HomeMy WebLinkAboutReso 93-424 - Approve entering into a Calif Vision Serv Agreement between the COR & Vision Service Plan (VSP) in which VSP will administer the City's Self Insured vision service plan 1
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RESOLUTION NO. '��!
'I A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF REDDING
APPROVING ENTERING INTO A CALIFORNIA VISION SERVICE
AGREEMENT BETWEEN THE CITY OF REDDING AND VISION
SERVICE PLAN (VSP) , IN WHICH VSP WILL ADMINISTER THE
CITY'S SELF-INSURED VISION SERVICE PLAN; AND
AUTHORIZING THE MAYOR TO SIGN ALL NECESSARY
DOCUMENTATION.
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BE IT RESOLVED that the City Council of the City of Redding
hereby approves entering into a one-year contract with Vision
Service Plan to administer the City' s self-insured Vision Service
Plan, with the City paying $1. 45 per employee per month. A
sample of the type of contract is attached hereto and
incorporated herein by reference.
BE IT FURTHER RESOLVED that the Mayor of the City of Redding
is hereby authorized and directed to sign an Agreement with
Vision Service Plan on behalf of the City of Redding, when
approved by the City Attorney; and the City Clerk is hereby
authorized and directed to attest the signature of the Mayor and
to impress the official seal of the City of Redding thereto.
I HEREBY CERTIFY that the foregoing Resolution was
introduced and read at a regular meeting of the. City Council of
the City of Redding on the 21st day of December, 1993 , and was
duly adopted at said meeting by the following vote:
AYES: COUNCIL MEMBERS: Anderson, Kehoe, Moss and Arness
NOES: COUNCIL MEMBERS: None
ABSENT: COUNCIL MEMBERS: Dahl
ABSTAIN: COUNCIL MEMBERS: None
CARL ARNESS, Mayor
City of Redding
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ATTEST- FORM APPROVED: \}
CONNIE STRO YER, City Cle RANDALL A. HAYS, City Attorney
DEC 15 '93 10:49AM VSP SALFc" ADMIN —P;2
V BION RIPMVICE PIAAN
CALIFORNIA VISION SERVICE
(Hereinafter Called VSP)
and
CITY OF REDDING
(0237134)
(Hereinafter Called Group)
AGREE AS FOLLOWS:
a
VSP shall provide a panel of doctors to perform services for persons certified as eligible,
subject to the terms and conditions of this contract.
1. TERM AND CANCELLATION
1 3 for an Initial Term of
This contract shall be effective commencing vin the
i twelve(12_1 months, and continuing thereafter until terminated by either p arty gi S
other sixty (60) days prior written notice.
The contract shall terminate at midnight, the last day of the month for which the notice has
been given.
AGREEMENT - ADMINISTRATION
VSP shall process requests for benefit forms which shall be forwarded to VSP by Covered
Persons, Group, or by the administrator.
Benefit forms shall be issued by VSP in accordance with the latest eligibility information
furnished by Group. Any benefit form so issued by VSP shall constitute a certification to the
VSP Member Doctor that payment will be made, and VSP sball not be held liable for any
benefit forms issued in error, provided they were issued in accordance with these provisions.
VSP shall furnish to Group on a monthly basis, a list of all benefits paid pursuant to this
! contract.
In the event of termination of this contract by either party, Group agrees to provide funds for
rounded such benefit
payment pursuant to benefit forms issued prior to the termination date, p
forms.are filed with VSP within six (6) months after termination of this contract.
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VLftqoN sFjwxcE FTAAN .--�—
AGREEUMNT
This instrument contains all of the provisions of the contract between the parties hereto, and
no promise or agreement not contained herein shall be binding on the parties unless the same
is in writingand attached to this contract. This contract may be amended only by a written
instrument signed by an authorized representative of Group and an officer of VSP. Consent
of Covered Persons is not required to effect any such amendment.
This contract shall be governed by and construed under the laws of the State of California.
The provisions and conditions set forth on the following pages shall form a part of this
contract as fully as if recited over the signatures hereto affixed.
MY OF DING CALIFORNIA VISION SERVICE
By
Title Mayor Title_ Vice Presi t
Date February 18, 1993 Date J• u 1`993
FORM APPROVEI
Cmr LEGA! WT.
