HomeMy WebLinkAbout1994-009 Employee Benefits ORDINANCE NO. 94 - 9
AN ORDINANCE relating to employee benefits,
adopting an Employees' Welfare Benefit
Program; approving Participation Agreements
with certain groups of employees represented
by collective bargaining agents; adding a new
section to chapter 2.04 of the Yakima
Municipal Code amending section 2.20.094D and
chapter 3.10 of the City of Yakima Municipal
Code; repealing Chapter 3 09 of the Yakima
Municipal Code, and providing for related
matters
WHEREAS, chapter 41.56 RCW authorizes and requires the City
IIIP of Yakima ( "City ") to engage in collective bargaining with duly
' authorized representatives of employees with respect to benefits,
WHEREAS, chapter 41.56 RCW authorizes the City to engage in
interest arbitration with respect to benefits for such employees,
WHEREAS, chapter 48.62 RCW authorizes the City to self -
insure risks individually or jointly with other governmental
agencies or subdivisions thereof and to engage in related
activities,
WHEREAS, the City deems it necessary and advisable to adopt
an employee welfare benefit program in order to coordinate
various employee benefit plans and to improve consistency among
employee benefits;
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WHEREAS, the City deems it necessary and advisable to enter
into agreements with duly represented groups of employees to
establish the terms for their participation in the employee
welfare benefit program,
WHEREAS, the City deems it necessary and advisable to allow
inclusion of city council members in the employee welfare benefit
program,
WHEREAS, the City is a participant in the Yakima Air
Terminal established pursuant to interlocal agreement,
WHEREAS, the City deems it necessary and advisable to allow
the Yakima Air Terminal to join in the City's self- insurance plan
upon adoption by the Air Terminal Board of the City's employee
welfare benefit program and plans thereunder,
NOW, THEREFORE, BE IT ORDAINED BY THE CITY OF YAKIMA
Section 1 A new section 2 04.100 is hereby added to
chapter 2 04 of the Yakima Municipal code to read as follows
A The City of Yakima Employees' Welfare Benefit
Program, attached as appendix 1 hereto and incorporated
herein by reference, is adopted and approved.
B. The City Manager, or his designee, shall be
authorized and directed to perform all management,
administration and other responsibilities of the City under
the City of Yakima's Employees' Welfare Benefit Program,
except as expressly provided by such Program or as required
by law.
C. The Participation Agreements between the City and
the Washington State Council of County and Municipal
Employees, Washington State Council of County and City
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• Employees, AFSCME, Local 1122, AFL -CIO ( "AFSCME "); Yakima
Pol ±ice' Patrolmans Association' ( "YP ?A" )°and Local 469,
international Association of r'irefighters, AFL -CIO, attached
hereto as appendices 2, .3, 4 and 5, respectively and
incorporated herein by reference, are approved, and the City
Manager is authorized and directed to execute said
participation agreement
D The Yakima Air Terminal may join the City's
employee welfare benefit program and its management
employees and duly represented employees may participate in
plans thereunder by action of the Airport Terminal Board
E. In the event that there is a conflict between any
provision ot this section or any provision ot the Employee
Weltare Benefit Program and any other section ot this
chapter, this section and the Employee Weltare Benefit
Program shall take precedence
Section 4 Section 2.20.94D of the Yakima Municipal Code
is amended to read as follows
D Fringe Benefits. Commencing January 1, 1992,
members of the city council, including the mayor and
assistant mayor, shall receive no compensation for
serving as mayor, assistant mayor, or councilmember
other than the salary provided by subsections A, B
and C of this section, and the following additional
benefits, which are authorized
1. Reimbursement for expenditures as provided by
Section 2 20.086 of this chapter;
2. Protection of a five thousand dollar life
insurance policy, with the premium fully paid by the
city,
3 Protection of Workmen's Compensation
Insurance coverage under the State Industrial Insurance
system;
4. Protection by a policy of insurance known
variously as professional liability insurance or errors
and omission insurance, covering councilmembers acting
in their official capacity, with coverage in the same
amount as obtained from time to time for the protection
of other city officers and employees, with the premium
fully paid by the city;
5. Payment by the city of its portion of Social
Security payroll tax on earnings of councilmembers; and
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any other benefits expressly required by applicable
laws,-
— 6 Participation in the city employee welfare
benefit program established by section 2 U4 100 of this
cnapter, provided that an election and payment are made
as provided in section 2.04.030 D.4 of this chapter
Section 3 Chapter 3.09 of the Yakima Municipal Code is
hereby repealed
Section 4 Chapter 3 10 of the Yakima Municipal Code is
amended to read as follows.
3 10 010 Fund created -- Purpose.
There is created a fund to be known as the
employee welfarehcalth benefit reserve fund The
purpose of such fund shall be for the payment
oftransfcr of moncy from that fund to the employee
welfarehcalth benefit claims fund in order to pay for
medical, and dental and other covered costs incurred by
persons covered by ante employee welfarehcalth benefit —
plan of the city, aTIU to pay expenses incurred in
connection with administering the city's employee
welfare benefit program and employee welfare benefit
plans . (Ord. 2311 § 2 (part), 19/9)
3 10 020 Source of Funds
All money to bc refunded to he city by the
Great West Life As3urancc Company on account of tho
termination of incurancc policies cxicting on tho
effective date of thc ordinance codified in thin
chapter with that company shall bc deposited in thc
cmploycc hcalth bcncfit reserve fund.
A$ All money to be applied to pay for the
benefits to employees covered by a citythe employee
welfarehcalth benefit plan, and to otherwise finance
the administration of sucht plans and of the city's
employee welfare benefit program, whether that money be
paid directly by the city or deducted from employees'
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4111
salaries or wages, shall be deposited in the employee
welfareh benefit reserve fund.
36. Money designated by the city council from any
other available source for the purpose of paying for
benefits under, or financing the administration of,
an -e employee welfarehcalth benefit plan also shall be
deposited in the employee welfarehcalth benefit reserve
fund. (Ord. 2311 S 2 (part) , 19 !9) .
3.10.030 Expenditures.
epprove3 Such cxpcndittirc by cnacting an ordinance
appropriating money within that -Poei for thc purpooc
for which thc expenditure i3-to be made, or by
budget, 441-4.- 2311 5 2 (part), 1979).
4111 Expenditures may be made from the employee welfare
b enefit reserve fund by warrants drawn against such
fund only for the purposes specified in
Section 3.1U.U1U or this chapter.
Section 5. If any provision of this ordinance is
declared by a court of competent jurisdiction to be void or
unenforceable, then the remaining provisions shall remain
enforceable.
Section 6. This ordinance shall be effective thirty (30)
days after its passage, approval and publication as provided by
law and the City Charter.
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PASSED BY THE CITY COUNCIL, signed and approved this 22 " d day
of February , 1994
CITY OF YAKIMA, WASHINGTON
B y (T;
Mayor
ATTEST
City Clerk
Publication Date 2 -25 -94
Effective Date 3 -27 -94
Erot t DOC
ED 2J17/94 2 41 PM
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APPENDIX I
CITY OF YAKIMA
EMPLOYEES' WELFARE BENEFIT PROGRAM
TABLE OF CONTENTS
Page
Article I
Purpose and Term
1 Purpose 4
2 Term of Program 4
Article II
Definitions
Article III
The Board
1 The Program 8
2 Number of Board Members 8
3 Identity of Present Board 9
4 Appointment of Additional or Successor Board Members 10
5 Board Member Liability 10
6 Term of Appointment 10
7 Termination of Appointment by Employee Group 11
8 Recommendation for Termination of Appointment for Failure to Attend Meetings 11
9 Resignation of Appointment 11
10 Vacancies 12
11 Return of Books and Records 12
12 Manner of Voting 12
13 Super Majority Vote 12
14 Constitution of a Quorum 13
15 Motions i 13
16 Regular Meetings 13
17 Special Meetings 13
18 Appointment of Chairman and Vice - Chairman 14
19 Duties of Chairman and Vice - Chairman 14
20 Board Expenses 14
21 Benefits to Board Members Not Prohibited 14
Article IV
Allocation or Delegation of Board Responsibilities
1 Allocation of Responsibilities to Committees 15
Article V
Board Responsibilities
1 General Responsibilities 15
2 Existing and Future Benefit Plans 16
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• Page
3 Additional Benefit Plans 16
4 Design of the Benefit Plans 16
5 Means of Providing Benefits 17
6 Administrative Agent 17
7 Other Professional and Nonprofessional Help 17
8 Benefit Fund Amounts 18
9 Records 18
10 Procedure for Review of Benefit Claims 18
Article VI
City Responsibilities
1 Program Administration 18
2 Contributions and Paid Benefits 19
3 Application of Benefit Fund Assets 19
4 Agents for Service of Process 20
5 Investment 20
6 Annual Audit 20
7 Program Description 21
• 8 Documents to be Examined or Furnished 21
9 All Records 21
Article VII
Dispute Resolution Process
1 The Process 22
Article VIII
Amendments and Termination
1 Amendments 23
2 Termination of Entire Agreement 23
3 Allocation Upon Termination 24
4 Withdrawal of a Participating Employee Group 24
5 Benefit Fund Reserves - Participating Employee Group Withdrawal 25
Article IX
Enrollment into the Health Benefit Program
1 Initial Enrollment, Existing Employee Groups 25
2 Enrollment of Future Employee Groups 26
3 Enrollment of Withdrawn and Nonenrolled Employee Groups 26
• Article X
Severability
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CITY OF YAKIMA
EMPLOYEES' WELFARE
BENEFIT PROGRAM
INTRODUCTION
For years the City of Yakima has discussed the idea of the consolidation of all employee
groups health and dental insurance plans into a smaller, more manageable number of plans and
provide employees a larger group base to pool health and welfare benefit costs As medical costs
continued to spiral upwards, it was recognized that employees needed to be educated and better
informed regarding the use and costs of health insurance The continued nse in health care costs
411
led to protracted contract negotiations between the City and the Amencan Federation of State,
County and Municipal Employees ( "AFSCME") bargaining unit including discussions regarding
their leaving the City's self - insured program With the settlement of the 1989 -1991 AFSCME
collective bargaining agreement, the first employee /employer point health insurance committee
was formed, the AFSCME Joint Committee on Health Insurance (the "Committee ") The
Committee was comprised of four AFSCME members and four City representatives The
purpose of the committee was "to study and become informed regarding health insurance
programs including the City's modified self - funded program, to identify perceived and real
problems, and make recommendations to the City and the Union on ways to improve and enhance
in an economical fashion the health insurance program." Further, the Committee was to explore
the concept of a trust fund specifically for AFSCME employees and establishing a completely
separate health insurance program for AFSCME employees
• The AFSCME Joint Committee on Health Insurance began meeting late 1990 and met on
a weekly basis carefully scrutinizing the benefits contained within City's Health Benefit Program,
how the program is administered, how premium rates are established, trust insurance programs of
other employers and studying health insurance as a whole Dunng the course of the committee's
study, the topic of consolidating the seven divisions within the City's self - insured program was
discussed at length Through these discussions it became apparent to members of the Committee
that it would be advantageous to Employees and the City to consolidate plans into one self -
insured program
Durin: the same time that the AFSCME Joint Committee on Health Insurance was
meeting. the City and the Fire Law Enforcement Officer and Fire Fighter ( "LEOFF ") bargaining
unit was embroiled in lengthy contract negotiations covering several years, the dispute centered
• on multiple topics one of which was health insurance and the LEOFF's ability to leave the City's
self - insured health program Settlement was reached in 1992 and the parties agreed to establish a
Fire Health Insurance Comnttee to study the current program as well as alternative programs
The Committee was comprised of Fire LEOFF and Fire Public Employees Retirement System
( "PERS ") representatives and the City Management representatives
The City and AFSCME Joint Health Insurance Committee suggested that it would be
beneficial to all parties if the Fire Health Committee could take advantage of what had been
learned by the AFSCME Committee either by inviting some of the AFSCME members to
participate in the meetings or possibly to link the two committees together In light of the
AFSCME discussion on consolidating the health care plans, it was suggested that the two
Committees join forces to study health insurance as well as consolidation of the plans. At the
same time an invitation was extended to the Yakima Police Patrolman's Association to join the
Committee and in late 1992 the City -wide point health care committee began.
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On January 12, 1993 the AFSCME Joint Health Insurance Committee met with the City 411
Council and explained the history of the Committee, its accomplishments and the future of the
City's self - insured health care plan. Considerable time was spent discussing the consolidation of
all employee groups and the concept was supported by the Council
On February 24, 1993 the City -wide Health Insurance Committee met with Executive
Board representative of all organized employee groups, AFSCME, Yakima Police Patrolmans
Association ( "YPPA "), Fire LEOFF and Fire PERS plus representatives of the management group
including Police, Fire and General Management, Supervisors and Confidential employees The
history of the AFSCME Committee was shared and how it evolved into a City -wide Committee
plus the accomplishments of the Committee up to February 1993 The need for consolidating all
groups was explained and the administrative steps to accomplish that end was outlined
411
The City -wide Employees' Health & Welfare Committee has, dunng 1993, drafted a
Program establishing a Board to assist in the management of the City's Employees' Health &
Welfare program Representatives from all recognized employee groups within the City of
Yakima are included The Committee has prepared recommendations for benefits contained
within the Health & Welfare Plan and along with this document are ready to share the new
program with City employees
The Yakima Air Terminal is Jointly operated by the City and Yakima County Air
Terminal employees currently participate in medical plans sponsored by the City The City desires
to permit the Yakima Air Terminal Board to adopt the Program and Plans so that its employees
may participate in the Plans Neither the Yakima Air Terminal nor Yakima County will have any
control over the Program or Plans
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• THEREFORE, effective April 1, 1994, the City hereby adopts the following Employees'
Welfare Benefit Program ( "Program ") to establish and maintain Employee Welfare Benefit Plans
for the benefit of eligible employees and retirees of the City and of the Yakima Air Terminal, and
the Beneficiaries of all such employees and retirees
Article I
Purpose and Term
1 Purpose
The purpose of the Employees' Welfare Benefit Program is to provide procedures for
establishing and maintaining Employee welfare benefits for the City's and the Air Terminal's
0 eligible employees and retirees and their beneficianes The Program itself is not an Employee
Welfare Benefit Plan The Program sets forth the rules for establishing and adnumstenng some of
the City's Welfare Benefit Plans In order for represented Employee Groups to participate in the
Plans administered through the Program, the groups' collective bargaining agents must enter into
Participation Agreements with the City agreeing to amend any underlying collective bargaining
agreements so as to participate in the Plans established and maintained through the Program.
The Program shall be administered and managed by the City However, the Board
established by this Program and comprised of employee representatives shall have the nght, as set
forth herein, to make recommendations to the City regarding the management of the Program.
2 Term of Program
• The Program shall be effective as of Apnl 1, 1994, and shall continue indefinitely until
such time as it may be terminated in accordance with Article VIII herein.
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Article 11
Definitions
The following definitions apply to this Program
1 "Air Terminal" -- the entity jointly operated by the City and Yakima County
pursuant to the Joint Air Terminal Operations Agreement between the City and Yakima County
dated June 30, 1982, as amended ( "Airport Agreement ") Neither the Air Terminal Board (as
defined in the Airport Agreement) nor Yakima County shall participate in or have any authonty
with respect to the establishment, amendment or administration of the Program or Plans
2 "Beneficiary" -- any dependent of a Participating Employee, who is entitled to
benefits as defined in a benefit plan, also, any person designated by a Participating Employee or
dependent, or by the terms of a benefit plan, to receive benefits upon the death of such
Participating Employee or dependent.
3 "Benefits" or "Plan Benefits" or "Employee Welfare Benefits" -- the benefits
provided by a Plan
4 "Benefit Fund" -- formerly called the Employees' Health Benefit Reserve Fund,
now called the Employees' Welfare Benefit Reserve Fund, a separate account of the City
designated by Chapter 3 10 of the Yakima Municipal Code as a source of funding for the
Program's Plan benefits The Benefit Fund is not a trust
5 "Board" -- the body created under Article III of this Program representing
Participating Employee Groups
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•
6 "City" -- the City of Yakima, a municipal corporation under the laws of the State
of Washington The City is the Plan Administrator, the entity responsible for managing and
administering the Program and the Plans under the Program As Plan Administrator, the City is
responsible for the day to day functions and management of the Plans The City may employ
persons or firms to process claims and perform other Plan connected services
7 "Contributions" -- the payments of premiums required of the City or of the Air
Terminal for their respective employees. or premiums by Participating Employees paid through
payroll or pension deductions or otherwise, pursuant to the terms of a collective bargaining
agreement, Participation Agreement, ordinance or resolution, for the purpose of providing
Employee Welfare Benefits to the employees and retirees covered by any such agreement,
• ordinance or resolution and their Beneficianes The Participating Employee's portion of
premiums for Welfare Benefit Plan coverage may be paid through a cafetena plan pursuant to
Section 125 of the Internal Revenue Code of 1986, as amended The Board may recommend to
the City which plans should be part of the cafeteria plan
8 "Employee Group" -- a group of employees of the City or Air Terminal
represented by a collective bargaining representative or that group of City or Air Terminal
Management employees not covered by any collective bargaining agreement with the City or Air
Terminal
9 "Participating Employee" -- any individual employed by the City or the Air
Terminal and for whom contributions are made to the Plans pursuant to the terms of a City
ordinance or resolution, Air Terminal Board resolution, collective bargaining agreement or
0 Participation Agreement and any eligible retirees.
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10 "Participating Employee Grou " -- any represented or nonrepresented group of III
1 P g P Y P P g P
Participating Employees of the City or of the Air Terminal including employees represented by
AFSCME 1122, IAFF 469, YPPA, and non - represented City Management employees This is not
an exclusive list and may be modified in the future as new employee groups are recognized by the
City and elect to participate in the Program. For purposes of this Program and the Plans,
members of the City's City Council and nonrepresented employees of the City and of the Air
Terminal shall be treated as City Management employees
11 "Participation Agreement" -- a written agreement entered into between the City
and the union representing a Participating Employee Group, and any supplement, amendment,
continuation, or renewal thereof, for the purpose of amending any underlying collective
bargaining agreement to provide employee Benefits under the Program to the eligible employees
and retirees covered by the collective bargaining agreement, and their beneficianes
0
12 "Plan" -- or "Employee Welfare Benefit Plan" or "Benefit Plan" -- any lawful
employee welfare benefit plan including but not limited to medical, dental, vision, prescnption
drug, life insurance, disability income (salary insurance), preventative health care, and cafeteria
plans For each type of welfare benefit plan under the Program, there is a separate benefit plan for
each Participating Employee Group (or subgroup thereof) which receives different benefits under
the Plan or has different Contribution rates Separate plans are established for each Participating
Employee Group (or subgroup thereof) with different plan benefits or Contribution rates pursuant
to Sections 105(h)(2) and (4) of the Internal Revenue Code of 1986 The initial Plans under the
Program shall be substantially in the form attached hereto as Exhibit A, and may be amended from
time to time
41/
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III 13 "Plan Sup•. rvisor" -- the person or group providing administrative services to the
City in connection with the operation of the Plan and performing such other functions, including
processing and payment of claims, as may be delegated to it by the City
14 "Program" -- City of Yakima Employees' Welfare Benefit Program
Article ID
The Board
1 The Program
The Program shall be subject to ongoing review by the Board The Board may make
4110 recommendations regarding Program and Plan management to the City
2 Number of Board Members
The Board may consist of both voting and nonvoting members ( "Board Members ") Each
Board Member must be a City employee Upon termination of employment, the Board Member
shall be replaced (See Section 4 in this Article)
Initially there shall be ten (10) voting Board Members. Each represented Participating
Employee Group shall appoint or elect its representatives (if any) to the Board. The City
Management employees shall be represented by the City's Director of Finance and Budget and the
City's Deputy Personnel Officer or their designees. The initial number of voting Board Members
will be four AFSCME, two YPPA, two IAFF, and two members representing City Management
employees
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The number of Board Members representing each Participating Employee Group shall
0
remain as set forth above in this Section 2 until the Board agrees to change the number of Board
Members for each group The Board shall meet annually to reassess whether the number of
Board Members which represent each Participating Employee Group should be changed If a new
Employee Group is recognized by the City, the Board shall meet within 30 calendar days of
recognition to determine the group's representation on the Board, if any, including the number of
voting or non - voting Board Members that will represent the group and, if voting representations
is allowed, whether the group will be allowed to elect or adopt its own Board Member(s) or will
be represented by current Board Members
3 Identity of Present Board
The voting Board Members serving as of April 1, 1994 are as follows
III
AFSCME 1 Mel Young
2 Clara Sanders
3 Jared Sweesy
4 Bob Desgrosellier
YPPA. 1 To Be Determined
2 _To Be Determined
IAFF 1 _To Be Determined
2 _To Be Determined
City Mgt 1 Director of Finance and Budget or designee
2 Deputy Personnel Officer or designee 0
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III
4 Appointment of A iitional or Successor Board Members
In the event of the termination of appointment, resignation, termination of employment or
death of a Board Member, a successor Board Member shall be appointed or elected by the
represented Participating Employee Group In the event of the termination of employment or
death of the City's Director of Finance and Budget or Deputy Personnel Officer, his or her
successor or designee shall assume the vacated Board position Such appointment shall be
effective as of the date specified in a written notice of the appointment or the date of delivery of
0 the written notice to the Board Chairman, whichever is later
5 Board Member Liability
Each Board Member who has accepted his /her appointment and agrees to abide by the
terms and provisions of this Program is carrying out his or her duties as a City employee and, as
such, will be covered by the City's indemnification provisions as set forth in City Council
Resolution No D 5820 The City may in its discretion provide errors and omissions or personal
liability coverage for Board Members by purchasing insurance
6 Term of Appointment
Each Board Member shall serve until termination of appointment, resignation, termination
of employment or death.
III
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7 Termination of Appointment by Employee Group 0
The appointment of a Board Member may be terminated, at any time, by a represented
Participating Employee Group in accordance with its election or appointment procedures or by
the City for non - represented City Management Board Members
The termination of a Board Member's appointment shall be effective upon the termination
date specified in a wntten notice of termination or the date of delivery of the notice of termination
to the Board Chairman, whichever is later
8 Recommendation for Termination of Appointment for Failure to Attend
Meetings
0
The Board may recommend that the appointment of a Board Member be terminated if
such Board Member fails to attend three (3) consecutive meetings of the Board, without being
excused from attendance by specific action of the remaining Board Members The notification is
to be forwarded to the appropriate Participating Employee Group and the City
9 Resignation of Appointment
A Board Member may resign his/her appointment at any time Such resignation shall be
effective upon the resignation date specified in a written notice of resignation or the date of
delivery of the notice of termination to the Board Chairman, whichever is later
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• 10 Vacancies
No vacancy in the position of Board Member shall impair the power of the remaining
Board Members to take action so long as a quorum exists as specified
1 1 Return of Books and Records
In the event of the termination of appointment, resignation, termination of employment or
death of a Board Member, the Board Member (or the Board Member's legal guardian, heirs or
personal representative) shall, upon the request of the Chairman or the Secretary of the Board
return to the Chairman or Secretary any and all records, books, documents, and other property
regarding the Program in the possession of the Board Member
•
12 Manner of Voting
Any action to be taken by the Board at a meeting shall be determined by a majonty vote of
voting Board Members in attendance at the meeting except for actions requiring a super majonty
vote
13 Super Majority Vote
For purposes of this Program, a super majonty vote requires the affirmative vote of a
majonty of all of the voting Board Members then serving as described in Article III, Section 2
plus one voting Board Member Proxy voting will not be permitted for actions requiring a super
majonty vote
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l4 Constitution of a Quorum
To constitute a valid regular or special meeting of the Board, a quorum must be present.
