Healthcare System Choice Health Plan - PD/SPD Group #2003020 - January 1, 2012

TABLE OF CONTENTS

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

IN-NETWORK BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

SCHEDULE OF MEDICAL BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

PHARMACY BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7COST SHARING PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8EXCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8SERVICE OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9DRUG OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9COPAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10SUPPLY LIMITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10STEP THERAPY PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10PRIOR AUTHORIZATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

MEDICAL BENEFIT DETERMINATION REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11ELIGIBLE SERVICES, TREATMENTS AND SUPPLIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11DEDUCTIBLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11BENEFIT PERCENTAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11OUT-OF-POCKET MAXIMUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11MAXIMUM BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT . . . . . . . . . . . . . . . . 11CHANGES IN COVERAGE CLASSIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

MEDICAL BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12DIAGNOSTIC LABORATORY SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16DURABLE MEDICAL EQUIPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17HOME HEALTH CARE BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17INJURY TO OR CARE OF MOUTH, TEETH AND GUMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18JAW JOINT DISORDERS (TMJ SYNDROME) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18LAP BAND SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18MENTAL ILLNESS, ALCOHOLISM AND/OR CHEMICAL DEPENDENCY . . . . . . . . . . . . . . . . 19ORGAN OR TISSUE TRANSPLANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19OUTPATIENT RENAL DIALYSIS BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20PREVENTIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21PROSTHETIC OR ORTHOPEDIC APPLIANCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22SKILLED NURSING FACILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22SPINAL MANIPULATION / CHIROPRACTIC CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23ROUTINE NURSERY CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23RECONSTRUCTIVE BREAST SURGERY/NON-SURGICAL AFTER CARE BENEFIT . . . . . . 23

COST MANAGEMENT SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24PRE-CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24UTILIZATION MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Notification Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Concurrent Stay Review, Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Alternative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27SmartChoice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

CASE MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

GENERAL PLAN EXCLUSIONS AND LIMITATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

iiNCH Healthcare System Choice Health Plan - PD/SPD Group #2003020 - January 1, 2012

COORDINATION OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ORDER OF BENEFIT DETERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Non-Dependent/Dependent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Child Covered Under More Than One Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Active or Inactive Employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Longer or Shorter Length of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36No Rules Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

COORDINATION WITH MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36For Working Aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36For Covered Persons who are Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37For Covered Persons with End Stage Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 37

COORDINATION WITH MEDICAID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37COORDINATION WITH TRICARE/CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

PROCEDURES FOR CLAIMING BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38NOTICE OF AN ADVERSE BENEFIT DETERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40APPEALING AN ADVERSE BENEFIT DETERMINATION FOR AN URGENT CARE CLAIM . . 41APPEALING AN ADVERSE BENEFIT DETERMINATION FOR A PRE-SERVICE CLAIM . . . . 41APPEALING AN ADVERSE BENEFIT DETERMINATION FOR A POST-SERVICE CLAIM . . . 42NOTICE OF AN ADVERSE BENEFIT DETERMINATION ON APPEAL . . . . . . . . . . . . . . . . . . 43INDEPENDENT EXTERNAL REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

MEDICAL COVERAGE OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

ELIGIBILITY PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47EMPLOYEE ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47WAITING PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47DEPENDENT ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . 49

EFFECTIVE DATE OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50PARTICIPANT COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50DEPENDENT COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50NEWBORN COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50OPEN ENROLLMENT PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50SPECIAL ENROLLMENT PERIOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51EMPLOYMENT STATUS CHANGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53CHANGE IN STATUS EVENTS FOR ENROLLMENT OR TERMINATION OF COVERAGE . . 53

QUALIFIED MEDICAL CHILD SUPPORT ORDER PROVISION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER . . . . . . . . . . . . . . . . . . . 55PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS . . . . . . . . . . . . . . . . . . . . . . 56ERISA REPORTING AND DISCLOSURE REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 56NATIONAL MEDICAL SUPPORT NOTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

TERMINATION OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57PARTICIPANT TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57DEPENDENT TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57RESCISSION OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

CONTINUATION COVERAGE AFTER TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59NOTIFICATION RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

iiiNCH Healthcare System Choice Health Plan - PD/SPD Group #2003020 - January 1, 2012

ELECTION OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60MONTHLY PREMIUM PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE . . . . . . 60SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION

COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61MEDICARE ENROLLMENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION

COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61WHEN COBRA CONTINUATION COVERAGE ENDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61QUESTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62INFORM THE PLAN OF ADDRESS CHANGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

COVERAGE FOR A MILITARY RESERVIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

FRAUD AND ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64MISSTATEMENT OF AGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64MISREPRESENTATION OF ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64MISUSE OF IDENTIFICATION CARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64REIMBURSEMENT TO PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

RECOVERY/REIMBURSEMENT/SUBROGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65RIGHT TO RECOVER BENEFITS PAID IN ERROR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65REIMBURSEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65SUBROGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65RIGHT OF OFF-SET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

PLAN ADMINISTRATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68PURPOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68PLAN YEAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68PLAN SPONSOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68PLAN SUPERVISOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68NAMED FIDUCIARY AND PLAN ADMINISTRATOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68PLAN INTERPRETATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68CONTRIBUTIONS TO THE PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69PLAN AMENDMENTS/MODIFICATION/TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69NOTICE OF REDUCTION OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69TERMINATION OF PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69SUMMARY PLAN DESCRIPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

CREDITABLE COVERAGE PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70CERTIFICATE OF CREDITABLE COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71EXAMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71PAYMENT OF CLAIMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71LEGAL PROCEEDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71NO WAIVER OR ESTOPPEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71VERBAL STATEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71FREE CHOICE OF PHYSICIAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72WORKERS' COMPENSATION NOT AFFECTED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72CONFORMITY WITH LAW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72MISCELLANEOUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72FACILITY OF PAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72PROTECTION AGAINST CREDITORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72PLAN IS NOT A CONTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

GENERAL DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

ivNCH Healthcare System Choice Health Plan - PD/SPD Group #2003020 - January 1, 2012

ERISA STATEMENT OF RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT . . . . . . . . . . . . . . . . . . . . . . . . . 87IDENTIFICATION OF FUNDING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

HIPAA PRIVACY AND SECURITY STANDARDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88PRIVACY CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88SECURITY CERTIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

NCH HEALTHCARE SYSTEM CHOICE HEALTH PLAN SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . 90

1NCH Healthcare System Choice Health Plan - PD/SPD Group #2003020 - January 1, 2012

INTRODUCTION

NCH Healthcare System, Inc. hereinafter referred to as the “Company” or “Employer”, previously establishedthe NCH Healthcare System Choice Health Plan, which provides benefits, rights and privileges to participatingEmployees, referred to as “Participants,” and the eligible Dependents of such Participants, as defined, by theCompany and referred to as the “Plan.” Effective January 1, 2012, the Company amended the Plan. Thisbooklet describes the Plan in effect as of January 1, 2012.

Coverage provided under this Plan for Employees and their Dependents will be in accordance with theEligibility, Effective Date, Qualified Medical Child Support Order, Termination, Family and Medical Leave Actand other applicable provisions as stated in this Plan.

NCH Healthcare System, Inc. (the Plan Sponsor) has retained the services of an independent PlanSupervisor, experienced in claims processing, to handle health claims. The Plan Supervisor for the Plan is:

Allegiance Benefit Plan Management, Inc.P.O. Box 3018

Missoula, MT 59806-3018

We recommend that you read this booklet carefully before incurring any medical expenses. If you wish, youmay call or write to Allegiance Benefit Plan Management, Inc. regarding any detailed questions you may haveconcerning the Plan.

This Plan is not intended to, and cannot be used as workers compensation coverage for any employee or anycovered dependent of an employee. Therefore, this plan generally excludes claims related to any activityengaged in for wage or profit including, but not limited to, farming, ranching, part-time and seasonal activities.See Plan Exclusions for specific information.

The information contained in this Plan Document/Summary Plan Description is only a general statementregarding FMLA, COBRA, USERRA, and QMCSO’s. It is not intended to be and should not be relied uponas complete legal information about those subjects. Covered Persons and Employers should consult theirown legal counsel regarding these matters.

This Plan requires pre-notification for certain services. See “Cost Management Services” for further details.


IN-NETWORK BENEFIT

This Plan provides benefits through a group of contracted providers (In-Network Providers). An In-NetworkProvider means using a Physician who is part of the group of contracted providers. Using In-NetworkPhysicians offers cost-savings advantages because a Covered Person pays only a percentage of thescheduled fee for services provided.

Out-of-Network Provider means a provider who is not an In-Network Provider. A Covered Person who goesOut-of-Network will pay more and his or her share of the cost may not apply to the Out-of-Pocket Maximum.

For a list of providers in the CHP Network, contact (239) 659-7760 or (888) 594-9008. To determine if aPhysician or health care provider qualifies as an eligible In-Network Provider under this Plan, please consultAllegiance’s website at www.abpmtpa.com/nch to access links for directories of participating providers.


SCHEDULE OF MEDICAL BENEFITSFOR

ELIGIBLE PARTICIPANTS AND DEPENDENTS

ALL BENEFITS PAYABLE UNDER THIS PLAN ARE SUBJECT TO THE APPLICABLE PLANEXCLUSIONS AND THE USUAL, CUSTOMARY AND REASONABLE LIMITS OF THE PLAN

THE BENEFIT PERIOD IS A CALENDAR YEAR

COST SHARING PROVISIONS

BASIC PLAN HEALTHY CHOICE HEALTHY PARTNER

Deductible Per Benefit Period (applies unless specifically indicated as waived)

Employee onlyEmployee + 1 DependentEmployee + 2 or more

$1,080$2,080$3,080

$580$1,080$1,580

$330$580$830

An individual Covered Person cannot receive credit for more than the Employee Only Deductible statedabove.

Employee plus one Dependent (spouse or child): If members of a Family Unit of Employee plus oneDependent have satisfied individual Deductible amounts that collectively equal the Employee plus oneDependent Deductible during the same Benefit Period, no further Deductible will apply to any member ofthat Family during that Benefit Period.

Employee plus two Dependents (spouse or children): If members of a Family Unit of Employee plustwo Dependents have satisfied individual Deductible amounts that collectively equal the Employee plus twoDependents Deductible during the same Benefit Period, no further Deductible will apply to any member ofthat Family during that Benefit Period.

Benefit Percentage in excess of the Deductible (applies unless specifically indicated otherwise)

70% 70% 80%

Out-of-Pocket Maximum per Benefit Period (Does not include Deductible and Out of Networkservices not pre-certified)

Employee onlyEmployee + 1 DependentEmployee + 2 or more

$4,000$8,000$8,000

$3,000$6,000$6,000

$2,000$4,000$4,000

Expenses Incurred in a single Benefit Period after satisfaction of the Out-of-Pocket Maximum per CoveredPerson or per Family, whichever is applicable, will be paid at 100% of the Eligible Expense for theremainder of the Benefit Period. An individual Covered Person cannot receive credit for more than theEmployee Only Out-of-Pocket Maximum stated above.

Employee plus one Dependent or two or more Dependents (spouse or children): If members of aFamily Unit of Employee plus one Dependent or two or more Dependents have satisfied individual Out-of-Pocket Maximum amounts that collectively equal the Employee plus one or two or more Dependents Out-of-Pocket Maximum during the same Benefit Period, no further Out-of-Pocket Maximum will apply to anymember of that Family during that Benefit Period.

Maximum Lifetime Benefit NONE NONE NONE

Schedule of Medical Benefits


BENEFIT PERCENTAGE AND LIMITATIONSAll services listed in the Schedule of Benefits that are received from providers who are outside ofLee County or Collier County must be pre-certified by CHP.


NCH Healthcare Group and/or NCH Healthcare Hospital and Facility ChargesInpatient andOutpatient Services

70% as approved byCHP; 40% if notapproved by CHP



Emergency Services(Emergency Only)

100%(Deductible Waived)



Emergency Services(Non-Emergency)

50% 50% 50%

NCH Healthcare System Facilities include the NCH Downtown or North Naples Hospital, NCH and NCHHealthcare Group Outpatient Rehabilitation Centers, NCH Healthcare Group Radiology Centers, NaplesDiagnostic and Imaging Centers, NCH and NCH Healthcare Group Wound Care Centers, Naples DaySurgery, Marco Island Urgent Care Center, NHC Healthcare Group Sleep Center.

Non-NCH Healthcare Hospital and Facility ChargesInpatient andOutpatient Services

70% of UCR if pre-certified by CHP and• Services are not

available at NCH; or• the covered individual

lives more than 100miles from Naples.

Otherwise 0%




Otherwise 0%




Otherwise 0%

Emergency Services(Emergency only)




Emergency Services (Non-Emergency)

50% 50% 50%

Employees who reside in Estero or north of Estero also have the option of using Lee Memorial HealthSystem facility for services; however, such services (other than Emergency only services) must be pre-authorized. Charges for any services (other than Emergency only services) received from a Lee MemorialHealth System facility that are not pre-authorized will be paid at 0%.

Ancillary, Radiology and Pathology ServicesNCH and NCHHealthcare Group

80% 80% 100% (Deductible Waived)

Non-NCH provider 70% of UCR if pre-certified by CHP and• Services are not



Otherwise 0%




Otherwise 0%




Otherwise 0%





Home Health Care Services70% 70% 80%

120 Visits per Benefit period.

Physician ServicesIn-Network 70% 70% 80%

Out-of-Network 40%; or 70% if services arenot available In-Networkand approved by CHP

40%; or 70% if services arenot available In-Networkand approved by CHP

40%; or 80% if services arenot available In-Networkand approved by CHP

In-Network means using a Physician who is in the CHP Network, or for Employees who reside in Estero ornorth of Estero, In-Network means using a Physician who is in the CHP Network or CIGNA Network withinLee County. Physician Services received from any other provider must be pre-certified by CHP. Using In-Network Physicians offers cost-savings advantages because a Covered Person pays only a percentage ofthe scheduled fee for services provided. A Covered Person who goes Out-of-Network will pay more and hisor her share of the cost may not apply to the Out-of-Pocket Maximum. For a list of In-Network providers,contact (239) 659-7760; (888) 594-9008 or www.abpmtpa.com/nch.

Ambulance Service (See Medical Benefits for restrictions)Note: Most air ambulance services are Out-of-Network and use of such Out-of-Network services may resultin the Covered Person being responsible for charges that exceeds this Plan’s Usual, Customary andReasonable limits or other limits of this Plan.

70% 70% 80%

Physical, Occupational and Speech Therapy (see Medical Benefits for restrictions)NCH and NCHHealthcare Group

70% 70% 100%(Deductible Waived)

Non-NCH provider 70% of UCR if pre-certified by CHP and• Services are not



Otherwise 0%




Otherwise 0%




Otherwise 0%

Diagnostic Laboratory Services (see Medical Benefits for restrictions)NCH and NCHHealthcare Group

80% 80% 100%

CHP Physician’sOffice (Refer toapproved list)

70% 70% 80%

Quest lab (only ifresides in Estero ornorth of Estero)

70% 70% 80%

Non-Network 0% 0% 0%





Durable Medical Equipment (See pre-certification requirements)70% 70% 80%

Prosthetics/Orthopedic Appliances70% 70% 80%

Spinal Manipulation/Chiropractic Services70% 70% 80%

$1,500 Maximum Benefit per Benefit Period

Preventive Care (See Medical Benefits for details)Preventive Care services must be obtained from a provider who is in the CHP Network. Exception: For aCovered Person who resides in Estero or north of Estero, Preventive Care Services must be obtained froma provider who is in the CHP Network or CIGNA Network within Lee County. Preventive Care servicesobtained by a provider otherwise are not covered, regardless of whether services are pre-approved.

100%, deductible waived 100%, deductible waived 100%, deductible waived

Outpatient Renal Dialysis Benefit70% 70% 80%

Medical Supplies: Maximum Benefit of 125% Medicare AllowableESRD Related drugs: Maximum Benefit of 125% of the Average Sales Price (ASP)

Skilled Nursing Facility70% 70% 80%

120 Days per Benefit period

Lap Banding Surgery (only if pre-certified by Community Health Partners)50% 50% 50%

Wig or Artificial Hairpiece due to loss of hair from chemotherapy or other medical condition70% 70% 80%

Jaw Joint Disorders (TMJ Syndrome)70% 70% 80%

Maximum Benefit of 3 months conservative treatment per Benefit Period. See Medical Benefits for details on conservative treatment.


PHARMACY BENEFITApplies to all Plan Options

Prescription drug charges are payable only through the Plan’s Pharmacy Benefit Management (PBM)program, which is sponsored in conjunction with and is an integral part of this Plan. Copayments do not serveto satisfy the Medical Benefits Annual Deductible or Out-of-Pocket Maximum. The Pharmacy BenefitManager (PBM) will provide separate information for details regarding Network pharmacies, PreferredBrand prescriptions and Specialty Drugs upon enrollment for coverage under this Plan.

COST SHARING PROVISIONS

Pharmacy Deductible Per Covered Person Per Benefit Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100Per Family per Benefit Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300

Pharmacy Out-of-Pocket MaximumPer Covered Person per Benefit Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $5,000Pharmacy Out-of-Pocket Maximum does not include Pharmacy Deductible.

Copayment per Prescription per 30 day supply (90 day supply Generic)

Drug Type Retail - PBMNetwork

MemberSubmit*

Mail Order Specialty Drug

Generic 20%; min $10 20%; min $10 10%; min $30 20%; min $10

Preferred Brand 20%; min $25 20%; min $25 10%; min $75 20%; min $25

Non-Preferred Brand 50%; min $40 50%; min $40 50%; min $120 50%; min $40

*For Member Submit prescriptions, the PBM will reimburse the contract cost of the prescription drug, lessthe applicable Copayment per Prescription. Contract cost is the PBM’s discounted cost of the prescriptiondrug. Reimbursement will not exceed what the PBM would have reimbursed for a Network Prescription.

Generics preferred - Physician choice (DAW2) - If the Physician does not prescribe “Dispense asWritten”, and there is a generic alternative for the prescription drug, and the Covered Person chooses abrand name instead, the Covered Person must pay the difference in cost between the generic and brandname medication plus the applicable brand copayment amount.

If the Physician prescribes a brand name drug and communicates on the prescription “Dispense as Written”(DAW), the Covered Person will pay the brand name copayment only.

Pharmacy Benefit does not apply if the actual cost of the drug is less than the applicablecopayment. Member is responsible for the total cost of the drug.

There is no coordination of benefits for Pharmacy Benefits.

Pharmacy Benefit


COVERAGE

Coverage for prescription drugs will include only those drugs requiring a written prescription of a Physicianor Licensed Health Care Provider, if within the scope of practice of the Licensed Health Care Provider, andthat are Medically Necessary for the treatment of an Illness or Injury.

Coverage also includes prescription drugs or supplies that require a written prescription of a Physician orLicensed Health Care Provider, if within the scope of practice of the Licensed Health Care Provider, as follows:

1. Self-administered contraceptives, including Emergency (Plan B).

Contraceptive Management, injectable contraceptives and contraceptive devices are coveredunder the Medical Benefits of this Plan.

2. Legend vitamins (oral only): Prenatal agents used in pregnancy; therapeutic agents used for specificdeficiencies and conditions; legend multivitamins; supplemental agents; and hemopoetic agents usedto treat anemia. Except for prenatal, all legend vitamins are subject to prior authorization.

3. Legend fluoride products (oral only): Dental or pediatric.

4. Diabetic supplies, including syringes, needles, swabs, blood test strips (glucose or ketone), bloodglucose calibration solutions, urine tests, lancets and lancet devices.

5. Smoking cessation products: Legend or Over-the-counter products prescribed by a Physician.

6. Erectile dysfunction: Non-injectable (Viagra, Levitra, Cialis, Muse), subject to prior authorization.

7. Over-the-counter equivalent for Prilosec (Prilosec OTC) as if it were a generic prescription drug.

8. Tretinoin agents used in the treatment of acne and/or for cosmetic purposes (Retin A).

9. Estrogen replacement.

10. Injectables (must use CuraScript).

CuraScript, Inc. Is a wholly owned subsidiary of Express Scripts, Inc., one of the nation’slargest Pharmacy Benefit Managers (PBM’s). As an experienced leader in the specialtypharmacy industry, CuraScript specializes in providing specialty medications and support toindividuals with chronic illnesses requiring these complex, high-cost therapies.

EXCLUSIONS

Prescription drugs or supplies in the following categories are specifically excluded:

1. Cosmetic only indications, including but not limited to, photo-aged skin products (Renova); HairGrowth Agents (Propecia, Vaniqa); and Injectable cosmetics (botox cosmetic); depigmentationproducts used for skin conditions requiring a bleaching agent.

2. Legend homeopathic drugs.

3. Fertility agents, oral, vaginal and injectable.

4. Erectile dysfunction: Injectable and Yohimbine (not FDA approved for this indication).

5. Weight management.

Pharmacy Benefit


6. Allergen injectables.

7. Serums, toxoids and vaccines.

8. Over-the-counter equivalents and non-legend medications (OTC), except as specifically covered.

9. Blood monitors and kits (glucose or ketone)*.

10. Durable Medical Equipment*.

11. Experimental or Investigational drugs.

*Eligible for coverage under the Medical Benefits, subject to all provisions and limitations of this Plan.

SERVICE OPTIONS

The Program includes the following Service Options for obtaining prescriptions under the Pharmacy Benefit:

PBM Network Prescriptions: Available only through a retail pharmacy that is part of the PBM Network. Thepharmacy will bill the Plan directly for that part of the prescription cost that exceeds the deductible Copayment(Copayment amount must be paid to pharmacy at time of purchase). The prescription identification cardis required for this option.

Member Submit Prescriptions: Available only if the prescription identification card cannot be used becausethe prescription identification card has not yet been received or the prescription identification card is not usedat a PBM pharmacy. Prescriptions must be paid for at the point of purchase and the prescription drugreceipt must be submitted to the Pharmacy Benefit Manager (PBM), along with a reimbursement form(Direct Reimbursement). The PBM will reimburse the contract cost of the prescription drug, less theapplicable Deductible or Copayment per Prescription. Contract cost is the PBM’s discounted cost ofthe prescription drug. Reimbursement will not exceed what the PBM would have reimbursed for aNetwork Prescription.

Mail Order Prescriptions: Available only through a licensed pharmacy that is part of the PBM Network whichfills prescriptions and delivers them to Covered Persons through the United States Postal Service, UnitedParcel Service or other delivery service. The pharmacy will bill the Plan directly for prescription coststhat exceed the Copayment.

Specialty Drug(s): These medications are generic or non-generic drugs classified by the Plan and listed bythe PBM as Specialty Drugs and require special handling (e.g., most injectable drugs other than insulin).Specialty drugs must be obtained from a preferred specialty pharmacy. Only your first prescription can beobtained at a network retail pharmacy. All subsequent refills must be obtained through a preferredspecialty pharmacy in order to be covered under the Plan. A list of specialty drugs and preferredspecialty pharmacies may be obtained from the PBM or Plan Supervisor.

DRUG OPTIONS

The drug options available are:

Generic: Those drugs and supplies listed in the most current edition of the Physicians Desk Reference or bythe PBM Program as generic drugs.

Preferred Brand: Non-generic drugs and supplies listed as “Preferred Brand” by the PBM Program as statedin a written list provided to Covered Persons and updated from time to time.

Non-Preferred Brand: Copyrighted or patented brand name drugs (Non-Generic) which are not recognizedor listed as Preferred Brand drugs or supplies by the PBM Program.

Pharmacy Benefit


COPAYMENT

“Copayment” means a dollar amount fixed as either a percentage or a specific dollar amount per prescriptionpayable to the pharmacy at the time of service. Copayments are specifically stated in this section.Copayments are not payable by the Plan and do not serve to satisfy the Medical Benefits Annual Deductibleor Out-of-Pocket Maximum.

SUPPLY LIMITS

Supply is limited to 30 days for PBM Network and Member Submit Prescriptions or a 90-day supply for MailOrder Prescriptions.

Prescription drug refills are not allowed until 75% of the prescribed day supply is used.

The amount of certain medications are limited to promote safe, clinically appropriate drug usage. If you haveexceeded a limit and your physician believes you need an additional supply of a medication, it will be reviewedfor medical necessity by the PBM. A current list of applicable quantity limits can be obtained by contactingthe PBM at the number listed on your identification card.

STEP THERAPY PROGRAM

Step Therapy is a program especially for people who take prescription drugs regularly for ongoing conditionslike arthritis and high blood pressure. It helps the Covered Person get an effective medication to treat thecondition while keeping costs as low as possible.

In Step Therapy, drugs are grouped in categories based on cost:

1. Front-line drugs - Step 1 drugs are generic drugs proven to be safe, effective and affordable. Thesedrugs should be tried first because they can provide the same health benefit as more expensivedrugs, at a lower cost.

2. Back-up drugs - Step 2 and Step 3 drugs are brand-name drugs like those that are advertised onTV. There are lower-cost brand drugs (Step 2) and higher-cost brand drugs (Step 3). Back-up drugstypically cost more than front-line drugs.

The next time a doctor writes a prescription for a Covered Person, ask if a generic medication as a front-linedrug would work instead. It makes good sense to ask for these drugs first because, for most everyone, theywork as well as brand-name drugs, and they almost always cost less. And, because these drugs have beenon the market for a long time, they have a more established safety record than newer drugs.

If a front-line drug has been tried for a Covered Person, or the doctor decides one of these drugs isn’tappropriate, then the doctor can prescribe a back-up drug. Ask the doctor if one of the lower-cost brands(Step 2 drugs) is appropriate. Remember, a higher-cost brand-name drug can always be obtained at a highercopayment if the front-line or Step 2 back-up drugs don’t work. The doctor can call 800-417-8164 to requesta prior authorization for the medication.

For more information on the how Step Therapy works and its benefits, watch this short video at:www.StepTherapyFacts.com.

PRIOR AUTHORIZATION

Certain drugs require approval before the drug can be dispensed. A current list of drugs that require priorauthorization can be obtained by contacting the PBM at the number listed on your identification card.


MEDICAL BENEFIT DETERMINATION REQUIREMENTS

ELIGIBLE SERVICES, TREATMENTS AND SUPPLIES

Services, treatments or supplies are eligible for coverage if they meet all of the following requirements:

1. They are administered, ordered or provided by a Physician or other eligible Licensed Health CareProvider; and

2. They are Medically Necessary for the diagnosis and treatment of an Illness or Injury or they arespecifically included as a benefit if not Medically Necessary; and

3. Charges do not exceed the Usual, Customary and Reasonable limits of the Plan; and

4. They are not excluded under any provision or section of this Plan.

DEDUCTIBLE

The Deductible is stated in the Schedule of Medical Benefits and refers to the amount of Expenses Incurredfor which no benefits will be paid. This amount does not accrue toward the annual Out-of-Pocket Maximum.

BENEFIT PERCENTAGE

The Benefit Percentage is stated in the Schedule of Medical Benefits. The Plan will pay the BenefitPercentage of the Eligible Expense indicated.

OUT-OF-POCKET MAXIMUM

The Out-of-Pocket Maximum is stated in the Schedule of Medical Benefits and includes amounts in excessof the Benefit Percentage paid by the Plan. Eligible Expenses applied toward the Annual Deductible or Out-of-Network services do not accrue towards the Out-of-Pocket Maximum. Expenses Incurred in a single BenefitPeriod after satisfaction of the Out-of-Pocket Maximum per Covered Person or per Family, whichever isapplicable, will be paid at 100% of the Eligible Expense for the remainder of the Benefit Period (subject to anybenefit limitations under the Plan).

MAXIMUM BENEFIT

The amount payable by the Plan will not exceed any Maximum Benefit or Maximum Lifetime Benefit as statedin the Schedule of Medical Benefits, for any reason.

APPLICATION OF DEDUCTIBLE AND ORDER OF BENEFIT PAYMENT

Deductibles will be applied to Expenses Incurred in the chronological order in which they are adjudicated bythe Plan. Expenses Incurred will be paid by the Plan in the chronological order in which they are adjudicatedby the Plan. The manner in which the Deductible is applied and Expenses Incurred are paid by the Plan willbe conclusive and binding on all Covered Persons and their assignees.

CHANGES IN COVERAGE CLASSIFICATION

A change in coverage that decreases a benefit of this Plan will become effective on the stated effective dateof such change with regard to all Covered Persons to whom it applies.


