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HomeMy WebLinkAboutReso 92-487 - Approve entering into a Calif Vision Serv agreement between COR & VSP n RESOLUTION NO. �d 7 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. 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. 43 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 15th day of December, 1992, and was duly adopted at said meeting by the following vote: AYES• COUNCIL MEMBERS: Anderson, Arness, Dahl, Kehoe & Moss NOES: COUNCIL MEMBERS: None ABSENT: COUNCIL MEMBERS: None ABSTAIN: COUNCIL MEMBERS: None CHARLIE MOSS, Mayor City of Redding N A ST: FORM PROVED: G CONNIE STROHMAYER, ity Clerk RANDALL A. HAYS, City Attorney VISION SERVICE CALIFORNIA VISION SERVICE (Hereinafter Called VSP) and (Hereinafter Called Group) AGREE AS FOLLOWS: VSP shall provide a panel of doctors to perform services for persons certified as eligible, subject to the terms and conditions of this contract. I. TERM AND CANCELLATION This contract shall be effective commencing for an Initial Term of months, and continuing thereafter until terminated by either parry giving the 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 shall 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 payment pursuant to benefit forms issued prior to the termination date, provided.such benefit forms are filed with VSP within six (6) months after termination of this contract. l ASP 05/91 VISI& SERVICE AGREEMENT 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 writing and 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. CALIFORNIA VISION SERVICE By By Title Title Vice President Date Date November 16. 1992 .i gyp, Q i r tem ASP 05/91 VLSII SERVICE PEA* II. ELIGIBILITY DETERMINATION EMPLOYEES For purposes of this Plan, eligible participants shall be defined as all full-time employees of the employer who work or more hours per week at the employer's normal place of business. New employees shall be added on the first day of the calendar month following complete month(s) of continuous full-time service. Terminating employees shall be excluded from the Plan on the last day of the month in which their employment terminates. DEPENDENTS 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 birthday, or to their birthday if attending school full-time. An unmarried child age 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 the two-year period following the child's attainment of the limiting age. 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 persons upon the termination of employment of said participant, or the termination of the relationship between said participant and his or her dependents. If, and only to the extent, COBRA applies to the parties to this contract, VSP shall make the statutorily-required continuation coverage available for purchase in accordance with COBRA. - , 05/91 VLSI T SERVICE 11LAA M. BENEFITS AND COVERAGE SERVICES FROM VSP MMdBER DOCTORS 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 months. B. MATERIALS Where the vision examination indicates that new lenses or frames or<both are necessary for the proper visual health and welfare of a Covered Person, they will be supplied, together with such professional services as are 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. �i Each Covered Person is entitled to new lenses once each months. 2. FRAMES - New frames will be provided once each months. 'f VSP reserves the right to limit the cost of the frames provided by its Member Doctors under 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 SELECT A MORE EXPENSIVE FRAME THAN THAT ALLOWED UNDER THE PROGRAM, THE COST DIFFERENCE SHALL BE BY AGREEMENT BETWEEN THE COVERED PERSON AND THE DOCTOR. \ ' -2- A 05/91 i VIszOEv SR VICE Pf.,A4 3. CONTACT LENSES - LB=ATIONS Necessary 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. MATERIALS." CONTACT LENSES ONCE FURNISHED UNDER THIS PLAN AS DESCRIBED ABOVE CAN BE REPLACED ONLY WITH PRIOR AUTHORIZATION BY VSP, BUT IN NO EVENT MORE FREQUENTLY THAN EVERY MONTHS. Elective 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 AUTHORIZATION - When a Member Doctor suspects a low vision condition, the doctor requests advance-approval prior to beginning services. VSP consultants may authorize supplementary testing by the doctor to determine the nature of the problem and to allow the doctor to gather enough facts to propose a treatment plan. The supplementary testing is paid by the Plan with no copayment by the patient. 2. COPAYMENT - After supplementary testing, the doctor submits the treatment plan 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 beingaid b VSP and 25% of the cost being aid b the tient. P Y gP Pa Y 3. MANIMUM BENEFIT - VSP will pay a maximum of$1,000 (excluding co- payment) every two (2) years for approved Low Vision care. Maximum includes the Supplementary Testing. _ c —3— y Yea y, L4' A01/92E VISIA4 SERVICE PLAZO IV. FACELITIES 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. 'i r F 41 -4- 05/91 i VISI& SERVICE 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 (unless the Plan contains a deductible). Selecting a doctor from the VSP list assures direct payment to the doctor and a guarantee of quality and cost control. SERVICES FROM NON-MEMBER PROVIDER LIABILITY OF COVERED PERSONS FOR PAYMENT REIMBURSEMENT PROVISIONS When a Covered Person chooses to go to a non-member provider, services may be secured from any optometrist, ophthalmologist and/or dispensing optician. This Plan then becomes an indemnity 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 EXAMINATION OR THE MATERIALS. AVAILABILITY OF SERVICES UNDER THIS REIMBURSEMENT SCHEDULE IS SUBJECT TO THE SAME TIME LIMITS AND DEDUCTIBLE EXCEPT AS NOTED ELSEWHERE HEREIN AS THOSE DESCRIBED FOR MEMBER SERVICES. SERVICES OBTAINED FROM A NON-NEI�IIBER PROVIDER ARE IN LIEU OF j OBTAINING SERVICES FROM A PANEL. MEMBER OF VSP. MAXIMUM REIMBURSEMENT FOR SERVICES FROM NON-MEMBER PROVIDER PROFESSIONAL FEES Vision Examination, up to $ 40.00 MATERIALS PAIR Single Vision Lenses, up to $ 40.00 Bifocal Lenses, up to 60.00 Trifocal Lenses, up to 80.00 Lenticular Lenses, up to 125.00 Frame, up to 45.00 CONTACT LENSES* (MATERIALS, FITTINGS AND EVALUATION ONLY) Necessary, up to $210.00 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 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. �T -5- AB El 01/92 A VISAN SERVICE P1.,A* LOW 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. THE LENS ALLOWANCES ARE FOR TWO LENSES; IF ONLY ONE LENS IS NEEDED, THE ALLOWANCE WILL BE ONE-HALF THE PAIR ALLOWANCE. 