ASP 05191
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VISION SERVICE 1TAAN
II. EUGIBMM DETERMINATION
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E"LOYSES
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For purposes of this Plan, eligible participants shall be defined as all full-time employees of
the employer who work f 40) or more hours per week at the employer's normal place of
business.
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New employees shall be added on their date of em In ovment.
Terminating employees shall be excluded from the Plan on the last day of the month in
which their employment terminates.
DSP
p,NDENTS
If dependent coverage is provided under this contract, then for the purposes of this Plan,
dependents eligible shall be the covered employee's spouse and unmarred dependent children
who have not attained their nineteenth ly3t
birthday, or to their y-
birthday if attending school full-time.
An unmarried child age ninet mn 1 or over may continue to be eligible as a dependent if
the child is:
1. Incapable of self-sustaining employment by reason of mental or physical handicap,
and
2. Chiefly dependent upon the covered employee for support and maintenance.
PROVIDED, HOWEVER, proof of such incapacity and dependency is furnished to
the Group or VSP by the Covered Person within thirty-one (31) days of the request
for such information-by VSP to the Group. Additional information may be
subsequently required by VSP or Group but not more frequently than annually after
'I the two-year period following the child's attainment of the limiting age.
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CONTINUATION COVERAGE
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that under
certain circumstances health plan benefits available to an eligible participant and his or her
dependents be made available for purchase by said of n of
the relaersons tionship betn tho twweenosaid participant
employment of said participant, or the terminatio lies to the arties to this
and his or her dependents. If, and only to the extent, COBRA app p
contract, VSP shall make the statutorily-required continuation coverage available for purchase
in accordance with COBRA.
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Nai!410N SERYIC'E Pi1AN
III. BENEFITS AND COVERAGE
SERVICES FROM VSP MEMBER DOCTORS
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A, VISION EXAMINATION
A complete analysis of the eyes and related structures will be provided to determine
the presence of vision problems or other abnormalities.
Each Covered Person shall be entitled to a vision examination once each twelyc
months.
B. MATERIALS
Where the vision prominvtis al health and welfare of a Covered Person, tht new lenses or frames or both ey will be
necessary for the prop
supplied, together with such professional services as aro necessary, which shall
include, but not be limited to:
• Prescribing and ordering proper lenses
• Assisting in the selection of a frame
• Verifying the accuracy of the finished lenses
• Proper fitting and adjustment of the spectacles
1. LENSES - The VSP Member Doctor will order the proper lenses necessary for
the Covered Person's visual welfare.
Each Covered Person is entitled to new lenses once each
t - r 2 months.
2. FRAMES - New frames will be provided once each rwe -four (24) months.
VSP reserves the right to limit the cost of the frames provided by its Member
Doctors undei the Plan. The allowance shall be published periodically by VSP
to its Member Doctors and will be set at a level to cover the majority of
frames in common use.
IF THE COVERED PERSON WISHES TO SEL13CT A MORE EXPENSIVE
FRAME THAN THAT ALLOWED UNDER THE PROGRAM, THE COST
DIFFERENCE SHALL BE BY AGREEIv1MNT BETWEEN THE COVERED
PERSON ANA THE DOCTOR.
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A05191
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DEC 15 '93 10:51 AM VSP SPLES ADMIN P.6
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MESION SERVICE PI-LAN
3. CONTACT LENSPS - LWTATIONS
Necessa�C
Contact lenses are furnished under the VSP Plan when the VSP Member
Doctor secures prior approval for any of the following conditions:
• Following cataract surgery
To correct extreme visual acuity problems that cannot be corrected with
spectacle lenses
• Certain conditions of Anisometropia
• Keratoconus
When the VSP Member Doctor receives prior approval for such cases, they
are fully covered by VSP and are IN LIEU OF THOSE BENEFITS
DESCRIBED UNDER "B. MA'T'ERIALS,°
CONTACT LENSES ONCE$FURNISHED�ONLY��p��OR
DESCRIBED ABOVE CAN
AUTHORIZATION BY VSP, BUT IN MNO EVENT ONTHS MORE FREQUENTLY
THAN EVERY ?'W�Y-FOUR (2-1
When Covered Persons choose contact lenses from a VSP Member Doctor for
reasons other than those mentioned above, VSP will provide benefits as
follows: The initial basic examination will be covered in full as described
under "A. VISION EXAMINATION" and an allowance will be paid toward
contact lens evaluation fee, fitting costs and materials in lieu of those benefits
described under "B.