MEDICAL BENEFITS

Charges for the following Medical Benefits are payable as stated in the Schedule of Medical Benefits, subjectto any benefit limits and all terms and conditions of this Plan:

1. Charges for the following services provided by a Hospital:

A. Daily Room and Board in a Semi-Private Room (or private room if no Semi-Private room isavailable or when confinement in a private room is Medically Necessary) and general nursingservices, or confinement in an Intensive Care Unit, not to exceed the applicable limits shownin the Schedule of Medical Benefits.

B. Medically Necessary Hospital Miscellaneous Expenses other than Room and Board furnishedby the Hospital, including Inpatient miscellaneous service and supplies, Outpatient Hospitaltreatments for chronic conditions and emergency room use for an Emergency only, PhysicalTherapy treatments, hemodialysis, and x-ray.

C. Nursery neonatal units, general nursing services, including Hospital Miscellaneous Expensesfor services and supplies, Physical Therapy, hemodialysis and x-ray, care or treatment ofInjury or Illness, congenital defects, birth abnormalities or premature delivery incurred by aNewborn Dependent.

D. Therapy which has been prescribed by a speech pathologist or Physician and includes awritten treatment plan with estimated length of time for therapy, along with a statementcertifying all above conditions are met.

Care, treatment, services and supplies furnished at facilities other than NCH are covered only if 1)the service is not available at NCH; or 2) the service involves a Dependent who lives further than 100miles from Naples. However, in each of these cases, pre-certification will be required.

2. Charges made by an Ambulatory Surgical Center when treatment has been rendered.

“Ambulatory Surgical Center” (also called same-day surgery center or Outpatient surgery center)means a licensed establishment with an organized staff of Physicians and permanent facilities, eitherfreestanding or as a part of a Hospital, equipped and operated primarily for the purpose of performingsurgical procedures and which a patient is admitted to and discharged from within a twenty-four (24)hour period. Such facilities must provide continuous Physician and registered nursing serviceswhenever a patient is in the facility. An Ambulatory Surgical Center must meet any requirements forcertification or licensing for ambulatory surgery centers in the state in which the facility is located.

“Ambulatory Surgical Center” does not include an office or clinic maintained by a Dentist or Physicianfor the practice of dentistry or medicine, a Hospital emergency room or trauma center.

3. Charges made by an Urgent Care Facility when treatment has been rendered.

“Urgent Care Facility” means a free-standing facility which is engaged primarily in diagnosing andtreating Illness or Injury for unscheduled, ambulatory Covered Persons seeking immediate medicalattention. A clinic or office located in or in conjunction with or in any way made a part of a Hospitalwill be excluded from the terms of this definition.

4. Charges for services and supplies furnished by a Birthing Center.

A “Birthing Center” means a freestanding or hospital based facility which provides obstetrical deliveryservices under the supervision of a Physician, and through an arrangement or an agreement with aHospital.

Medical Benefits


5. Charges made by a Hospice within any one Hospice Benefit Period for:

A. Room and Board, including any charges made by the facility as a condition of occupancy, oron a regular daily or weekly basis such as general nursing services. If private roomaccommodations are used, the daily Room and Board charge allowed will not exceed thefacility's average Semi-Private charges or an average Semi-Private rate made by arepresentative cross section of similar institutions in the area.

B. Nursing care by a Registered Nurse (R.N.), a Licensed Practical Nurse (L.P.N.), a publichealth nurse who is under the direct supervision of a Registered Nurse.

C. Medical supplies, including drugs and biologicals and the use of medical appliances.

D. Physician's services.

E. Services, supplies, and treatments deemed Medically Necessary and ordered by a licensedPhysician.

“Hospice Benefit Period” means a specified amount of time during which the Covered Personundergoes treatment by a Hospice. Such time period begins on the date the attending Physician ofa Covered Person certifies a diagnosis of terminal Illness, and the Covered Person is accepted intoa Hospice program. The period will end the earliest of six months from this date or at the death of theCovered Person. A new Hospice Benefit Period may begin if the attending Physician certifies thatthe patient is still terminally ill; however, additional proof will be required by the Plan Administratorbefore a new Hospice Benefit Period can begin.

6. Charges for the services of a licensed Physician or Licensed Health Care Provider for medical careand/or treatments, including office, home visits, Hospital Inpatient care, Hospital Outpatientvisits/exams, clinic care, and surgical opinion consultations.

Charges are eligible for drugs intended for use in a physicians’ office or settings other than home usethat are billed during the course of an evaluation or management encounter.

7. Charges for Pregnancy for a Participant or covered spouse only, including charges for prenatal care,childbirth, miscarriage, abortion, and any medical complications arising out of or resulting fromPregnancy. Charges related to a Pregnancy for any other Dependent is excluded.

8. Charges for Surgical Procedures.

When two or more Surgical Procedures occur during the same operative session, charges will beconsidered as follows:

A. When multiple or bilateral Surgical Procedures are performed that increase the time andamount of patient care, 100% of the Eligible Expense will be considered for the MajorProcedure; and 50% of the Eligible Expense will be considered for each of the lesserprocedures, except for contracted or negotiated services. Contracted or negotiated serviceswill be reimbursed at the contracted or negotiated rate.

B. When an incidental procedure is performed through the same incision, only the EligibleExpense for the Major Procedure will be considered. Examples of incidental procedures are:excision of a scar, appendectomy at the time of other abdominal surgery, lysis of adhesions,etc.

Medical Benefits


When an assisting Physician is required to render technical assistance during a Surgical Procedure,the charges for such services will be limited to 25% of the primary surgeon's Eligible Expense for theSurgical Procedure. When an assisting non-physician is required to render technical assistanceduring an operation, charges for such services will be limited to 25% of the surgeon’s EligibleExpense for the Surgical Procedure.

9. Charges for Registered Nurses (R.N.'s) or Licensed Practical Nurses (L.P.N.'s) for private dutynursing.

10. Charges for home infusion services ordered by a Physician and provided by a home infusion therapyorganization licensed and approved within the state in which the services are provided. A homeinfusion therapy organization is a health care facility that provides home infusion therapy services andskilled nursing services. Home infusion therapy services include the preparation, administration, orfurnishing of parenteral medications, or parenteral or enteral nutritional services to a Covered Personby a home infusion therapy organization. Services also include education for the Covered Person,the Covered Person’s caregiver, or a family member. Home infusion therapy services includepharmacy, supplies, equipment and skilled nursing services when billed by a home infusion therapyorganization. Pre-certification is required if a facility other than NCH or NCH Healthcare Groupis utilized for infusion care and without pre-certification will result in reduction of benefits.

Skilled nursing services billed by a home health agency are covered under the Home HealthCare Benefit.

11. Charges for Ambulance Service to the nearest facility where Emergency care or treatment can berendered; or from one facility to another for care, but in any event, no more than fifty (50) miles (usingGoogle maps) from the place of pickup, unless the Plan Administrator finds a longer trip wasMedically Necessary.

12. Charges for drugs requiring the written prescription of a Physician or a Licensed Health Care Providerand Medically Necessary for the treatment of an Illness or Injury. Coverage also includes prescriptioncontraceptive drugs not available through the Pharmacy Benefit regardless of Medical Necessity.

Conditions of coverage for outpatient prescription drugs and supplies available through thePharmacy Benefit are as stated in the Pharmacy Benefit section of the Plan.

13. Charges for blood transfusions, blood processing costs, blood transport charges, blood handlingcharges, administration charges, and the cost of blood, plasma and blood derivatives. Any creditallowable for replacement of blood plasma by donor or blood insurance will be deducted from the totalEligible Expense.

14. Charges for oxygen and other gases and their administration.

15. Charges for x-rays, microscopic tests, and laboratory tests.

16. Charges for radiation therapy or treatment and chemotherapy.

17. Charges for electrocardiograms, electroencephalograms, pneumoencephalograms, basal metabolismtests, CT scans (including PET Scans), MRIs, or similar well-established diagnostic tests generallyaccepted by Physicians throughout the United States. Refer to Prior Authorization section for a listof procedures that require prior authorization.

18. Charges for the cost and administration of an anesthetic.

19. Charges by a Physician or Licensed Health Care Provider for dressings, sutures, casts, splints,trusses, crutches, braces, adhesive tape, bandages, antiseptics or other Medically Necessary medicalsupplies, except for dental braces or corrective shoes, which are specifically excluded.

Medical Benefits


20. Charges for voluntary sterilization.

21. Reasonable charges for producing medical records only if incurred for the purpose of utilizationreview, audits or investigating a claim for benefits if requested and approved by the Plan. Chargesthat exceed limits for such charges imposed by applicable law will not be deemed to be reasonable.

22. Charges for Contraceptive Management, regardless of Medical Necessity. “ContraceptiveManagement” means Physician fees related to a prescriptive contraceptive device, obtaining aprescription for contraceptives, purchasing, fitting, injecting, implantation or placement of anycontraceptive device. Charges for removal of contraceptive device covered only when medicallynecessary.

23. Charges for the initial purchase of eyeglasses or contact lenses following cataract surgery.

24. Charges for diabetes treatment services, including equipment, supplies, and services used to treatdiabetes, outpatient self management training and education services. However, only educationalservices provided by NCH are covered.

Coverage for diabetic supplies are eligible for coverage under the Pharmacy Benefit of this Plan,including insulin, needles, syringes and test strips.

25. Charges for osteoporosis diagnosis and treatment for high-risk individuals who are less than sixty (60)years of age, including, but not limited to, estrogen deficient individuals who are at clinical risk forosteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-ternglucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individualswho have a family history of osteoporosis.

26. Charges for screening, diagnosis, intervention and treatment of Autism Spectrum Disorders in certainchildren. To be eligible for Applied Behavior Analysis (ABA) services, the treatment must beprescribed by the Covered Person’s treating Physician in accordance with a treatment plan; and theCovered Person must be diagnosed as having Autism Spectrum Disorder at eight (8) years of ageor younger. ABA benefits and coverage is available to a Covered Person who is either younger thaneighteen (18) years of age or is eighteen (18) years of age or older and in high school.

“Autism Spectrum Disorder” means any of the following as defined in the current edition of theDiagnostic Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV):Autistic Disorder, Asperger’s Syndrome, Pervasive Developmental Disorder Not Otherwise Specified.

27. Charges for Attention Deficit Disorder treatment by a licensed psychiatrist, psychologist or counselor.

28. Charges for a wig or artificial hairpiece due to loss of hair from chemotherapy or other medicalcondition up to the limit stated in the Schedule of Medical Benefits.

29. Charges for circumcision, regardless of whether done on an Inpatient or Outpatient basis.

30. Charges for custom-made shoe inserts (orthotics) only when custom-made and prescribed by aPhysician for treatment of an Illness or Injury. Charges for orthotics available over-the-counter areexcluded.

Medical Benefits


DIAGNOSTIC LABORATORY SERVICES

Charges are payable for Diagnostic Laboratory Services as specifically stated in the Schedule of Benefits.Coverage includes charges for the following laboratory services performed for diagnostic purposes only ifprovided in a Physician’s office. “Laboratory Services” means the testing of materials, fluids or tissuesobtained from a Covered Person for the purpose of screening, diagnosing a condition and for determiningappropriate treatment. If the following laboratory services are performed for routine purposes, benefits arepayable under the Preventive Care Benefit.

CPT Code Type of Service36415 Venipuncture81000 Urinalysis with Micro (non-automated)81001 Urinalysis with Micro (automated)81002 Urinalysis w/o Micro (non-automated)81003 Urinalysis w/o Micro (automated)81015 Urinalysis, microscopic, only81025 Pregnancy test urine visual color82009 Acetone/Ketone bodies, qualitative82247 Bilirubin, total82248 Bilirubin, direct82270 Blood Occult feces, 1-3 specimens82565 Creatinine/Blood82947 Glucose; quantitative82948 Glucose, Blood; Regent Strip82962 Glucometer84132 Potassium; Serum84702 Pregnancy test, Quantitative (Gonadotropin, chorionic hCG)85018 Hemoglobin by single analyte ins85025 CBC w/diff henogram & platelet count85610 Prothrombin Time (Protime)86308 Mono Screen (Mono spot)87210 Wet mount w/stain87275 Influenza B antigen detection87276 Influenza A antigen detection87400 Influenza A/B antigen87430 Strep test/rapid by EIA87880 Strep test/rapid by Immunoassay w/direct observation88142 Pap smear, Thin-Layer Prep (if diagnostic) - Must go to Naples Pathology AssociatesG0123 Pap smear, Thin-Layer Prep (if screening, for Medicare) -

Must go to Naples Pathology Associates88150 Pap smear (if diagnostic) - Must go to Naples Pathology Associates88164 Pap smear (if diagnostic) - The Bethesda System -

Must go to Naples Pathology Associates88321 Pap smear, Consultation on referred slides - Must go to Naples Pathology AssociatesP3001 Pap smear (if screening, for Medicare) - Must go to Naples Pathology Associates

Medical Benefits


DURABLE MEDICAL EQUIPMENT

Coverage includes charges for rental of, up to the purchase price of, a wheelchair, Hospital bed, respiratoror other Durable Medical Equipment required for therapeutic use, or the purchase of this equipment ifeconomically justified, whichever is less. If the purchase is not medically feasible, rental charges will be paidwithout limitation based upon purchase price. Pre-certification is required if the cost for the Durable MedicalEquipment is over $500.

HOME HEALTH CARE BENEFIT

Benefit limits apply as stated in the Schedule of Medical Benefits.

Coverage under this benefit includes charges made by a Home Health Care Agency for care in accordancewith a Home Health Care Plan for the following services:

1. Part-time or intermittent nursing care by a Registered Nurse (R.N.) or by a Licensed Practical Nurse(L.P.N.), a vocational nurse, or public health nurse who is under the direct supervision of a RegisteredNurse;

2. Home health aides;

3. Medical supplies, drugs and medicines prescribed by a Physician, and laboratory services providedby or on behalf of a Hospital.

“Home Health Care Agency” means an organization that provides skilled nursing services and therapeuticservices (home health aide services, physical therapy, occupational therapy, speech therapy, medical socialservices) on a visiting basis, in a place of residence used as the Covered Person’s home. The organizationmust be Medicare certified and licensed within the state in which home health care services are provided.

“Home Health Care Plan” means a program for continued care and treatment administered by a Medicarecertified and licensed Home Health Care Agency, for the Covered Person who may otherwise have beenconfined as an Inpatient in a Hospital or Skilled Nursing Facility or following termination of a Hospitalconfinement as an Inpatient and is the result of the same related condition for which the Covered Person washospitalized and is approved in writing by the Covered Person's attending Physician.

Home Health Care specifically excludes the following:

1. Services and supplies not included in the approved Home Health Care Plan.

2. Services of a person who ordinarily resides in the home of the Covered Person, or who is a CloseRelative of the Covered Person who does not regularly charge the Covered Person for services.

3. Services of any social worker.

4. Transportation services.

5. Housekeeping services.

6. Custodial Care

Medical Benefits


INJURY TO OR CARE OF MOUTH, TEETH AND GUMS

Coverage under this benefit includes charges for Injury to or care of the mouth, teeth, gums and alveolarprocesses only if that care is for the following oral surgical procedures:

1. Excision of tumors and cysts of the jaw, cheeks, lips, tongue, roof and floor of the mouth.

2. Emergency repair due to Injury to sound natural teeth. Such repair must be made within twelve (12)months from the date of the Injury.

3. Surgery needed to correct Accidental Injury to the jaw, cheeks, lips, tongue, floor and roof of themouth.

4. Excision of benign bony growths of the jaw and hard palate.

5. External incision and drainage of cellulitis.

6. Incision of sensory sinuses, salivary glands or ducts.

7. Removal of impacted teeth.

Dental and oral surgical procedures involving orthodontic care of the teeth, periodontal disease and preparingthe mouth for the fitting of or continued use of dentures are not covered under the Plan but may be coveredunder the Dental plan.

JAW JOINT DISORDERS (TMJ SYNDROME)

Coverage includes care and treatment of jaw joint disorders, including conditions of structures linking thejawbone and skull and complex muscles, nerves, and other tissues related to the temporomandibular joint.Care and treatment includes but is not limited to, physical therapy and any appliance that is attached to orrests on the teeth.

Benefits for care and treatment of jaw joint disorders are, limited to three months conservative treatment perBenefit Period. Conservative treatment utilizes the following approaches:

1. Bite splint or orthotics.2. Medication for pain control and muscle relaxation.3. Physical Therapy.4. Injections for relief of pain (anesthetic or steroid).5. Behavioral modification (stress relief, habit avoidance, improved sleep and nutritional habits).

LAP BAND SURGERY

A Covered Person must enroll and actively participate in Community Health Partners’ SmartChoice WeightManagement Program for twelve (12) consecutive months immediately prior to consideration for pre-certification for surgery and six (6) consecutive months following the surgery.

Coverage includes charges for Medically Necessary surgical treatment and follow-up care for MorbidObesity/Clinically Severe Obesity, including all pre-surgery and post surgery office visits and anycomplications resulting from the surgery.

Recommendation regarding request for gastric procedures is limited to laparoscopic adjustable gastricbanding.

Medical Benefits


The following criteria will be used for pre-certifying benefits for the above procedures:

1. A clinical history of unsuccessful diet and other weight management programs.

2. Must receive a positive assessment of surgery risk-benefit from all evaluating staff members of thepre-surgery program. This assessment is completed by the performing surgeon. It also is criteriarequired to support medical necessary of the surgery based on Interqual Criteria that CommunityHealth Partners references.

3. Must be at least 18 years of age and less than 70 years of age.

The following are specifically excluded:

1. Surgical procedures except for laparoscopic adjustable gastric banding surgery.

2. Any redo or revision of a prior surgical procedure.

3. A second surgical procedure, whether or not the first procedure was performed while covered underthis plan or not.

MENTAL ILLNESS, ALCOHOLISM AND/OR CHEMICAL DEPENDENCY

Coverage under this benefit includes the following services:

1. Physician or Licensed Health Care Provider charges for diagnosis and Medically NecessaryPsychiatric Care and treatment, including but not limited to group therapy.

2. Charges for well-established medically accepted diagnostic testing generally accepted by Physiciansin the United States.

3. Charges for in-patient and partial hospitalization, for Medically Necessary treatment, for the sameservices as are covered for hospitalization for physical Illness or Injury by this Plan.

4. Charges for Medically Necessary treatment at a Psychiatric Facility, including aftercare, at anAlcoholism and/or Chemical Dependency Treatment Facility.

ORGAN OR TISSUE TRANSPLANTS

Coverage includes charges in connection with non-Experimental or non-Investigational organ or tissuetransplant procedures, subject to the following conditions:

1. A second opinion is recommended prior to undergoing any transplant procedure. This second opinionshould concur with the attending Physician's findings regarding the Medical Necessity of suchprocedure. The Physician rendering this second opinion must be qualified to render such a serviceeither through experience, specialist training or education, or such similar criteria, and must not beaffiliated in any way with the Physician who will be performing the actual surgery.

2. If the donor is covered under this Plan, expenses Incurred by the donor will be considered for benefitsto the extent that such expenses are not payable by the recipient’s plan.

3. If the recipient is covered under this Plan, expenses Incurred by the recipient will be considered forbenefits. Expenses Incurred by the donor, who is not ordinarily covered under this Plan accordingto eligibility requirements, will be considered for payment to the extent that such expenses are notpayable by the donor's plan. In no event will benefits be payable in excess of the benefit limits stillavailable to the recipient.

Medical Benefits


4. If both the donor and the recipient are covered under this Plan, Expenses Incurred by each personwill be treated separately for each person.

5. The Eligible Expense of securing an organ from a cadaver or tissue bank, including the surgeon'scharge for removal of the organ and a Hospital's charge for storage or transportation of the organ, willbe considered for payment.

Benefits are not available for non-human and artificial organ implant procedures. The Plan does not coverany transportation, lodging or meal expenses or the purchase price of any bone marrow, organ, tissue, or anysimilar items that are sold rather than donated.

OUTPATIENT RENAL DIALYSIS BENEFIT

Coverage includes charges for outpatient renal dialysis up to the limits stated in the Schedule of MedicalBenefits. In order to avoid or reduce liability for amounts not covered by the Plan, a Covered Person who isdiagnosed with End Stage Renal Disease (ESRD) must immediately follow these steps:

1. Notify Plan Administrator when you are diagnosed with ESRD by your doctor;

2. Notify Plan Administrator if or when you begin to receive dialysis treatments; and

3. Enroll in Parts A and B of Medicare. The Plan Sponsor may assist you with payment of Medicarepremiums up to a lifetime total of $5,500.

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY

Coverage includes charges for the following as specifically stated in the Schedule of Medical Benefits:

1. Physical Therapy rendered by a licensed physical therapist. The therapy must be in accord with aPhysician’s exact orders as to type, frequency and duration and improve a body function.

2. Occupational Therapy rendered by a licensed occupational therapist. Therapy must be ordered bya Physician and result from an Injury or Illness.

3. Speech Therapy, also called speech pathology, rendered by a licensed speech therapist or speechpathologist. Therapy must be ordered by a Physician and follow either 1) surgery for correction of acongenital condition of the oral cavity, throat or nasal complex (other than a frenectomy); 2) an Injury;or 3) an Illness that is other than a learning or Mental Disorder. The Plan will pay for one evaluationto determine Medical Necessity.

4. Aquatic therapy rendered by a physical therapist. Therapy must be ordered by a Physician, resultfrom an Injury or Illness and improve a body function.

5. Massage therapy only when part of a covered course of physical therapy and is provided by or underthe direct supervision of a Physical Therapist.

After twelve (12) visits to a licensed therapist for Physical Therapy, Speech Therapy or Occupational Therapy,pre-certification for Medical Necessity will be required for any additional visits during the same Benefit Period.However, pre-certification will be required for any Physical Therapy, Speech Therapy and OccupationalTherapy treatments from a non-NCH facility.

Medical Benefits


PREVENTIVE CARE

“Preventive Care” means routine treatment or examination provided when there is no objective indication oroutward manifestation of impairment of normal health or normal bodily function, which is not provided as aresult of any Injury or Illness.

Coverage under this benefit includes the following routine services, subject to the following limitations:

1. Routine Wellness care for children and adults for the following:

A. Routine physical examinations by a Physician or Licensed Health Care Provider, which willinclude a medical history, physical examination, developmental assessment, and anticipatoryguidance as directed by a Physician or Licensed Health Care Provider and associated routinetesting provided or ordered at the time of the examination; and

B. Routine immunizations according to the schedule of immunizations which is recommendedby the Advisory Committee on Immunization Practices (ACIP) that have been adopted by theDirector of the Centers for Disease Control and Prevention.

2. Recommended preventive services as set forth in the recommendations of the United StatesPreventive Services Task Force (Grade A and B rating), the Advisory Committee on ImmunizationPractices of the Centers for Disease Control and Prevention, and the guidelines supported by theHealth Resources and Services Administration. The complete list of recommendations and guidelinescan be viewed at: http://www.healthcare.gov/center/regulations/prevention/recommendations.html.

3. Office visit charges only if the primary purpose of the office visit is to obtain a recommendedPreventive Care service identified above.

4. Occupational Health Services for Employees only for the following:

A. Chest X-ray (scheduled with Occupational Health) to employees who have a positive skin testfor tuberculosis (PPD).

B. Tetanus toxoid immunization and the Pneumovax immunization provided by NCH once every10 years. A physician prescription is required.

C. Flu immunization provided by NCH.

Expenses payable under this Preventive Care benefit will not be subject to the Medical Necessityprovisions of this Plan. Charges for Preventive care that involve excessive, unnecessary or duplicatetests are specifically excluded.

Charges for treatment of an active Illness or Injury are subject to the plan provisions, limitations andexclusions and are not eligible in any manner under Preventive Care.

Medical Benefits


PROSTHETIC OR ORTHOPEDIC APPLIANCES

Coverage includes charges for the following:

1. The initial purchase, fitting, repair and replacement of fitted Prosthetic Appliance, including but notlimited to artificial limbs, eyes, larynx. Charges for replacement are covered only when there is asufficient change in the Covered Person’s physical condition to make the original device no longerfunctional.

“Prosthetic Appliance” means a device or appliance that is designed to replace a natural body partlost or damaged due to Illness or Injury, the purpose of which is to restore full or partial bodily functionor appearance.

2. Initial purchase, fitting or refitting for normal bodily growth, repair and replacement of OrthopedicAppliance such as braces, splints or other appliances. Charges for replacement are covered onlywhen there is a sufficient change in the Covered Person’s physical condition to make the originaldevice no longer functional.

“Orthopedic Appliance” means a rigid or semi-rigid support used to restrict or eliminate motion in adiseased, injured, weak or deformed body member.

SKILLED NURSING FACILITY

Benefit limits apply as stated in the Schedule of Medical Benefits.

Coverage includes charges for the following services and supplies furnished by a Skilled Nursing Facility upto the benefit limits stated in the Schedule of Benefits. Only charges in connection with convalescence fromthe Illness or Injury for which the Covered Person was Hospital-confined will be eligible for benefits. Theseexpenses include:

1. Room and Board, including any charges made by the facility as a condition of occupancy, or on aregular daily or weekly basis such as general nursing services. If private room accommodations areused, the daily Room and Board charge allowed will not exceed the facility's average Semi-Privatecharges or an average Semi-Private rate made by a representative cross section of similar institutionsin the area.

2. Medical services customarily provided by the Skilled Nursing Facility, with the exception of privateduty or special nursing services and Physicians' fees.

3. Drugs, biologicals, solutions, dressings and casts, furnished for use during the Convalescent Period,but no other supplies.

Such confinement in a Skilled Nursing Facility must meet all of the following conditions:

1. The confinement starts within fourteen (14) days of a Hospital confinement of at least three (3) days(or is pre-certified by Community Health Partners Utilization Management);

2. The attending Physician certifies that the confinement is needed for further care of the condition; and

3. The attending Physician completes a treatment plan which includes diagnosis, the proposed courseof treatment and the projected date of discharge from the Skilled Nursing Facility.

Medical Benefits


SPINAL MANIPULATION / CHIROPRACTIC CARE

Benefit limits are stated in the Schedule of Medical Benefits.

Coverage includes charges for skeletal adjustments, manipulation or other treatment in connection with thedetection and correction by manual or mechanical means of structural imbalance or subluxation in the humanbody. Such treatment is done by a Doctor of Chiropractic (D.C.) to remove nerve interference resulting from,or related to, distortion, misalignment or subluxation of, or in, the vertebral column.

ROUTINE NURSERY CARE

Charges are payable for Routine Nursery Care, including room, board and Hospital Miscellaneous Expensesprovided to a Newborn Dependent child while the mother is Hospital confined after birth, including aPhysician’s first pediatric visit to the Newborn child after birth while Hospital confined.

This coverage is also available to a Newborn who is not enrolled in the Plan, provided the parent was coveredunder the Plan at the time of the Newborn’s birth and the child is an eligible Dependent who is neither injuredor ill.

RECONSTRUCTIVE BREAST SURGERY/NON-SURGICAL AFTER CARE BENEFIT

Coverage includes charges for reconstructive breast surgery subsequent to any Medically Necessarymastectomy, limited to charges for the following:

1. Reconstruction of the breast(s) upon which the mastectomy was performed, including implants;

2. Surgical procedures and reconstruction of the non-affected breast to produce a symmetricalappearance, including implants;

3. Non-surgical treatment of lymphedemas and other physical complications of mastectomy, includingnon-surgical prostheses and implants for producing symmetry.

Specifically excluded from this benefit are expenses for the following:

1. Solely Cosmetic procedures unrelated to producing a symmetrical appearance;

2. Breast augmentation procedures unrelated to producing a symmetrical appearance;

3. Implants for the non-affected breast unrelated to producing a symmetrical appearance;

4. Non-surgical prostheses or any other procedure unrelated to producing a symmetrical appearance.


COST MANAGEMENT SERVICES

The Plan does not cover any services or supplies that are not Medically Necessary. Community HealthPartners (CHP) makes determinations of Medical Necessity on behalf of the Plan. To help avoid a personreceiving services that are not Medically Necessary and not payable under the Plan, CHP provides a numberof cost management services. The Cost Management Services they provide are: Pre-certification, UtilizationManagement, Large Case Management, and SmartChoice.