A quorum shall consist of a simple majonty plus one of the voting Board Members then serving as
specified in Article III, Section 2
15 Motions
Any Board Member, including the Board Chairman, may offer or second any motion or
resolution presented for the Board's consideration
16 Regular Meetings
•
The Board Members shall hold penodic meetings consistent with the needs of the
Program. provided that there shall be at least one (1) regular meeting held dunng each quarter of
the calendar year The Board Members shall determine the time and place of all regular meetings.
17 Special Meetings
Either the Chairman or any two (2) Board Members may call a special meeting of the
Board by giving wntten notice to all the other Board Members of the time and place of the
meeting at least two (2) calendar days before the date set for the meeting, provided that two (2)
calendar days advance notice shall not be necessary if all the Board Members are agreeable to an
earlier meeting.
411
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0 18 Appointment of Chairman and Vice- Chairman
The Board shall appoint the Chair of the Board by simple majority vote of the voting
Board Members in attendance at the first Board meeting held each calendar year Similarly, the
Vice -Chair shall be elected by the Board and shall serve as Secretary of the Board
19 Duties of Chairman and Vice - Chairman
The Chairman shall chair the meetings of the Board, shall appoint all committees, and shall
carry out such other duties as the Board may assign
The Vice - Chair, in the absence of the r!hairman, shall act in the place of the Chairman and
• perform the Chairman's duties The Vice -Chair shall also advise the Board as to all
correspondence pertaining to the Program and shall keep minutes or records of all meetings,
proceedings, and actions of the Board
20 Board Expenses
Each Board Member shall be reimbursed out of the Benefit Fund for all expenses properly
and actually incurred by such Board member in the management of the Program.
21 Benefits to Board Members Not Prohibited
Nothing in this Program shall prohibit a Board Member from receiving any benefits under
the terms of a Benefit Plan.
1111 ,
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Article IV 0
Allocation or Delegation of Board Responsibilities
1 Allocation of Responsibilities to Committees
The Board may establish one or more committees of the Board and assign to such
committee(s) all or part of the Board's responsibilities, except actions that require a super majority
vote
In the event the Board wishes to create a committee, it shall do so by the adoption of a
motion or resolution calling for the appointment of a committee and specifying the particular
responsibility that is being assigned With respect to the responsibility that is allocated, the
committee shall have all the powers of the full Board 0
Article V
Board Responsibilities
1 General Responsibilities
As described in this Program document, the Board shall make recommendations to the
City regarding management of the Plans under the Program. The Board may suggest and
recommend arrangements with other welfare providers to participate in their Plans as is further
described in Section 5 of this Article
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• 2 Existing and Future Benefit Plans
The types of Plans that are or may be made available through the Program are medical,
dental, vision, prescription drug, life insurance, disability income (salary insurance), preventative
health care plans, a cafeteria plan, or other Plans that may be recommended in the future The
Board may make recommendations to the City regarding amendments to existing Plans, or any
Plans hereafter adopted, including amendments that expand, restnct, or terminate all or part of the
rules relating to eligibility for benefits, or to the amount and nature of such benefits, as is further
described in Section 4 of this Article Amendments may be made on a prospective or retroactive
basis, provided, however, that any such amendments must comply with applicable law In making
recommendations to the City, the Board may consider prevailing benefits practices and industry
standards The Board may consider the history of claims approvals and denials under the Plans in
• recommending amendments to Plans
3 Additional Benefit Plans
The Board may recommend to the City the creation of additional Employee Welfare
Benefit Plans Each represented Participating Employee Group may enroll in any such additional
Benefit Plan by executing a Participation Agreement for any such Benefit Plan. The City may
enroll non - represented Management employees by resolution or ordinance
4 Design of the Benefit Plans
The Board may recommend to the City the design of the Plans in accordance with
applicable law, including the determination of the rules under which Participating Employees shall
be eligible for benefits and the nature and amount of such benefits. The Board may recommend
• whether benefits shall be extended to beneficiaries of Participating Employees and, if so, to
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determine which class or classes of beneficianes shall be eligible for benefits, the eligibility rules
411
which will apply to such class or classes of beneficiaries, and the nature and amount of such
benefits If there are different contribution rates, the Board may recommend the establishment of
different eligibility rules for the Participating Employees and their beneficiaries who are affected
thereby
5 Means of Providing Benefits
The Board may recommend to the City whether the benefits, in whole or in part, should be
directly paid from the Benefit Fund or whether the City should contract with an insurance camer,
service organization. health maintenance organization, or other entity, to underwrite part or all of
such benefits
6 Administrative Agent
The Board may recommend to the City whether to retain, at the expense of the Benefit
Fund, one or more administrative agents to assist in the day -to -day administration of the Program.
7 Other Professional and Nonprofessional Help
The Board may recommend to the City that it retain, at the expense of the Benefit Fund,
outside consultants including without limitation one or more accountants, actuanes, attorneys,
employee benefit plan consultants, third party claims administrators, auditors, and other
professional or nonprofessional help, as the Board may deem necessary in the administration of
the Program and the Benefit Plans.
-17- DL015.DOC DRAFT of 04!02/17
• The Board may periodically review and make recommendations to the City regarding the
performance of such outside consultants
8 Benefit Fund Amounts
The Board may recommend to the City the amount to be kept in the Benefit Fund as
reserves for future contingencies or liabilities under the Program's Plans as it may deem necessary,
provided, however, that the Board may not recommend a Benefit Fund amount that falls below or
exceeds prevailing industry standards Any recommendations on Benefit Fund levels shall be
forwarded to the City by July 1 for the next calendar year
9 Records
0 The Board shall maintain the records of its actions and any correspondence it sends or
receives
10 Procedure for Review of Benefit Claims
All benefit claims are adjudicated and reviewed by the Plan Supervisor The Board may
review benefit claims and make recommendations to the City regarding amendments to the Plans
Article VI
City Responsibilities
1 Program Administration
The City shall manage and admnuster the Program and design, adopt, amend and
• administer the Plans under the Program in accordance with all applicable federal, state and local
-18- DL015.DOC DRAFT of 94/02/17
a
laws The City may, at the expense of the Benefit Fund, contract a t with agents to assist in the
Program's Plan administration, program audit, claims adjudication and payments
2 Contributions and Paid Benefits
The basis on which Contributions of the City and Contributions of Participating
Employees (if any) are made shall be as specified in the underlying collective bargaining
agreement, Participation Agreement, ordinance or resolution covenng the Participating Employee
The basis on which benefits are paid under the Program's Plans, including without limitation,
deductibles, co- insurance, copayments and maximum benefit limits, shall be as specified in the
Employee Welfare Benefit Plans
3 Application of Benefit Fund Assets
411
The assets of the Benefit Fund shall be held for the exclusive purposes of providing
welfare benefits to Participating Employees and their beneficianes and defraying reasonable
expenses of administering and managing the Program. The City may pay Program benefits with
funds other than the Benefit Fund In addition to the payment of Plan benefits, the City may pay
from the Benefit Fund expenses directly or indirectly related to the Program or Plans. Expenses
may also be paid out of the Benefit Fund which are not related to the Program or Plans as long as
the amounts paid come from funds which were separately contributed to the Benefit Fund for that
purpose, and not from funds contributed for Plan benefits. Examples of expenses which are
directly or indirectly related to the Program or Plans include such things as plan summanes, claims
audits, salanes and expenses for support personnel and other City overhead expenses related to
the Program or Plans The expenses, upon recommendation of the Board, may be included as
Plan benefit costs Examples of expenses that may be paid out of the Benefit Fund and that are
-19- DL015.DOC DRAFT of 94/02/17
0 not related to the Program or Plans include such things as the City's wellness program and its
employee assistance program
4 Agents for Service of Process
The City shall be the agent of the Program for the sole purpose of accepting service of
legal process, provided that the City may designate its administrative agent or another person as
agent of the Program for this purpose
5 Ins estment
The City may invest all or any portion of the Contributions to the Benefit Fund or other
0 moneys in the Benefit Fund not required for the payment of current Plan benefits or Program
expenses The City may invest said funds as allowed for any municipal investments Any
investments of and returns on Benefit Fund monies not invested specifically in the name of the
Benefit Fund, including City General Investments (Treasurer's Cash Investment), shall accrue to
the Benefit Fund Investments of the Benefit Fund may also include City interfund loans Said
loans will be repaid at the current market interest rates for term and amount as determined by the
City's Office of Finance and Budget
6 Annual Audit
The Benefit Fund may be audited as a part of the City's annual audit. Additionally, the
City will engage an independent qualified professional and, at the expense of the Benefit Fund,
shall authorize the professional to conduct an examination of the Program at a minimum of once
0 every three years A statement of the results of each examination shall be submitted to the City
and Board for their review
-20- DL015.DOC DRAFT of 84/02/17
7 Program Description
The City shall prepare a summary plan description for each Welfare Benefit Plan provided
under the Program for the Board's review and shall furnish copies of such summary plan
descriptions and any material modifications or changes thereto to the Participating Employees
covered by such Plans
8 Documents to be Examined or Furnished
The City shall make copies of (a) this Program document, (b) the latest updated plan
descriptions of the Plans, and (c) any other contracts or instruments under which a Benefit Plan is
established or operated available for examination by Participating Employees or their Beneficiaries
in the City of Yakima Human Resources office or Administrator's office
9 All Records
All records pertaining to Program or Plan administration required by law or set forth in
this document shall be maintained by the City
-21- DL015.DOC DRAFT of 94/02/17
III Article VII
Dispute Resolution Process
1 The Process
In the event the City is not in agreement with the Board's Program recommendations, the
dispute resolution process may be invoked The dispute resolution process shall be as follows
a If the City disagrees with a recommendation of the Board, the City
Manager or designee shall meet with the Board within 15 calendar days of the Board's
recommendation to discuss reasons for the disagreement
111 b If the disagreement over a recommendation cont :nues to exist, then upon,
and within 15 calendar days of, a super majonty vote of the Board, a dispute resolution panel shall
be appointed The panel shall consist of three members who are neutral and independent from the
City and the Participating Employee Groups The panelists shall include one member appointed
by the Board, one member appointed by the City, and one member appointed by the first two
panelists Unless the City and Board agree otherwise, the panelists shall have at least five years
experience in one of the following fields medicine, insurance, or employee welfare benefits
consulting or administration
c The panel shall meet within 15 calendar days of its formation to conduct a
hearing The heanng shall be conducted under the rules and regulations of the Amencan
Arbitration Association. The submission of a dispute to the panel will be based on an agreed
wntten submission of the Board and the City The power and authonty of the panel is limited by
applicable law The panel may consider the prevailing industry standards. The panel shall issue a
• wntten decision within 30 calendar days of the conclusion of the hearing. The decision of the
_22_ DL015.DOC DRAFT of 84102/17
0
panel shall be final and binding on all parties The costs of arbitration shall be paid out of the
Benefit Fund
If the parties resolve their dispute at any time prior to issuance of a decision by the panel,
the dispute resolution process may be terminated Any time period or deadline set forth in this
Article VII may be extended as mutually agreed by the City and Board.
Article VIII
Amendments and Termination
1 Amendments
This Program document may be amended at any time by agreement of the City and Board
0 Amendments must be approved by resolution of the City Council and by the super majority vote
of the voting Board Members. Changes to the Plans and Exhibit A hereto shall not be considered
amendments to the Program document, and do not require City Council approval.
2 Termination of Entire Agreement
If timely notice of termination is not provided, the Program will continue from calendar
year to calendar year This Program may be terminated at any time upon notice of intent to
terminate either by the City or by the Board Chairman and the City Manager, provided that notice
of termination is delivered to the Board Chairman and the City Manager by April 1 of the year
preceding termination. A decision by the Board to terminate the Program must be approved by a
super majority vote. A decision by the City to terminate the Program must be approved by the
City Council, The Program may be terminated without notice by agreement of the City and
Board by resolution of the City Council and a super majority vote of the Board, or if required by
law
11
-23- Mo CAM' of Merl IS
•
3 Allocation Upon Termination
Upon the termination of this Program, the City shall conclude the affairs of the Benefit
Fund With respect to termination, any and all moneys and assets remaining in the Benefit Fund,
after the payment of expenses, will be used for the continuance of the benefits provided by the
then - existing Benefit Plans, or replacement Plans unless some other disposition is required by
applicable law or is agreed to by the City and Board by resolution of the City Council and a super
majority vote of the Board
4 Withdrawal of a Participating Employee Group
• A Participating Employee Group may withdraw from the Program by giving wntten notice
P g P
of intent to withdraw to the Board Chairman The type and nature of Plan benefits, including
without limitation, benefit and Contribution formulas and levels for any withdrawing Employee
Group will remain unchanged from those available under the Program at the date of withdrawal
until any underlying collective bargaining agreement expires and the parties negotiate a successor
contract Until the collective bargaining agreement is amended to revise the Contribution
formula, the Contribution amounts paid by the City on behalf of the eligible employees in a
withdrawn Employee Group shall be determined under the formula set forth in the collective
bargaining agreement with that Group, provided, however, that the maximum dollar amount the
City must contribute for each eligible employee may not exceed the dollar amount the City was
paying for each such employee under the Plans of the Program on the date of withdrawal. Any
and all billings for medical, dental, vision or other covered benefits will be accepted for sixty (60)
calendar days after the effective withdrawal date for services received pnor to the withdrawal
• date
-24- DL015.DOC DRAFT of 94/02/17
5 Benefit Fund Reserves - Participating Employee Group Withdrawal
0
All money and assets within the Benefit Fund classified as Reserves, or otherwise, will
remain with the Benefit Fund upon withdrawal of a Participating Employee Group, except as
stated in Article VIII, Section 4, "Withdrawal of a Participating Employee Group "
Article IX
Enrollment into the Health Benefit Program
1 Initial Enrollment, Existing Employee Groups
All existing Employee Groups within the City shall have until June 1, 1994 to enroll in the
Program, the Board and the City may agree to grant an additional forty -five (45) calendar days to
III
any group if deemed necessary Should an existing Employee Group elect not to enroll in the
Program by June 1, 1994, the next opportunity for enrollment shall be April 1, 1999 and require
approval by a super majonty vote of the Board (see Section 3 below) This Section applies to all
Employee Groups that are in existence and recognized by the City prior *o April 1, 1994
10
-25- DL015.DOC DRAFT of 84!02/17
•
2 Enrollment of Future Employee Group.
Any represented Employee Group recognized by the City after April 1, 1994 shall have
sixty (60) calendar days after recognition by the City to enroll in the Program. Should any such
Employee Group elect not to enroll in the Program within the sixty (60) calendar days allowed for
enrollment, the next opportunity for enrollment shall be five (5) years from the date of recognition
of the Employee Group and will require a super majority vote of the Board (see Section 3 below).
3 Enrollment of Withdrawn and Nonenrolled Employee Groups
Any Employee Group which elects to withdraw from or not enroll in the Program shall
io have the opportunity to enroll in the Program after the time periods specified in Sections 1 and 2
of this Article only if the enrollment is approved by a super majority vote of the Board (as defined
in Article III, Section 13)
Article X
Severability
The provisions of this Program document shall be deemed severable and the invalidity or
unenforceability of any provision of this Program document shall not affect the validity and
enforceability of any other provision hereof. If any provision of this Program document is
unenforceable for any reason whatever, such provision shall be appropriately limited and given
effect to the extent that it may be enforceable.
•26- DLO1S DOC MART of OL 2A
• 02'17 94 12 39 V206 623 7022 PTSG&E SEATTLE
43002
• APPENDIX 2
PARTICYPAT'ION AGREEMENT
This Participation Agreement is made and entered into this day of February, 1994,
by and between the City of Yakima, Washington (the "City") and Washington State Council of
County and City Employees, AFSCME, Local 1122, AFL-CIO (the "Union ") on behalf of the
bargaining unit identified in Article I of the 'Collective Bargaining Agreement Between City of
Yakima, Washington and Washington State Council of County and City Employees, AFSCME,
Local 1122, AFL -CIO, effective January 1, 1992 through December 31, 197-t," (the "1992 -1994
Agreement "), a copy of which Agreement is appended hereto and incorporated ht-,rein by this
• reference as Attachment A..
WHEREAS, effective April 1, 1994, the City has established the City of Yakima
Employees' Welfare Bereefit Program (the "Program "), a copy of which Program is appended
hereto and incorporated herein by this reference as Exhibit B, and
WHEREAS, the purpose of the Prograrn is to provide for and to consolidate the
administration and management of the City's vanous health and welfare benefit plans under the
Program to enhance efficiency, to realize cost savings, and to achieve consistency in benefits
among the vanous welfare benefit plans available to employees; and
WHEREAS, the parties agree that rt is in their best interest to reopen and to modify the
1992 -1994 Agreement and to reach a separate agreement governing the provision of certain
health benefits for covered employees, retirees and their dependents;
•
2117 12:20 PH
AFSCME Puticipalim A�1' �
02/17/94 12 40 15 623 7022 PTSG&E SEATTLE ■ 003
NOW THEREFORE, the City and the Union agree that the 1992 -1994 Agreement is
modified and a new and separate agreement for the provision of health benefits is made by and
between the parties as follows Effective April 1, 1994, covered bargaining unit employees,
retirees and their dependents will discontinue participation in any plan(s) providing medical,
dental, prescription and/or vision benefits as set forth in Article XVIII of and Attachment A to,
the 1992 -1994 Agreement and will join and participate in the 'City of Yakima Employees' Health
& Welfare Benefit Plans ", appended hereto and incorporated herein by this reference as Exhibit C
Eligibility rules, types and levels of benefits, payment of premiums through a cafeteria
plan, copayment, coinsurance and deductibility requirements, and all other terms and conditions
for the provision of these health benefits will be governed by the Program effective April 1, 1994,
with the exception of the premium contribution levels of the City and covered employees, which
level of contributions will remain as set forth in Article XVIII of the 1992 -1994 Agreement or in
any successor agreement reached by the parties
This agreement is effective April 1, 1994 and shall continue indefinitely or until the Union
withdraws from the Program or the Program is terminated as specified in the Program, whichever
occurs first
Recommended by
Clara Sanders, President Richard A. Zais, Jr
AFSCME Local 11222 City Manager
City of Yakima
APSCMSE Pardcipa:ion Agr 2(11/4412.20 PM
02/17 94 12 40 12208 623 7022 PTSG&E SEATTLE £ 004
•
Executed by the parties hereto this day of February, 1994
CITY OF YAKIMA
By
R.A. Zais, Jr
City Manager
ATTEST
City Clerk
THE WASHINGTON STATE COUNCIL OF
COUNTY AND CITY EMPLOYEES, LOCAL
1122, AFSCME, AFL -CIO
By
J: IcAm2573610.03n SA1 A2 '7i0iG
•
AFSCME Participation Aireea+eac 211794 1210 FM
02 17/94 12 44 V206 623 7022 PTSG&E SEATTLE 4011
• APPENDIX 3
PARTICIPATION AGREEMENT
This Participation Agreement is made and entered into this day of February, 1994,
by and between the City of Yakima, Washington (the "City ") and Yakima Police Patrolman
Association (the "Union ") on behalf of the bargaining unit identified in Article l of the "Collective
Bargaining Agreement By and Between City of Yakima and Yakima Police Patrolmans
Association, Effective January 1, 1991 through December 31, 1993" (the "1991 -1993
Agreement "), a copy of which Agreement is appended hereto and incorporated herein by this
reference as Attachment A.
1111 WHEREAS, effective April 1, 1994, the City has established the City of Yakima
Employees' Welfare Benefit Program (the "Program "), a copy of which Program is appended
hereto and incorporated herein by this reference as Exhibit B, and
WHEREAS, the purpose of the Program is to provide for and consolidate the
adrrunistration and management of the City's various health and welfare benefit plans under the
Program to enhance efficiency, to realize cost savings, and to achieve consistency in benefits
among the various welfare benefit plans available to employees, and
WHEREAS, the parties acknowledge and agree that, although a successor agreement has
not yet been reached on other terms and conditions of employment, it is in their best interest to
reach an immediate and separate agreement governing the provision of certain health benefits for
employees, retirees and their dependents covered by the 1991 -1993 Agreement;
0
2/17/941236 PM
Patrolman Participation Agreement
02 17/94 12 45 V206 623 7022 PTSG&E SEAT11.t:
NOW THEREFORE, the City and the Union agree as follows Effective April 1, 1994,
covered bargaining unit employees, retirees and their dependents will discontinue participation in
any plan(s) providing medical, dental, prescription and/or vision benefits as set forth in Article 20
of the 1991 -1993 Agreement and will join and participate in the "City of Yakima Employees'
Health & Welfare Benefit Plans ", appended hereto and incorporated herein by this reference as
Exhibit C
Eligibility rules, types and levels of benefits, payment of premiums through a cafeteria
plan, copayment, coinsurance and deductibility requirements, and all other terms and conditions
for the provision of these health benefits will be governed by the Program effective April 1, 1994,
with the exception of the premium contribution levels of the City and covered employees, which
level of contributions will remain as set forth in Article 20 of the 1991 -1993 Agreement or in any
successor agreement reached by the parties.
This agreement is effective April 1, 1994 and continues in effect indefinitely or until the
Union withdraws from the Program or the Program is terminated as specified in the Program,
whichever occurs first.
Recommended by
Richard A. Zais, Jr
Steve Finch, Chairman City Manager
Yakima Police Patrolmn ger
a City of Ya
Association
2117194 12:36 PM
Patrolman,' Patticipalice Agrecrnett
02/17 94 12 45 $206 623 7022 PTSG&E SEATTLE 1st 013
•
Executed by the parties hereto this day of February, 1994
CITY OF YAKIMA
By
R A Zais, Jr
City Manager
ATTEST
City Clerk
YAKIMA POLICE PATROLMANS ASSOCIATION
•
By
y -9C X1N1 3A1N0C -C
•
Putrolmans Participation Agrstment 2117/94 12.36 PM
0217 94 12 41 U206 623 7022 PTSG&E SEATTLE t® 005
APPENDIX 4
•
PARTICIPATION AGREEMENT
This Participation Agreement is made and entered into this day of February, 1994,
by and between the City of Yakima, Washington (the "City ") and Local 469, International
Association of Firefighters, AFL-CIO (the "Union ") on bP-hAtf of the bargaining unit identified in
Article I of the "Collective Bargaining Agreement Covering PERS Fire Department Employees
By and Between City of Yaima, Washington and Local 469, International Association of
Firefighters, AFL -CIO, Effective January 1, 1993 until December 31, 1993" (the "1993
Agreement "), a copy of which Agreement is appended hereto and incorporated herein by this
reference as Attachment A_
• WHEREAS, effective April 1, 1994, the City has established the Ciry of Yakima
Employees' Welfare Benefit Program (the "Program"), a copy of which Program is appended
hereto and incorporated herein by this reference as Exhibit B, and
WHEREAS, the purpose of the Program is to provide for and consolidate the
adrnuustration and management of the City's various health and welfare benefit plans under the
Program to enhance efficiency, to realize cost savings, and to achieve consistency in benefits
among the vanous welfare benefit plans available to employees; and
WHEREAS, the parties acknowledge and agree that, although a successor agreement has
not yet been reached on other terms and conditions of employment, it is in their best interest to
reach an immediate and separate agreement governing the provision of certain health benefits for
employees, retirees and their dependents covered by the 1993 Agreement
LA.F.F (PERS) Participation Agr°®mt 2/17194 1223 PM
02 17, 94 12 41 TY 206 623 7022 PTSG&E SEATTLE 1m 006
III
NOW THEREFORE, the City and the Union agree as follows. Effective April 1, 1994,
covered bargaining unit employees, retirees and their dependents will discontinue participation in
any plan(s) providing medical, dental, prescription and/or vision benefits as set forth in Article
XIII of and Appendix B to, the 1993 Agreement and will join and participate in the "City of
Yakima Employees' Health & Welfare Benefit Plans', appended hereto and incorporated herein by
this reference as Exhibit C
Eligibility rules, types and levels of benefits, payment of premiums through a cafeteria
plan, copayment, coinsurance and deductibility requirements, and all other terms and conditions
for the provision of these health benefits will be governed by the Program effective April 1, 1994,
with the exception of the premium contribution levels of the City and covered employees, which
level of contributions will remain as set forth in the 1993 Agreement or in any successor III
agreement reached by the parties
This agreement is effective April 1, 1994 and shall contuwe indefinitely or until the Uruon
withdraws from the Program or the Program is terminated as specified in the Program, whichever
occurs first.
