CRST International - Redacted HWM

From: BWilley@crst.com Sent: Tuesday, October 19, 2010 11:30 AM To: HHS HealthInsurance (HHS) Cc: jbarnes@crst.
com Subject: Waiver Application - CRST International Attachments: CRST Waiver Application.pdf; CRST International Bridge Plan L3V 010110.pdf; Bridge Enrollment Guide.pdf
Attn: James Mayhew - Health and Human Services, Office of Consumer Information and Insurance Oversight Dear Mr. Mayhew: Attached please find the application for a waiver from CRST International, Inc.
Kind regards, Brooke Willey, VP - Human Resources CRST International, Cedar Ra direct: 319/390-2856 cell: (b)(6)
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file:////co-adshare/...rocessing%20Team/Brandon/CRST%20International/Waiver%20Application%20-%20CRST%20International%20.htm[11/09/2011 5:19:44 PM]
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Brooke Willey, VP Human Resources bwilley@crst.com 3930 16th Avenue SW Cedar Rapids, IA 52404 October 15, 2010 Health & Human Services Office of Consumer Information and Insurance Oversight Room 737-F-04 200 Independence Ave. SW Washington, DC 20201 Attention: James Mayhew RE: Annual Limits Waiver
Office Phone 319/390-2856 Office Fax 319/731-3954
Dear Mr. Mayhew: CRST International Inc. is one of the nations lead long haul truckload carriers. Currently, CRST offers to employee drivers a group medical benefit plan that they are eligible to enroll in after (b)(4) days of full time employment. In order to assist our drivers during this waiting period CRST has offered a Bridge Plan since January 2002. Our current Bridge Plan covers the drivers from their first day of hire and is intended to assist them and their family members with medical care during their waiting period. Upon satisfying the (b)(4) day waiting period, drivers are given the option to enroll in our group plan that will meet the PPACA requirements. We would also like to note CRST currently credits the Bridge Plan as credible coverage when they enroll in our group major medical plan. A summary of the terms of our bridge plan are as follows; (a copy of our enrollment guide and coverage manual is included for your review); Network and Admi s Blue Cross Blue Shield Lifetime Maximum (b)(4) Single Deductible (b)(4) Family Deductible (b)(4) Office Visit Copay (b)(4) Deductible waived Inpatient/Outpatient Services (b)(4) % coinsurance after deductible
If CRST Internationals Bridge Plan is not granted a waiver to continue operating the plan as we have since 2002 we will most likely terminate the plan and the coverage to over (b)(4) employee drivers and their families which represents over in annual claims expenditures yearly. We (b)(4) know how much our employees rely on this coverage and utilize this plan while they are waiting to enroll in our major medical group offering. With my signature below as Plan Administrator of CRST International, I herby attest to the following; 1) That the plan was in force prior to September 23, 2010; and 2) That the application of restricted annual limits to such plans or policies would result in a significant decrease in access to benefits for those currently covered by such plans or policies. We appreciate your attention to this matter. Sincerely,
Brooke Willey Vice President, Human Resources CRST International, Inc., Plan Administrator
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Our annual limit on this bridge plan is the same as our lifetime limit, (b)(4) . However, this lifetime limit is intended to be in place for only (b)(4) days while the driver is in the waiting period for our group plan to take effect. The monthly premium for the bridge plan is (b)(4) for single coverage and (b)(4) for family coverage.
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Currently our bridge plan covers (b)(4) employee drivers and represents over (b)(4) total individuals. We have averaged over (b)(4) drivers monthly for the last two years. Our annualized claims payments for 2010 are averaging over $ (b)(4) which is in line with our two year average claims expense.
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1.
What You Pay
This section is intended to provide you with an overview of your payment obligations under this group health plan. This section is not intended to be and does not constitute a complete description of your payment obligations. To understand your complete payment obligations you must become familiar with this entire coverage manual, especially the Factors Affecting What You Pay and Choosing a Provider sections.
Payment Summary
Category
Deductible
You Pay
(b)(4)
per person (maximum) per family*
Office Visit Copayment

(b)(4)
for covered services received from PPO providers.
Coinsurance
(b)(4)
Lifetime Benefits Maximum