To make sure these programs are effective, this Plan includes certain notification provisions. The CoveredPerson is responsible for making sure the notification was completed by his or her Physician before anyservices are rendered.

If the Covered Person or his or her Physician does not provide the required notification as explained in thissection, benefits paid for any Eligible Expenses incurred at an NCH facility or from an In-Network Physicianwill be reduced to 40%; benefits paid for Eligible Expenses incurred from an Out-of-Network Physician will bereduced to 40%; and any Eligible Expenses incurred from a non-NCH facility will be reduced to 0%.

Any reduced reimbursement due to failure to follow the notification requirement will not accrue towardthe Out-of-Pocket Maximum.

PRE-CERTIFICATION

Unless otherwise provided below, the Covered Person or the Covered Person’s Physician must call CHP, thensend the information via facsimile, at least twenty-four (24) hours in advance of the requested service, supplyor admission requiring pre-certification. CHP can be reached in Collier County at (239) 659-7770, or 1-888-594-9008.

The following services must be performed at a NCH Facility and require pre-certification, unless statedotherwise under the exceptions:

Pre-certification Required Exceptions

All elective (non-urgent) admissions NoneBlepharoplasty NoneBreast Reduction NoneCataract surgery NoneDiagnostic Imaging• All CT Scans (including PET Scans)• All MRI Scans• All Nuclear Scans• Nuclear stress testing

• Echocardiograms• EKG• EMG (Electromyography)• Nuclear stress testing for evaluation of chest

pain if performed at an NCH-owned facility on anUrgent basis

• stress testing other than nuclearDurable Medical Equipment (DME) with cost inexcess of $500 rental or purchase

DME $500 or less

Endoscopies/OP Surgical Procedures• EGD (Esophagogastroduodenoscopy)

• Bladder scan performed in a Physician’s Office• Cystoscopy w/ or w/o dilation, catheterization or

stint removal performed in a Physician’s Office• D & C (Dilatation of cervix and Curettage of

uterus)• Uroflow• Vasectomy

Cost Management Services

Pre-certification Required Exceptions


Home Health Care discipline to include PhysicalTherapy, Occupational Therapy, Speech Therapyand SN (skilled nursing) (Includes Hospice)

None

Hospice Care Outpatient and Inpatient NoneHospital Admission (see Utilization Management) Emergency AdmissionOncology Services call CHP NoneOut-of-area or Out-of-Network services notavailable In-Network

None

Outpatient Rehab Services• Physical Therapy• Occupational Therapy• Speech Therapy• Biofeedback

Pre-certification not required for first 12 visits ifperformed at an NCH facility

Pain management (epidurals, facet blocks, nervestimulators)

None

Skilled Nursing Facility admission or transfer atleast 3 working days prior to admission

None

Sleep disorders studies / treatment / C-Pap NoneAll Transplants NoneLap Band Surgery None

In addition, pre-certification is required if a facility other than NCH or NCH Healthcare Group is utilized for thefollowing services and without pre-certification will result in reduction of benefits:

! Biopsy simple - other than in a Physician’s office.! Bronchoscopy! Cardiac catheterization! Cataract surgery! Chemotherapy! Colonoscopy! D & C (Dilatation of cervix and Currettage of uterus)! Infusion care. Call 436-5460 for an appointment! Outpatient surgery! Transplants

UTILIZATION MANAGEMENT

Utilization Management is a program designed to help ensure that all Covered Persons receive necessary andappropriate health care while avoiding unnecessary expenses when a Hospital confinement is proposed. Inorder for this program to work, advance notification of elective admissions or procedures and timely notificationof Emergency admissions or procedures must be received.

The program consists of:

1. Determination of the Medical Necessity for all non-Emergency Hospital admissions before medicalservices are provided where possible;

2. Retrospective review of the Medical Necessity for all Emergency Hospital admissions;

3. Concurrent review, based on the admitting diagnosis, of the number of days of Hospital confinementrequested by the attending Physician; and

4. Review of the length of confinement and discharge planning.



The purpose of the program is to determine what is payable by the Plan. This program is not designed to bethe practice of medicine or to be a substitute for the medical judgment of the attending Physician or otherhealth care provider. The notification provision allows CHP to begin a timely review of your service. Thishelps minimize the potential that a service will be denied retrospectively as not being Medically Necessary.The more time CHP has to review a proposed admission/procedure, the better. Therefore, whenever possible,CHP should be contacted in advance of the required time frames.

If a particular course of treatment is not Medically Necessary, it will not be covered under the Plan.

In order to avoid penalties for late notification, please read the following provisions carefully.

Notification Requirement

Before a Covered Person enters the Hospital on a non-Emergency basis, notification must be provided. Anon-Emergency Hospitalization is one that can be scheduled in advance.

The Utilization Management process is set in motion by a notification telephone call from the CoveredPerson’s Physician’s office or the Covered Person. To meet the notification provision, the Covered Personor Physician must call CHP at 239-659-7770 or toll free 1-888-594-9008. The Covered Person should beprepared to provide the information outlined below. If call is made after hours, leave this information on CHP’svoice mail system. This call must be made at least twenty-four (24) hours prior to the admission or procedure.

1. The name of the Covered Person and relationship to the Employee2. The name, Social Security Number and address of the Employee3. The name of Employer4. The name and telephone number of the attending Physician5. The name of the Hospital and proposed date of admission6. The diagnosis and/or type of surgery7. The proposed length of Hospital stay

If there is an Emergency admission to the Hospital or procedure, the Covered Person, his or her familymember, Hospital or attending Physician must contact CHP, Medical Services Department within forty-eight (48) hours following admission or procedure.

CHP will determine the number of days of Hospital confinement authorized for payment.

Inpatient days or procedures determined not to be Medically Necessary will be denied in accordance with theprovisions of the Plan.

Concurrent Stay Review, Discharge Planning

Concurrent stay review and discharge planning are parts of the Utilization Management Program. CHP willmonitor the Covered Person’s Hospital stay and coordinate with the attending Physician, Hospital andCovered Person either the scheduled release from the Hospital or an extension of the Hospital admission.

If the attending Physician feels that it is Medically Necessary for the Covered Person to stay in the Hospitalfor a greater length of time than has been pre-certified, the attending Physician must request the additionaldays.



Alternative Care

When a catastrophic condition, such as a spinal cord Injury, a degenerative Illness, debilitating condition, highrisk condition, selective chronic conditions or a neurological paralytic disease occurs, a person will requirelong-term, perhaps lifetime, care. After the Covered Person’s condition is stabilized in the Hospital, he or shemight be able to be moved out of the Hospital and into another type of care setting - even to his or her home.

Sometimes, specialized care or adaptions to the home are required, but are not covered under the Plan. TheAlternative Care program was initiated for those situations in which there would be a large cash outlay for non-covered expenses for catastrophic conditions. It is a way in which these non-covered expenses can be paidby the Plan.

Alternative care occurs in the following situations:

1. The Covered Person has been Hospitalized and the attending Physician feels the condition isstabilized.

2. The Covered Person must continue to require an acute level of care, but that care need not be in aHospital.

3. Moving the Covered Person to the new care setting must entail expenditures that are notreimbursable under the Plan.

4. The Case Manager will coordinate and implement the Alternative Care by providing guidance andinformation on available resources and suggesting the most appropriate treatment plan.

5. The Plan Administrator, attending Physician, Covered Person and his or her family must all agree tothe alternate treatment plan.

6. Once agreement has been reached, the Plan Administrator will direct the Plan to reimburse forexpenses as stated in the treatment plan, even if these expenses normally would not be paid by thePlan.

Note: Alternative Care is a service; however, there is no reduction of benefits or penalties if theCovered Person and family choose not to participate.

SmartChoice

SmartChoice is a medically supervised health education program for individuals who have or are at risk forchronic diseases such as heart disease, high blood pressure, diabetes, high cholesterol, asthma and weightmanagement. The key to managing these conditions is long-term lifestyle changes, not short-term solutions.Six (6) months in length and highly personalized, SmartChoice focuses on education, prevention, behaviormodification, and self-management to minimize common health risks. Intended for adults, hundreds ofindividuals have found that it benefits the whole family.

The following are just a few of the benefits of SmartChoice:

1. Personal, one-on-one confidential counseling sessions with a nurse and licensed dietitian.2. Health risk-specific coaching and planning.3. Individualized meal planning with attention to specific health risks.4. On-going contact with the SmartChoice case managers via telephone, email and meetings.5. SmartChoice Tool Kit for help with meal planning and portion control.6. Access and referrals to a premier network of local physicians and hospitals.

Any Employee with a medical concern may call SmartChoice and respond to a brief screening conducted bya case manager. Payment options will be explained to those for whom SmartChoice is not a health planbenefit. For more information, call (239) 659.7740.



CASE MANAGEMENT

Community Health Partners (CHP) will monitor a Covered Person’s emerging risk, a condition or diagnosisthat may be potentially significant by utilizing several different methods such as Verisk Medical Intelligence,Notification request, Pharmacy and TPA reports.

When a Covered Person has been identified with emerging risk they will be encouraged to enroll in CaseManagement and actively participate in their care plan. Active participation is described as, communicatingwith their Case Manager on a weekly basis until less intensity is needed determined by the Case Manageror the Covered Person is disenrolled from program. Communication may be in the form of letters, phone calls,face to face meetings or encrypted emails. If a Covered Person cancels an appointment with the casemanager, it is the Covered Person’s responsibility to reschedule with 48 business hours. If a Covered Personrefuses to participate and their level of medical and pharmacy spend combined exceeds $100,000 in a six (6)month period, they will receive a monetary benefit adjustment for failure to participate.

First Contact: Covered Persons will be contacted by a Case Manager as soon as a trend is identified to enrollthe Covered Person into Case Management. Initially a letter will be sent from Community Health Partnersadvising the Covered Person they have been identified to participate in Case Management and will becontacted within one week. The letter will provide the Case Manager’s contact information and ask theCovered Person to be pro-active and reach out to the case manager and communicate the best time toschedule a call with the Covered Person.

Second Contact: If no-response, the Case Manager will confirm with the Human Resource Department thatthey have the most current contact information. A second call will be place within 48 business hours.

Third Contact: Third call will be place to the Covered Person within another 48 business hour cycle. This callwill be placed after normal business hours between 5 and 7pm.

Fourth contact: Certified letter requiring a signature will be sent to the Covered Person’s current homeaddress. This letter will outline the attempts made to contact the Covered Person as well as the potentialbenefit adjustment due to failure to participate.

While participation in Case Management is voluntary, declining to participate or declining to continue toparticipate in Large Case Management services when requested by the Plan will result in an automaticenrollment change in coverage option for the Employee and covered Dependents to the Basic option. Thisenrollment change will become effective the following pay period for the remainder of the Benefit Period.


GENERAL PLAN EXCLUSIONS AND LIMITATIONS

The following general exclusions and limitations apply to all Expenses Incurred under this Plan regardless ofwhether such services or supplies are Medically Necessary or recommended by a Physician:

1. Charges for services rendered or started, or supplies furnished prior to the effective date of coverageunder the Plan, or after coverage is terminated under the Plan, except as specifically provided for inthe Plan provisions.

2. Expenses Incurred by persons other than the Covered Person receiving treatment.

3. Charges for services or supplies that are not specifically listed as a Covered Benefit of this Plan.

4. Charges for services, treatment or supplies not considered legal in the United States.

5. Charges for which the Covered Person is not, in the absence of this coverage, legally obligated topay, or for which a charge would not ordinarily be made in the absence of this coverage.

6. Charges by the Covered Person for all services and supplies resulting from any Illness or Injury whichoccurs in the course of employment for wage or profit, or in the course of any volunteer work whenthe organization, for whom the Covered Person is volunteering, has elected or is required by law toobtain coverage for such volunteer work under state or federal workers’ compensation laws or otherlegislation, including Employees’ compensation or liability laws of the United States (collectively called“Workers’ Compensation”). This exclusion applies to all such services and supplies resulting froma work-related Illness or Injury even though:

A. Coverage for the Covered Person under Workers’ Compensation provides benefits for onlya portion of the services Incurred;

B. The Covered Person’s employer/volunteer organization has failed to obtain such coveragerequired by law;

C. The Covered Person waived his/her rights to such coverage or benefits;

D. The Covered Person fails to file a claim within the filing period allowed by law for suchbenefits;

E. The Covered Person fails to comply with any other provision of the law to obtain suchcoverage or benefits; or

F. The Covered Person is permitted to elect not to be covered by Workers’ Compensation butfailed to properly make such election effective.

G. The Covered Person is permitted to elect not to be covered by Workers’ Compensation andhas affirmatively made that election.

This exclusion will not apply to household and domestic employment, employment not in theusual course of the trade, business, profession or occupation of the Covered Person oremployer, or employment of a Dependent member of an employer’s family for whom anexemption may be claimed by the Employer under the Internal Revenue Code.

7. Charges for care, treatment, services or supplies not recommended and approved by a Physician;or treatment, services or supplies when the Covered Person is not under the regular care of aPhysician. Regular care means ongoing medical supervision or treatment which is appropriate carefor the Injury or Illness.

General Plan Exclusions and Limitations


8. Charges for services or supplies which are obtained from any governmental agency without cost bycompliance with laws or regulations enacted by any governmental body.

9. Charges to the extent that the Covered Person could have obtained payment, in whole or in part, ifhe or she had applied for coverage or obtained treatment under any federal, state or othergovernmental program or in a treatment facility operated by a government agency, except whererequired by law, such as for cases of medical emergencies or for coverage provided by Medicaid.

10. Charges for services, supplies or treatments or procedures, surgical or otherwise, not recognized asgenerally accepted and Medically Necessary for the diagnosis and/or treatment of an active Illnessor Injury, or which are Experimental or Investigational, except as specifically stated as a CoveredBenefit of this Plan.

11. Charges in excess of the Usual, Customary and Reasonable limits.

12. Charges for care, treatment, services or supplies received as a result of Injury or Illness caused byor contributed to by engaging in an illegal act or occupation; by committing or attempting to commitany crime, criminal act, or assault or other felonious behavior; occurred as a result of a CoveredPerson’s illegal use of alcohol; or by participating in any of the forgoing, or in a riot or publicdisturbance. This exclusion does not apply if the Injury or Illness resulted from an act ofdomestic violence or a medical condition, health status, or health factor (including bothphysical and mental health).

13. Charges which are caused by or arising out of war or act of war, (whether declared or undeclared),civil unrest, armed invasion or aggression, or caused during service in the armed forces of anycountry.

14. Charges for services rendered by a Physician or Licensed Health Care Provider who is a CloseRelative of the Covered Person, or resides in the same household of the Covered Person and whodoes not regularly charge the Covered Person for services.

15. Charges in connection with the care or treatment of, surgery performed for, or as the result of, aCosmetic procedure. This exclusion will not apply when such treatment is rendered to correcta condition resulting from an Accidental Injury or an Illness, or when rendered to correct acongenital anomaly for a covered Dependent child.

16. Charges for any surgical, medical or Hospital services and/or supplies rendered in connection withradial keratotomy, LASIK or any other procedure designed to correct farsightedness, nearsightednessor astigmatism. This exclusion does not apply to aphakic patients and soft lenses or sclerashells intended for use as corneal bandages.

17. Charges in connection with eye refractions, the purchase or fitting of eyeglasses, contact lenses,except for the initial purchase of eyeglasses or contact lenses following cataract surgery.

18. Charges in connection with hearing aids, or such similar aid devices.

19. Charges for routine medical examinations, routine health check-ups or preventive immunizations notnecessary for the treatment of an Injury or Illness, except as specifically listed as a Covered Benefit.

20. Charges for hospitalization when such confinement occurs primarily for physiotherapy, hydrotherapy,convalescent or rest care, or any routine physical examinations, tests or treatments not connectedwith the actual Illness or Injury.

21. Charges related to Custodial Care.



22. Charges for care or treatment of weak, strained, flat, unstable or unbalance feet, metatarsalgia orbunions, and treatment of corns, calluses or toenails, except open cutting operations unless neededin treatment of a metabolic or peripheral-vascular disease.

23. Charges for non-medical expenses such as training, education, instructions or educational materials,even if they are performed, provided or prescribed by a Physician.

24. Charges for services or supplies used primarily for cosmetic, personal comfort, convenience,beautification items, television or telephone use that are not related to treatment of a medicalcondition.

25. Charges for services, treatments or supplies that may be useful to persons in the absence of Illnessor Injury such as air conditioners, purifiers, humidifiers, special furniture, bicycles, whirlpools,dehumidifiers, exercise equipment, health club memberships, etc., whether or not they have beenprescribed or recommended by a Physician.

26. Charges in connection with services or supplies provided for the treatment of obesity and weightreduction, except as specifically listed as a covered benefit.

27. Charges for any services, care or treatment for sexual dysfunction, trans-sexualism, gender dysphoriaor sexual reassignment including related drugs, medications, surgery, medical or Psychiatric Care ortreatment.

28. Charges resulting from or in connection with the reversal of a sterilization procedure.

29. Charges related to or in connection with fertility studies, sterility studies, procedures to restore orenhance fertility, artificial insemination, or in-vitro fertilization, or any other assisted reproductivetechnique.

30. Charges for ongoing care, treatment, services or supplies for smoking cessation not otherwisecovered under the Plan’s prescription drug program

31. Exercise programs for treatment of any condition.

32. Charges for care, treatment, services or supplies of an Injury or Illness that results from engaging ina Hazardous Hobby. A hobby is hazardous if it is an unusual activity which is characterized by aconstant threat of danger or risk of bodily harm. Examples of hazardous hobbies are skydiving, autoracing, hang gliding or bungee jumping.

33. Charges for the following treatments, services or supplies:

A. Care, treatment, services or supplies related to or connected with treatments, services orsupplies that are excluded under this Plan.

B. Charges that are the result of any medical complication resulting from a treatment, serviceor supply which is, or was at the time the charge was incurred, excluded from coverage underthis Plan.

34. Travel Expenses Incurred by any person for any reason.

35. Charges for care, treatment, services or supplies for Injury or Illness resulting from the consumptionof any controlled substance, drug hallucinogen or narcotic not administered on the advice of aPhysician. This exclusion does not apply if the Injury or Illness resulted from an act ofdomestic violence or a medical condition, health status, or health factor (including bothphysical and mental health).



36. Charges for care and treatment of Pregnancy and complications of Pregnancy for a Dependent otherthan a covered spouse.

37. Charges for self-care or self-help training and any related diagnostic testing, hypnosis, medication andpain control.

38. Charges for hypnotism or hypnotic anesthesia.

39. Charges for acupuncture, naturopathy, holistic medical procedures or rolfing.

40. Hair transplant procedures, wigs and artificial hairpieces, or drugs which are prescribed to promotehair growth, except as specifically listed as an Eligible Expense.

41. Charges or orthognathic surgery and related charges.

42. Charges for any food item, including infant formulas, medical foods, non-prescription vitamins,nutritional supplements and other nutritional items, unless these supplements are needed to sustainlife or are specifically covered under the Preventive Care Benefit.

43. Charges that are incurred outside of the United States if the Covered Person traveled to such alocation for the purpose of obtaining treatment, services, drugs, or supplies.

44. Charges for massage therapy, except as specifically listed as a covered benefit.

45. Special duty nursing services are excluded:

A. Which would ordinarily be provided by the Hospital staff or its Intensive Care Unit (theHospital benefit of the Plan pays for general nursing services by Hospital staff); or

B. When private duty nurse is employed solely for the convenience of the patient or the patient'sFamily or for services which would consist primarily of bathing, feeding, exercising,homemaking, moving the patient, giving medication or acting as a companion, sitter or whenotherwise deemed not Medically Necessary as requiring skilled nursing care.

46. Charges for spinal manipulation or chiropractic treatment which are not related to an actual Illnessor Injury or which exceed the maximum benefit as stated in the Schedule of Medical Benefits.

47. Charges for non-prescription contraceptives supplies or devices, or the removal of contraceptivedevices, unless Medically Necessary.

48. Charges for midwife services regardless of whether provided by a Certified Nurse Midwife (CNM) ora direct-entry or lay midwife.

49. Charges for professional services on an Outpatient basis in connection with disorders of any type orcause, that can be credited towards earning a degree or furtherance of the education or training ofa Covered Person regardless of the diagnosis.

50. Charges for preparation of reports or itemized bills in connection with claims, unless specificallyrequested and approved by the Plan.

51. Charges for any services or supplies to the extent that benefits are otherwise provided under thisPlan, or under any other plan of group benefits that the Participant’s Employer contributes to orsponsors.



52. Charges for incidental supplies or common first-aid supplies, such as, but not limited to, adhesivetape, bandages, antiseptics, analgesics, etc.

53. Charges for treatment, services or supplies not actually rendered to or received and used by theCovered Person.

54. Charges for Physicians' fees for any treatment which is not rendered by or in the physical presenceof a Physician.

55. Charges for Licensed Health Care Providers’ fees for any treatment which is not rendered by or in thephysical presence of a Licensed Health Care Provider.

56. Charges for marital counseling, family counseling, recreational counseling or milieu therapy.

57. Complications that directly result from acting against medical advice, non-compliance with specificphysician’s orders or leaving an inpatient facility against medical advice.

58. Breast pumps.

59. Equipment, including, but not limited to, motorized wheelchairs or beds, that exceeds the patient’sneeds for every day living activities as defined by the Americans with Disabilities Act as amendedfrom time to time, unless Medically Necessary by independent review and not primarily for personalconvenience.

60. Specialized computer equipment, including, but not limited to, Braille keyboards and voice recognitionsoftware, unless determined to be Medically Necessary by independent review, and not primarily forpersonal convenience.

61. Immunizations, medications and other preventive treatments that are recommended because ofincreased risk due to your type of travel, including, but not limited to, immunizations, medicationsand/or other preventive treatments for malaria and yellow fever.

62. Examinations for employment, licensing, insurance or adoption purposes.

63. Court-ordered examinations or treatment.

64. Expenses for examinations and treatment conducted for the purpose of medical research.

65. FAA and DOT Physicals.

66. Genetic testing.


COORDINATION OF BENEFITS

The Coordination of Benefits provision prevents the payment of benefits which exceed the Allowable Expense.It applies when the Participant or Dependent who is covered by this Plan is or may also be covered by anyother plan(s). This Plan will always pay either its benefits in full or a reduced amount which, when added tothe benefits payable by the other plan(s), will not exceed 100% of Allowable Expense. Only the amount paidby this Plan will be charged against the Plan maximums.

In the event of a motor vehicle or premises accident; or an act of violence with the intent to disrupt electronic,communications, or any other business system, this Plan will be secondary to any auto “no fault” andtraditional auto “fault” type contracts, homeowners, commercial general liability insurance and any othermedical benefits coverage.

The Coordination of Benefits provision applies whether or not a claim is filed under the other plan or plans.If needed, authorization is hereby given this Plan to obtain information as to benefits or services available fromthe other plan or plans, or to recover overpayments.

All benefits under the Plan are subject to this provision, except for the Pharmacy Benefit.

DEFINITIONS

“Allowable Expense” as used herein means:

1. If the claim as applied to the primary plan is subject to a contracted or negotiated rate, AllowableExpense will be equal to that contracted or negotiated amount.

2. If the claim as applied to the primary plan is not subject to a contracted or negotiated rate, but theclaim as applied to the secondary plan is subject to a contracted or negotiated rate, the AllowableExpense will be equal to that contracted or negotiated amount of the secondary plan.

3. If the claim as applied to the primary plan and the secondary plan is not subject to a contracted ornegotiated rate, then the Allowable Expense will equal to the secondary plan’s chosen limits for non-contracted providers.

“Plan” as used herein means any plan providing benefits or services for or by reason of medical, dental orvision treatment, and such benefits or services are provided by:

1. Group insurance or any other arrangement for coverage for Covered Persons in a group whether onan insured or uninsured basis, including but not limited to:

A. Hospital indemnity benefits; and

B. Hospital reimbursement-type plans which permit the Covered Person to elect indemnity atthe time of claims; or

2. Hospital or medical service organizations on a group basis, group practice and other group pre-payment plans; or

3. Hospital or medical service organizations on an individual basis having a provision similar in effectto this provision; or

4. A licensed Health Maintenance Organization (H.M.O.); or

5. Any coverage for students which is sponsored by, or provided through a school or other educationalinstitution; or

Coordination of Benefits


6. Any coverage under a Governmental program, and any coverage required or provided by any statute;or

7. Automobile insurance; or

8. Individual automobile insurance coverage on an automobile leased or owned by the Company or anyresponsible third-party tortfeasor; or

9. Individual automobile insurance coverage based upon the principles of “No-Fault” coverage; or

10. Homeowner or premise liability insurance, individual or commercial.

“Plan” will be construed separately with respect to each policy, contract, or other arrangement for benefits orservices, and separately with respect to that portion of any such policy, contract, or other arrangement whichreserves the right to take the benefits or services of other plans into consideration in determining its benefitsand that portion which does not.

ORDER OF BENEFIT DETERMINATION

1. Non-Dependent/Dependent

The plan that covers the person as other than a dependent, (e.g., as an employee, member,subscriber, retiree) is primary and the plan that covers the person as a dependent is secondary.

2. Child Covered Under More Than One Plan

A. The primary plan is the plan of the parent whose birthday is earlier in the year if:

1) The parents are married;2) The parents are not separated (whether or not they have ever been married), or3) A court decree awards joint custody without specifying that one parent has the

responsibility to provide health care coverage.

B. If both parents have the same birthday, the plan that has covered either of the parents longeris primary.

C. If the specific terms of a court decree state that one of the parents is responsible for thechild’s health care expenses or health care coverage and the plan of that parent has actualknowledge of those terms, that plan is primary. If the parent with financial responsibility hasno coverage for the child’s health care services or expenses, but that parent’s spouse does,the spouse’s plan is primary. This subparagraph will not apply with respect to any claimdetermination period, Benefit Period or Plan Year during which benefits are paid or providedbefore the entity has actual knowledge.

D. If the parents are not married or are separated (whether or not they were ever married) or aredivorced, and there is no court decree allocating responsibility for the child’s health careservices or expenses, the order of benefit determination among the plans of the parents andthe parents’ spouses (if any) is:

1) the plan of the custodial parent2) the plan of the spouse of the custodial parent3) the plan of the non-custodial parent4) the plan of the spouse of the non-custodial parent



3. Active or Inactive Employee

The Plan that covers a person as an employee who is neither laid-off nor retired (or as thatemployee’s dependent) is primary. If the other plan does not have this rule, and if, as a result, theplans do not agree on the order of benefits, this rule will not be followed.

4. Longer or Shorter Length of Coverage

If the preceding rules do not determine the order of benefits, the plan that has covered the person forthe longer period of time is primary.

A. To determine the length of time a person has been covered under a plan, two plans will betreated as one if the Covered Person was eligible under the second within 24 hours after thefirst ended.

B. The start of a new plan does not include:

1) A change in the amount or scope of a plan’s benefits2) A change in the entity that pays, provides, or administers the plan’s benefits; or3) A change from one type of plan to another (such as from a single employer plan to

that of a multiple-employer plan).

C. A person’s length of time covered under a plan is measured from the person’s first date ofcoverage under that plan. If that date is not readily available for a group plan, the date theperson first became a member of the group will be used as the date from which to determinethe length of time the person’s coverage under the present plan has been in force.

5. No Rules Apply

If none of these preceding rules determines the primary plan, the Allowable Expense will bedetermined equally between the plans.

COORDINATION WITH MEDICARE

Medicare Part A and Part B will be considered a plan for the purposes of coordination of benefits. ThisPlan will coordinate benefits with Medicare whether or not the Covered Person is actually receivingMedicare Benefits. This means that the Plan will only pay the amount that Medicare would not havecovered, even if the Covered Person does not elect to be covered under Medicare. Also, failure toenroll in Medicare Part B when a person is initially eligible may result in the person being assesseda significant surcharge by Medicare for late enrollment in Part B.

1. For Working Aged

A covered Employee who is eligible for Medicare Part A or Part B as a result of age may be coveredunder this Plan and be covered under Medicare, in which case this Plan will pay primary. A coveredEmployee, eligible for Medicare Part A or Part B as a result of age, may elect not to be covered underthis Plan. If such election is made, coverage under this Plan will terminate.

A covered Dependent, eligible for Medicare Part A or Part B as a result of age, of a coveredEmployee may also be covered under this Plan and be covered under Medicare, in which case thePlan again will pay primary. A covered Dependent, eligible for Medicare Part A or Part B as a resultof age, may elect not to be covered under this Plan. If such election is made, coverage under thisPlan will terminate.