MATERIALS"
C. LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual
problems that are not correctable with regular lenses. This benefit is subject to the
following limitations:
1. PRIOR AUTSORIZATION - When a Member Doctor suspects a low vision
condition, the doctor requests advance approval prior to beginning services.
VSP consultants may authorize and to�allows the doctor to gather enough
by the doctor to
determine the nature of the problem
facts to propose a treatment plan. The supplementary testing is paid by the
plan with no copayment by the patient.
testis
2. COPAYMENT - After supplementary g, the doctor submits the treatment
P
lan to the VSP consultants. The consultants will review the plan and, if the
Plan is approved, will authorize benefits on a copayment basis with 75% of the
cost being paid by VSP and 25% of the cost being paid by the patient.
3. MAXDUM BENEFIT
- vsp will ears for approved Low Visiom ofn 1care� (excluding
co-
payment) every Y
includes the Supplementary Testing.
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DEC 15 '93 10:51 VSP SALES ADMIN P.7 p
Vl610N SIETMGE N
IV. FACILITIES
This vision care plan is an agreement among various state vision service corporations
throughout the United States. Through these service plans and their extensive nationwide
network of doctors, VSP provides professional vision care to employees and dependents
covered under group vision care plans.
A list of Member Doctors in the Covered Person's geographical location will accompany the
benefit form sent to the Covered Person upon verification of their eligibility. This list
contains the names, addresses and telephone numbers of the Member Doctors. If this list
does not cover the geographical area in which the Covered Person desires to seek services,
the Covered Person may call or write the VSP office nearest him to obtain one which does.
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VISION R"cTI MAN
V.' CHOICE OF PROVIDERS
The VSP Plan provides Covered Persons with a dual choice. If they elect to receive vision
care services from one of the VSP Member Doctors, VSP is a PREPAID program and
covered services as described herein are provided at no out-of-pocket cost (unlessthe
a Plan
the
contains a deductible). Selecting a doctor from the VSP list assures direct payment
doctor and a guarantee of quality and cost control.
SERVICES FROM NON-MPUMER PROVIDER
LIABILITY OF COVERED PERSONS FOR PA'YMEN'T
REnvIBURSEMEN'T PROVISIONS
When a Covered Person chooses to go to a non-member provider, services may be secured
from any optometrist, ophthalmologist hthalmolo st and/or di ensing optician. This Plan then becomes
sP
an indernn�ty plan reimbursing according to a schedule of allowances, The Covered Person
should pay the doctor his full fee. VSP will reimburse in accordance with the following
schedule. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT
TO PAY FOR THE CATION OR THE MATERIALS.
AV OF SERVICES UNDER THIS REI SURSBMENT SCHEDULE I5
SUBJECT TO THE SAME TIME Ln4jTS AND DEDUCTIBLE EXCEPT AS NOTED
ELSEW11EME HEREIN AS, THOSE DESCRIBED FOR MENS13R SERVICES.
SERVICES OBTAINEDFROM A � PROVIDER ARE IN LIEU OF
OBTAINING SERVICES A P gO
MA701vIL1M REMMURSEMLNT FOR SERVICES
FROM NON-M MMER PROVIDER
PROFESSIONAL FEFS $ 40.00
Vision Examination, up to
MAI
M $ 4000
Single Vision Lenses, up to 60.00
Bifocal Lenses, up to 80.00
Trifocal Lenses, up to 125.00
Lenticular Lenses, up to 451 .00
Frame, up to
CQMACT =SO*
(MATERIALS, mTTINGS AND EVALUATION ONLY)
Necessary, up to $210.00
i Elective, up to 105.00
*Determination of "necessary" versus "elective" contact lenses under the non-member
reimbursement schedule will be consistent with Member Doctor services. Reimbursement
'i allowance for necessary and elective contact lenses includes contact lens evaluation fee,
fitting costs and materials and is in lieu of all other material benefits, including spectacle
lenses and frame.
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DEC 15 '93 10:53AM VSP SALES ADMIN P.9
--�� V1SION SERVICE PLAN
r nW VISION BENEFIT
Low Vision benefits secured from a doctor who is NOT a member of the VSP panel
are subject to the same time limits and copayment arrangements as described above
for a VSP Member Doctor. The Covered Person should pay the non-member
provider his full fee. Covered Persons will be reimbursed in accordance with an
amount not to exceed what VSP would pay a member provider in similar
circumstances. NOTE: There is no assurance that this amount will be within the
25% copayment feature.