(b)(4)
per person
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*Family amounts are reached from amounts accumulated on behalf of any combination of family members. **Participating and nonparticipating providers are non-PPO. See Choosing a Provider, page 27.
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% for covered services received from PPO providers. % for covered services received from participating and nonparticipating providers.**
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This chart summarizes your payment responsibilities. It is only intended to provide you with an overview of your payment obligations. It is important that you read this entire section and not just rely on this chart for your payment obligations.
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2.
At a Glance - Covered and Not Covered
The headings in this chart provide the following information:
Category. Service categories are listed alphabetically and are repeated, with additional detailed information, in Details Covered and Not Covered. Covered. The listed category is generally covered, but some restrictions may apply. Not Covered. The listed category is generally not covered. See Page. This column lists the page number in Details Covered and Not Covered where there is further information about the category.
Not Covered
Category
Acupuncture Treatment Ambulance Services Anesthesia
See Page
Covered
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Allergy Testing and Treatment
Blood Administration
Chemical Dependency Treatment Chemotherapy and Radiation Therapy Cosmetic Services Counseling Services Dental Treatment for Accidental Injury Dialysis Education Services for Diabetes Emergency Services
Form Number: Wellmark IA Grp/AGC_ 1009
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11 11 11 11 11 11 11 11 11 11 12 12 12
Service Maximum. This column lists maximum benefit amounts that each member is eligible to receive per covered service, benefit year, or lifetime. Service maximums that apply per benefit year or per lifetime are reached from claim payment amounts accumulated under this group health plan and any prior group health plans sponsored by your employer or group sponsor and administered by Wellmark Blue Cross and Blue Shield of Iowa.
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Your coverage provides benefits for many services and supplies. There are also services for which this coverage does not provide benefits. The following chart is provided for your convenience as a quick reference only. This chart is not intended to be and does not constitute a complete description of all coverage details and factors that determine whether a service is covered or not. All covered services are subject to the contract terms and conditions contained throughout this coverage manual. Many of these terms and conditions are contained in Details Covered and Not Covered, page 11. To fully understand which services are covered and which are not, you must become familiar with this entire coverage manual. Please call us if you are unsure whether a particular service is covered or not.
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At A Glance Covered and Not Covered
Not Covered
Category
Fertility Services Genetic Testing Hearing Services (related to an illness or injury) Home Health Services Home/Durable Medical Equipment Hospice Services
See Page 12 13 13 13 14 14
Covered
Service Maximum
(b)(4)
Hospitals and Facilities Illness or Injury Services Infertility Treatment Inhalation Therapy Maternity Services Medical and Surgical Supplies Mental Health Services Morbid Obesity Treatment Motor Vehicles Musculoskeletal Treatment Nonmedical Services Occupational Therapy Orthotics Over-the-Counter Products Physical Therapy
14 15 15 15 15 16 16
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Physicians and Practitioners Advanced Registered Nurse Practitioners Audiologists Chiropractors Doctors of Osteopathy Licensed Independent Social Workers Licensed Marriage and Family Therapists. Licensed Mental Health Counselors Medical Doctors Occupational Therapists Optometrists Oral Surgeons Physical Therapists Physician Assistants
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8 Form Number: Wellmark IA Grp/AGC_ 1009
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days per lifetime for inpatient hospice respite care. days per lifetime for outpatient hospice respite care. Please note: Hospice respite care must be used in increments of not more than five days at a time.
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At A Glance Covered and Not Covered
Not Covered
Category
Podiatrists Psychologists Speech Pathologists Prescription Drugs Preventive Care
See Page 17 17 17 17 18
Covered
Service Maximum
(b)(4)
For women 40-49 years of age:

(b)(4)
Prosthetic Devices Reconstructive Surgery Self Help Programs Sleep Apnea Treatment Speech Therapy Supplemental Accidental Injury Benefit Surgery Temporomandibular Joint Disorder (TMD) Transplants Travel or Lodging Costs
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Vision Services (related to an illness or injury) Wigs or Hairpieces X-ray and Laboratory Services
Form Number: Wellmark IA Grp/AGC_ 1009
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20
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(b)(4) (b)(4)
50 years of age and older:
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Mammograms according to the following schedule unless recommended more frequently by your physician: For women 35-39 years of age: (b)(4)
(b)(4)
(b)(4)
per accident.
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3.
Details - Covered and Not Covered
All covered services or supplies listed in this section are subject to the general contract provisions and limitations described in this coverage manual. Also see the section General Conditions of Coverage, Exclusions, and Limitations, page 23. If a service or supply is not specifically listed, do not assume it is covered.
Acupuncture Treatment
Not Covered: Acupuncture and acupressure treatment.
Blood Administration
Covered: Blood administration. Not Covered: Blood. This exclusion does not apply to members with hemophilia.
Allergy Testing and Treatment

Covered.
Chemical Dependency Treatment
Ambulance Services
Covered: Professional air and ground ambulance transportation to a hospital or nursing facility in the surrounding area where your ambulance transportation originates.
All of the following are required to qualify for benefits:
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No other method of transportation is appropriate. The services required to treat your illness or injury are not available in the facility where you are currently receiving care if you are an inpatient at a facility. You are transported to the nearest hospital or nursing facility with adequate facilities to treat your medical condition.
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See Also:
Transplants later in this section.
Anesthesia
Covered: Anesthesia and the administration of anesthesia. Not Covered: Local or topical anesthesia billed separately from related surgical or medical procedures.
Form Number: Wellmark IA Grp/DE_ 1009
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See Also: See Also:
Not Covered.
Chemotherapy and Radiation Therapy