2. For Covered Persons who are Disabled

The Plan is primary and Medicare will be secondary for the covered Employee or any coveredDependent who is eligible for Medicare by reason of disability, if the Employee is actively employedby the Employer.

The Plan is secondary and Medicare will be primary for the covered Employee or any coveredDependent who is eligible for Medicare by reason of disability if the Employee is retired or otherwisenot actively working for the Employer.

3. For Covered Persons with End Stage Renal Disease

Except as stated below*, for Employees and their Dependents, if Medicare eligibility is due solely toEnd Stage Renal Disease (ESRD), this Plan will be primary only during the first thirty (30) months ofMedicare coverage. Thereafter, this Plan will be secondary with respect to Medicare coverage,unless after the thirty-month period described above, the Covered Person has no dialysis for a periodof twelve (12) consecutive months and:

A. Then resumes dialysis, at which time the Plan will again become primary for a period of thirty(30) months; or

B. The Covered Person undergoes a kidney transplant, at which time the Plan will againbecome primary for a period of thirty (30) months.

*If a Covered Person is covered by Medicare as a result of disability, and Medicare is primary for thatreason on the date the Covered Person becomes eligible for Medicare as a result of End Stage RenalDisease, Medicare will continue to be primary and the Plan will be secondary.

COORDINATION WITH MEDICAID

If a Covered Person is also entitled to and covered by Medicaid, the Plan will always be primary and Medicaidwill always be secondary coverage.

COORDINATION WITH TRICARE/CHAMPVA

If a Covered Person is also entitled to and covered under TRICARE/CHAMPVA, the Plan will always beprimary and TRICARE/CHAMPVA will always be secondary coverage. TRICARE coverage will includeprograms established under its authority, known as TRICARE Standard, TRICARE Extra and TRICAREPrime.

If the Covered Person is eligible for Medicare and entitled to veterans benefits through the Department ofVeterans Affairs (VA), the Plan will always be primary and the VA will always be secondary for non-serviceconnected medical claims. For these claims, the Plan will make payment to the VA as though the Plan wasmaking payment secondary to Medicare.


PROCEDURES FOR CLAIMING BENEFITS

Claims must be submitted to the Plan within twelve (12) months after the date services or treatments arereceived or completed. Non-electronic claims may be submitted on any approved claim form, available fromthe provider. The claim must be completed in full with all the requested information. A complete claim mustinclude the following information:

• Date of service;• Name of the Participant;• Name and date of birth of the patient receiving the treatment or service and his/her

relationship to the Participant;• Diagnosis [code] of the condition being treated;• Treatment or service [code] performed;• Amount charged by the provider for the treatment or service; and• Sufficient documentation, in the sole determination of the Plan Administrator, to support the

medical necessity of the treatment or service being provided and sufficient to enable the PlanSupervisor to adjudicate the claim pursuant to the terms and conditions of the Plan.

When completed, the claim must be received by the Plan Supervisor, Allegiance Benefit Plan Management,Inc., at P.O. Box 3018, Missoula, Montana 59806-3018, 855-333-1002 or through any electronic claimssubmission system or clearinghouse to which Allegiance Benefit Plan Management, Inc. has access.

A claim will not, under any circumstances, be considered for payment of benefits if initially submitted to thePlan more than twelve (12) months from the date that services were incurred.

Upon termination of the Plan, final claims must be received within three (3) months of the date of termination,unless otherwise established by the Plan Administrator.

CLAIMS WILL NOT BE DEEMED SUBMITTED UNTIL RECEIVED BY THE PLAN SUPERVISOR.

The Plan will have the right, in its sole discretion and at its own expense, to require a claimant to undergo amedical examination, when and as often as may be reasonable, and to require the claimant to submit, orcause to be submitted, any and all medical and other relevant records it deems necessary to properlyadjudicate the claim.

CLAIM DECISIONS ON CLAIMS AND ELIGIBILITY

Claims will be considered for payment according to the Plan’s terms and conditions, industry-standard claimsprocessing guidelines and administrative practices not inconsistent with the terms of the Plan. The Plan may,when appropriate or when required by law, consult with relevant health care professionals and accessprofessional industry resources in making decisions about claims that involve specialized medical knowledgeor judgment. Initial eligibility and claims decisions will be made within the time periods stated below. Forpurposes of this section, “Covered Person” will include the claimant and the claimant’s authorizedrepresentative; “Covered Person” does not include a health care provider or other assignee, and said healthcare provider or assignee does not have an independent right to appeal an Adverse Benefit Determinationsimply by virtue of the assignment of benefits.

THE PLAN DOES NOT MAKE TREATMENT DECISIONS. ANY DECISION TO RECEIVE TREATMENTMUST BE MADE BETWEEN THE PATIENT AND HIS OR HER HEALTHCARE PROVIDER; HOWEVER,THE PLAN WILL ONLY PAY BENEFITS ACCORDING TO THE TERMS, CONDITIONS, LIMITATIONS ANDEXCLUSIONS OF THIS PLAN.

Procedures for Claiming Benefits


1. Urgent Care Claims - An Urgent Care Claim is any claim for medical care or treatment with respectto which:

A. In the judgment of a prudent layperson possessing an average knowledge of health andmedicine could seriously jeopardize the life or health of the claimant or the ability of theclaimant to regain maximum function; or

B. In the opinion of a Physician with knowledge of the claimant’s medical condition, wouldsubject the claimant to severe pain that cannot be adequately managed without the care ortreatment that is the subject of the claim.

In the case of an Urgent Care Claim, the Plan will notify the claimant of the benefit determination(whether adverse or not) as soon as possible, recognizing the medical exigencies particular to theclaimant’s situation, but not later than seventy-two (72) hours after receipt of the claim.

If the claimant fails to provide information sufficient to determine whether, or to what extent, benefitsare covered or payable under the Plan, the claimant shall be notified as soon as possible, but notmore than twenty-four (24) hours after receipt of the claim, of the specific information necessary tocomplete the claim. The claimant shall be given a reasonable amount of time, but not less than forty-eight (48) hours, to provide the necessary information. The claimant will be notified of the Plan’sbenefit determination, as soon as possible, but in no event more than forty-eight (48) hours after theearlier of (i) the date the requested information is received or (ii) the end of the period afforded theclaimant to provide the specified additional information.

2. Pre-Service Claims - Pre-Service Claims must be submitted to the Plan before the Covered Personreceives medical treatment or service. A Pre-Service Claim is any claim for a medical benefit whichthe Plan terms condition the Covered Person’s receipt of the benefit, in whole or in part, on approvalof the benefit before obtaining treatment. The Plan will provide notice of its decision on a Pre-ServiceClaim within a reasonable period of time, but no later than fifteen (15) days after receipt of the claimby the Plan Supervisor. In special circumstances, this period may be extended for up to an additionalfifteen (15) days. In such case, the claimant will be notified before the end of the first 15-day periodof the circumstances requiring the extension and the date by which a decision is expected to berendered.

3. Post-Service Claims - A Post-Service Claim is any claim for a medical benefit under the Plan withrespect to which the terms of the Plan do not condition the Covered Person’s receipt of the benefit,or any part thereof, on approval of the benefit prior to obtaining medical care, and for which medicaltreatment has been obtained prior to submission of the claim(s).

If Post-Service Claim is denied in whole or in part, the Plan will provide timely notice of the AdverseBenefit Determination within a reasonable period of time, but no later than thirty (30) days afterreceiving the claim. In special circumstances, this period may be extended for up to an additionalfifteen (15) days. In such case, the claimant will be notified before the end of the 30-day period of thecircumstances requiring the extension and the date by which a decision is expected to be rendered.

4. Concurrent Care Review - For individuals who face early termination or reduction of benefits for acourse of treatment previously certified by the Plan, a decision by the Plan to reduce or terminatebenefits for ongoing care is considered an Adverse Benefit Determination. (Note: Exhaustion of thePlan’s benefit maximums is not an Adverse Benefit Determination.) The Plan will notify the CoveredPerson sufficiently in advance to allow an appeal for uninterrupted continuing care before the benefitis reduced or terminated. Any request to extend an Urgent Care course of treatment beyond theinitially prescribed period of time must be decided within twenty-four (24) hours of the Plan’s receiptof the request. The appeal for ongoing care or treatment must be made to the Plan at least twenty-four (24) hours prior to the expiration of the initially-prescribed period.

As part of the claims process, each Covered Person, on request and free of charge, will be given reasonableaccess to, and copies of, all documents, records, and other information relevant to his or her claim for benefits.



NOTICE OF AN ADVERSE BENEFIT DETERMINATION

If a claim is denied in whole or in part, the Covered Person will receive written notification of the AdverseBenefit Determination. A claim denial or Explanation of Benefits (EOB) will be provided by the Plan showing:

1. Information sufficient to allow the Covered Person to identify the claim involved and a statementregarding the availability of, upon request, the diagnosis and treatment codes and their correspondingmeanings;

2. The specific reason the claim was denied, including a description of the Plan’s standard, if any, thatwas used in denying the claim;

3. Reference(s) to the specific plan provision(s) or rule(s) upon which the decision was based whichresulted in the Adverse Benefit Determination;

4. A description of any additional information needed to perfect the claim and why such information isneeded;

5. A statement regarding the Covered Person’s right, on request and free of charge, to access andreceive copies of documents, records and other information that are relevant to the claim for benefits;

6. If a rule, guideline, protocol or similar criterion was relied upon in making the Adverse BenefitDetermination, a copy of the rule, guideline, protocol or similar criterion or a statement that a rule,guideline, protocol or similar criterion was relied upon and will be provided upon request, withoutcharge;

7. If the Adverse Benefit Determination is based on medical necessity, experimental treatment or similarexclusion of limit, an explanation of the scientific or clinical judgment for the decision as applied to theCovered Person’s medical circumstances or a statement that such an explanation will be providedupon request, without charge;

8. A description of the Plan’s internal and external appeals procedures, including information on how toinitiate an appeal and the applicable time limits;

9. An explanation of the Covered Person’s right to appeal the Adverse Benefit Determination for a fulland fair review and the right to bring a civil action under Section 502(a) of ERISA following anAdverse Benefit Determination on appeal; and

10. The availability of and contact information for any applicable office of health insurance consumerassistance or ombudsman established under applicable federal law to assist individuals with theinternal claims and appeals and external review processes.

In the case of an Urgent Care Claim, the Plan may provide such notification orally, provided that a writtennotification is provided to the claimant within three (3) days after the oral notification.

If a Covered Person does not understand the reason for any Adverse Benefit Determination, he or she shouldcontact the Plan Supervisor at the address or telephone number shown on the claim denial.

The Covered Person must appeal the Adverse Benefit Determination before the Covered Person mayexercise his or her right to bring a civil action under Section 502(a) of ERISA. This Plan generallyprovides two (2) levels of benefit determination review and the Covered Person must exercise bothlevels of review (other than in the case of an Urgent Care Claim) before bringing a civil action.

To initiate the first level of benefit review, the Covered Person must submit in writing an appeal or a requestfor review of the Adverse Benefit Determination to the Plan within one hundred eighty (180) days after theAdverse Benefit Determination. Failure to appeal the Adverse Benefit Determination within the 180- day timeperiod will render the determination final. Any appeal received after the 180-day time period has expired willreceive no further consideration.



As part of each level of benefit review, the Covered Person has the right to submit comments, documents,records and other information relevant to his or her claim for benefits and to present evidence and testimony.The Covered Person should include any additional information supporting the appeal or the informationrequired by the Plan which was not initially provided and forward it to the Plan Supervisor within the 180-daytime period. The Covered Person will be given, upon request and free of charge, reasonable access to, andcopies of, all documents, records and other information relevant to his or her claim for benefits and also to hisor her claim file. The Covered Person will also be provided, free of charge, with any new or additionalevidence considered, relied upon, or generated by the Plan or at the direction of the Plan in connection withthe claim and any new or additional rationale. Any such evidence and/or rationale will be provided to theCovered Person as soon as reasonably possible and sufficiently in advance of the due date for the notice offinal internal Adverse Benefit Determination so that the Covered Person will have a reasonable opportunityto respond prior to the due date.

APPEALING AN ADVERSE BENEFIT DETERMINATION FOR AN URGENT CARE CLAIM

Appeals or requests for review of Adverse Benefit Determinations for Urgent Care Claims must besubmitted in writing to Community Health Partners, P.O. Box 9529, Naples, FL 34101 or via facsimileat (239) 659-7799.

1. Benefit Determination Review

The Medical Review Committee at NCH will review the materials provided by Community HealthPartners with respect to the claim in question, including any information submitted by the CoveredPerson. The Plan will conduct a full and fair review of the claim by the Medical Review Committee atNCH who is neither the original decisionmaker nor the decisionmaker’s subordinate. The MedicalReview Committee at NCH will not give deference to the initial benefit determination. The MedicalReview Committee at NCH may, when appropriate or if required by law, consult with relevant healthcare professionals in making decisions about appeals that involve specialized medical judgment.Where the appeal involves issues of medical necessity or experimental treatment, the Medical ReviewCommittee at NCH will consult with a health care professional with appropriate training who wasneither the medical professional consulted in the initial determination or his or her subordinate. Aftera full and fair review of the Covered Person’s appeal, the Plan will provide a written or electronicnotice of the final benefit determination, within seventy-two (72) hours after receipt of the claimant’srequest for a review.

APPEALING AN ADVERSE BENEFIT DETERMINATION FOR A PRE-SERVICE CLAIM

Appeals or requests for review of Adverse Benefit Determinations for Pre-Service Claims must besubmitted in writing to Community Health Partners, P.O. Box 9529, Naples, FL 34101. Supportingmaterials may be submitted via facsimile at (239) 659-7799.

1. First Level of Benefit Determination Review

The first level of benefit determination review is done by Community Health Partners (CHP). CHPwill conduct a full and fair review of the claim along with any additional information submitted by theCovered Person. CHP will not give deference to the initial benefit determination made by the PlanSupervisor. Notice of the decision on the first level of review will be sent to the Covered Person withinfifteen (15) days following the date CHP receives the request for reconsideration.

If, based on CHP’s review, the initial Adverse Benefit Determination remains the same and theCovered Person does not agree with that benefit determination, the Covered Person may initiate thesecond level of benefit review. The Covered Person must request the second review in writing andsend it to CHP, not later than sixty (60) days after receipt of CHP’s decision from the first level ofreview. Failure to initiate the second level of benefit review within the 60-day time period will renderthe determination final.



2. Second Level of Benefit Determination Review

The Medical Review Committee at NCH will review the claim in question along with the additionalinformation submitted by the Covered Person. The Plan will conduct a full and fair review of the claimby the Medical Review Committee at NCH who is neither the original decisionmaker nor thedecisionmaker’s subordinate. The Medical Review Committee at NCH will not give deference to theinitial benefit determination or the determination made at the first level of appeal. The Medical ReviewCommittee at NCH may, when appropriate or if required by law, consult with relevant health careprofessionals in making decisions about appeals that involve specialized medical judgment. Wherethe appeal involves issues of medical necessity or experimental treatment, the Medical ReviewCommittee at NCH will consult with a health care professional with appropriate training who wasneither the medical professional consulted in the initial determination or first level of appeal or his orher subordinate.

After a full and fair review of the Covered Person’s appeal, the Plan will provide a written or electronicnotice of the final benefit determination, within fifteen (15) days.

APPEALING AN ADVERSE BENEFIT DETERMINATION FOR A POST-SERVICE CLAIM

Appeals or requests for review of Adverse Benefit Determinations must be submitted to the Plan inwriting to P.O. Box 1269, Missoula, MT 59806-1269. Supporting materials may be submitted via mail,electronic claims submission process, facsimile (fax) or electronic mail (e-mail).

1. First Level of Benefit Determination Review

The first level of benefit determination review is done by the Plan Supervisor. A full and fair reviewof the claim along with any additional information submitted by the Covered Person will be conductedby an individual who is neither the decisionmaker in the initial benefit determination nor a subordinateof such decisionmaker. No deference will be given to the initial benefit determination made by thePlan Supervisor. Notice of the decision on the first level of review will be sent to the Covered Personwithin thirty (30) days following the date the Plan Supervisor receives the request for reconsideration.

If, based on the Plan Supervisor’s review, the initial Adverse Benefit Determination remains the sameand the Covered Person does not agree with that benefit determination, the Covered Person mayinitiate the second level of benefit review. The Covered Person must request the second review inwriting and send it to the Plan Supervisor, not later than sixty (60) days after receipt of the PlanSupervisor’s decision from the first level of review. Failure to initiate the second level of benefit reviewwithin the 60-day time period will render the determination final.

2. Second Level of Benefit Determination Review

The Medical Review Committee at NCH will review the claim in question along with the additionalinformation submitted by the Covered Person. The Plan will conduct a full and fair review of the claimby the Medical Review Committee at NCH who is neither the original decisionmaker nor thedecisionmaker’s subordinate. The Medical Review Committee at NCH will not give deference to theinitial benefit determination or the determination made at the first level of review. The Medical ReviewCommittee at NCH may, when appropriate or if required by law, consult with relevant health careprofessionals in making decisions about appeals that involve specialized medical judgment. Wherethe appeal involves issues of medical necessity or experimental treatment, the Medical ReviewCommittee at NCH will consult with a health care professional with appropriate training who wasneither the medical professional consulted in the initial determination or his or her subordinate.

After a full and fair review of the Covered Person’s appeal, the Plan will provide a written or electronicnotice of the final benefit determination within a reasonable time, but no later than thirty (30) days fromthe date the appeal is received by the Plan at each level of review.



All claim payments are based upon the terms contained in this Plan Document/SPD. The Covered Personmay request, free of charge, more detailed information, names of any medical professionals consulted andcopies of relevant documents, as defined in and required by law, which were used by the Plan to adjudicatethe claim.

NOTICE OF AN ADVERSE BENEFIT DETERMINATION ON APPEAL

If a claim on appeal (first and second level) is denied in whole or in part, the Covered Person will receivewritten notification of the Adverse Benefit Determination. A claim denial or Explanation of Benefits (EOB) willbe provided by the Plan showing:

1. Information sufficient to allow the Covered Person to identify the claim involved and a statementregarding the availability of, upon request, the diagnosis and treatment codes and their correspondingmeanings;

2. The specific reason the claim was denied, including a description of the Plan’s standard, if any, thatwas used in denying the claim (and in the case of a final Adverse Benefit Determination, a discussionof the decision);

3. Reference(s) to the specific plan provision(s) or rule(s) upon which the decision was based whichresulted in the Adverse Benefit Determination on appeal;

4. A statement regarding the Covered Person’s right, on request and free of charge, to access andreceive copies of documents, records and other information that are relevant to the claim for benefits;

5. If a rule, guideline, protocol or similar criterion was relied upon in making the Adverse BenefitDetermination on appeal, a copy of the rule, guideline, protocol or similar criterion or a statement thata rule, guideline, protocol or similar criterion was relied upon and will be provided upon request,without charge;

6. If the Adverse Benefit Determination on appeal is based on medical necessity, experimental treatmentor similar exclusion of limit, an explanation of the scientific or clinical judgment for the decision asapplied to the Covered Person’s medical circumstances or a statement that such an explanation willbe provided upon request, without charge;

7. In the case of a first level appeal, a description of the Plan’s internal and external appeals procedures,including information on how to initiate a second level appeal and the applicable time limits;

8. An explanation of the Covered Person’s right to bring a civil action under Section 502(a) of ERISAfollowing a second-level Adverse Benefit Determination; and

9. The availability of and contact information for any applicable office of health insurance consumerassistance or ombudsman established under applicable federal law to assist individuals with theinternal claims and appeals and external review processes.

INDEPENDENT EXTERNAL REVIEW

After exhaustion of all appeal rights stated above, a Covered Person may be eligible to request that the claimbe reviewed under the Plan’s external review process. An external review is available for any Adverse BenefitDetermination on claims involving (a) medical judgment (excluding those that involve only contractual or legalinterpretation without any use of medical judgment) as determined by the external reviewer; or (b) a rescissionof coverage (whether or not the rescission has any effect on any particular benefit at the time).

To assert this right to independent external medical review, the Covered Person must request such reviewin writing within four (4) months after receipt of the Adverse Benefit Determination upon the second levelbenefit determination above.



The Plan Administrator will complete a preliminary review of the external review request within five (5)business days after receiving the request. The preliminary review will determine whether:

1. The individual is (or was) covered under the Plan when the health care item or service was requested;for retroactive reviews, the Plan will determine whether the claimant was covered under the Planwhen the health care item or service was provided;

2. The benefit denial does not relate to the individual’s failure to meet the Plan’s eligibility requirements;

3. The individual has exhausted the Plan’s internal appeals process (unless he or she is not requiredto do so under the appeals regulations); and

4. The individual has provided all the information needed to process the External Review.

Within one business day after completion of this preliminary review, the Plan Administrator will provide writtennotification to the individual of whether the claim is eligible for external review.

If the request for review is complete but not eligible for external review, the Plan Administrator will notify theindividual of the reason(s) for its ineligibility. The notice will include contact information for the EmployeeBenefits Security Administration at its toll free number (866-444-3272).

If the request is not complete, the notice will describe the information needed to complete it. The individualwill have 48 hours or until the last day of the four (4) month filing period, whichever is later, to submit theadditional information.

If the request is eligible for the external review process, the Plan will assign it to a qualified independent revieworganization ("IRO"). The IRO is responsible for notifying the individual, in writing, that the request for externalreview has been accepted. The notice should include a statement that the individual may submit in writing,within ten (10) business days, additional information the IRO must consider when conducting the review. TheIRO will share this information with the Plan. The Plan may consider this information and decide to reverseits denial of the claim. If the denial is reversed, the Plan will notify the claimant in writing and the externalreview process will end.

If the Plan does not reverse the denial, the IRO will make its decision on the basis of its review of all of theinformation in the record, as well as additional information where appropriate and available, such as:

1. The claimant's medical records;

2. The attending health care professional's recommendation;

3. Reports from appropriate health care professionals and other documents submitted by the Plan orissuer, claimant, or the claimant's treating provider;

4. The terms of the Plan;

5. Appropriate practice guidelines, which include applicable evidence-based standards;

6. Any applicable clinical review criteria developed and used by the Plan; and

7. The opinion of the IRO's clinical reviewer.

The IRO must provide written notice to the Plan and the claimant of its final decision within 45 days after theIRO receives the request for the External Review. The IRO's decision notice must contain:

1. A general description of the reason for the external review, including information sufficient to identifythe claim;

2. The date the IRO received the assignment to conduct the review and the date of the IRO's decision;



3. References to the evidence or documentation the IRO considered in reaching its decision, includingspecific provisions and evidence-based standards;

4. A discussion of the principal reason(s) for the IRO's decision, including the rationale of its decisionand any evidence-based standards relied upon in making the decision;

5. A statement that the determination is binding (unless other remedies are available) and that judicialreview may be available to the claimant; and

6. Contact information for any applicable office of health insurance consumer assistance or ombudsman.

Generally, a claimant must exhaust the Plan's claims and appeals procedures in order to be eligible for theexternal review process. However, in some cases the Plan provides for an expedited external review if:

1. The claimant receives an Adverse Benefit Determination that involves a medical condition for whichthe time for completion of the Plan's internal claims and appeal procedures would seriously jeopardizethe claimant's life or health or ability to regain maximum function and the claimant has filed a requestfor an expedited internal review; or

2. The claimant receives a Final Adverse Benefit Determination that involves a medical condition wherethe time for completion of a standard external review process would seriously jeopardize theclaimant's life or health or the claimant's ability to regain maximum function, or if the final AdverseBenefit Determination concerns an admission, availability of care, continued stay, or health care itemor service for which the claimant received emergency services, but has not been discharged from afacility.

Immediately upon receipt of a request for expedited external review, the Plan must determine and notify theclaimant whether the request satisfies the requirements for expedited review, including the eligibilityrequirements for External Review listed above. If the request qualifies for expedited review, it will be assignedto an IRO. The IRO must make its determination and provide a notice of the decision as expeditiously as theclaimant's medical condition or circumstances require, but in no event more than 72 hours after the IROreceives the request for an expedited External Review. If the original notice of its decision is not in writing, theIRO must provide written confirmation of the decision within 48 hours to both the claimant and the plan.


MEDICAL COVERAGE OPTIONS

This Plan offers the following three medical coverage options: Healthy Partner, Healthy Choice and Basic.In order to be eligible to participate in the Health Choice or Healthy Partner coverage options for a subsequentPlan Year, certain additional requirements apply.

If an Employee has an odd birth year (e.g., 1965), the Employee and his/her spouse must complete therequirements within a twelve month period beginning with every even year between October 1 and endingSeptember 30 (e.g., October 1, 2010 - September 30, 2011). In contrast, an Employee with an even birth year(e.g., 1966) must complete the requirements within a twelve month period beginning with every odd yearbetween October 1 and ending September 30 (e.g., October 1, 2011 - September 30, 2012). For example,an Employee born in 1965 must complete the specified requirements before September 30, 2011 in order toqualify for the Healthy Choice or Healthy Partner coverage option for 2012.

Employees who do not complete these requirements will be limited to enrollment in the Basic coverage optionfor the following Plan Year.

Employees who initially qualify for coverage under the Healthy Choice or Healthy Partner coverage optionsare required to notify the Plan Administrator if they (or their covered spouses) fail to meet any ongoingrequirement (such as remaining tobacco or nicotine-free or non-compliance with case management). SuchEmployees and their covered Dependents will be enrolled in the Basic coverage option, effective the next payperiod.

For further details regarding requirements for participation in Healthy Choice and Healthy Partner coverageoption, refer to the NCH Healthcare System Benefits Guide.

Please direct any questions to Human Resources at (239) 436-5167 (Downtown) or (239) 552-7255 (NorthNaples).


ELIGIBILITY PROVISIONS

If both the husband and wife are employed by the Company, and both are eligible for Dependent Coverage,either the husband or wife, but not both, may elect Dependent Coverage for their eligible Dependents. No onecan be covered under this Plan as both an Employee and a Dependent. No one can be covered under thisPlan as a Dependent by more than one Participant.

EMPLOYEE ELIGIBILITY

An eligible Employee under this Plan includes only a person who is employed by the Company on a continuingand regular full-time or part-time basis and is in one of the following eligible classes:

1. Regular Full-Time or Regular Part-Time Employee.

2. Seasonal Full-Time or Seasonal Part-Time Employee.

“Regular Full-Time” are those Employees hired into a regular position whose position has scheduled hoursof sixty-four (64) to eighty (80) hours in a two-week period.

“Regular Part-Time” are those Employees hired int a regular position whose position has scheduled hours offorty-eight (48) to sixty-three (63) hours in a two-week period.

“Seasonal Full-Time” is an Employee hired during peak periods of the year and have a seasonal employmentagreement from four (4) to six (6) months or more, whose position has scheduled hours of sixty-four (64) toeighty (80) hours in a two-week period.

“Seasonal Part-Time” is an Employee hired during peak periods of the year and have a seasonal employmentagreement from four (4) to six (6) months or more, whose position has scheduled hours of forty-eight (48) tosixty-three (63) in a two-week period.

An Employee is not eligible while on active military duty if that duty exceeds a period of thirty-one (31)consecutive days.

WAITING PERIOD

With respect to a person covered by a previous plan or previous group health insurance of the Employer onthe effective date of this Plan, the effective date of coverage under this Plan will be the effective date of thePlan.

With respect to an eligible employee, coverage under the Plan will not start until the Employee completes aWaiting Period. The Plan’s Waiting Period is the period of time commencing on the Enrollment Date, (the datethe Employee meets the eligibility requirements stated above) to the first day of the month following ninety (90)days from the Enrollment Date.

With respect to a seasonal Employee who completes a minimum ninety (90) days of continuous employmentwith the Employer during the immediately preceding season and returns as an Employee who meets theeligibility requirements stated above is eligible for coverage on the first day of the month after his or her returndate. Any other Employee who terminates employment with the Employer and is subsequently rehired willbe treated as a new hire and be required to satisfy the Plan’s Waiting Period, unless the Waiting Period iswaived as a result of a special recruitment program as determined by the Plan Administrator.