Recommended by
Ron Johnson, President Richard k Zais, Jr_
Local 469, I.A.F.F City Manager
City of Yakima
0
LA_F.F (PERS) Participation Agreement 2/17A4 1223 PM
02 12 42 '208 623 7022 PTSG&E SEATTLE 1®007
•
Executed by the parties hereto this day of February, 1994
CITY OF YAKIMA
By
R.A Zais, Jr
City Manager
Al IEST
• City Clerk
LOCAL 469, INTERNATIONAL ASSOCIATION
OF FIREFIGHTERS, AFL -CIO
By
1D AM:5 AD 00111 SA 1 N1 DOC
•
I. A.FF (PERS) Participation Agreement 2)17194 12.23 PM
02 17 94 12 43 17206 623 7022 PTSG&E SEATTLE Id 008
III APPENDIX 5
PARTICIPATION AGREEMENT
This Participation Agreement is made and entered into this day of February, 1994,
by and between the City of Yakima, Washington (the "City") and Local 469, International
Association of Firefighters, AFL-CIO (the "Union ") on behalf of the bargaining unit identified in
Article 1 of the "1992 -1994 Collective Bargaining Agreement By and Between The City of
Yakima, Washington and Local 469, International Association of Firefighters, AFL -CIO` (the
"1992 -1994 Agreement "), a copy of which Agreement is appended hereto and incorporated herein
by this reference as Attachment A.
•
WHEREAS, effective April 1, 1994, the City has established the City of Yakuna
Employees' Welfare Benefit Program (the "Program "), a copy of which Program is appended
hereto and incorporated herein by this reference as Exhibit B, and
WHEREAS, the purpose of the Program is to provide for and consolidate the
admiiistration and management of the City's various health and welfare benefit plans under the
Program to enhance efficiency, to realize cost savings, and to achieve consistency in benefits
among the various welfare benefit plans available to employees; and
WHEREAS, the parties agree that it is in their but interest to reopen and to modify the
1992 -1994 Agreement and to reach a separate agreement governing the provision of certain
health benefits for covered employees, retirees and their dependents;
III
2/17/941213 PM
j./.F.F Pa¢tiopstion Agrsaneat
02 17 94 12 43 x'206 623 7 022 PTSG&E SEATTLE I® C09
NOW THEREFORE, the City and the Union agree that the1992 -1994 Agreement is
modified and a new and separate agreement for the provision of health benefits is rnade by and
between the parties as follows Effective April 1, 1994, covered bargaining unit employees,
retirees and their dependents will discontinue participation in any plan(s) providing medical,
dental, prescnption and/or vision benefits as set forth in Article 13 and Article 14 of the 1992-
1994 Agreement and will join and participate in the "City of Yakima Employees' Health &
Welfare Benefit Plans ", appended hereto and incorporated herein by this reference as Exhibit C
Eligibility rules, types and levels of benefits, payment of premiums through a cafeteria
plan, copayment, coinsurance and deductibility requirements, and all other terms and conditions
for the prow sion of these health benefits will be governed by the Program effective April 1, 1994,
levels of the City the exception of the premium contribution tY and covered employees, which
level of contributions will remain as set forth in Articles 13 and 14 of the 1992 -1994 Agreement
or In any successor agreement reached by the parties
This agreement is effective April 1, 1994 and shall continue indefinitely or until the Union
withdraws from the Program or the Program is terminated as specified in the Program, whichever
occurs first.
Recommended by
Ron Johnson President Richard A. Zais, Jr
Local 469, I.A.F.F City Manager
City of Yakima
2/17/94 12.25 PM i „�F. Puticipatioa Agsrma'+K
0217 94 12 44 1$206 623 7022 P1SG&E SEATTLE Lei U10
•
Executed by the parties hereto this day of February, 1994
CITY OF YAKIMA
B _
RA Zais, Jr
City Manager
ATTEST
City Clerk
LOCAL 469, LN'TERNATION ASSOCIATION OF FIREFIGHTERS, AFL-CIO
By
President
•
2/11941225 PM
I.AF.F Panicipstioo Agreement t
• EXHIBIT A
CITY OF YAKIMA
EMPLOYEES' HEALTH AND WELFARE
BENEFIT PLANS
DRAFT
February 18, 1994
MEDICAL PRESCRIPTIONS DENTAI. VISION
•
TO OUR VALUED EMPLOYEES
Welcome to our Program!
We are pleased to provide you with this comprehensive program of medical, prescription drug, dental and
vision coverage. Our Plan is designed to provide protection for you and your family against the high cost of
health care.
With the exception of very large medical claims which the Plan is protected against by insurance, all Plan
expenses are directly paid by our Plan. This means that careful use of the Plan will benefit both you and the
City of Yalama by allowing us to continue to provide high quality benefits.
We encourage you to read this Plan Document thoroughh and become familiar with its provisions. If you
have am questions regarding either your Plan's benefits or the procedures necessary to receive these benefits.
please call DIRECT ADMMZSTRATORS at (509) 248 -7938
All of us at the Citv of Yakima sincerer wish that you and your famih become wise health care consumers
and enioN good health. However should you need to use the Plan, the benefits are excellent. In appreciation
for your efforts on behalf of the City of Yakima, we are pleased to sponsor this Plan for you and your fann1
•
We wish you the best of health.
The Cat\ of 'x akima Health Benefits Committee
410
Many illnesses and disabilities are caused by what people do to themselves. Most of us are born healthy and
too often become sick because of failure to observe simple rules of good health. When these rules are
observed, each of us has a better chance for a longer and healthier life.
Here are several suggestions which go a long way in improving your health_
CHECK YOUR BLOOD PRESSURE
High blood pressure - if known and treated - can easily be controlled The danger is
unknown high blood pressure. Blood pressure tests are quick and painless, so get your blood
pressure checked regularly
STOP SMOKING
Smokers, as a group, have twice the nsk of heart attack as non - smokers. Smoking is also a
senous risk factor leading to cancer and other diseases. If you smoke, the single most
important thing you can do for yourself is stop!
EAT A HEALTHY DIET
• Based on evidence at hand.. following a few simple guidelines will improve your health and
reduce your nsk for disease_ The American Cancer Society recommends that you limit your
intake of fats and increase your fiber intake. This means cut back on fried foods, butter and
esss. and eat more fruits. vegetables and whole grains. (P S This is good for your heart.
too!)
GET REGULAR EERCISE
Unless your doctor advises otherwise, exercise on a regular basis. Twenty minutes three
times a week of brisk walking, swimming, bicycling, or other activity will have you looking
good and feeling fit! Remember to start with warm -ups and end with a cool -down period to
avoid injuries.
WEAR YOUR SEAT BELT
No one intends to have an accident, but the odds are 1 in 3 you will be in a serious accident
during your lifetime. Wearing a seat belt reduces your chances of death and injury by more
than 50 percent_ Protect yourself - buckle up!
DRINK IN MODERATION
Most people who drink are able to control their intake of alcohol and to avoid undesired
effects. However excessive drinking is a leading cause of accidents and some diseases. So,
if you drink, do it wise\ and in moderation.
•
B0101 2/1/94 Page 1
TABLE OF CONTENTS
WAYS TO STAY HEALTHY
1 III
TABLE OF CONTENTS 2
IMPORTANT INFORMATION - PLEASE READ CAREFULLY 5
SCHEDULE OF BENEFITS 7
Maximum Benefits While Covered Under This Plan 7
Major Medical 7
Pharmaceutical Card Service 9
Dental 10 10
Vision Benefits
ELIGIBILITY PROVISIONS 11
Eligibility 11 12
Enrollment 13
Effective Dates of Coverage
Termination of Coverage 14
Conunuation of Coverage 15
Nouficauon Requirements and Election Penod 16
Type of Coverage. Premium Payments 16
Maximum Coverage Penods 16
Terminauon Before The End Of The Maximum Coverage Penod 17
Other Information 17
PRE- AUTHORIZATION/UTILIZATION REVIEW 18
MAJOR MEDICAL BENEFITS 20
Descripuon of Benefits 20
Pre - Existing Conditions and Waiting Penods 20
Individual Deductible 20
Family Deductible 20 20
Coinsurance Percentage
Copayment 20
2
Maximum Out of Pocket Expense 21
Major Medical Lifetime Maximum Benefit 21
Eligible Expenses 21
Physician Services 21
Surgery and Related Services 22
Hospital Services 22
Alternatives to Hospitalization - Special Provisions 23
Home Health and Home Nursing Care
Hospice Care 23
Horne 24
Exclusions to Hoe Health and Nursing Care and Hospice Care 2 4
Skilled Nursing Facility or Rehabilitation Benefit 2
Prescnpd 4
on Drugs 24
Allergy Treatment 25
Pre - Admission Testing 25
Mammography and Pap Smear Tests 25
Maternity Services 26
Newborn Nursery Care Benefit 26
III
Elective Sterilization 26
Ambulance 26
Infusion Therapy Benefit
B0101 2/1/94 Page 2
Replacement of Organs and Tissue 26
• Durable Medical Egwpment 27
Prosthetic Appliances 27
Other Medical Supplies 27
Blood Charges 27
Physical Therapy 28
Speech Therapy 28
Occupational Therapy 28
Neurodevelopmental Therapy Services 28
Chiropractic Care 28
Alcohol and Drug Abuse Treatment 28
Inpatient and Outpatient Treatment of Mental and Nervous Disorders 29
Smoking Cessation Benefit 30
Dental Services 30
Photocopying 30
Hospital Audit and Case Management Fees 30
Supplemental Accident 30
Audit Incentive 31
General Exclusions To The Medical Plan 31
PHARMACEUTICAL CARD SERVICE (PCS Benefit) 35
Payment Schedule Plan 35
Copavrnent 35
Drees Covered 35
Drugs Excluded and Lirruted 35
ID Dispensing Limitations 36
Benefit Limitations 36
Benefits for Employees and Dependents Without a PCS Card 36
DENTAL BENEFITS 37
Opuonal Predetermination of Benefits 37
Descnpuon of Benefits 37
Deductible 37
Calendar Year Maximum 37
Covered Dental Expenses 37
Alternate Treatment 38
Type I Preventive Expenses 38
Type II Basic and Restorative Expenses 38
Type III Prosthetics and Major Expenses 39
The Prosthesis Replacement Rule 39
Benefits After Termsnauon of Coverage 40
Orthodontic Benefits 40
Exclusions and Limitations To The Dental Plan 41
VISION BENEFITS 43
Covered Services 43
Exclusions To The Vision Plan 43
Vision Benefits After Terrnmauon of Coverage 44
GENERAL DEFINITIONS 45
RCW 41.20 ACTIVE AND RETIRED EMPLOYEES 51
III GENERAL PROVISIONS 52
Procedures for Filing a Claim 52
Appealing a Claim 52
Admirustration of the Group Medical Plan 52
80101 211/94 Page3
HEHL T H uHkE M - iiribEMENT TEL 20b— b65 -540 Feb 1 T , 94 14 3o No U14 P 03
Conditions Precedent to the Payment of Benefits 52
Privileges as to Dependents 53 •
Application and Identification Card 53
Summary Plan Description 53
Cancellation 53
Assignment of Pay mil( 53
Amendment of Plan Document 54
Notice 54
Coordination of Benefits 54
Subrogation (Third Party Liability) 55
Medicare 56
Facility of Payment 57
Misrepresentation 57
Inadvertent Error 57
Free Choice of Physician 57
Right of Recovery 57
Plan is not a Contract of Employment 38
Funding 58
Effect of Termination of the Plan 58
PLAN SPECIFICATIONS 59
PLAN ACCEPTANCE 60
II
This booklet is the Summary Plan Description This booklet and any Amendments constitute the Plan
Document for this benefit plan. This Plan is maintained for the exclusive benefit of the Plan Employees and
each Covered Individual's rights under this Plan are legally enforceable.
The Plan Administrator has the right to amend this Plan at any thne In accordance with the provisions
of the City of Yakima Lmplo)ce's Health and Welfare Benoit Plans, The Plan Administrator, through the
Board, will make every effort to communicate to the Plan Employees all Plan amendments on a timely basis.
0
BO101 4/1/94 Page 4
=' art =-_s ?- - `-_~ ° =- -`
1111 Pre- Autborizadon of Hos P itallzatlon
This plan requires pate authorization of all hospital adzn1siom. Failure to obtain the authorization prior so
hospitalization will result in the loss of benefits. There is a S300 penalty for failure to obtain the
pre-authorization. Failure to call PROW for will result in s SS00 penalty. PRO/W
will determine if the hospitalization is medically necessary PROW may recommend an alternate health care
setting or treatment that will maintain both quality health care and cost-effective options. If PROW does not
authorize your treatment (Le. hospitalization) and you decide to proceed with that treatment instead of the
alternative treatment r000mmendod by PRO/W, all benefits related to your unauthorized treatment (Le.
hospitalization) will be reduced to 60''/. Compliance with the pre-authorization requirements will result in
your receiving the &II benefits available.
When your physician recommends hospitalization, you must call PRO/W as soon as possible but no later than
48 hours before the scheduled admission. inpatient bospitalimrinns must be pre - authorized. You, your
physician, or a family member should call PROW to request pre authorization. PROW health care
professionals, including nurses and physicians, will review the proposed hospitalization. If the hospitalization
is approved, you, your physician, claims payor, and the hospital will be notified. If emergency hospitalization
is necessary, you, a family member, your physician of the hospital must contact PROIW within 48 of
admission.
Please refer to the Pre- Authorization/Utillzation Review section for fall details on the Pre - Admission
procedure. Pre- authorization does not guarantee payment of benefits. The UR Coordinator should be
contacted at the following numbers:
gir PROFESSIONAL REVIEW ORGANIZATION/WEST (PRO/W)
(206) 368.8271 In. Seattle
1400- 7834606 - Outside Seattle
Continuation of Coverage Provisions (COBRA)
Both you and your spouse should take the time to read the Contin of Coverage Previsions, Under certain
you and/or your dependents may be eligible for a temporary extension of health coverage, as
group rates, where coverage under the plan world otherwise end The information in this section is intended
to inform you, in arm►nary fashion of your rights and obligations under the continuation of coinage
provisions. To find out more abort your oontinuation of coverage rights refer to the Eligibility Section of this
booklet
i
BO101 2/1/94
Pages
How To File A Claim
1 You may ask your provider to bill DA directly Your provider should submit complete, itemized bills.
An itemized bill is one that shows a patient's name, date of service, the type of service rendered, charge
for each service, provider's name, address, Federal Tax ID number and the nature of the accident or
illness being treated. Providers frequently request that you assign the benefits to them, however, if you
have paid the bill or want the benefits sent to you, this should also be noted on the bill.
2. To submit a claim for payment yourself you should complete a claim form and attach an itemized bill
and send it to the address shown on the claim form. See your employer for claim forms. If you wish
your benefits paid directly to the provider, sign the assignment of benefits section. A separate claim form
should be submitted for each family member
3. All claims for reimbursement must be submitted within one year of the date incurred.
Contact for Questions about the Plan Benefits
You are encouraged to contact Direct Administrators (DA) with anv question you have regarding this Plan.
DA is available to answer questions about claims and how your benefits work. You may contact DA at:
DIRECT ADMINISTRATORS, LVC.
120 South Third Street, P O. Box 22700 -B, Yakima, WA 98907 -2700
(509) 248 -7938 •
Please note. The UR Coordinator cannot answer questions regarding your Benefit Plan or what benefits
you have available - DA is available to provide this information. DA cannot pre - authorize hospital
admissions - this can only be done by the UR Coordinator
BO101 2/1/94 Page 6
SCHEDULE OF BEN FILS
•
This Schedule ei Benefits is s summary of the benefits provided ender this Pisa. Please read the entire
booklet, for details a specific beadit emltadoas sad mas3mams, waiting periods sad esdnslons M
benefits are subject to reasonabk and commonly accepted fees
Approval must be obtained from Professional Review Organization/West (PRO/W) prior to use of a
hospital
MAXIMUM BENEFITS WHILE COVERED UNDER THIS PLAN
Major Medical Lifetime Maximum Benefit $750,000
Alcohol and Drug Abuse Lifetime Maximum Benefit 510,000
Mental Health Services Lifetime Maximum Benefit 524,000
MEDICAL BENEFITS
ANNUAL DEDUCTtBL$
Individual 5100
Family 5200
MAXIMUM OUT OF POCKET
Individual 5600
(including deducables)
Family 51,200
(including doductibles)
PRE-AUTHORIZATION FOR Ropired
HOSPITAL ADMISSION OR SURGERY 5500 ply d ca
pTe
After the deductible and comments have been satisfied, the Plan pays the coinsurance amounts listed
below for eligible expenses incurred by an individual in s calendar Year
Second Surgical Opinion 100%, No Dedumble
With approval from the UR Coordinator.
Physician Services:
Office, hoax and hospital visits 100%
Not subject to the deductible.
25 office visits maximum per calendar year.
Outpatient surgeon's fee
Inpatient surgeon's foe
Assistant surgeon's fee SO% np to 25%• of
Surgeon's Fee
Anesthesiologist•
Hospital Services, Inpatient:
Room and board (semi- private)
Intensive care
'•
• Nur s e ves •
Nurt SO%
BO101 2/1/94 Page 7
Hospital Services, Outpatient:
Pre- adrrussion tesung (prior to surgery per UR Coordinator) 100%
Outpauent surgical facility 80%
Emergence Room/Services S25 Copayment, then 80%
Copayment is waived if
admitted
Supplemental Accident 100 %, No Deductible
For treatment initiated within 48 hours
of an accidental injury
$500 maximum per accident.
Home Health and Horne Nursing Care 80%
S 10,000 maximum per calendar year
Hospice Care 80%
Six months lifetime maximum.
Stalled Nursing Facility/Rehabilitation. 80%
30 days maximum per calendar year
120 days lifetime maximum.
Lab and X -ray 80%
Radiauoa Chemotherap"/Dialysis 30%
Marnmograph\ /Pap Smear Tests 80%
Prescription Drugs. Inpaneat 80%
Ambulance 80%
Allergy Treatment 80%
Maternity Care
Hospital Inpatient 80%
Durable Medical Equipment/ 80%
Supplies/Prosthetics
Blood Bank Charges 80%
Physical Therapy /Speech Therapy /Outpatient Rehab. 80%
S4,000 maximum per calendar year
Chiropractic Care: 80%
S1 000 maxmum per calendar year
Alcohol & Substance Abuse -
Inpauent 30%
Outpauent 50%
S5,000 inpatient/outpatient combined maximum
every two consecutive calendar years.
Subject to a lifetime maximum of S10,000
30101 2/1;94 Palle
Mental Health Services.
inpatient 80%
III S9,000 maximum per calendar year
Outpatient 50%
$3,000 maximum per calendar year
S12,000 inpauent/outpattent combined
maximum per calendar year
Subject to a lifetime maximum of S24,000
Dental Services - Major Medical 80%
See Page 30
Smoking Cessation
See Page 30
$50 hfetune maximum for Nicorettes
Audit Incentive 50%
See Page 31
S500 maximum per incident.
PHAR\LAkCEUTICAL CARD SERVICE (PCS)
See Page 35
• PCS Recap Pharmacies
Genenc Drugs S4 00 Copavment
Name Brand Drugs S" 00 Copayment
using your PCS Recap card when purchasing prescriptions and paving the applicable copa }beat, the Plan
pays 100% of the balance due the PCS Recap Pharmacy direct to the pharmacy
If the PCS card is not used by the covered individual at the time of the prescription purchase or the
prescnpuon is purchased at a non - participating pharmacy, you must file a claim directly with PCS using a
PCS claim form
When you do not use the PCS Recap card.. the benefit is less because the arescrotion drugs cost More. When
you submit a prescription claim to PCS, the charges which include: (1) the copavment you wcuid normally
pay, (2) the difference between the pharmacy retail price and the amount the pharmacy would have charged if
the PCS Recap card was used; and (3) a handling fee, will be deducted from your total reimbursement
NOTE. Be sure to ask your doctor about generic equivalents.
III
BO101 2:1/ Page 9
DENTAL BENEFITS (Subject to reasonable and commonly accepted fees.)
DEDUCTIBLE
None
MAXIMUM BENEFIT S 1,000
Per covered individual, per calendar year
Type I - Preventive
See Page 38. 100%
Oral Exam, Cleaning, X -ray
Type II - Basic and Restorative 80%
Fillings, Oral Surgery, Denture Repair
Type III - Major Prosthetics 50%
Bridgework, Crowns, Dentures
Type IV - Orthodontia 50%
Lifetime maximum $2,000
VISION BENEFITS
Vision benefits are payable according to the following scheduled maximums and are not subject to a
deductible. Benefits are payable once dunng any calendar year for an EXAMINATION Benefits are payable
for a PAIR OF LENSES with FRAMES and/or a PAIR OF CONTACT LENSES not to exceed S200 during
any two consecutive calendar years. •
Examinanon
S60 maximum per calendar year 100%
Lenses and Frames AND /OR Contact Lenses
S200 maximum every two consecutive calendar years. 100%
B0101 2/1/94 Page 10
III ELIGIBILITY AND ENROLLMENT PROVISIONS
ELIGIBILITY
Employee Eligibility
Employees eligible for coverage under this plan are:
Active full -time and part -time employees regularly scheduled to work 20 hours or more per week are eligible
for coverage under this plan.
Retirees eligible to receive payments under the Washington State Retirement System up to age 65 Retirees
under the Washington State Retirement System (RCW 41.20) are eligible for coverage under this Plan with no
age limit.
Ineligible classes of employees are: (1) part-time employees normally scheduled to work less than 20 hours per
week; (2) temporary employees.
An employee is defined as an individual directly involved in the regular business of and compensated for
services by the City of Yakima, who is regularh scheduled to work at least the minimum number of hours, as
indicated above, on an active, full -time basis or other individual's listed above who are eligible for coverage.
Dependent Eligibility
0 Dependents eligible for coverage under this plan are.
1 your legally married spouse (who is neither divorced nor legally separated, unless coverage is
required by a coup decree).
2 your unmarred dependent child(ren) under age 21 who are not employed on a full -time basis.
3 your unmarried dependent child(ren) age 21 and through age 23 who are enrolled in an accredited
school as a full -ume student as defined by the school being attended for a minimum of five months
per calendar year
4 your unmarried dependent child(ren) who is incapable of self - support because of mental retardation.
mental illness, or physical incapacity that began pnor to the date on which the child's eligibility
would have terminated due to age. Proof of incapacity must be received within 120 days after the
date on which the maximum age is attained Subsequent evidence of disability or dependency may
be required as often as is reasonably needed to venfy continued eligibility for benefits.