Covered: Use of chemical agents or radiation to treat or control a serious illness.
Cosmetic Services
Not Covered: Cosmetic services, supplies, or drugs unless provided primarily to restore function lost or impaired as the result of an illness, accidental injury, or a birth defect including treatment for any complications resulting from a noncovered cosmetic procedure. Reconstructive Surgery later in this section.
Counseling Services
Not Covered: Bereavement counseling or services (including volunteers or clergy), family counseling or training services, and marriage counseling or training services. Genetic Testing later in this section.
Dental Services
Covered: Dental treatment for accidental injuries when:
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Details Covered and Not Covered
Not Covered:
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General dentistry including, but not limited to, diagnostic and preventive services, restorative services, endodontic services, periodontal services, indirect fabrications, dentures and bridges, and orthodontic services. Injuries associated with or resulting from the act of chewing. Maxillary or mandibular tooth implants (osseointegration).
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Treatment is completed within six months of the injury. Anesthesia (general) and hospital or ambulatory surgical facility services related to covered dental services if: You are under age 14 and, based on a determination by a licensed dentist and your treating physician, you have a dental or developmental condition for which patient management in the dental office has been ineffective and requires dental treatment in a hospital or ambulatory surgical facility; or Based on a determination by a licensed dentist and your treating physician, you have one or more medical conditions that would create significant or undue medical risk in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical facility. Impacted teeth removal (surgical) as an inpatient or outpatient of a facility only when you have a medical condition (such as hemophilia) that requires hospitalization. Facial bone fracture reduction. Incisions of accessory sinus, mouth, salivary glands, or ducts. Jaw dislocation manipulation. Treatment of abnormal changes in the mouth due to injury or disease.
Dialysis
Covered: Removal of toxic substances from the blood when the kidneys are unable to do so when provided as an inpatient in a hospital setting or as an outpatient in a Medicare-approved dialysis center.
Education Services for Diabetes
Emergency Services
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Covered: When treatment is for a medical condition manifested by acute symptoms of sufficient severity, including pain, that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect absence of immediate medical attention to result in: Placing the health of the individual or, with respect to a pregnant woman, the health of the woman and her unborn child, in serious jeopardy; or Serious impairment to bodily function; or Serious dysfunction of any bodily organ or part.
In an emergency situation, if you cannot reasonably reach a PPO provider, covered services will be reimbursed as though they were received from a PPO provider. However, because we do not have contracts with nonparticipating providers and they may not accept our payment arrangements, you are responsible for any difference between the amount charged and our amount paid for a covered service. See Also: Nonparticipating providers, page 36.
Fertility Services
Covered: Fertility prevention, such as tubal ligation (or its equivalent) or vasectomy (initial surgery only).
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Not Covered: Diabetes education programs.
Genetic Testing
Covered: Genetic molecular testing (specific gene identification) and related counseling are covered when both of the following requirements are met:
The care is prescribed by a physician and approved by a Wellmark case manager.
The following are covered services and supplies: Home Health Aide Serviceswhen provided in conjunction with a medically necessary skilled service also received in the home. Home Skilled Nursing. Treatment must be given by a registered nurse (R.N.) or licensed practical nurse (L.P.N.) from an agency accredited by the Joint Commission for Accreditation of Health Care Organizations (JCAHO) or a Medicare-certified agency. Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting. The daily benefit for home skilled nursing services will not exceed the daily rate for a comparable level of care in a facility setting, and annual benefits will not exceed the total amount we would pay in one year for a comparable level of care in a facility setting. Home skilled nursing will be coordinated by a case manager. Custodial care is not included in this benefit. Inhalation Therapy. Medical Equipment. Medical Social Services. Medical Supplies. Occupational Therapybut only for services to treat the upper extremities, which means the arms from the shoulders to the fingers. You are not covered for occupational therapy supplies. Oxygen and Equipment for its administration. Parenteral and Enteral Nutrition.
See Also: Prior Approval, page 30.
Hearing Services
Covered:
Not Covered:

Home Health Services
You require a medically necessary skilled service such as skilled nursing, physical therapy, or speech therapy. Services are received from an agency accredited by the Joint Commission for Accreditation of Health Care Organizations (JCAHO) and/or a Medicare-certified agency. Services are prescribed by a physician and approved by our case manager for the treatment of illness or injury. Services are not more costly than alternative services that would be effective for diagnosis and treatment of your condition.
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Covered: All of the following requirements must be met in order for home health services to be covered:
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Hearing aids. Routine hearing examinations.
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Hearing examinations, but only to test or treat hearing loss related to an illness or injury.
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You are an appropriate candidate for a test under medically recognized standards (for example, family background, past diagnosis, etc.). The outcome of the test is expected to determine a covered course of treatment or prevention and is not merely informational.
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Physical Therapy. Prescription Drugs and Medicines administered in the vein or muscle. Prosthetic Devices and Braces. Speech Therapy. Not Covered: Custodial home care services and supplies, which help you with your daily living activities. This type of care does not require the continuing attention and assistance of licensed medical or trained paramedical personnel. Some examples of custodial care are assistance in walking and getting in and out of bed; aid in bathing, dressing, feeding, and other forms of assistance with normal bodily functions; preparation of special diets; and supervision of medication that can usually be selfadministered. You are also not covered for sanitaria care or rest cures. See Also: Case Management, page 31. Precertification, page 29.
Personal Convenience Items in the section General Conditions of Coverage, Exclusions, and Limitations, page 25. Prosthetic Devices later in this section. Prior Approval, page 30.
Hospice Services
Covered: Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice care covers the same services as described under Home Health Services, as well as hospice respite care from a facility approved by Medicare or by the Joint Commission for Accreditation of Health Care Organizations (JCAHO). Hospice respite care offers rest and relief help for the family caring for a terminally ill patient. Inpatient respite care can take place in a nursing home, nursing facility, or hospital. Hospice care must be precertified. Service Maximum:
(b)(4)
Covered: Equipment that meets all of the following requirements:
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Home/Durable Medical Equipment
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In addition, we determine whether to pay the rental amount or the purchase price amount for an item, and we determine the length of any rental term. Benefits will never exceed the lesser of the amount charged or the maximum allowable fee. See Also: Medical and Surgical Supplies later in this section. Orthotics later in this section.
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See Also:
days per lifetime for inpatient pice respite care. (b)(4) days per lifetime for outpatient spice respite care. Not more than (b)(4) days of hospice respite care at a time.
Precertification, page 29.
Hospitals and Facilities

Covered: Hospitals and other facilities that meet standards of licensing, accreditation or certification. Following are some recognized facilities: Ambulatory Surgical Facility. This type of facility provides surgical services on an outpatient basis for patients who do not need to occupy an inpatient hospital bed. Hospital. This type of facility provides for the diagnosis, treatment, or care of injured or sick persons on an inpatient and outpatient basis. The facility must
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be licensed as a hospital under applicable law. Nursing Facility. This type of facility provides continuous skilled nursing services as ordered and certified by your attending physician on an inpatient basis. A registered nurse (R.N.) must supervise services and supplies on a 24hour basis. The facility must be licensed as a nursing facility under applicable law.
Inhalation Therapy
Covered: Respiratory or breathing treatments to help restore or improve breathing function.
Maternity Services
Covered: Prenatal and postnatal care, delivery, including complications of pregnancy. A complication of pregnancy refers to a cesarean section that was not planned, an ectopic pregnancy that is terminated, or a spontaneous termination of pregnancy that occurs during a period of gestation in which a viable birth is not possible. Complications of pregnancy also include conditions requiring inpatient hospital admission (when pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. In accordance with federal or applicable state law, maternity services include a minimum of:
Illness or Injury Services

Covered: Services or supplies used to treat any bodily disorder, bodily injury, disease, or mental health condition unless specifically addressed elsewhere in this section. This includes pregnancy and complications of pregnancy. Treatment may be received from an approved provider in any of the following settings:

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See Also:
Precertification, page 29.
Not Covered:
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Infertility treatment if the infertility is the result of voluntary sterilization. Infertility treatment related to the collection or purchase of donor semen (sperm) or oocytes (eggs); freezing of sperm, oocytes, or embryos; surrogate parent services. Infertility diagnosis and treatment. Reversal of a tubal ligation (or its equivalent) or vasectomy.
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See Also:
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48 hours of inpatient care (in addition to the day of delivery care) following a vaginal delivery, or 96 hours of inpatient care (in addition to the day of delivery) following a cesarean section.
A practitioner is not required to seek Wellmarks review in order to prescribe a length of stay of less than 48 or 96 hours. The attending practitioner, in consultation with the mother, may discharge the mother or newborn prior to 48 or 96 hours, as applicable. If the inpatient hospital stay is shorter, coverage includes a follow-up postpartum home visit by a registered nurse (R.N.). This nurse must be from a home health agency under contract with Wellmark or employed by the delivering physician. Coverage Change Events, page 43.
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Medical and Surgical Supplies

Covered: Medical supplies and devices such as:

Not Covered:
Dressings and casts. Oxygen and equipment needed to administer the oxygen. Insulin syringes and supplies.
Weight reduction programs or supplies (including dietary supplements, foods, equipment, lab testing, examinations, and prescription drugs), whether or not weight reduction is medically appropriate.
Not Covered:
Elastic stockings or bandages including trusses, lumbar braces, garter belts, and similar items that can be purchased without a prescription.
Motor Vehicles
Home/Durable Medical Equipment earlier in this section. Orthotics later in this section. Prescription Drugs later in this section. Personal Convenience Items in the section General Conditions of Coverage, Exclusions, and Limitations, page 25. Prosthetic Devices later in this section.
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Mental Health Services

