HomeMy WebLinkAboutResolution - 2005-R0242 - Adopt And Modify City Of Lubbock Health Plan - 06/09/2005Resolution No. 2005-RO242
June 9, 2005
Item 32A
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to adopt the .City of Lubbock Health Plan as of January 1, 2005 and modifying
said plan to limit out of network utilization and reducing reimbursement levels. Said
documents are attached hereto and incorporated in this resolution as if fully set forth
herein and shall be included in the minutes of the City Council.
Passed by the City Council this 9th day of
ATTEST:
Rebecca Garza, City Secretary
APPROVED AS TO
, / e---r ,P
Scott Snider, Director of Human Resources
APPROVED AS TO FORM:
M.
as/CityAtt/John/Resolutions/Lubbock Health Plan
June 3, 2005
EMPLOYEE BENEFIT
HEALTH PLAN
ANNOUNCEMENT
Notice of Changes
In order to continue to be able to bring you quality, comprehensive benefits at an affordable price,
we will be making several benefit changes to our employee benefit plan effective July 1, 2005. We
are pleased to report that the benefits for in -network services will be remaining the same.
Effective July 1, 2005, there will be changes to the out -of -network benefits as outlined below. Unless noted,
maximums and limitations still apply. Please refer to your Summary Plan Document for additional information.
benefit
etorkoiclers .
Ikon-Norlc.rv�cter
Annual Deductible:
Individual
$500
$1,000
Family
$1,000
$2 000
Out of Pocket Maximum:
Individual
$2,000
$12,000
Family
$4,000
$24,000
Coinsurance
80%
50%
Office Visits
$25 copay
Deductible + 50% coinsurance
Inpatient Hospital
$0 copay per admission
$200 Copay per admission+
50% coinsurance
Dialysis — Outpatient
Deductible + coinsurance
Paid at in -network benefit level
Skilled Nursin ome Health Care
100% up to $10,000 per calendar year
50% up to $7,000 er calendar year
Hospice__
100% up to $20,000 per lifetime
50% up to $14,000 per lifetime
Mental/Nervous Inpatient &
Deductible + 80% coinsurance
Deductible + 50% coinsurance
Outpatient Treatment
Drug & Alcohol Inpatient &
Outpatient Treatment
Deductible + 80% coinsurance
Deductible + 50% coinsurance
Also effective July 1, 2005, the plan will change the reimbursement schedule for OUT -OF -NETWORK providers.
However, there will be NO changes to in -network provider reimbursement schedules. Please review the
following changes carefully since it impacts the allowable amount billed by out of network providers that is
eligible for reimbursement under the plan. This may increase your out of pocket cost if you elect to use an out of
network provider.
Eligible Medical Expenses (EME) — The maximum allowable amount the plan will pay for a particular
Covered Service as determined by the plan in accordance with the plan Reimbursement Schedule. In -
Network Providers have agreed to accept the plan's reimbursement as payment in full for Covered Services,
less any applicable Copayment, Deductible or Coinsurance, whereas Out -of -Network Providers have not.
Eligible participants who use the services of Out -of -Network Providers will receive no benefit payments or
reimbursements for charges in excess of the plan's Reimbursement Schedule for any Covered Services. In
no event will the plan pay more than the maximum payment allowance established in the plan's
Reimbursement Schedule.
Eligible Medical Expenses are determined by the following...
Physician charges: Medicare Allowable based on Resource Based Relative Value Scale (RBRVS)
Facility charges: Medicare Allowable based on Resource Based Relative Value Scale (RBRVS)
Resource Based Relative Value Scale (RBRVS) — This scale bases relative values on a computation of
total work, practice cost and malpractice expense involved in performing a procedure. These three elements
of the value are modified by a geographic index. After the geographic modification, the three values are
summed to reach a single value. The single value is then multiplied by a conversion factor, determined by
Congress, to arrive at a charge.
City, ol'Lubbock Page 1 of ! Jtrrtc= i U, 2005
RV 01 '05 02*17PM NTHN 9727512368
IHEALTHSMART T
P R E F E R R E D C A R E
June 1, 2005
Lee Ann Dumbmu .d, CFO
City of Lubbock
PO Box 2000
Lubbock, TX 794 57
Dear Ms Dumbatiid:
Per conversations and written correspondence with Covenant Health System, Covenant
has agreed to a 3% rebate based on net revenue on those patients who have an admisslon
date at Covenant on or after implementatien of the new benefit plats through December
31, 2005. This nibate will allow for additional savings to be available on patients who
are beneficiaries c n the City of Lubbock group health plan.
The 3% rebate will be based on Covenant's revenue which is the total of all payments
received for the seMces rendered. This will include inpatient and outpatient services
performed at Covenant Medical Center, Covenant Medical Center Lakeside, Covenant
Children's Hospital, Joe Arington Cancer Center, Covenant Imaging Center, Aeroeare,
and Covenant Ce3der for Outpatient Diabetes Education and Owens -White Rehabilitation
Center.
The rebate will be, calculated using Covenant's IT system approximately.90 days after the
end of the period to allow ample time for all' payments to be received. A detaii patient
list will be provided and can be validated by personnel from the City, ICON and/or
HealthSmart. After this dollar figure has been validated them a check will be cut from
Covenant to the City of Lubbock to equal the 3% rebate. Once the check has been cut
then the rebate period will be considered closed with no fiutber settlements based on this.
proposal, At the time of settlement, ICON will provide Covenant with a listing of all
charges and payments to out -to -network providers within the Lubbock service area.
Due to the limitei availability of dialysis services in Lubbock, tho City of Lubbock will
not be making any changes to their current plan as it relates to dialysis. We ate hopeful
this will not caus<; issue with Covenant.
We look forward to continuing to work on behalf of the City of Lubbock. Should you
need additional information please do not hesiWe to contact Julie Crow at 473-2599.
Sincerely,
Mark Blakemore
Sr Vice President of Corp Development/Network Management
2
222 West less Colinas Blvd / Suite 2000 North / Irvin, TX 76039
Phone 214.374.2300 / Fox•Sales:214.574,2300
Fix -Provider Reledons: 214.574,23681 Tell Free: 000.388.3"S
Internet: a vvW.htalthsmtrt.i*t
i�. A, 'nnx�lrators
�y�ibol;cafB�cceltence<
Group No. 3010
City of Lubbock
Employee Benefit Plan
Effective Date
January 1, 2004
City of Lubbock is pleased to provide for its employees the excellent benefit program
described in this brochure. The information contained in this brochure is complete; it
is an exact copy of the plan document that governs this program. We have selected
ICON Benefit Administrators as plan supervisor for claims arising under the Plan.
ICON Benefit Administrators provides prompt and highly competent claims service,
and will be happy to answer any questions you may have regarding your coverage or
claims service. You may call them at 800-658-9777.
PLAN DOCUMENT AMENDMENT
To be attached to and made part of the Master Plan Document issued to Crty of LUBBOCK (GROUP Na
3010) Employee Benefit Plan.
AMENDMENT No.1
THE PLAN DOCUMENT IS AMENDED IN THE MANNER HEREIN DESCRIBED.
1. The following section under the DEDUCTIBLE PER CALENDAR YEAR section (page 12) of the
Schedule of Benefits is hereby amended to read as follows:
nvw
The Calendar Year deductible is waived for the following Co-,
- Skilled Nursing Facility In -Network, Out -of -Area
- Home Health Care - In -Network, Out -of -Area
- Hospice - In -Network, Out -of -Area
Routine Well Adult and Child_ Care - Out -of -Area
- Required Childhood Immunizations
Office Surgery - In -Network
OUT -OF -AREA
Charges:
II. The Physician Services section (page14) of the Schedule of Benefits is hereby amended by the addition
of the following section:
NETWORK NON -NETWORK JOUT-OF-AREA
PROVIDERS PROVIDERS
Office Surgery 80% 60.%after 180% after
deductible deductible
Cm of Lumom
January 21, 2004 - Pup 1 of 2
III. The Office visits section (page 14) under the Physician Services section of the Schedule of Benefits is
hereby amended to read as follows:
NETWORK
PROVIDERS
100% after
NON -NETWORK
PROVIDERS
70% after deductible
OUT -OF -AREA
80% after deductible
Office visits
(including ancillary
copayment
charges performed
in and billed by the
Physician's office)
The copayment
benefit does not
apply to any
service requiring
precertification or
chiropractic
benefits.
IV. DEFINED TERMS (pages 30-35) is hereby amended by the addition of the following:
Out -of -Area covers Plan Participants who reside outside of the Plan Service Area (Plan Service Area is
defined as the geographical area designated by the Employer which determines eligibility for PPO
benefits) and therefore do not have access to Network Providers.
V. The following line of the 9`h paragraph (page 12) of the MEDICAL BENEFITS section is hereby
amended to read as follows:
If a Covered Person has no choice of Network Providers for the treatment they are seeking within the
PPO service area.
This Amendment takes effect January 1, 2004 and is subject to all of the provisions and conditions of the
Plan.
Signed this day of , 2004.
Authorized Signature
Attest
CrrY of Lumom
January 21, 2004 - Page 2 of 2
PLAN DOCUMENT AMENDMENT
To be attached to and made part of the Master Plan Document issued to 0TY OF LUBBOCK (GROUP No.
3010) Employee Benefit Plan.
AMENDMENT No. 2
THE PLAN DOCUMENT IS AMENDED IN THE MANNER HEREIN DESCRIBED.
I. The following paragraph under WHEN CLAIMS SHOULD BE FILED (page 43) is hereby amended to
read as:
Claims should be filed with the Claims Supervisor within 365 days of the date charges for the service
were incurred. Benefits are based on the Plan's provisions at the time the charges were incurred. Claims
filed later than that date may be declined or reduced unless:
II. The first paragraph of Eligible Classes of Dependents, (1) (page 3) is hereby amended to read as
follows:
A covered Employee's Spouse and unmarried children from birth to the limiting age of 25 years.
When a child reaches the limiting age, coverage will end on the last day of the child's birthday
month.
III. The Physician Services section (page 14) of the Schedule of Benefits is hereby amended to read as
follows:
Inpatient visits
NETWORK
PROVIDERS
80% after deductible
NON -NETWORK
PROVIDERS
60% after deductible
OUT -OF -AREA
80% after deductible
Office visits
100% after
70% after deductible
80% after deductible
(including ancillary
copayment
charges performed
on the same day as
the Physician's
office visit)
The copayment
benefit does not
apply to any service
requiring
precertification or
chiropractic
benefits.
OTY of LUBsoCX
Jerre 7, 2004 -Page 1 of 6
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Ancillary charges
100% after
70% after deductible
80% after deductible
performed afteT the
copayment
day of the
Physician's office
visit
The copayment
benefit does not
apply to any service
requiring
precertification or
chiropractic
benefits.
Office Sure
80%
60% after deductible
80% after deductible
Diagnostic
80% after deductible
60% after deductible
80% after deductible
Procedures -limited
to: All
knee/shoulder
arthroscopies,
Bone Scan,
Cardiac Stress
Test, CT Scan,
Carotid
Ultrasounds, MRI,
Myelogram, PET
Scan, and
Endoscopic
Procedures
Other Diagnostic
100%
60% after
80% after
Medical Services
deductible
deductible
(Freestanding
facility)
Other Outpatient
80% after
60% after
80% after
Services and
deductible
deductible
deductible
Supplies
Allergy Testing
80% after
70% after
80% after
and Treatment
deductible Ideductible
deductible
Sure
80% after deductible
60% after deductible
80% after deductible
CITY OF LumocK
June 7, 2004 - Page 2 of 6
IV. The following section under the DEDUCTIBLE PER CALENDAR YEAR section (page 12) of the
Schedule of Benefits is hereby amended to read as:
NETWORK NON -NETWORK JOUT-OF-AREA
PROVIDERS PROVIDERS
The Calendar Year deductible is waived for the following Covered Charges:
- Skilled Nursing Facility - In -Network, Out -of -Area
- Home Health Care - In -Network, Out -of -Area
- Hospice - In -Network, Out -of -Area
- Routine Well Adult and Child Care - Out -of -Area
- Required Childhood Immunizations
- Office Surgery - In -Network
- Other Diagnostic Medical Services(Freestanding facility) - In -Network
V. Effective April 14, 2004: The following is hereby added to the Plan as HIPAA A PRIVACY RULE:
The City of Lubbock Employee Benefit Plan ("Health Plan") amends the Plan Document to comply with
the requirements of the Health Insurance Portability and Accountability Act ("HIPAA") and it's
implementing regulations ("HIPAA Privacy Rule") by establishing the extent to which the Plan Sponsor
will receive, use and/or disclose Protected Health Information ("PHI"). Accordingly, the Health Plan is
hereby amended as follows:
1. Health Plan's Designation of Person/Entity to Act on its Behalf
The Plan has determined that it is a group health plan within the meaning of the HIPAA Privacy Rule,
and the Health Plan designates the Plan Sponsor to take all actions required to be taken by the Health
Plan in connection with the HIPAA Privacy Rule.
2. Definitions
All terms defined in the HIPAA Privacy Rule, shall have the meaning set forth therein. The following
additional definitions apply to the provisions set forth in this Amendment.
A. Health Plan means the City of Lubbock Employee Benefit Plan.
B. Plan Documents mean the Health Plan's governing documents and instruments (i.e., the
documents under which the Health Plan was established and is maintained), including but not limited
to the City of Lubbock Employee Benefit Plan Document.
C. Plan Sponsor means "plan sponsor" as defined at section 3(16) (B) of ERISA, 29 U.S.C. §
1002(16) (B). The Plan sponsor is City of Lubbock.
3. Certification of Compliance by Plan Sponsor
Except as provided below with respect to the Health Plan's disclosure of summary health information,
the Health Plan will disclose Protected Health Information to the Plan Sponsor, or permit the
disclosure of Protected Health Information to the Plan Sponsor by a health insurance issuer or HMO
with respect to the Health Plan, only upon receipt of a certification by the Plan sponsor that:
A. the Plan Documents have been amended to establish the permitted and required uses and
disclosures of such information by the Plan sponsor, consistent with the HIPAA Privacy Rule, and
B. the Plan Documents have been amended to incorporate the provisions set forth in this
Amendment, and
CITY or Lummx
Jane 7, 2004 - Page 3 of 6
C. the Plan Sponsor agrees to comply with the provisions as modified by this Amendment.
4. Health Plan's Disclosure of Individuals' Protected Health Information to Plan Sponsor
A. The Health Plan (and any business associate acting on behalf of the Health Plan), or any health
insurance issuer or HMO servicing the Health Plan, will disclose individuals' Protected Health
Information to the Plan Sponsor only to permit the Plan Sponsor to carry out plan administration
functions. Such disclosure will be consistent with the provisions of this Amendment.
B. All disclosures of the Protected Health Information of the Health Plan's individuals by the Health
Plan's business associates, health insurance issuer, or HMO to the Plan Sponsor will comply with
the restrictions and requirements set forth in this Amendment and in the HIPAA Privacy Rule.
C. The Health Plan (and any business associate acting on behalf of the Health Plan), may not
disclose, and may not permit a health insurance issuer or HMO to disclose, individuals' Protected
Health Information to the Plan Sponsor for employment -related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor.
D. 'The Plan Sponsor will not use or further disclose individuals' Protected Health Information other
than as described in the Plan Documents and permitted by the HIPAA Privacy Rule.
E. The Plan Sponsor will ensure that any agent(s), including a subcontractor, to whom it provides
individuals' Protected Health Information received from. the Health Plan (or from the Health
Plan's health insurance issuer or HMO), agrees to the same restrictions and conditions that apply
to the Plan Sponsor with respect to such Protected Health Information.
F. The Plan Sponsor will not use or disclose individuals' Protected Health Information for
employment -related actions and decisions or in connection with any other benefit or employee
benefit plan of the Plan Sponsor,
G. The -Plan Sponsor will report to the Health Plan any use or disclosure of Protected Health
Information that is inconsistent with the uses or disclosures provided for in the Plan Documents
(as amended) and in the HIPAA Privacy Rule, of which the Plan sponsor becomes aware.
5. Health Plan's Disclosure of Summary Health Information and Enrollment Information to the
Plan Sponsor
A. The Health Plan (or a health insurance issuer or HMO with respect to the Health Plan) may
disclose summary health information to the Plan Sponsor, if the Plan sponsor requests the
summary health information for the purpose of:
1. obtaining premium bids for providing health insurance coverage under the Health Plan, or
2. modifying, amending, or terminating the Health Plan.
B. The Health Plan (or a health insurance issuer or HMO with respect to the Health Plan) may
disclose enrollment and disenrollment information to the Plan Sponsor.
6. Disclosure of Individuals' Protected Health Information by Plan Sponsor
A. The Plan Sponsor will make the Protected Health Information of the individual who is the subject
of the Protected Health Information available to such individual in accordance with the HIPAA
Privacy Rule.
B. The Plan Sponsor will make individuals' Protected Health Information available for amendment
and incorporate any amendments to individuals' Protected Health Information in accordance with
the HIPAA Privacy Rule.
C. The Plan Sponsor will make and maintain an accounting so that it can make available those
disclosures of individuals' Protected Health Information that it must account for in accordance
with the HIPAA Privacy Rule.
CITY OF Lumom
June 7, 2004 - Page 4 of 6
D. The Plan Sponsor will make its internal practices, books and records relating to the use and
disclosure of individuals' Protected Health Information received from the Health Plan available to
the U.S. Department of Health and Human Services for purposes of determining compliance with
the HIPAA Privacy Rule.
E. The Plan Sponsor will, if feasible, return or destroy all individuals' Protected Health Information
that it still maintains in any form after such information is no longer needed for the purpose for
which the use or disclosure was made. Additionally, the Plan Sponsor will not retain copies of
such Protected Health Information after such information is no longer needed for the purpose for
which the use or disclosure was made. If, however, such return or destruction is not feasible, the
Plan Sponsor will limit further uses and disclosures to those purposes that make the return or
destruction of the information infeasible.
F. The Plan sponsor will ensure that the required adequate separation, described in paragraph 7
below, is established and maintained.
7. Adequate Separation
In accordance with the HIPAA Privacy Rule, the following employees or classes of employees or
workforce members under the control of the Plan Sponsor may be given access to individuals'
Protected Health Information received from the Health Plan or from a health insurance issuer or HMO
servicing the Health Plan:
Benefit Staff
Accounting
Privacy Officer
This list reflects the employees, classes of employees, or other workforce members of the Plan
Sponsor who receive individuals' Protected Health Information relating to payment under, health care
operations of, or other matters pertaining to plan administration functions that the Plan Sponsor
provides for the Health Plan. These individuals will have access to individuals' Protected Health
Information solely to perform these identified functions. For any use or disclosure of individuals'
Protected Health Information in violation of, or noncompliance with, the provisions of this
Amendment, they will be subject to disciplinary action and/or sanctions pursuant to the Plan
Sponsor's employee discipline and termination procedures.
Any suspected occurrences of improper use or disclosure of PHI may be reported to the Health Plan's
Privacy Officer at (806) 775-2312. The Plan sponsor will promptly report any such breach, violation,
or noncompliance to the Health Plan and will cooperate with the Health Plan to correct the violation
or noncompliance, to impose appropriate disciplinary action and/or sanctions, and to mitigate any
deleterious effect of the violation or noncompliance.
This Amendment takes effect January 1, 2004, if not stated differently above, and is subject to all of the
provisions and conditions of the Plan.
CITY of Lumom
June 7, 2004 - Page 5 of 6
Signed this % day of 2004.
t
Attest
Gn of LUBBOCK
Jape T, 2064 = Psp,6 of 6
TABLE OF CONTENTS
......................................................... . ... .....
INTRODUCTION ........................................... ..... .................... .................... I
ELIGIBILITY, FUNDING, EFFECTIVE DATE AND TERMINATION PROVISIONS ............................................ 3
OPENENROLLMENT................................................................................................................................................10
SCHEDULEOF BENEFITS..............................................................................................................................11
... .... ........... ............ .....
MEDICAL BENEFITS .................................. .... .... ............................ .......................................19
COST MANAGEMENT SERVICES. .......... ............. ........... .... .. ... ...... ...............
26
DEFINEDTERMS...................................................................................................................................................
30
PLANEXCLUSIONS..................................................................................................................................................
36
DENTALBENEFITS..................................................................................... ............................. ...................
39
HOWTO SUBMIT A CLAIM.....................................................................................................................................