Eligibility Provisions


An ineligible Employee who has an employment status change which makes him/her eligible for coverage willbe given credit for days of employment with the Company as an ineligible employee which credit will beapplied toward the Waiting Period. The effective date of coverage will be the first day of the monthimmediately following ninety (90) days from the Enrollment Date, which ninety (90) day period will be reducedon a day-for-day basis by days employed by the Company as an ineligible employee.

No Waiting Period will be considered a break in coverage for purposes of applying Creditable Coverage evenif an eligible person maintains no Creditable Coverage during said Waiting Period.

DEPENDENT ELIGIBILITY

An eligible Dependent includes any person who is a citizen, resident alien, or is otherwise legally present inthe United States or in any other jurisdiction that the related Participant has been assigned by the Employer,and who is either:

1. The Participant's legal spouse of the opposite sex, according to the marriage laws of the state wherethe marriage was first solemnized or established; however, this does not include an Employee’scommon-law spouse (even if the state recognizes common-law marriages), domestic partner, aspouse who is legally separated from the Employee or an ex-spouse.

2. The Participant's Dependent child who meets any of the following “Required Eligibility Conditions”:

A. Is a natural child; step-child; legally adopted child; a child who has been Placed with theParticipant for adoption; a person for whom the Participant has been appointed the legalguardian by a court of competent jurisdiction.

B. Is less than twenty-six (26) years of age. This requirement is waived if the Participant’s childis Totally Disabled, provided that the child was a covered Dependent when reaching thelimiting age and is incapable of self-supporting employment and is chiefly dependent uponthe Participant for support and maintenance. Proof of incapacity must be furnished to thePlan Administrator upon request, and additional proof may be required from time to time.

C. Is the Employee’s grandchild and less than eighteen (18) months and child is properlyenrolled, provided the parent of the child is a covered Dependent at the time of the child’sbirth.

Dependents on active military duty for more than thirty-one (31) consecutive days are not eligible.

The following documentation of Eligibility is required when enrolling a Dependent:

1. Spouse - Marriage certificate (not license), or tax documentation (front page is sufficient).

2. Natural born child, step-child or grandchild - Birth certificate (must list name of child and parents),or hospital certificate (must list name of child and parents).

3. Placement for Adoption - Proof of placement of the child in the Employee’s home, i.e. court orderor other legal document that indicates that the child has been placed with the Participant for thepurpose of adoption, which includes the child’s name and date of birth).

4. Adopted Child (Adoption Final) - Final Adoption papers, or amended birth certificate (naming theEmployee as parent).

Eligibility Provisions


5. Totally Disabled Child - Statement of Total and Permanent Disability (completed and signed by thedependent’s Physician), or Tax documentation (front page is sufficient if child is listed).

PARTICIPANT ELIGIBILITY FOR DEPENDENT COVERAGE

Each Employee will become eligible for Dependent Coverage on the latest of: 1) the date the Employeebecomes eligible for Participant coverage; or 2) the date on which the Employee first acquires a Dependent.


EFFECTIVE DATE OF COVERAGE

All coverage under the Plan will commence at 12:01 A.M. in the time zone in which the Covered Personpermanently resides, on the date such coverage becomes effective.

PARTICIPANT COVERAGE

Participant coverage under the Plan will become effective on the date the Employee satisfies the applicableeligibility requirements, provided that application for such coverage is made on the Plan’s enrollment formwithin ninety (90) days immediately following the Enrollment Date.

An eligible Employee who declines Participant coverage under the Plan during the Initial Enrollment Periodwill be able to become covered later during the Open Enrollment, Special Enrollment and as a result of anEmployment Status Change. Except as otherwise provided by this Plan, an Employee’s coverage electionis irrevocable during the Benefit Period.

DEPENDENT COVERAGE

Each Participant who requests Dependent Coverage on the Plan’s enrollment form will become covered forDependent Coverage as follows:

1. On the Participant’s effective date of coverage, if application for Dependent Coverage is made on thePlan’s enrollment form at the same time as the Employee. This subsection applies only toDependents who are eligible on the Participant’s effective date of coverage.

2. Except for Special Enrollment Period, if a Dependent becomes eligible after the Participant’s effectivedate of coverage, coverage will begin on the first day of the month following the Plan’s receipt of anenrollment form and any required documentation.

NEWBORN COVERAGE

A Newborn child of a covered Employee or an Employee’s covered Dependent is covered under the Plan forthe first pediatrician visit while the mother is hospitalized and for routine nursery care, regardless of whethersuch Newborn child is enrolled in the Plan. In order for coverage for the Newborn child to extend to Non-routine nursery care, Illness or Injury, including Medically Necessary care and treatment of congenital defects,birth abnormalities or complications resulting from prematurity, the Covered Employee must enroll theNewborn child in accordance with the Plan’s Special Enrollment procedures relating to the acquisition of newDependent.

OPEN ENROLLMENT PERIOD

The Open Enrollment Period will be as determined by the Plan Administrator, during which Participants areable to elect a different level of coverage and change the Dependents covered under the Plan; and anEmployee and the Employee’s eligible Dependents, who are not covered under this Plan, may requestParticipant or Dependent coverage. Coverage must be requested on the Plan’s enrollment form.

Coverage or changes requested during any Open Enrollment Period will begin on the January 1st followingthe Open Enrollment Period and will remain in effect through the end of the Benefit Period unless a specialenrollment event arises.

Employees who do not make an election during the Open Enrollment Period will be deemed to have electedto continue their present coverage and will automatically be enrolled in the same coverage for the upcomingBenefit Period. However, if such an Employee is presently covered under the Healthy Choice or HealthyPartner options but does not satisfy the requirements described in the NCH Healthcare System BenefitsGuide, coverage for the upcoming Benefit Period will be under the Basic option.

Effective Date of Coverage


All Employees and Participants will receive detailed information regarding the annual Open Enrollment Periodfrom the Employer.

SPECIAL ENROLLMENT PERIOD

In addition to other enrollment times allowed by this Plan, certain persons may enroll during the SpecialEnrollment Periods described below. An eligible person who makes a special enrollment request during anysuch applicable Special Enrollment Period will not be considered a Late Enrollee.

“Special Enrollment Period” means a period of time allowed under this Plan, other than the eligible person’sInitial Enrollment Period or an Open Enrollment Period, during which an eligible person can request coverageunder this Plan as a result of certain events that create special enrollment rights.

Coverage will become effective on the date of the event if the Employee’s application for such coverage ismade on the Plan’s enrollment form within thirty-one (31) days of the event.

1. An eligible Employee who is not enrolled and eligible Dependents, including step children, who areacquired under the following specific events may enroll and become covered:

A. Marriage to the Employee;

B. Birth of the Employee’s child; or

C. Adoption of a child by the Employee; or

D. Placement for Adoption with the Employee.

2. A Participant may enroll eligible Dependents, including step children, who are acquired under thefollowing specific events:

A. Marriage to the Participant;

B. Birth of the Participant’s child; or

C. Adoption of a child by the Participant; or


3. The spouse of a Participant (Covered Employee), may enroll and will become covered on the dateof the following specific events:

A. Marriage to the Participant;

B. Birth of the Participant’s child; or

C. Adoption of a child by the Participant; or




4. If the following individual(s) did not enroll in the Plan when eligible due to coverage under anotherhealth care plan or health insurance, he or she may enroll and become covered when such othercoverage terminates due to loss of eligibility or if employer contributions to the other coverage ends(Loss of Coverage), subject to the following:

A. If the eligible Employee loses coverage, the eligible Employee who lost coverage and anyeligible Dependents of the eligible Employee may enroll and become covered.

B. If an eligible Dependent loses coverage, the eligible Dependent who lost coverage and theeligible Employee may enroll and become covered.

Further, Loss of Coverage means only one of the following:

A. COBRA Continuation Coverage under another plan and the maximum period of COBRAContinuation Coverage under that other plan has been exhausted; or

B. Group or insurance health coverage that has been terminated as a result of termination ofEmployer contributions* towards that other coverage; or

C. Group or insurance health coverage (includes other coverage that is Medicare) that has beenterminated only as a result of a loss of eligibility for coverage for any of the following:

1) Legal separation or divorce of the eligible Employee;2) Cessation of Dependent status; 3) Death of the eligible Employee; 4) Termination of employment of the eligible Dependent;5) Reduction in the number of hours of employment of the eligible Dependent;6) Termination of the eligible Dependent’s employer’s plan; or7) Any loss of eligibility after a period that is measured by reference to any of the

foregoing; or 8) Any loss of eligibility for individual or group coverage because the eligible Employee

or Dependent no longer resides, lives or works in the service area of the HMO orother such plan.

*Employer contributions include contributions by any current or former employer that wascontributing to the other non-COBRA coverage.

A loss of eligibility for coverage does not occur if coverage was terminated due to a failure of theEmployee or Dependent to pay premiums on a timely basis or termination of coverage for cause.

5. Individuals may enroll and become covered when coverage under Medicaid or any state children’sinsurance program recognized under the Children’s Health Insurance Program Reauthorization Actof 2009 is terminated due to loss of eligibility, subject to the following:

A. A request for enrollment must be made either verbally or in writing within sixty (60) days afterthis special enrollment event, and written application for such coverage must be made withinninety (90) days after such event.

B. If the eligible Employee loses coverage, the eligible Employee who lost coverage and anyeligible Dependents of the eligible Employee may enroll and become covered.

C. If an eligible Dependent loses coverage, the eligible Dependent who lost coverage and theeligible Employee may enroll and become covered.



6. Individuals who are eligible for coverage under this Plan may enroll and become covered on the datethey become entitled to a Premium Assistance Subsidy authorized under the Children’s HealthInsurance Program Reauthorization Act of 2009. The date of entitlement shall be the date stated inthe Premium Assistance Authorization entitlement notice issued by the applicable state agency (CHIPor Medicaid). A request for enrollment, either verbal or in writing, must be made within sixty (60) daysafter this special enrollment event, and written application for such coverage must be made in writingwithin ninety (90) days after such event.

EMPLOYMENT STATUS CHANGE

A Part-Time or Seasonal Employee who declines coverage during their Initial Enrollment Period for thespecific reason of not being able to pay the contribution may also enroll for coverage in the event of anemployment status change to a Full-Time Employee. The effective date of coverage will be the first day ofthe month following the date of employment status change, provided that application for such coverage ismade on the Plan’s enrollment form before the first day of the month following the change in employmentstats.

If a Covered Dependent under the Plan becomes an eligible Employee of the Company, he/she may continuehis/her coverage as a Dependent and/or elect to be covered as a Participant. If an eligible Employee who iscovered as a Participant of this Plan ceases to be an Employee of the Company, but is eligible to be coveredas a Dependent under another Employee/Participant, he/she may elect to continue his/her coverage as aDependent of such Employee/Participant. Application for coverage due to such employment changes mustbe made on the Plan’s enrollment form, within thirty-one (31) days immediately following the date theEmployee becomes or ceases to be an eligible Employee. The change in employment status will not bedeemed to be a break or termination of coverage and will not operate to reduce or increase any coverage oraccumulations toward satisfaction of the deductible and Out-of-Pocket Maximum to which the Covered Personwas entitled prior to the change in employment status.

CHANGE IN STATUS EVENTS FOR ENROLLMENT OR TERMINATION OF COVERAGE

An eligible Employee or Participant may be able to change his or her coverage election (e.g., enroll in or dropcoverage for himself/herself or an eligible Dependent) under the Plan before the next open enrollment periodunder the following limited circumstances:

1. Change in legal marital status (e.g., marriage, divorce, legal separation or annulment);

2. Change in the number of dependents (e.g., death, birth, adoption or placement for adoption);

3. Change in employment status (e.g., termination or commencement of employment, a strike or lockout,commencement of or return from a leave of absence, a change in worksite, or any other change inemployment status that affects eligibility for benefits) of Employee or Dependent;

4. A Dependent satisfies or ceases to satisfy dependent eligibility requirements; or

5. A change in the legal residence of Employee or Dependent; or

6. An order by a court or state child support agency requiring Employee to provide health coverage tohis or her eligible child.

A coverage change is permissible only if the change in status event affects the eligibility of an eligibleEmployee, Participant or Dependent under the Plan or another employer group health plan. Further, anyrequested election change must be on account of and correspond with the change in status event.



An eligible Employee or Participant may also be permitted to make a coverage change due to the following:

1. A significant increase or decrease in the cost of coverage under the Plan;

2. A significant curtailment or cessation of coverage under the Plan;

3. The addition or elimination of a medical coverage option under the Plan; or

4. A change in coverage under a Dependent’s group health plan.

Any request to enroll in or drop coverage under the Plan based on a change in status event must be madein writing to the Plan Administrator within thirty-one (31) days immediately following the change in status event.Any requested change in coverage is limited to the affected individual and the modification will be effectiveon the first day of the month following the date the change form is completed and returned to the PlanAdministrator, who has the discretionary authority to make a determination as to whether an event hasoccurred permitting a change during the coverage period, whether the requested change is on account of andconsistent with the change in status event and the permissible scope of the requested change.


QUALIFIED MEDICAL CHILD SUPPORT ORDER PROVISION

PURPOSE

Pursuant to Section 609(a) of ERISA, the Plan Administrator adopts the following procedures to determinewhether Medical Child Support Orders are qualified in accordance with ERISA's requirements, to administerpayments and other provisions under Qualified Medical Child Support Orders (QMCSOs), and to enforcethese procedures as legally required.

DEFINITIONS

For QMCSO requirements, the following definitions apply:

1. “Alternate Recipient” means any child of a Participant who is recognized under a Medical ChildSupport Order as having a right to enroll in this Plan with respect to the Participant.

2. “Medical Child Support Order” means any state or court judgment, decree or order (including approvalof settlement agreement) issued by a court of competent jurisdiction, or issued through anadministrative process established under State law and which has the same force and effect of lawunder applicable State law and:

A. Provides for child support for a child of a Participant under this Plan, or;

B. Provides for health coverage for such a child under state domestic relations laws (includingcommunity property laws) and relates to benefits under this Plan; and

C. Is made pursuant to a law relating to medical child support described in Section 1908 of theSocial Security Act.

3. “Plan” means this self-funded Employee Health Benefit Plan, including all supplements andamendments in effect.

4. “Qualified Medical Child Support Order” means a Medical Child Support Order which creates(including assignment of rights) or recognizes an Alternate Recipient's right to receive benefits towhich a Participant or Qualified Beneficiary is eligible under this Plan, and has been determined bythe Plan Administrator to meet the qualification requirements as outlined under “Procedures” of thisprovision.

CRITERIA FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER

To be qualified, a Medical Child Support Order must clearly:

1. Specify the name and the last known mailing address (if any) of the Participant and the name andmailing address of each Alternate Recipient covered by the order, except that, to the extent providedin the order, the name and mailing address of an official of a State or a political subdivision thereofmay be substituted for the mailing address of any such Alternate Recipient; and

2. Include a reasonable description of the type of coverage to be provided by the Plan to each AlternateRecipient, or the manner in which such type of coverage is to be determined; and

3. Specify each period to which such order applies.

In order to be qualified, a Medical Child Support Order must not require the Plan to provide any type or formof benefits, or any option, not otherwise provided under the Plan except to the extent necessary to meet therequirements of Section1908 of the Social Security Act (relating to enforcement of state laws regarding childsupport and reimbursement of Medicaid).

Qualified Medical Child Support Order Provision


PROCEDURES FOR NOTIFICATIONS AND DETERMINATIONS

In the case of any Medical Child Support Order received by this Plan:

1. The Plan Administrator will promptly notify the Participant and each Alternate Recipient of the receiptof such order and the plan’s procedures for determining whether Medical Child Support Orders arequalified orders; and

2. Within a reasonable period after receipt of such order, the Plan Administrator will determine whethersuch order is a Qualified Medical Child Support Order and notify the Participant and each AlternateRecipient of such determination.

ERISA REPORTING AND DISCLOSURE REQUIREMENTS

The Plan Administrator will ensure that the Alternate Recipient is treated by the Plan as a beneficiary forERISA reporting and disclosure purposes, such as by distributing to the Alternate Recipient a copy of theSummary Plan Description and any subsequent Summaries of Material Modifications generated by a Planamendment.

NATIONAL MEDICAL SUPPORT NOTICE

If the Plan Administrator of a group health plan which is maintained by the Employer of a noncustodial parentof a child, or to which such an employer contributes, receives an appropriately completed National MedicalSupport Notice as described in Section 401(b) of the Child Support Performance and Incentive Act of 1998in the case of such child, and the Notice meets the criteria shown above for a qualified order, the Notice willbe deemed to be a Qualified Medical Child Support Order in the case of such child.


TERMINATION OF COVERAGE

PARTICIPANT TERMINATION

Participant coverage will automatically terminate immediately upon the earliest of the following dates, exceptas provided in any Continuation of Coverage Provision:

1. The date the Participant's employment terminates; or

2. The date the Participant ceases to be eligible for coverage; or

3. The date the Participant fails to make any required contribution for coverage; or

4. The date the Plan is terminated; or

5. The date the Company terminates the Participant's coverage; or

6. The date the Participant dies; or

7. The date the Participant enters the armed forces of any country as a full-time member, if active dutyis to exceed thirty-one (31) days; or

8. The date the Participant requests coverage be terminated, if applicable.

A Participant whose Active Service ceases because of disability may remain covered as an Employee inActive Service for a limited time. Such continuance of coverage will extend no later than the twelve (12) monthperiod beginning with the month following the month in which the Employee’s Active Service ceases.

A Participant whose Active Service ceases because of a non-FMLA leave of absence in excess of thirty (30)days may remain covered as an Employee during the leave by paying the COBRA premium rate. Suchcontinuance of coverage will extend no later than 1) the end of the personal leave of absence; or 2) if theEmployee does not return to work (or returns to a non-benefits eligible position), the end of a six (6) monthperiod which begins on the 1st of the month following the month in which Active Service ceased.

A Participant whose Active Service ceases as a result of any approved FMLA leave of absence may remaincovered as an Employee in Active Service for a period of twelve (12) weeks pursuant to the Family andMedical Leave Act.

If a Participant's coverage is to be continued during disability or approved leave of absence, the amount ofhis or her coverage will be the same as the Plan benefits in force for an active Employee, subject to the Plan’sright to amend coverage and benefits.

DEPENDENT TERMINATION

Each Covered Person, whether Participant or Dependent, is responsible for notifying the PlanAdministrator, within sixty (60) days after loss of Dependent status due to death, divorce, legalseparation or ceasing to be an eligible Dependent child. Failure to provide this notice may result inloss of eligibility for COBRA Continuation Coverage After Termination.

Coverage for a Dependent will automatically terminate immediately upon the earliest of the following dates,except as provided in any Continuation of Coverage Provision:

1. The date the Dependent ceases to be an eligible Dependent as defined in the Plan; or

2. The date the Participant's coverage terminates under the Plan; or

Termination of Coverage


3. The date the Participant ceases to be eligible for Dependent Coverage; or

4. The date the Participant fails to make any required contribution for Dependent Coverage; or

5. The date the Plan is terminated; or

6. The date the Company terminates the Dependent's coverage; or

7. The date the Participant dies; or

8. The date the Dependent enters the armed forces of any country as a full-time member if active dutyis to exceed thirty-one (31) days; or

9. The date the Participant requests coverage be terminated, if applicable.

RESCISSION OF COVERAGE

Coverage for an Employee and/or Dependent may be rescinded if the Plan Administrator determines that theEmployee or a Dependent engaged in fraud or intentional misrepresentation in order to obtain coverage and/orbenefits under the Plan. In such case, the Participant will receive written notice at least thirty (30) days beforethe coverage is rescinded.


CONTINUATION COVERAGE AFTER TERMINATION

Under Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended,Employees and their enrolled Dependents may have the right to continue coverage beyond the time coveragewould ordinarily have ended.

The Plan Administrator is NCH Healthcare System, Inc.; 350 Seventh Street North, Naples FL 34102; (239)436-5167. COBRA Continuation Coverage for the Plan is administered by Allegiance COBRA Services, Inc.;P.O. Box 2097; Missoula, MT 59806, 406-721-2222. Please direct all questions to the COBRA Administrator.

COBRA Continuation Coverage is available to any Qualified Beneficiary whose coverage would otherwiseterminate due to any Qualifying Event. COBRA Continuation Coverage under this provision will begin on thefirst day following the date of the Qualifying Event.

1. Qualifying Events for Participants, for purposes of this section, are the following events, if such eventresults in a loss of coverage under this Plan:

A. The termination (other than by reason of gross misconduct) of the Participant’s employment.

B. The reduction in hours of the Participant’s employment.

2. Qualifying Events for covered Dependents, for purposes of this section are the following events, ifsuch event results in a loss of coverage under this Plan:

A. Death of the Participant.

B. Termination of the Participant’s employment.

C. Reduction in hours of the Participant’s employment.

D. The divorce or legal separation of the Participant from his or her spouse.

E. A covered Dependent child ceases to be a Dependent as defined by the Plan.

NOTIFICATION RESPONSIBILITIES

The Covered Person must notify the Employer of the following Qualifying Events within sixty (60) days afterthe date the event occurs so that the Employer may notify the Plan Administrator:

1. Death of the Participant.

2. The divorce or legal separation of the Participant from his or her spouse.

3. A covered Dependent child ceases to be a Dependent as defined by the Plan.

The Employer must notify the Plan Administrator of the following Qualifying Events within thirty (30) days afterthe date of the event occurs:

1. Termination (other than by reason of gross misconduct) of the Participant’s employment.

2. Reduction in hours of the Participant’s employment.

Continued Coverage After Termination


ELECTION OF COVERAGE

When the Plan Administrator is notified of a Qualifying Event, the Plan Administrator will notify the QualifiedBeneficiary of the right to elect continuation of coverage. Notice of the right to COBRA Continuation Coveragewill be sent by the Plan no later than fourteen (14) days after the Plan Administrator is notified of the QualifyingEvent.

A Qualified Beneficiary has sixty (60) days from the date coverage would otherwise be lost or sixty (60) daysfrom the date of notification from the Plan Administrator, whichever is later, to notify the Plan Administratorthat he or she elects to continue coverage under the Plan. Failure to elect continuation within that period willcause coverage to end.

MONTHLY PREMIUM PAYMENTS

A Qualified Beneficiary is responsible for the full cost of continuation coverage. Monthly premium forcontinuation of coverage must be paid in advance to the Plan Administrator. The premium required under theprovisions of COBRA is as follows:

1. For a Qualified Beneficiary: The premium is the same as applicable to any other similarly situatednon-COBRA Participant plus an additional administrative expense of up to a maximum of two percent(2%).

2. Social Security Disability: For a Qualified Beneficiary continuing coverage beyond eighteen (18)months due to a documented finding of disability by the Social Security Administration within 60 daysafter becoming covered under COBRA, the premium may be up to a maximum of 150% of thepremium applicable to any other similarly situated non-COBRA Participant.

3. For a Qualified Beneficiary with a qualifying Social Security Disability who experiences a secondQualifying Event:

A. If another Qualifying Event occurs during the initial eighteen (18) months of COBRAcoverage, such as a death, divorce or legal separation, the monthly fee for qualified disabledperson may be up to a maximum of one hundred and two percent (102%) of the applicablepremium.

B. If the second Qualifying Event occurs during the nineteenth (19th) through the twenty-ninth(29th) month (the Disability Extension Period), the premium for a Qualified Beneficiary maybe up to a maximum of one hundred fifty percent (150%) of the applicable premium.

Payment of claims while covered under this COBRA Continuation Coverage Provision will be contingent uponthe receipt by the Employer of the applicable monthly premium for such coverage. The monthly premium forcontinuation coverage under this provision is due the first of the month for each month of coverage. A graceperiod of thirty (30) days from the first of the month will be allowed for payment. Payment will be made in amanner prescribed by the Employer.

DISABILITY EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE

If the Qualified Beneficiary who is covered under the Plan is determined by the Social Security Administrationto be disabled at any time before the qualifying event or within sixty (60) days after the qualifying event, andthe Plan Administrator is notified in a timely fashion, the Qualified Beneficiary covered under the Plan canreceive up to an additional 11 months of COBRA Continuation Coverage, for a total maximum of 29 months.The Plan Administrator must be provided with a copy of the Social Security Administration’s disabilitydetermination letter within sixty (60) days after the date of the determination and before the end of the original18-month period of COBRA Continuation Coverage. This notice should be sent to: Allegiance COBRAServices, Inc.; P.O. Box 2097; Missoula, MT 59806.



SECOND QUALIFYING EVENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE

If another qualifying event occurs while receiving COBRA Continuation Coverage, the spouse and dependentchildren of the Employee can get additional months of COBRA Continuation Coverage, up to a maximum ofthirty-six (36) months. This extension is available to the spouse and dependent children if the formeremployee dies or becomes divorced or legally separated. The extension is also available to a dependent childwhen that child stops being eligible under the Plan as a dependent child. In all of these cases, the PlanAdministrator must be notified of the second qualifying event within sixty (60) days of the secondqualifying event. This notice must be sent to: Allegiance COBRA Services, Inc.; P.O. Box 2097;Missoula, MT 59806. Failure to provide notice within the time required will result in loss of eligibilityfor COBRA Continuation Coverage.

MEDICARE ENROLLMENT EXTENSION OF 18-MONTH PERIOD OF CONTINUATION COVERAGE

The dependents of a former employee are eligible to elect COBRA Continuation Coverage if they losecoverage as a result of the former employee’s enrollment in Part A or Part B of Medicare, whichever occursearlier.

When the former employee enrolls in Medicare before the Qualifying Event of termination, or reduction inhours, of employment occurs, the maximum period for COBRA Continuation Coverage for the spouse anddependent children ends on the later of:

1. Eighteen (18) months after the Qualifying Event of termination of employment or reduction in hoursof employment; or

2. Thirty-six (36) months after the former employee’s enrollment in Medicare.

When the former employee enrolls in Medicare after the Qualifying Event of termination, or reduction in hours,of employment, the maximum period for COBRA Continuation Coverage for the spouse and dependentchildren ends eighteen (18) months after the Qualifying Event, unless a second Qualifying Event, as describedabove occurs within that eighteen (18) month period.

WHEN COBRA CONTINUATION COVERAGE ENDS

COBRA Continuation Coverage and any coverage under the Plan that has been elected with respect to anyQualified Beneficiary will cease on the earliest of the following:

1. On the date the Qualified Beneficiary becomes covered under another group health plan or healthinsurance, unless the other group health plan contains a provision excluding or limiting coverage fora pre-existing condition applicable to a condition of the Qualified Beneficiary under this Plan.However, if the exclusionary period does not apply due to prior Creditable Coverage, COBRAcontinuation coverage ends. Coverage will not be terminated as stated until the pre-existingexclusionary period of the other coverage is no longer applicable.

This exception applies to all Qualified Beneficiaries.

2. On the date, after the date of election for COBRA Continuation Coverage, that the QualifiedBeneficiary becomes enrolled in Medicare (either Part A, B or D);

3. On the first date that timely payment of any premium required under the Plan with respect to COBRAContinuation Coverage for a Qualified Beneficiary is not made to the Plan Administrator.

4. On the date the Employer ceases to provide any group health plan coverage to any Employee.

5. On the date of receipt of written notice that the Qualified Beneficiary wishes to terminate COBRAContinuation Coverage.



6. On the date that the maximum coverage period for COBRA Continuation Coverage ends, as follows:

A. Eighteen (18) months for a former employee who is a Qualified Beneficiary as a result oftermination, or reduction in hours, of employment;

B. Eighteen (18) months for a Dependent who is a Qualified Beneficiary unless a secondQualifying Event occurs within that eighteen month period entitling that Dependent to anadditional eighteen (18) months;

C. For the Dependent who is a Qualified Beneficiary as a result of termination, or reduction inhours, of employment of the former employee if that former employee enrolled in Medicarebefore termination, or reduction in hours, of employment, the later of eighteen (18) monthsfrom the Qualifying Event, or thirty-six (36) months following the date of enrollment inMedicare.

D. On the first day of the month beginning thirty (30) days after a Qualified Beneficiary isdetermined to be no longer disabled by the Social Security Administration if the QualifiedBeneficiary was found to be disabled on or within the first sixty (60) days of the date of theQualifying Event and has received at least eighteen (18) months of COBRA ContinuationCoverage. COBRA Continuation Coverage will also terminate on such date for allDependents who are Qualified Beneficiaries as a result of the Qualifying Event unless thatDependent is entitled to a longer period of COBRA Continuation Coverage without regard todisability.