Not Covered.
Morbid Obesity Treatment
Covered: Weight reduction surgery provided you meet eligibility criteria for age and medical condition and history. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is strongly recommended. For information on how to submit a prior approval request, refer to Prior Approval in the Notification Requirements and Care Coordination section of this coverage manual, or call the Customer Service number on your ID card. For the criteria we use to determine prior approval, you may call the Customer Service number on your ID card or visit our Web site at www.wellmark.com.
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Not Covered:
See Also:
Not Covered: Purchase or rental of motor vehicles such as cars or vans. You are also not covered for equipment or costs associated with converting a motor vehicle to accommodate a disability.
Musculoskeletal Treatment
Covered: Outpatient nonsurgical treatment of ailments related to the musculoskeletal system, such as manipulations or related procedures to treat musculoskeletal injury or disease. Not Covered: Massage therapy.
Nonmedical Services
Not Covered: Such services as telephone consultations, charges for failure to keep scheduled appointments, charges for completion of any form, charges for medical information, and educational or recreational therapy or services or supplies that are nonmedical.
Occupational Therapy
Covered: Services are covered, but only those services to treat the upper extremities, which means the arms from the shoulders to the fingers. Occupational therapy supplies. Occupational therapy provided as an inpatient in the absence of a separate medical condition that requires hospitalization.
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CRST:000087
Orthotics
Not Covered: Orthotic foot devices such as arch supports or in-shoe supports, orthopedic shoes, elastic supports, or examinations to prescribe or fit such devices. See Also: Home/Durable Medical Equipment earlier in this section. Personal Convenience Items in the section General Conditions of Coverage, Exclusions, and Limitations, page 25. Prosthetic Devices later in this section.
Audiologists. Chiropractors. Doctors of Osteopathy (D.O.). Licensed Independent Social Workers. Medical Doctors (M.D.). Occupational Therapists. This provider is covered only when treating the upper extremities, which means the arms from the shoulders to the fingers. Optometrists. Oral Surgeons.
Physical Therapy
Covered.
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Not Covered: Physical therapy provided as an inpatient in the absence of a separate medical condition that requires hospitalization.
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Physicians and Practitioners
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Covered: Most services provided by practitioners that are recognized by us and meet standards of licensing, accreditation or certification. Following are some recognized physicians and practitioners: Advanced Registered Nurse Practitioners (ARNP). An ARNP is a registered nurse with advanced training in a specialty area who is registered with the Iowa Board of Nursing to practice in an advanced role with a specialty designation of certified clinical nurse specialist, certified nurse midwife, certified nurse practitioner, or certified registered nurse anesthetist.
17
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Not Covered: Most over-the-counter products, including nutritional dietary supplements. However, certain over-thecounter products prescribed by a physician may be covered. To determine if a particular over-the-counter product is covered, call the Customer Service number on your ID card.
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Podiatrists. Not Covered: See Also: Covered:
Over-the-Counter Products
Physical Therapists.
Physician Assistants. Psychologists. Psychologists must have a doctorate degree in psychology with two years clinical experience and meet the standards of a national register. Speech Pathologists. Athletic Trainers. Licensed Marriage and Family Therapists. Licensed Mental Health Counselors.
Choosing a Provider, page 27.
Prescription Drugs
Prescription drugs and medicines received as an inpatient or outpatient of a facility.
A prescription drug is one that bears the legend, Caution, Federal Law prohibits dispensing without a prescription.
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CRST:000088
L3V
Additional prescription drugs and medicines covered under this medical benefits plan include: Drugs and Biologicals. Drugs and biologicals approved by the Food and Drug Administration. This includes such supplies as globulin, serum, vaccine, antitoxin, or antigen used in the prevention or treatment of disease. Insulin. Intravenous Administration. Intravenous administration of nutrients, antibiotics, and other drugs and fluids when provided in the home (home infusion therapy). Self-Administered Injectable Drugs. Self-administered injectable drugs are generally covered under this medical benefits plan. Not Covered:
Oral contraceptives. Prescription drugs and devices used to treat nicotine dependence, including related medical evaluations, psychotherapy, and x-ray and lab services.
See Also: Medical and Surgical Supplies earlier in this section.
Preventive Care
Covered:

Prescriptions purchased from a retail pharmacy. Please note: Although your plan does not include benefits for prescription drugs at a pharmacy, you may save money when you use your ID card to fill prescriptions under your plan. Even though you must pay in full for any otherwise eligible prescription drug, the amount you pay at a participating pharmacy under this plan is the maximum allowable fee, which may be less than the charged amount that you would pay in the absence of your coverage. See Maximum Allowable Fee, in the Factors Affecting What You Pay section.
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Mammograms. Pap smears. However, you are not covered for the office examination in which the Pap smear is taken if the Pap smear is for a preventive physical examination. Normal newborn care (physician services provided to a baby during the mother's initial hospitalization).
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Service Maximum:
(b)(4)
Mammograms according to the following: For women between the ages of 35 (b)(4) 39: For women between the ages of 40 49: (b)(4)
For women age 50 and older:

(b)(4)
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Prior Authorization, page 32.
(b)(4)
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For this benefit, a year is 12 consecutive months. Mammograms may be more frequent if recommended by your physician. Not Covered:
Drugs purchased outside the United States. Contraceptive devices. Contraceptives absorbed through the skin. Implanted contraceptives. Injected contraceptives.
18
Routine foot care, including related services or supplies. Periodic physicals or health examinations, screening procedures, or immunizations performed solely for school, sports, employment, insurance, licensing, or travel.
CRST:000089
L3V
Gynecological examinations. Immunizations. Physical examinations including related services. Well-child care.
See Also: Hearing Services earlier in this section. Vision Services later in this section.
impaired as the result of an illness, injury, or a birth defect (even if there is an incidental improvement in physical appearance) including breast reconstructive surgery following mastectomy. Breast reconstructive surgery includes the following:
Covered: Devices used as artificial substitutes to replace a missing natural part of the body or to improve, aid, or increase the performance of a natural function. Also covered are braces, which are rigid or semi-rigid devices commonly used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Braces do not include elastic stockings, elastic bandages, garter belts, arch supports, orthodontic devices, or other similar items. Not Covered:
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Devices such as eyeglasses and air conduction hearing aids or examinations for their prescription or fitting. Elastic stockings or bandages including trusses, lumbar braces, garter belts, and similar items that can be purchased without a prescription.
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See Also:
Home/Durable Medical Equipment earlier in this section. Medical and Surgical Supplies earlier in this section. Orthotics earlier in this section. Personal Convenience Items in the section General Conditions of Coverage, Exclusions, and Limitations, page 25.
Reconstructive Surgery
Covered: Reconstructive surgery primarily intended to restore function lost or
Form Number: Wellmark IA Grp/DE_ 1009 19
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See Also: Not Covered:
Prior Approval, page 30. Cosmetic Services earlier in this section.
Self Help Programs

Not Covered: Self-help and self-cure products or drugs.
Sleep Apnea Treatment

Covered: Obstructive sleep apnea diagnosis and treatments. Not Covered: Treatment for snoring without a diagnosis of obstructive sleep apnea.
Speech Therapy
Covered: Rehabilitative speech therapy treatment. Speech therapy services not coordinated through home health services when the services are received through a home health agency. Speech therapy to treat certain developmental, learning, or communication disorders, such as stuttering and stammering.
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Prosthetic Devices
Reconstruction of the breast on which the mastectomy has been performed. Surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses. Treatment of physical complications of the mastectomy, including lymphedemas.
CRST:000090
L3V
Temporomandibular Joint Disorder (TMD)

Covered. Not Covered: Dental extractions, dental restorations, or orthodontic treatment for temporomandibular joint disorders.
Supplemental Accidental Injury Benefit

Covered: If you are injured accidentally and are treated within 90 days of the accident, you have supplemental accidental injury benefits. Please note: This supplemental accidental injury benefit is applied to charges relating to an accidental injury in the order received by us. In the event that your medical benefits plan already covers such charges, the supplemental accidental injury benefit will not be available. The supplemental accidental injury benefit only applies to:

Transplants
Travel or Lodging Costs

Not Covered.
Service Maximum:
(b)(4)
per accident.
Not Covered:

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Surgery

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Dental treatment. Disease or infection (except pyogenic infection occurring through an accidental cut or wound). Services or supplies excluded by your medical benefits plan.
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Covered. This includes the following: Major endoscopic procedures. Operative and cutting procedures. Preoperative and postoperative care.
See Also: Dental Services earlier in this section. Reconstructive Surgery earlier in this section.
L3V
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Hospital Services. Practitioner Services. Services of a Registered Nurse (R.N.). X-ray and Laboratory Services.
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Vision Services
Not Covered:
Covered: Vision examinations but only when related to an illness or injury. Surgery to correct a refractive error (i.e., when the shape of your eye does not bend light correctly resulting in blurred images). Eyeglasses or contact lenses, including charges related to their fitting. Eye exercises. Prescribing of corrective lenses. Eye examinations for the fitting of eyewear. Routine vision examinations.
Wigs or Hairpieces
Not Covered.
X-ray and Laboratory Services

Covered: Tests, screenings, imagings, and evaluation procedures as identified in the American Medical Association's Current Procedural Terminology (CPT) manual, Standard Edition, under Radiology Guidelines and Pathology and Laboratory Guidelines.
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Not Covered: All services or supplies related to transplants, treatment, and complications, including ambulance services for transplants.