43
COORDINATIONOF BENEFITS.......................................................................................................................... .
47
THIRD PARTY RECOVERY PROVISION............................................................. ........... .............................
50
COBRACONTINUATION OPTIONS....................................................................................................................
52
RESPONSIBILITIES FOR PLAN ADMINISTRATION............................................................................................
57
GENERALPLAN INFORMATION...........................................................................................................................
60
INTRODUCTION
This document is a description of City of Lubbock Employee Benefit Plan (the Plan). No oral interpretations can
change this Plan. The Plan described is designed to protect Plan Participants against certain catastrophic health
expenses.
Coverage under the Plan will take effect for an eligible Employee and designated Dependents when the Employee
and such Dependents satisfy the Waiting Period and all the eligibility requirements of the Plan.
The Employer reserves the right to terminate, suspend, discontinue or amend the Plan at any time and for any reason.
Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, deductibles, maximums,
copayments, exclusions, limitations, definitions, eligibility and the like.
Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no
coverage at all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan,
such as coordination of benefits, subrogation, exclusions, timeliness of COBRA elections, utilization review or other
cost management requirements, lack of Medical Necessity, lack of timely filing of claims or lack of coverage. These
provisions are explained in summary fashion in this document: additional information is available from the Plan
Administrator at no extra cost.
The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable for
expenses incurred before coverage began or after coverage terminated. An expense for a service or supply is incurred
on the date the service or supply is furnished.
If the Plan is terminated, amended, or benefits are eliminated, the rights of Covered Persons are limited to Covered
Charges incurred before termination, amendment or elimination.
This document summarizes the Plan rights and benefits for covered Employees and their Dependents and is divided
into the following parts:
Eligibility, Funding, Effective Date and Termination. Explains eligibility for coverage under the Plan, funding of
the Plan and when the coverage takes effect and terminates.
Schedule of Benefits. Provides an outline of the Plan reimbursement formulas as well as payment limits on certain
services.
Benefit Descriptions. Explains when the benefit applies and the types of charges covered.
Cost Management Services. Explains the methods used to curb unnecessary and excessive charges.
This part should be read carefully since each Participant is required to take action to assure that the
maximum payment levels under the Plan are paid.
Defined Terms. Defines those Plan terms that have a specific meaning.
Plan Exclusions. Shows what charges are not covered.
Claim Provisions. Explains the rules for filing claims and the claim appeal process.
Coordination of Benefits. Shows the Plan payment order when a person is covered under more than one plan.
Third Party Recovery Provision. Explains the Plan's rights to recover payment of charges when a Covered Person
has a claim against another person because of injuries sustained.
COBRA Continuation Options. Explains when a person's coverage under the Plan ceases and the continuation
options which are available.
ERISA Information. Explains the Plan's structure and the Participants' rights under the Plan.
ELIGIBILITY, FUNDING, EFFECTIVE DATE
AND TERMINATION PROVISIONS
A Plan Participant should contact the Plan Administrator (City of Lubbock) to obtain additional information, free of
charge, about Plan coverage of a specific benefit, particular drug, treatment, test or any other aspect of Plan benefits
or requirements.
ELIGIBILITY
Eligible Classes of Employees. All Active and Retired Employees of the Employer.
Eligibility Requirements for Employee Coverage. A person is eligible for Employee coverage from the first day
that he or she:
(I) is a Full -Time, Active Employee of the Employer. An Employee is considered to be Full -Time if he or
she normally works at least 40 hours per week and is on the regular payroll of the Employer for that
work.
(2) is a Retired Employee of the Employer. Retired Employees will be eligible for coverage only if they are
eligible for coverage when they are Employees and choose to remain eligible for coverage under this
Plan after they become a Retired Employee. An Employee who retires and declines the opportunity to
remain eligible under the Plan will no longer be eligible as a Retired Employee. A Retired Employee
may not regain either medical or dental coverage if coverage is terminated at any time during retirement.
A surviving spouse of a retired City of Lubbock Employee may retain coverages after the covered
Retired Employee's death.
Retired Employees are eligible for dental benefits.
(3) is in a class eligible for coverage.
(4) completes the employment Waiting Period of one full pay period as an Active Employee or first of the
month after reaching retiring status for Retired Employees. A "Waiting Period" is the time between the
first day of employment and the fast day of coverage under the Plan. The Waiting Period is counted in
the Pre -Existing Conditions exclusion time.
Eligible Classes of Dependents. A Dependent is any one of the following persons:
(I) A covered Employee's Spouse and unmarried children from birth to the limiting age of 25 years. When a
child reaches the limiting age, coverage will end on the child's birthday.
The term "Spouse" shall mean the person recognized as the covered Employee's husband or wife under
the laws of the state where the covered Employee lives. The Plan Administrator may require
documentation proving a legal marital relationship.
The term "children" shall include natural children of the Employee, adopted children or children placed
with a covered Employee in anticipation of adoption, or Foster Children. Step -children may also be
included as long as a natural parent remains married to the Employee.
If a covered Employee is the Legal Guardian of an unmarried child or children, these children may be
enrolled in this Plan as covered Dependents. The Plan Administrator may require documentation proving
Legal Guardianship.
The phrase "child placed with a covered Employee in anticipation of adoption" refers to a child whom
the Employee intends to adopt, whether or not the adoption has become final, who has not attained the
age of 18 as of the date of such placement for adoption. The term "placed" means the assumption and
retention by such Employee of a legal obligation for total or partial support of the child in anticipation of
3
adoption of the child. The child must be available for adoption and the legal process must have
commenced.
Any child of a Plan Participant who is an alternate recipient under a qualified medical child support
order shall be considered as having a right to Dependent coverage under this Plan.
A participant of this Plan may obtain, without charge, a copy of the procedures governing qualified
medical child support order (QMCSO) determinations from the Plan Administrator.
(2) A covered Dependent child who reaches the limiting age and is Totally Disabled, incapable of
self-sustaining employment by reason of mental or physical handicap, primarily dependent upon the
covered Employee for support and maintenance and unmarred. The Plan Administrator may require, at
reasonable intervals during the two years following the Dependent's reaching the limiting age,
subsequent proof of the child's Total Disability and dependency.
After such, two-year period, the Plan Administrator may require subsequent proof not more than once
each year. The Plan Administrator reserves the right to have such Dependent examined by a Physician of
the Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity.
These persons are excluded as Dependents: other individuals living in the covered Employee's home, but who are not
eligible as defined; the legally separated or divorced former Spouse of the Employee; any person who is on active
duty in any military service of any country; or any person who is covered under the Plan as an Employee.
If a person covered under this Plan changes status from Employee to Dependent or Dependent to Employee, and the
person is covered continuously under this Plan before, during and after the change in status, credit will be given for
deductibles and all amounts applied to maximums.
If both mother and father are Employees, their children will be covered as Dependents of the mother or
father, but not of both.
Eligibility Requirements for Dependent Coverage. A family member of an Employee will become eligible for
Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family member
satisfies the requirements for Dependent coverage.
At any time, the Plan may require proof that a Spouse or a child qualifies or continues to qualify as a Dependent as
defined by this Plan.
FUNDING
Cost of the Plan. City of Lubbock pays the entire cost of Employee coverage under this Plan.
The covered Employees pay for coverage for their Dependents. The enrollment application for coverage will include
a payroll deduction authorization. This authorization must be filled out, signed and returned with the enrollment
application.
The level of any Employee contributions is set by the Plan Administrator. The Plan Administrator reserves the right
to change the level of Employee contributions.
PRE-EXISTING CONDITIONS
NOTE: The length of the Pre -Existing Conditions Limitation may be reduced or eliminated if an eligible
person has Creditable Coverage from another health plan.
An eligible person may request a certificate of Creditable Coverage from his or her prior plan within 24
months after losing coverage and the Employer will assist any eligible person in obtaining a certificate of
Creditable Coverage from a prior plan.
A Covered Person will be provided a certificate of Creditable Coverage if he or she requests one either
before losing coverage or within 24 months of coverage ceasing.
If, after Creditable Coverage has been taken into account, there will still be a Pre -Existing Conditions
Limitation imposed on an individual, that individual will be so notified.
Covered charges incurred under Medical Benefits for Pre -Existing Conditions are not payable unless incurred 12
consecutive months, or 18 months if a Late Enrollee after the person's Enrollment Date. This time may be offset if the
person has Creditable Coverage from his or her previous plan.
A Pre -Existing Condition is a condition for which medical advice, diagnosis, care or treatment was recommended or
received within six months prior to the person's Enrollment Date under this Plan. Genetic Information is not a
condition. Treatment includes receiving services and supplies, consultations, diagnostic tests or prescribed medicines.
In order to be taken into account, the medical advice, diagnosis, care or treatment must have been recommended by,
or received from, a Physician.
The Pre -Existing Condition does not apply to pregnancy, to a newborn child who is covered under this Plan within 31
days of birth, or to a child who is adopted or placed for adoption before attaining age 18 and who, as of the last day of
the 31-day period beginning on the date of the adoption or placement for adoption, is covered under this Plan. A Pre -
Existing Condition exclusion may apply to coverage before the date of the adoption or placement for adoption.
The prohibition on Pre -Existing Condition exclusion for newborn, adopted, or pre -adopted children does not apply to
an individual after the end of the first 63-day period during all of which the individual was not covered under any
Creditable Coverage.
ENROLLMENT
Enrollment Requirements. An Employee must enroll for coverage by filling out and signing an enrollment
application along with the appropriate payroll deduction authorization. The covered Employee must also enroll any
Dependents when Dependent coverage is requested.
Enrollment Requirements for Newborn Children.
A newborn child of a covered Employee who has Dependent coverage is not automatically enrolled in this Plan.
Charges for covered nursery care will be applied toward the Plan of the newborn child. If the newborn child is
required to be enrolled and is not enrolled in this Plan on a timely basis, as defined in the section "Timely
Enrollments" following this section, there will be no payment from the Plan and the covered parent will be
responsible for all costs.
Charges for covered routine Physician care will be applied toward the Plan of the newborn child. If the newborn child
is required to be enrolled and is not enrolled in this Plan on a timely basis, there will be no payment from the Plan and
the covered parent will be responsible for all costs.
If the child is required to be enrolled and is not enrolled within 31 days of birth, the enrollment will be considered a
Late Enrollment.
TIMELY OR LATE ENROLLMENT
(1) Timely Enrollment - The enrollment will be "timely" if the completed form is received by the Plan
Administrator no later than 31 days after the person becomes eligible for the coverage, either initially or
under a Special Enrollment Period.
If two Employees (husband and wife) are covered under the Plan and the Employee who is covering the
Dependent children terminates coverage, the Dependent coverage may be continued by the other covered
Employee with no Waiting Period as long as coverage has been continuous.
(2) Late Enrollment - An enrollment is "late" if it is not made on a "timely basis" or during a Special
Enrollment Period. Late Enrollees and their Dependents who are not eligible to join the Plan during a
Special Enrollment Period may join only during open enrollment.
If an individual loses eligibility for coverage as a result of terminating employment or a general
suspension of coverage under the Plan, then upon becoming eligible again due to resumption of
employment or due to resumption of Plan coverage, only the most recent period of eligibility will be
considered for purposes of determining whether the individual is a Late Enrollee.
The time between the date a Late Enrollee fast becomes eligible for enrollment under the Plan and the
fast day of coverage is not treated as a Waiting Period. Coverage begins on fast of the month following
Open Enrollment. Late Enrollees will be subject to an 18 month pre-existing condition offset by the
Covered Person's certificate of creditable coverage.
SPECIAL ENROLLMENT PERIODS
The enrollment date for anyone who enrolls under a Special Enrollment Period is the first date of coverage. Thus, the
time between the date a special enrollee first becomes eligible for enrollment under the Plan and the first day of
coverage is not treated as a Waiting Period.
(1) Individuals losing other coverage. An Employee or Dependent who is eligible, but not enrolled in this
Plan, may enroll if each of the following conditions is met:
(a) The Employee or Dependent was covered under a group health plan or had health insurance
coverage at the time coverage under this Plan was previously offered to the individual-
(b) If required by the Plan Administrator, the Employee stated in writing at the time that coverage
was offered that the other health coverage was the reason for declining enrollment.
(c) The coverage of the. Employee or Dependent who had lost the coverage was under COBRA and
the COBRA coverage was exhausted, or was not under COBRA and either the coverage was
terminated as a result of loss of eligibility for the coverage (including as.a result of legal
separation, divorce, death, termination of employment or reduction in the number of hours of
employment) or employer contributions towards the coverage were terminated.
(d) The Employee or Dependent requests enrollment in this Plan not later than 31 days after the date
of exhaustion of COBRA coverage or the termination of coverage or employer contributions,
described above. Coverage will begin no later than the first day of the first calendar month
following the date the completed enrollment form is received.
If the Employee or Dependent lost the other coverage as a result of the individual's failure to pay premiums or
required contributions or for cause (such as making a fraudulent claim), that individual does not have a Special
Enrollment right.
(2) Dependent beneficiaries. If:
(a) The Employee is a participant under this Plan (or has met the Waiting Period applicable to
becoming a participant under this Plan and is eligible to be enrolled under this Plan but for a
failure to enroll during a previous enrollment period), and
(b) A person becomes a Dependent of the Employee through marriage, birth, adoption or placement
for adoption,
then the Dependent (and if not otherwise enrolled, the Employee) may be enrolled under this Plan as a
covered Dependent of the covered Employee. In the case of the birth or adoption of a child, the Spouse
of the covered Employee may be enrolled as a Dependent of the covered Employee if the Spouse is
otherwise eligible for coverage.
The Dependent Special Enrollment Period is a period of 31 days and begins on the date of the marriage,
birth, adoption or placement for adoption.
The coverage of the Dependent enrolled in the Special Enrollment Period will be effective:
(a) in the case of marriage, as of the date of marriage;
(b) in the case of a Dependent's birth, as of the date of birth; or
(c) in the case of a Dependent's adoption or placement for adoption, the date of the adoption or
placement for adoption.
EFFECTIVE DATE
Effective Date of Employee Coverage. An Employee will be covered under this Plan as of the first day that the
Employee satisfies all of the following:
(1) The Eligibility Requirement.
(2) The Active Employee Requirement.
(3) The Enrollment Requirements of the Plan.
Active Employee Requirement.
An Employee must be an Active Employee (as defined by this Plan) for this coverage to take effect.
Effective Date of Dependent Coverage. A Dependent's coverage will take effect on the day that the Eligibility
Requirements are met; the Employee is covered under the Plan; and all Enrollment Requirements are met.
TERMINATION OF COVERAGE
When coverage under this Plan stops, Plan Participants will receive a certificate that will show the period
of coverage under this Plan. Please contact the Plan Administrator for further details.
When Employee Coverage Terminates. Employee coverage will terminate on the earliest of these dates (except in
certain circumstances, a covered Employee may be eligible for COBRA continuation coverage. For a complete
explanation of when COBRA continuation coverage is available, what conditions apply and how to select it, see the
section entitled COBRA Continuation Options):
(1) The date the Plan is terminated.
(2) The last day of the calendar month in which the covered Employee ceases to be in one of the Eligible
Classes. This includes death or termination of Active Employment of the covered Employee. (See the
COBRA Continuation Options.)
Continuation During Periods of Employer -Certified Leave of Absence or Layoff. A person may remain eligible
for a limited time if Active, full-time work ceases due to leave of absence or layoff. This continuance will end as
follows:
For leave of absence or layoff only: the end of the 12 calendar month period that next follows the month in
which the person last worked as an Active Employee.
While continued, coverage will be that which was in force on the last day worked as an Active Employee. However,
if benefits reduce for others in the class, they will also reduce for the continued person.
Continuation During Family and Medical Leave. Regardless of the established leave policies mentioned above,
this Plan shall at all times comply with the Family and Medical Leave Act of 1993 as promulgated in regulations
issued by the Department of Labor.
During any leave taken under the Family and Medical Leave Act, the Employer will maintain coverage under this
Plan on the same conditions as coverage would have been provided if the covered Employee had been continuously
employed during the entire leave period.
If Plan coverage terminates during the FMLA leave, coverage will be reinstated for the Employee and his or her
covered Dependents if the Employee returns to work in accordance with the terms of the FMLA leave. Coverage will
be reinstated only if the person(s) had coverage under this Plan when the FMLA leave started, and will be reinstated
to the same extent that it was in force when that coverage terminated. For example, Pre -Existing Conditions
limitations and other Waiting Periods will not be imposed unless they were in effect for the Employee and/or his or
her Dependents when Plan coverage terminated.
Rehiring a Terminated Employee. A terminated Employee who is rehired will be treated as a new hire and be
required to satisfy all Eligibility and Enrollment requirements. However, if the Employee is returning to work directly
from COBRA coverage, this Employee does not have to satisfy any employment waiting period or Pre -Existing
Conditions provision.
Employees on Military Leave. Employees going into or returning from military service may elect to continue Plan
coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act under the following
circumstances. These rights apply only to Employees and their Dependents covered under the Plan before leaving for
military service.
(1) The maximum period of coverage of a person under such an election shall be the lesser of:
(a) The 18 month period beginning on the date on which the person's absence begins; or
(b) The day after the date on.which the person was required to apply for or return to a position or
employment and fails to do so.
(2) A person who elects to continue health plan coverage may be required to pay up to 102% of the full cost
under the Plan, except a person on active duty for 30 days or less cannot be required to pay more than the
Employee's share, if any, for the coverage.
(3) An exclusion or Waiting Period may not be imposed in connection with the reinstatement of coverage
upon reemployment if one would not have been imposed had coverage not been terminated because of
service. However, an exclusion or Waiting Period may be imposed for coverage of any Illness or Injury
determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the
performance of uniformed service.
When Dependent Coverage Terminates. A Dependent's coverage will terminate on the earliest of these dates
(except in certain circumstances, a covered Dependent may be eligible for COBRA continuation coverage. For a
complete explanation of when COBRA continuation coverage is available, what conditions apply and how to select it,
see the section entitled COBRA Continuation Options):
(1) The date the Plan or Dependent coverage under the Plan is terminated.
(2) The date that the Employee's coverage under the Plan terminates for any reason including death.
The Dependents of an Employee who dies during the course of their duty may remain eligible for
coverage if they had existing coverage under this Plan at the time of the Employee's death.
(3) The date a covered Spouse loses coverage due to loss of dependency status. (See the COBRA
Continuation Options.)
(4) On the fast date that a Dependent child ceases to be a Dependent as defined by the Plan. (See the
COBRA Continuation Options.)
(5) The end of the period for which the required contribution has been paid if the charge for the next period
is not paid when due.
OPEN ENROLLMENT
OPEN ENROLLMENT
During the annual open enrollment period, which starts on the 3'a Wednesday of November and ends on the Yd
Wednesday in December, Employees and their Dependents who are Late Enrollees will be able to enroll in the Plan.
Benefit choices for Late Enrollees made during the open enrollment period will become effective first of the month
following Open Enrollment.
Plan Participants will receive detailed information regarding open enrollment from their Employer.
10
SCHEDULE OF BENEFITS
Verification of Eligibility 1-800-658-9777
Call this number to verify eligibility for Plan benefits before the charge is incurred.
MEDICAL BENEFITS
All benefits described in this Schedule are subject to the exclusions and limitations described more fully herein
including, but not limited to, the Plan Administrators determination that: care and treatment is Medically Necessary;
that charges are Usual and Reasonable: that services, supplies and care are not Experimental and/or Investigational.
The meanings of these capitalized terms are in the Defined Terms section of this document.
Note: The following services must be precertified or reimbursement from the Plan maybe reduced. If the
Covered Person does not receive authorization as explained in this section, the benefit payment will be reduced by
$250. This penalty will not apply when a Covered Person utilizes a Network Provider. See the Cost Management
section for further details.
The attending Physician does not have to obtain precertification from the Plan for prescribing a maternity
length of stay that is 48 hours or less for a vaginal delivery or 96 hours or less for a cesarean delivery.
All outpatient IV therapies
Back surgery
Breast surgery
Bypass surgery
Cardiac catheterization
Cardiac pacemaker implant
Cataract removal
Chemotherapy
Cholecystectomy (removal of gall bladder)
Coronary arteriography
Dialysis
Dilation and curettage of uterus
Ear surgery
Facial and jaw surgery
Hemorrhoid removal
Hernia repair
Hip surgery
Home Health
Home infusion therapy
Hospice care
Hysterectomy (removal of uterus)
Knee surgery
Ligation & stripping of varicose veins
Mental illness treatment
Nose surgery
Prostatectomy
Serious mental illness treatment
Substance abuse treatment
Toe & foot surgery
Tonsillectomy and/or adenoidectomy
Transfers to another facility or transfers to or from a specialty unit within a facility
Please see the Cost Management section in this booklet for details.