E. Twenty-nine (29) months for any Qualified Beneficiary if a Disability Extension Period ofCOBRA Continuation Coverage has been granted for such Qualified Beneficiary.

F. Thirty-six (36) months for all other Qualified Beneficiaries.

7. On the same basis that the Plan can terminate for cause the coverage of a similarly situated non-COBRA Participant.

QUESTIONS

Any questions about COBRA Continuation Coverage should be directed to Allegiance COBRA Services, Inc.or contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee BenefitsSecurity Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices areavailable through EBSA’s website at www.dol.gov/ebsa.

INFORM THE PLAN OF ADDRESS CHANGES

In order to protect the Employee’s family’s rights, the Employee should keep the Plan Administratorinformed of any changes in the addresses of family members. The Employee should also keep a copy,for his/her records, of any notices sent to the Plan Administrator.


COVERAGE FOR A MILITARY RESERVIST

To the extent required by the Uniform Services Employment and Reemployment Rights Act (USERRA), thefollowing provisions will apply:

1. If a Participant is absent from employment with Employer by reason of service in the uniformedservices, the Participant may elect to continue coverage under this Plan for himself or herself and hisor her eligible Dependents as provided in this subsection. The maximum period of coverage undersuch an election will be the lesser of:

A. The twenty-four (24) month period beginning on the date on which the Participant’s absencebegins; or

B. The period beginning on the date on which the Participant’s absence begins and ending onthe day after the date on which he or she fails to apply for or return to a position ofemployment, as required by USERRA.

2. A Participant who elects to continue Plan coverage under this Section may be required to pay notmore than one hundred two percent (102%) of the full premium under the Plan (determined in thesame manner as the applicable premium under Section 4980B(f)(4) of the Internal Revenue Code of1986) associated with such coverage for the Employer’s other Employees, except that in the case ofa person who performs service in the uniformed services for less than thirty-one (31) days, suchperson may not be required to pay more than the regular Employee share, if any, for such coverage.

3. In the case of a Participant whose coverage under the Plan is terminated by reason of service in theuniformed services, an exclusion or Waiting Period may not be imposed in connection with thereinstatement of such coverage upon reemployment if an exclusion or Waiting Period would not havebeen imposed under the Plan had coverage of such person by the Plan not been terminated as aresult of such service. This paragraph applies to the Employee who notifies the Employer of his orher intent to return to employment in a timely manner as defined by USERRA, and is reemployed andto any Dependent who is covered by the Plan by reason of the reinstatement of the coverage of suchEmployee. This provision will not apply to the coverage of any Illness or Injury determined bythe Secretary of Veterans Affairs to have been caused by or aggravated during, performanceof service in the uniformed services.


FRAUD AND ABUSE

THIS PLAN IS SUBJECT TO FEDERAL LAW WHICH PERMITS CRIMINAL PENALTIES FORFRAUDULENT ACTS COMMITTED AGAINST THE PLAN. STATE LAW MAY ALSO APPLY.

Anyone who knowingly defrauds or tries to defraud the Plan, or obtains Plan funds through false statementsor fraudulent schemes, may be subject to criminal prosecution and penalties. The following may be consideredfraudulent:

1. Falsifying eligibility criteria for a Dependent, such as marital status or age, to get or continue coveragefor that Dependent when not otherwise eligible for coverage;

2. Falsifying or withholding medical history or information required to calculate benefits or determine pre-existing conditions when no creditable coverage exists;

3. Falsifying or altering documents to get coverage or benefits;

4. Permitting a person not otherwise eligible for coverage to use a Plan ID card to get Plan benefits; or

5. Submitting a fraudulent claim or making untruthful statements to the Plan to get reimbursement fromthe Plan for services that may or may not have been provided to a Covered Person.

The Plan Administrator, in its sole discretion, may take additional action against the Participant or CoveredPerson, including, but not limited to terminating the Participant or Covered Person’s coverage under the Plan.

MISSTATEMENT OF AGE

If the Covered Person’s age was misstated on an enrollment form or claim, the Covered Person’s eligibilityor amount of benefits, or both, will be adjusted to reflect the Covered Person’s true age. If the Covered Personwas not eligible for coverage under the Plan or for the amount of benefits received, the Plan has a right torecover any benefits paid by the Plan. A misstatement of age will not continue coverage that was otherwiseproperly terminated or terminate coverage that is otherwise validly in force.

MISREPRESENTATION OF ELIGIBILITY

If a Participant misrepresents a Dependent’s marital status, age, dependent child relationship or other eligibilitycriteria to get coverage for that Dependent, when he or she would not otherwise be eligible, coverage for thatDependent will terminate as though never effective.

MISUSE OF IDENTIFICATION CARD

If a Covered Person permits any person who is not otherwise eligible as a Covered Person to use an ID card,the Plan Sponsor may, at the Plan Sponsor’s sole discretion, terminate the Covered Person’s coverage.

REIMBURSEMENT TO PLAN

Payment of benefits by the Plan for any person who was not otherwise eligible for coverage under this Planbut for whom benefits were paid based upon fraud as defined in this section must be reimbursed to the Planby the Participant. Failure to reimburse the Plan upon request may result in an interruption or a loss ofbenefits by the Participant and Dependents.


RECOVERY/REIMBURSEMENT/SUBROGATION

By enrollment in this Plan, Covered Persons agree to the provisions of this section as a condition precedentto receiving benefits under this Plan. Failure of a Covered Person to comply with the requirements of thissection may result in the Plan pending the payment of benefits.

RIGHT TO RECOVER BENEFITS PAID IN ERROR

If the Plan makes a payment in error to or on behalf of a Covered Person or an assignee of a Covered Personto which that Covered Person is not entitled, or if the Plan pays a claim that is not covered, the Plan has theright to recover the payment from the person paid or anyone else who benefitted from the payment. The Plancan deduct the amount paid from the Covered Person’s future benefits, or from the benefits for any coveredFamily member even if the erroneous payment was not made on that Family member’s behalf.

Payment of benefits by the Plan for Participants’ spouses, ex-spouses, or children, who are not eligible forcoverage under this Plan, but for whom benefits were paid based upon inaccurate, false information providedby, or information omitted by, the Employee will be reimbursed to the Plan by the Employee. The Employee’sfailure to reimburse the Plan after demand is made, may result in an interruption in or loss of benefits to theEmployee, and could be reported to the appropriate governmental authorities for investigation of criminalfraud.

The Plan may recover such amount by any appropriate method that the Plan Administrator, in its solediscretion, will determine.

The provisions of this section apply to any Physician or Licensed Health Care Provider who receives anassignment of benefits or payment of benefits under this Plan. If a Physician or Licensed Health CareProvider fails to refund a payment of benefits, the Plan may refuse to recognize future assignments of benefitsto that provider.

REIMBURSEMENT

The Plan’s right to Reimbursement is separate from and in addition to the Plan’s right of Subrogation. If thePlan pays benefits for medical expenses on a Covered Person’s behalf, and another party was responsibleor liable for payment of those medical expenses, the Plan has a right to be reimbursed by the Covered Personfor the amounts the Plan paid.

Accordingly, if a Covered Person, or anyone on his or her behalf, settles, is reimbursed or recovers moneyfrom any person, corporation, entity, liability coverage, no-fault coverage, uninsured coverage, underinsuredcoverage, or other insurance policies or funds for any accident, Injury, condition or Illness for which benefitswere provided by the Plan, the Covered Person agrees to hold the money received in trust for the benefit ofthe Plan. The Covered Person agrees to reimburse the Plan, in first priority, from any money recovered froma liable third party, for the amount of all money paid by the Plan to the Covered Person or on his or her behalfor that will be paid as a result of said accident, Injury, condition or Illness. Reimbursement to the Plan will bepaid first, in its entirety, even if the Covered Person is not paid for all of his or her claim for damages andregardless of whether the settlement, judgment or payment he or she receives is for or specifically designatesthe recovery, or a portion thereof, as including health care, medical, disability or other expenses or damages.

SUBROGATION

The Plan’s right to Subrogation is separate from and in addition to the Plan’s right to Reimbursement.Subrogation is the right of the Plan to exercise the Covered Person’s rights and remedies in order to recoverfrom any third party who is liable to the Covered Person for a loss or benefits paid by the Plan. The Plan mayproceed through litigation or settlement in the name of the Covered Person, with or without his or her consent,to recover benefits paid under the Plan.

Recovery/Reimbursement/Subrogation


The Covered Person agrees to subrogate to the Plan any and all claims, causes of action or rights that he orshe has or that may arise against any entity who has or may have caused, contributed to or aggravated theaccident, Injury, condition or Illness for which the Plan has paid benefits, and to subrogate any claims, causesof action or rights the Covered Person may have against any other coverage, including but not limited toliability coverage, no-fault coverage, uninsured motorist coverage, underinsured motorist coverage, or otherinsurance policies, coverage or funds.

In the event that a Covered Person decides not to pursue a claim against any third party or insurer, theCovered Person will notify the Plan, and specifically authorize the Plan, in its sole discretion, to sue for,compromise or settle any such claims in the Covered Person’s name, to cooperate fully with the Plan in theprosecution of the claims, and to execute any and all documents necessary to pursue those claims.

The Following Paragraphs Apply to Both Reimbursement and Subrogation:

1. Under the terms of this Plan, the Plan Supervisor is not required to pay any claim where there isevidence of liability of a third party unless the Covered Person signs the Plan’s Third-PartyReimbursement Agreement and follows the requirements of this section. However, the Plan, in itsdiscretion, may instruct the Plan Supervisor not to withhold payment of benefits while the liability ofa party other than the Covered Person is being legally determined. If a repayment agreement isrequested to be signed, the Plan’s right of recovery through Reimbursement and/or Subrogationremains in effect regardless of whether the repayment agreement is actually signed.

2. If the Plan makes a payment which the Covered Person, or any other party on the Covered Person’sbehalf, is or may be entitled to recover against any liable third party, this Plan has a right of recovery,through reimbursement or subrogation or both, to the extent of its payment.

3. The Covered Person will cooperate fully with the Plan Administrator, its agents, attorneys andassigns, regarding the recovery of any benefits paid by the Plan from any liable third party. Thiscooperation includes, but is not limited to, make full and complete disclosure in a timely manner ofall material facts regarding the accident, Injury, condition or Illness to the Plan Administrator; reportall efforts by any person to recover any such monies; provide the Plan Administrator with any and allrequested documents, reports and other information in a timely manner, regarding any demand,litigation or settlement involving the recovery of benefits paid by the Plan; and notify the PlanAdministrator of the amount and source of funds received from third parties as compensation ordamages for any event from which the Plan may have a reimbursement or subrogation claim.

4. Covered Persons will respond within ten (10) days to all inquiries of the Plan regarding the status ofany claim they may have against any third parties or insurers, including but not limited to liability, no-fault, uninsured and underinsured insurance coverage. The Covered Person will notify the Planimmediately of the name and address of any attorney whom the Covered Person engages to pursueany personal Injury claim on his or her behalf.

5. The Covered Person will not act, fail to act, or engage in any conduct directly, indirectly, personallyor through third parties, either before or after payment by the Plan, the result of which may prejudiceor interfere with the Plan’s rights to recovery hereunder. The Covered Person will not conceal orattempt to conceal the fact that recovery has occurred or will occur.

6. The Plan will not pay or be responsible, without its written consent, for any fees or costs associatedwith a Covered Person pursuing a claim against any third party or coverage, including, but not limitedto, attorney fees or costs of litigation. Monies paid by the Plan will be repaid in full, in first priority,notwithstanding any anti-subrogation, “made whole,” “common fund” or similar statute, regulation,prior court decision or common law theory unless a reduction or compromise settlement is agreed toin writing or required pursuant to a court order.

Recovery/Reimbursement/Subrogation


RIGHT OF OFF-SET

The Plan has a right of off-set to satisfy reimbursement claims against Covered Persons for money receivedby the Covered Person from a third party, including any insurer. If the Covered Person fails or refuses toreimburse the Plan for funds paid for claims, the Plan may deny payment of future claims of the CoveredPerson, up to the full amount paid by the Plan and subject to reimbursement for such claims. This right of off-set applies to all reimbursement claims owing to the Plan whether or not formal demand is made by the Plan,and notwithstanding any anti-subrogation, “common fund,” “made whole” or similar statutes, regulations, priorcourt decisions or common law theories.


PLAN ADMINISTRATION

PURPOSE

The purpose of this Plan Document/SPD is to set forth the provisions of the Plan which provide for thepayment or reimbursement of all or a portion of the claim. The terms of this Plan are legally enforceable andthe Plan is maintained for the exclusive benefit of eligible Employees and their covered Dependents.

It is the intention of the Employer to establish a program of benefits constituting an “Employee Welfare BenefitPlan” under the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments thereto.

PLAN YEAR

The Plan Year will commence January 1st and end on the last day of December of each year.

PLAN SPONSOR

The Plan Sponsor is NCH Healthcare System, Inc..

PLAN SUPERVISOR

The Supervisor of the Plan is Allegiance Benefit Plan Management, Inc.

NAMED FIDUCIARY AND PLAN ADMINISTRATOR

The Named Fiduciary and Plan Administrator is NCH Healthcare System, Inc., a Florida corporation, who hasthe authority to control and manage the operation and administration of the Plan. The Plan Administrator maydelegate responsibilities for the operation and administration of the Plan. The Plan Administrator will havethe authority to amend the Plan, to determine its policies, to appoint and remove other service providers ofthe Plan, to fix their compensation (if any), and exercise general administrative authority over them and thePlan. The Administrator has the sole authority and responsibility to review and make final decisions on allclaims to benefits hereunder.

PLAN INTERPRETATION

The Named Fiduciary and the Plan Administrator have full discretionary authority to interpret and apply all Planprovisions including, but not limited to, resolving all issues concerning eligibility and determination of benefits.The Plan Administrator may contract with an independent administrative firm to process claims, maintain Plandata, and perform other Plan-connected services. Final authority to interpret and apply the provisions of thePlan rests exclusively with the Plan Administrator. Decisions of the Plan Administrator made in good faith willbe final and binding.

Plan Administration


CONTRIBUTIONS TO THE PLAN

The amount of contributions to the Plan are to be made on the following basis:

The Company will from time to time evaluate the costs of the Plan and determine the amount to becontributed by the Company, if any, and the amount to be contributed, if any, by each Participant.

The Company provides a portion of contributions for coverage under this Plan for Participant andDependent coverage. The Participant is required to provide the remainder of contributions forcoverage under this Plan. No portion of contributions for COBRA Continuation Coverage will be paidby the Company or the Plan. Specific information regarding the actual amount of any contribution forcoverage under this Plan may be obtained from the Plan Sponsor, by contacting the BenefitsManager or Benefits Coordinator at 239-436-5167 and requesting that information. The amount ofany contribution for coverage, except the amounts for COBRA Continuation Coverage, may beincreased, decreased or modified at any time by the Plan.

If the Company terminates the Plan, the Company and Participants will have no obligation tocontribute to the Plan after the date of termination.

PLAN AMENDMENTS/MODIFICATION/TERMINATION

The Plan Document contains all the terms of the Plan and may be amended at any time by the PlanAdministrator. Any changes will be binding on each Participant and on any other Covered Persons referredto in this Plan Document. The authority to amend the Plan is delegated by the Plan Administrator to the ChiefHuman Resources Officer or his or her equivalent, whichever is applicable, of the Company. Any suchamendment, modification, revocation or termination of the Plan will be authorized and signed by the ChiefHuman Resources Officer or his or her equivalent, whichever is applicable, of the Company, pursuant to acorporate policy, granting that individual the authority to amend, modify, revoke or terminate this Plan. A copyof the executed policy will be supplied to the Plan Supervisor. Written notification of any amendments,modifications, revocations or terminations will be given to Plan Participants within one-hundred and twenty(120) days of such decision, except for notices of reduction of benefits.

NOTICE OF REDUCTION OF BENEFITS

All changes or amendments to this Plan that directly or indirectly reduce any benefit or coverage under thePlan, including any increase in contribution for coverage required from a Participant, will be reported to alleligible Participants and Dependents within sixty (60) days of the date such change or amendment is adopted.

TERMINATION OF PLAN

The Company reserves the right at any time to terminate the Plan by a written notice. All previouscontributions by the Company will continue to be issued for the purpose of paying benefits and fixed costsunder provisions of this Plan with respect to claims arising before such termination, or will be used for thepurpose of providing similar health benefits to Participants, until all contributions are exhausted.

SUMMARY PLAN DESCRIPTIONS

Each Participant covered under this Plan will be issued a Summary Plan Description (SPD) describing thebenefits to which the Covered Persons are entitled, the required Plan procedures for eligibility and claimingbenefits and the limitations and exclusions of the Plan.


CREDITABLE COVERAGE PROCEDURES

CERTIFICATE OF CREDITABLE COVERAGE

The Plan will provide Certificate of Creditable Coverage for coverage under this Plan as required by the UnitedStates Department of Labor to any Covered Person or the Covered Person’s designated and authorizedagent, guardian, conservator, health care plan or health insurance as follows:

1. At the time the Covered Person ceases to be covered under this Plan; and,

2. At the time a Covered Person ceases to be covered by the COBRA Continuation Coverage providedby this Plan, if any; and,

3. At any other time that a request is made on behalf of the Covered Person for such certification, butnot later than twenty four (24) months after cessation of coverage as set out in subparagraphs 1 and2 above, whichever is later.


GENERAL PROVISIONS

EXAMINATION

The Plan will have the right and opportunity to have the Covered Person examined whenever Injury or Illnessis the basis of a claim when and so often as it may reasonably require to adjudicate the claim. The Plan willalso have the right to have an autopsy performed in case of death to the extent permitted by law.

PAYMENT OF CLAIMS

All Plan benefits are payable to a Participant, Qualified Beneficiary or Alternate Recipient, whichever isapplicable. All or a portion of any benefits payable by the Plan may, at the Covered Person’s option andunless the Covered Person requests otherwise in writing not later than the time of filing the claim, be paiddirectly to the health care provider rendering the service, if proper written assignment is provided to the Plan.No payments will be made to any provider of services unless the Covered Person is liable for such expenses.

If any benefits remain unpaid at the time of the Covered Person’s death or if the Covered Person is a minoror is, in the opinion of the Plan, legally incapable of giving a valid receipt and discharge for any payment, thePlan may, at its option, pay such benefits to the Covered Person’s legal representative or estate. The Plan,in its sole option, may require that an estate, guardianship or conservatorship be established by a court ofcompetent jurisdiction prior to the payment of any benefit. Any payment made under this subsection willconstitute a complete discharge of the Plan’s obligation to the extent of such payment and the Plan will notbe required to oversee the application of the money so paid.

LEGAL PROCEEDINGS

No action at law or equity will be brought to recover on the Plan prior to the expiration of sixty (60) days afterproof of loss has been filed in accordance with the requirements of the Plan, nor will such action be broughtat all unless brought within three (3) years from the expiration of the time within which proof of loss is requiredby the Plan.

NO WAIVER OR ESTOPPEL

No term, condition or provision of this Plan will be waived, and there will be no estoppel against theenforcement of any provision of this Plan, except by written instrument of the party charged with such waiveror estoppel. No such written waiver will be deemed a continuing waiver unless specifically stated therein, andeach such waiver will operate only as to the specific term or condition waived and will not constitute a waiverof such term or condition for the future or as to any act other than that specifically waived.

VERBAL STATEMENTS

Verbal statements or representations of the Plan Administrator, its agents and Employees, or CoveredPersons will not create any right by contract, estoppel, unjust enrichment, waiver or other legal theoryregarding any matter related to the Plan, or its administration, except as specifically stated in this subsection.No statement or representation of the Plan Administrator, its agents and Employees, or Covered Persons willbe binding upon the Plan or a Covered Person unless made in writing by a person with authority to issue sucha statement. This subsection will not be construed in any manner to waive any claim, right or defense of thePlan or a Covered Person based upon fraud or intentional material misrepresentation of fact or law.

General Provisions


FREE CHOICE OF PHYSICIAN

The Covered Person will have free choice of any licensed Physician, Licensed Health Care Provider orsurgeon and the patient-provider relationship will be maintained.

Using In-Network Physicians offers cost-savings advantages because a Covered Person pays only apercentage of the scheduled fee for services provided.

WORKERS' COMPENSATION NOT AFFECTED

This Plan is not in lieu of, supplemental to Workers’ Compensation and does not affect any requirement forcoverage by Workers' Compensation Insurance.

CONFORMITY WITH LAW

If any provision of this Plan is contrary to any law to which it is subject, such provision is hereby amended toconform to the minimum requirements of the applicable law. Only that provision which is contrary to applicablelaw will be amended to conform; all other parts of the Plan will remain in full force and effect.

MISCELLANEOUS

Section titles are for convenience of reference only, and are not to be considered in interpreting this Plan.

No failure to enforce any provision of this Plan will affect the right thereafter to enforce such provision, nor willsuch failure affect its right to enforce any other provision of the Plan.

FACILITY OF PAYMENT

Whenever payments which should have been made under this Plan in accordance with this provision havebeen made under any other plan or plans, the Plan will have the right, exercisable alone and in its solediscretion, to pay to any insurance company or other organization or person making such other payments anyamounts it determines in order to satisfy the intent of this provision. Amounts so paid will be deemed to bebenefits paid under this Plan and to the extent of such payments, the Plan will be fully discharged from liabilityunder this Plan.

The benefits that are payable will be charged against any applicable maximum payment or benefit of this Planrather than the amount payable in the absence of this provision.

PROTECTION AGAINST CREDITORS

No benefit payment under this Plan will be subject in any way to alienation, sale, transfer, pledge, attachment,garnishment, execution or encumbrance of any kind, and any attempt to accomplish the same will be void,except an assignment of payment to a provider of Covered Services. If the Plan Administrator finds that suchan attempt has been made with respect to any payment due or which will become due to any Participant, thePlan Administrator, in its sole discretion, may terminate the interest of such Participant or former Participantin such payment. In such case, the Plan Administrator will apply the amount of such payment to or for thebenefit of such Participant or covered Dependents or former Participant, as the Plan Administrator maydetermine. Any such application will be a complete discharge of all liability of the Plan with respect to suchbenefit payment.

PLAN IS NOT A CONTRACT

The Plan Document constitutes the primary authority for plan administration. The establishment,administration and maintenance of this Plan will not be deemed to constitute a contract of employment, giveany Participant of the Company the right to be retained in the service of the Company, or to interfere with theright of the Company to discharge or otherwise terminate the employment of any Participant.


GENERAL DEFINITIONS

Certain words and phrases in this Plan Document are defined below. If the defined term is not used in thisdocument, the term does not apply to this Plan.

Masculine pronouns used in this Plan Document will include either the masculine or feminine gender unlessthe context indicates otherwise.

Any words used herein in the singular or plural will include the alternative as applicable.

ACCIDENTAL INJURY

“Accidental Injury” means an Injury sustained as a result of an external force or forces that is/are sudden,direct and unforeseen and is/are exact as to time and place. A hernia of any kind will only be considered asan Illness.

ACTIVE SERVICE

“Active Service” means that an Employee is in service with the Company on a day which is one of theCompany's regularly scheduled work days and that the Employee is performing all of the regular duties ofhis/her employment with the Company on a regular basis, either at one of the Company's businessestablishments or at some location to which the Company's business requires him/her to travel.

ADVERSE BENEFIT DETERMINATION

“Adverse Benefit Determination” means any of the following: a denial, reduction, or termination of, or a failureto provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination,or failure to provide or make payment that is based on a determination of a Participant’s or beneficiary’seligibility to participate in the Plan, and including, with respect to group health plans, a denial, reduction, ortermination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from theapplication of any utilization review, as well as a failure to cover an item or service for which benefits areotherwise provided because it is determined to be Experimental or Investigational or not Medically Necessaryor appropriate, and any rescission of coverage.

ALCOHOLISM

“Alcoholism” means a morbid state caused by excessive and compulsive consumption of alcohol thatinterferes with the patient's health, social or economic functioning.

ALCOHOLISM AND/OR CHEMICAL DEPENDENCY TREATMENT FACILITY

“Alcoholism and/or Chemical Dependency Treatment Facility” means a licensed institution which provides aprogram for diagnosis, evaluation, and effective treatment of Alcoholism and/or Chemical Dependency;provides detoxification services needed with its effective treatment program; provides infirmary-level medicalservices or arranges with a Hospital in the area for any other medical services that may be required; is at alltimes supervised by a staff of Physicians; provides at all times skilled nursing care by licensed nurses whoare directed by a full-time Registered Nurse (R.N.); prepares and maintains a written plan of treatment foreach patient based on medical, psychological and social needs which is supervised by a Physician; and meetslicensing standards.

AMBULANCE SERVICE

“Ambulance Service” means an entity, its personnel and equipment, including, but not limited to, automobiles,airplanes, boats or helicopters, which are licensed to provide Emergency medical and Ambulance servicesin the state in which the services are rendered.

General Definitions


BENEFIT PERCENTAGE

“Benefit Percentage” means that portion of Eligible Expenses payable by the Plan, which is stated as apercentage in the Schedule of Benefits.

BENEFIT PERIOD

“Benefit Period” refers to a time period of one year, which is either a Calendar Year or other annual period,as shown in the Schedule of Benefits. Such Benefit Period will terminate on the earliest of the following dates:

1. The last day of the one year period so established; or

2. The day the Maximum Lifetime Benefit applicable to the Covered Person becomes paid; or

3. The date the Plan terminates.

CALENDAR YEAR

“Calendar Year” means a period of time commencing on January 1 and ending on December 31 of the sameyear.

CHEMICAL DEPENDENCY

“Chemical Dependency” means the physiological and psychological addiction to a controlled drug orsubstance, or to alcohol. Dependence upon tobacco, nicotine, caffeine or eating disorders are not includedin this definition.

CLOSE RELATIVE

“Close Relative” means the spouse, parent, brother, sister, child, or in-laws of the Covered Person.

COBRA

“COBRA” means Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

COBRA CONTINUATION COVERAGE

“COBRA Continuation Coverage” means the coverage provided under the provisions of the ConsolidatedOmnibus Budget Reconciliation Act of 1985 and its amendments.

COMPANY

“Company” means NCH Healthcare System, Inc. or any affiliated company that has adopted this Plan for itsEmployees and which is a “controlled group” as defined by applicable state and federal law, as amended.

CONVALESCENT NURSING FACILITY

See “Skilled Nursing Facility”.

COSMETIC

“Cosmetic” means services or treatment ordered or performed solely to change a Covered Person'sappearance rather than for the restoration of bodily function.

General Definitions


COVERED PERSON

“Covered Person” means any Participant or Dependent of a Participant meeting the eligibility requirementsfor coverage and properly enrolled for coverage as specified in the Plan.

CREDITABLE COVERAGE

“Creditable Coverage” means health or medical coverage under which a Covered Person was covered, priorto that Covered Person’s Enrollment Date under this Plan, which prior coverage was under any of thefollowing:

1. A group health plan.

2. Health insurance coverage.

3. Part A, Part B or Part C 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 underSection 1928 (program for distribution of pediatric vaccines).

5. Chapter 55 of Title 10, United States Code (TRICARE).

6. A medical care program of the Indian Health Service or a tribal organization.

7. A state health benefits risk pool.

8. The Federal Employee Health Benefits Program.

9. A public health plan, including any plan established or maintained by a State, the US Government,a foreign country or any political subdivision of the foregoing.

10. A health benefit plan under Section 5 (e) of the Peace Corps Act.

11. The State Children’s Health Insurance Program.

CUSTODIAL CARE

“Custodial Care” means the type of care or service, wherever furnished and by whatever name called, whichis designed primarily to assist a Covered Person in the activities of daily living. Such activities include, butare not limited to: bathing, dressing, feeding, preparation of special diets, assistance in walking or in gettingin and out of bed, and supervision over medication which can normally be self-administered.

DEDUCTIBLE

“Deductible” means a specified dollar amount that must be incurred before the Plan will pay any amount forany benefit during each Benefit Period.

DENTIST

“Dentist” means a person holding one of the following degrees–Doctor of Dental Science, Doctor of MedicalDentistry, Master of Dental Surgery or Doctor of Medicine (oral surgeon) -- who is legally licensed as such topractice dentistry in the jurisdiction where services are rendered, and the services rendered are within thescope of his or her license.