5 spouse and eligible dependent children of retirees under the Washington State Retirement System up
to age 65
The term "dependent children" means anv of your natural children, legally adopted children or step children
who depend on you for support, or children who have been placed under the legal guardianship of you or your
spouse by a court decree or placement by a State agency
A dependent is defined as an individual listed on the employee's application as a dependent of the employeee,
who is eligible for dependent coverage (based on the criteria above), whose application has been timely
0 submitted to the City's Human Resources offio.
BO101 2/1/94 Page 11
ENROLLMENT
Regular Enrollment
To apply for coverage under this plan, the employee must complete and submit an enrollment form within 31
days of the date the individual first becomes eligible for coverage. If you fail to enroll during the enrollment
eligibility period, you will be required to submit a Proof of Good Health application unless you become
eligible to enroll as a result of loss of other group coverage. The completed enrollment form should list all
eligible dependents to be covered. IndivifiiAlc not enrolled when first eligible may be required to submit Proof
of Good Health to enroll in the Plan. Proof of Good Health is defined as, evidence satisfactory to the Plan
Adrn;mctrator that an applicant for coverage is in good health and does not have any significant medical
condition.
When you acquire an eligible dependent (birth, marriage, adoption etc.) the dependents must be enrolled
within the enrollment eligibility periods specified below
Newly acquired dependent: A newly acquired dependent (ex=pt a newborn child or a child placed for
adoption) must be enrolled within 31 days of the date of acquisition.
Newborn. A newborn child may be covered from birth provided the child is enrolled within 60 days of
the date of both.
Adopted Child. A child placed for adoption may be covered from the date of placement provided the
child is enrolled within 60 days of the date of placement.
Enrollment Due to Loss of Other Group Coverage
If you or a dependent loses eligibility under another group plan due to either termination of employment or
termination of the other group medical plan, those individuals losing coverage become eligible for coverage
under this plan provided. (1) enrollment for coverage is made within 31 days of termination of the other
group coverage; (2) there is no lapse in coverage between the pnor group plan and coverage under this plan,
and (3) a letter from the employer sponsoring the coverage confirms that coverage was terminated under the
pncr program due to termination of employment or termination of the group plan. Proof of Good Health will
not be required and the waiting period for coverage of pre - existing conditions will be calculated from the
original date of eligibility under this Plan.
Late Enrollment
If you or a dependent are not enrolled during the regular enrollment periods specified, you may enroll by
subrrutting a Proof of Good Health application for each eli individual applying for coverage. You must
submit a Proof of Good Health application for approval. The Plan Administrator may require the individual
applying for coverage to have a physical examination, at no expense to the Plan, in addition to submission of
the Proof of Good Health application. Coverage may begin only when and if the Plan Administrator approves
the application for enrollment and notifies the individual of the effective date. Once approved, individuals
must enroll within 31 days to be eligible for coverage.
R nwni �i1/91 Page 12
• hi- rh.CTIVE DATE OF COVERAGE Employee Effective D ate
The effective date of coverage for eligible employees is the date of hire.
If you are not actively at work due to illness or accident on the date your benefits would otherwise be effective,
the effective date of your coverage will be delayed until the date you meet the following: (1) you are no longer
disabled (that is ill or injured) and away from work and (2) you are regularly working the Participating
Group's normal work week of at least the minimum number of hours required for eligibility at any of the
Participating Group's business establishments, or at some other location to which you are required to travel for
business reasons by the Participating Group.
A covered employee will be considered actively at work if on the last scheduled work day prior to or coinciding
with the effective date of coverage the employee is performing all of the regular duties of his employment on a
full -time basis at his customary place of employment or at some other location if that employment requires
him to travel. An employee will also be considered actively at work if he is absent from work solely due to
vacauon or a non - medical approved leave of absence.
Approved Medical Leave of Absence
If vou are granted an approved medical leave of absence, vou will be eligible to continue coverage under the
Plan for up to 12 weeks. The premiums vou will pay to continue coverage during the 12 week period will be
the same as what you would pav if still an active employee. If your leave extends more than 12 weeks you will
be eligible to continue coverage under the (COBRA) Continuauon of Coverage Provisions of the Plan.
ii Please contact your Human Resources Department for information on how to qualify for a Medical Leave of
Absence.
Approved Leave of Absence (other than Medical Leave of Absence)
If you are granted an approved leave of absence (other than medical leave of absence) you and your covered
dependents will be eligible to continue coverage for up to 90 days. You will be responsible for paying all of
the premiums dung the 90 days. If your leave extends more than 90 days you will be eligible to continue
coverage under the (COBRA) Continuation of Coverage Provisions of the Plan.
An emplovee and dependents who are being reinstated to an active status after an approved leave of absence do
not have to satisfy the tnival waiting penod again if it was satisfied pnor to going out on the approved leave of
absence. There will be no lapse in coverage for employees and dependents that have continued coverage while
on the approved leave of absence. If the employee did not continue coverage while on the leave of absence.
then coverage will be reinstated on the first day of month following the return to active status.
An employee and any dependents who had not satisfied the waiting period prior to the approved leave of
absence will receive credit for the portion of the initial waiting period that was satisfied prior to the leave of
absence. Coverage will begin on the first of the month following their satisfaction of any remaining eligibility
waiting period.
A new employee who has not vet satisfied their pre- existing condition waiting period and has been granted an
approved leave of absence, will be subject to the "pre-eMisting condition" waiting period. The employee and
dependents will receive credit for the amount of time that they had satisfied towards the pre -existing waiting
period before the leave of absence began as long as the leave is less than 90 days.
III
BO101 2!1;94 Paste 13
The pre-existing waiting period will be waived for both employees and dependents, when the employee returns
from an approved leave, if the following conditions are met. (1) all individuals had satisfied the pre - existing
waiting penod pnor to the leave of absence; and (2) the employee's leave was 90 days or less. A covered
employee and his/her dependents who are reinstated after an approved leave of absence, which extends
beyond 90 days, will start a new "pre- existing condition waiting period" unless they have been continuously
covered under the Plan during their approved leave of absence.
Please contact your Human Resources Department for information on how to qualify for an Approved Leave of
Absence.
Rehire
If an employee who was covered under this Plan tertninates employment or loses eligibility for coverage and is
rehired or again becomes eligible for coverage within 6 months of the date of termination, credit will be given
towards the pre -existing condition waiting period for the time previously covered under this Plan. Coverage
will begin on the date of rehire, if coverage is elected. Individuals not reinstated on the Plan within 6 months
will be required to re- satisfy the full pre - existing condition waiting period, unless continuously covered under
COBRA. Individuals continuously covered under the COBRA continuation coverage of this Plan, will be
given credit for the time covered under this Plan toward meeting the Pre - Existing Condition requirement.
Dependent Effective Date
If, as a new hire, you elect coverage for your dependents during the first 31 days of eligibility, their effective
date will be the same as your effecuve date.
New h acquired dependents become effecuve on the date of mamage, date of birth, date of adoption or the date
of eligibilir
If a newly acquired dependent is not timely enrolled (see page 12), your dependent will be required to apply for
approval of coverage by submitting a Proof of Good Health application. If you submit Proof of Good Health
for approval, the effective date of coverage will be the first of the month following the date of approval.
A covered dependent will be considered in active service on arD day if the indivithial is then engaging in all
normal activiues of a person in good health of the same age and sex, and he is not confined in a medical
facility or confined at home.
TER'vflNATION OF COVERAGE
An employee s or dependent's coverage will automaticallv end on the earliest of the following dates:
1 The date the coverage or the Plan ends; or
2. The date the employee or dependent becomes ineligible; or
3 The last day of the month in which the employee'semployment ends; or
4 The date the employee or dependent begins active service in the armed forces; or
5 The date the employee fails to make any required contribution when coverage is contributory
BO101 2.'1194 Page 14
• An employee's employment is deemed to end on the date he ceases active work_ However, in the following
circumstances, employment will be deemed to continue as shown below, or until the employer, acting under
rules that preclude individual selection terminates the employee's employment_
1 Sickness or injury - according to the participating group's personnel pohc� , or
2. Approved leave of absence (other than medical leave of absence) - to the end of the 3rd calendar
month following the calendar month in which such event occ :. z The employee must pay all
contributions during this period of leave of absence; or
3 Temporary lay -off - to the end of the calendar month in which such event occurs.
CONTINUATION OF COVERAGE (COBRAI
This provision provides continuation of coverage in compliance with the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA) as amended by the Omnibus Budget Reconciliation Act of 1989 An
employee or dependent whose coverage ends under this Plan may be a qualified beneficiary entitled to elect
continuation of coverage under this Plan. Coverage is elected on the enrollment form provided by the Plan
Supervisor Both you and your spouse should take the time to read the Continuation of Coverage provisions.
If you are an employee covered by the Plan, you have the right to elect continuanon coverage if you lose
coverage under the Plan because of anv one of the following "qualifying events'
1 Termination (for reasons other than gross misconduct on your part) of your employment; or
• 2 Reduction in the hours of your employment.
If you are the spouse of an employee covered by the Plan you have the right to elect continuation coverage if
you lose coverage under the Plan because of any of the following four "qualifying events"
1 The death of your spouse; or
2 The terminauon of your spouse's employment (for reasons other than gross misconduct) or
reduction in your spouse's hours of employment with the Employer, or
3 Divorce or legal separation from your spouse; or
4 Your spouse becomes entitled to Medicare benefits.
In the case of a dependent child of an employee covered bti the Plan_ he or she has the right to elect
continuation coverage if group health coverage under the Plan is lost because of anv of the following five
%pinIifying events"
i
1 The death of the employee parent; or
2. The termination of the employee parent's employment (for reasons other than gross misconduct) or
reduction in the employee parent's hours of employment with the Employe:, or
3 Parent's divorce or legal separation; or
4 The employee parent becomes entitled to Medicare benefits; or
III The dependent ceases to be an eligible "dependent child' under the Plan.
BO101 2/1/94 Page 15
If an employee, spouse or dependent child is covered under another group health plan when a qualifying event
occurs. that individual is not eligible to elect continuation of coverage under this Plan unless they have a pre -
exisung condition that is limited or excluded under the other group coverage.
NOTIFICATION REQUIREMENTS AND ELECTION PERIOD
Under the law, the employee or a family member has the responsibility to notify the Employer when the
qualifying event is a divorce, legal separation, or a child losing dependent status. When you or a family
member have one of the above qualifying events you become a'qualified beneficiary' If notice is not given to
the employer within 60 days of the qualifying event or within 60 days of the date the qualified beneficiary
would lose coverage due to the qualifying event, the qualified beneficiary will not be offered the option to elect
continuation coverage.
When the Employer is notified that one of these events has occurred, you will be notified that you have the
right to elect continuation coverage. Under the law, you must elect continuation coverage within 60 days of
the date Plan coverage would end or within 60 days of the date that the Employer sends you notice of your
right to elect continuation coverage, whichever is later If the qualified beneficiary does not elect COBRA
continuation coverage during this election penod, they will not be eligible to enroll at a later date.
A covered employee or the spouse of the covered employee may elect continuation coverage for all family
members. The covered employee, and his or her spouse and dependent child(ren) each have an independent
nght to elect conunuauon coverage. For example, a spouse and/or dependent child(ren) may elect
conunuation coverage even if the covered employee does not elect it.
TYPE OF COVERAGE. PREMIUM PAYMENTS
If you elect continuation coverage. the Employer must give you coverage that, as of the time coverage is
provided, is identical to the coverage provided under the Employer's plan to similarly situated employees or
family members. This means that if the coverage for similarly situated employees or family members is
modified. your coverage will be modified.
A person covered under the plan as a dependent child who elects COBRA Continuanon of coverage Hill
continue to have pregnancy coverage restricted to the coverage available for dependent children as s:aied in
the plan document
When a COBRA participant is covered by another group benefits plan, this plan will coordinate benefits with
the other plan. The benefits of this Plan will be payable as the secondary after the other plan has paid as the
primary plan.
You must pay premium payments for your "initial premium months" by the 45th day after you elect
conunuauon coverage. Your inival premium months are the months that end on or before the 45th day after
you elect continuation coverage. All other premiums are due on the 1st of the month for which the premium is
being paid, subject to a 30-day grace period.
MAXIMUM COVERAGE PERIODS
If a spouse or dependent child(ren) loses group health coverage because of the employer's death, divorce, legal
separauon or entitlement to Medicare. or because you lose your status as a dependent under the Plan. the
maximum coverage period for the spouse and/or de endent child(ren) is 36 months from the date of the
qualifying event
4 110
n stAI .1/1/11 Paee'S
If the employee loses group health coverage because of a termination or reduction in hours of the employee's
ill employment the maximum continuation coverage period (for the employee. spouse and/or dependent
child(ren)) is 18 months from the date of termination or reduction in hours. There,.are two exceptions to this
Wile.
- For an employee or family member who is disabled on the date of termination or reduction in
hours, the conunuation coverage period is 29 months from the date of termination or reduction in
hours. The disability that extends the 18 -month coverage period must be determined under Title II
(Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security Income) of the
Social Security Act. For the 29 month continuation coverage period to apply, notice of the
determination of disability under the Social Security Act must be provided by the disabled
individual to the Employer within the 18 month coverage period. The premium rate to be paid
dunng the 18 to 29 month extension will be 150 percent of the normal full premium rate for the
coverage elected.
- If a second qualifying event occurs (for example, the employee dies or becomes divorced) within the
18 month or 29 month coverage period., the maximum coverage period becomes 36 months from
the date of the termination or reduction in hours for participating spouse and/or child(ren).
Special rule involving employee's entitlements to Medicare benefits. This rule applies only if you are the
employee's spouse or dependent child(ren) and you have continuation coverage because of a qualifying event
that was not the employee's becoming entitled to Medicare benefits. If the employee becomes entitled to
Medicare (either before or after that qualifying event), your maximum coverage period ends 36 months from
the date the employee became entitled to Medicare.
iio TER. S ATION BEFORE THE END OF THE MAXIMUM COVERAGE PERIOD
Your (employee, spouse or dependent child(ren)) continuation coverage automatically terminates (even before
the end of the maximum coverage period) when any one of the following events occurs:
1 The employer no longer provides group health coverage to am of its employees; or
2. The premium for your continuation coverage is not paid timely (within the 30 day grace penod); or
3 The employee, spouse or dependent child(ren) becomes covered under another group health plan
(as an employee or dependent), which does not contain any exclusion or limitation with respect to
any pre - existing condition of the covered individual, or
4 You become entitled to Medicare benefits; or
5 You are entitled to a 29 month maximum coverage period, but then there is a final determination
under Title II or XVI of the Social Security Act that you are no longer disabled; however,
continuation coverage will not end until the month that begins more than 30 days after the
determination and not before the end of the 18 month coverage period except as noted in items 1
through 4 above.
OTHER INFORMATION
If you have anv questions about this nonce or COBRA, please contact your employer
If your marital status changes. or a dependent ceases to be a dependent eligible for coverage under the
Plan terms. or you or your spouse's address changes, You must immediately notify your employer.
III
30101 211.'94 Page 17
PRE- AUTHORIZATION/U'I REVIEW _
Mandatory Pre- Aathorfzatioa for Hospital Admission
To help contra increasing costs of medical benefits and insure quality d cue, the City et Yakima has
implemented a Healthcare Utilization Mangy prognna
The City of Yakima has contracted with the Professional Review Organization/West (PROM) to be its
medical reviewing agency to review for medial or surgical necessity whoa hospitalization is recommended.
The following programs, administered by PROW, will assist you in becoming better informed about the
propose4 treatment while assuring quality of care and cost eontanament.
E .E-At
The pre - authorization program helps to determine medical or surgical necessity of hospitalization and the
appropriate treatment sating. In addition, the length of the hospital stay is certified for the City of Yakima
emPlorcs or dependents.
tom- 1,TTHORIZAIDN FOR HOSPITALIZATION
When )our physician recommends hospitalization, you must call PROW as soon as possible tut no later that
48 hour before the scheduled admission. A SS00 penalty will be assessed, if you do not comply. Failure to
call PROW for pre - authorization will result in a SS00 penalty If PROW does not authorize your treatment
(i.e. hopitalization) and you decide to proceed with that treatment instead of the alternative treatment
recommended by PRO /W, all benefits related to you unauthorized hospitalisation will be reduced to 60%. •
Inpatient hospitalizations needs to be pre-authorized You your physician, or a fatally member should call
PROAV to request pre - authorization. PROW health care professionals, including nurses and physicians, will
review the proposed hospitalization. If the hospitalization is approved, you, your physician, claims payor, and
the hospital will be noufied
If PROM determines that an admission is not medically or surgically may, they will recommend
alternate health rare settings or treatment that will mairazin both quaiity can and Cost - effective
options.. You will also be noted of yourtigtt to appeal such a decision
The telephone numbers for PROW are listed below'
In Seattle Call. (206) 3684211
Outside Seattle Call: 1- 800. 7834606
EGENCY HOSPITAL O13
If emergency hospitalization is necessary, you, a family member, your physician or the hospital unit cots=
PROAV within 48 hours of admission. In all situations, the ultimate responsibility for calling PROW is yours.
The r ason for using PRAJW for emergency admissions is to help determine the ongoing necessity of
went and appropriate length of the hospital stay
If You call PROW on the weekend or at night, you should leave a message on the PROW voice answering
machilne. Your message should include:
• Year Mme
• Patient's name, if other than you
• Identify yourself as a City of Yakima employee
• Telephone =bet where yea or a family member can be reached
• Name of hospital when the patient is being admitted
• Reason for hospital admission
BO le 1 2/1/94 Page 18
Failure to call PROW tot
petipithorization will result in a 5303 pewit, If PROM d no stwnyo
treatment (Le. treatment _ a p ace d wvA that treatment r000mmeaded by PROW all benefits related to your unauthorized (Le.
val be reduced to 60%.
The PROW health case professional will continue to monitor � review your medical situation
date, If your condition requires a base than initially
to determine if the additional days are medically necessary
Yakima employers and eligible dependents and is A4
This program is available .a. set-to City d provide support when there is eligible
serious chronic of
completely voluntary The program is designed P wily, and Li. c"
catastrophic illness. PROM uses nurses and other health rare Professionals to assist you, your
and the City of Yakima in coordinating quality, cost-effective care. and care plans manager that are %;)4-
your with h elan. and coordinating the treatment you and the necessary parties in communicating
medically receive the most from your health
ically necessary and appropriate. This allows you and your family
cart dollars without compromising the quality and integrity of care.
• E •ND • 1 •PLKI•N
s health rare professionals may regt that you obtain a second
On occasion, the utilization review responsible scheduling your own appointment. The second surgical opinion
must cal opinion You are d-cer who is not financaallY associated with your own
must be rendered by a board-certified surgeon or specialist
doctor
The n a s i f req
and reasonable charges of the second surgical opinion consultation, including additional oal
recommends a diagnostic ostic teas if required. are Paid at 100% by the Plan if the utilisation reuses' aw n recommended by the
surgical opinion. No deductible or copaymeII1 is required for the second surgery opinio
utilization review agency
as r 11 1_•i•ND •
•P' •N
After you obtain the second surge opinion, inion, you mu reconraa =Indian Indion review agency, and semi them
the resulu of the second surgical *ion. If the necessity of the surgery is confirmed by the second p•iaio4
the Plan will cover and pay for the surgery under normal Plan benefits. The utilization review agency will
monitor your length e[ gay in the hospital under the concurrent review program`
onion surgeon does not recommend surgery, the Plan will only pay si room m
you the coos to The second opinion surgeon will provide
you choose to proceed review w surgery ble alternative treatment plans. You will be notified of
you and the utilization trview agency $ '� chose to have s4rgexy is tilii'rY's youTS•
your right to appeal a decision of rwa-covesa8n.
•• • IN IL ••ND 'lL' n •Pr • ie bt_ .1, WHEN RE• Lip' B
�" � • ttu�W AG>:LS�Y
• .�.fl r ern NATION
If you do not obtain a second surgical °pin'
on and therefore fail to obtain for a
hospitalization, the penalties described above will be applied. The Plan does not cove services, treatment, or
procedures that are ma medically or surgically necessary
y
•
Pare 19
MAJOR MEDICAL BENEFITS
DESCRIPTION OF BENEFTTS
PRE - EXISTING CONDITIONS AND WAITING PERIODS
A pre - existing condition is a condition for which a person received medical treatment, sought medical advice,
had a condition which had manifested itself, or had a medical condition which would cause a reasonably
prudent person to seek treatment in the 90 days pnor to his effective date.
No benefits shall be paid for any pre -existing condition until the earliest of the following:
- A Covered Employee - the last day of a 90-day period during which no treatment was received, or
- A Covered Employee - the day immediately following 6 consecutive months of active, full -time
employment with the City; or
- A Covered Dependent, the day immediately after which the dependent has completed 12 consecutive
months of coverage under this plan, or
- Only for Covered Spouses relating to pregnancy, the day immediately following 6 consecutive months
of coverage under this plan.
NOTE If the employee or dependent is disabled, confined at home or confined at a treatment facility at
the end of the waiting period, coverage for the conditions specified above will not begin until the person
is no longer disabled or confined. •
If a claim is paid that was related to a pre-existing condition, the payment will not constitute a waiver of this
exclusion for that claim or an subsequent claim if it is later determined that the condition was pre-existing.
Right of recovery rnav apply (See Page 57)
INDIVIDUAL DEDUCTIBLE
The deductible is the amount of eligible medical expenses each calendar year that an employee or dependent
must incur before any benefits are payable by the Plan. The individual deductible amount is listed in the
Schedule of Benefits.
FAvf LY DEDUCTIBLE
When the deductible amounts accumulated by all covered members of the family reach the family deductible
shown in the Schedule of Benefits during one calendar year, no further deductibles will apply to any family
members for the rest of that calendar year However, no single family member will be required to satisfy more
than the individual deductible in a calendar year
COINSURANCE PERCENTAGE
After you have met the deductible for the calendar year eligible expenses in excess of the deductible incurred
in that calendar year shall be paid at the Coinsurance Percentage as specified in the Schedule of Benefits.
COPArvf NT
This is the amount paid by you each time treatment is received before the Plan pays the coinsurance
percentage listed in the Schedule of Benefits.
30101 211,'94 Page 20
• MAXTvfUM OUT OF POCKET EXPENSE
The amount of the coinsurance which is your responsibility is called your out-of-pocket expense. When your
out -of- pocket total reaches the out -of- pocket amount shown in the Schedule of Benefits during one calendar
year, the Plan will pay 100% of that individual's incurred eligible medical expenses for the remainder of the
calendar year
MAJOR MEDICAL LIFETIME MAXIMUM BENEFIT .
The Major Medical Lifetime Maximum Benefit per person while covered under this Plan is S150,000
ELIGIBLE EXPENSES
When medically necessary for the diagnosis or treatment of an illness or an accident, the following services are
eligible expenses for employees and dependents covered under this Plan. Eligible expenses are subject to the
deductible, coinsurance and copayment amounts shown in the Schedule of Benefits and are limited by certain
provisions listed in the General Exclusions in this section. Major Medical expenses are subject to all Plan
conditions, exclusions and limitations.