11
The Plan is a plan that contains a network Preferred Provider Organization (PPO or Network Provider). For further
Network Provider information, including contact information, please refer to the Employee ID Card.
This Plan has entered into an agreement with certain Hospitals, Physicians and other health care providers, which are
called Network Providers. Because these Network Providers have agreed to charge reduced fees to persons covered
under the Plan, the Plan can afford to reimburse a higher percentage of their fees.
Therefore, when a Covered Person uses a Network Provider, that Covered Person will receive a higher payment from
the Plan than when a Non -network Provider is used. It is the Covered Person's choice as to which Provider to use.
Under the following circumstances, the higher in -Network benefits will be made for non -Network services:
If a Covered Person has no choice of Network Providers in the specialty that the Covered Person is seeking
within the PPO service area.
If a Covered Person is out of the PPO service area and has a Medical Emergency requiring immediate care.
If a Covered Person does not live within a radius of 75 miles of a PPO facility.
Additional information about this option, as well as a list of Network Providers, will be given to Plan Participants, at
no cost, and updated as needed.
Deductibles/Copayments payable by Plan Participants
Deductibles/Copayments are dollar amounts that the Covered Person must pay before the Plan pays.
A deductible is an amount of money that is paid once a Calendar Year per Covered Person. Typically, there is one
deductible amount per Plan and it must be paid before any money is paid by. the Plan for any covered services. Each
January 1 st, a new deductible amount is required. However, covered expenses incurred in, and applied toward the
individual deductible in October, November and December will be applied to the individual deductible in the next
Calendar Year as well as the current Calendar Year. Deductibles do not accrue toward the 100% maximum out-of-
pocket payment.
A copayment is a smaller amount of money that is paid each time a particular service is used. Typically, there may be
copayments on some services and other services will not have any copayments. Copayments do not accrue toward the
100% maximum out-of-pocket payment.
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
MAXIMUM
LIFETIME BENEFIT
$1,000,000
AMOUNT
Note: The maximums listed below are the total for Network and Non -Network expenses. For
example, if a maximum of 60 days is listed twice under a service, the Calendar Year maximum
is 60 days total which may be split between Network and Non -Network providem
Per Covered Person $500 $600 $500
Per Family Unii
$1,000 1$1,200 1$1,000
The Calendar Year deductible is waived for the following Covered Charges:
- Skilled Nursing Facility - In -Network, Out -of -Area
- Home Health Care - In -Network, Out -of -Area
- Hospice — In -Network, Out -of -Area
- Routine Well Adult and Child Care — Out -of -Area
- Required Childhood Immunizations
12
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Physician visits
$25.00
70% after deductible
80% after deductible
Emergency room
$50.00
$50.00
80% after deductible
facility charges
Mental Disorders
$25.00
70% after deductible
80% after deductible
Outpatient —
Physician/Consultant
visits
30 visit Calendar Year
maximum
Serious Mental Illness
$25.00
70% after deductible
80% after deductible
Outpatient —
Physician/Consultant
visits
60 visit Calendar Year
maximum
Second or Third
$25.00
70% after deductible
80% after deductible
Surgical Opinions
Routine Well Adult and
$25.00
70% after deductible
80%
Child Care
Per Covered Person $2 000
f'
$3,000
$2,000
Per Family Unit 1$4,000
1$6.000
1$4,000
The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are
reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the
Calendar Year unless stated otherwise.
The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%.
Deductible(s)
Cost containment penalties
Co a ents
Second or Third 100% after copayment 70% after deductible 80% after deductible
Surgical Opinions
Pre -Admission Testing
80% after deductible
60% after deductible
80% after deductible
inpatient and outpatient
Outpatient/Ambulatory
80% after deductible 60% after deductible
80% after deductible
Su 'cal Procedures
Inpatient Hospital
None $100
$100
deductible per
confinement
Room and Board
80% after deductible
60% after deductible
80% after deductible
the semiprivate room
the semiprivate room
the semiprivate room
rate
rate
rate
Intensive Care Unit
80% after deductible
60% after deductible
80% after deductible
Hos ital's ICU Charge
Hospital's ICU Charge
Ho ital's ICU Charge
13
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Emergency/Trest-
80% after copayment
80% after copayment
80% after deductible
ment Room (services
rendered within 48
hours of an accident or
medical emergency)
Facility char es
Emergency/Treat-
80% after deductible
80% after deductible
80% after deductible
ment Room (services
rendered within 48
hours of an accident or
medical emergency)
Physician charges
Skilled Nursing Facility
100%
70% after deductible
100%
the facility's semiprivate
the facility's semiprivate
the facility's semiprivate
room rate
room rate
room rate
$10,000 Calendar Year
$7,000 Calendar Year
$10,000 Calendar Year
maximum
80% after deductible
maximum
60% after deductible
maximum
80% after deductible
Inpatient visits
Office visits (including
100% after copayment
70% after deductible
80% after deductible
ancillary charges
performed in and billed
by the Physician's
office)
Does not apply to the
Chiropractic benefit
Diagnostic Procedures
80% after deductible
60% after deductible
80% after deductible
—includes but is not
limited to: Bone Scan,
Cardiac Stress Test, CT
Scan, MRI,
Myelogram, PET Scan,
Ultrasound, and
Mammograrn
Sure
80% after deductible
60% after deductible
80% after deductible
Home Health Care
100%
70% after deductible
100%
$10,000 Calendar Year
$7,000 Calendar Year
$10,000 Calendar Year
maximum
maximum
maximum
Outpatient Private
80% after deductible
60% after deductible
80% after deductible
:Duty Nursing
Hospice Care
100%
70% after deductible
100%
$20,000 inpatient and
$14,000 inpatient and
$20,000 inpatient and
outpatient Lifetime
outpatient Lifetime
outpatient Lifetime
maximum
maximum
maximum
Ambulance Service
80% after deductible
60% after deductible
80% after deductible
14
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Jaw Joint/TMJ
80% after deductible
60% after deductible
80% after deductible
(Coverage excluded after
Covered Person's 19d'
birthday except
orthognathic surgery for
treatment of
temporomandibular joint
disorders and conditions
of temporomandibular
Joint disorders)
Speech and Hearing
80% after deductible
60% after deductible
80% after deductible
Services
Includes hearing aids
(limited to $1,000 per
36-monthperiod)
Home Infusion
80% after deductible
60% after deductible
80% after deductible
Therapy
Durable Medical
80% (rental up to
60% (rental up to
80% (rental up to
Equipment
purchase price) after
purchase price) after
purchase price) after
deductible
deductible
deductible
Prosthetics
80% after deductible
60% after deductible
80% after deductible
Orthotics
80% after deductible
60% after deductible
80% after deductible
Spinal Manipulation
80% after deductible
60% after deductible
80% after deductible
Chiropractic and
$1,500 Calendar Year
$1,500 Calendar Year
$1,500 Calendar Year
Physical Medicine
maximum
maximum
maximum
Service which includes
physical and
occupational therapy
Maximums listed are for
Spinal
Manipulation/Chiroprac-
tic and Physical Medical
Service combined
Inpatient
80% after deductible
60% after deductible
80% after deductible
30 day Calendar Year
15 day Calendar Year
30 day Calendar Year
maximum
maximum
maximum
Outpatient - 100% after copayment
70% after deductible
80% after deductible
Physician/Consultant
visits
Outpatient - 80% after deductible
60% after deductible
80% after deductible
Facility/Outpatient
Professional Provider
30 visit Calendar Year maximum for all Outpatient
combined
Inpatient 80% after deductible
60% after deductible
80% after deductible
45 day Calendar Year
45 day Calendar Year
45 day Calendar Year
maximum
maximum
maximum
15
NETWORK
NON -NETWORK
OUT-O&AREA
PROVIDERS
PROVIDERS
Outpatient -
100% after copayment
70% after deductible
80% after deductible
Physician/Consultant
visits
Outpatient -
80% after deductible
60% after deductible
80% after deductible
Facility/Outpatient
Professional Provider
60 visit Calendar Year maximum
for all Outpatient
combined
60% after deductible
80% after deductible
inpatient
80% after deductible
Outpatient
80% after deductible
60% after deductible
80% after deductible
Inpatient / Outpatient
Combined
3 separate series of
3 separate series of
3 separate series of
treatment Lifetime
treatment Lifetime
treatment per Lifetime
maximum
maximum
maximum
Routine Well Adult 100% after copayirient 70% after deductible 80%
Care
Includes: office visits, routine physical examination, prostate screening and cancer exam, routine
mammography, colorectal cancer screenings annual hearing test, annual vision test and
immunizations/flu shots.
Annual limit for Mammogram: 1 per Calendar Year
Age 35 or older
Routine Well Newbom
80% after deductible
60% after deductible
80% after deductible
Care
Routine Well Child 100% after copayment 70% after deductible 80%
Care
Includes: office visits, routine physical examination, annual hearing test and annual vision test.
Includes immunizations for children ages 6 and older.
Required Childhood 100% 100%
100%
Immunizations — for
children up to age 6
Covered immunizations are: Diphtheria, Hemophilus influenza type b, Hepatitis
B, Measles, Mumps,
Pertussis, Polio, Rubella, Tetanus, Varicella, and any other immunizations re
uired by law.
Organ Transplants
80% after deductible
60% after deductible
80% after deductible
Pregnancy
80% after deductible
60% after deductible
80% after deductible
Dependent daughters are
covered
Newborn Nursery
Charges will be applied
to Newborn's own
deductible and co-
insurance
All maternity expenses and treatment in progress as of the effective date of this Plan and
currently covered under this Plan, that is being provided by a BC-BS network physician or
facility, will continue to be eligible for payment at the Network benefit level until the post partum
follow up is complete.
16
PRESCRIPTION DRUG BENEFIT
Pharmacy Option (up to a 30-day supply)
Generic drug
Copayment ..............................
Brand Name drugs
Copayment..............................
............................................................... $13.00
....................................................... ....... $26.00
Mail Order Prescription Drug Option (up to a 90-day supply)
Generic drug
Copayment.......................................................................................................... $21.00
Brand Name drugs
Copayment..................................................................................................... $42.00
Please Note: if a generic drug is available and the prescription order does not permit the use of the generic
alternative or if the Covered Person chooses a brand name drug, the Covered Person will pay the Brand Name
drugs copayment plus the difference between the cost of the brand name drug and the generic drug. This
provision applies to the Pharmacy Option and Mail Order Option.
Participating pharmacies have contracted with the Plan to charge Covered Persons reduced fees for covered
Prescription Drugs. Medco Health is the administrator of the pharmacy drug plan. The copayment amount is
not a covered charge under the medical plan. For additional information about coverage and exclusions, please
contact Medco Health.
17
DENTAL BENEFITS
Calendar Year deductible,
perperson ........................................................................................................... $75.00
perFamily Unit ................................................................................................... $225.00
The deductible applies to these Classes of Service:
Class B Services - Basic
Class C Services - Major
Dental Percentage Payable
Class A Services -
Preventive........................................................................................................... 100%
Class B Services -
Basic................................................................................................................... 80%
Class C Services -
Major.................................................................................................................. 50%
Class D Services -
Orthodontia......................................................................................................... 50%
Orthodontia coverage is only available up to age 25.
Maximum Benefit Amount
For other than Class D-Orthodontia:
Per person per Calendar
Year(up to age 25) ............................................................................................. $1,200
For Class D-Orthodontia:
Lifetime maximum per person ............................................................................ $1,000
18
MEDICAL BENEFITS
Medical Benefits apply when Covered Charges are incurred by a Covered Person for care of an Injury or Sickness
and while the person is covered for these benefits under the Plan.
DEDUCTIBLE
Deductible Amount. This is an amount of Covered Charges for which no benefits will be paid. Before benefits can
be paid in a Calendar Year a Covered Person must meet the deductible shown in the Schedule of Benefits.
This amount will not accrue toward the 100% maximum out-of-pocket payment.
Deductible Three Month Carryover. Covered expenses incurred in, and applied toward the individual deductible in
October, November and December will be applied toward the individual deductible in the next Calendar Year.
Family Unit Limit. When the maximum amount shown in the Schedule of Benefits has been incurred by members of
a Family Unit toward their Calendar Year deductibles, the deductibles of all members of that Family Unit will be
considered satisfied for that year.
BENEFIT PAYMENT
Each Calendar Year, benefits will be paid for the Covered Charges of a Covered Person that are in excess of the
deductible and any copayments. Payment will be made at the rate shown under reimbursement rate in the Schedule of
Benefits. No benefits will be paid in excess of the Maximum Benefit Amount or any listed limit of the Plan.
OUT-OF-POCKET LIMIT
Covered Charges are payable at the percentages shown each Calendar Year until the out-of-pocket limit shown in the
Schedule of Benefits is reached. Then, Covered Charges incurred by a Covered Person will be payable at 100%
(except for the charges excluded) for the rest of the Calendar Year.
When a Family Unit reaches the out-of-pocket limit, Covered Charges for that Family Unit will be payable at 100%
(except for the charges excluded) for the rest of the Calendar Year.
MAXIMUM BENEFIT AMOUNT
The Maximum Benefit Amount is shown in the Schedule of Benefits. It is the total amount of benefits that will be
paid under the Plan for all Covered Charges incurred by a Covered Person.
COVERED CHARGES
Covered charges are the Usual and Reasonable Charges that are incurred for the following items of service and
supply. These charges are subject to the benefit limits, exclusions and other provisions of this Plan. A charge is
incurred on the date that the service or supply is performed or furnished.
(1) Hospital Care. The medical services and supplies furnished by a Hospital or Ambulatory Surgical
Center or a Birthing Center. Covered charges for room and board will be payable as shown in the
Schedule of Benefits. After 48 observation hours, a confinement will be considered an inpatient
confinement.
Room charges made by a Hospital having only private rooms will be covered at the average private room
rate.
Charges for an Intensive Care Unit stay are payable as described in the Schedule of Benefits.
19
(2) Coverage of Pregnancy. The Usual and Reasonable Charges for the care and treatment of Pregnancy
are covered the same as any other Sickness.
Group health plans generally may not, under Federal law, restrict benefits for any hospital length of stay
in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not
prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging
the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and
issuers may not, under Federal law, require that a provider obtain authorization from the plan or the
issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
(3) Skilled Nursing Facility Care. The room and board and nursing care furnished by a Skilled Nursing
Facility will be payable if and when:
(a) the patient is confined as a bed patient in the facility;
(b) the attending Physician certifies that the confinement is needed for further care of the condition
that caused the Hospital confinement; and
(c) the attending Physician completes a treatment plan which includes a diagnosis, the proposed
course of treatment and the projected date of discharge from the Skilled Nursing Facility.
Covered charges for a Covered Person's care in these facilities is limited to the covered daily maximum
shown in the Schedule of Benefits.
(4) Physician Care. The professional services of a Physician for surgical or medical services.
(a) Charges for multiple surgical procedures will be a covered expense subject to the following
provisions:
(i) If bilateral or multiple surgical procedures are performed by one (1) surgeon, benefits
will be determined based on the Usual and Reasonable Charge that is allowed for the
primary procedures; 50% of the Usual and Reasonable Charge will be allowed for each
additional procedure performed through the same incision. Any procedure that would
not be an integral part of the primary procedure or is unrelated to the diagnosis will be
considered "incidental" and no benefits will be provided for such procedures;
(ii) If multiple unrelated surgical procedures are performed by two (2) or more surgeons on
separate operative fields, benefits will be based on the Usual and Reasonable Charge
for each surgeon's primary procedure. If two (2) or more surgeons perform a procedure
that is normally performed by one (1) surgeon, benefits for all surgeons will not exceed
the Usual and Reasonable percentage allowed for that procedure; and
(III) If an assistant surgeon is required, the assistant surgeon's covered charge will not
exceed 20% of the surgeon's Usual and Reasonable allowance.
(5) Private Duty Nursing Care. The private duty nursing care by a licensed nurse (R.N., L.P.N. or L.V.N.).
Covered charges for this service will be included to this extent:
(a) Inpatient Nursing Care. Charges are covered only when care is Medically Necessary or not
Custodial in nature and the Hospital's Intensive Care Unit is filled or the Hospital has no
Intensive Care Unit.
(b) Outpatient Nursing Care. Charges are covered only when care is Medically Necessary and not
Custodial in nature. The only charges covered for Outpatient nursing care are those shown
below, under Home Health Care Services and Supplies. Outpatient private duty nursing care on
a 24-how-shift basis is not covered.
20
(6) Home Health Care Services and Supplies. Charges for home health care services and supplies are
covered only for care and treatment of an Injury or Sickness when Hospital or Skilled Nursing Facility
confinement would otherwise be required. The diagnosis, care and treatment must be certified by the
attending Physician and be contained in a Home Health Care Plan.
Benefit payment for nursing, home health aide and therapy services is subject to the Home Health Care
limit shown in the Schedule of Benefits.
A home health care visit will be considered a periodic visit by either a nurse or therapist, as the case may
be, or four hours of home health aide services.
(7) Hospice Care Services and Supplies. Charges for hospice care services and supplies are covered only
when the attending Physician has diagnosed the Covered Person's condition as being terminal,
determined that the person is not expected to live more than six months and placed the person under a
Hospice Care Plan.
Covered charges for Hospice Care Services and Supplies are payable as described in the Schedule of
Benefits.
(8) Other Medical Services and Supplies. These services and supplies not otherwise included in the items
above are covered as follows:
(a) Local Medically Necessary professional land or air ambulance service. A charge for this item
will be a Covered Charge only if the service is to the nearest Hospital or Skilled Nursing Facility
where necessary treatment can be provided unless the Plan Administrator finds a longer trip was
Medically Necessary.
(b) Treatment of acquired brain injury. Covered charges for the following services, medically
necessary as a result of or related to an acquired brain injury: cognitive rehabilitative therapy;
cognitive communication therapy; neurocognitive therapy and rehabilitation; neurobehavioral,
neurophysiological, neuropsychological and psychophysiological testing or treatment;
neurofeedback therapy; remediation; post -acute transition services; and community reintegration
services.
The following definitions apply to this benefit:
Acquired brain injury means a neurological insult to the brain, which is not hereditary,
congenital or degenerative. The injury to the brain occurred after birth and results in a change in
neuronal activity, which results in an impairment of physical functioning, sensory processing,
cognition or psychosocial behavior.
Cognitive communication therapy means services designed to address modalities of
comprehensive and expression, including understanding, reading, writing and verbal expression
of information.
Cognitive rehabilitation therapy means services designed to address therapeutic cognitive
activities, based on an assessment and understanding of the individual's brain -behavioral
deficits.
Community reintegration services means services that facilitate the continuum of care as an
affected individual transitions into the community.
Neurobehavioral testing means an evaluation of the history of neurological and psychiatric
difficulty, current symptoms, current mental status and premorbid history, including the
identification of problematic behavior and the relationship between behavior and the variables
that control behavior. This may include interviews of the individual, family and others.
21
Neurobehavioral treatment means interventions that focus on behavior and the variables that
control behavior.
Neurocognitive rehabilitation means services designed to assist cognitively impaired individuals
to compensate for deficits in cognitive functioning by rebuilding cognitive skills and/or
developing compensatory strategies and techniques.
Neurocognitive therapy means services designated to address neurological deficits in
informational processing and to facilitate the development of higher level cognitive abilities.
Neurofeedback.therapy means services that utilize operant conditioning learning procedure
based on electroencephalography (EEG) parameters and that are designed to result in improved
mental performance and behavior and stabilized mood.
Neurophysiological testing means an evaluation of the functions of the nervous system.
Neurophysiological treatment means interventions that focus on the functions of the nervous
system.
Neuropsychological testing means the administering of a comprehensive battery of tests to
evaluate neurocognitive, behavioral and emotional strengths and weaknesses and their
relationship to normal and abnormal central nervous system functioning.
Neuropsychological treatment means interventions designed to improve or minimize deficits in
behavioral and cognitive processes.
Post -acute transition services means services that facilitate the continuum of care beyond the
initial neurological insult through rehabilitation and community reintegration.
Psychophysiological testing means an evaluation of the interrelationships between the nervous
system and other bodily organs and behavior.