A “Dentist” will not include the Covered Person or any Close Relative of the Covered Person who does notregularly charge the Covered Person for services.

General Definitions


DEPENDENT

“Dependent” means a person who is eligible for coverage under the Dependent Eligibility subsection of thisPlan.

DEPENDENT COVERAGE

“Dependent Coverage” means eligibility for coverage under the terms of the Plan for benefits payable as aconsequence of Eligible Incurred Expenses for an Illness or Injury of a Dependent.

DURABLE MEDICAL EQUIPMENT

“Durable Medical Equipment” means equipment which is:

1. Able to withstand repeated use, i.e., could normally be rented, and used by successive patients; and

2. Primarily and customarily used to serve a medical purpose; and

3. Not generally useful to a person in the absence of Illness or Injury.

ELIGIBLE EXPENSES

“Eligible Expenses” means the maximum amount of any charge for a covered service, treatment or supply thatmay be considered for payment by the Plan, including any portion of that charge that may be applied to theDeductible or used to satisfy the Out-of-Pocket Maximum. Eligible Expenses are equal to the actual billedcharge or UCR, whichever is less or a contracted or negotiated rate, if applicable.

EMERGENCY

“Emergency” means a medical condition manifesting itself by acute symptoms which occur suddenly andunexpectedly and for which the Covered Person receives medical care no later than 48 hours after the onsetof the condition. Emergency is any medical condition for which a reasonable and prudent layperson,possessing average knowledge of health and medicine, would expect that failure to seek immediate medicalattention would result in death, more severe or disabling medical condition(s), or continued severe pain withoutcessation in the absence of medical treatment. Emergency may include, but is not limited to, severe Injury,hemorrhaging, poisoning, loss of consciousness or respiration, fractures, convulsions, injuries reasonablylikely to require sutures, severe acute pain, severe burns, prolonged high fever and symptoms normallyassociated with heart attack or stroke.

“Emergency” will specifically exclude usual out-patient treatment of childhood diseases, flu, commoncold, pre-natal examinations, physical examinations and minor sprains, lacerations, abrasions andminor burns, and other medical conditions usually capable of treatment at a clinic or doctor’s officeduring regular working hours.

EMPLOYEE

“Employee” means a person employed by the Employer on a continuing and regular basis who is a common-law Employee and who is on the Employer’s W-2 payroll.

Employee does not include any employee leased from another employer, including but not limited tothose individuals defined in Code Section 414(n), or an individual classified by the Employer as acontract worker, independent contractor, temporary, seasonal or casual employee, whether or not anysuch persons are on the Employer’s W-2 payroll, or any individual who performs services for theEmployer but who is paid by a temporary or other employment agency such as “Kelly,” “Manpower,”etc.

General Definitions


EMPLOYER

“Employer” means the Company or any affiliated entity that has adopted this Plan for its Employees and whichis a “controlled group” as defined by applicable state and federal law, as amended.

ENROLLMENT DATE

“Enrollment Date” means the date a person becomes eligible for coverage under this Plan or the eligibleperson’s effective date of coverage under this Plan, whichever occurs first. For Late Enrollees, EnrollmentDate will always be the effective date of coverage under this Plan.

ERISA

“ERISA” refers to the Employee Retirement Income Security Act of 1974, as amended.

EXPERIMENTAL/INVESTIGATIONAL

“Experimental/Investigational” means:

1. Any drug or device that cannot be lawfully marketed without approval of the U.S. Food and DrugAdministration and approval for marketing has not been given at the time the drug or device isfurnished; or

2. Any drug, device, medical treatment or procedure for which the patient informed consent documentutilized with the drug, device, treatment or procedure, was reviewed and approved by the treatingfacility’s Institutional Review Board or other body serving a similar function, or if federal law requiressuch review or approval; or

3. That the drug, device or medical treatment or procedure is under study, prior to or in the absence ofany clinical trial, to determine its maximum tolerated dose, its toxicity, or its safety, or

4. That based upon Reliable Evidence, the drug, device, medical treatment or procedure is the subjectof an on-going phase I or phase II clinical trial. (A Phase III clinical trial recognized by the NationalInstitute of Health is not considered Experimental or Investigational.) For chemotherapy regimens,a Phase II clinical trial is not considered Experimental or Investigational when both of these criteriaare met:

A. The regimen or protocol has been the subject of a completed and published Phase II clinicaltrial which demonstrates benefits equal to or greater than existing accepted treatmentprotocols, and

B. The regimen or protocol listed by the National Comprehensive Cancer Network is supportedby level of evidence Phase I or Phase IIA only; or

5. Based upon Reliable Evidence, any drug, device, medical treatment or procedure that the prevailingopinion among experts is that further studies or clinical trial are necessary to determine the maximumtolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with generally medicallyaccepted means of treatment or diagnosis; or

6. Any drug, device, medical treatment or procedure used in a manner outside the scope of use forwhich it was approved by the FDA or other applicable regulatory authority (U.S. Department of Health,The Centers for Medicare and Medicaid Services (CMS), American Dental Association, AmericanMedical Association.)

“Reliable Evidence” means only reports and articles published in authoritative medical and scientific literature;the written protocol or protocols used by a treating facility or the protocol(s) of another facility studyingsubstantially the same drug, device, medical treatment or procedure; or the informed consent document usedby the treating facility or by another facility studying substantially the same drug, device, medical treatmentor procedure.

General Definitions


FAMILY

“Family” means a Participant and his or her eligible Dependents as defined herein.

FMLA

“FMLA” means Family and Medical Leave Act.

HIPAA

“HIPAA” means the Health Insurance Portability and Accountability Act of 1996, as amended.

HOSPICE

“Hospice” means a health care program providing a coordinated set of services rendered at home, inOutpatient settings or in institutional settings for Covered Persons suffering from a condition that has aterminal prognosis. A Hospice must have an interdisciplinary group of personnel which includes at least onePhysician and one Registered Nurse (R.N.), and it must maintain central clinical records on all patients. AHospice must meet the standards of the National Hospice Organization (NHO) and applicable state licensingrequirements.

HOSPITAL

“Hospital” means an institution which meets all of the following conditions:

1. It is engaged primarily in providing medical care and treatment to ill and injured persons on anemergent or inpatient basis at the patient's expense; and

2. It is licensed as a hospital or a critical access hospital under the laws of the jurisdiction in which thefacility is located; and

3. It maintains on its premises the facilities necessary to provide for the diagnosis and treatment of anIllness or an Injury or provides for the facilities through arrangement or agreement with anotherhospital; and

4. It provides treatment by or under the supervision of a physician or osteopathic physician with nursingservices by registered nurses as required under the laws of the jurisdiction in which the facility islicensed; and

5. It is a provider of services under Medicare. This condition is waived for otherwise Eligible IncurredExpenses outside of the United States; and

6. It is not, other than incidentally, a place for rest, a place for the aged, a place for drug addicts, a placefor alcoholics, or a nursing home.

HOSPITAL MISCELLANEOUS EXPENSES

“Hospital Miscellaneous Expenses” mean the actual charges made by a Hospital on its own behalf for servicesand supplies rendered to the Covered Person which are Medically Necessary for the treatment of suchCovered Person. Hospital Miscellaneous Expenses do not include charges for Room and Board or forprofessional services, regardless of whether the services are rendered under the direction of the Hospital orotherwise.

General Definitions


ILLNESS

“Illness” means a bodily disorder, Pregnancy, disease, physical sickness, mental illness, or functional nervousdisorder of a Covered Person.

INCURRED EXPENSES OR EXPENSES INCURRED

“Incurred Expenses” or “Expenses Incurred” means those services and supplies rendered to a CoveredPerson. Such expenses will be considered to have occurred at the time or date the treatment, service orsupply is actually provided.

INITIAL ENROLLMENT PERIOD

“Initial Enrollment Period” means the time allowed by this Plan for enrollment when a person first becomeseligible for coverage.

INJURY

“Injury” means physical damage to the Covered Person's body which is not caused by disease or bodilyinfirmity.

INPATIENT

“Inpatient” means the classification of a Covered Person when that person is admitted to a Hospital, Hospice,or Skilled Nursing Facility for treatment, and charges are made for Room and Board to the Covered Personas a result of such treatment.

INTENSIVE CARE UNIT

“Intensive Care Unit” means a separate, clearly designated service area which is maintained within a hospitalsolely for the care and treatment of patients who are critically ill. This also includes what is referred to as a“coronary care unit” or “critical care unit”. It has facilities for special nursing care not available in regular roomsand wards of the hospital, special life saving equipment which is immediately available at all times, at leasttwo (2) beds for the accommodation of the critically ill and at least one registered nurse (R.N.) in continuousand constant attendance twenty-four (24) hours a day.

LICENSED HEALTH CARE PROVIDER

“Licensed Health Care Provider” means any provider of health care services who is licensed or certified byany applicable governmental regulatory authority to the extent that services are within the scope of the licenseor certification and are not specifically excluded by this Plan.

LICENSED PRACTICAL NURSE

“Licensed Practical Nurse” means an individual who has received specialized nursing training and practicalnursing experience, and is licensed to perform such nursing services by the state or regulatory agencyresponsible for such licensing in the state in which that individual performs such services.

LICENSED SOCIAL WORKER

“Licensed Social Worker” means a person holding a Masters Degree (M.S.W.) in social work and who iscurrently licensed as a social worker in the state in which services are rendered, and who provides counselingand treatment in a clinical setting for Mental Illnesses.

General Definitions


MAXIMUM LIFETIME BENEFIT

“Maximum Lifetime Benefit” means the maximum benefit payable while a person is covered under this Plan.The Maximum Lifetime Benefit will not be construed as providing lifetime coverage, or benefits for a person’sIllness or Injury after coverage terminates under this Plan.

MEDICAID

“Medicaid” means that program of medical care and coverage established and provided by Title XIX of theSocial Security Act, as amended.

MEDICALLY NECESSARY

“Medically Necessary” means treatment, tests, services or supplies provided by a Hospital, Physician, or otherLicensed Health Care Provider which are not excluded under this Plan and which meet all of the followingcriteria:

1. Are to treat or diagnose an Illness or Injury; and,

2. Are ordered by a Physician or Licensed Health Care Provider and are consistent with the symptomsor diagnosis and treatment of the Illness or Injury; and,

3. Are not primarily for the convenience of the Covered Person, Physician or other Licensed Health CareProvider; and,

4. Are the standard or level of services most appropriate for good medical practice that can be safelyprovided to the Covered Person and are in accordance with the Plan’s Medical Policy; and,

5. Are not of an Experimental/Investigational or solely educational nature; and,

6. Are not provided primarily for medical or other research; and,

7. Do not involve excessive, unnecessary or repeated tests; and,

8. Are commonly and customarily recognized by the medical profession as appropriate in the treatmentor diagnosis of the diagnosed condition; and,

9. Are approved procedures or meet required guidelines or protocols of the Food and DrugAdministration (FDA) or The Centers For Medicare/Medicaid Services (CMS), pursuant to that entity’sprogram oversight authority based upon the medical treatment circumstances.

MEDICAL POLICY

“Medical Policy” means a policy adopted by the Plan which is created and updated by physicians and othermedical providers and is used to determine whether health care services including medical and surgicalprocedures, medication, medical equipment and supplies, processes and technology meet the followingnationally accepted criteria:

1. Final approval from the appropriate governmental regulatory agencies;

2. Scientific studies showing conclusive evidence of improved net health outcome; and

3. In accordance with any established standards of good medical practice.

General Definitions


MEDICARE

“Medicare” means the programs established under the “Health Insurance for the Aged Act,” Public Law 89-97under Title XVIII of the Federal Social Security Act, as amended, to pay for various medical expenses forqualified individuals, specifically those who are eligible for Medicare Part A, Part B or Part D as a result of age,those with end-stage renal disease, or with disabilities.

MENTAL ILLNESS

“Mental Illness” means a medically recognized psychological, physiological, nervous or behavioral condition,affecting the brain, which can be diagnosed and treated by medically recognized and accepted methods, butwill not include Alcoholism, Chemical Dependency or other addictive behavior. Conditions recognizedby the Diagnostic Statistical Manual (the most current edition) will be included in this definition.

MORBID OBESITY/CLINICALLY SEVERE OBESITY

“Morbid Obesity/Clinically Severe Obesity” means maintaining a Body Mass Index (BMI) of 40 or more for aperiod of at least 12 consecutive months, or a BMI of at least 35 for a period of at least 12 consecutivemonths, combined with at least one of the following conditions which must be documented by a physician aslife-threatening:

1. Severe sleep apnea;

2. Pickwickian syndrome;

3. Congestive heart failure;

4. Cardiomyopathy;

5. Insulin dependent or oral medication dependent diabetes;

6. Severe Musculoskeletal dysfunction;

7. Gastric Esophageal Reflux Disorder;

8. Pulmonary edema; or

9. Hypertension.

Body Mass Index (BMI) is calculated by dividing a person’s weight (in kilograms) by his/her height squared(in meters).

NAMED FIDUCIARY

“Named Fiduciary” means the Plan Administrator which has the authority to control and manage the operationand administration of the Plan.

NEWBORN

“Newborn” refers to an infant from the date of his/her birth until the initial Hospital discharge or until the infantis fourteen (14) days old, whichever occurs first.

General Definitions


OCCUPATIONAL THERAPY

“Occupational Therapy” means a program of care ordered by a Physician which is for the purpose of improvingthe physical, cognitive and perceptual disabilities that influence the Covered Person’s ability to performfunctional tasks related to normal life functions or occupations, and which is for the purpose of assisting theCovered Person in performing such functional tasks without assistance.

OUT-OF-POCKET MAXIMUM

“Out-of-Pocket Maximum” means the maximum dollar amount, as stated in the Schedule of Medical Benefits,that any Covered Person or Family will pay in any Benefit Period for covered services, treatments or supplies.

OUTPATIENT

“Outpatient” means a Covered Person who is receiving medical care, treatment, services or supplies at aclinic, a Physician's office, a Licensed Health Care Provider’s office or at a Hospital if not a registeredbedpatient at that Hospital, Psychiatric Facility or Alcoholism and/or Chemical Dependency Treatment Facility.

PARTIAL HOSPITALIZATION

“Partial Hospitalization” means care in a day care or night care facility for a minimum of six (6) hours and amaximum of twelve (12) hours per day, during which therapeutic clinical treatment is provided.

PARTICIPANT

“Participant” means an Employee of the Company who is eligible and enrolled for coverage under this Plan.

PHYSICAL THERAPY

“Physical Therapy” means a plan of care ordered by a Physician and provided by a licensed physical therapist,to return the Covered Person to the highest level of motor functioning possible.

PHYSICIAN

“Physician” means a person holding the degree of Doctor of Medicine, Dentistry or Osteopathy, or Optometrywho is legally licensed as such.

“Physician” does not include the Covered Person or any Close Relative of the Covered Person who does notregularly charge the Covered Person for services.

PLACEMENT OR BEING PLACED FOR ADOPTION

“Placement” or “Being Placed for Adoption” means the assumption and retention of a legal obligation for totalor partial support of a child by a person with whom the child has been placed in anticipation of the child’sadoption. The child’s placement for adoption with such person ends upon the termination of such legalobligation.

PLAN

“Plan” means the NCH Healthcare System Choice Health Plan as set forth in this Plan Document/SPD andany other relevant documents pertinent to its operation and maintenance.

General Definitions


PLAN ADMINISTRATOR

“Plan Administrator” means the Company and/or its designee which is responsible for the day-to-day functionsand management of the Plan. The Plan Administrator may employ persons or firms to process claims andperform other Plan-connected services. For the purposes of the Employee Retirement Income Security Actof 1974, as amended, and any applicable state legislation of a similar nature, the Company will be deemedto be the Plan Administrator of the Plan unless the Company designates an individual or committee to act asPlan Administrator of the Plan.

PLAN SUPERVISOR

“Plan Supervisor” means the person or firm employed by the Plan to provide consulting services to the Planin connection with the operation of the Plan and any other functions, including the processing and paymentof claims. The Plan Supervisor is Allegiance Benefit Plan Management, Inc. The Plan Supervisor providesministerial duties only, exercises no discretion over plan assets and will not be considered a fiduciary asdefined by ERISA (Employee Retirement Income Security Act) or any other State or Federal law or regulation.

PREGNANCY

“Pregnancy” means a physical condition commencing with conception, and ending with miscarriage or birth.

PREVENTIVE CARE

“Preventive Care” means routine examinations or services provided when there is no objective indication oroutward manifestation of impairment of normal health or normal bodily function, which is not provided fortreatment or diagnosis of any Injury or Illness.

PSYCHIATRIC CARE

“Psychiatric Care,” also known as psychoanalytic care, means treatment for a Mental Illness or disorder, afunctional nervous disorder, Alcoholism or drug addiction by a licensed psychiatrist, psychologist, LicensedSocial Worker or licensed professional counselor acting within the scope and limitations of his/her respectivelicense, provided that such treatment is Medically Necessary as defined by the Plan, and within recognizedand accepted professional psychiatric and psychological standards and practices.

PSYCHIATRIC FACILITY

“Psychiatric Facility” means a licensed institution that provides Mental Illness treatment and which providesfor a psychiatrist who has regularly scheduled hours in the facility, and who assumes the overall responsibilityfor coordinating the care of all patients.

PSYCHOLOGIST

“Psychologist” means a person currently licensed in the state in which services are rendered as a psychologistand acting within the scope of his/her license.

QMCSO

“QMCSO” means Qualified Medical Child Support Order as defined by Section 609(a) of ERISA, as amended.

General Definitions


QUALIFIED BENEFICIARY

“Qualified Beneficiary” means an Employee, former Employee or Dependent of an Employee or formerEmployee who is eligible to continue coverage under the Plan in accordance with applicable provisions of TitleX of COBRA or Section 609(a) of ERISA in relation to QMCSO's.

“Qualified Beneficiary” will also include a child born to, adopted by or Placed for Adoption with an Employeeor former Employee at any time during COBRA Continuation Coverage.

REGISTERED NURSE

“Registered Nurse” means an individual who has received specialized nursing training and is authorized touse the designation of “R.N.” and who is licensed by the state or regulatory agency in the state in which theindividual performs such nursing services.

ROOM AND BOARD

“Room and Board” refers to all charges which are made by a Hospital, Hospice, or Skilled Nursing Facility asa condition of occupancy. Such charges do not include the professional services of Physicians or intensivenursing care by whatever name called.

SEMI-PRIVATE

“Semi-Private” refers to the class of accommodations in a Hospital or Skilled Nursing Facility in which at leasttwo patient beds are available per room.

SKILLED NURSING FACILITY

“Skilled Nursing Facility” means an institution, or distinct part thereof, which meets all of the followingconditions:

1. It is currently licensed as a long-term care facility or skilled nursing facility in the state in which thefacility is located;

2. It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mentally disabledpersons, custodial or educational care, or care of mental disorders; and

3. It is certified by Medicare.

This term also applies to Incurred Expenses in an institution known as a Convalescent Nursing Facility,Extended Care Facility, Convalescent Nursing Home, or any such other similar nomenclature.

SPEECH THERAPY

“Speech Therapy” means a course of treatment, ordered by a Physician, to treat speech deficiencies orimpediments.

General Definitions


TOTAL DISABILITY (TOTALLY DISABLED)

“Total Disability” means the physical state of a Covered Person resulting from an Illness or Injury which whollyprevents:

1. In the case of a Participant, the Covered Person from engaging in any business or occupation or fromperforming any work activity as a volunteer; and

2. In the case of a Dependent, the Covered Person from engaging in Major Life Functions associatedwith a similarly situated non-disabled person of like age and gender. Major Life Function, as usedherein, refers to the definition of the same stated in the Americans with Disabilities Act, and courtopinions pursuant to that Act which construe the term.

USERRA

“USERRA” means the Uniformed Services Employment and Reemployment Rights Act, as amended.

USUAL, CUSTOMARY AND REASONABLE (UCR)”

“Usual, Customary and Reasonable (UCR)” means the maximum amount considered for payment by this Planfor any covered treatment, service, or supply, subject however, to all Plan annual and lifetime maximumbenefit limitations. The following will apply in the order below to determination of the Usual, Customary, andReasonable amount:

1. A contracted amount as established by a preferred provider or other discounting contract; or,

2. An amount established through a nationally recognized, published Usual, Customary and Reasonable(UCR) data base utilized by the Plan Supervisor and adopted by the Plan Administrator using the 90th

percentile of said database; or

3. The billed charge if less than A or B above.


ERISA STATEMENT OF RIGHTS

As a Participant in the Plan you are entitled to certain rights and protections under the Employees RetirementIncome Security Act of 1974 (ERISA). ERISA provides that all Plan Participants shall be entitled to:

1. Examine, without charge, at the Plan Administrator's office and at other specified locations, such asworksites and union halls, all documents governing the plan, including insurance contracts andcollective bargaining agreements and a copy of the latest annual report (Form 5500 Series) filed bythe plan with the U.S. Department of Labor.

2. Obtain, upon written request to the Plan Administrator, copies of documents governing the operationof the plan, including insurance contracts and collective bargaining agreements, and copies of thelatest annual report (Form 5500 Series) and updated summary plan description. The PlanAdministrator may make a reasonable charge for the copies.

3. Receive a summary of the Plan's annual financial report. The Plan Administrator is required by lawto furnish each Participant with a copy of this summary annual report upon request.

4. Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage underthe plan as a result of a qualifying event. You or your dependents may have to pay for suchcoverage. Review this summary plan description and the documents governing the plan on the rulesgoverning your COBRA continuation coverage rights.

5. Reduction or elimination of exclusionary periods of coverage for preexisting conditions under yourgroup health plan, if you have creditable coverage from another plan. You should be provided acertificate of creditable coverage, free of charge, from your group health plan or health insuranceissuer when you lose coverage under the plan, when you become entitled to elect COBRAcontinuation coverage, when your COBRA continuation coverage ceases, if you request it beforelosing coverage, or if you request it up to 24 months after losing coverage. Without evidence ofcreditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18months for late enrollees) after your enrollment date in your coverage.

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsiblefor the operation of the employee benefit Plan. The people who operate your Plan, called "fiduciaries" of thePlan, have a duty to do so prudently and in the interest of you and the other Plan participants andbeneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwisediscriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rightsunder ERISA.

If your claim for a welfare benefit is denied or ignored, in whole or in part (an Adverse Claims Determination),you have a right receive a written explanation of the reason why this was done, to obtain copies of documentsrelating to the decision without charge, and to appeal any denial for a full and fair review and reconsiderationby the Plan Administrator, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materialsfrom the Plan and do not receive them within thirty (30) days you may file suit in a federal court. In such case,the court may require the Plan Administrator to provide the materials and pay you up to one hundred and tendollars ($110.00) a day until you receive the materials, unless the materials were not sent because of reasonsbeyond the control of the Plan Administrator.

ERISA Statement of Rights


If you have a claim for benefits which is denied or ignored, in whole or in part (an Adverse BenefitDetermination), you may file suit in a state or federal court once you have exhausted your appeal rights underthe Plan’s claims and appeals procedures. If you believe the Plan fiduciaries have misused Plan assets, orthat you have been discriminated against for asserting your rights under ERISA, you may seek assistancefrom the U.S. Department of Labor, or you may file suit in a federal court. The court will decide which partywill pay the court costs and legal fees. The court may order the losing party to pay these court costs and fees.You may be ordered to pay these costs and fees if you lose and the court finds your claim to be frivolous.

If you have any questions about your Plan, you should contact the Plan Administrator. If you have anyquestions about your rights under ERISA, you should contact the nearest office of the U.S. Department ofLabor, Frances Perkins Building, 200 Constitution Avenue, N.W., Washington, D.C. 20210, (866) 444-3272,or www.dol.gov/ebsa.

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT: Group health insurance issuers offering grouphealth insurance coverage generally may not, under Federal law, restrict benefits for any hospital length ofstay in connection with childbirth for the mother or newborn child to less than 48 hours following a normalvaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally doesnot prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from dischargingthe mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuersmay not, under Federal law, require that a provider obtain authorization from the plan or the issuer forprescribing a length of stay not in excess of 48 hours (or 96 hours).

IDENTIFICATION OF FUNDING: Your benefits under this plan will be paid from employee or employercontributions up to the limits defined in this Plan Document and Summary Plan Description (SPD). Benefitsin excess of the amount stated in the stop loss policy are reimbursable to the employer by stop loss insurance,pursuant to the stop loss insurance contract or policy, subject, however, to the terms of this Plan and the stoploss insurance contract.

WOMEN’S HEALTH AND CANCER RIGHTS ACT: A federal law known as the Women’s Health and CancerRights Act of 1998 (WHCRA), requires group health plans that provide coverage for mastectomy-relatedbenefits to Covered Persons. Specifically, when a Covered Person receives benefits for a mastectomy anddecides to have reconstructive breast surgery, the Plan must provide coverage, in a manner determined inconsultation with the attending Physician, for:

1. All stages of reconstruction of the breast on which the mastectomy was performed;

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

3. Prostheses and treatment of physical complications at all stages of the mastectomy, includinglymphedemas.

Coverage for the provides will be the same as that for any other covered medical / surgical benefits under thePlan. Certain general coverage limitations may apply, including, but not limited to, deductibles, coinsurance,copayments and Usual, Customary and Reasonable charges. Call your Plan Administrator for moreinformation.


HIPAA PRIVACY AND SECURITY STANDARDS

These standards are intended to comply with all requirements of the Privacy and Security Rules of theAdministrative Simplification Rules of HIPAA as stated in 45 CFR Parts 160, 162 and 164, as amended fromtime to time.

DEFINITIONS

“Protected Health Information” (PHI) means information, including demographic information, that identifies anindividual and is created or received by a health care provider, health plan, employer, or health careclearinghouse; and relates to the physical or mental health of an individual; health care that individual hasreceived; or the payment for health care provided to that individual. PHI does not include employment recordsheld by the Plan Sponsor in its role as an employer.

“Summary Health Information” means information summarizing claims history, expenses, or types of claimsby individuals enrolled in a group health plan and has had the following identifiers removed: names;addresses, except for the first three digits of the zipcode; dates related to the individual (ex: birth date); phonenumbers; email addresses and related identifiers; social security numbers; medical record numbers; accountor plan participant numbers; vehicle identifiers; and any photo or biometric identifier.

PRIVACY CERTIFICATION

The Plan Sponsor agrees to:

1. Not use or further disclose the information other than as permitted or required by the Plan Documentsor as required by law. Such uses or disclosures may be for the purposes of plan administration,including but not limited to, the following:

A. Operational activities such as quality assurance and utilization management, credentialing,and certification or licensing activities; underwriting, premium rating or other activities relatedto creating, renewing or replacing health benefit contracts (including reinsurance or stoploss); compliance programs; business planning; responding to appeals, external reviews,arranging for medical reviews and auditing, and customer service activities. Planadministration can include management of carve-out plans, such as dental or visioncoverage.

B. Payment activities such as determining eligibility or coverage, coordination of benefits,determination of cost-sharing amounts, adjudicating or subrogating claims, claimsmanagement and collection activities, obtaining payment under a contract for reinsurance orstop-loss coverage, and related data-processing activities; reviewing health care services formedical necessity, coverage or appropriateness of care, or justification of charges; orutilization review activities.

C. For purposes of this certification, plan administration does not include disclosing SummaryHealth Information to help the plan sponsor obtain premium bids; or to modify, amend orterminate group health plan coverage. Plan administration does not include disclosure ofinformation to the Plan Sponsor as to whether the individual is a participant in; is an enrolleeof or has disenrolled from the group health plan.