The following services are subject to the deductible, copayment and coinsurance amounts listed in the
Schedule of Benefits. Covered services include but are not limited to the following:
PHYSICIAN SERVICES
Services of a licensed physican will be paid as shown in the Schedule of Benefits for office, home, and
• hospital outpauent calls (including x -ray and laboratory services) and hospital inpatient care. Other services payable at the amount shown in the Schedule of Benefits include but not limited to:
Radiauon Therapy
Chemotherapy
Dialysis
Pathology
Electrocardiograms
Electroencephalograms
SURGERY AND RELATED SERVICES
Benefits are provided for the follow inpatient or outpatient services:
- surgen ,
- surgeon charges;
- assistant surgeons charges (not to exceed 25% of the reasonable and commonly accepted fee
allowable for the primary surgeon).
- anesthesia.
If two or more surgical procedures are performed through the same incision during an operation, full benefits
are onh provided for the primary procedure and one half for the lesser procedure(s).
•
B0101 2/1/94 Page 21
HOSPITAL SERVICES
Outpatient Care
Benefits will be provided for minor surgery and for emergency room treatment of an accidental injury or a
medical emergency
Emergency Room Copayment: A S25 Emergency Room Copayme m for each hospital emergency room visit
must be satisfied before benefits for emergency room services can be provided_ However, this copayment need
not be satisfied if one of the following is true:
- you are admitted as an inpatient directly from the emerged room; or
- emergency room care is for treatment of an accidental ihjury which is received on the day of the
accidental injury or within the next two days after th.z: date. The accidental injury must have
occurred on or after your effective date.
Inpatient Care
The following benefits will be provided for inpatient care in an a edited hospital when the patient is under
the care of a physician.
- room and board and general nursing care in a semi -prig =e room,
- intensive care, cardiac care, isolation or other special car unit;
- pnvate room accommodations, if medically necessary;
- prescribed drugs and medications administered in the hospital.
- anesthesia and its scim,mnzation,
- oxveen and its administration:
- dressings. supplies, cans and splints;
- diagnostic services:
- the use of durable medical equipment
Hospital Miscellaneous - All other charges made by a hospital dzr•ng an inpatient confinement are eligible,
exclusive of: personal items; s not necessary for the tre`ment of an illness or injury, or services
specifically excluded by the plan.
ALTERNATIVES TO HOSPITALIZATION - SPECIAL PROVISIONS
Home Health and Home Nursing Care, Hospice Care and Skilled Nursing Facility/Rehabilitation Benefits are
provided in lieu of and as an alternative to inpatient hospitalization_
1 They are subject to the concurrent opinion of the atten ng physician, the Plan Supervisor or the
Plan's UR Coordinator that they will be less costly tha= inpatient hospitalization that would have
been required.
2 They should be outlined in a written Treatment Plan.
3 The Treatment Plan is to be developed and reviewed pe: by the attending physician.
4 The Treatment Plan should include an estimate of the cm of services and supplies to be rendered.
Page 22
Ilk the benefits of this Special Provisions section are exhausted, the employee may apply for a limited extension
benefits under this section subject to the following:
1 An updated Treatment Plan is submitted and approved by the Plan Supervisor or the Plan's UR
Coordinator
2. Skilled care is needed to prevent admission or readmission to an acute care facility, or,
3 If rehabilitative, the treatment is demonstrated to be improving and restoring bodily functions lost
due to illness or injury and is needed to rerun the patient to normal living.
4 The care is not custodial.
5 Inpatient benefits are only available when care cannot be safely provided on an outpatient basis.
6 The extension will be for a maximum of 30 days at a time.
HOME HEALTH AND HOME NURSING CARE
Charges made by a home health care agency (approved by Medicare or state certified) for the following
services and supplies furnished to a covered individual in his home for care in accordance with a home health
care plan are included as covered medical expenses. Charges for home health care services of any kind will
be applied to the home health care benefit and subject to the home health care maximum of 510,000. Once the
maximum benefit is reached no further benefits are payable under Major Medical, except as allowed under the
limited extension of benefits described on page 22 This benefit is not intended to provide custodial care but is
provided for care in lieu of inpatient hospital or skilled nursing facility care for patients who are homebound.
The following sen•ices will be considered eligible expenses:
1 Part-tune or intermittent nursing care by a registered graduate nurse (RN), or by a licensed
• practical nurse (LPN) if the services of a registered graduate nu.-se are not needed.
2 Part -ume or intermittent home health aide service which consists primaril) of caring for the
individual.
3 Physical, occupational, and speech therapy when rendered in a home setting.
4 Medical supplies, drugs and medicines prescribed by a physician. and laboratory services normally
used by a panent in a skilled nursing facility or hospital. but only to the extent that they would have
been covered under this Plan if the individual had remained in the hospital.
HOSPICE CARE
Services and supplies furnished by a licensed Hospice (Medicare approved or state certified) for necessary
treatment of the covered person, pursuant to a written Treatment Plan furnished by the attending physician,
will be eligible for payment under the Major Medical Plan. Charges for hospice care services of any kind will
be applied to the hospice care benefit and subject to the hospice care maximum of six months. Once the
maximum benefit is reached no further benefits are payable under Major Medical, except as allowed under the
liauted extension of benefits described on page 22. The following services will be considered eli
expenses.
1 Services and supplies furnished by an approved home health care agency
2. Confinement in a host facility for short term inpatient care when included in the treatment plan.
3 Care in the patient's home on an outpatient basis when included in the treatment plan.
With respect to hospice care a Treatment Plan must include:
1 A description of the medically necessary care to be provided to a termina11 ill patient for palliative
care or medically necessan treatment of an illness or injury but not for cur nve care.
2. A provision that care will be reviewed and approved by the physician at least `very 60 days.
ill 3 A prognosis of six months or less to live.
4 The concurrent opinion of the physician and the Plan Supervisor that hospice care will cost less in
total than alternate treatment
E0101 2!1194 Page 23
EXCLUSIONS TO HOME HEALTH AND HOME NURSING CARE AND HOSPICE CARE
1 Non - medical or custodial services except as specifically included as an eligible expense.
2. Meals on Wheels or similar home delivered food services.
3 Nutritional guidance.
4 Services performed by a member of the patient's family or household.
5 Services not included in the approved treatment plan.
6 Supportive environmental materials such as handrails, ramps, telephones, air conditioners or
similar appliances or devices.
SKILLED NURSING FACILITY OR REHABILITATION BENEFIT
Rehabilitative services are provided when medically necessary to restore and improve function previously
normal but lost due to illness or injury Benefits will also be provided for treatment of congenital anomalies
for a newborn child covered from birth under this Plan or a previous Plan sponsored by this employer
Eligible expenses incurred during a covered confinement in a skilled nursing facility or rehabilitation facility
(Medicare approved or state certified) If the rehabilitation facility is part of an acute care hospital, it must be
a separate specialized department and approved by the Plan Supervisor The maximum limitation for skilled
nursing facility or rehabilitation benefit is 30 days per calendar year This benefit has a lifetime maximum of
120 days.
The eligible expenses are the skilled nursing facility or rehabilitation facility charges - up to the limits shown
in the Schedule of Benefits for the following services and supplies furnished while the patient requires 24 -hour
care and is under continuous care of the attending physician.
Room, board and other services and supplies furnished by the facility for necessary care (other than •
personal items and professional services),
- Use of special treatment rooms,
- X -ray and laboratory exam t aeons.
- Physical, occupational and speech therapy
- Oxygen and other gas therapy
This benefit is not provided for custodial care.
PRESCRIPTION DRUGS
Inpatient drugs are covered when administered to an individual for treatment of a covered illness or accident,
while confined. Inpatient prescription drugs will be paid under Major Medical at S0% and are subject to the
deductible.
Outpatient prescription drugs are reimbursable through your PCS Plan. The following outpatient prescription
drugs, if excluded from PCS, will be eligible for reimbursement under the Major Medical Plan when medically
necessary for the treatment of an illness; Retin -A (for individual's over 26 years of age); Dexedrine (not
covered for weight loss conditions); and birth control drugs (only when prescribed for the treatment of an
illness) Retrovir (Zidovine. AZT, Audothymidine) or any other AIDS specific drugs are eligible under the
Major Medical Plan when prescribed by a physician as part of an "Approved Treatment Plan." See definition
of "Approved Treatment Plan" in the Definitions Section. Maternity vitaminq are covered when prescribed by
a physician. Check with your PCS pharmacist about the maintenance prescription program.
Prescription drugs for treatment of dental conditions are reimbursable through your PCS Plan. There is no
prescription drug benefit under the Dental Plan.
ALLERGY TREATMENT
Eligible charges for the syringe and medication only will be payable as shown in the Schedule of Benefits.
EO101 2/1194 Page 24
• PRE - ADMISSION TESTING
Charges for tests ordered by the physician for the diagnosis and treatment of a condition and performed within
7 days prior to the scheduled hospital admission. Following the patient's admission to the hospital, the surgery
must be performed within 48 hours. Claims should be clearly marked as "Pre- Admission Testing" for surgery,
and must have a hospital admission date. Claims clearly marked "Pre- Admission Testing" will be paid at
100 %. If not marked, claims will be paid at 80 %.
MAMMOGRAPHY AND PAP SMEAR TESTS
Preventive mammograms are covered for female employees and spouses when recommended by a physician
and done within the following guidelines:
- one baseline mammogram for women age 35 through 40;
- one mammogram each two years for women ages 40 to 50;
- one mammogram each year for women age 50 and over
A pap smear test and cervical examination will be provided once per year
Mammograms and pap smear tests may be done as often as medically necessary to treat or diagnose an illness.
Both benefits (mammography or pap smear test) will be paid at 80% as shown in the Schedule of Benefits.
MATERNITY SERVICES
el Benefits for maternit} care and services are available to a covered employee or spouse, but not to a dependent
child. Pregi anc, and complrcauons of pregnancy (see below) will be covered as any other medical condition_
Hospital. surgical and medical benefits are available on an inpauent or outpatient basis for the following
matern.tty semces.
- normal delivery - 2 days allowed in the hospital, unless there are complications or the number of
days authorized bv the liR Coordinator,
- cesarean deliver, - 4 days allowed in the hospital. unless there are complications or the number of
days authorized bv the LR Coordinator,
- routine prenatal and postnatal care; and
- treatment of complications of pregnancy
Complications of Pregnancy
Benefits are available to a covered employee or spouse for services rendered to treat the following
complications of pregnancy
1 Hyperemesis gravidarnm (pernicious vomiting of pregnancy), eclampsia of pregnancy (toxemia
with convulsions), severe antipartum hemorrhaging due to premature separation of the placenta for
any reason. Postpartum hemorrhaging severe enough to require the transfusion of blood, missed
abortion, or RH incompatibility requiring amniotic fluid tests, analysis for intrauterine fetal
transfusion; or
2 Cesarean section for extrauterine pregaanc , or
3 Spontaneous terminanon of pregnancy which occurs during a period of gestation in which a viable
III birth is not possible.
4 Bodily or mental disorder whose diagnosis is distinct from pregnancy but which is adversely
affected by pregnancy or is caused by pregnancy, such as acute nephritis, nephrosis, cardiac
decompensation. and similar medical and surgical conditions of comparable severity, or
EO 10 i 211194 Pace 25
5 Therapeutic abortion necessary as part of the treatment of a severe bodily or mental disorder
included in one above.
•
In no event shall the term Complication of Pregnancy include cesarean section delivery as an alternative to
vaginal delivery after the 35th week of pregnancy, false labor, occasional spotting, physician prescribed rest,
morning sickness, pre-eclampsia, or similar conditions associated with the management of a difficult
pregnancy but not constituting a classifiably distinct complication of pregnancy
NEWBORN NURSERY CARE BENEFIT
Hospital charges incurred by a well newborn during the initial period of hospital confinement (as determined
by the UR coordinator) will be covered as charges of the baby In addition, a circumcision performed in an
outpatient setting within 30 days of the birth of the baby will be covered under this benefit.
Charges for routine immunizations and examination will not be considered eligible expenses under this
benefit.
ELECTIVE STERILIZATION
The Plan pays for certain elective sterilization procedures such as tubal ligation and vasectomies. These
procedures shall be paid under the Major Medical benefits for covered employees and spouses.
Eligible expenses under this Plan shall not include reversal or attempted reversal of these procedures.
AMBULANCE
ANCE
Services of a licensed ambulance company for transportation to the nearest hospital where the required sera=
is available, if other transportation would endanger the patient's health and the purpose of the transportation is •
not for personal or convenience reasons. Benefits for licensed air ambulance service are subject to pre-
authorization br the Plan Supervisor or the UR Coordinator and will be provided to the nearest hospital
equipped to render the medrealh necessary treatment Pre - authorization is not required if it is a life
threatening emergency
INFUSION THERAPY BENLr 11
Inpatient and outpatient services and supplies for infusion therapy will be provided under the Major Medical
benefits up to a maximum of S25,000, paid by the Plan, per calendar year The attending physician must
submit, and periodically review, a written treatment plan that specifically describes the infusion therapy
services and supplies to be provided_ The treatment plan must be approved in advance by the Plan Supervisor
or the UR Coordinator Drugs and supplies used in conjunction with infusion therapy will be provided only
under this benefit.
REPLACEMENT OF ORGANS OR TISSUE
Prior authorization by the Plan's UR Coordinator is required for all surgeries. See Pre -
Authonzation/Utilization Review Section. Eligibility for benefits relating to a transplant are subject to the pre-
existing waiting period under this Plan.
A. The following procedures are payable on the same basis as an illness up to the lifetime maximum of the
Plan or $150,000 whichrer is less. This maximum applies for each type of procedure (but not more than
once for any one procedure) and to all charges incurred as a result of the transplant.
1. Cornea transplants
2. Cataract lens implant
3 Artery and vein transplants
4 Heart transplants
5 Heart and lung transplants
E0101 2/1/94 Page 26
S 6 Liver transplants
7 Kidney transplants
8 Bone marrow transplants
9 Lung transplants
B. Benefits for a donor are payable only in the absence of other coverage and chap not exceed a
maximum payment of 55,000 Donor expenses are payable only when the organ recipient is covered
under this Plan and are considered expenses of the recipient
C. No benefits will be provided for the following:
1 Any procedure which has not been proven effective and is experimental or investigative. (see
definition of experimental and investigative). This exclusion includes procedures relating to
autologous and allogeneic bone marrow transplants or associated high -dose chemotherapy
2. Nonhuman, artificial, or mechanical transplants.
3 When donor benefits are available through other group coverage.
4 When government funding of any kind is available.
5 When the recipient is not covered under this Plan.
6 Lodging, food, or transportation costs.
7 Living (non - cadaver) donor transplants of the lung, liver, or other organ (except kidney) including
selective islet cell transplants of the pancreas.
DURABLE MEDICAL EOUIPMENT
Benefits are provided for rental or purchase (if more economical in the judgment of the Plan Supervisor) of
40 medically necessary durable medical equipment. Durable medical equipment is equipment able to withstand
repeated use, is primarily and customarily used to serve a medical purpose, and is not generally used in the
absence of illness or injury The durable medical equipment must be prescribed by a physician for therapeutic
use. and include the length of time needed, the cost of rental and cost of purchase prior to any benefits being
paid. Examples include the following: crutches; iron lungs; wheelchairs; kidney dialysis equipment; hospital
beds traction equipment; and equipment for ad ranistradon of ox Repairs or replacement of eligible
equipment shall be covered when necessary to meet the medical needs of the covered panent.
Benefits are not provided for certain equipment including, but not limited to, air conditioners. dehumidifiers,
purifiers, arch supports, corrective shoes, heating pads. deluxe equipment such as motorized wheelchairs or
beds, enuresis ( bed - wetting) training equipment, hearing aids, exercise equipment, whirlpool baths, orthotics,
weights. or hot nibs.
PROSTHETIC APPLIANCES
Benefits are provided for purchase of prostheses for artificial replacement devices of a missing body part or a
diseased part of the body Benefits will be payable for the first external and first permanent internal breast
prosthesis following a mastectomy Also covered is a glass eye which is inserted following removal of a
diseased eye. Benefits are not provided for cosmetic prostheses.
OTHER MEDICAL SUPPLIES
When prescribed by a physician, the following items: braces; surgical and orthopedic appliances; colostomy
bags and supplies required for their use; catheters; syringes and needles when medically necessary for diabetes
or allergic conditions: dressings when medically necessary for surgical wounds. cancer burns, or diabetic
ulcers; and oxygen.
BLOOD CHARGES
•
Charges made by a blood bank for processing of blood and its derivatives, cross- matrhing, and other blood
bank services; charges made for whole blood, blood components, and blood derivatives to the extent not
replaced by volunteer donors.
B0101 2/1/94 Page 27
PHYSICAL THERAPY
Services of a registered physical therapist when prescribed by a physician is subject to the Physical
Therapy /Speech Therapy /Outpatient Rehabilitation combined benefit limitation shown in the Schedule of
Benefits.
SPEECH THERAPY
Charges are covered when prescribed by a Physician and when necessary to restore a function lost or impeded
due to illness or injury A treatment plan must be submitted and approved in advance by the Plan Supervisor
or UR Coordinator This benefit is subject to the Physical Therapy / Spewh Therapy / Outpanent Rehabilitation
combined benefit limitation shown in the Schedule of Benefits.
OCCUPATIONAL THERAPY
Charges are covered when prescribed by a Physician and when necessary to restore a function lost or impeded
due to illness or injury A treatment plan must be submitted and approved in advance by the Plan Supervisor
or UR Coordinator
NEURODEVELOPMENTAL THERAPY SERVICES
Benefits will be provided for medically necessary neurodevelopmemal therapy treatment to restore and
improve function for children age six and under This benefit includes :maintenance services where significant
detenorauon of the patient's condition would result without the service. The services of a physician, physical
therapist, speech therapist, or occupational therapist will be provided in the home, office, hospital outpatient
department. Inpauent hospital or skilled nursing facility expenses wil: elig b1e when care cannot be safely
provided on an outpatient basis. The physician must submit a treatment plan to the Plan Supervisor for prior 41
approval and must periodically review the treatment plan.
Benefits are payable, after the deductible, at a constant 80 %, (not appl e:l to the out of pocket maximum) and
limited to a maximum of 54,000 paid by the Plan per calendar year :.: all services combined. Benefits for
rehabilitative services or other treatment programs and this bene£. will not be available for the same
condition.
CHIROPRACTIC CARE
Covered chiropractic services includes spinal manipulation, adjunctive therapy, vertebral alignment,
sublu.xation, spinal column adjustments and other chiropractic tr, ment of the spinal column, neck,
extremities or other joints, other than for fractures or surgery, provided by a licensed Chiropractor, MD or
D 0 Examinations, associated laboratory and x -rav tests. and supplies such as a cervical collar, pillow, back
brace, etc.) in connection with Chiropractic Care are subject to the chiropractic limit shown in the Schedule of
Benefits.
ALCOHOL AND DRUG ABUSE TREATMENT
Benefits will be provided for services of a physician and/or an approved chemical dependency treatment
facility for medically necessary inpatient and outpatient treatment of chemical dependency, including
detoxification and supportive services. Eligible expenses for treatment of drug or alcohol abuse shall be paid
according to the limitations shown in the Schedule of Benefits. The be :eats for a covered person under this
Plan will be reduced by the amount of benefits paid by the prior P'.-_s sponsored by this employer in the
immediately preceding 24 month period.
•
D .e IQ
ii Treatment for drug and alcohol abuse includes:
1 Medical and psychiatric evaluations;
2. Inpatient room and board (includes detoxification);
3 Psychotherapy (indr idual and gro up), counseling (individual and group), behavior therapy,
recreation therapy, family therapy (individual and group) for the patient and covered family
members:
4 Prescription drugs prescribed by and administered while in an approved treatment facility,
5 Supplies prescribed by an approved treatment facility, except for personal items.
Drug and alcohol abuse treatment does not include:
1 Personal items;
2. Items or treatment not necessary to the care or recovery of the panent;
3 Addiction to or dependency on tobacco, tobacco products or food.
4 Court- ordered servuos related to deferred prosecution, deferred or suspended sentencing, or to
driving rights.
Inpatient Treatment
When inpatient drug or alcohol abuse treatment is recommended, the patient must first contact the Plan's UR
Coordinator to pre - authorize admission. In addition to pre- authorization the following is required.
1 Treatment must be ordered in writing b) a physician or certified by the Plan's UR Coordinator, for
ii• the entire length of time the patient is confined,
2 Under extenuating c rcumstances. such as emergency tnpatient alcohol and drug treatment, you
must obtained authorization within 48 hours of admission by the Plan Supervisor or UR
Coordinator Wnnen explanation of the extenuating circumstances should be submitted to support
the need for the emergency admission.
3 The patient must complete the approved course of treatment in a hospital or an approved
alcoholism or drug uemment facility as defined by the Plan.
Outpatient Treatment
If treatment is provided on an outpatient basis, then treatment must be provided by a physician as defined
under tlus Plan.
INPATIENT AND OUTPATLNT TREATMENT OF MENTAL DISORDERS
Benefits will be provided for mental health care when treatment is rendered by any of the following:
physicians; licensed clinical psychologists; accredited hospitals; state mental hospitals; or mental health
agencies licensed by the state. Treatment of psychiatric conditions will be subject to the limitations shown in
the Schedule of Benefits. Pre :mission authorization is required.
Inpatient Treatment
When inpatient mental disorder treatment is recommended. the pauent must first contact the Plan's UR
Coordinator to pre - authorize admission. In addition to pre- authonzation the following is required.
• 1 Treatment must be ordered in writing by a physician or certified by the Plan's UR Coordinator, for
the entire length of time the patient is confined;
BO101 '!1:94 Page 39
2 Under extenuating circumstances, such as emergency inpatient mental disorder treatment, you must
obtained authorization within 48 hours of admission by the Plan Supervisor or UR Coordinator
•
Wntten explanation of the extenuating circumstances should be submitted to support the need for
the emergency admission.
3 The pauent must complete the approved course of treatment in a hospital as defined by the Plan.
4 In the event that room and board charges are made during a psychiatric leave from an inpatient
facility, a maximum of two days will be paid during any one leave with a limit of six leave days
paid per confinement
Outpatient Treatment
If treatment is provided on an outpatient basis, then treatment must be provided by a physician as defined
under this Plan.
SMOKING CESSATION BENEFIT
Nicorettes are covered up to a lifetime maximum of $50 00
DENTAL SERVICES
Dental services provided by a dentist, oral surgeon, or physician, including all related hospital inpatient or
outpatient charges, for only the following:
1 Treatment for accidental injunes to natural teeth or facial bones provided that the injury
occurred while covered under this Plan. Treatment for up to 24 months from the date of the
•
accident for accidental injuries is provided under this Plan. Injunes caused by biting or chewing
are not covered under the medical plan.
2 Extraction of teeth or other dental processes when adequate care can not be provided outside the
hospital and when there is an underlying medical condiuon that requires hospitalization.
PHOTOCOPYING
Reasonable charges made by a provider for photocopies of medical records when the copies are requested by
the Plan Supervisor shall be payable.
HOSPITAL AUDIT AND CASE MANAGEMENT FEES
Reasonable charges made by an audit and/or case management firm when the services are requested by the
Plan Supervisor and approved by the participating employer shall be payable.
SUPPLEMENTAL ACCIDENT EXPENSE BENEFIT
This benefit is designed to supplement the Major Medical Expense Benefit and therefore is not subject to any
deductible. All charges incurred by a Covered Person in connection with injunes sustained in or resulting
from one accident and covered under this provision will be paid at 100% up to the maximum allowance stated
in the Schedule of Benefits. Any portion of the charges exceeding such maximum allowable amount will be
considered under the Major Medical Expense portion of the Plan subject to all Plan conditions, exclusions and
limitations.
