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HHRC-EOC 02.10.2017 i Evidence of Coverage <br />EMPLOYEE ASSISTANCE PROGRAM <br />COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM <br />TABLE OF CONTENTS <br />I. DEFINITIONS .............................................................................................................................................. 2 <br />II. HOW TO OBTAIN BENEFITS................................................................................................................... 3 <br />III. EMERGENCY SERVICES..........................................................................................................................3 <br />IV. CRISIS INTERVENTION ........................................................................................................................... 4 <br />V. PREPAYMENT OF FEES ........................................................................................................................... 4 <br />VI. CHOICE OF EAP PROVIDERS.................................................................................................................4 <br />VII. FACILITIES .................................................................................................................................................. 5 <br />VIII. LIABILITY OF PLAN / MEMBERS .......................................................................................................... 5 <br />A. LIABILITY OF PLAN ................................................................................................................................... 5 <br />B. LIABILITY OF MEMBERS ........................................................................................................................... 5 <br />C. MEMBER LIABILITY TO NON-EAP PROVIDERS ......................................................................................... 5 <br />IX. PROVIDER COMPENSATION .................................................................................................................. 5 <br />X. SECOND OPINION POLICY ..................................................................................................................... 5 <br />XI. ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE ............................................... 6 <br />XII. TERMINATION OF BENEFITS ................................................................................................................ 6 <br />A. CANCELLATION OF GROUP CONTRACT FOR NONPAYMENT OF PREMIUMS ................................................6 <br />B. REINSTATEMENT OF THE CONTRACT AFTER CANCELLATION .................................................................... 7 <br />C. MEMBER TERMINATION FOR NON-ELIGIBILITY ........................................................................................ 7 <br />D. TERMINATION FOR GOOD CAUSE .............................................................................................................. 7 <br />XIII. CONTINUITY OF CARE ............................................................................................................................ 8 <br />A. NEW MEMBERS ......................................................................................................................................... 8 <br />1) Eligibility........................................................................................................................................... 8 <br />REV: 03-10-23 MI <br />ATTY/AGR.2023.039/Aetna (EAP Services Agreement) (Page 23 of 42)