Eligibility & Enrollment

You never signed a form explaining the consequences of the employee’s decision.

Your signed form exists but cannot be produced as evidence of the employee’s informed decision.

Coverage for Eligible Retirees

You and your Eligible Dependent(s) may be eligible for Valley Health Plan Group Coverage if you are retired. To continue or obtain Coverage as a retired Subscriber: • You must be an Eligible Retiree from a Group that offers VHP as a benefit to its retired employees; • You and your Eligible Dependent(s) must be enrolled in VHP and VHP must receive prepayment fees or premiums from the Group; • You must meet the Group’s eligibility criteria and the Group’s applicable waiting period requirements; • You must reside continuously within the Service Area, San Francisco County, or any adjacent counties to the Service Area. Adjacent counties include: San Mateo, Alameda, Stanislaus,

Merced, San Benito, Monterey, and Santa Cruz Counties; and • If you are eligible for Medicare, you must enroll in Medicare and contact your Group and VHP

Member Services. To enroll in Valley Health Plan as an Eligible Retiree, contact your employer. Your employer will give you the necessary paperwork, including the VHP application form. Your employer will advise you of your responsibility for any portion of VHP monthly membership fees or premiums. Refer to the “Retiree Continuation of Coverage” section of this EOC.

When Coverage Begins

Covered Services begin on the Effective Date of Coverage established by your employer if you enroll:

• When you or your Eligible Dependent(s) first became eligible; or • At an Open Enrollment Period; or • Within 31 days of a late enrollment. (Refer to the “Enrolling Late or During Open Enrollment” section.) Covered Services begin for your Dependent: • Newborn natural child—at the moment of birth; or • Adopted child—on the date you obtain adoptive custody or when you receive the legal right to control the adopted Eligible Dependent child’s health care; or • Ward who is an Eligible Dependent child—on the commencement date of legal guardianship.

To ensure continued Coverage, you must enroll your newly Eligible Dependent(s) within 31 days after birth, custody, or legal guardianship. If you fail do to so, you must wait until your employer’s next Open Enrollment Period to enroll them.

Continuing Group Coverage for Dependents

Health Coverage may continue for your Eligible Dependent(s) as follows: 1. Physically or mentally handicapped Eligible Dependent(s) who is incapable of sustaining

employment and is dependent upon you for support and maintenance may continue Coverage if the child was handicapped on the day before reaching age 26. The child can be covered under the Plan through age 25 or until the child recovers from the handicap or the date the child is no longer chiefly dependent on you for support and maintenance.

Verification of disability and dependency may be required as often as deemed necessary by VHP.

However, the Plan will not request verification more often than once a year. 2. Newborn, newly adopted, or new legal ward child can continue Coverage after the first 31 days when you enroll your child within the first 31 days following the child’s birth, adoption, or guardianship.

After this period, you must wait until your employer’s next Open Enrollment Period to enroll your child.

3. Your or your spouse’s natural child, step-child, legally adopted child, or a child under your courtordered legal guardianship, residing with you or with your present or former spouse, can be covered under the Plan until the end of the benefit year for dependents that reach the age 26.

An enrolled Dependent child who reaches age 26 during a benefit year may remain enrolled as a dependent until the end of that benefit year. The dependent coverage shall end on the last day of the benefit year during which the Dependent child becomes ineligible. Verification of dependent status may be requested by VHP. 4. When the eligible dependent reaches age 26 coverage will not be terminated while the child is and continues to meet both of the following criteria: a. Incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness, or condition. b. Chiefly dependent upon the subscriber for support and maintenance.

Renewal Provisions

The Agreement renews automatically as long as premiums have been properly paid. You do not need to reapply at the time of Open Enrollment or renewal unless changes are needed. Monthly premiums may change upon Open Enrollment or at the time of renewal. If Coverage for you or your Dependent(s) is terminated, you must submit a new application for membership to be reinstated.

Contract Period of This Evidence of Coverage

The Agreement is revised when the contract between your Group and VHP is changed. Any future changes to the Agreement may affect this Combined Evidence of Coverage and Disclosure Form (EOC). The description of Benefits discussed in this Valley Health Plan Benefits and Coverage Handbook is applicable after August 2012. VHP makes revisions to its EOC annually but may not print and distribute it. VHP also distributes member communications regarding Benefits or changes. These communications act as changes and will supersede the current EOC in effect.

It is important to keep all Benefit information or changes mailed to you with the most current EOC.

If you would like copies of the EOC or of recent Member communications such as the VHP Member newsletter “Perspectives,” visit www.valleyhealthplan.org or call the VHP Member Services Department at 1.888.421.8444 (toll-free).

Please read the following information so you will know from whom or what group of providers health care may be obtained.