The Plan will pay for benefits for the following when furnished for medical care to the Covered Person for
accidental injuries, including but not limited to:
A. Services and supplies (including room and board) furnished by a hospital for medical care in that
hospital.
20101 2/1/94 Page 30
• B Doctor's services for surgical procedures and other medical care;
Surgical Dressings;
C 1� s; g
D X -rays and laboratory examinations;
E. Private duty nursing services by a registered nurse (R.N) or Licensed Practical
Nurse (L.P.N.);
F Drugs and medicines requiring the written prescription of a licensed physician;
G Casts, splints, muses, braces and crutches;
K Dentist's services for repair of injury to sound natural teeth.
I. Ambulance service for local travel.
The injuries must be sustained subsequent to the Covered Person's effective date Treatment must begin within
48 hours of the injury and the Person must be continuously covered under this Plan from the date of the
injury Services and supplies must be ordered by a doctor
AUDIT INCENTIVES
If a covered employee or a dependent discovers an error in the provider's medical billing which is subsequently
recovered or if the benefits payable are reduced due to the identification of the error the medical plan will
• reimburse the covered individual 50% of the recovered or reduced amount up to $500 per incident. No benefit
is payable for any errors made by the Plan Admunutrator in processing the claim.
GENERAL EXCLUSIONS TO THE MEDICAL PLAN
1 Charles that are not for the medically necessary diagnosis. care or treatment of an accident or illness
except as specifically provided for in this Plan.
2 Cosmetic surgery or related hospital admission, unless made necessary
a) by an accidental injury while covered ulna this plan;
b) for correction of congenital deformity within six years of birth if born while covered under this
Plan, or if not born while covered by this Plan. after a penod of two years of coverage under this
Plan,
c) for reconstntctive surgery as necessary for the prompt treatment of a diseased condition while
covered under this Plan;
d) for reconstructive breast surgery following a covered mastectomy while covered by this Plan; or if
the mastectomy was not done while covered by this Plan, after a period of two years of coverage
under this Plan
3 Charges for or in connection with the treatment of the teeth, periodontium, periodontal disease,
penapical disease or any condition (other than a malignant tumor) involving the teeth, surrounding nssue
or structure, except for oral surgery for repair of accidental injury to sound, natural teeth while covered
III under this Plan, or as otherwise provided heron.
B0101 2/1/94 Page 31
4 Medical treatment of Myofacial Pain Dysfunction, Temporomandibular Joint Dysfunction (TMJ) and
other jaw disorders and services directly attributable to the TMJ dysfunction will not be covered. Direct
treatment to the teeth or periodontium shall be considered dental services and are excluded from the
medical portion of this Plan, except as provided herein.
5 Services covered by or for which the employee is entitled to benefits under any Worker's Compensation
or similar law
6 Services in a hospital owned or operated by the United States government or any government outside the
United States in which the employee or dependent is entitled to receive benefits, except charges which
are billed by the Veterans Administration or the Department of Defense of the United States, for services
and supplies which are covered herein and which are not incurred during or as a result of service in the
Armed Forces of the United States.
7 Charges that the employee is not legally required to pay for, or for charges which would not have been
made in the absence of this coverage.
8 Charges that are in excess of the reasonable and commonly accepted fees; or that are not generally
accepted medical procedures for the treatment of the diagnosed illness or injury
9 Charges that are reimbursed, or that are eligible to be reimbursed by any public program except as
otherwise required by law
10 Pre - existing conditions except as provided herein.
11 provided Except rovided under the Drug and Alcohol Abuse Treatment, any medical treatment required
because of the use of narcotics or the use of hallucinogens in any form unless the drug is prescribed by a
physician.
12 Treatment made necessary by war, declared or undeclared, or any act of war An act of terrorism will not
be considered an act of war, declared or undeclared.
13 Eyeglasses, contact lens, eye refractions or examinations for prescriptions or fining of eyeglasses, contact
lens or charges for radial keratotomy, except as provided in the Vision benefits.
14 Charges or supplies with regard to hearing aids.
15 Routine services such as, but not limited to. routine physical exams, premarital exams, insurance exams.
routine pap smears and routine mammograms except as specifically provided for herein.
16 Routine pediatric care of well newborns, except as specifically provided for herein.
17 Elective, voluntary abortions except in the case of incest, rape and congenital deformities of the fetus as
determined by pre-natal testing unless otherwise, specifically provided for in the Schedule of Benefits.
18 Travel, whether or not recommended by a physician, except as proyided herein.
19 Sanitanum or rest cures.
20 Custodial care, except as specifically provided herein. Custodial care is care whose primary purpose is to
meet personal rather than medical needs and which is provided by persons with no special medical sldlls
or training. Such care includes, but is not limited to: helping a patient walk, getting in or out of bed, and
taking normally self- administered medicine. The Plan Supervisor in conjunction with the Medical Case
Manager shall determine based on reasonable medical evidence, whether care is custodial.
21 Treatment or services provided by anyone other than a physician operating within the scope of his
License, as defined herein.
.,,. .11 ,n , Page 32
0 22. Services considered to be experimental, investigational or generally non - accepted medical practices at the
time thev are rendered.
23 Birth control medications or devices.
24 Hospital services performed in a facility other than as defined herein.
25 Services or supplies that are primarily educational in nature.
26 Organ transplant surgeries except for transplant surgery which is not considered experimental in nature
and is specifically provided for herein.
27 Charges for suicide, attempted suicide, suicide gesture; or any intentionally self - inflicted injury or illness;
or injuries self inflicted:
a) while under the influence of alcohol, drugs, or other chemical substance, whether or not the patient
was then capable of intending to inflict self- injury,
b) while engaged in any activity which results in a felony conviction; or
c) while performing any act of violence or unusual physical force, such as hitting an object or person with
one's fist.
23 Expenses that are submitted more than one year after the date incurred.
4110 29 Charges for reversal or attempted reversal of sterilization.
30 Charges for sex change or for procedures to change one's physical characteristics to those of the opposite
sex.
31 Charges for breast or penile implants except as provided herein.
32. Charges for any illegal treatment or treatment listed by the AMA as having no medical value.
33 Charges for vision analysis, therapy or training relating to muscular imbalance of the eye; orthoptics.
34 Upper or lower jaw augmentation or reduction procedures (orthognathic surgery), except in the case of a
person covered continuously under this plan from birth.
35 Routine foot care procedures such as, but not limited to. trimming of nails, corns, calluses, or routine
hygienic care, except when medically necessary for treatment of diabetes. Orthotic appliances for the
feet, including but not limited to, heel lifts, foot pads, arch supports, corrective shoes, services or supplies
for fallen arches, or other symptomatic complaints of the feet Impression casting of the feet for
prosthetics and appliances.
36 Services or supplies for learning disabilities, marital, sexual or family counseling outreach, job training
or other education or training services; treatment or classes to stop smoking except as specifically
provided for in the Schedule of Benefits.
37 Charges associated with impotency, infertility, and procedures to restore fertility or to induce pregnancy,
including but not limited to: corrective or reconstructive surgery, hormone injections; in -vitro
fertilization, artificial insemination, gamma infra- fallopian transfer (G.LF T ).
38. Charges in connection with any injury or g
• illness arising out of or in the course of any employment for
wage or profit; or related to professional or semi - professional athletics, including practice.
39 Occupational therapy, except as specifically provided herein.
B0101 2!1/94 Page 33
40 Milieu therapy (a treatment designed to provide a change in environment or a controlled environment). •
41 Hospital admission primarily for rehabilitative care including, but not limited to, speech and occupational
therapy except as provided under the Major Medical Plan. Further, when the type of care rendered
dunng a continuous period of hospital confinement develops into primarily rehabilitative care, that
portion of the stay primarily for rehabilitative care is covered under this Plan as provided under the
rehabilitation provisions in the Major Medical Plan.
42 Transportation by private automobiles or taxi service.
43 To the extent that benefits are payable under the terms of any automobile, medical, no fault, or cimitar
contract insurance.
44 Treatment for obesity (excessive weight) including surgery or complications of such surgery, wiring
of the jaw or procedures of similar nature.
45 Charges that are a result of any injury or illness incurred by a covered individual while that covered
individual is participating in the commission of a felony
46 Charges for any injury to a covered individual sustained while driving a vehicle that is involved in an
accident where the covered individual is found guilty of Drring While Intoxicated (under the influence
of alcohol or illegal drugs).
47 Charges incurred for treatment or care by a Physician, R.N., L.P.V., licensed or certified practitioner if
he or she is a relative, or treatment or care provided by any person who ordinarily resides with the
covered individual. •
Upon termination of this Plan, all expenses incurred prior to the termination of this Plan, but not
submitted to the Plan Supervisor within 75 days of the effective date of termination of this Plan, will be
excluded from any benefit consideration.
rrnini 1n ,94 Page 34
PHARMACEUTICAL CARD SERVICE
(PCS RECAP
CARD BENEFIT PLAN #3184)
"Legend Drugs" are those drugs which cannot be purchased without a prescription written by a physician or
dentist.
PAYMENT SCHEDULE PCS PLAN
Legend drugs and insulin are payable up to the wholesale price less 10 %, and according to the Maximum
Allowable Cost (MAC) program C, plus a professional dispensing fee as set by the Plan Administzator
COPAYMENT
A copayment is payable for each prescription filled according to the amounts shown in the Schedule of
Benefits.
DRUGS COVERED
- Legend Drugs. Exceptions: See Exclusion list below
- Insulin.
- Disposable needles/svringes.
- Disposable blood/urine/glucose /acetone testing agents (e.g. Chem strips. Acetest tablets, Clinitest tablets,
Diasux strips and Tes -Tape)
• - Treunotn, all dosage forms (e.g. Retn A), for individuals through age 25 years.
- Compounded medication of which at least one ingredient is a prescnption Legend Drug.
- Any other drug which under the applicable state law may only be dispensed upon written prescription of
a physician or other lawful prescriber
DRUGS EXCLUDED AND LLM TED
This Plan does not cover
- Contraceptives, oral or other, whether medication or device, regardless of intended use.
- Anorectics (any drug used for the purpose of weight loss).
- Dietary supplements.
- Growth hormones.
- Immnm7'tion agents, biological sera, blood or blood plasma.
- Infertilit, medications.
- Levonorgestrel (Norplant).
- Minoxidil (Rogaine) for the treatment of alopecia.
- Non - legend drugs other than those listed above.
- Smoking deterrent medication containing nicotine or any other smoking cessation aids, all dose forms
(e.g. Nicorettes, Nicoderm, etc.). Benefits may be provided for some of these items under the Major
Medical section on page 30
- Tretinoin, all dosage forms (e.g. Retin -A), for individuals 26 years of age or older.
- Vitamins singly or in combination.
- Therapeutic devices or appliances, including support garments and other non - medicinal substances,
regardless of intended use. Benefits may be provided for some of these items under the Major Medical
section.
- Charges for the administration or injection of any drug.
• - Drugs labeled "caution - limited by federal law to investigational rise ", or experimental drugs, even
though a charge is made to the covered individuaL
B0101 211194 Page 35
\►
- Medication which is taken by or administered to an individual, in whole or in part, while he or she is a
pa 4114
tient in a licensed hospital, rest home, sanitarium_ extended care facility, convalescent hospital,
nursing home or sunilar institution which operates on its premises, or allows to be operated on its
premises, a facility for dispensing pharmaceuticals. Benefits may be provided for some of these items
under the Major Medical section.
- Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after
one year from the physician's original order
DISPENSING LIMITATIONS
The amount normally prescribed by a physician, but not to exceed a 30 day supply Check with your PCS
pharmacist about the maintenance drug program
BENEFIT LIMITATIONS
Using your PCS Recap card when purchasing prescriptions and paying the applicable copavment, the Plan
pays 100% of the balance due the PCS Recap Pharmacy direct to the pharmacy
If the PCS card is not used by the covered individual at the time of the prescription purchase or the
prescnpnon is purchased at a non - participating pharmacy, you must file a claim directly with PCS using a
PCS claim form.
When you do not use the PCS Recap card, the benefit is less because the prescription drugs cost more. When
you submit a prescription claim to PCS, the charges which include (1) the copayment you would normally
pas (2) the difference between the pharmacy retail pnce and the amount the pharmacy would have charged if
the PCS Recap card was used, and (3) a handling fee. will be deducted from your total reimbursement
BENt:.r l 1 S FOR EMPLOYEES AND DEPENDENTS WITHOUT A PCS RECAP CARD
At the option of the Plan Administrator, any employee or dependent of an employee may be required to
surrender their PCS Recap Card_
Prescription drugs that are reimbursed by the PCS program can be submitted to the Plan Supervisor (I-Lk)
only during the initial period of eligibility prior to the enrollee's receipt of the first PCS card, or in the event
the enrollee is required to surrender the PCS card. To claim this benefit, a receipt for the paid prescription
with a Healthcare Management Administrators claim form must be submitted to HMA. HMA will reimburse
eligible claims as if the PCS card had been used. That is: 100% reimbursement following the applicable
copavment.
BO101 2/1/94 Page 36
III DENTAL BENEFTTS
For eligible employees and their eligible dependents covered under this section, the Plan will pay the dental
benefits listed herein. Benefits are subject to the limitations shown in the Schedule of Benefits in addition to
limitations shown in this section. Charges in excess of the reasonable and commonly accepted fees in the
geographic area where treatment is rendered are not eligible under this Plan.
OPTIONAL PREDETERMINATION OF BENEFITS
Before beginning a course of treatment for which dentist's charges are expected to be S300 or more, you are
encouraged to send a description of the proposed course of treatment and charges to the Plan Supervisor This
information may be transmitted on a standard dental claim form available from the dentist. The Plan
Supervisor will then determine the estimated benefits payable for the proposed treatment and advise the
employee and the dentist before treatment begins.
The estimate will allow both the patient and the dentist to know in advance what benefits will be payable by
the Plan If desired, the estimate will also allow the patient to discuss the proposed treatment with another
dentist and obtain a competitive opinion of needed treatment and the price for the treatment
Please note that the estimate from the Plan Supervisor will be based on the coverage available at the time the
estimate is given and will always be subject to the annual dental maximum benefit shown in the Schedule of
Benefits.
40 DESCRIPTION OF BENEFITS
incurred during a calendar
The Plan pays for covered dental expenses that are g year on behalf of a covered Y
individual for listed preventive dental care, treatment of dental disease, failing dental restorations and for
injury to teeth not otherwise covered under a medical benefit. Plan benefits are subject to the coinsurance
percentage and annual dental ma. -amum shown in the Schedule of Benefits.
DEDUUI 113LE
There is no deductible on Dental Benefits.
CALENDAR YEAR MAXIMUM
Not more than the Calendar Year Maximum shown in the Schedule of Benefits is payable under the Dental
section for all dental expenses incurred by an individual in a calendar year, regardless of any interruption in
coverage.
COVERED DENTAL EXPENSES
Covered dental expenses are the dentist's charges for the services and supplies listed below which meet all of
the following tests:
1. They are necessary and customarily employed nationwide for the treatment of the dental condition.
2. They are appropriate and meet professionally recognized national standards of quality
Benefits are determined by American Dental Association codes submitted on the itemized bills. The correct
0 American Dental Association code must be used to ensure the benefit is paid at the correct coinsurance level.
BO101 2/1/94 Page 37
ALTERNATE TREATMENT
If alternate services or supplies are used to treat a dental condition, covered dental expenses will be limited to
the services and supplies which are customarily employed nationwide to treat the rirnrai condition and which
are recognized by the profession to be appropriate methods of treatment in accordance with broadly aarpted
national standards of dental practice, taking into account the patient's total current oral condition.
TYPE I PREVENTIVE EXPENSES
Only those Preventive services listed below are covered by the Plan.
The following services and supplies are payable at the 100% coinsurance amount shown in the Schedtile of
Benefits:
VISITS AND X -RAYS
1 Preventive oral examinations during regular business hours limited to two visits per calendar year.
2. Prophylaxis (preventive t cleaning - American Dental Association Code 1110) limited to two
treatments per calendar year
3 Topical application of fluonde limited to two treatments per calendar year
4 Dental x -rays:
a. full mouth x -rays are limited to once each three years;
b charges for bitewing x -rays alone are covered up to twice per calendar year
TYPE II BASIC AND RESTORATIVE EXPENSES
The following services and supplies are payable at SO% coinsurance as shown in the Schedule of Benefits.
They include, but are not limited to.
1 Exuaction of teeth, oral surgery
2. Periodontal treatment to include root scaling, planing, periodontal splinting and periodontal cleaning.
3 Amalgam and composite restorations. Composite restoration is covered only on teeth anterior to the
first molar If composites are used to restore a molar, the charge will be allowable up to the amoarnt of
an amalgam restoration_ Stainless steel crowns are covered when necessary to restore: a primary tooth.
4 General anesthetic when medically necessary and administered in connection with oral surgery only
Local anesthesia is included in the allowance for the procedure.
5 Endodontic treatment.
6. Special consultations and oral examinations related to Type II expenses by a specialist for case
presentation when diagnostic procedures have been performed by a general dentist-
7 Emergency palliative examination and treatment including injection of antibiotics and after boars
visits.
S. X -ray and pathology when related to Type II expenses.
9 Repair or recementi.ng of crowns, inlays, bridgework or dentures or relining of dentures.
• 10 Sealants for permanent teeth to prevent crevice decay
11 Space maintainers for premature loss of primary teeth.
TYPE III PROSTHETICS and MAJOR EXPENSES
The following services and supplies are payable at 50% coinsurance as shown in the Schedule of Benefits.
1 Study models related to Type III expenses.
2. Initial installation of partial or full removable dennires (including adjustments for the six month period
following installation) to replace one or more natural teeth extracted while the individual is covered by
this Plan.
3 Replacement of an existing partial or full removable denture by a new denture, or the addition of teeth
to a partial removable denture. However, only replacements and additions that meet the "Prosthesis
Replacement Rule" shown below will be covered.
4 Lab processed composite, ceramic (porcelain) or gold restorations and crowns, if initial placements.
Porcelain crowns covered only on teeth anterior to first molar If replacement, then the original
placement or crown must be five years old or older, as specified in the "Prosthesis Replacement Rule"
5 Initial installation of fixed bndgework to replace one or more natural teeth exiracted while the
individual is covered by this Plan.
• 6 Replacement of fixed bridgework by new bridgework. or the addition of teeth to existing fixed
bridgework. However, only replacements and additions that meet the "Prosthesis Replacement Rule"
will be covered_
6 Prosthodonncs including bonded bridges.
7 Implants (fixture, abutment and crown) not to exceed the amount that would be allowed for fixed
bridgework that would restore the missing teeth
8. Treatment of Myofacial Pain Dysfunction, Temporomandibular Joint Disorder, Bruxism and all
occlusal adjustments will be payable at the 50% coinsurance level, up to a maximum of S300 paid per
calendar year Expenses will also be applied towards the annual dental maxomirm shown in the
Schedule of Benefits. Treatment includes, but is not limited to, occlusal adjustments, joint
manipulations, splints, mouth guards and other appliances.
THE PROSTHESIS REPLACEMENT RULE
The Prosthesis Replacement Rule requires that replacements or additions to existing dentures or bridgework
will be covered only if evidence satisfactory to the Plan Supervisor is furnished and that at least one of the
following applies:
a. The replacement or addition of teeth is required to replace one or more teeth extracted after the
existing denture or bridgework was installed, and while the individual was covered by this Plan;
b. The existing denture or bridgework cannot be made serviceable and was installed at least five years
prior to its replacemen
• c. The existing denture is an immediate temporary dentate and replacement by a permanent denture is
required within 12 months from the date of initial installation of the immrrtiatP, temporary denture.
BO101 2/1/94 Page 39
BENEFITS Al- t hlt TERM NATION OF COVERAGE
Expenses incurred for a covered individual, after termination of the individual's coverage under this benefit 110
section, for any of the following items:
- Dentures
- Fixed bridgework
- Crowns
- Root Canal
The above will be considered to be expenses incurred when treatment has started prior to termination of
coverage, but only if the item is finally installed, delivered or completed no later than 30 days after termination
of coverage.
For dentures, treatment is considered started if impressions have been taken.
For fixed bridgework or crowns, treatment is considered started when the teeth which will serve as retainers or
support, or which are being restored, have been fully prepared to receive the item, and impressions have been
taken.
For root canal, treatment is considered started when the pulp chamber has been opened.
ORTHODONTIC BENEFIT
411
The following services and supplies are payable at 50% of the reasonable and commonly accepted amount, and are limited to a lifetime maxunum benefit of 52,000 per covered individual, provided that the charge is
incurred dung the time penod, as described below
Charges of a dentist for services and supplies rendered to a covered individual in connection with orthodonnc
treatment will be included as covered dental expenses, subject however, to the following.
1 All terms of this benefit section applicable to other types of dental treatment, except that any benefits
payable will be at the rate shown in the Schedule of Benefits for covered dental expenses
2. The aggregate benefit payable for all orthodontic treatment rendered to an individual will not exceed
the Orthodontic Maximum Benefit shown in the Schedule of Benefits regardless of any interruption
in coverage.
In addition to the above, charges shall only be eligible under this provision if the charges are actually made to
the covered individual and if such charge is part of an orthodontic treatment plan which, prior to performance
of the procedure, has been (1) submitted to the Plan Supervisor and (2) returned to the orthodontist, showing
estimated benefits. An orthodontic treatment plan is an orthodontist's report, on a form satisfactory to the Plan
Supervisor, which (1) provides a classification of the malocclusion or malposition, (2) recommends and
describes necessary treatment by orthodontic procedures, (3) estimates the duration over which treatment will
be complete, (4) estimates the total charges for such treatment and (5) is accompanied by cephalometric x-
rays, study models, and other such supporting evidence as the Plan Supervisor may reasonably require.
The total eligible charges scheduled to be made in accordance with an orthodontic treatment plan shall be
considered to be made in monthly installments (except that the amount of the first installment shall be twin
that of the others) over a period of time equal to the estimated duration of the orthodontic treatment plan. The
first installment shall be considered to occur on the date on which the orthodontic appliances are inserted
and/or active banding has been started, and subsequent installments shall be considered to occur at the end of
each month thereafter.
Page 40
BO101 2/1/94
40 Orthodontic treatment that began before the effective date of the individual's coverage will be considered a pre-
existing condition. As such, no benefit is payable for expenses incurred for that treatment plan.
Covered Expenses include the following:
- X -rays
- Extractions
- Space maintainers
- Appliances for tooth guidance
- Appliances to control harmful habits
- Retention appliances
- Diagnostic procedures
- Study models
- Banding
- Post treatment
EXCLUSIONS and LIMITATIONS TO THE DENTAL PLAN
Covered dental expenses do not include and benefits are not payable for
1 Charges for any dental services and supplies which are covered expenses in whole or in part under any
other part of this Plan, or under any other plan of group benefits provided by the Company, whether or
not benefits are payable under such section or plan as to such charges.
• 2. Charges for treatment by other than a dentist except that scaling or cleaning of teeth and topical
applicanon of fluoride may be performed by a licensed dental hygienist or dental assistant if the
treatment is rendered under the supervision or the direction of the dentist and is in accordance with state
law
3 Charges for services or supplies that are cosmetic in nature.
4 Charges for the replacement of a lost, missing or stolen prosthetic device.
5 Charges for any service or supplies which are for orthodontic treatment, except as specifically provided.
6. Charges for dentures, crowns, inlays, onlays, bridgework, splinting, other appliances or service, the
primary purpose of which is to increase vertical dimension or restore occlusion, except as specifically
provided herein.