Psychophysiological treatment means interventions designed to alleviate or decrease abnormal
physiological responses of the nervous system due to behavioral or emotional factors.
Remediation means the process or processes of restoring or improving a specific function.
Services means the work of testing, treatment and providing therapies to an individual with an
acquired brain injury.
Therapy means the scheduled remedial treatment provided through direct interaction with the
individual to improve a pathological condition resulting from an acquired brain injury.
(c) Anesthetic; oxygen; blood and blood derivatives that are not donated or replaced; intravenous
injections and solutions. Administration of these items is included.
(d) Cardiac rehabilitation as deemed Medically Necessary provided services are rendered (a)
under the supervision of a Physician; (b) in connection with a myocardial infarction, coronary
occlusion or coronary bypass surgery; (c) initiated within 12 weeks after other treatment for the
medical condition ends; and (d) in a Medical Care Facility as defined by this Plan.
(e) Radiation or chemotherapy and treatment with radioactive substances. The materials and
services of technicians are included.
(f) Initial contact lenses or glasses required following cataract surgery.
22
(g) Rental of durable medical or surgical equipment if deemed Medically Necessary. These items
may be bought rather than rented, with the cost not to exceed the fair market value of the
equipment at the time of purchase, but only if agreed to in advance by the Plan Administrator.
(h) Medically Necessary services for care and treatment of jaw joint conditions, including
Temporomandibular Joint syndrome.
(i) Laboratory studies.
G) Treatment of Mental Disorders and Substance Abuse. Covered charges for care, supplies and
treatment of Mental Disorders and Substance Abuse will be limited as follows:
All treatment is subject to the benefit payment maximums shown in the Schedule of Benefits.
Physician's visits are limited to one treatment per day.
Psychiatrists (M.D.), psychologists (Ph.D.), counselors (Ph.D.) or Masters of Social Work
(M.S.W.) may bill the Plan directly. Other licensed mental health practitioners must be under
the direction of and must bill the Plan through these professionals.
(k) Injury to or care of mouth, teeth and gums. Charges for Injury to or care of the mouth, teeth,
gums and alveolar processes will be Covered Charges under Medical Benefits only if that care is
for the following oral surgical procedures:
Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth.
Emergency repair due to Injury to sound natural teeth. Charges must occur within 24 months of
the accidental injury.
Surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor and roof of
the mouth.
Excision of benign bony growths of the jaw and hard palate.
External incision and drainage of cellulitis.
Incision of sensory sinuses, salivary glands or ducts.
Removal of impacted teeth.
Reduction of dislocations and excision of temporomandibular joints (TMjs).
No charge will be covered under Medical Benefits for dental and oral surgical procedures
involving orthodontic care of the teeth, and periodontal disease. Dentures and preparing the
mouth for the fitting of or continued use of dentures are not covered except for the following
conditions: if tooth loss is related to, or necessitated by medical treatment of a covered illness or
injury-
(1) Occupational therapy by a licensed occupational therapist. Therapy must be ordered by a
Physician, result from an Injury or Sickness and improve a body function. Covered expenses do
not include recreational programs, maintenance therapy or supplies used in occupational
therapy.
(m) Organ transplant limits. Charges otherwise covered under the Plan that are incurred for the
care and treatment due to an organ or tissue transplant are subject to these limits:
The transplant must be performed to replace an organ or tissue.
23
Charges for obtaining donor organs or tissues are Covered Charges under the Plan when the
recipient is a Covered Person. When the donor has medical coverage, his or her plan will pay
first. The benefits under this Plan will be reduced by those payable under the donor's plan.
Donor charges include those for:
evaluating the organ or tissue;
removing the organ or tissue from the donor; and
transportation of the organ or tissue from within the United States and Canada to the place
where the transplant is to take place.
(n) The initial purchase, fitting and repair of orthotic appliances such as braces, splints or other
appliances which are required for support for an injured or deformed part of the body as a result
of a disabling congenital condition or an Injury or Sickness.
(o) Physical therapy by a licensed physical therapist. The therapy must be in accord with a
Physician's exact orders as to type, frequency and duration and for conditions which are subject
to significant improvement through short-term therapy.
(p) Prescription Drugs (as defined).
(q) Routine Preventive Care. Covered charges under Medical Benefits are payable for routine
Preventive Care as described in the Schedule of Benefits.
Charges for Routine Well Adult Care. Routine well adult care is care by a Physician that is
not for an Injury or Sickness.
Charges for Routine Well Child Care. Routine well child care is routine care by a Physician
that is not for an Injury or Sickness.
(r) The initial purchase, fitting and repair of fitted prosthetic devices which replace body parts.
(s) Reconstructive Surgery. Correction of abnormal congenital conditions and reconstructive
mammoplasties will be considered Covered Charges.
This mammoplasty coverage will include reimbursement for:
(i) reconstruction of the breast on which a mastectomy has been performed,
(ii) surgery and reconstruction of the other breast to produce a symmetrical appearance, and
(iii) coverage of prostheses and physical complications during all stages of mastectomy,
including lymphedemas,
in a manner determined in consultation with the attending Physician and the patient.
(t) Speech therapy by a licensed speech therapist. Therapy must be ordered by a Physician and
follow either: (1) surgery for correction of a congenital condition of the oral cavity, throat or
nasal complex (other than a frenectomy) of a person; (ii) an Injury; or (iii) a Sickness that is
other than a learning or Mental Disorder.
(u) Spinal Manipulation/Chiropractic services by a licensed M.D., D.O. or D.C.
(v) Sterilization procedures.
24
(w) Surgical dressings, splints, casts and other devices used in the reduction of fractures and
dislocations.
(x) Coverage of Well Newborn Nursery/Pbysician Care.
Charges for Routine Nursery Care. Routine well newborn nursery care is care while the
newborn is Hospital -confined after birth and includes room, board and other normal care for
which a Hospital makes a charge.
This coverage is only provided if a parent is a Covered Person who was covered under the Plan
at the time of the birth and the newborn child is an eligible Dependent and is neither injured nor
in.
The benefit is limited to Usual and Reasonable Charges for nursery care for the first 5 days after
birth while the newborn child is Hospital confined as a result of the child's birth.
Charges for covered routine nursery care will be applied toward the Plan of the newborn child.
Group health plans generally may not, under Federal law, restrict benefits for any hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48
hours following a vaginal delivery, or less than 96 hours following a cesarean section. However,
Federal law generally does not prohibit the mother's or newborn's attending provider, after
consulting with the mother, from discharging the mother or her newborn earlier than 48 hours
(or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require
that a provider obtain authorization from the plan or the issuer for prescribing a length of stay
not in excess of 48 hours (or 96 hours).
Charges for Routine Physician Care. The benefit is limited to the Usual and Reasonable
Charges made by a Physician for routine pediatric care for the first 5 days after birth while the
newborn child is Hospital confined.
Charges for covered routine Physician care will be applied toward the Plan of the newborn
child.
(y) Diagnostic x-rays.
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COST MANAGEMENT SERVICES
Cost Management Services Phone Number
Please refer to the Employee ID card for the Cost Management Services phone number.
The patient or family member must call this number to receive certification of certain Cost Management Services.
This call must be made at least in advance of services being rendered or within 2 business days after an emergency.
Any reduced reimbursement due to failure to follow cost management procedures will not accrue toward the
100% maximum out-of-pocket payment.
UTILIZATION REVIEW
Utilization review is a program designed to help insure that all Covered Persons receive necessary and appropriate
health care while avoiding unnecessary expenses.
The program consists of:
(a) Precertification of the Medical Necessity for the following non -emergency services before
Medical and/or Surgical services are provided:
All outpatient IV therapies
Back surgery
Breast surgery
Bypass surgery
Cardiac catheterization
Cardiac pacemaker implant
Cataract removal
Chemotherapy
Cholecystectomy (removal of gall bladder)
Coronary arteriography
Dialysis
Dilation and curettage of uterus
Ear surgery
Facial and jaw surgery
Hemorrhoid removal
Hernia repair
Hip surgery
Home Health
Home infusion therapy
Hospice care
Hysterectomy (removal of uterus)
Knee surgery
Ligation & stripping of varicose veins
Mental illness treatment
Nose surgery
Prostatectomy
Serious mental illness treatment
Substance abuse treatment
Toe & foot surgery
Tonsillectomy and/or adenoidectomy
Transfers to another facility or transfers to or from a specialty unit within a facility
26
(b) Retrospective review of the Medical Necessity of the listed services provided on an emergency
basis;
(c) Concurrent review, based on the admitting diagnosis, of the listed services requested by the
attending Physician; and
(d) Certification of services and planning for discharge from a Medical Care Facility or cessation of
medical treatment.
The purpose of the program is to determine what charges may be eligible for payment by the Plan. This program is
not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician
or other health care provider.
If a particular course of treatment or medical service is not certified, it means that either the Plan will not pay for the
charges or the Plan will not consider that course of treatment as appropriate for the maximum reimbursement under
the Plan. The patient is urged to find out why there is a discrepancy between what was requested and what was
certified before incurring charges.
The attending Physician does not have to obtain precertification from the Plan for prescribing a maternity length of
stay that is 48 hours or less for a vaginal delivery or 96 hours or less for a cesarean delivery.
In order to maximize Plan reimbursements, please read the following provisions carefully.
Here's bow the program works.
Precertification. Before a Covered Person enters a Medical Care Facility on a non -emergency basis or receives other
listed medical services, the utilization review administrator will, in conjunction with the attending Physician, certify
the care as appropriate for Plan reimbursement. A non -emergency stay in a Medical Care Facility is one that can be
scheduled in advance.
The utilization review program is set in motion by a telephone call from the Covered Person or provider. Contact the
utilization review administrator at the telephone number on your ID card at least before services are scheduled to be
rendered with the following information:
- The name of the patient and relationship to the covered Employee
- The name, Social Security number and address of the covered Employee
- The name of the Employer
- The name and telephone number of the attending Physician
- The name of the Medical Care Facility, proposed date of admission, and proposed length of stay
- The diagnosis and/or type of surgery
- The proposed rendering of listed medical services
If there is an emergency admission to the Medical Care Facility, the patient, patient's family member, Medical Care
Facility or attending Physician must contact the utilization review administrator within 2 business days of the first
business day after the admission.
The utilization review administrator will determine the number of days of Medical Care Facility confinement or use
of other listed medical services authorized for payment. Failure to follow this procedure may reduce
reimbursement received from the Plan.
If the Covered Person does not receive authorization as explained in this section, the benefit payment will be
reduced by $250. This penalty will not apply when a Covered Person utilizes a Network Provider.
Concurrent review, discharge planning. Concurrent review of a course of treatment and discharge planning from a
Medical Care Facility are parts of the utilization review program. The utilization review administrator will monitor
the Covered Person's Medical Care Facility stay or use of other medical services and coordinate with the attending
27
Physician, Medical Care Facilities and Covered Person either the scheduled release or an extension of the Medical
Care Facility stay or extension or cessation of the use of other medical services.
If the attending Physician feels that it is Medically Necessary for a Covered Person to receive additional services or to
stay in the Medical Care Facility for a greater length of time than has been precertified, the attending Physician must
request the additional services or days.
SECOND AND/OR THIRD OPINION PROGRAM
Certain surgical procedures are performed either inappropriately or unnecessarily. In some cases, surgery is only one
of several treatment options. In other cases, surgery will not help the condition.
In order to prevent unnecessary or potentially harmful surgical treatments, the second and/or third opinion program
fulfills the dual purpose of protecting the health of the Plan's Covered Persons and protecting the financial integrity of
the Plan.
Benefits will be provided for a second (and third, if necessary) opinion consultation to determine the Medical
Necessity of an elective surgical procedure. An elective surgical procedure is one that can be scheduled in advance;
that is, it is not an emergency or of a life -threatening nature.
The patient may choose any board -certified specialist who is not an associate of the attending Physician and who is
affiliated in the appropriate specialty.
While any surgical treatment is allowed a second opinion, the following procedures are ones for which surgery is
often performed when other treatments are available.
Appendectomy
Cataract surgery
Cholecystectomy
(gall bladder removal)
Deviated septum
(nose surgery)
Hemorhoidectomy
Hernia surgery
Hysterectomy
Mastectomy surgery
Prostate surgery
Salpingo-oophorectomy
(removal of tubes/ovaries)
PREADMISSION TESTING SERVICE
Spinal surgery
Surgery to knee, shoulder, elbow
or toe
Tonsillectomy and adenoidectomy
Tympanotomy
(inner ear)
Varicose vein ligation
The Medical Benefits percentage payable will be for diagnostic lab tests and x-ray exams when:
(l) performed on an outpatient basis within seven days before a Hospital confinement;
(2) related to the condition which causes the confinement; and
(3) performed in place of tests while Hospital confined.
Covered charges for this testing will be payable at 80% for In -Network services and 60% for Out -of -Network
services even if tests show the condition requires medical treatment prior to Hospital confinement or the Hospital
confinement is not required.
28
CASE MANAGEMENT
Case Management is a program whereby a case manager monitors patients and explores, discusses and recommends
coordinated and/or alternate types of appropriate Medically Necessary care. The case manager consults with the
patient, the family and the attending Physician in order to develop a plan of care for approval by the patient's
attending Physician and the patient. This plan of care may include some or all of the following:
-- personal support to the patient;
-- contacting the family to offer assistance and support;
-- monitoring Hospital or Skilled Nursing Facility;
-- determining alternative care options; and
-- assisting in obtaining any necessary equipment and services.
Case Management occurs when this alternate benefit will be beneficial to both the patient and the Plan.
The case manager will coordinate and implement the Case Management program by providing guidance and
information on available resources and suggesting the most appropriate treatment plan. The Plan Administrator,
attending Physician, patient and patient's family must all agree to the alternate treatment plan.
Once agreement has been reached, the Plan Administrator will direct the Plan to reimburse for Medically Necessary
expenses as stated in the treatment plan, even if these expenses normally would not be paid by the Plan.
Note: Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient
and family choose not to participate.
Each treatment plan is individually tailored to a specific patient and should not be seen as appropriate or
recommended for any other patient, even one with the same diagnosis.
29
DEFINED TERMS
The following terms have special meanings and when used in this Plan will be capitalized.
Active Employee is an Employee who is on the regular payroll of the Employer and who has begun to perform the
duties of his or her job with the Employer on a full-time basis.
Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery, has a staff
of Physicians, has continuous Physician and nursing care by registered nurses (R.N.$) and does not provide for
overnight stays.
Birthing Center means any freestanding health facility, place, professional office or institution which is not a
Hospital or in a Hospital, where births occur in a home -like atmosphere. This facility must be licensed and operated
in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the facility is located.
The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide
care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse -midwife;
and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop
complications or require pre- or post -delivery confinement.
Calendar Year means January 1st through December 31st of the same year.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
Cosmetic Dentistry means dentally unnecessary procedures.
Covered Person is an Employee, Retiree or Dependent who is covered under this Plan.
Creditable Coverage includes most health coverage, such as coverage under a group health plan (including COBRA
continuation coverage), HMO membership, an individual health insurance policy, Medicaid or Medicare.
Creditable Coverage does not include coverage consisting solely of dental or vision benefits.
Custodial Care is care (including room and board needed to provide that care) that is given principally for personal
hygiene or for assistance in daily activities and can, according to generally accepted medical standards, be performed
by persons who have no medical training. Examples of Custodial Care are help in walking and getting out of bed;
assistance in bathing, dressing, feeding; or supervision over medication which could normally be self-administered.
Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of
such license.
Durable Medical Equipment means equipment which (a) can withstand repeated use, (b) is primarily and
customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of an Illness or
Injury and (d) is appropriate for use in the home.
Employee means a person who is an Active, regular Employee of the Employer, regularly scheduled to work for the
Employer in an Employee/Employer relationship. For the purposes of this Plan, City Councilmen will be considered
Employees of the Employer.
Employer is City of Lubbock.
Enrollment Date is the first day of coverage or, if there is a Waiting Period, the first day of the Waiting Period.
ERISA is the Employee Retirement Income Security Act of 1974, as amended.
30
Experimental and/or Investigational means services, supplies, care and treatment which does not constitute
accepted medical practice properly within the range of appropriate medical practice under the standards of the case
and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical and dental
community or government oversight agencies at the time services were rendered.
The Plan Administrator must make an independent evaluation of the experimental/nonexperimental standings of
specific technologies. The Plan Administrator shall be guided by a reasonable interpretation of Plan provisions. The
decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim
and the proposed treatment. The decision of the Plan Administrator will be final and binding on the Plan. The Plan
Administrator will be guided by the following principles:
(1) if the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug
Administration and approval for marketing has not been given at the time the drug or device is furnished;
or
(2) if the drug, device, medical treatment or procedure, or the patient informed consent document utilized
with the drug, device, treatment or procedure, was reviewed and approved by the treating facility's
Institutional Review Board or other body serving a similar function, or if federal law requires such
review or approval; or
(3) if Reliable Evidence shows that the drug, device, medical treatment or procedure is the subject of
on -going phase I or phase II clinical trials, is the research, experimental, study or Investigational arm of
on -going phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose,
its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or
diagnosis; or
(4) if Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device,
medical treatment or procedure is that further studies or clinical trials are necessary to determine its
maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard
means of treatment or diagnosis.
Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature;
the written protocol or protocols used by the treating facility or the protocol (s) of another facility studying
substantially the same drug, service, medical treatment or procedure; or the written informed consent used by the
treating facility or by another facility studying substantially the same drug, device, medical treatment or procedure.
Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved
by the Food and Drug Administration for general use.
Family Unit is the covered Employee or Retiree and the family members who are covered as Dependents under the
Plan.
Foster Child means an unmarried child under the limiting age shown in the Dependent Eligibility Section of this
Plan for whom a covered Employee has assumed a legal obligation. All of the following conditions must be met: the
child is being raised as the covered Employee's; the child depends on the covered Employee for primary support; the
child lives in the home of the covered Employee; and the covered Employee may legally claim the child as a federal
income tax deduction.
A covered Foster Child is not a child temporarily living in the covered Employee's home; one placed in the covered
Employee's home by a social service agency which retains control of the child; or whose natural parent(s) may
exercise or share parental responsibility and control.
Genetic Information means information about genes, gene products and inherited characteristics that may derive
from an individual or a family member. This includes information regarding carrier status and information derived
from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations,
family histories and direct analysis of genes or chromosomes.
31
Home Health Care Agency is an organization that meets all of these tests: its main function is to provide Home
Health Care Services and Supplies; it is federally certified as a Home Health Care Agency; and it is licensed by the
state in which it is located, if licensing is required.
Home Health Care Plan must meet these tests: it must be a formal written plan made by the patient's attending
Physician which is reviewed at least every 30 days; it must state the diagnosis; it must certify that the Home Health
Care is in place of Hospital confinement; and it must specify the type and extent of Home Health Care required for
the treatment of the patient.
Home Health Care Services and Supplies include: part-time or intermittent nursing care by or under the supervision
of a registered nurse (R.N.); part-time or intermittent home health aide services provided through a Home Health Care
Agency (this does not include general housekeeping services); physical, occupational and speech therapy; medical
supplies; and laboratory services by or on behalf of the Hospital.
Hospice Agency is an organization where its main function is to provide Hospice Care Services and Supplies and it is
licensed by the state in which it is located, if licensing is required.
Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice Agency and
supervised by a Physician.
Hospice Care Services and Supplies are those provided through a Hospice Agency and under a Hospice Care Plan
and include inpatient care in a Hospice Unit or other licensed facility, home care, and family counseling during the
bereavement period.
Hospice Unit is a facility or separate Hospital Unit, that provides treatment under a Hospice Care Plan and admits at
least two unrelated persons who are expected to die within six months.
Hospital is an institution which is engaged primarily in providing medical care and treatment of sick and injured
persons on an inpatient basis at the patient's expense and which fully meets these tests: it is accredited as a Hospital
by the joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association
Healthcare Facilities Accreditation Program; it is approved by Medicare as a Hospital; it maintains diagnostic and
therapeutic facilities on the premises for surgical and medical diagnosis and treatment of sick and injured persons by
or under the supervision of a staff of Physicians; it continuously provides on the premises 24-hour-a-day nursing
services by or under the supervision of registered nurses (R.N.$); and it is operated continuously with organized
facilities for operative surgery on the premises.
The definition of "Hospital" shall be expanded to include the following:
A facility operating legally as a psychiatric Hospital or residential treatment facility for mental health
and licensed as such by the state in which the facility operates.