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THE LENS OWANCES ARE FOR TWO ALLOWANCE WILL BE NE HALF THE AIR; IF ONLY ALLOWANCE.
LENS IS
NEEDED,
THE AMOUNTS SHOWN ARE MAXIMUMS. THE ACTUAL AMOUNT TO BE PAID
IN REIMBURSEMENT TO THE COVERED PERSON SHALL BE THE MAXIMUM
SHOWN IN THE SCHEDULE OF SERVICE, THE AMOUNT CHARGED, OR THE
AMOUNT USUALLY CHARGED BY THE PROVIDER OF SUCH SERVICES TO HIS
PRIVATE PATIENTS, WHICHEVER IS DETERMINED BY VSP TO BE THE LEAST
AMOUNT.
NOT ASSIGNABLE.
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VL%3goN. SEfrVICE MAN
! VI. PROCEDURES FOR USING THE PLAN
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1. A Covered Person must receive an approval of service before visiting a Member
Doctor. Such approval is obtained from VSP-
2. The Covered Person will be provided a list of Member Doctors and will make an
appointment with a Member Doctor of their choice.
I The Covered Person pays only the deductible (if any) to the doctor for the services
covered by the Plan and for any additional ictlaccord ng toeived not their agreement wbth the the
VSP will pay the Member Doc y
doctor.
octor ut su
4. Should the Covered Person receive services from a of a VSP Member Dooetorchhe
mber D
approval or obtain services from a provider who is
Covered Person is responsible for payment in full to the provider.
5, When such approval is received by a Covered Person and services are performed
prior to the expiration date shown on the approval, this will constitute a claim against
the Plan in spite of the Covered Person's termination of coverage or the termination
of the Plan.
6. In emergency cases, when immediate vision care is necessary, a Covered Person can
obtain covered
oves rdservices
nccee c with ythe agreeme t between VSP and the Member Doctor, will be
made m accordance
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05191
DEC 15 '93 10:54AM VSP SALES ADMIN P.11
""ION SERICE PLAN
VII. EXCLUSI6NS AND LIMITATIONS OF BENEFITS
PATIENT OPTIONS
This vision service plan is designed to cover visual n=dS rather than cosmetic matte.
When a Covered Person selects any of the following extras, the Plan will pay the basic cost
of the allowed lenses, and the Covered Person will pay the additional costs for the options.
1. Blended lenses.
2. Contact lenses (except as noted elsewhere herein).
3. Oversize lenses.
4. Photochromic lenses; tinted lenses except Pink #1 and Pink #2.
5. Progressive multifocal lenses.
6. The coating of the lens or lenses.
7. The laminating of the lens or lenses.
8. A frame that costs more than the Plan allowance.
9. Certain limitations on low vision care,
10. Cosmetic lenses.
11. Optional cosmetic processes.
12, UV (ultraviolet) protected lenses.
NOT COVERED
There is no benefit for professional services or materials connected with:
1. Orthoptics or vision training and any associated supplemental testing; Plano lenses; or
two pair of glasses in lieu of bifocals;
2. Replacement of lenses and frames furnished under this Plan which are lost or broken
except at the normal intervals when services are otherwise available;
3. Medical or surgical treatment of the eyes;
4. Any eye examination, or any corrective eye wear, required by an employer as a
condition of employment.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN
THE IOF THE COVERED PERSONS, THIS IS NECESSARY FOR
THE VISUAL WELFARE
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DEC 15 '93 10a54AM VSPS11*
ADMIN • P.12
VISION SERVICE MAN
VM. GENERAL- PROVISIONS
1. VSP acts as a contracting agency hereunder to enable the Group and Covered Persons
to acquire professional vision care on a prepaid basis. VSP shall not assume any
i fiduciary obligations of the Group and is not a named fiduciary or Pian Administrator
as those terms are defined in ERISA. Under no circumstances shall VSP or Group be
liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any
other person or organization performing services or supplying materials in connection
with this contract.
2. All notices provided hereunder shall be deemed as having been properly made upon
depositing the same in the United States mail, postage prepaid, and addressing such
notices to e books of VSP at least or to thirty (30)pdays prioratove at the said action address
taking effeecct.