CRST:000091
See Also: Preventive Care earlier in this section.
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CRST:000093
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CRST:000094
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CRST:000095
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CRST:000096
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CRST:000097
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CRST:000098
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CRST:000099
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CRST:000100
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CRST:000101
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CRST:000102
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CRST:000103
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CRST:000104
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CRST:000105
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CRST:000106
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CRST:000107
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CRST:000108
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CRST:000109
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CRST:000110
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CRST:000111
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CRST:000112
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CRST:000113
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CRST:000114
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CRST:000115
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CRST:000116
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CRST:000117
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CRST:000118
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CRST:000119
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CRST:000120
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CRST:000121
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CRST:000122
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CRST:000123
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CRST:000124
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CRST:000125
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CRST:000126
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CRST:000127
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CRST:000128
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CRST:000129
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CRST:000130
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CRST:000131
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CRST:000132
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CRST:000133
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CRST:000134
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CRST:000135
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CRST:000136
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CRST:000137
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CRST:000138
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CRST:000139
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CRST:000140
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CRST:000141
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CRST:000142
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CRST:000143
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CRST:000144
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CRST:000145
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CRST:000146
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CRST:000147
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CRST:000148
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CRST:000149
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CRST:000150
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CRST:000151
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CRST:000152
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CRST:000153
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CRST:000154
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CRST:000155
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CRST:000156
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CRST:000157
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CRST:000158
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CRST:000159
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CRST:000160
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CRST:000162
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CRST:000163
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CRST:000166
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CRST:000169
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CRST:000171
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CRST:000173
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CRST:000178
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From: Scelzo, Kathleen (HHS/OCIIO) Sent: Thursday, November 04, 2010 11:56 AM To: 'bwilley@crst.com' Cc: Habit, Sandra (HHS/OCIIO) Subject: CRST Internation Waiver Application Attachments: CRST International Waiver Application Questions.doc
Brooke Willey, I left you a message yesterday about CRST Internation application for Annual Limits Requirements of the PHS Act Section 2711. Attached above is the document that needs to be completed in order to finalize the application process. Many thanks for your assistance with this document. Kathleen M. Scelzo, RN, MSN Rules Compliance Division Office of Insurance Oversight Office of Consumer Information and Insurance Oversight (OCIIO) Department of Health and Human Services 7501 Wisconsin Avenue Bethesda, MD 301-492-4121
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CRST:000200
file:////co-adshare/...FOI%20Processing%20Team/Brandon/CRST%20International/Request%20for%20Additional%20Info%2011.4.10.htm[11/09/2011 5:19:50 PM]
Dear Applicant: RE: CRST International:
November 4, 2010
1. Effective date of policy.
EE
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EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)
4. Type of Plan: Limited Benefit Comprehensive
3. Indicate if the plan is fully-insured plan or a self-insured plan. Prescription Other HRA
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2. (The premium amounts is the total cost to the employer and the employee) Premium Premium Premium % increase if the (current level) (renewal) (if $750,000 $750,000 was annual limit was implemented applied)
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Thank you for your application for the Waiver of the Annual Limits Requirements of the PHS Act Section 2711. In order to complete your application, please provide the following information about the CRST International Plan:
CRST:000201
Please provide this information by 5:00 pm, Monday November 8, 2010. We look forward to receiving your completed application. Thank you. Sincerely, Kathleen M. Scelzo, RN, MSN Rules Compliance Division Office of Insurance Oversight Office of Consumer Information and Insurance Oversight (OCIIO) Department of Health and Human Services 301-492-4121
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CRST:000202
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From: BWilley@crst.com Sent: Thursday, November 04, 2010 7:09 PM To: Scelzo, Kathleen (HHS/OCIIO) Cc: Habit, Sandra (HHS/OCIIO) Subject: Re: CRST Internation Waiver Application Attachments: CRST International Waiver Application Questions.doc; CRST International Waiver Application Questions.doc
Kathleen Attached please find the completed application, per your email. Should you have any questions, please feel free to contact me at the number listed below. Kind regards,
From: To: Cc: Date: Subject:
"Scelzo, Kathleen (HHS/OCIIO)" <Kathleen.Scelzo@hhs.gov> "'bwilley@crst.com'" <bwilley@crst.com> "Habit, Sandra (HHS/OCIIO)" <Sandra.Habit@hhs.gov> 11/04/2010 10:56 AM CRST Internation Waiver Application
Brooke Willey, I left you a message yesterday about CRST Internation application for Annual Limits Requirements of the PHS Act Section 2711. Attached above is the document that needs to be completed in order to finalize the application process. Many thanks for your assistance with this document. Kathleen M. Scelzo, RN, MSN Rules Compliance Division Office of Insurance Oversight Office of Consumer Information and Insurance Oversight (OCIIO) Department of Health and Human Services 7501 Wisconsin Avenue Bethesda, MD 301-492-4121
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CRST:000203
Brooke Willey, VP - Human Resources CRST International, Cedar Rapids, IA direct: 319/390-2856 cell: (b)(6)
file:////co-adshare/...essing%20Team/Brandon/CRST%20International/Request%20for%20Additional%20Info%20Response%2011.4.10.htm[11/09/2011 5:20:00 PM]
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November 4, 2010
1. Effective date of policy.
EE
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EE + Child (if applicable or other appropriate tier) EE + Spouse (if applicable or other appropriate tier) Family (if applicable or other appropriate tier)
4. Type of Plan: Limited Benefit Comprehensive
3. Indicate if the plan is fully-insured plan or a self-insured plan. Prescription Other HRA
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CRST:000204
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CRST:000205
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November 4, 2010
1. Effective date of policy. The policy is a calendar year policy and is in effect on January 1 of each calendar year, since inception of 1/1/02.
EE
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EE + Child (if NA applicable or other appropriate tier) EE + Spouse (if NA applicable or other appropriate tier) Family (if applicable or other appropriate tier)
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NA NA
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(b)(4)
NA
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3. Indicate if the plan is fully-insured plan or a self-insured plan. The plan is self insured. x Prescription (discounts) Other HRA
4. Type of Plan: x Limited Benefit Comprehensive
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NA NA
CRST:000206
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From: Botwinick, Alexandra (HHS/OCIIO) Sent: Monday, November 15, 2010 9:48 AM To: 'bwilley@crst.com' Subject: Waiver of the Annual Limits Requirements of PHS Act Section 2711 Importance: High Attachments: Updated Jan 1 Approval Letter .pdf Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section for CRST International. HHS has reviewed your application and made its determination. Please see the attached letter. Please confirm receipt of this letter by replying to this e-mail address with a copy to OCIIOOversight@hhs.gov. Please let me know if I can be of further assistance. Sincerely,