A facility operating primarily for the treatment of Substance Abuse if it meets these tests: maintains
permanent and full-time facilities for bed care and full-time confinement of at least 15 resident patients;
has a Physician in regular attendance; continuously provides 24-hour a day nursing service by a
registered nurse (R.N.); has a full-time psychiatrist or psychologist on the staff; and is primarily engaged
in providing diagnostic and therapeutic services and facilities for treatment of Substance Abuse.
Illness means a bodily disorder, disease, physical sickness or Mental Disorder. Illness includes Pregnancy, childbirth,
miscarriage or complications of Pregnancy.
Injury means an accidental physical Injury to the body caused by unexpected external means.
Intensive Care Unit is defined as a separate, clearly designated service area which is maintained within a Hospital
. solely for the care and treatment of patients who are critically ill. This also includes what is referred to as a "coronary
care unit" or an "acute care unit." It has: facilities for special nursing care not available in regular rooms and wards of
the Hospital; special life saving equipment which is immediately available at all times; at least two beds for the
32
accommodation of the critically ill; and at least one registered nurse (R.N.) in continuous and constant attendance 24
hours a day.
Late Enrollee means a Plan Participant who enrolls under the Plan other than during the fast 31-day period in which
the individual is eligible to enroll under the Plan or during a Special Enrollment Period.
Legal Guardian means a person recognized by a court of law as having the duty of taking care of the person and
managing the property and rights of a minor child.
Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations. Lifetime is understood
to mean while covered under this Plan. Under no circumstances does Lifetime mean during the lifetime of the
Covered Person.
Medical Care Facility means a Hospital, a facility that treats one or more specific ailments or any type of Skilled
Nursing Facility.
Medical Emergency means a sudden onset of a condition with acute symptoms requiring immediate medical care
and includes such conditions as heart attacks, cardiovascular accidents, poisonings, loss of consciousness or
respiration, convulsions or other such acute medical conditions.
Medically or Dentally Necessary care and treatment is recommended or approved by a Physician or Dentist; is
consistent with the patient's condition or accepted standards of good medical and dental practice; is medically proven
to be effective treatment of the condition; is not performed mainly for the convenience of the patient or provider of
medical and dental services; is not conducted for research purposes; and is the most appropriate level of services
which can be safely provided to the patient.
All of these criteria must be met; merely because a Physician recommends or approves certain care does not mean
that it is Medically Necessary.
The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary.
Medicare is the Health Insurance For The Aged and Disabled program under Title XVIII of the Social Security Act,
as amended.
Mental Disorder means any disease or condition, regardless of whether the cause is organic, that is classified as a
Mental Disorder in the current edition of International Classification of Diseases, published by the U.S. Department
of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental
Disorders, published by the American Psychiatric Association.
Morbid Obesity is a diagnosed condition in which the body weight exceeds the medically recommended weight by
either 100 pounds or is twice the medically recommended weight for a person of the same height, age and mobility as
the Covered Person.
No -Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining
fault in connection with automobile accidents.
Outpatient Care and/or Services is treatment including services, supplies and medicines provided and used at a
Hospital under the direction of a Physician to a person not admitted as a registered bed patient; or services rendered in
a. Physician's office, laboratory or X-ray facility, an Ambulatory Surgical Center, or the patient's home.
Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.),
Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed
Professional Counselor, Licensed Professional Physical Therapist, Master of Social Work (M.S.W.), Midwife,
Occupational Therapist, Optometrist (O.D.), Physiotherapist, Psychiatrist, Psychologist (Ph.D.), Speech Language
Pathologist and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency
and is acting within the scope of his or her license.
33
Plan means City of Lubbock Employee Benefit Plan, which is a benefits plan for certain employees of City of
Lubbock and is described in this document.
Plan Administrator is the City of Lubbock
Plan Participant is any Employee, Retiree or Dependent who is covered under this Plan.
Plan Year is the 12-month period beginning on either the effective date of the Plan or on the day following the end of
the first Plan Year which is a short Plan Year.
A Pre -Existing Condition is a condition for which medical advice, diagnosis, care or treatment was recommended or
received within six months prior to the person's Enrollment Date under this Plan. Genetic Information is not a
condition. Treatment includes receiving services and supplies, consultations, diagnostic tests or prescribed medicines.
In order to be taken into account, the medical advice, diagnosis, care or treatment must have been recommended by,
or received from, a Physician.
The Pre -Existing Condition does not apply to pregnancy, to a newborn child who is covered under this Plan within 31
days of birth, or to a child who is adopted or placed for adoption before attaining age 18 and who, as of the last day of
the 31-day period beginning on the date of the adoption or placement for adoption, is covered under this Plan. A Pre -
Existing Condition exclusion may apply to coverage before the date of the adoption or placement for adoption.
The prohibition on Pre -Existing Condition exclusion for newborn, adopted, or pre -adopted children does not apply to
an individual after the end of the first 63-day period during all of which the individual was not covered under any
Creditable Coverage.
Pregnancy is childbirth and conditions associated with Pregnancy, including complications.
Preferred Provider Organization/PPO/Network Provider means a group of medical providers who, as a group or
individually, agree to provide services or treatment to Covered Persons under the Plan at negotiated rates as a cost
containment measure for the Employer and participating Employees. Contact the Plan Administrator for current name
and address of participating providers.
Prescription Drug means any of the following: a Food and Drug Administration -approved drug or medicine which,
under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription";
injectable insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed
Physician. Such drug must be Medically Necessary in the treatment of a Sickness or Injury.
Serious Mental Illness means any of the eight major diagnostic categories; schizophrenia. Paranoid and other
psychotic disorders, Bipolar disorders, Major depressive disorders, and Schizo -affective disorders, Pervasive
developmental disorders, Obsessive -Compulsive disorders, and Depression in childhood and adolescence.
Retired Employee is a former Active Employee of the Employer who was retired while employed by the Employer
under the formal written plan of the Employer and elects to contribute to the Plan the contribution required from the
Retired Employee. A Retired Employee must be eligible to retire under the Texas Municipal Retirement System or
the Firemen's Relief and Retirement Fund and be employed by the Employer for five (5) consecutive years; or be
approved for disability retirement under the Texas Municipal Retirement System or Firemen's Relief and Retirement
Fund. Eligible to retire means eligible to draw an annuity from the Texas Municipal Retirement System or the
Firemen's Relief and Retirement Fund at the time of termination from the Employer. Members of the City Council
will be considered a Retired Employee if they have served in -office for at least five (5) years.
Sickness is a person's Illness, disease or Pregnancy (including complications).
34
Skilled Nursing Facility is a facility that fully meets all of these tests:
(1) It is licensed to provide professional nursing services on an inpatient basis to persons convalescing from
Injury or Sickness. The service must be rendered by a registered nurse (R.N.) or by a licensed practical
nurse (L.P.N.) under the direction of a registered nurse. Services to help restore patients to self -care in
essential daily living activities must be provided.
(2) Its services are provided for compensation and under the full-time supervision of a Physician.
(3) It provides 24 hour per day nursing services by licensed nurses, under the direction of a full-time
registered nurse.
(4) It maintains a complete medical record on each patient.
(5) It has an effective utilization review plan.
(6) It is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, mental retardates,
Custodial or educational care or care of Mental Disorders.
(7) It is approved and licensed by Medicare.
This term also applies to charges incurred in a facility referring to itself as an extended care facility, convalescent
nursing home, rehabilitation hospital, long-term acute care facility or any other similar nomenclature.
Spinal Manipulation/Chiropractic Care means skeletal adjustments, manipulation or other treatment in connection
with the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human
body. Such treatment is done by a Physician to remove nerve interference resulting from, or related to, distortion,
misalignment or subluxation of, or in, the vertebral column.
Substance Abuse is regular excessive compulsive drinking of alcohol and/or physical habitual dependence on drugs.
This does not include dependence on tobacco and ordinary caffeine -containing drinks.
Temporomandibular Joint (TMJ) syndrome is the treatment of jaw joint disorders including conditions of structures
linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the temporomandibular
joint. Care and treatment shall include, but are not limited to orthodontics, crowns, inlays, physical therapy and any
appliance that is attached to or rests on the teeth.
Total Disability (Totally Disabled) means: In the case of a Dependent child, the complete inability as a result of
Injury or Sickness to perform the normal activities of a person of like age and sex in good health.
Usual and Reasonable Charge is a charge which is not higher than the usual charge made by the provider of the care
or supply and does not exceed the usual charge made by most providers of like service in the same area. This test will
consider the nature and severity of the condition being treated. It will also consider medical complications or unusual
circumstances that require more time, skill or experience.
The Plan will reimburse the actual charge billed if it is less than the Usual and Reasonable Charge.
The Plan Administrator has the discretionary authority to decide whether a charge is Usual and Reasonable.
35
PLAN EXCLUSIONS
Note: All exclusions related to Dental are shown in the Dental Plan.
For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:
(1) Abortion. Services, supplies, care or treatment in connection with an abortion unless the life of the
mother is endangered or when medically required.
(2) Acupuncture. Charges for acupuncture or acupressure treatment.
(3) Adolescent Behavior Disorders. Any services or supplies provided for the treatment of adolescent
behavior disorders, including conduct disorders and oppositional disorders.
(4) Artificial Insemination. Charges for artificial insemination
(5) Chelation Therapy. services or supplies rendered to any Covered Person as, or in conjunction with,
chelation therapy, except for the treatment of acute metal poisoning.
(6) Complications of non -covered treatments. Care, services or treatment required as a result of
complications from a treatment not covered under the Plan are not covered. Complications from a non -
covered abortion are covered.
(7) Cosmetic Surgery. Charges incurred as a result of or in relation to cosmetic surgery.
(S) Custodial care. Services or supplies provided mainly as a rest cure, maintenance or Custodial Care.
(9) Educational or vocational testing. Services for educational or vocational testing or training.
(10) Environmental Sensitivity. Services or supplies rendered to any Covered Person primarily for:
Environmental Sensitivity testing or treatment
Clinical Ecology testing or treatment; or
Inpatient allergy testing or treatment;
(11) Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is in excess
of the Usual and Reasonable Charge.
(12) Exercise programs. Exercise programs for treatment of any condition, except for Physician -supervised
cardiac rehabilitation, occupational or physical therapy covered by this Plan.
(13) Experimental or not Medically Necessary. Carle and treatment that is either
ExperimentalMvestigational or not Medically Necessary.
(14) Eye care. Radial keratotomy or other eye surgery to correct refractive disorders. Also, routine eye
examinations, including refractions, lenses for the eyes and exams for their fitting. This exclusion does
not apply to aphakic patients and soft lenses or sclera shells intended for use as corneal bandages or as
may be covered under the well adult or well child sections of this Plan.
(15) Foot care. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgla or bunions
(except open cutting operations), and treatment of corns, calluses or toenails (unless needed in treatment
of a metabolic or peripheral -vascular disease). A fungal (mycotic) infection of the toenail will be covered
if there is:
36
Clinical evidence of mycosis of the toenail;
Medical evidence that the patient has a marked limitation of ambulation requiring active
treatment of the foot or, in the case of a non -ambulatory patient, has a condition that is
likely to result in significant medical complications in the absence of such treatment; and
Excision of a nail without using an injectable or general anesthetic.
(1 t7 Foreign travel. Care, treatment or supplies out of the U.S. if travel is for the sole purpose of obtaining
medical services.
(17) Government coverage. Care, treatment or supplies furnished by a program or agency funded by any
government. This does not apply to Medicaid or when otherwise prohibited by law.
(18) Hair loss. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair
growth, whether or not prescribed by a Physician.
(19) Hearing aids and exams. Charges for services or supplies in connection with hearing aids or exams for
their fitting, except as may be listed as covered in the schedule of benefits this Plan.
(20) Hospital employees. Professional services billed by a Physician or nurse who is an employee of a
Hospital or Skilled Nursing Facility and paid by the Hospital or facility for the service.
(21) Illegal drugs or medications. Services, supplies, care or treatment to a Covered Person for Injury or
Sickness resulting from thavCovered Person's voluntary taking of or being under the influence of any
controlled substance, drug, hallucinogen or narcotic not administered on the advice of a Physician.
Expenses will be covered for Injured Covered Persons other than the person using controlled substances
and expenses will be covered for Substance Abuse treatment as specified in this Plan. This exclusion
does not apply if the Injury resulted from an act of domestic violence or a medical (including both
physical and mental health) condition.
(22) Impotence. Care, treatment, services, supplies or medication in connection with treatment for impotence
unless to be determined to be organic or because the condition is the result of an injury or use of a
prescribed medication.
(23) Infertility. Care, supplies, services and treatment for infertility, artificial insemination, or in vitro
fertilization.
(24) No charge. Care and treatment for which there would not have been:a charge if no coverage had been in
force.
(25) Non -emergency Hospital admissions. Care and treatment billed by a Hospital for non -Medical
Emergency admissions on a Friday or a Saturday. This does not apply if surgery is performed within 24
hours of admission.
(26) Non-prescription drugs. Charges for non-prescription drugs, vitamins, nutritional supplements, or
special diets.
(Yn No obligation to pay. Charges incurred for which the Plan has no legal obligation to pay.
(28) No Physician recommendation. Care, treatment, services or supplies not recommended and approved
by a Physician; or treatment, services or supplies when the Covered Person is not under the regular care
of a Physician. Regular care means ongoing medical supervision or treatment which is appropriate care
for the Injury or Sickness.
(29) Not specified as covered. Non-traditional medical services, treatments and supplies which are not
specified as covered under this Plan.
37
(30) Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a
part of the treatment plan for another Sickness.
(31) Occupational. Care and treatment of an Injury or Sickness that is occupational -- that is, arises from
work for wage or profit including self-employment
(32) Personal comfort items. Personal comfort items or other equipment, such as, but not limited to, air
conditioners, air -purification units, humidifiers, electric heating units, orthopedic mattresses, blood
pressure instruments, scales, elastic bandages or stockings, nonprescription drugs and medicines, and
first -aid supplies and nonhospital adjustable beds.
(33) Plan design excludes. Charges excluded by the Plan design as mentioned in this document
(34) Relative giving services. Professional services performed by a person who ordinarily resides in the
Covered Person's home or is related to the Covered Person as a Spouse, parent, child, brother or sister,
whether the relationship is by blood or exists in law.
(35) Replacement braces. Replacement of braces of the leg, arm, back, neck, or artificial arms or legs, unless
there is sufficient change in the Covered Person's physical condition to make the original device no
longer functional.
(36) Routine care. Charges for routine or periodic examinations, screening examinations, evaluation
procedures, preventive medical care, or treatment or services not directly related to the diagnosis or
treatment of a specific Injury, Sickness or pregnancy -related condition which is known or reasonably
suspected, unless such care is specifically covered in the Schedule of Benefits.
(37) Services before or after coverage. Care, treatment or supplies for which a charge was incurred before a
person was Covered under this Plan or after coverage ceased under this Plan.
(38) Sex changes. Care, services or treatment for non -congenital transsexualism, gender dysphorla or sexual
reassignment or change. This exclusion includes medications, implants, hormone therapy, surgery,
medical or psychiatric treatment.
(39) Sleep disorders. Care and treatment for sleep disorders unless deemed Medically Necessary.
(40) Social Services. Charges for any medical social services, except as provided for under Hospice Care
services.
(41) Smoking cessation. Care and treatment for smoking cessation programs, including smoking deterrent
patches, unless Medically Necessary due to a severe active lung Illness such as emphysema or asthma.
(42) Surgical sterilization reversal. Care and treatment for reversal of surgical sterilization.
(43) TMJ. Any treatment of the temporomandibular (jaw) joint, or jaw related neuromuscular conditions with
oral appliances or splints, physical therapy, or alteration of the occlusal relationship of the teeth or jaws
to eliminate pain or dysfunction of the temporomandibular joint and all adjacent muscles and nerves
after the Covered Person's 19'h birthday. Orthognathic surgery for treatment of temporomandibular joint
disorders and conditions of temporomandibular joint disorders will still be eligible for coverage after the
Covered Person's 19u' birthday.
(44) Travel or accommodations. Charges for travel or accommodations, whether or not recommended by a
Physician, except for ambulance charges as defined as a covered expense.
(45) War. Any loss that is due to a declared or undeclared act of war.
38
DENTAL BENEFITS
This benefit applies when covered dental charges are incurred by a person while covered under this Plan.
DEDUCTIBLE '
Deductible Amount. This is an amount of dental charges for which no benefits will be paid. Before benefits can be
paid in a Calendar Year, a Covered Person must meet the deductible shown in the Schedule of Benefits.
Deductible Three Month Carryover. Covered expenses incurred in, and applied toward the individual deductible in
October, November and December will be applied toward the individual deductible in the next Calendar Year.
Family Unit Limit. When the dollar amount shown in the Schedule of Benefits has been incurred by
members of a Family Unit toward their Calendar Year deductibles, the deductibles of all members of that
Family Unit will be considered satisfied for that year.
BENEFIT PAYMENT
Each Calendar Year benefits will be paid to a Covered Person for the dental charges in excess of the deductible
amount. Payment will be made at the rate shown under Dental Percentage Payable in the Schedule of Benefits. No
benefits will be paid in excess of the Maximum Benefit Amount.
MAXIMUM BENEFIT AMOUNT
The Maximum dental benefit amount is shown in the Schedule of Benefits.
DENTAL CHARGES
Dental charges are the Usual and Reasonable Charges made by a Dentist or other Physician for necessary care,
appliances or other dental material,listed as a covered dental service.
A dental charge is incurred on the date the service or supply for which it is made is performed or furnished. However,
there are times when one overall charge is made for all or part of a course of treatment. In this case, the Claims
Supervisor will apportion that overall charge to each of the separate visits or treatments. The pro rata charge will be
considered to be incurred as each visit or treatment is completed.
COVERED DENTAL SERVICES
Class A Services:
Preventive and Diagnostic Dental Procedures
The limits on Class A services are for routine services. If dental need is present, this Plan will consider for
reimbursement services performed more frequently than the limits shown.
(1) Routine oral exams. Limit of 2 per Covered Person each 12 months.
(2) • Professional cleaning. Limit of 2 per Covered Person each 12 months.
(3) One bitewing x-ray series every 6 months.
(4) One full mouth x-ray every 36 months.
(5) Two fluoride treatments for covered Dependent children under age 19 each 12 months.
(6) Emergency palliative treatment for pain.
39
(7) Sealants on the occlusal surface of a permanent posterior tooth (once per Lifetime per tooth) for
Dependent children under age 14.
Class B Services:
Basic Dental Procedures
(1) Dental x-rays not included in Class A.
(2) Oral surgery. Oral surgery is limited to removal of teeth, preparation of the mouth for dentures and
removal of tooth -generated cysts of less than 1/4 inch.
(3) Periodontics (gum treatments).
(4) Endodontics (root canals).
(5) Extractions. This service includes local anesthesia and routine post -operative care.
(6) Space maintainers for Covered Persons under 19 years of age.
(7) Recementing bridges, crowns or inlays.
(8) Fillings, other than gold.
(9) General anesthetics, upon demonstration of Medical Necessity.
(10) Antibiotic drugs.
Class C Services:
Major Dental Procedures
(1) Gold restorations, including inlays, onlays and foil fillings. The cost of gold restorations in excess of the
cost for amalgam, synthetic porcelain or plastic materials will be included only when the teeth must be
restored with gold.
(2) Installation of crowns.
(3) Installing precision attachments for removable dentures.
(4) Installing partial, full or removable dentures to replace one or more natural teeth. This service also
includes all adjustments made during 6 months following the installation.
(5) Addition of clasp or rest to existing partial removable dentures.
(6) Initial installation of fixed bridgework to replace one or more natural teeth.
(7) Repair of crowns, bridgework and removable dentures.
(8) Rebasing or relining of removable dentures. Limit 1 service every 36 months.
(9) Replacing an existing removable partial or full denture or fixed bridgework; adding teeth to an existing
removable partial denture; or adding teeth to existing bridgework to replace newly extracted natural
teeth. However, this item will apply only if one of these tests is met:
(a) The existing denture or bridgework was installed at least five years prior to its replacement and
cannot currently be made serviceable.
40
(b) The existing denture is of an immediate temporary nature. Further, replacement by permanent
dentures is required and must take place within 12 months from the date the temporary denture
was installed.