7 Charges for precision or other elaborate attachments for any appliance.
8. Charges for congenital malformation.
9 Charges for sealants, except as provided under Type I benefits.
10. Treatment of Myofacial Pain Dysfunction or Temporomandibular Joint Disorder except as provided
wider Type III benefits.
11 Any charges incurred for a partial or full removable denture or fixed bridgework, if involving
replacement of one or more naniral teeth missing prior to becoming covered herein, unless the denture or
fixed bridgework also includes replacement of a natural tooth which (1) is exacted while covered herein
III extracted
and (2) was not an abutment to a partial denture or fixed bridge installed within the immediately
preceding 5 years.
BO101 2/1/94 Page 41
12. Dental services started prior to the date the person became eligible for services under this Plan incl
but not limited to charges incurred fora service to a covered person which is (1) an appliance, or
modification of an appliance, for which a tooth was prepared before becoming covered herein, or (2) root
canal therapy, for which the pulp chamber was opened prior to coverage herein.
13 Procedures to alter vertical dimension or restore occlusion except as covered under the MPD /IMJ section
or rnriPr orthodontia benefits if provided herein.
14 Prescriptions are not covered under the Dental Plan. Dental prescriptions are paid under your
Pharmaceutical Card Service (PCS) Plan.
Rnuni 211/94
Page 42
VISION BENEFITS
Vision benefits are payable according to the following scheduled maximums and are not subject to a
deductible. Benefits are payable once during any calendar year for an EXAMINATION Benefits are payable
for a PAIR OF LENSES with FRAMES and/or a PAIR OF CONTACT LENSES not to exceed $200 during
any two consecutive calendar years.
COVERED SERVICES
Examination 100%
S60 maximum per calendar year
An eye examination consists of the inspection of internal and
external appearance of the eye, eye movement, visual acuity, visual
field, color vision, glaucoma and a refraction test, to assess whether
glasses or contact lenses are necessary
An eye examination must be completed by an Optometnst or
Ophthalmologist
Lenses and Frames AND /OR Contact Lenses 100%
S200 maximum every two consecutive calendar years.
• EXCLUSIONS TO '11±L VISION PLAN
To assure coverage at a reasonable cost, and to prevent unnecessary use of services, the following exclusions
have been incorporated.
1 Charges for special procedures. such as orthopucs or vision training, or for special supplies. such as
nonprescription sunglasses and subnormal vision aids.
2. Spare glasses, a spare contact lens or lenses, or spare frames.
3 Replacement of lost, stolen or broken glasses, or contact lenses.
4 Drugs or medications of any kind.
5 Charges for services or supplies which are received while the individual is not covered.
6 Charges for any vision care services or supplies which are Included as covered expenses under any other
benefit section included in this Plan, or under any other medical or vision care expense benefit plan
carried or sponsored by the Company, whether benefits are payable as to all or only part of the charges.
7 Charges for vision care services or supplies for which benefits are provided under any worker's
compensation law or any other law of irnilar purpose, whether ben. is are payable as to all or only part
of the charges.
8. Charges for any eye examination required by an employer as a condition of a plovment, or which an
employer is required to provide under a labor agreement. or which u required by any law or government
B0101 2/1/94 Page 43
VISION BENEFITS AFTER TERMINATION OF COVERAGE
Expenses incurred for lenses and/or frames within 30 days of termination of the employee's or covered
dependent's coverage under the benefit will be considered to be covered Vision Care Expenses, but only if a
complete eye examination, including refraction, was performed during the 30 day period immediately
preceding the termination of coverage and while coverage was in force and the examination resulted in lenses
being prescribed for the first time or new lenses required because of a change in prescription.
BO101 2/1/94 Page 44
GENERAL DEFINITIONS
•
ACCIDENT / ACCIDENTAL INJURY - Shall mean a personal bodily injury to the employee or dependent
effected solely through external violent and nnimentionaT means. All injnnes sustained in connection with
one accident will be considered one Accidental Injury Accidental Injury does not include ptomaine poisoning,
disease or infection (except pyogenic infection occurring through an accidental cut or wound).
ALLOWABLE EXPENSE - The reasonable and commonly accepted amount of expenses, at least a portion of
which is paid under at least one of any multiple plans covering the person for whom the claim is made. In no
event will more than 100% of total allowable expenses be paid between all plans, nor will total payment by
this Plan exceed the amount which this Plan would have paid as primary plan.
APPROVED ALCOHOLISM OR DRUG TREATMENT FACILITY - For the purpose of treatment of alcohol
or drug abuse, the definition of the term hospital includes any public or private treatment facility providing
services for the treatment of alcoholism which has been licensed or approved as an alcoholism treatment
facility by the state in which it is located.
APPROVED TREATMENT PLAN - A written outline of proposed treatment that is submitted by the
attending physician to the Plan Supervisor for review and approvaL
BIRTHING CENTERS - An outpatient facility licensed in the jurisdiction where it is located to provide
comprehensive birth services to individuals considered normal, low risk pandits.
CALENDAR YEAR - The 12 months be January 1 and ending December 31 of the same year
• CONTRIBUTORY - The employee is required to pay a portion of the cost to be eligible to participate in the
Plan.
COVERED PERSON OR LNDIVIDUAL - An emplovee. spouse or child who is eligible for benefits under this
Plan.
CL STODIAL CARE - Care or service which is designed essentially to assist a person in the activities of daily
living. Such care includes, but is not limited to. bathing, feeding, preparation of special diets, assistance in
walking, dressing, getting into or out of bed and supervision over taking of medication which can normally be
self- artminictered.
DEDUCTIBLE - The amount of expenses for covered serices that an employ= must pav, before the Plan will
begin its coinsurance payments.
DISABILI'T'Y - See Total Disability
DONOR - A donor is the person who provides the organ for the recipient in connection with organ transplant
surgery A donor may or may not be an employee or covered under the provisions of this Plan.
EFFECTIVE DATE - The effective date shall mean the first day this Plan was in effect as shown in the Plan
Specifications. As to the individual, it is the first day the benefits under this Plan would be in effect, after
sausfaction of the waiting period and any other provisions or limitations contained herein.
ELECTIVE SURGICAL PROCEDURE - A surgical procedure that need not be performed on an emergency
basis because reasonable delay will not cause life endangering complications.
III
B0101 2/1/94 Page 45
EXPERIMENTAL OR INVESTIGATIVE - This Plan does not consider eligible for benefits any treatment,
procedure, facility, equipment, drug, drug usage, device or supply which, at the time rendered, does not meet
the cntena listed below
1 Approval has been granted by the Federal Food and Drug Administration (FDA), or by another
United States governmental agency, for general public use for ueatment of a condition; or
2 It has been scientifically demonstrated by the medical profession to have efficacy in terms of:
- When the prognosis for the patient's condition is terminal, that the treatment substantially
extends the probabilities of the person's survival, or
- When deterioration of a body system is progressive and reasonably certain to (or has) disabled or
incapacitated the patient, that the treatment can be substantially expected to improve the
probabilities of arresting the condition's progress for five or more years; or
- When the body function has been lost by the patient, that the treatment has been shown to restore
the body function to usefulness at least sixty percent of the time treatment has been utilized.
Treatment must be ordered by an institution or provider within the United States that has scientifically
proficiency directly in such treatment All services dly coved with a non - approved experimental
or investigational procedure are not covered.
HOMEBOUND - A patient is homebound when leaving the home could be harmful, involves a considerable
and taxing effort and the patient is unable to use transportation without the assistance of another
HOSPITAL - An institution accredited by the Joint Commission on Accreditation of Healthcare Organizations
and which receives compensation from its patients for services rendered. On an inpatient basis, it is primarily
engaged m providing the following:
1 Diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment and care of
inured and ill persons.
2. Services performed In or under the supervision of a staff of physicians who are duly licensed to
practice medicine.
3 Continuous twenty -four (24) hours a day nursing services by registered grades nurses.
It is not, other than incidentally, a place for rest, or for the aged.
For the services covered under this Plan and for no other purpose. inpatient treatment of mental illness or
substance abuse, provided by any psychiatric hospital licensed by the State Board of Health or the Department
of Mental Health, will be considered services rendered in a hospital as defined subject to the limitations shown
in this booklet
ILLNESS - The term illness means an illness causing loss while this Plan is in force as to the covered person
whose illness is the basis of the claim. Illness shall also be deemed to include disability caused or contributed
to by pregnancy, miscarriage. childbirth and recovery therefrom It shall only mean illness or disease which
requires treatment by a physician.
INCURRED CHARGE - The charge for a service or supply is considered to be incurred on the date it is
furnished In the absence of due proof to the contrary, when a single charge is made for a series of services,
each service will be considered to bear a pro rata share of the charge.
INJURY - The term injury shall mean only bodily injury caused by an accident while tlx Plan is in force as to
those injuries which require
the covered person whose injury is the basis shall mean only of the claim. Injury Y
treatment by a physician. A hernia shall be considered an illness, not an injury
BO101 2/1/94 Page 46
• INPATIENT - Anyone treated as a registered bed patient in a hospital or other institutional provider LIFE ENDANGERING COir T)ITTON - An accident or sickness which requires immediate medical attention,
without which death or serious impairment to a person's bodily functions could occur.
LIFE ENDANGERING CONDITION OF PREGNANCY - A mother's condition due to pregnancy is
considered Life Endangering when the attending physician and a second opinion physician attest, in writing,
that the mother's life is in danger should the pregnancy go to full term.
MANIFEST - Refers to that point in time where symptoms of a health condition are apparent, i.e. are felt,
visible, etc., to such a point where an ordinary prudent person would have sought medical diagnosis or
treatment. A health condition does not necessarily manifest itself at the time of diagnosis.
MEDICAL CASE MANAGER / UTILIZATION REVIEW COORDINATOR - The individual or organization
designated by the Plan Administrator to authorize hospital admissions and surgeries and to determine the
medical necessity of treatment for which Plan benefits are claimed
MEDICAL EMERGENCY - An illness or injury which is life threatening or one that must be treated promptly
to avoid senous adverse health consequences to the covered person.
MEDICALLY NECESSARY - Medical services and/or supplies which are absolutely needed and essential to
diagnose or treat an illness or injury of a covered employee or dependent while covered by this Plan. The
following cnteria must be met. The treatment must be:
1 Consistent with the symptoms or diagnosis and treatment of the covered person's condition; and
• 2 Appropriate with regard to standards of good medical practice; and
3 Not solely for the convenience of the covered person, family members or a provider of services or
supplies; and
4 The least costly of the alternative supplies or levels of service which can be safely provided to the
covered person. When specifically applied to a hospital inpatiez . it further means that the service
or supplies cannot be safely provided in other than a hospital inpatient setting without adversely
affecting the covered person's condition or the quality of medical care rendered.
MEDICARE - The programs established by Title XVIII of the U.S. Social Security Act as amended and as
may be amended. entitled Health Insurance for the Aged Act. and which includes Part A - Hospital Insurance
Benefits for the Aged.; and Part B - Supplementary Medical Insurance Bents for the Aged.
NON - EMERGENCY HOSPITAL ADMISSION - A hospital admission (including normal childbirth) which
may be scheduled at the convenience of a person without endangering such person's life or without causing
serious impairment to that person's bodily functions.
ORDER OF BENS 11 S DETERMINATION - The method for ascertaining the order in which the Plan
renders payment hereunder. The principle applies when another plan has a Coordination of Benefits
provision.
ORTHOTICS / ORTHOSIS - An orthopedic appliance or apparatus used to support, align, prevent or correct
deformities or to improve function of movable parts of the body
OUTPATIENT SURGICAL FACILITY - A licensed surgical facility, surgical suite or hospital surgical center
• in which a surgery is performed and the patient is not admitted for an overnight stay
I
BO10 2/1194 Page 47
PHYSICIAN - The term physician means a Doctor of Medicine (M.D ), Doctor of Naturopathy (ND) or
Doctor of Osteopathy (D 0) who is legally qualified and licensed without limitation to practice medicine,
surgery, or obstetrics at the time and place service Ls rendered. For services covered by this Plan and for no
other purpose, doctors of dental surgery, doctors of dental medicine, doctors of podiatry or surgical chiropody,
optometnsts, chiropractors and licensed health service providers in psychology are deemed to be physicians
when acting within the scope of their license for services covered by this Plan.
Registered Physical Therapists, Registered Speech Therapists, Occupational Therapists, Registered Nurses
(RN) and Licensed Practical Nurses (LPN) will be covered under this definition when prescribed by a medical
doctor (M.D ).
A Licensed Masters in Social Work (MSW), Licensed Masters of Arts (M.A.), or Licensed Masters of
Counseling (MC.) who is licensed by the state and performing services within a state licensed facility will be
covered under this definition when prescribed and reviewed by a medical doctor (MD ).
A Licensed Midwife or Nurse Practitioner who is licensed by the state to perform services for which benefits
are provided under the Plan, and who acts within the scope of such license is included in the term "physician"
PLAN - Shall mean the Benefits described in the Plan Document
PLAN ADMINISTRATOR - The person, group or orpani7anon responsible for the day to day functions and
management of the Plan. The Plan Administrator may employ persons or firms to process claims and perform
other Plan connected services. The Plan Administrator is as shown in the Plan Specifications.
PLAN DOCUMENT - The term "Plan Document' whenever used herein shall, without qualification, mean the
document containing the complete details of the benefits provided by this Plan. The Plan Document is kept on
file at the office of the Plan Administrator
PLAN SUPERVISOR - The person or group providing administrative services to the Plan Administrator in
connection with the operation of the Plan and performing such other function& including processing and
payment of claims. as ma\ be delegated to it by the Plan Administrator
PLAIN YEAR - The term „ Plan Year' means an annual period beginning on the effecnve date of this Plan and
ending twelve (12) calendar months thereafter or upon termination of the Plan, whichever occurs earliest
PRE - EXISTING CONDITION - Based upon the time limits this is a condition for which the employee or
dependent received medical advice or treatment; or symptoms existed which would ordinarily cause a prudent
person to seek medical advice or treatment; or the condition had manifested itself.
PREGNANCY - The term "pregnancy” means the condition of being pregnant and all conditions and/or
complications resulting therefrom. Pregnancy is covered the same as an illness.
PRIMARY CARE PHYSICIANS - When specified in the Schedule of Benefits, these are Physicians (usually
general practice, family practice, pediatrics, infernal medicine and OB /GYN physicians) designated by the
Preferred Provider Org ni7atinn who are eligible to coordinate patient care and make referrals to Specialist
Physicians. If specified in the Schedule of Benefits, all care must be coordinated by the Primary Care
Physician in order to be payable at Preferred Plan Benefits.
PROOF OF GOOD HEALTH - Evidence satisfactor• to the Plan Administrator that an applicant for coverage
is in good health and does not have any significant medical condition.
REASONABLE AND COMMONLY ACCEPTED FEE - A reasonable fee that is commonly accepted as
payment for a given service by physicians or suppliers of services in a geographical area.
B0101 2/1/94 Page 48
RECIPIENT - The recipient is the person who receives the organ for transplant from the organ donor The
•
recipient shall be an employee or dependent covered under the provisions of this Plan. Only those organ
transplants not considered experimental in name and specifically come ed herein are eligible for coverage
under this Plan.
RELATIVE - When used in this document shall mean a husband, wife, soli, daughter, mother, father, sister or
brother of the employee or any covered dependent
ROOM AND BOARD CHARGES - The institution's charges for room and board and its charges for other
necessary institunonal services and supplies, made regularly at a daily or weekly rate as a condition of
occupancy of the type of accommodations occupied.
SECOND SURGICAL OPINION - The second opinion of a physician or surgeon to determine the medical
advisability of a person undergoing a planned surgical procedure. If the second opinion does not confirm that
the planned surgical procedure is medically advisable, then Second Surgical Opinion shall aLso mean and
include a third surgical opinion.
SEMI- PRIVATE RATE - The daily room and board charge which an institution applies to the greatest
number of beds in its semi- pnvate rooms containing 2 or more beds. If the institution has no semiprivate
rooms, the semi-private rate will be the daily room and board rate most commonly charged for semi- private
rooms with two or more beds by similar institutions in the area. The term "area" means a city, a county, or
any greater area necessary to obtain a representative cross section of similar institutions.
SKILLED NURSING / REHABILITATION FACILITY - An insutunoa. or a distinct part of an institution
meeting all of the following tests:
• - It is licensed to provide and is engaged in providing, on an inpatient basis. for persons convalescing
from injury or disease, professional nursing services rendered by a registered graduate nurse (RN)
or by a licensed pracncal nurse (LPN) under the direction of a registered graduate nurse, physical
restoration services to assist patients to reach a degree of body funcnoning to permit self -care in
essential dal\ living activities.
- Its services are provided for compensation from its patients and patients are under the full-time
supervision of a physician or registered graduate nurse (RN)
- It provides 24 hours per day nursing services by a licensed nurse, under the direction of a full-time
registered graduate nurse (RN).
- It mainiainc a complete medical record on each patient
- It has an effective utilization review plan.
- It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, the mentally
handicapped, custodial or educational care, or care of mental disorders.
SPECIALIST PHYSICIANS - A physician whose practice is limited to a particular branch of medicine or
surgery, especially one who, by virtue of advanced training, is certified M a specialty board as being qualified
to so limit his practice. When specified in this booklet these are physicians designated by the Preferred
Provider Organi7auon who are not eligble to coordinate care or make rrferraLs to other Specialists or Primary
Care Physicians. When specified in this booklet, these physicians may only be seen on a referral basis when
you are seeking Preferred Plan Benefits.
SPOUSE - The man or woman to whom the employee is legally married; not including a common -law
II) marriage.
t
BO101 2/1/94 Page 49
SUMMARY PLAN DESCRIPTION - The document containing a summary of the benefits provided i nr1Pr the
Plan. In the event of a discrepancy between the summary and the Plan Document, the provisions stated in the
Plan Document will control. 0
SURGICAL PROCEDURE - A surgical procedure means cutting, suturing, treating burns, correcting a
fracture, reducing dislocation, manipulating a joint under general anesthesia, electrocatne icing, paracentesis,
applying in plaster casts, administering pneumothorax, endoscopy, injecting sclerosing solution, arthroscopic
procedures or urethral dilation.
TOTAL DISABILITY AND DISABLED - The terms total disability and disabled mean for the
a) employee - his inability to engage,
as a result of accident or illness, in his normal occupation with
the Participating Company on a full time basis;
b) dependent - his inability to perform the usual and customary duties or activities of a person in good
health and of the same age and sex.
TREAT;viENT - Any service or supply used to evaluate, diagnose or remedy a condition of an employee or his
covered dependents.
TREATMENT PLAN - A written outline of proposed treatment that is submitted by the attending physician to
the Plan Supervisor or the UR Coordinator for review and approval.
•
Page :0
BO101 2/1/94
SPECIAL, PROVISIONS
411 I. LEOFF I EMPLOYEES
Leoff I employees, defined as Law Fnforcement Officers and Firefighters hired prior to October 1, 1977, who
are not eligible for Washington State Industrial Compensation, are eligible for the following special benefits'
1 Eligibility date is date of hire.
2 The Major Medical Deductible will bc waived.
3 Major Medical charges shall not be subject to reasonable and customary limitations as defined
elsewhere in ibis lseeldet, except few s; ml- pel.hlt WWII MO Wald.
4 The co-Insurance level for medical coverage will be 100% (the 20% payment on covered charges by
the employee is waived)
5 Occupational injuries are covered.
6 The lifetime %Nor Medical maximum Hilt bc $1,000,000
7 Upon retirement, medical coverage is continued without any premium contribution requirements
for lifetime.
8. Upon disability retirement, medical coverage is continued without premium contribution
requirements for the disabled employee.
9 Retirees may elect to cover their eligible dependents for medical insurance (provided such
dependents were enrolled prior to retirement) upon payment of appropriate premium contribution
until the spouse reaches age 65 or when a dependent no longer meets the definition of an eligible
dependent.
NOTE.: LFOFF 1 employees' Dental and Vision Care benefits are subject to the schedules and limitations as
described elsewhere in this booklet.
LEOFF I employees' dependents are subject to the schedules and limitations as described herein with respect to
Major Medical Coverage, Vision and Dental Care coverage.
11. RCW 41.20 ACTIVE AND RETIRED EMPLOYEES
Employees who were hired prior to October 1, 1977 and who are under the retirement system RCW 41.20 are
eligible for the following special benefits;
1 Eligibility date is date of hire.
2 The Major Medical Dedueiibtc will be waived.
3 Major Medical charges will not be subject to resonable and customary limitations as defined
elsewhere in this Plan, except for semi - private room and board.
4 The coinsurance level for medical coverage will be 100% (the 20% payment on covered charges by
the employee is waived)
5 Occupational injuries are covcrod.
BO101 4/1/94 Page Si
6 The lifetime Major Medical maximum will be $1,000,000
7 Upon retirement, medical coNerage Is continued without any premium contribution required for
life.
8 Upon disability retirement, medical coaeragc is continued without premium contribution
requirements for the disabled employee.
9 Retirees may elect to cover their eligible dependents for medical insurance (provided such
dependents were enrolled prior to retirement) upon payment of the appropriate premium
contribution until the spouse reaches age 65 or dependent no longer meets the definition of an
eligible dependent.
10 Retirees may slat Vision Care Benefits for themselves upon payment of the appropriate premium
contribution until the employee reaches age 65
NOTE: RCW 41 20 employees' Vision Care Benefits arc subject to the schedules and limitations as described
elsewhere in this Plan.
These special benefits are not available to RCW 41 20 employees' dependents and are subject to the schedules
and limitations ns described herein with respect to Major Medical Coverage and Vision Care Coverage
80101 4/1/94 Page 52
GENERAL PROVISIONS
• VOCEDURFS FOR FILING A CLAIM
1 You may ask your provider to bill DA directly Your provider should submit complete, itemised bills.
An itemised bill is one that shows a patient's name, date of service, the type of service rendered, charge
for each service, provider's name, address, Federal Tax ID number and the nature of the accident or
illness being treated. Providers frequently request that you assign the benefits to them, however, if you
have paid the bill or want the benefits sent to you, this should also be noted on the bill.
2. To submit a claim for payment yourself, you should complete a claim form and attach an itemi/ed bill
and send it to the address shown on the claim form. See your employer for claim forms. If you wish
your benefits paid directly to the provider, sign the assignment ofbenefits section. A separate claim fora'
should be submitted for each family member
3 All claims for reimbursement must be submitted within one year of the date incurred.
QpPEAT TNG A CLAIM
If your claim is denied in whole or in par(, you will receive written notification delivered in the same fashion
as reimbursement for a claim. An Explanation of Benefits will be provided by the Plan Supervisor showing
the calculation of the total amount payable, charges not payable, and the reason. If additional information is
needed, you may be requested to pros ide the information prior to payment of your claim. You may request a
review by filing a written application with the Plan Administrator On receipt of a written request for review
of a claim, the Plan Supervisor will review the claim and fun) ' copies of all documents and all reasons and
facts relating to the decision. You or your authorized represent twe may examine pertinent documents (except
• AS Information may be contained therein which the "physicia, does not wish made known to the claimant)
which the Plan has and you may submit your opinion of the issues and your comments in writing Requests
( review must be filed within 120 days after denial Is received; however, we must it be filed
taro` whcrncr,possible, Decision by the Plan Supervisor will be made within 60 days unless special
circumstances require extension This decision will also be delivered to you in writing setting forth specific
references to the pertinent Plan provisions upon which the decision is based. This decision will be final
AD.MT I,S:i RATION OF THE GROUP mrDJCAL PLAN
The Plan is adrninistered through the Plan Administrator The Plan Administrator has retained the ser' ices of
an independent Plan Supervisor experienced in claims processing.