` ng
last on th
,
Group agrees to cooperate with VSP in disseminating to its members any disclosure
forms, Plan summaries or other material that may be required to be disseminated to
plan enrollees by the Knox-Keene Health Plan Act. It is understood that any such
material required to be disseminated shall be delivered to Group by VSP, and
disseminated by Group to plan enrollees no later than thirty (30) days after the receipt
thereof.
3. Upon receipt of a request for benefits from a Covered Person, VSP will issue a
benefit form to such Covered Person provided:
a) The request is certified b)+ Group; or
b) The member appears eligible by reason of the latest information available to
VSP as furnished by Group.
Benefit forms so issued shall be assigned an expiration date, allowing a reasonable
period of time for the Covered Person to obtain services. Such benefit forms,
prop rl used, shall constitute a claim against VSP, irrespective of later loss of
eligibility by the Covered Person or cancellation of this contract.
4. If any provision of this contract is declared invalid or unenforceable, the remaining
provisions hereof shall remain in full force and effect. The failure of either party to
protest any default or breach shall not constitute a waiver of such party's rights under
this contract, or such parry's rights upon any subsequent default or breach.
S. Neither this contract, nor any benefits hereunder, including the payment of money, is
assignable, except with the prior consent of VSP.
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DEC 15 '93 10:55AM SALES ADMIN • P.13
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VZ,�-;ION SMI"CE FTAN
6. VSP reserves the right to'reject any and all claims for services or benefits which are
filed with it more than one hundred eighty (180) days after completion of services-
7. It is the responsibility of Group representatives to disseminate notice with respect to
material matters to Covered Persons in the Group.
8. Benefitsrovided to Covered Persons will be pursuant to the terms of this contract.
Each Covered Person shall be entitled to obtain the services enumerated herein from
any participating VSP Member Doctor. The names, addresses and telephone numbers
of the participating Member Doctors shall be made available to Covered Persons
when seeking services.
9. The named Plan Administrator for Group's vision benefit plan shall be designated in
the APPLICATION FOR VISION SERVICE PIAN and shall have authority to
control and manage the operation and administration of the Plan on behalf of the
Group.
10. VSP is subject to regulation by the California State Department of Corporations, and
this contract is subject to the
trer3 o Title 10 of atherements of eCalifornialAdon 2 of the ministrative.Code
Chapter and Safety Code and of p
Any provisions required to be in the contract by either of the above shall bind the
Plan whether or not provided in the contract.
11. VSP shall have the right at all reasonable times to inspect such records of Group as
VSP deems necessary to determine the number and eligibility of Covered Persons,
and Group agrees to make such records available at such times and upon such
requests.
12. Group its representatives Snot � roCovered els to any
particular doctors shall
hther ornot a member of the VSP Pan
13. If a VSP provider leaves the Plan for any reason, VSP shall remain responsible for
furnishing vision hecareectin of VSt to P,nthrough anothents of such er Member Doctor.either the
provider, ,
14. VSP agrees to indemnify, defend and hold harmless Group, its shareholders,
directors, officers, agents, employees, successors and assigns from and against any
and ail liability, claim, loss, injury, cause of action and expense (including defense
costs and legal fees) of any nature whatsoever arising from the failure of VSP, its
officers, agents or employees, to perform any of the activities, duties or
responsibilities specified herein. Group agrees to indemnify, defend and hold
harmless, VSP its members, shareholders, directors, officers, agents, employees,
successors and assigns from and against any and all liability, claim, loss, injury,
cause of action and expense (including defense costs and legal fees) of any nature
whatsoever arising or resulting from the failure of Group, its officers or employees to
perform any of the duties or responsibilities specified herein.
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0
VZSI�I�T SERVICE FT_�
Ix. COSTS UNDER THE PLAN
BENEFIT COSTS AND ADVANCE PAYMENT
Group shall provide all funds necessary to pay the covered costs of professional services and
ophthalmic materials (benefits) furnished to Covered Persons pursuant to this contract. In
order to assure timely and adequate payment, Group agrees to make an advance payment of
S6090.QQ. This advance payment is an estimate of benefit costs for one month. Group
agrees to pay the actual costs of benefits on a monthly basis within ten (10) days after receipt
of VSP's statement of benefits paid. The advance payment amount may be adjusted each
contract term if the average of monthly benefit costs increases or decreases. The artier
agree that such advance payment is reimbursable to the Group upon termina io been
contract, after the Group's indebtedness to VSP and/or its benefit providers
satisfied. However, amounts paid to VSP as advance payment shall not be considered assets
of the Group, and need not be held in trust by VSP.