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. REIMBURSEMENT BENEFITS ARE NOT ASSIGNABLE. i -V- 05/91 VISAN SERVICE PLA-0 VI. PROCEDURES FOR USING THE PLAN 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. 3. The Covered Person pays only the deductible (if any) to the doctor for the services covered by the Plan and for any additional services received not covered by the Plan. VSP will pay the Member Doctor directly according to their agreement with the doctor. 4. Should the Covered Person receive services from a Member Doctor without such approval or obtain services from a provider who is not a VSP Member Doctor, the 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 services by contacting a VSP Member Doctor. Reimbursement will be made in accordance with the agreement between VSP and the Member Doctor. �a s Ick. -7- 05/91 'j VLSt&v SERVICE P1.A*1 VII. EXCLUSIONS AND LE IITATIONS OF BENEFITS PATIENT OPTIONS This vision service plan is designed to cover visual needs rather than cosmetic materials. 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 !I 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 OPINION OF OUR OPTOMETRIC CONSULTANTS, THIS IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON. -8- AB 07/91 I VISAN SERVICE MAO. VIII. 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 fiduciary obligations of the Group and is not a named fiduciary or Plan 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 VSP at its main office, or to Group representative at the address appearing last on the books of VSP, at least thirty (30) days prior to said action taking effect. 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 by 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, properly 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 party's rights upon any subsequent default or breach. 5. Neither this contract, nor any benefits hereunder, including the payment of money, is assignable, except with the prior consent of VSP. -9- ASP 05/91 CA VIL.S444 SERVICE PLAV. 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. Benefits provided 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 PLAN 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 requirements of Chapter 2.2 of Division 2 of the Health and Safety Code and of Chapter 3 of Title 10 of the California Administrative Code. 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. 11. Group or its representatives shall not engage in referring Covered Persons to any particular doctor, or doctors, whether or not a member of the VSP Panel. 12. If a VSP provider leaves the Plan for any reason, VSP shall remain responsible for furnishing vision care pursuant to patients of such provider, either through the provider, or, at the election of VSP, through another VSP Member Doctor. 13. VSP agrees to indemnify, defend and hold harmless Group, its 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 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. -10- ASP 05/91 CA j VLSI*i SERVICE PT-A,19 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 I . 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 parties agree that such advance payment is reimbursable to the Group upon termination of this contract, after the Group's indebtedness to VSP and/or its benefit providers has been 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. ADMINISTRATIVE FEE In consideration of the services rendered by VSP, Group agrees to pay an administrative fee of$ 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 Group. In the event of such an increase, VSP shall provide Group with sixty (60) days advance notice. d DEDUCTIBLE 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 i\ EMBER DOCTOR AT THE TIME OF THE EXAMINATION. ASP 05/91 CPM SIN SER VICE PEAR OTHER CHARGES Any additional care, service, and/or materials not covered by this Plan may be arranged between the Covered Person and the doctor. 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. 4 -12- 05/91 i II VISIMIN S vVICE P1.4,0 X. RENEWAL PROVISIONS TERM 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 first day of each month, unless proper notice has been given in accordance with the cancellation conditions shown on the face page of this contract. When VSP initiates a cost increase, the date said cost increase is to take effect shall become the new contract renewal date. TERMINATION OF CONTRACT - SERVICES BEING RENDERED 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 (6) 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 making payment to VSP at the minimum group size. -13- ASP 05/91 VISIN SERVICE PLA19. 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 opportunity 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. 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 !i Doctor's office. i 5. All complaints will be retained by VSP. IF GROUP OR COVERED PERSONS HAVE ANY QUESTIONS ABOUT BENEFITS OR PROFESSIONAL SERVICES RECEIVED, CONTACT VSP. -14- 07/91 - VISION SERVILE . XII. DEFINITIONS ANISOMETROPIA A condition of unequal refractive state for the two eyes, one eye requiring a different 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 CLAIM A benefit form which has been presented to a member or non-member provider at 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 MATERIALS Lenses, frame, low vision aids, contact 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 rye\ -15- 05/91 I VISION SERVICE PI.A14, OVERSIZE LENSES Larger than standard lens blanks to accommodate prescriptions 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 'i 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, green, gray, blue, etc.) .i 77 E' 7 ". :. 05/91 VISlol\ SERVICE ;i GROUP VISION CARE CONTRACT TABLE OF CONTENTS j PAGE I. TERM AND CANCELLATION Cover II. ELIGIBILITY DETERMINATION 1 i III. BENEFITS AND COVERAGE - SERVICES FROM 2 VSP MEMBER DOCTORS VISION EXAMINATION MATERIALS LENSES, FRAMES, CONTACT LENSES LOW VISION BENEFIT IV. FACILITIES 4 V. CHOICE OF PROVIDERS 5 SERVICES FROM NON-MEMBER PROVIDER LIABILITY OF COVERED PERSONS FOR PAYMENT REIMBURSEMENT PROVISIONS VI. PROCEDURES FOR USING THE PLAN 7 i VII. EXCLUSIONS AND LIMITATIONS OF BENEFIT 8 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 05/91