Legal notices may be filed with, and legal process served upon the Plan Administrator
CONDITIONS PRFC1- .0EN..1'O THE PAYMENT OF BENEFITS
The employee or dependent shall present the "Plan" identification card to the provider of service upon
admission to a hospital or upon receiving service from a physician.
Written proof of the nature and extent of sea ice performed by a physician or other provider of service shall be
furnished to the Plan Supervisor within one year after the service was rendered. Claim forms are available
through the Plan Supervisor, and are required along with an itemized statement with a diagnosis, the
employee's name and Social Security number and the name of the Plan Administrator or the Participating
Group.
III
,_.
, ..,-,,,
BO101 4/1/94 Page 53
The employee and all dependents agree that in order to receive benefits hereunder, any physician, nurse,
hospital or other provider of service, having rendered service or being in possession of information or records
relating thereto, is authorized and direena.1 to furnish the Plan Supervisor, at any time, upon request, any and
all such information and records, or copies thereof.
The Plan Supervisor shall have the right to review these records with the Plan's Insurance Company and with
any medical consultant or with the Medical Case Manager as needed to determine the medical necessity of the
treatment being rendered,
ERIVII.F.GFS AS TO DEPENDENTS
The employee shall have the privilege of adding or withdrawing the name or names of any dependent(s) to or
from this coverage, as permitted by the Plan, by submitting to the Plan Administrator an application for
reclassification on the enrollment form furnished by the Plan Supervisor Each dependent added to the
coverage shall bc subject to all conditions and limitations contained in this Plan.
APPLICATION AND IDENTIFICATION CARD
To obtain coverage, an eligible employee must complete and deliver to the Plan Administrator an application
on the enrollment form supplied by the Plan Supervisor
Acceptance of this application will be evidenced by the delivery of an identification card showing; the
Employee's name, by the Plan Supervisor to the Plan Administrator
SUMMARY PLAN DFSCRIPTION
This document is the Summary Plan Description.
CANCELLATION •
An employee may cancel dependent coverage by giving written notice to the Plan Administrator who wi ll
notify the Plan Supervisor
In the event of the cancellation of this Plan, or the cancellation of the Participating Group's participation in the
Plan, all employee's and dependent's coverage shall cease automatically without notice Employees and
dependents shall not be entitled to further coverage or benefits whether or not any medical condition was
covered by the Plan prior to termination or cancellation.
The Plan niay be cancelled or terminated subject to the City of Yakima's Health and Welfare Benefit Plans By-
laws.
Upon termination of this Plan, or the cancellation of the Participating Group's participation in the Plan, all
claims incurred prior to termination, but not submitted to the Plan Supervisor within 75 days of the effective
date of termination of this Plan, will bc excluded from any benefit consideration.
ASSIGNMENT OF PAYMENT
The Plan will pay any benefits accruing under this Plan to the employcc unless the employee shall assign
benefits to a hospital, physician or other provider of service furnishing the scrviees for which benefits are
provided herein. No assignment, however, shall be binding on the Plan unless the Plan Supervisor is notified
in writing of such assignment prior 10 payment hereunder Preferred Providers normally bill the Plan directly
If service has been recei‘'ed front a Preferred Provider, benefits are automatically paid to that provider Any
balance due after the Plan payment will then be billed to the patient by the Preferred Provider
4111
BO101 4/1/94
Page 54
A1ENDMENT OF PLAN DOCUMENT
The Plan Administrator may terminate, modify or amend the Plan in accordance with the City of Yakima's
0 Health and Welfare Benefit Plans By -laws. Such termination, amendment or modification which affects
covered employees and their dependents will be communicated to the employees. The amended. Plan Benefits
shall be the basis for determining all Plan payments for all expenses incurred on or aticr the effective date of
such amendment. Plan payments made under the Plan prior to amendment shall continue to be included as
Plan pay mcnis in determining the total benefits remaining toward satisfaction of any benefit maximums
calculated. on either a Plan year, calendar year or lifetime basis.
j4lOT10E
Any notice given under this Plan shall be sufficient, if given to the Plan Administrator when addressed to it at
its office, if given to the Plan Supervisor, when addressed to it at its office; or if given to an employee, when
addressed to the employee at his address as it appears on the records of the Plan Supervisor on the cmployas
enrollment form and any corrections made to it.
COORDINATION OF 13LNLTHIS
Definitions.
The term "allowable expense" shall mean the reasonable and customary amount of expenses, at least a portion
of which is paid under al least one of any multiple plans covering the person for whom the claim is made. in
no event will more than 100% of total allowable expenses be paid between all plans, nor will total pay nment by
this Plan exceed the amount which this Plan would have paid as primary plan.
The tern "order of benefits determination" shall mean the method for ascertaining the order in which the Plan
40 rend. rs payment hereunder The principle applies when another plan has a Coordination of Benefits
pro\ ision.
Application
Under the order of benefits determination method, the plan which is obligated to pay its benefits first is known
as the "primary" plan. The plan which is obligated to pay additional benefits for allowable expenses not paid
by the primary plan is known as the "secondary" plan. Where another plan contains a Coordination of
Benefits provision, the following order of benefits determination will establish the responsibility for payment
hereunder
1 The plan covering the patient as an employee shall be deemed the primary plan and is obligated to
pay before the plan covering the patient as a dependent.
2 The plan covering the patient as a dependent of the person whose birthday occurs earlier in the
calendar year shall be deemed to be the primary plan and is obligated to pay before thc plan
covering the patient as a dependent of the person whose birthday occurs later in the calendar year
If the birthday anniversaries are identical, thc plan which has been in force the longer period of
time shall be deemed to be primary
If either plan is lawfully issued in another state or in this state and does not have the coordination
of benefits procedure regarding dependents based on birthday anniversaries as provided herein, and
as a result each plan determines its benefits after the other, the Coordination of Benefits procedure
set forth in the plan which does not have the Coordination of Benefits procedure based on birthday
anniversaries shall be primary
In the event of divorce or legal separation, the following order will establish responsibility for
• payment. if this order of benefit determination is not recognized by the plan being coordinated
with, order will be determined at time option of the Plan Supervisor on a case -by -case basis.
BO101 4/1/94 Page 55
a. If a court decree has determined financial responsibility for a child's health care expenses, the
plan or the parent having that responsibility' pays tint.
b. The plan of the parent with custody of the child pays before the plan of the other parent or the •
plan of any stepparent
c. The plan of the stepparent married to the parent with custody of the child pays before the plan of
the parent not having custody
3 Where the order of payment cannot be determined in accordance with (1) and (2) above, the
primal) plan shall be deemed to be the plan which has covered the patient for the longer period to
time
As the primal) plan, the Plan will provide payment in accordance with the provisions of this Plan.
As a secondary plan, the Plan will provide payment for allowable expenses and services of physicians, but only
to the extent that payment for such allowable expenses and services of physicians are not provided by the
primary plan or other secondary plans.
The difference between the amount which the Plan would have paid as primary plan and the amount which
was actually paid as secondary plan through the application of the Coordination of Benefits provision on a
given claim will accrue to the credit of the individual patient only for the remainder of the calendar year It is,
therefore, availabh. in an amount not to execed that which would have been payable by the Plan as primary
plan, to pay for allowable expenses and services ofphysicians, subsequently incurred which may not be paid in
full by the primary and secondary plans (that is, payable from Coordination of Benefits savings)
This Plan shall be considered to be the secondary plan when the other plan does not contain a Coordination of
Benefits provision. The total payment by this Plan for allowable expenses and physician's services shall not
exceed the amount which would have been paid as a secondary plan, •
Benefits under this Plan shall not be reduced or otherwise limited because of the existence of another non -
group contract which is issued as a hospital indemnity, surgical indemnity, specified disease or other plan of
disability coverage
A health maintenance organization is not required to pay claims or coordinate benefits for services which arc
not pro\ ided or authorized by the health maintenance organisation and which are not benefits under the health
maain iota n a contract.
In states which mandate medical payments under no fault" auto insurance, this Plan will be secondary and
will coordinate benefits with "no fault" auto insurance.
SUBROGATION
In the event of any payment for services under this Plan, the Plan shall, when such payments exceed $300, be
subrobated to an the rights of recovery of the employee or dependent arising out of any claims or cause of
action which may accrue because of the alleged negligent conduct of a third party Any such employee or
dependent hereby agrees to reimburse the Plan up to the full amount of Plan payments paid for any benefits
hereunder out of any monies recovered from such third party as the result of judgment, settlement or
otlremise, whether such recovered monies satisfy' in full, or only in part, a judgment or settlement obtained by
such employee or dependent, and such employee or dependent hereby agrccs to take such action, to furnish
such information and assistance, and to execute and deliver all necessary instruments as the Plan may require
to facilitate the enforcement of their rights. This provision shall not apply, however, to a recovery obtained by
an employee or dependent from an insurance company on a policy under which such employee or dependent is
entitled to indemnity as a named person.
B0101 4/1/94 Page 56
ICE
Medicare • as used in this section shall mean Title XVIII (Health insurance for the Aged) of the United States
411 Social Security Act, as added to by the Social Security Amendments of 1965, the Tax Equity and Fiscal
Responsibility Act of 1982, or as later amended.
Person - as used in this section mums a person who Is eligible for benefits as an employee in an eligible class
otthis Plan and who is or could be covered by Medicare Parts A and B, whether or not actually enrolhxl.
Eligible Expenses - As used in this section with respect lo services, supplies and treatment shall mean the
same benefits, limits and exclusions as defined in this Plan Document. However, if the provider accepts
Medicare assignment as payment in full, then Eligible Expenses shall mean the lesser of the total amount of
charges allowable by Medicare, whether enrolled or not, and the total eligible expenses allowable under this
Plan exclusive of coinsurance and deductible,
Order of Benefits Determination • as used in this section shall mean the order in which Medicare benefits
are paid, in relation to the benefits of this Plan.
Total benefits of this Plan shall be determined as follows.
Acth a Employee age 65 or older
For active employees and/or non - working spouses of active employees age 65 or over This Plan will be
primary and Medicare will be secondary
Disabled Employees with Medicare (Except those with End -Stage Renal Disease)
0 For persons eligible for Medicare by reason of Disability thc order of determination will be as shown
below
If employed by a company with 100 or more employees: This Plan will be primary and Medicare
will be secondary The employer will remain the primary payor of medical benefits until the
earliest of the following events occurs. (1) the group coverage ends for all employees; (2) the group
cover as an active individual ends,
1j employed by a company with less than 100 employees. This Pian will be secondary and
Medicare will be primary
The Omnibus Budget Reconciliation Act of 1986 defnes a large group health plan as one that covers
employees of at least one employer that 'normally employed at least 100 employees on a typical
business day during the pre\ sous calendar year " A "typical busing day' is defined as 50 percent or
more of the employer's regular business days during the previous calendar year
Disabled Employees with End -Stage Renal Disease (ESRD)
This Plan shall be primary during the initial 18 montli period which begins on the date of Medicare
Entitlement ESRD Medicare Entitlement begins on thc fourth month of renal dialysis, but can start as
early as the first month of dialysis for individuals who take a course in self - dialysis training during the
three month waiting period.
III
BO1o1 4/1/94
Page 57
Retirees with Medicare
For covered persons who are not active employees age 65 or over, and that are eligible for Medicare by
reason of age alone, this Plan will be secondary and Medicare will be primary The following formula
shall be used in determining the total payable under this Plan as secondary payor during each claim
submission.
COORDINATION - The regular Coordination of Benefits provision of this Plan applies in relation
to the amount Medicare pays as primary payor
LACII.iTY OF PAYMENT
If, in the opinion of the Plan Supervisor, a valid release cannot be rendered for the payment of any benefit
payable under this Plan, the Plan Supervisor may, at its option, make such payment to the lndividiwals as have,
in the Plan Superisor's opinion, assumed the care and principal support of the covered person and are
therefore equitably entitled thereto. In the event of the death of the covered person prior to such time as all
benefit payments due him have been made, the Plan Supervisor may, at its sole discretion and option, honor
benefit assibmments, if any, prior to the death of such coscred person.
Any payment made by the Plan Supervisor in accordance with the above provisions shall fully discharge the
Plan and the Plan Supervisor to the extent of such payment.
REPRESENTATION
Any material misrepresentation on the part of the Plan Administrator or the employee in making application
for cov crai;e, or any application for reclassification thereof, or for service thereunder shall render the coverage
null and void.
jtADVCR I'FNT ERROR
Inadvertent error by the Plan Administrator in the keeping of records or in the transmission of employee's
applications shall not deprive any employee or dependent of benefits otherwise due, provided that such
inadvertent error be corrected by the Plan Administrator within ninety (90) days after it was made
EZFF CHOICE OF PHYSICIAN
The employer and dependents shall have free choice of any licensed physician or surgeon, and the physician -
patient relationship shall be maintained.
NOT LIABLE FOR AC1'S OF HOSPITALS, PHYSICIANS OR THE MEDICAL CASE MANAGER /
UTILIZATION REVIEW COORDINATOR
Nothing contatned herein shall confer upon an employee or dependent any claim, right, or cause of
action, either at law or in equity, against the Plan for the acts of any hospital in which he retches care,
fur the acts of any physician from whom he receives service under this Plan, or for the acts of the
Medical Case Manager / Utilization Review Coordinator in performing their duties under this Plan.
RIGHT OF RECOVERY
Whenever payments have been made (or benefits have been quoted) by the Plan Supervisor in excess of the
maximum amount of payment necessary at that time to satisfy the intent of this Plan, the Plan Supervisor shall
have the right to recover such payment (or avoid making such payment), to the extent of such excess, from
among one or mono of the following as the Plan Supervisor shall determine any persons to or fur, ur with
respect to whom such pay menta were made, and/or any Insurance companies and other organizations.
BO101 4/1/94 Page 58
PLAN IS NOT A CONTRACT OF EMPLOYMENT
The Plan shall not be deemed to constitute a contract of employment berween the Plan Administrator or
• Participaung Company and any employee or. to be a consideration for, or an inducement to or condition of the
employment of any employee. Nothing in the Plan shall be deemed to give any employee the right to be
retained in the service of the Plan Administrator or Participating Company or to interfere with the right of the
Plan Administrator or Participating Company to discharge any employee at any time; provided however, that
the foregoing shall not be deemed to modify the provisions of any collective bargaining agreements which -may
be made by the Plan Administrator or Participating Company with the bargaining representative of any
employees.
FUNDING
Tf contributions are required of employees or dependents covered under this Plan, the Plan Administrator the
maintain a Health Benefit Reserve Fund or otherwise account for the receipt of money and property to fund
Plan, for the management and investment of such funds and for the payment of claims and expenses from such
funds. The terms of the Health Benefit Reserve Fund (when applicable) are hereby incorporated by reference,
as of the effecuve date of the Health Benefit Reserve Fund, as a part of this Plan.
The Participating Groups shall deliver from time to time to the Plan Administrator or the Health Benefit
Reserve Fund such amounts of money and property as shall be necessary to provide the Health Benefit Reserve
Fund with sufficient funds to pay all claims and reasonable expenses of administering the Plan as the same
shall be due and payable The Plan Administrator may provide for all or any part of such funding b%
insurance issued b% a company duly qualified to issue insurance for sun h purpose in the state of sites, and may
pay the premiums therefore direct') or by funds deposited in the Health Benefit Reserve Fund_
A;I funds received bn the Health Benefit Reserve Fund and all earnings of the Health Benefit Reserve Fund
shall be applied toward the payment of claims and reasonable expenses of administration of the Plan except to
the extent otherwise provided by the Plan Documents. The Plan Administrator may appoint an investment
manager or managers to manage (including the power to acquire and dispose of) any assets of the Plan.
A: s fiduc.ar, employee agent. representative or other person performing services to or for the Plan or Health
Be^.efi Reserve Fund shall be enutled to reasonable compensation for services rendered, unless such person is
the ?Ian .Administrator and for reimbursement of expenses properly and actually incurred.
EF` ECT OF TERMINATION OF THE PLAN
Upon complete or partial termination of the Plan, the Plan Administrator may, after the payment or provision
for payment of all benefits to each Employee who has incurred covered expenses and charges properly payable
hereunder including all expenses incurred and to be incurred in the liquidation and distribution of the Health
neie t Reserve Fund or separate account. direct the disposition of all assets held in the Health Benefit Reserve
Fa. or separate account .o the Parucipauiig Group or Groups. subject to any applicable requirement of an
accompanying Health Benefit Reserve Fund Document or applicable law or regulation.
III
BC 10I 211;94 94 Page :8
PLAN SPECIFICATIONS
PARTICIPATING GROUP City of Yakima
PLAN ADMINIS1 BATOR City of Yakima
129 North 2nd Street
Yakima, WA 98901
TELEPIIONE NUMBER OF
PLAN ADMINISTRATOR (509) 575 -6090
EMPLOYER IDENTIFICATION
NUMBER 91- 16001293
NAME OF PLAN City of Yakima Employee's Health and Welfare Benefit
Plans
EMPLOYEES Eligible Employees of City of Yakima
EFFECTIVE DATE April 1, 1994
GROUP NUMRFR BO101
PLAN NUMBER Medical, Prescription, Dental It Vision/501
PLAN SUPERVISOR Healthcare Management Administrators, Inc
P 0 Box 97038
•
Redmond, WA 98073.9738
CUSTOMER SERVICE Direct Adminisirdlors
120 South Third Street
P 0 Box 22700
Yakima, WA 98907-2700
(509) 248.7938
4110
B0101 4/1/94 Page 60
PLAN ACCEPTANCE
f Yakima, Washington herd C$Iablishcs this Plan for the payment of certain The City of Yakima, o ak g y PaY expenses
for the benefit of its eligible employees to be known u the City of Yakima Employee's Health and Welfare
Benefit Plans.
The CiI) of Yakima, assures its covered employees that during the continuance of the Plan, all benefits herein
described shall be paid to or on behalf of the employees in the event they become eligible for benefits.
The Plan is subject to all the terms, provisions and conditions recited on the preceding pages hereof
This Plan is not in lieu of and does not affect any requirement for coverage by Worker's Compensation
Insurance
The City of Yakima, has caused this Plan to lake efr� as of 1201 A.M. on April 1, 1994 at Yakima,
Washington,
Aulhori/cd Signature
Printed Name and Title Date
•
B01o1 4/1/94 Page 61
•
Plan Effective April 1, 1994
Local Services By:
BBM FINANCIAL SERVICES, INC.
DIRECT ADMINISTRATORS
(509) 248 -7938
IP
all BUSINESS OF THE CITY COUNCIL
YAKIMA, WASHINGTON
AGENDA STATEMENT
Item No ( c k
For Meeting Of 2/22/94
ITEM TITLE. Legislation adopting an integrated health care program for City
employees and providing for amendments to the Yakima Municipal
Code
SUBMITTED BY City of Yakima Employees' Welfare Benefit Program Committee
CONTACT PERSON /TELEPHONE. Sheryl M. Smith, x6090, John Hanson x6070, Glenn
Rice, x6051
SUMMARY EXPLANATION
•
The purpose of this report is to request Council's approval of the attached ordinance. This action will (1) adopt
the Employees' Welfare Benefit Program, (2) authorize the execution of participation agreements with certain
groups of represented employees, (3) provide for amendments to various sections of the Municipal Code
regarding welfare benefits, and (4) continue to allow Yakima Air Terminal employees to participate in the
Citys' Welfare Benefit Program.
As you are aware, the City of Yakima Employees' Health Insurance Committee has been diligently working on
streamlining the City's self - insured healthcare program. This project has taken nearly four years to complete
and was borne out of the the 1989 -1991 collective bargaining settlement with AFSCME. The purpose of this
effort is to provide for a uniform benefits package for all employee groups. This process has been monumental,
requiring a significant time commitment by all Committee members, the Committee has been meeting on a
weekly basis for the last year Participation by the entire group has been excellent and cumulatively, over the
past year, over 2,000 manhours of effort has gone into this project.
The initial Committee has consisted of four representatives from the Fire Department, two representatives
from the Police Department, four AFSCME representatives and five management employees. The Board
established by the new Program will consist of ten members, four AFSCME representatives, two YPPA
representatives, two IAFF respresentatives and the Deputy Personnel Officer and Director of Finance and
Budget will be permanent Board members. The Program and attached Health Benefit Plans have been shared
with all affected collective bargaining units and management employees, all represented employee groups
have agreed to participate in the program.
Additionally, the Program has been reviewed by outside legal counsel, consisting of specialists in general
municipal law, labor law and tax law Every effort has been made in the final drafting of the Program to
address any legal shortcomings with existing programs which might befall the proposed Program.
The attached document accomplishes the vision of the Health Insurance Committee to coordinate all employee
henefits. Some of the goals include: (1) take advantage of large group numbers in providing benefits and costing
med benefits, (2) to reduce overhead costs of providing the benefits, (3) to update the Plans to reflect health
care changes in the delivery of benefits to the City's employees and (4) allow the ability to evaluate and
implement additional cost saving measures in the future such as the use of preferred provider organizations,
HMO arrangements, and other cost saving arrangements benefiting both employees and the City in a timely and
efficient manner
Below is a chronology of key dates and activities that have occurred over the past year
• On January 12, 1993 the AFSCME Joint Health Insurance Committee met with the City Council and
explained the history of the Committee, its' accomplishments and the future of the City's self - insured
health care plan. Considerable time was spent discussing the consolidation of all employee groups and the
concept was supported by the Council.
• On February 24, 1993 the City -wide Health Insurance Committee met with Executive Board representative
of all organized employee groups, AFSCME, YPPA, Fire LEOFF and Fire PERS plus representatives of the
management group including Police, Fire and General Management, Supervisors and Confidential
employees. The history of the AFSCME Committee was shared and how it evolved into a City -wide
Committee plus the accomplishments of the Committee up to February 1993. The need for consolidating all
groups was explained and the administrative steps to accomplish that end was outlined.
• On November 23, 1993 the City -wide Health Insurance Committee met with Executive Board
representative of all organized employee groups, AFSCME, YPPA, Fire LEOFF and Fire PERS plus
representatives of the management group including Police, Fire and General Management, Supervisors and
Confidential employees. The purpose of this meeting was to explain the draft by -laws of the Board,
timelines for implementation of the program and review the draft Plan booklet.
• On December 15, 1993 the City -wide Health Insurance Committee met with all management employees to
explain the concept of coordinated plans, the establishment of the new Board and its' by -laws and review
the new Plan booklet. The history of the Committee and the work it had accomplished was also
explained.
• Between December 15, 1993 and February 1, 1994, all represented employee groups voted to participate in
the new Program.
t
• On January 21, 1994, the Management team again met with Committee to provide employees an opportunity
to ask questions regarding the new program and its' implementation.
• Between mid - January and mid - February 1994 outside counsel has reviewed this program and amended the
documents to provide for possible legal snafus. Final bargaining unit authorization will be after Council
adoption by signing the participation agreements.
Resolution Ordinance X Contract Other (1)Program Document
(2)Participation Agreement
Funding Source Employees' Health Benefit Reserve Fund
APPROVED FOR SUBMITTAL
City Manager
STAFF RECOMMENDATION Adopt ordinance.
BOARD /COMMISSION RECOMMENDATION
COUNCIL ACTION