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ADMINISTRATIVE PEE
in consideration of the services rendered by VSP, Group agrees to pay-an administrative fee
J1.
of 2 per eligible employee, per month. Such administrative fee shall be payable monthly
on or before the first (1st) day of each month. After the Initial Term, VSP may, upon sixty
(60) days prior written notice, change this administrative fee provided that VSP shall not
increase this fee more often than once in any twelve (12) month period.
COST INCREASE DUE TO TAX
Notwithstanding the above, VSP reserves the right to increase the amounts due pursuant to
this contract by the amount of any tax or assessment, not now in effect, which is
subsequently levied upon VSP by any state or other taxing authority and which is attributable
to the payments VSP receives from Croup, In the event of such an increase, VSP shall
provide Group with sixty (60) days advance notice.
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DEDUCTIBLE
.j The benefits described herein are available to each Covered Person from any participating
VSP Member Doctor at no cost to the Covered Person. The Covered Person must follow the
proper procedures by obtaining a VSP benefit form and presenting it to the doctor at the time
of the examination.
A DEDUCTIBLE AMOUNT OF * SHALL BE PAYABLE BY THE COVERED
PERSON TO THE MEMBER DOCTOR AT THE TIlVIE OF THE EXAMINATION.
*FIVE DOLLARS ($5.00) or TWENTY-FIVE DOLLARS ($25.00) AS D BY
GROUP.
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DEC 15 '93 10:56AM VSP SALES ADMIN P.15
N71SION SERVICE
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OTHER CHARGES
Any additional care, service, and/or materials not covered by this Plan may be arranged
between the Covered Person and the doctor. p
If the Covered Person does not obtain the VSP benefit form in advance, but visits the
Member Doctor as a private patient, the Member Doctor is not obligated to accept VSP fees
as full payment for these services but may elect to charge his usual and customary fees, the
difference of which is to be paid by the Covered Person.
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VISION SERNUCE PIAN
X. RENEWAL PROVISIONS
'PERM AND CANCELLATION CONDITIONS OF THIS VISION CARE CONTRACT
ARE SHOWN ON THE FACE PAGE OF THIS CONTRACT.
CONTRACT
After the Initial Term of the contract, the contract shall continue on a "month-to-month"
basis, automatically renewing the f�rstday
eonditions shown unless
onface page of this contract.
er notice has been
given in accordance with the cancellation n on
When VSP initiates a cost increase, the date said cost increase is to take effect shall become
the new contract renewal date.
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TERMINATION OF CONTRACT - SERVICES BEING RENDERED
i If service for a Covered Person herein is being rendered as of the termination date of this
contract, such service shall be continued to completion, but in no event beyond six (5)
months after the termination date of contract.
INDIVIDUAL CONTINUATION OF BENEFITS
The VSP program is available to groups of a minimum of ten (10) employees and is,
therefore, not available on an individual basis. When a Group terminates its coverage,
individual coverage is not available for Covered Persons who may desire to retain same.
BASIS FOR 'TERMINATION OF CONTRACT
1. Failure of Group to make payment to VSP as outlined under "IX. COSTS UNDER
THE PLAN"; or
2. The Group falls below minimum size requirement. However, in the event that a.
group falls below ten (10) employees, the group may continue receiving benefits
under this contract by maldng payment to VSP at the minimum group size.
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DEC 15 '93 10:57AM VSP SALES ADMIN P.17
KION SE CE vr.,L� -
XI. CLAIMS APPEAL PROCEDURES
COMPLAINTS - BENEFIT ELIGIBILITY
1. If a claim for benefits is denied, VSP will notify the claimant in writing of the
specific reasons for the denial, including specific references to pertinent Plan
provisions. VSP will also describe any additional materials or information necessary.
2. If the claimant, or the duly authorized representative, so requests within ninety (90)
days of the date of receipt of written denial of the claim, the Group or its designated
Plan Administrator will review the decision denying the claim.
3. The Group or its designated Plan Administrator will give the claimant a reasonable
op rtunity for a full and fair review of the decision denying the claim. The claimant
will be given the opportunity to review pertinent documents, and to submit any
statements, documents, or written arguments in support of this claim,
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4. If thereafter claim is denied, the Group or its designated Plan Administrator will,
within sixty (60) days after receipt of the request for review, advise the claimant in
writing of the specific reasons for the decision, including specific references to the
pertinent Plan provisions on which a decision is based.