Class D Services:
Orthodontic Treatment and Appliances
This is treatment to move teeth by means of appliances to correct a handicapping malocclusion of the mouth.
These services are available for Covered Persons under age 25 and include preliminary study, including x-rays,
diagnostic casts and treatment plan, active treatments and retention appliance.
Payments for comprehensive full -banded orthodontic treatments are made in installments.
PREDETERMINATION OF BENEFITS
Before starting a dental treatment for which the charge is expected to be $300 or more, a predetermination of benefits
form must be submitted.
A regular dental claim form is used for the predetermination of benefits. The covered Employee fills out the
Employee section of the form and then gives the form to the Dentist.
The Dentist must itemize all recommended services and costs and attach all supporting x-rays to the form.
The Dentist should send the form to the Claims Supervisor at this address:
ICON Benefit Administrators
P.O. Box 53070
Lubbock, Texas 79453
1-800-658-9777
The Claims Supervisor will notify the Dentist of the benefits payable under the Plan. The Covered Person and the
Dentist can then decide on the course of treatment, knowing in advance how much the Plan will pay.
If a description of the procedures to be performed, x-rays and an estimate of the Dentist's fees are not submitted in
advance, the Plan reserves the right to make a determination of benefits payable taking into account alternative
procedures, services or courses of treatment, based on accepted standards of dental practice. If verification of
necessity of dental services cannot reasonably be made, the benefits may be for a lesser amount than would otherwise
have been payable.
ALTERNATE TREATMENT
Many dental conditions can be treated in more than one way. This Plan has an "alternate treatment" clause which
governs the amount of benefits the Plan will pay for treatments covered under the Plan. If a patient chooses a more
expensive treatment than is needed to correct a dental problem according to accepted standards of dental practice, the
benefit payment will be based on the cost of the treatment which provides professionally satisfactory results at the
most cost-effective level.
For example, if a regular amalgam filling is sufficient to restore a tooth to health, and the patient and the Dentist
decide to use a gold filling, the Plan will base its reimbursement on the Usual and Reasonable Charge for an amalgam
filling. The patient will pay the difference in cost
41
EXCLUSIONS
A charge for the following is not covered:
(1) Administrative costs. Administrative costs of completing claim forms or reports or for providing dental
records.
(2) Broken appointments. Charges for broken or missed dental appointments.
(3) Crowns. Crowns for teeth that are restorable by other means or for the purpose of Periodontal Splinting.
(4) Excluded under Medical. Services that are excluded under Medical Plan Exclusions.
(5) Hygiene. Oral hygiene, plaque control programs or dietary instructions.
(6) Implants. Implants, including any appliances and/or crowns and the surgical insertion or removal of
implants.
(7) Medical services. Services that, to any extent, are payable under any medical expense benefits of the
Plan.
(8) No listing. Services which are not included in the list of covered dental services.
(9) Orthognathic surgery. Surgery to correct malpositions in the bones of the jaw.
(10) Personalization. Personalization of dentures.
(11) Replacement. Replacement of lost or stolen appliances.
(12) Splinting. Crowns, fillings or appliances that are used to connect (splint) teeth, or change or alter the
way the teeth meet, including altering the vertical dimension, restoring the bite (occlusion) or are
cosmetic.
42
HOW TO SUBMIT A CLAIM
Benefits under this Plan shall be paid only if the Plan Administrator decides in its discretion that a
Covered Person is entitled to them.
When a Covered Person has a Claim to submit for payment that person must:
(1) Obtain and complete a group claim transmittal form from the Personnel Office or the Plan Administrator.
(2) Complete the Employee portion of the form. ALL QUESTIONS MUST BE ANSWERED.
(3) Have the Physician or Dentist complete the provider's portion of the form.
(4) For Plan reimbursements, attach bills for services rendered. ALL BILLS MUST SHOW:
- Name of Plan
- Employee's name
- Name of patient
- Name, address, telephone number of the provider of care
- Diagnosis
- Type of services rendered, with diagnosis and/or procedure codes
- Date of services
- Charges
(5) Send the above to the Claims Supervisor at this address:
ICON Benefit Administrators
P.O. Box 53070
Lubbock, Texas 79453
1-800-658-9777
WHEN CLAIMS SHOULD BE FILED
Claims should be filed with the Claims Supervisor within 90 days of the date charges for the service were incurred.
Benefits are based on the Plan's provisions at the time the charges were incurred. Claims filed later than that date may
be declined or reduced unless:
(a) it's not reasonably possible to submit the claim in that time
The Claims Supervisor will determine if enough information has been submitted to enable proper consideration of the
claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan
Participant seek a second medical opinion.
CLAIMS PROCEDURE
Following is a description of how the Plan processes Claims for benefits. A Claim is defined as any request for a Plan
benefit, made by a claimant or by a representative of a claimant, that complies with the Plan's reasonable procedure
for making benefit Claims. The times listed are maximum times only. A period of time begins at the time the Claim is
filed. Decisions will be made within a reasonable period of time appropriate to the circumstances. "Days" means
calendar days.
There are different kinds of Claims and each one has a specific timetable for either approval, payment, request for
further information, or denial of the Claim. If you have any questions regarding this procedure, please contact the
Plan Administrator.
43
The definitions of the types of Claims are:
Urgent Care Claim
A Claim involving Urgent Care is any Claim for medical care or treatment where using the timetable for a non -
urgent care determination could seriously jeopardize the life or health of the claimant; or the ability of the claimant to
regain maximum function; or in the opinion of the attending or consulting Physician, would subject the claimant to
severe pain that could not be adequately managed without the care or treatment that is the subject of the Claim.
A Physician with knowledge of the claimant's medical condition may determine if a Claim is one involving Urgent
Care. If there is no such Physician, an individual acting on behalf of the Plan applying the judgment of a prudent
layperson who possesses an average knowledge of health and medicine may make the determination.
In the case of a Claim involving Urgent Care, the following timetable applies.
Notification to claimant of benefit determination 1
72 hours
Insufficient information on the Claim, or failure to follow the Plan's
procedure for filing a Claim:
Notification to claimant, orally or in writing
24 hours
Response by claimant, orally or in writing
48 hours
Benefit determination, orally or in writing
48 hours
Ongoing courses of treatment, notification of:
Reduction or termination before the end of treatment
72 hours
Determination as to extending course bf treatment
24 hours
If there is an adverse benefit determination on a Claim involving Urgent Care, a request for an expedited appeal may
be submitted orally or in writing by the claimant. All necessary information, including the Plan's benefit
determination on review, may be transmitted between the Plan and the claimant by telephone, facsimile, or other
similarly expeditious method.
Pre -Service Claim
A Pre -Service Claim means any Claim for a benefit under this Plan where the Plan conditions receipt of the benefit,
in whole or in part, on approval in advance of obtaining medical care. These are, for example, Claims subject to pre -
certification. Please see the Cost Management section of this booklet for further information about Pre -Service
Claims.
In the case of a Pre -Service Claim, the following timetable applies:
Notification to claimant of benefit determination 15 days
Extension due to matters beyond the control of the Plan 15 days
Insufficient information on the Claim:
Notification of 15 days
Response by claimant 45 days
Notification, orally or in writing, of failure to follow the 5 days
44
Plan's procedures for filing a Claim
Ongoing courses of treatment:
Reduction or termination before the end of the treatment
Request to extend course of treatment
Review of adverse benefit determination
Reduction or termination before the end of the treatment
Request to extend course of treatment
Post -Service Claim
15 days
15 days
15 days per benefit appeal
15 days
15 days
A Post -Service Claim means any Claim for a Plan benefit that is not a Claim involving Urgent Care or a Pre -Service
Claim; in other words, a Claim that is a request for payment under the Plan for covered medical services already
received by the claimant.
In the case of a Post -Service Claim, the following timetable applies:
Notification tb claimant of benefit determination 30 days
Extension due to matters beyond the -control of the Plan 15 days
Extension due to insufficient information on the Claim 15 days
Response by claimant following notice of insufficient 45 days
information
Review of adverse benefit determination 30 days per benefit appeal
Notice to claimant of adverse benefit determinations
Except with Urgent Care Claims, when the notification may be orally followed by written or electronic notification
within three days of the oral notification, the Plan Administrator shall provide written or electronic notification of any
adverse benefit determination. The notice will state, in a manner calculated to be understood by the claimant:
(1) The specific reason or reasons for the adverse determination. }
(2) Reference to the specific Plan provisions on which the determination was based.
(3) A description of any additional material or information necessary for the claimant to perfect the Claim
and an explanation of why such material or information is necessary.
(4) A description of the Plan's review procedures and the time limits applicable to such procedures. This will
include a statement of the claimant's right to bring a civil action under section 502 of ERISA following
an adverse benefit determination on review.
(5) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to,
and copies of, all documents, records, and other information relevant to the Claim.
(6) If the adverse benefit determination was based on an internal rule, guideline, protocol, or other similar
criterion, the specific rule, guideline, protocol, or criterion will be provided free of charge. If this is not
practical, a statement will be included that such a rule, guideline, protocol, or criterion was relied upon in
45
making the adverse benefit determination and a copy will be provided free of charge to the claimant
upon request
() If the adverse benefit determination is based on the Medical Necessity or Experimental or Investigational
treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to the claimant's medical circumstances, will be provided.
If this is not practical, a statement will be included that such explanation will be provided free of charge,
upon request
Appeals
When a claimant receives an adverse benefit determination, the claimant has 180 days following receipt of the
notification in which to appeal the decision. A claimant may submit written comments, documents, records, and other
information relating to the Claim. If the claimant so requests, he or she will be provided, free of charge, reasonable
access to, and copies of, all documents, records, and other information relevant to the Claim.
The period of time within which a benefit determination on review is required to be made shall begin at the time an
appeal is filed in accordance with the procedures of the Plan. This timing is without regard to whether all the
necessary information accompanies the filing.
A document, record, or other information shall be considered relevant to a Claim if it:
(1) was relied upon in making the benefit determination;
(2) was submitted, considered, or generated in the course of making the benefit determination, without
regard to whether it was relied upon in making the benefit determination;
(3) demonstrated compliance with the administrative processes and safeguards designed to ensure and to
verify that benefit determinations are made in accordance with Plan documents and Plan provisions have
been applied consistently with respect to all claimants; or
(4) constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment
option or benefit
The review shall take into account all comments, documents, records, and other information submitted by the
claimant relating to the Claim, without regard to whether such information was submitted or considered in the initial
benefit determination. The review will not afford deference to the initial adverse benefit determination and will be
conducted by a fiduciary of the Plan who is neither the individual who made the adverse determination nor a
subordinate of that individual:'
If the determination was based on a medical judgment, including determinations with regard to whether a particular
treatment, drug, or other item is Experimental, Investigational, or not Medically Necessary or appropriate, the
fiduciary shall consult with a health care professional who was not involved in the original benefit determination.
This health care professional will have appropriate training and experience in the field of medicine involved in the
medical judgment. Additionally, medical or vocational experts whose advice was obtained on behalf of the Plan in
connection with the initial determination will be identified.
46
COORDINATION OF BENEFTTS
Coordination of the benefit plans. Coordination of benefits sets out rules for the order of payment of Covered
Charges when two or more plans -- including Medicare -- are paying. When a Covered Person is covered by this Plan
and another plan, or the Covered Person's Spouse is covered by this Plan and by another plan or the couple's Covered
children are covered under two or more plans, the plans will coordinate benefits when a claim is received.
The plan that pays first according to the rules will pay as if there were no other plan involved. The secondary and
subsequent plans will pay the balance due up to 100% of the total allowable expenses.
Benefit plan. This provision will coordinate the medical and dental benefits of a benefit plan. The term benefit plan
means this Plan or any one of the following plans:
(1) Group or group -type plans, including franchise or blanket benefit plans.
(2) Blue Cross and Blue Shield group plans.
(3) Group practice and other group prepayment plans.
(4) Federal government plans or programs. This includes Medicare.
(5) Other plans required or provided by law. This does not include Medicaid or any benefit plan like it that,
by its terns, does not allow coordination.
(6) No Fault Auto Insurance, by whatever name it is called, when not prohibited by law.
Allowable charge. For a charge to be allowable it must be a Usual and Reasonable Charge and at least part of it must
be covered under this Plan.
In the case of HMO (Health Maintenance Organization) or other in -network only plans: This Plan will not consider
any charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an
HMO or network plan is primary and the Covered Person does not use an HMO or network provider, this Plan will
not consider as an allowable charge any charge that would have been covered by the HMO or network plan had the
Covered Person used the services of an HMO or network provider.
In the case of service type plans where services are provided as benefits, the reasonable cash value of each service
will be the allowable charge.
Automobile limitations. When medical payments are available under vehicle insurance, the Plan shall pay excess
benefits only, without reimbursement for vehicle plan deductibles. This Plan shall always be considered the
secondary carrier regardless of the individual's election under PIP (personal injury protection) coverage with the auto
carrier.
Benefit plan payment order. When two or more plans provide benefits for the same allowable charge, benefit
payment will follow these rules.
(1) Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision
will be considered after those without one.
(2) Plans with a coordination provision will pay their benefits up to the Allowable Charge:
(a) The benefits of the plan which covers the person directly (that is, as an employee, member or
subscriber) ("Plan A") are determined before those of the plan which covers the person as a
dependent ("Plan B").
47
(b) The benefits of a benefit plan which covers a person as an Employee who is neither laid off nor
retired are determined before those of a benefit plan which covers that person as a laid -off or
Retired Employee. The benefits of a benefit plan which covers a person as a Dependent of an
Employee who is neither laid off nor retired are determined before those of a benefit plan which
covers a person as a Dependent of a laid off or Retired Employee. If the other benefit plan does
not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule
does not apply.
(c) The benefits of a benefit plan which covers a person as an Employee who is neither laid off nor
retired or a Dependent of an Employee who is neither laid off nor retired are determined before
those of a plan which covers the person as a COBRA beneficiary.
(d) When a child is covered as a Dependent and the parents are not separated or divorced, these
rules will apply:
(i) The benefits of the benefit plan of the parent whose birthday falls earlier in a year are
determined before those of the benefit plan of the parent whose birthday falls later in
that year;
00 If both parents have the same birthday, the benefits of the benefit plan which has
covered the patient for the longer time are determined before those of the benefit plan
which covers the other parent
(e) When a child's parents are divorced or legally separated, these rules will apply:
(i) This Wile applies when the parent with custody of the child has not remarried. The
benefit plan of the parent with custody will be considered before the benefit plan of the
parent without custody.
(ii) This Wile applies, when the parent with custody of the child has remarried. The benefit
plan of the parent with custody will be considered first The benefit plan of the
stepparent that covers the child as a Dependent will be considered next The benefit
plan of the parent without custody will be considered last
(iii) This rule will be in place of items (1) and (11) above when it applies. A court decree may
state which parent is financially responsible for medical and dental benefits of the child.
In this case, the benefit plan of that parent will be considered before other plans that
cover the child as a Dependent
(iv) If the specific temps of the court decree state that the parents shall share joint custody,
without stating that one of the parents is responsible for the health care expenses of the
child, the plans covering the child shall follow the order of benefit determination Hiles
outlined above when a child is covered as a Dependent and the parents are not separated
or divorced.
(v) For parents who were never married to each other, the rules apply as set out above as
long as paternity has been established.
(1) If there is still a conflict after these rules have been applied, the benefit plan which has covered
the patient for the longer time will be considered first. When there is a conflict in coordination
of benefit rules, the Plan will never pay more than 50% of allowable charges when paying
secondary.
(3) Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare is to be
the primary payer, this Plan will base its payment upon benefits that would have been paid by Medicare
under Parts A and B, regardless of whether or not the person was enrolled under both of these parts.
48
(4) If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will
pay fast and this Plan will pay second.
Claims determination period. Benefits will be coordinated on a Calendar Year basis. This is called the claims
determination period.
Right to receive or release necessary information. To make this provision work, this Plan may give or obtain
needed information from another insurer or any other organization or person. This information may be given or
obtained without the consent of or notice to any other person. A Covered Person will give this Plan the information it
asks for about other plans and their payment of allowable charges.
Facility of payment. This Plan may repay other plans for benefits paid that the Plan Administrator determines it
should have paid. That repayment will count as a valid payment under this Plan.
Right of recovery. This Plan may pay benefits that should be paid by another benefit plan. In this case this Plan may
recover the amount paid from the other benefit plan or the Covered Person. That repayment will count as a valid
payment under the other benefit plan.
Further, this Plan may pay benefits that are later found to be greater than the allowable charge. In this case, this Plan
may recover the amount of the overpayment from the source to which it was paid.
49
THIRD PARTY RECOVERY PROVISION
RIGHT OF SUBROGATION AND REFUND
When this provision applies. The Covered Person may incur medical or dental charges due to Injuries which may be
caused by the act or omission of a Third Party or a Third Party may be responsible for payment In such
circumstances, the Covered Person may have a claim against that Third Parry, or insurer, for payment of the medical
or dental charges. Accepting benefits under this Plan for those incurred medical or dental expenses automatically
assigns to the Plan any rights the Covered Person may have to Recover payments from any Third Party or insurer.
This Subrogation right allows the Plan to pursue any claim which the Covered Person has against any Third Party, or
insurer, whether or not the Covered Person chooses to pursue that claim. The Plan may make a claim directly against
the Third Party or insurer, but in any event, the Plan has a lien on any amount Recovered by the Covered Person
whether or not designated as payment for medical expenses. This lien shall remain in effect until the Plan is repaid in
full.
The Covered Person:
(1) automatically assigns to the Plan his or her rights against any Third Party or insurer when this provision
applies; and
(2) must repay to the Plan the benefits paid on his or her behalf out of the Recovery made from the Third
Party or insurer.
In addition to, neither the Plan nor the Company shall be responsible for any of the Covered Individual's
attorney's fees or the costs of the Covered Individual's litigation.
Amount subject to Subrogation or Refund. The Covered Person agrees to recognize the Plan's right to Subrogation
and reimbursement. These rights provide the Plan with a 100%, first dollar priority over My and all Recoveries and
funds paid by a Third Party to a Covered Person relative to the Injury or Sickness, including a priority over any claim
for non -medical or dental charges, attorney fees, or other costs and expenses. Accepting benefits under this Plan for
those incurred medical or dental expenses automatically assigns to the Plan any and all rights the Covered Person
may have to recover payments from any Responsible Third Party. Further, accepting benefits under this Plan for those
incurred medical or dental expenses automatically assigns to the Plan the Covered Person's Third Party Claims.
Notwithstanding its priority to funds, the Plan's Subrogation and Refund rights, as well as the rights assigned to it, are
limited to the extent to which the Plan has made, or will make, payments for medical or dental charges as well as any
costs and fees associated with the enforcement of its rights under the Plan. The Plan reserves the right to be
reimbursed for its court costs and attorneys' fees if the Plan needs to file suit in order to Recover payment for medical
or dental expenses from the Covered Person. Also, the Plan's right to Subrogation still applies if the Recovery
received by the Covered Person is less than the claimed damage, and, as a result, the claimant is not made whole. In
addition, the Plan shall not be responsible for any of the Covered Person's attorney's fees or the costs of the Covered
Person's litigation.
When a right of Recovery exists, the Covered Person will execute and deliver all required instruments and papers as
well as doing whatever else is needed to secure the Plan's right of Subrogation as a condition to having the Plan make
payments. In addition, the Covered Person will do nothing to prejudice the right of the Plan to Subrogate.
Conditions Precedent to Coverage. The Plan shall have no obligation whatsoever to pay medical or dental benefits
to a Covered Person if a Covered Person refuses to cooperate with the Plan's reimbursement and Subrogation rights
or refuses to execute and deliver such papers as the Plan may require in furtherance of its reimbursement and
Subrogation rights. Further, in the event the Covered Person is a minor, the Plan shall have no obligation to pay any
medical or dental benefits incurred on account of Injury or Sickness caused by a responsible Third Party until after
the Covered Person or his authorized legal representative obtains valid court recognition and approval of the Plan's
100%, first dollar reimbursement and Subrogation rights on all Recoveries, as well as approval for the execution of
any papers necessary for the enforcement thereof, as described herein.
50
Defined terms; "Covered Person" means anyone covered under the Plan, including minor dependents.