Valley Health Plan is a non-profit health plan that contracts with Plan Providers who provide and coordinate Covered Services for Members. As a Member of Valley Health Plan, you must receive all of your Covered Services from these Plan Providers except in the event of an Emergency, Urgently Needed Services or if VHP has pre-authorized the services. Refer to the “Liability of Subscriber or Enrollee for Payment” section under “Payment and Reimbursement Responsibility.” Each Member can select a Primary Care Physician (PCP) upon enrollment. If a PCP is not selected, VHP will assign you a PCP. Your PCP provides all basic medical care, and coordinates any Prior Authorized specialty and Hospital Services you may need. Your Member packet contains information about VHP’s Primary Care Physicians, facilities, pharmacies, clinics, and laboratories. Although the list(s) of VHP Plan Providers is subject to change, we recommend that you keep this information with this Combined Evidence of Coverage and Disclosure Form. For updated Plan Provider information, visit www.valleyhealthplan.org or call a Member Services Representative at 1.888.421.8444 (toll-free). To understand the meaning of important definitions, such as Plan Providers and Service Area, refer to the“Definitions” section of this EOC.

Choosing Your Primary Care Physician

VHP encourages you and your Dependent(s) to choose a VHP Primary Care Physician (PCP). If you do not select a PCP, VHP will assign one to you and your enrolled Dependent(s). For updated Plan Provider information, visit www.valleyhealthplan.org or call a Member Services Representative at 1.888.421.8444 (toll-free).

To choose a PCP:

1. Include the name of the Primary Care Physician of your choice on your Enrollment Application when enrolling initially. 2. Select a Primary Care Physician who is located near your home or work. You may choose a different PCP for each Dependent. VHP will make every effort to assign you to the PCP of your choice, however, if this is not possible, VHP will contact you to make another selection. If you need any assistance in selecting a PCP, please call a Member Services Representative at 1.888.421.8444 (toll-free) or go to www.valleyhealthplan.org and use the Provider Search. You may also download a hard copy of the Provider directory on our website.

VHP encourages you to identify your baby’s Primary Care Physician during the last few months of Pregnancy.

Changing Your Primary Care Physician

You can change your PCP at any time by calling the Member Services Department or by requesting the change in writing. The effective date of the change will be first of the next month after your request is received, provided you are not receiving hospital or other institutional care at the time of your request. In the event you are institutionalized, discuss your effective date with the Member Services Department. If needed, a new VHP Identification Card (VHP ID Card) will be mailed to you. In the event your PCP terminates his/her relationship with VHP, you will be notified by VHP and will be assigned a new PCP. As a Member of VHP, you are selecting our health plan to provide you and/or your family health care. You must receive all Covered Services from Plan Providers inside our Service Area, except as described in the “Emergency and Urgently Needed Services” section. Through our health plan, you have convenient access to all of the Covered Services you may need such as Routine Care with your Primary Care Physician, hospital care, mental health, laboratory and pharmacy services and other Benefits listed in the “Benefits Description Table” and in the “Benefit Descriptions” section.

Scheduling Appointments

VHP offers a wide section of Primary Care Physicians (PCPs) throughout its Service Area. To schedule an appointment with your PCP, call your PCP’s appointment line. For your PCP’s appointment line, go to www.valleyhealthplan.org or call Member Services at 1.888.421.8444 (toll-free) for assistance. VHP provides a free 24-hour Medical Advice line at 1.866.682.9492 (toll-free). Language services are available to you at no cost through your Plan Provider.

If you are a female Member, you may obtain Covered Services through direct access (self-refer) from a Plan OB/GYN and/or through direct access from a Plan family practice physician and surgeon (Plan Provider). VHP recommends you call in advance to schedule your routine doctor’s appointments. Be prepared to provide your name, the VHP ID number on your VHP ID Card, a daytime telephone number where you can be reached, and the reason for the visit (so that adequate time can be scheduled for your appointment). For more immediate or urgent care attention, tell the office of the urgency of your call and request the next available appointment. If you need to cancel an appointment, be sure to call your Primary Care Physician’s appointment number immediately so another patient can be scheduled. Whenever possible, you should give at least 24 hours notice when canceling an appointment. At the time of your doctor’s appointment, you will be asked to show your VHP ID Card and another form of identification. VHP suggests that you carry your VHP ID Card at all times.

Receiving Primary Health Care

The PCP you or your Dependent(s) have chosen will provide or arrange for the majority of your general medical, pediatric, and OB/GYN Covered Services from VHP Plan Providers. To ensure quality health care, you should regularly schedule general checkups and office visits.

Receiving Specialty Care and Referrals

Your PCP will coordinate all specialty care or other Covered Services: • Before you receive specialty services from a VHP Physician, (such as general surgery, orthopedic surgery or cardiology), you must receive a referral from your PCP. Certain self-referred care is an exception. • Your PCP will obtain Authorization for specialty services. Your PCP will instruct you how to make an appointment to see the Plan Specialist. Making an appointment will be your responsibility.

Services received by specialists with no Prior Authorization could result in your financial responsibility. Some specialty referrals may require additional review by the VHP Medical

Director. When all necessary referral information has been provided, VHP will inform you and your PCP of its decision within five (5) business days. Your Primary Care Physician provides any other special instructions for your specialty visit. • If you have a Serious Chronic Condition your PCP can request a standing referral to your Plan

Specialist. Your PCP must request the standing referral and must continue to coordinate these services. You will be advised of VHP’s decision within two (2) business days. • If you require mental health or chemical dependency services, refer to the “Benefits Description” section under “Mental Health Services” or “Chemical Dependency Services.” To receive more information about referrals and Authorizations, call a VHP Member Services Representative at 1.888.421.8444 (toll-free), or refer to the “Authorization and Denial of Services” section.