2. Ensure that any agents, including a subcontractor, to whom it provides PHI received from the Planagree to the same restrictions and conditions that apply to the Plan Sponsor with respect to suchinformation;

3. Not use or disclose the PHI for employment-related actions and decisions or in connection with anyother benefit or employee benefit plan of the Plan Sponsor;

HIPAA Privacy and Security Standards


4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses ordisclosures provided for of which it becomes aware;

5. Make available PHI as required to allow the Covered Person a right of access to his or her PHI asrequired and permitted by the regulations;

6. Make available PHI for amendment and incorporate any amendments into PHI as required andpermitted by the regulations;

7. Make available the PHI required to provide an accounting of disclosures as required by theregulations;

8. Make its internal practices, books, and records relating to the use and disclosure of PHI received fromthe Plan available to any applicable regulatory authority for purposes of determining the Plan’scompliance with the law’s requirements;

9. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in anyform and retain no copies of such information when no longer needed for the purpose for whichdisclosure was made, except that, if such return or destruction is not feasible, limit further uses anddisclosures to those purposes that make the return or destruction of the information infeasible; and

10. Ensure that the adequate separation required between the Plan and the Plan Sponsor is established.To fulfill this requirement, the Plan Sponsor will restrict access to nonpublic personal information tothe Plan Administrator(s) designated in this Plan Document or employees designated by the PlanAdministrator(s) who need to know that information to perform plan administration and healthcareoperations functions or assist eligible persons enrolling and disenrolling from the Plan. The PlanSponsor will maintain physical, electronic, and procedural safeguards that comply with applicablefederal and state regulations to guard such information and to provide the minimum PHI necessaryfor performance of healthcare operations duties. The Plan Administrator(s) and any employee sodesignated will be required to maintain the confidentiality of nonpublic personal information and tofollow policies the Plan Sponsor establishes to secure such information.

When information is disclosed to entities that perform services or functions on the Plan’s behalf, such entitiesare required to adhere to procedures and practices that maintain the confidentiality of the Covered Person’snonpublic personal information, to use the information only for the limited purpose for which it was shared, andto abide by all applicable privacy laws.

SECURITY CERTIFICATION

The Plan Sponsor agrees to:

1. Implement and follow all administrative, physical, and technical safeguards of the HIPAA SecurityRules, as required by 45 CFR §§164.308, 310 and 312.

2. Implement and install adequate electronic firewalls and other electronic and physical safeguards andsecurity measures to ensure that electronic PHI is used and disclosed only as stated in the PrivacyCertification section above.

3. Ensure that when any electronic PHI is disclosed to any entity that performs services or functions onthe Plan’s behalf, that any such entity shall be required to adhere to and follow all of the requirementsfor security of electronic PHI found in 45 CFR §§164.308, 310, 312, 314 and 316.

4. Report to the Plan Administrator or the Named Fiduciary of the Plan any attempted breach, or breachof security measures described in this certification, and any disclosure or attempted disclosure ofelectronic PHI of which the Plan Sponsor becomes aware.


NCH HEALTHCARE SYSTEM CHOICE HEALTH PLAN SUMMARY

The following information, together with the information contained in this booklet, form the Summary PlanDescription.

1. PLAN

The name of the Plan is the NCH HEALTHCARE SYSTEM CHOICE HEALTH PLAN, which Plandescribes the benefits, terms, limitations and provisions for payment of benefits to or on behalf ofeligible Participants.

2. PLAN BENEFITS

This Plan provides benefits for covered expenses incurred by eligible participants for:

Hospital, Surgical, Medical, Maternity, other eligible medically related, necessaryexpenses.

3. PLAN SPONSOR

Name: NCH Healthcare System, Inc.Phone (239) 436-5000Address: 350 Seventh Street North

Naples FL 34102

4. PLAN ADMINISTRATOR

The Plan Administrator is the Plan Sponsor.

5. NAMED FIDUCIARY

Name: NCH Healthcare System, Inc.Phone (239) 436-5000Address: 350 Seventh Street North

Naples FL 34102

6. PLAN FISCAL YEAR

The Plan fiscal year ends December 31.

7. PLAN TERMINATION

The right is reserved by the Sponsor to terminate, suspend, withdraw, amend or modify the Plan inwhole or in part at any time.

8. IDENTIFICATION NUMBER

Plan Number: 501Group Number: 2003020Employer Identification Number: 59-0694358

Plan Summary


9. PLAN SUPERVISOR

Name: Allegiance Benefit Plan Management, Inc.Address: P.O. Box 3018

Missoula, MT 59806

10. ELIGIBILITY

Employees and dependents of employees of the Plan Sponsor may participate in the Plan basedupon the eligibility requirements set forth by the Plan.

11. PLAN FUNDING

Benefits are paid from the general assets of the Company.

12. AGENT FOR SERVICE OF LEGAL PROCESS

The Plan Administrator is the agent for service of legal process.

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2017 NCH Road To Wellness (RTW) and HRA Point Plan NCH offers two medical plan options: The Road to Wellness Plan (RTW) and The Basic Plan. Spouses and employees must be on the same plan. Click HERE for a plan comparison.

Road to Wellness Plan

This plan offers the richest benefits including co-pays, a lower deductible and lower out of pocket costs. To be eligible for the RTW Plan during Open Enrollment 2018, employees and covered spouses must complete all requirements below by the applicable deadlines. Employees will receive 250 points for completion of RTW requirements.

Basic Plan

This plan has a higher deductible and greater out of pocket costs and is available to those who choose not to participate in the Road to Wellness Plan. Employees who do not complete all RTW requirements below by the applicable deadlines are only eligible for the Basic Plan during Open Enrollment 2018. Basic Plan members can earn up to 750 HRA points if they completed RTW Fasting Labs / biometrics by the deadline.

New Hires, Transfers and Seasonal Employees New enrollees and employees transferring into benefit eligible positions may elect the RTW Plan. Employees and covered spouses must complete all Required Preventive Measures by the deadlines below, based on their benefits effective/hire date; otherwise, they will only be eligible for the Basic Plan in 2018.

• If hired on or before March 1, 2017, you are REQUIRED to complete RTW requirements in 2017 to be eligible for RTW in 2018.

• If hired after March 1, 2017, you are NOT required to complete RTW requirements in 2017 and will

automatically be eligible for RTW plan in 2018.

BENEFITS EFFECTIVE/HIRE DATE COURTESY HRA POINTS March 2, 2016– Dec. 31, 2017 Members automatically receive 250 HRA Points for their 2017 deductible. March 2, 2017 – Dec. 31, 2018 Members automatically receive 250 HRA Points for their 2018 deductible.

Mark Your Calendars with These Important Dates

• May 1, 2017 – Complete RTW Fasting Labs and biometrics - REQUIRED to maintain RTW for 2018 • September 1, 2017 – Complete Preventive Screenings & Healthy Education - REQUIRED to maintain RTW

for 2018 • November 10, 2017 – Must have all classes and affidavits submitted by this date – OPTIONAL to offset

deductible expense in 2018

http://mynch/documents/human%20resources/2016%20NCH%20Benefit%20Summary%20-%20In-Area%20-%20(10-22-15).pdf

Page 2 of 10

Employee & Spouse Road to Wellness REQUIREMENTS DUE DATE

RTW Fasting Labs and Biometrics – All screenings will be provided through Health Designs and will take place ONSITE at NCH. View LIST of screenings available and SCHEDULE appointment. Waist circumference, blood pressure, cholesterol, glucose, A1C, blood serum nicotine test, height, and weight will be measured. Physician ordered labs do NOT count for the RTW lab work requirement.

May 1, 2017

Tobacco / Nicotine Free Status based on lab results through Health Designs (Cotinine of >41 = Positive)

May 1, 2017

Diabetics – Existing Diabetics with an A1c above 7.5% will be REQUIRED to participate in the following 3-part educational series:

• Living the Sweet Life is an educational series of 3 classes to build Diabetes Management awareness. Complete a series of 3 live webinars (View SCHEDULE of live webinars) OR complete a series of 3 recorded sessions in addition to 3 telephonic health coaching calls (recorded sessions are located in Healthstream).

Non-Diabetics – Non-Diabetics with an A1c above 5.6% will be REQUIRED to participate in the following 3-part educational series:

• State of your Health Series is an educational series of 3 classes to learn how small changes can significantly reduce your risk of developing Diabetes. Complete a series of 3 live webinars (View SCHEDULE of live webinars) OR complete a series of 3 recorded sessions in addition to 3 telephonic health coaching calls (recorded sessions are located in Healthstream).

It is recommended to begin educational series by July 15 to complete by the deadline.

September 1, 2017

Colonoscopy – every 10 years beginning at age 50 through the age of 75 (If your 50th birthday falls on or before September 1, 2017, you are required to complete by deadline). Due to time needed to process claims, please fax 239.938.9205 documentation of completion with cover page to the onsite Florida Blue representative for colonoscopies completed after June 1, 2017.

September 1, 2017

Mammogram – every 2 years beginning at age 50 through the age of 74 (If your 50th birthday falls on or before September 1, 2017, you are required to complete by deadline). Due to time needed to process claims, please fax 239.938.9205 documentation of completion with cover page to the onsite Florida Blue representative for mammograms completed after June 1, 2017.

September 1, 2017

Pap Smear – every 3 years from the date of your last pap beginning at age 21 through the age of 65 (If your 21st birthday falls on or before September 1, 2017, you are required to complete by deadline). Due to time needed to process claims, please fax 239.938.9205 documentation of completion with cover page to the onsite Florida Blue representative for pap smears completed after June 1, 2017.

September 1, 2017

http://mynch/default.aspx?id=2205

https://pickatime.com/client?ven=11608961



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Personal health information obtained by the vendors above is Protected Health Information (PHI) and is secured in accordance with the Health Insurance Portability and Accountability Act (HIPAA). NCH does not have access to individual results.

HRA Points

What are HRA points?

HRA Points are earned for healthy or improved labs/biometrics and participating in various wellness related activities through the myHealth Program. One wellness point earned equals one dollar contributed to your Health Reimbursement Account (HRA) through Health Equity. Dollars earned during 2017 will automatically offset medical deductible expenses generated by you or your covered dependents in 2018. Any unused HRA Dollars at the end of the calendar year will be forfeited.

Who can earn points?

Both employees and spouses on the RTW and Basic Plans can earn HRA Points if they have completed RTW Fasting Labs through Health Designs by the May 1 deadline.

How many points can I earn?

• Road to Wellness Plan Members can earn a maximum of 1000 HRA Points ($1000.00) • Basic Plan Members can earn a maximum of 750 HRA Points ($750.00) if they’ve completed labs • Spouses can earn a maximum of 300 HRA Points for healthy / improved labs and biometrics and by

attending/participating in select activities. ($300.00) • Basic Plan Members of 2017: If you are completing RTW requirements to select RTW in 2018 you are

eligible to earn 1000 points in 2017 to use in 2018. Eligible employees’ HRA accounts are funded for the succeeding plan year. To receive the HRA funding, the employee must (a) be a current NCH employee; (b) earn wellness points; and (c) enroll in the health plan for the 2018 plan year.

Where can I see my earned points?

To view points earned so far in 2017 to offset medical deductible expenses in 2018, visit the employee’s Rewards Page on the Florida Blue portal. The employee’s Rewards Page will show earned points for both the employee and spouse. Go to www.FloridaBlue.com, select “Health & Wellness”, “Discounts & Rewards”, “Earn Blue Rewards and “Learn More”.

When do I earn points?

Employees and spouses have the opportunity to earn points between November 16, 2016 and November 10, 2017 to offset medical deductible expenses in 2018.

How do I use points?

http://www.floridablue.com/

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HRA points are automatically applied to medical deductible expenses when a claim is processed. You will be invoiced for the remaining balance. No special card is required to use earned HRA Points. If your physician requires upfront payment before the HRA Points are applied, Health Equity will send you a check for the amount that should have been covered by HRA Points.

What programs are offered for points?

The myHealth Program coordinates numerous health education opportunities to improve health and earn points. HRA points may also be earned for healthy or improved biometrics. Programming focuses on the Blue Zones Power 9 Principles. Residents living in the original Blue Zones areas share common principles called Power 9®—these are healthy lifestyle habits that help them live longer, healthier, happier lives.

Move Naturally Make daily physical activity an unavoidable part of your environment - You don’t have to run out and buy a gym membership to be more active. Instead, build activities that you like to do into your lifestyle, whether it’s riding your bike, chasing your kids, walking the dog, swimming, or anything else you enjoy.

Know Your Purpose Studies show that people with a clear goal in life, or something to wake up for every morning, live longer and stay mentally sharper than those who don’t. Your sense of purpose can come from something as simple as watching your children or grandchildren grow up, being engaged in a job or a hobby that gives you a sense of fulfillment, or learning something new.

Downshift Work less, slow down, take vacations. Studies suggest optimistic people may be happier, healthier, and have a lower chance of heart problems and lung disease. This may have to do with the amount of stress hormones released by the body. Someone with a happy outlook on life may release fewer stress hormones during difficult times.

Eat Until 80% Full Stop eating when you are 80% full. Studies show that cutting back on calories can lead to better heart health, longevity, and weight loss.

Plant Slant More veggies, less meat & processed food. Wine @ 5 Drink a glass of red wine each day - Studies show that people who have a healthy relationship with alcohol, enjoying a daily glass of wine, beer, or spirits, may reap some health benefits from doing so.

http://mynch/uploads/myHealth/Move%20Naturally%20Newsletter.pdf

http://mynch/uploads/myHealth/Know%20Your%20Purpose%20Newsletter.pdf

http://mynch/uploads/myHealth/Down%20Shift%20Newsletter.pdf

http://mynch/uploads/myHealth/80%20Percent%20Newsletter.pdf

http://mynch/uploads/myHealth/PlantSlant%20Newsletter.pdf

http://mynch/uploads/Wine%20at%20Five%20Newsletter.pdf

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Right Tribe Create a healthy social network - Did you know that having a social support network of loyal friends is good for your well-being and may add more healthy years to your life? Okinawans maintain strong social connections by regularly spending time with their moais – groups of lifelong friends.

Loved Ones First Blue Zones® researchers discovered that the healthiest, happiest centenarians in the world tend to build their lives around their families. Taking care of family is their main purpose in life.

Spiritually Community Having a sense of belonging seems to be an important part of enjoying a long and healthy life. Blue Zones® researchers discovered that people who are the healthiest and who live the longest all seem to have a strong sense of belonging and purpose.

HRA Point Menu Visit myHealth on the MyNCH website for all HRA point opportunities, details and REGISTRATION.

Point Opportunities Employee

Points Spouse Points

Waist Circumference • Male < 40 inches • Females < 35 inches

50 points (Max of 1)


Weight loss (points for weight loss by 5-9.99% comparing RTW Fasting Labs in 2016 and 2017) 50 points (Max of 1)


Weight loss (points for weight loss by 10-19.99% comparing RTW Fasting Labs in 2016 and 2017) 75 points (Max of 1)


Weight loss (points for weight loss by 20% or more comparing RTW Fasting Labs in 2016 and 2017)



Glucose • A1c < 5.7% • Existing diabetic with an A1c < 7.5% OR

Improve A1c Risk Category TO BE ELIGIBLE FOR IMPROVEMENT POINTS, YOU MUST HAVE COMPLETED LABS AND BIOMETRICS IN 2016 AND 2017. NON-DIAGNOSED DIABETES

• Low Risk: < 5.7% • Moderate Risk: 5.7% - 6.4% • High Risk: > 6.4%

Diagnosed Diabetes

• Low Risk: < 7.5% • High Risk: > 7.5%



Blood Pressure • Less than 120/80 OR

Improve Blood Pressure Risk Category

http://mynch/uploads/myHealth/Right%20Tribe%20Newsletter.pdf

http://mynch/uploads/myHealth/Loved%20Ones%20Newsletter.pdf

http://mynch/uploads/myHealth/Spiritual%20Newsletter.pdf

http://mynch.nchhcs.org/default.aspx?id=2539

http://mynch.nchhcs.org/default.aspx?id=2539

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TO BE ELIGIBLE FOR IMPROVEMENT POINTS, YOU MUST HAVE COMPLETED LABS AND BIOMETRICS IN 2016 AND 2017. • Low Risk: < 119 over < 79 • Moderate Risk: 120-139 over 80-89 • High Risk: > 140 over > 90



Cholesterol Ratio • 5.0 or less



Full Marathon Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate

100 points/event (Max of 3)


Half Marathon Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate



Olympic Triathlon Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate



Sprint Triathlon Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate



NCH Fit Need motivation to get to the gym? Find a small group of 4-6 employees to sign up for small group training with NCH Wellness Specialist. There are limited time slots so SIGN UP early. $ Cost to Participate

150 (30/36 sessions for points, max of 1) NA

Cycle Event 20+ miles Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate



NCH Sponsored Community Event Walk/Run/Cycle Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate



Passport Online Health Challenge - Session #1 (replacing Health Trails) 8-week challenge: Jan 16 – Mar 12 (REGISTRATION Jan 2 – 15) Track exercise and sleep to earn points.

50 points/20 hours of exercise

(Max of 1)

25 points/20 hours of exercise

(Max of 1)

Passport Online Health Challenge – Session #2 (replacing Health Trails) 8-week challenge: Apr 3 – May 28 (REGISTRATION Mar 20 – Apr 2) Track specific health behaviors to earn points.

50 points / 20 hours of exercise

(Max of 1)


(Max of 1)

Passport Online Health Challenge – Session #3 (replacing Health Trails) 8-week challenge: June 19 – Aug 13 (REGISTRATION June 5 – June 18) Track specific health behaviors to earn points.


(Max of 1)


(Max of 1)

Passport Online Health Challenge – Session #4 (replacing Health Trails) 8-week challenge: Sept 11 – Nov 5 (REGISTRATION Aug 21 – Sept 10) Track specific health behaviors to earn points.


(Max of 1)


(Max of 1) Attendance at NCH Wellness Centers Employees/spouses must swipe in with membership key tag. Verification does not need to be submitted. These points can be earned in addition to logging your exercise

during the Passport Health Challenges. $ Cost to Participate

45-70 visits: 50 71-110 visits 75

111-160 visits 100 161-200 visits 150

>200 visits 200 (Max of 1)

45-70 visits: 25 71-110 visits: 50

111-160 visits: 75 161-200 visits: 100

>200 visits: 125 (Max of 1)

mailto:[email protected]?subject=Volunteer%20Affidavit









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Non-NCH Sponsored Community Walk/Run with a Distance < 10 K or cycle event Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate

25 points /event (Max of 3)

25 points / event (Max of 1)

NCH Wellness Exercise Class Series Ready to start exercising, but not sure where to start? We’ll educate you on the importance of balancing cardio, strength, and flexibility. You’ll leave feeling strong, healthy, and energized!

10 points /class (Max of 6)

NA

Color Me Fit online series

75 points (Max of 1) Attend 4/5

25 points (Max of 1) Attend 4/5

Purpose Workshop – Discover Your True Purpose – that unique thing that makes you your best. Start Living yours and add up to 7 years to your life. Take home the tools you need to be the best possible you! Must sign in on attendance sheet for credit.


25 points

(Max of 1)

Volunteer - Volunteer your time at a non-profit organization. Submit affidavit to Wellness Coordinator for points before 11/10/17

5 points / hour max of 50 pts (Max of 10)

NA

Donating Blood – Community Blood Center, for donation times visit www.givebloodcbc.org or call 624-4120. Must complete HRA slip at blood center for points.

25 points/donation

(Max of 3)

NA

Health Education Workshops (Approximately 4 hours in length)

• Resilience Advantage Stress Reduction Program - This course provides tools and strategies to strengthen resiliency, improve decision making and increase productivity. Receive a practical framework of self-regulation tools and resilience-building practices to dramatically increase inner poise and clarity in the face of change and overwhelm.

• Parenting With Positive Discipline - Learn effective tools for how to use discipline that is kind and firm, creates connection before correction, is empowering and encouraging to children, develops capability, and keeps the joy in parenting. Gain practice with experiential exercises for “getting into the child’s world” to understand

the “belief behind” behavior in order to motivate change. Have fun and learn from the instructor AND other parents’ experience.

• Weigh / Eating Better Workshop - This single day workshop will help you better understand how to eat to boost metabolism, gain energy, and improve irritating symptoms such as gas, stuffy nose, brain fog, bloating, and hunger cravings. Identify foods to give you a health edge and give you a “better weigh”.







Florida Blue Stress Less and Thrive - Better You Stress Less is a 5 week program to help build resilience, enhance life balance and manage stress. You will explore the stressors in your life, and be given tools to help manage it. Every week there will be different stress management techniques so you can practice your skills to relax, stress less and thrive! (Must attend 4 out of the 5)



Read a Book - Downshift by reading entire novel. Complete affidavit and submit to Wellness Coordinator before 11/10/17

10 points /book (Max of 5)

NA



http://www.givebloodcbc.org/


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Complete Health Improvement Program (CHIP) A 12-week (18 session), on-site therapeutic lifestyle enrichment program designed to reduce disease risk factors through the adoption of better health habits and appropriate lifestyle

modifications. The goal is to lower blood cholesterol, hypertension, and blood sugar levels and reduce excess weight. This is done by improving dietary choices, enhancing daily exercise, increasing support systems and decreasing stress, thus aiding in preventing and reversing disease. The Complete Health Improvement Program will be fully subsidized for employees and/or spouses on the health plan, meeting a minimum of 3 health risks below, and meeting class attendance requirements. CHIP will be available to all other employees/spouses for a fee of $325.00. There will be limited class spots available. A waiting list will be available if the demand exceeds available spots. CHIP Eligibility Criteria for Subsidy (must meet a minimum of 3) A1C > 5.7% Blood Pressure of 130/85 or higher HDL < 40 for males, < 50 for females or Triglycerides > 150 Waist circumference > 40 inches for males, > 35 inches for females

250 points

Must attend 16 of the 18 weeks for

points

(Max of 1)

100 points

Must attend 16 of the 18 weeks for

points

(Max of 1)

Food For Life Classes (FFL) A plant-based approach to eating to lose weight, maintain a healthy weight, or simply embrace an overall healthful diet. It is not about restricting amounts of foods but rather choosing the right foods for health. Lower cholesterol, better diabetes control, lower blood pressure, as well as improvements in energy

and mood are some of the many benefits experienced. Discover which foods are optimal for weight management, learn about various health topics including blood pressure and digestion, and get empowered with the practical cooking skills needed to help you on your journey to better health. In our classes, attendees do all of this while enjoying a cooking demonstration and tasting delicious, healthful dishes in a supportive group setting.

25 points / Class (Max of 8)

Eligible, no points 0

Hot Topics in Nutrition Our Dietician, Dianne Cogburn will present Meals in Minutes, Eat healthy on a budget, Green is good, Super Foods, Supplements, Whole Grain

Truth, and provide grocery store tours.

25 points /class (No Max)


vonArx Get the Scoop – Monthly information on the following topics: Probiotics, Family Nutrition, Frozen Treats, Current Food Trends, Make Sense of Salt, What’s in Your Cup

25 points /class (Max of 6)

NA

Massage Therapy – Downshift by enjoying a massage. Complete affidavit and attach supporting documentation to Wellness Coordinator before 11/10/17 $ Cost to Participate

10 points /massage (Max of 5)

NA

Stress Release Restorative Experiential Class - A unique inner peace multi-sensory experience to feel relaxed, to release unwanted stress and learn stress release management tools and techniques. CEC units available for nurses

25 points / Class (No Max)


Smile Across Your Heart Course - This 6-hour empowerment course is to practice unconditional love and acceptance, forgiveness, effective heart centered communication and full empowerment. Based on the book, “Language of the Heart” by Laurie Martin. CEC units available for nurses




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vonArx Individual Nutrition Consultation - Work individually with a Registered Dietitian to achieve your health goals through improved nutrition. Receive individual guidance on topics such as weight gain/loss, kidney disease, sports nutrition, heart / lung disease, balanced diet, gluten allergy and more. Call 239.624.3450 to enroll. $Cost to Participate



Better Weigh / Eating Better Series - A 4-week series to help you better understand how to eat to boost metabolism, gain energy, and improve irritating symptoms such as gas, stuffy nose, brain fog, bloating, and hunger cravings. Identify foods to give you a health edge and give you a “better weigh”.

25 points / class

(Max of 8)

NA

Diabetes Self-Management Course –A comprehensive program covering every aspect of living and self-managing diabetes for those diagnosed with diabetes. A physician order is required to enroll in the course. Call 624-3450 for details and enrollment.

100 points /course (Max of 1)

50 points /course (Max of 1)

Attend NCH Wellness Event – Benefits, Volunteer, Moai Celebration, and more. Badge must be scanned for credit.

25 points (No Max)

NA

Parenting Classes – A variety of parenting classes will be offered. Intro to Positive Discipline, Chores without wars, Terrible Twos to Terrific Twos, Unplug in the plugged in world to name a few.

25 points / class

(No Max)

25 points / class

(No Max)

Family Wellness – This 5-week program teaches the participant how to be a champion for healthy family habits. Learn effective strategies to get family members on board to create a supportive home environment for healthy living. The program covers healthy eating for busy families, balancing screen time and physical activity,

good sleep habits and positive thinking. Participants build a culture of family wellness and create their own community resource kit to help sustain long term healthy habits. (Must attend 4 out of the 5)

75 points Attend 4/5 (Max of 1)


Successful People Do This - A 5-week program designed to help participants manage their physical, emotional and mental ENERGY to be successful in their personal and professional life. This program actively engages participants in skills to manage their energy and includes aspects of nutrition, exercise, stress management, interpersonal

skills, sleep, rest and recovery. The goal is to bring a new found focus and motivation to performing your best every day.



Financial Wellness Seminars from Shane, the money coach 25 points /class (No Max)

NA

Attend NCH Event Benefits, Blue Zone Celebration, Farmers Market, and more 25 points (No Max)

NA

Webinars (myHealth / Fidelity) Webinars provided by Fidelity or myHealth 25 points /webinar (No Max)

NA

Florida Blue Popular Wellness Presentations/Webinars Choose from a variety of topics 25 points /webinar (No Max)

25 points /webinar

Life Work Connect Health Webinars Choose from a variety of topics 25 points /webinar (No Max)

NA

Wellbeing 5 Assessment - This survey is the most complete measurement of well-being in the industry and will provide you with a much more holistic, accurate picture of your current well-being. Click HERE to take the survey.



Personal Health Assessment (PHA) – Log into www.floridablue.com, go to rewards page to complete PHA



https://southwestflorida.bluezonesproject.com/organization/well-being-5?c=SmFrUHBhVUZUMmVGQ3dOSkpx

http://www.floridablue.com/

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Annual Physical - Must be completed between November 1, 2016 and October 31, 2017. Completion will be verified through claims.



Preventive Dental Exams - Must be completed between November 1, 2016 and October 31, 2017. Completion will be verified through Cigna claims.



CBTs (Computer Based Training Modules) 20 points (Max of 5)

NA

Staying Healthy As You Age Class/Webinar 25 points (Max of 1)

25 points / Webinar (Max of 1)

Telephonic Health Coaching through Florida Blue 50 points / 4 calls (Max of 1)

25 points / 4 calls (Max of 1)

Blood Pressure Program: Journey Through Your Heart Our Targeted Self-Management Blood Pressure Program is aimed at improving and maintaining a participant’s blood pressure. The five, one hour weekly core sessions focus on individual blood pressure self-care management plan. Post core program contact at 3, 6 and 12 months include medication review, reinforcement follow up with health care provider, and maintenance labs.

75 points

Attend 4/5 (Max of 1)

25 points

Attend 4/5 (Max of 1)

Moai Social connectedness is a common thread for people living in the world’s Blue Zones areas. Having a social support network of loyal friends is good for your well-being and may add more healthy years to your life. Moais are groups of 5-9 co-workers who meet weekly for 10 weeks. Minimum of 8 weeks for walking and

minimum of 5 weeks for potluck or other moais. Leader completes Moai Tracker and submits to Wellness Coordinator for credit.

50 points / Moai (No Max)

NA

Healthy Addition Prenatal Program Florida Blue’s Healthy Addition Prenatal Program works with you and your health care provider to help you have a healthy pregnancy. Participants of the program receive pregnancy risk screening and monitoring, education on healthy lifestyle and

dietary habits, prenatal information, emotional support, answers to questions and concerns and reinforcement of provider’s plan of care. Must enroll in program before Nov. 15, 2016. To enroll, email [email protected] or call 1-800-955-7635, Option 6 Monday - Friday, 8 a.m. - 5:30 p.m. EST

25/ for registration (Max of 1)

50/ for completion of program

(Max of 1)

25/ for registration (Max of 1)

50/ for completion of program (Max of 1)

Breastfeeding Class through NCH For more information on times and locations call 239-552-7396. To receive discounted price, identify yourself as an NCH employee and provide your employee ID#. *Must provide affidavit, with signature, no later than Nov. 10, 2017* $ Cost

25/session (No Max)

25/session (No Max)

Note: If you are unable to meet a standard for a reward under this wellness program, refer to the NCH Healthcare Medical Plan Document. You might qualify for an opportunity to earn the same reward by different means. Updated: Nov 9, 2016

mailto:[email protected]?subject=Moai%20Tracker