"Recover," "Recovered," "Recovery" or "Recoveries" means all monies paid to the Covered Person by way of
judgment, settlement, or otherwise to compensate for all losses caused by the Injury or Sickness, whether or not said
losses reflect medical or dental charges covered by the Plan. "Recoveries" further includes, but is not limited to,
recoveries for medical or dental expenses, attorneys' fees, costs and expenses, pain and suffering, loss of consortium,
wrongful death, lost wages and any other recovery of any form of damages or compensation whatsoever.
"Refund" means repayment to the Plan for medical or dental benefits that it has paid toward care and treatment of the
Injury or Sickness.
"Subrogation" means the Plan's right to pursue and place a lien upon the Covered Person's claims for medical or
dental charges against the other person.
"Third Party" means any Third Party including another person or a business entity.
Recovery from another plan under which the Covered Person is covered. This right of Refund also applies when
a Covered Person Recovers under an uninsured or underinsured motorist plan (which will be treated as Third Party
coverage when reimbursement or Subrogation is in order), homeowner's plan, renter's plan, medical malpractice plan
or any liability plan.
Rights of Plan Administrator. The Plan Administrator has a right to request reports on and approve of all
settlements.
51
COBRA CONTINUATION OPTIONS
A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that most employers
sponsoring a group health plan ("Plan") offer Employees and their families covered under their health plan the
opportunity for a temporary extension of health coverage (called "COBRA continuation coverage") in certain
instances where coverage under the Plan would otherwise end. This notice is intended to inform Plan Participants and
beneficiaries, in summary fashion, of the rights and obligations under the continuation coverage provisions of
COBRA, as amended and reflected in final and proposed regulations published by the Department of the Treasury.
This notice is intended to reflect the law and does not grant or take away any rights under the law. Complete
instructions on COBRA, as well as election forms and other information, will be provided by the Plan Administrator
to Plan Participants who become Qualified Beneficiaries under COBRA.
Note: Special COBRA rights apply to employees who have been terminated or experienced a reduction of hours and
who qualify for a trade readjustment allowance or alternative trade adjustment assistance under a federal law called
the Trade Act of 1974. These employees must have made petitions for certification to apply for TAA on or after
November 4, 2002.
The employees, if they do not already have COBRA coverage, are entitled to a second opportunity to elect COBRA
coverage for themselves and certain family members, but only within a limited period of 60 days or less and only
during the six months immediately after their group health plan coverage ended.
Any employee who qualifies or may qualify for assistance under this special provision should contact his or her Plan
Administrator for further information.
What is COBRA continuation coverage? COBRA continuation coverage is group health plan coverage that an
employer must offer to certain Plan Participants and their eligible family members (called "Qualified Beneficiaries")
at group rates for up to a statutory -mandated maximum period of time or until they become ineligible for COBRA
continuation coverage, whichever occurs first. The right to COBRA continuation coverage is triggered by the
occurrence of one of certain enumerated events that result in the loss of coverage under the terms of the employer's
Plan (the "Qualifying Event"). The coverage must be identical to the Plan coverage that the Qualified Beneficiary had
immediately before the Qualifying Event, or if the coverage has been changed, the coverage must be identical to the
coverage provided to similarly situated active employees who have not experienced a Qualifying Event (in other
words, similarly situated nonCOBRA beneficiaries).
Who is a Qualified Beneficiary? In general, a Qualified Beneficiary is:
(1) Any individual who, on the day before a Qualifying Event, is covered under a Plan by virtue of being on
that day either a covered Employee, the Spouse of a covered Employee, or a Dependent child of a
covered Employee. If, however, an individual is denied or not offered coverage under the Plan under
circumstances in which the denial or failure to offer constitutes a violation of applicable law, then the
individual will be considered to have had the Plan coverage and will be considered a Qualified
Beneficiary if that individual experiences a Qualifying Event.
(ii) Any child who is born to or placed for adoption with a covered Employee during a period of COBRA
continuation coverage. If, however, an individual is denied or not offered coverage under the Plan under
circumstances in which the denial or failure to offer constitutes a violation of applicable law, then the
individual will be considered to have had the Plan coverage and will be considered a Qualified
Beneficiary if that individual experiences a Qualifying EvenL
(iii) A covered Employee who retired on or before the date of substantial elimination of Plan coverage which
is the result of a bankruptcy proceeding under Title 11 of the U.S. Code with respect to the Employer, as
Is the Spouse, surviving Spouse or Dependent child of such a covered Employee if, on the day before the
bankruptcy Qualifying Event, the Spouse, surviving Spouse or Dependent child was a beneficiary under
the Plan.
52
The term "covered Employee" includes not only common-law employees (whether part-time or full-time) but also
any individual who is provided coverage under the Plan due to his or her performance of services for the employer
sponsoring the Plan (e.g., self-employed individuals, independent contractor, or corporate director).
An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is attributable to a period
in which the individual was a nonresident alien who received from the individual's Employer no earned income that
constituted income from sources within the United States. If, on account of the preceding reason, an individual is not
a qualified beneficiary, then a Spouse or Dependent child of the individual is not considered a Qualified Beneficiary
by virtue of the relationship to the individual. A domestic partner is not a Qualified Beneficiary.
Each Qualified Beneficiary (including a child who is bom to or placed for adoption with a covered Employee during
a period of COBRA continuation coverage) must be offered the opportunity to make an independent election to
receive COBRA continuation coverage.
What is a Qualifying Event? A Qualifying Event is any of the following if the Plan provided that the Plan
participant would lose coverage (i.e., cease to be covered under the same terms and conditions as in effect
immediately before the Qualifying Event) in the absence of COBRA continuation coverage:
(i) The death of a covered Employee.
(ii) The termination (other than by reason of the Employee's gross misconduct), or reduction of hours, of a
covered Employee's employment.
(III) The divorce or legal separation of a covered Employee from the Employee's Spouse.
(iv) A covered Employee's enrollment in the Medicare program.
(v) A Dependent child's ceasing to satisfy the Plan's requirements for a Dependent child (e.g., attainment of
the maximum age for dependency under the Plan) .
(vi) A proceeding in bankruptcy under Title 11 of the U.S. Code with respect to an Employer from whose
employment a covered Employee retired at any time.
If the Qualifying Event causes the covered Employee, or the Spouse or a Dependent child of the covered Employee,
to cease to be covered under the Plan under the same terms and conditions as in effect immediately before the
Qualifying Event (or in the case of the bankruptcy of the Employer, any substantial elimination of coverage under the
Plan occurring within 12 months before or after the date the bankruptcy proceeding commences), the persons losing
such coverage become Qualified Beneficiaries under COBRA if all the other conditions of the COBRA law are also
met. Any increase in contribution that must be paid by a covered Employee, or the Spouse, or a Dependent child of
the covered Employee, for coverage under the Plan that results from the occurrence of one of the events listed above
is a loss of coverage.
The taking of leave under the Family and Medical Leave Act of 1993 ("FMLA") does not constitute a Qualifying
Event. A Qualifying Event occurs, however, if an Employee does not return to employment at the end of the FMLA
leave and all other COBRA continuation coverage conditions are present. If a Qualifying Event occurs, it occurs on
the last day of FMLA leave and the applicable maximum coverage period is measured from this date (unless coverage
is lost at a later date and the Plan provides for the extension of the required periods, in which case the maximum
coverage date is measured from the date when the coverage is lost.) Note that the covered Employee and family
members will be entitled to COBRA continuation coverage even if they failed to pay the employee portion of
premiums for coverage under the Plan during the FMLA leave.
What is the election period and how long must it last? An election period is the time period within which the
Qualified Beneficiary can elect COBRA continuation coverage under the Employer's Plan. A Plan can condition
availability of COBRA continuation coverage upon the timely election of such coverage. An election of COBRA
continuation coverage is a timely election if it is made during the election period. The election period must begin not
later than the date the Qualified Beneficiary would lose coverage on account of the Qualifying Event and must not
end before the date that is 60 days after the later of the date the Qualified Beneficiary would lose coverage on account
53
of the Qualifying Event or the date notice is provided to the Qualified Beneficiary of her or his right to elect COBRA
continuation coverage.
Is a covered Employee or Qualified Beneficiary responsible for informing the Plan Administrator of the
occurrence of a Qualifying Event? In general, the Employer or Plan Administrator must determine when a
Qualifying Event has occurred. However, each covered Employee or Qualified Beneficiary is responsible for
notifying the Plan Administrator of the occurrence of a Qualifying Event that is:
(i) A Dependent child's ceasing to be a Dependent child under the generally applicable requirements of the
Plan.
(ii) The divorce or legal separation of the covered Employee.
The Plan is not required to offer the Qualified Beneficiary an opportunity to elect COBRA continuation coverage if
the notice is not provided to the Plan Administrator within 60 days after the later of: the date of the Qualifying Event,
or the date the Qualified Beneficiary would lose coverage on account of the Qualifying Event
Is a waiver before the end of the election period effective to end a Qualified Beneficiary's election rights? If,
during the election period, a Qualified Beneficiary waives COBRA continuation coverage, the waiver can be revoked
at any time before the end of the election period. Revocation of the waiver is an election of COBRA continuation
coverage. However, if a waiver is later revoked, coverage need not be provided retroactively (that is, from the date of
the loss of coverage until the waiver is revoked). Waivers and revocations of waivers are considered made on the date
they are sent to the Employer or Plan Administrator, as applicable.
When may a Qualified Beneficiary's COBRA continuation coverage be terminated? During the election period,
a Qualified Beneficiary may waive COBRA continuation coverage. Except for an interruption of coverage in
connection with a waiver, COBRA continuation coverage that has been elected for a Qualified Beneficiary must
extend for at least the period beginning on the date of the Qualifying Event and ending not before the earliest of the
following dates:
(i) The last day of the applicable maximum coverage period.
(ii) The first day for which Timely Payment is not made to the Plan with respect to the Qualified
Beneficiary.
(iii) The date upon which the Employer ceases to provide any group health plan (including successor plans)
to any Employee.
(iv) The date, after the date of the election, that the Qualified Beneficiary first becomes covered under any
other Plan that does not contain any exclusion or limitation with respect to any pre-existing condition,
other than such an exclusion or limitation that does not apply to, or is satisfied by, the Qualified
Beneficiary.
(v) The date, after the date of the election, that the Qualified Beneficiary first enrolls in the Medicare
program (either part A or part B, whichever occurs earlier).
(vi) In the case of a Qualified Beneficiary entitled to a disability extension, the later of:
(a) (1) 29 months after the date of the Qualifying Event, or (ii) the first day of the month that is more
than 30 days after the date of a final determination under Title II or XVI of the Social Security
Act that the disabled Qualified Beneficiary whose disability resulted in the Qualified
Beneficiary's entitlement to the disability extension is no longer disabled, whichever is earlier;
or
(b) the end of the maximum coverage period that applies to the Qualified Beneficiary without
regard to the disability extension.
54
The Plan can terminate'for cause the coverage of a Qualified Beneficiary on the same basis that the Plan terminates
for cause the coverage of similarly situated nonCOBRA beneficiaries, for example, for the submission of a fraudulent
claim
In the case of an individual who is not a Qualified Beneficiary and who is receiving coverage under the Plan solely
because of the individual's relationship to a Qualified Beneficiary, if the Plan's obligation to make COBRA
continuation coverage available to the Qualified Beneficiary ceases, the Plan is not obligated to make coverage
available to the individual who is not a Qualified Beneficiary.
What are the maximum coverage periods for COBRA continuation coverage? The maximum coverage periods
are based on the type of the Qualifying Event and the status of the Qualified Beneficiary, as shown below.
(i) In the case of a Qualifying Event that is a termination of employment or reduction of hours of
employment, the maximum coverage period ends 18 months after the Qualifying Event if there is not a
disability extension and 29 months after the Qualifying Event if there is a disability extension.
(ii) In the case of a covered Employee's enrollment in the Medicare program before experiencing a
Qualifying Event that is a termination of employment or reduction of hours of employment, the
maximum coverage period for Qualified Beneficiaries other than the covered Employee ends on the later
of:
(a) 36 months after the date the covered Employee becomes enrolled in the Medicare program; or
(b) 18 months (or 29 months, if there is a disability extension) after the date of the covered
Employee's termination of employment or reduction of hours of employment
(iii) In the case of a bankruptcy Qualifying Event, the maximum coverage period for a Qualified Beneficiary
who is the retired covered Employee ends on the date of the retired covered Employee's death. The
maximum coverage period for a Qualified Beneficiary who is the Spouse, surviving Spouse or
Dependent child of the retired covered Employee ends on the earlier of the date of the Qualified
Beneficiary's death or the date that is 36 months after the death of the retired covered Employee.
(iv) In the case of a Qualified Beneficiary who is a child born to or placed for adoption with a covered
Employee during a period of COBRA continuation coverage, the maximum coverage period is the
maximum coverage period applicable to the Qualifying Event giving rise to the period of COBRA
continuation coverage during which the child was born or placed for adoption.
(v) In the case of any other Qualifying Event than that described above, the maximum coverage period ends
36 months after the Qualifying Event.
Under what circumstances can the maximum coverage period be expanded? If a Qualifying Event that gives rise
to an 18-month or 29-month maximum coverage period is followed, within that 18- or 29-month period, by a second
Qualifying Event that gives rise to a 36-months maximum coverage period, the original period is expanded to 36
months, but only for individuals who are Qualified Beneficiaries at the time of both Qualifying Events. In no
circumstance can the COBRA maximum coverage period be expanded to more than 36 months after the date of the
first Qualifying Event.
How does a Qualified Beneficiary become entitled to a disability extension? A disability extension will be
granted if an individual (whether or not the covered Employee) who is a Qualified Beneficiary in connection with the
Qualifying Event that is a termination or reduction of hours of a covered Employee's employment, is determined
under Title 11 or XVI of the Social Security Act to have been disabled at any time during the first 60 days of COBRA
continuation coverage. To qualify for the disability extension, the Qualified Beneficiary must also provide the Plan
Administrator with notice of the disability determination on a date that is both within 60 days after the date of the
determination and before the end of the original 18-month maximum coverage.
Can a Plan require payment for COBRA continuation coverage? Yes. For any period of COBRA continuation
coverage, a Plan can require the payment of an amount that does not exceed 102% of the applicable premium except
55
the Plan may require the payment of an amount that does not exceed 150% of the applicable premium for any period
of COBRA continuation coverage covering a disabled qualified beneficiary that would not be required to be made
available in the absence of a disability extension. A group health plan can tenninate a qualified beneficiary's COBRA
continuation coverage as of the first day of any period for which timely payment is not made to the Plan with respect
to that qualified beneficiary.
Must the Plan allow payment for COBRA continuation coverage to be made in monthly installments? •Yes
The Plan is also permitted to allow for payment at other intervals.
What is Timely Payment for payment for COBRA continuation coverage? Timely Payment means payment that
is made to the Plan by the date that is 30 days after the first day of that period. Payment that is made to the Plan by a
later date is also considered Timely Payment if either under the terms of the Plan, covered Employees or Qualified
Beneficiaries are allowed until that later date to pay for their coverage for the period or under the terms of an
arrangement between the Employer and the entity that provides Plan benefits on the Employer's behalf, the Employer
is allowed until that later date to pay for coverage of similarly situated nonCOBRA beneficiaries for the period.
Notwithstanding the above paragraph, a Plan cannot require payment for any period of COBRA continuation
coverage for a Qualified Beneficiary earlier than 45 days after the date on which the election of COBRA continuation
coverage is made for that Qualified Beneficiary. Payment is considered made on the date on which it is sent to the
Plan.
If Timely Payment is made to the Plan in an amount that is not significantly less than the amount the Plan requires to
be paid for a period of coverage, then the amount paid will be deemed to satisfy the Plan's requirement for the amount
to be paid, unless the Plan notifies the Qualified Beneficiary of the amount of the deficiency and grants a reasonable
period of time for payment of the deficiency to be made. A "reasonable period of time" is 30 days after the notice is
provided. A shortfall in a Timely Payment is not significant if it is no greater than the lesser of $50 or 10% of the
required amount.
Must a qualified beneficiary be given the right to enroll in a conversion health plan at the end of the maximum
coverage period for COBRA continuation coverage? If a Qualified Beneficiary's COBRA continuation coverage
under a group health plan ends as a result of the expiration of the applicable maximum coverage period, the Plan
must, during the 180- day period that ends on that expiration date, provide the Qualified Beneficiary with the option
of enrolling under a conversion health plan if such an option is otherwise generally available to similarly situated
nonCOBRA beneficiaries under the Plan. If such a conversion option is not otherwise generally available, it need not
be made available to Qualified Beneficiaries.
56
RESPONSIBILITIES FOR PLAN ADMINISTRATION
PLAN ADMINISTRATOR. City of Lubbock Employee Benefit Plan is the benefit plan of City of Lubbock, the
Plan Administrator, also called the Plan Sponsor. It is to be administered by the Plan Administrator in accordance
with the provisions of ERISA. An individual may be appointed by City of Lubbock to be Plan Administrator and
serve at the convenience of the Employer. If the Plan Administrator resigns, dies or is otherwise removed from the
position, City of Lubbock shall appoint a new Plan Administrator as soon as reasonably possible.
The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies,
interpretations, practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have
maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan, to make
determinations regarding issues which relate to eligibility for benefits, to decide disputes which may arise relative to a
Plan Participant's rights, and to decide questions of Plan interpretation and those of fact relating to the Plan. The
decisions of the Plan Administrator will be final and binding on all interested parties.
Service of legal process may be made upon the Plan Administrator.
DUTIES OF THE PLAN ADMINISTRATOR.
(1) To administer the Plan in accordance with its terms.
(2) To interpret the Plan, including the right to remedy possible ambiguities, inconsistencies or omissions.
(3) To decide disputes which may arise relative to a Plan Participant's rights.
(4) To prescribe procedures for filing a claim for benefits and to review claim denials.
(5) 'To keep and maintain the Plan documents and all other records pertaining to the Plan.
(6) To appoint a Claims Supervisor to pay claims.
(7) To perform all necessary reporting as required by ERISA.
(8) To establish and communicate procedures to determine whether a medical child support order is
qualified under ERISA Sec. 609.
(9) To delegate to any person or entity such powers, duties and responsibilities as it deems appropriate.
PLAN ADMINISTRATOR COMPENSATION. The Plan Administrator serves without compensation; however,
all expenses for plan administration, including compensation for hired services, will be paid by the Plan.
FIDUCIARY. A fiduciary exercises discretionary authority or control over management of the Plan or the
disposition of its assets, renders investment advice to the Plan or has discretionary authority or responsibility in the
administration of the Plan.
FIDUCIARY DUTIES. A fiduciary must carry out his or her duties and responsibilities for the purpose of providing
benefits to the Employees and their Dependent(s), and defraying reasonable expenses of administering the Plan.
These are duties which must be carried out:
(1) with care, skill, prudence and diligence under the given circumstances that a prudent person, acting in a
like capacity and familiar with such matters, would use in a similar situation;
(2) by diversifying the investments of the Plan so as to minimize the risk of large losses, unless under the
circumstances it is clearly prudent not to do so; and
(3) in accordance with the Plan documents to the extent that they agree with ERISA.
57
THE NAMED FIDUCIARY. A "named fiduciary" is the one named in the Plan. A named fiduciary can appoint
others to carry out fiduciary responsibilities (other than as a trustee) under the Plan. These other persons become
fiduciaries themselves and are responsible for their acts under the Plan. To the extent that the named fiduciary
allocates its responsibility to other persons, the named fiduciary shall not be liable for any act or omission of such
person unless either:
(1) the named fiduciary has violated its stated duties under ERISA in appointing the fiduciary, establishing
the procedures to appoint the fiduciary or continuing either the appointment or the procedures; or
(2) the named fiduciary breached its fiduciary responsibility under Section 405(a) of ERISA.
CLAIMS SUPERVISOR IS NOT A FIDUCIARY. A Claims Supervisor is not a fiduciary under the Plan by virtue
of paying claims in accordance with the Plan's rules as established by the Plan Administrator,
FUNDING THE PLAN AND PAYMENT OF BENEFITS
The cost of the Plan is funded as follows:
For Employee Coverage: Funding is derived solely from the funds of the Employer.
For Dependent Coverage: Funding is derived from contributions made by the covered Employees.
Benefits are paid directly from the Plan through the Claims Supervisor.
PLAN IS NOT AN EMPLOYMENT CONTRACT
The Plan is not to be construed as a contract for or of employment.
CLERICAL ERROR
Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records or a
delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly
terminated. An equitable adjustment of contributions will be made when the error or delay is discovered.