COMPLAINTS - PROFESSIONAL SERVICES
1. The Covered Person's written complaint will be referred to VSP for action.
2. The complaint will be evaluated and, if deemed appropriate, the original examining
doctor will be contacted.
3. If the complaint can be resolved within fifteen (15) days, the disposition of the
complaint will be forwarded to the complainant. Otherwise, a notice of receipt of the
complaint will be forwarded to the complainant advising the appropriate time for
resolution.
4. Grievance procedures and complaint forms will be maintained in each Member
Doctor's office.
S. All complaints will be retained by VSP.
IF GROUP OR COVERED PERSONS HAVE ANY QUES'T'IONS ABOUT BENEFITS OR
PROFESSIONAL SERVICES RECEIVED, CONTACT VSP.
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VISILONS V jCE P14�t'
XI1. DEFINITIONS
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ANISOMETROPIA
A condition of unequal refractive state for
the two eyes, one eye requiring a different
li lens correction than the other
BENEFIT FORM A form prepared for a Covered Person
who has received approval of service from
VSP
BLENDED LENSES Bifocals which do not have a visible
dividing line
A benefit form which has been presented
CLAIM
to a member or non-member provider at
,i the time the Covered Person secures
services
COATED LENSES A substance added to a finished lens on
one or both surfaces
COVERED PERSON The employee and dependents (if
dependent coverage is provided) of the
employer participating in the program
GROUP The entity that contracts with VSP on
behalf of its members
KERATOCONUS A developmental or dystrophic deformity
of the cornea in which it becomes
coneshaped due to a thinning and
stretching of the tissue in its central area
Lenses, frame, low vision aids, contact
MATERIALS lenses
ORTHOPTICS The teaching and training process for the
improvement of visual perception and
coordination of the two eyes for efficient
and comfortable binocular vision
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DEC 15 '93 10:58AM VSP SALES ADMIN P.19
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'ION SERVICE -.
OVERSIZE LENSES Larger than standard lens blanks to
accommodate prescriptions i
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PHOTOCHROMIC LENSES Lenses which change color with intensity
of sunlight
PLAN ADMINISTRATOR The person specifically so designated on
the application, or if an administrator is
not so designated, the Group
pLANO LENSES Lenses which have no refractive power
PROFESSIONAL SERVICE Examination, material selection, fitting of
glasses, related adjustments, etc,
TINTED LENSES Lenses which have an additional substance
added to produce constant tint (e.g. pink,
grecs, gray, blue, etc.)
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N7%10N SERVICE FTAZ,' .v
GROUP VISION CARE CONTRACT
TABLE OF CONTENTS
PAGE
I. TERM AND CANCELLATION Cover
ELIGIBILITY DETERMINATION 1
III. BENEFITS AND COVERAGE - SERVICES FROM 2
VSP MEMBER DOCTORS
VISION EXAMINATION
MATERIALS
LENSES, FRAMES, CONTACT LENSES
LOW VISION BENEFIT
IV. FACILITIES 4
j5
V. CHOICE OF PROVIDERS
SERVICES FROM NON-MEMBER PROVIDER
LIABILITY OF COVERED PERSONS FOR PAYMENT
REIMBURSEMENT PROVISIONS
VI. PROCEDURES FOR USING THE PLAN 7
VEXCLUSIONS AND LIMITATIONS OF BENEFIT 8
II.
VIII. GENERAL PROVISIONS 9
IX. COSTS UNDER THE PLAN 11
BENEFIT COSTS AND ADVANCE PAYMENT
ADMINISTRATIVE FEE
COST INCREASE DUE TO TAX
DEDUCTIBLE
OTHER CHARGES
X. RENEWAL PROVISIONS 13
CONTRACT
TERMINATION OF CONTRACT - SERVICES BEING
RENDERED
INDIVIDUAL CONTINUATION OF BENEFITS
BASIS FOR TERMINATION OF CONTRACT
XI. CLAIMS APPEAL PROCEDURES 14
COMPLAINTS - BENEFIT ELIGIBILITY
COMPLAINTS - PROFESSIONAL SERVICES
XII, DEFINITIONS 15
ASP 05191
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