alexandra.botwinick@hhs.gov
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Alexandra Botwinick Office of Oversight HHS/OCIIO
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CRST:000208
file:////co-adshare/...orres/DFOI%20Processing%20Team/Brandon/CRST%20International/Approval%20Letter%20Sent%2011-15-2010.htm[11/09/2011 5:20:17 PM]
CRST:000209
CRST:000210
From: BWilley@crst.com Sent: Monday, November 15, 2010 10:03 AM To: Botwinick, Alexandra (HHS/OCIIO) Cc: OCIIO Oversight Subject: Re: Waiver of the Annual Limits Requirements of PHS Act Section 2711
Alexandra This email confirms receipt of this correspondence. Kind regards, Brooke Brooke Willey, VP - Human Resources CRST International, Inc. 3930 16th Ave SW Cedar Rapids, IA 52406 direct: 319/390-2856 bwilley@crst.com www.crst.com
This email (including any attachments) is covered by the Electronic Communications Privacy Act, 18USC,2520-2521. It is confidential and may be legally privileged. If you are not the intended recipient, you are hereby notified that any retention, dissemination, distribution, or copying of this communication is strictly prohibited. Please reply to the sender that you have received the message in error and then delete it. Thank you.
From: To: Date: Subject:
"Botwinick, Alexandra (HHS/OCIIO)" <Alexandra.Botwinick@hhs.gov> "'bwilley@crst.com'" <bwilley@crst.com> 11/15/2010 08:48 AM Waiver of the Annual Limits Requirements of PHS Act Section 2711
Good Morning, Thank you for submitting an application for a Waiver of the Annual Limits Requirements of the PHS Act Section for CRST International. HHS has reviewed your application and made its determination. Please see the attached letter. Please confirm receipt of this letter by replying to this e-mail address with a copy to OCIIOOversight@hhs.gov. Please let me know if I can be of further assistance. Sincerely,

Alexandra Botwinick Office of Oversight HHS/OCIIO
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CRST:000211
file:////co-adshare/...OI%20Processing%20Team/Brandon/CRST%20International/Confirmation%20of%20Receipt%20of%20Approval.htm[11/09/2011 5:20:18 PM]
alexandra.botwinick@hhs.gov
[attachment "Updated Jan 1 Approval Letter .pdf" deleted by Brooke Willey/crst_inc]
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pl
et eC
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CRST:000212
file:////co-adshare/...OI%20Processing%20Team/Brandon/CRST%20International/Confirmation%20of%20Receipt%20of%20Approval.htm[11/09/2011 5:20:18 PM]
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CRST International - Redacted HWM

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From: BWilley@crst.com Sent: Tuesday, October 19, 2010 11:30 AM To: HHS HealthInsurance (HHS) Cc: jbarnes@crst.

file:////co-adshare/...rocessing%20Team/Brandon/CRST%20International/Waiver%20Application%20-%20CRST%20International%20.htm[11/09/2011 5:19:44 PM]

Office Phone 319/390-2856 Office Fax 319/731-3954

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