If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, the Plan retains a contractual right
to the overpayment. The person or institution receiving the overpayment will be required to return the incorrect
amount of money. In the case of a Plan Participant, if it is requested, the amount of overpayment will be deducted
from future benefits payable.
AMENDING AND TERMINATING THE PLAN
If the Plan is terminated, the rights of the Plan Participants are limited to expenses incurred before termination.
The Employer intends to maintain this Plan indefinitely; however, it reserves the right, at any time, to amend, suspend
or terminate the Plan in whole or in part. This includes amending the benefits under the Plan or the Trust agreement
(if any).
CERTAIN PLAN PARTICIPANTS RIGHTS UNDER ERISA
Plan Participants in this Plan are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 (ERISA). ERISA specifies that all Plan Participants shall be entitled to:
Examine, without charge, at the Plan Administrator's office, all Plan documents and copies of all
documents goveming the Plan, including a copy of the latest annual report (form 5500 series) filed
by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the
Employee Benefits Security Administration.
58
Obtain copies of all Plan documents and other Plan information upon written request to the Plan
Administrator. The Plan Administrator may make a reasonable charge for the copies.
Continue health care coverage for a Plan Participant, Spouse, or other dependents if there is a loss of
coverage under the Plan as a result of a qualifying event. Employees or dependents may have to pay for such
coverage.
Review this summary plan description and the documents governing the Plan or the rules governing COBRA
continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for Pre -Existing Conditions under this group
health Plan, if an Employee or dependent has Creditable Coverage from another plan. The Employee or
dependent should be provided a certificate of Creditable Coverage, free of charge, from the group health plan
or health insurance issuer when coverage is lost under the plan, when a person becomes entitled to elect
COBRA continuation coverage, when COBRA continuation coverage ceases, if a person requests it before
losing coverage, or if a person requests it up to 24 months after losing coverage. Without evidence of
Creditable Coverage, a Plan Participant may be subject to a Pre -Existing Conditions exclusion for 12 months
(18 months for Late Enrollees) after the Enrollment Date of coverage.
If a Plan Participant's claim for a benefit is denied or ignored, in whole or in part, the participant has a right to know
why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all
within certain time schedules.
Under ERISA, there are steps a Plan Participant can take to enforce the above rights. For instance, if a Plan
Participant requests a copy of Plan documents or the latest annual report from the Plan and does not receive them
within 30 days, he or she may file suit in a federal court. In such a case, the court may require the Plan Administrator
to provide the materials and to pay the Plan Participant up to $110 a day until he or she receives the materials, unless
the materials were not sent because of reasons beyond the control of the Plan Administrator. If the Plan Participant
has a claim for benefits which is denied or ignored, in whole or in part, the participant may file suit in state or federal
court.
In addition, if a Plan Participant disagrees with the Plan's decision or lack thereof concerning the qualified status of a
medical child support order, he or she may file suit in federal court.
In addition to creating rights for Plan Participants, ERISA imposes obligations upon the individuals who are
responsible for the operation of the Plan. The individuals who operate the Plan, called "fiduciaries" of the Plan, have a
duty to do so prudently and in the interest of the Plan Participants and their beneficiaries. No one, including the
Employer or any other person, may fire a Plan Participant or otherwise discriminate against a Plan Participant in any
way to prevent the Plan Participant from obtaining benefits under the Plan or from: exercising his or her rights under
ERISA.
If it should happen that the Plan fiduciaries misuse the Plan's money, or if a Plan Participant is discriminated against
for asserting his or her rights, he or she may seek assistance from the U.S. Department of Labor, or may file suit in a
federal court. The court will decide who should pay court costs and legal fees. If the Plan Participant is successful, the
court may order the person sued to pay these costs and fees. If the Plan Participant loses, the court may order him or
her to pay these costs and fees, for example, if it finds the claim or suit to be frivolous.
If the Plan Participant has any questions about the Plan, he or she should contact the Plan Administrator. If the Plan
Participant has any questions about this statement or his or her rights under ERISA or the Health Insurance
Portability and Accountability Act (HIPAA), that Plan Participant should contact either the nearest area office of the
Employee Benefits Security Administration, U.S. Department of Labor listed in the telephone directory or the
Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, at 200 Constitution
Avenue, N.W., Washington, DC 20210.
59
GENERAL PLAN INFORMATION
TYPE OF ADMINISTRATION
The Plan is a self -funded group health Plan and the administration is provided through a Third Party Claims
Supervisor. The funding for the benefits is derived from the funds of the Employer and contributions made by
covered Employees. The Plan is not insured.
PLAN NAME
City of Lubbock Employee Benefit Plan
PLAN NUMBER: 502
TAX ID NUMBER: 75-600059
PLAN EFFECTIVE DATE: January 1, 2004
PLAN YEAR ENDS: December 31st
EMPLOYER INFORMATION
City of Lubbock
Post Office Box 2000
1625 13 Street, City Manager's Office
Lubbock, Texas 79401
806-775-2317
PLAN ADMINISTRATOR
City Manager
City of Lubbock
Post Office Box 2000
1625 13 Street, City Managers Office
Lubbock, Texas 79401
806-775-2317
NAMED FIDUCIARY
City Manager
City of Lubbock
Post Office Box 2000
1625 13 Street, City Managers Office
Lubbock, Texas 79401
AGENT FOR SERVICE OF LEGAL PROCESS
City Manager
City of Lubbock
Post Office Box 2000
1625 13 Street, City Managers Office
Lubbock, Texas 79401
CLAIMS SUPERVISOR
ICON Benefit Administrators
P.O. Box 53070
Lubbock, Texas 79453 60
1-800-658-9777
Resolution No. 2005-RO242
City of Lubbock
Memo
To: Lee Ann Dumbauld, CFO, Assistant City Manager
Scott Snider, Director of Human Resources
From: Terri Smith, Benefits Coordinator
Date: August 10, 2005
Re: Health Plan Document Amendment No. 4
Attached is a revised Plan Document Amendment effective July 1, 2005. The
revisions are under Hospital Services Room and Board, Intensive Care Unit, and
Skilled Nursing Facility. Additionally, the definition of Resource Based Relative
Value Scale has been added to Defined Terms. These changes will be
incorporated into the benefits booklet when approved and signed.
Please review and let me know if you have any questions.
Cc: Lina Boisse, Benefit Specialist
Teresa Loving, Benefit Specialist
PLAN DOCUMENT AMENDMENT
To be attached to and made part of the Master Plan Document issued to CrryoF LUBBOCK (GROUP No. 3010)
Employee Benefit Plan_
AMENDMENT No. 4
THE PLAN DOCUMENT IS AMENDED IN THE MANNER HEREIN DESCRIBED.
I. The Schedule of Benefits (pages 12 through 16) is hereby deleted and replaced with the following:
NETWORK
NON -NETWORK
JOUT-OF-AREA
PROVIDERS
PROVIDERS
MAXIMUM
LIFETIME
$1,000,000
BENEFIT
AMOUNT
Note: The maximums listed below are the total for Network and Non -Network
expenses. For example, if a maximum of 60 days is listed twice under a service, the
Calendar Year maximum is 60 days total which may be split between Network and
Non -Network proA ers.
�I
3-1
L
C�
Per Covered Person $500
$1,000
$500
Per Family Unit $1,000
$2,000
$1,000
The Calendar Year deductible is waived for the following Covered Charges:
- Skilled Nursing Facility - In -Network, Out -of -Area
- Home Health Care - In -Network, Out -of -Area
- Hospice — In -Network, Out -of -Area
- Routine Well Adult and Child Care — Out -of -Area
- Required Childhood Immunizations
- Office Surgery — In -Network
- Other Diagnostic Medical Services — In -Network
m
Physician visits
$25.00
50% after deductible
80% after deductible
Ancillary charges
$25.00
50% after deductible
80% after deductible
performed after the
day of the Physician's
office visit
C ITY OF LUBBOC K
July 25, 2005 - Page l of 9
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Ancillary charges
$25.00
50% after deductible
80% after deductible
associated with
Routine Well Adult
and Child Care
performed after the
day of the office visit
Emergency room
$50.00
$50.00
80% after deductible
facility charges
Mental Disorders
$25.00
50% after deductible
80% after deductible
Outpatient —
Physician/Consultant
visits
30 visit Calendar
Year maximum
Serious Mental Illness
$25.00
50% after deductible
80% after deductible
Outpatient —
Physician/Consultant
visits
60 visit Calendar
Year maximum
Second or Third
$25.00
50% after deductible
80% after deductible
Surgical Opinions
Routine Well Adult
$25.00
50% after deductible
80%
and Child Care
�Ilk
�.�,
ir�l� ;�R� �?l�
� #�`, „�, ��„ s
.✓:,��, �'%, �
;ems. ,s��` a��m.
Per Covered Person
$2,000
$12,000
$2,000
Per Family Unit IS4,000
1$24,000
1$4,000
CITY OF LUBBOCK
July 25, 2005 - Page 2 of 9
(PROVIDERS 1PROVIDNETWO
E NON -NETWORK JOUT-OF-AREA
The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts
are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the
rest of the Calendar Year unless stated otherwise.
The following charges do not apply toward the out-of-pocket maximum and are never paid at
100%.
Deductible(s)
Cost containment penalties
Eligible Medical Expense (EME) is the maximum allowable amount that will be eligible
for a particular Covered Service as determined by the Plan in accordance with the Plan
reimbursement schedule. See Eligible Medical Expense in the Defined Terms section.
Second or Third 100% after copayment 50% after deductible 80% after deductible
Pre -Admission 80% after deductible 50% after deductible 80% after deductible
Testing inpatient and
outpatient
Outpatient/Ambulato 80% after deductible 50% after deductible 80% after deductible
ry Surgical
Procedures
Dialysis — Outpatient 180% after deductible 180% after Network 180% after deductible
Inpatient Hospital
deductible per
confinement
Room and Board
Intensive Care Unit
Emergency/Treat-
ment Room (servic
rendered within 48
hours of an accident
or medical
emergency)
None
$200
80% after deductible 50% after deductible
Limited to the Limited to the
senunnvate room rate
80% after deductible
Limited to Hospital's
ICU Charge
80% after copayment
semimivate room rate
50% after deductible
Limited to Hospital's
ICU Charge
80% after copayment
$100
80% after deductible
Limited to the
semiprivate room rate
80% after deductible
Limited to Hospital's
ICU Charge
80% after deductible
C ITY OF LU BBOC K
July 25, 2005 - Page 3 of 9
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Emergency/Treat-
80% after deductible
80% after deductible
80% after deductible
ment Room (service
rendered within 48
hours of an accident
or medical
emergency)
Physician charges
Skilled Nursing
100%
50%
100%
Facility
Limited to the facility's
Limited to the facility's
Limited to the facility's
semiprivate room rate
semiprivate room rate
semiprivate room rate
$10,000 Calendar
$7,000 Calendar Year
$10,000 Calendar
Year maximum
max mm
Year maximum
P� sYltn rvices µ
Inpatient visits
80% after deductible
50% after deductible
80% after deductible
Office visits (including
100% after copayment
50% after deductible
80% after deductible
ancillary charges
performed in the same
day as the Physician's
office visit)
The copayment
benefit does not apply
to any service
requiring
precertification or
chiropractic benefits.
Ancillary charges
100% after copayment
50% after deductible
80% after deductible
performed after the
day of the Physician's
office visit
The copayment
benefit does not apply
to any service
requiring
precertification or
chiro Tactic benefits.
Office Surgery
80%
50% after deductible
80% after deductible
C rrY OF LUBBOC K
July 25, 2005 - Page 4 of 9
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Diagnostic
80% after deductible
50% after deductible
80% after deductible
Procedures —limited
to: All knee/shoulder
arthroscopies, Bone
Scan, Cardiac Stress
Test, CT Scan,
Carotid Ultrasounds,
MRI, Myelogram,
PET Scan, and
Endoscopic
Procedures
Other Diagnostic
100%
50% after deductible
80% after deductible
Medical Services
(Freestanding facility)
Other Outpatient
80% after deductible
50% after deductible
80% after deductible
Services and Supplies
Allergy Testing and
80% after deductible
50% after deductible
80% after deductible
Treatment
Surgery
80% after deductible
50% after deductible
80% after deductible
Home Health Care
100%
50% after deductible
100%
$10,000 Calendar
$7,000 Calendar Year
$10,000 Calendar
Year maximum
maximum
Year maximum
Outpatient Private
80% after deductible
50% after deductible
80% after deductible
Duty Nursing
Hospice Care
100%
50% after deductible
100%
$20,000 inpatient and
$14,000 inpatient and
$20,000 inpatient and
outpatient Lifetime
outpatient Lifetime
outpatient Lifetime
maximum
maximum
maximum
Ambulance Service
80% after deductible
50% after deductible
80% after deductible
Jaw Joint/TMJ
80% after deductible
50% after deductible
80% after deductible
(Coverage excluded
after Covered Person's
191h birthday except
orthognathic surgery for
treatment of
temporomandibular
joint disorders and
conditions of
temporomandibular
joint disorders)
CITY OF LUBBOC K
July 25, 2005 - Page 5 of 9
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Speech and Hearing
80% after deductible
50% after deductible
80% after deductible
Services
Includes hearing aids
(limited to $1,000 per
36-month period)
Home Infusion
80% after deductible
50% after deductible
80% after deductible
Therapy
Durable Medical
80% (rental up to
50% (rental up to
80% (rental up to
Equipment
purchase price) after
purchase price) after
purchase price) after
deductible
deductible
deductible
Prosthetics
80% after deductible
50% after deductible
80% after deductible
Orthotics
80% after deductible
50% after deductible
80% after deductible
Spinal Manipulation
80% after deductible
50% after deductible
80% after deductible
Chiropractic
$1,500 Calendar Year
maximum
$1,500 Calendar Year
maximum
$1,500 Calendar Year
maximum
Physical Medicine
80% after deductible
50% after deductible
80% after deductible
Service which
$2,000 Calendar Year
$2,000 Calendar Year
$2,000 Calendar Year
includes physical and
maximuin
maximum
maximum
occupational therapy
R j'y,s� ,. WHO
Menla D�+rc,rNs� Yam,, ;� �H, .�n������
Inpatient
80% after deductible
50% after deductible
80% after deductible
30 day Calendar Year
maximum
15 day Calendar Year
maximum
30 day Calendar Year
mammon
Outpatient - 100% after copayment 50% after deductible 80% after deductible
Physician/Consultant
visits
Outpatient - 80% after deductible 50% after deductible 80% after deductible
Facility/Outpatient
Professional Provider
30 visit Calendar Year maximum for all Outpatient combined
Inpatient
80% after deductible
50% after deductible
80% after deductible
45 day Calendar Year
maximmm
45 day Calendar Year
maximum
45 day Calendar Year
maximum
Outpatient -
100% after copayment
50% after deductible
80% after deductible
Physician/Consultant
visits
CITY OF LUBBOCK
July 25, 2005 - Page 6 of 9
NETWORK
NON -NETWORK
OUT -OF -AREA
PROVIDERS
PROVIDERS
Outpatient - 80% after deductible 50% after deductible 80% after deductible
Facility/Outpatient
Professional Provider
60 visit Calendar Yearmaximumfor all combined
T"
II�iS>rii+r�#iuSe
mOutpatient
��ik ' �.>�
nlw11,
Irlpatient
80% after deductible
50% after deductible
80% after deductible
Outpatient
80% after deductible
50% after deductible
80% after deductible
Inpatient / Outpatient
Combined
3 separate series of
3 separate series of
3 separate series of
treatment Lifetime
maximum
treatment Lifetime
maxLim=
treatment per Lifetime
maximum
�i "✓4f T' fii �xp
Preehe mare
�
S'6£u� i S"�"° d" ✓'kS � ,3
5,-�'b#�
A r
Routine Well Adult I 100% after copayment 50% after deductible 80%
Care
Includes: office visits, routine physical examination, prostate screening and cancer exam, routine
mammography, colorectal cancer screenings annual hearing test, annual vision test and
immunizations/flu shots.
Annual limit for Mammogram: 1 per Calendar Year
Age 35 or older
Routine Well
80% after deductible
50% after deductible
80% after deductible
Newborn Care
Routine Well Child 100% after copayment 50% after deductible 80%
Care
Includes: office visits, routine physical examination, annual hearing test and annual vision test.
Includes immunizations for children ages 6 and older.
Required Childhood 100% 100% 100%
Immunizations — for
children up to age 6
Covered immunizations are: Diphtheria, Hemophilus influenza type b, Hepatitis B, Measles,
Mumps, Pertussis, Polio, Rubella, Tetanus, Varicella, and any other immunizations required by
law.
Ancillary charges
100% after copayment
50% after deductible
80% after deductible
associated with the
Routine Well Adult
and Child Care
performed after the
day of the office visit
CITY of LUBBOC K
July 25, 2005 - Page 7 of 9
NETWORK
NON -NETWORK
OUT -OF AREA
PROVIDERS
PROVIDERS
Human organ and tissue benefits are provided by a separate policy, as explained in full
in the AIG LIFE Organ & Tissue Transplant Policy. All eligible Employees and their
eligible Dependents requiring human organ and tissue transplant services will have
transplant -related charges covered under this separate AIG LIFE policy, according to
its terms and conditions, from the time of their evaluation through 365 days post
transplant operation. All transplant -related medical benefits incurred after this
specified period of coverage as well as all transplant related charges ineligible under
the separate policy will revert to the terms and conditions of health coverage under this
health plan document.
Organ Trans lants 80% after deductible 50% after deductible 80% after deductible
Pregnancy
80% after deductible
50% after deductible
80% after deductible
Dependent daughters
are covered
Newborn Nursery
Charges will be applied
to Newborn's own
deductible and co-
insurance
All maternity expenses and treatment in progress as of the effective date of this Plan
and currently covered under this Plan, that is being provided by a BGBS network
physician or facility, will continue to be eligible for payment at the Network benefit
level until the post partum follow up is complete.
H. The following is hereby added to DEFINED TERMS (page 30):
Eligible Medical Expense (EME) means the maximum allowable amount the Plan will pay for a particular
Covered Service as determined by the Plan in accordance with the Plan reimbursement schedule. In -Network
providers have agreed to accept the Plan's reimbursement as payment in full for Covered Services, less any
applicable copayment deductible or coinsurance, whereas Non -Network providers have not. Eligible Plan
Participants who use the services of Non -Network providers will receive no benefit payments or reimbursement
for charges in excess of the Plan's reimbursement schedule for any Covered Services. In no event will the Plan
pay more than the maximum payment allowance established in the Plan's reimbursement schedule.
Eligible Medical Expenses are determined by the following:
Physician charges: Medicare Allowable based on Resource Based Relative Value Scale (RBRVS)
Facility charges: Medicare Allowable based on Resource Based Relative Value Scale (RBRVS)
C ITY OF LU BBOC K
July 25, 2005 - Page 8 of 9
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III. The following is hereby added to DEFINED TERMS (page 30):
Resource Based Relative Value Scale (RBRVS) refers to a specific standardized scale of healthcare charges
that bases relative values on a computation of total work, practice cost, and malpractice cost involved in
performing a procedure. These three elements of the value are modified by a geographic index. After the
geographic modification, the three values are summed to reach a single value. The single value is then multiplied by
a conversion factor, determined by Congress, to arrive at a charge.
IV. The Usual and Reasonable Charge section (page 35) under DEFINED TERMS is hereby amended to read
as follows:
Usual and Reasonable Charge is a charge which is not higher than the usual charge made by the provider of
the care or supply and does not exceed the usual charge made by most providers of like service in the same area.
This test will consider the nature and severity of the condition being treated. It will also consider medical
complications or unusual circumstances that require more time, skill or experience.
The Plan will reimburse the actual charge billed if it is less than the Usual and Reasonable Charge.
The Plan Administrator has the discretionary authority to decide whether a charge is Usual and Reasonable.
For Non -Network provider and facility charges, Usual and Reasonable Charge is considered to mean
Eligible Medical Expense (EME) or Usual and Reasonable Charge, whichever is less.
V. Excess Charges (page 36) under PLAN EXCLUSIONS is hereby amended to read as follows:
(11) Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is in
excess of the Usual and Reasonable Charge or the Eligible Medical Expense.
This Amendment takes effect July 1, 2005 and is subject to all of the provisions and conditions of the Plan.
Signed this 17th d1V of August , 2005.
Authorized Signature
QQ
Attest
C ITY OF LUBBOC K
July 25, 2005 - Page 9 of 9