HomeMy WebLinkAboutReso 2006-080 - Section 125 Plan
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RESOLUTION NO. 2006 - ~
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF REDDING
APPROVING THE ESTABLISHMENT OF A SECTION 125 PLAN.
WHEREAS, staff recommends that the City Council approve the establishment of the Section
125 Plan in accordance with the provisions of the Memorandum of Understanding (MOU)
between the City of Redding and Redding Peace Officers Association (RPOA), authorizing the
Personnel Director to be the City's authorized representative to execute and revise the Plan as
described below and to serve as the Plan Administrator; and
WHEREAS, it is to be determined to be in the best interest of the City and its employees to
establish a Section 125 Plan;
NOW, THEREFORE, IT IS HEREBY RESOLVED by the City Council of the City of
Redding to establish the Section 125 Plan in accordance with the provisions of the Memorandum
of Understanding (MOU) between the City of Redding and Redding Peace Officers Association
(RPOA), and authorize the Personnel Director to be the City's authorized representative to
execute and revise the Plan as described below and to serve as the Plan Administrator.
I HEREBY CERTIFY that the foregoing Resolution was introduced, read, and adopted at a
regular meeting of the City Council of the City of Redding on the 6th day of June, 2006, by the
following vote:
AYES:
NOES:
ABSENT:
ABSTAIN :
COUNCIL MEMBERS:
COUNCIL MEMBERS:
COUNCIL MEMBERS:
COUNCIL MEMBERS:
Dickerson, Mathena, Pohlmeyer, Stegall, and Murray
None
None
None
ATTEST:
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FORM APPROVED:
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CONNIE STROHMA
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CITY OF REDDING
SECTION 125 PLAN
Effective June 1, 2006
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TABLE OF CONTENTS
SECTION ONE - ESTABLISHMENT AND PURPOSE ...................................;............................................ 1
1.1 Establishment and Purpose ............................................................................................................1
1.2 Effective Date.............. ............. ............ ........ ....................... ....... .... .... ........ ........ ...... ....... ................ 1
SECTION TWO - DEF INITIO NS......................................................... ................................... ....................... 2
2.1 Account........................................................................................... ........... ............. ........................ 2
2.2 Affiliated Organization..................................................................................................................... 2
2.3 Beneficiary or Beneficiaries ............................................................................................................ 2
2.4 Code.................................................................................................................... ............................ 2
2.5 Employee....................................................................................................................................... .2
2.6 Employer......................................................... ....................................... ......................................... 2
2.7 Participant....................................................................................................................................... 2
2.8 Plan................................................................................................................................................. 2
2.9 Plan Administrator........................................................................................................................... 2
2.10 Plan Year ..................................................................................................... ................................... 3
2.11 Salary Reduction Agreement.......................................................................................................... 3
2.12 Salary Reduction Contribution ........................................................................................................3
2.13 Sponsor......... ...... .................. ... ........... ........ ........ ......... ..... ........... ..... .............. .... ... ......... .... ........ ....3
SECTION THREE - ELIGIBILITY AND PARTICIPATION ........................................................................... 4
3.1 Eligibility and Participation .............................................................................................................. 4
3.2 Cessation of Participation ...............................................................................................................4
3.3 Reinstatement of Former Participant.............................................................................................. 4
SECTION FOU R - SALARY REDUCTION ... ........ ............. .... ......... ......... ................. .................. ...... ........... 5
4.1 Salary Reduction Contributions ......................................................................................................5
4.2 Salary Reduction Agreement..........................................................................................................5
4.3 Maximum Amount of Contributions.................................................................................................6
4.4 Notification........ ........ .......................... ............... ....... ............................ ...... ....... ......... ........ ............ 6
4.5 Return or Recharacterization of Contributions ...............................................................................6
SECTION FIVE - PARTICIPANT ACCOUNTS ............................................................................................ 7
5.1 Establishment of Accounts... .......... ............ ........ ........................ ........ ......... ........................... ........7
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Table of Contents
(continued)
SECTION SIX - BENEFIT ELECTIONS ... ..... ....... ................. ......... .......................... ............... ..... ........ ........ 8
6.1 Benefits Provided............................................................................................................................ 8
6.2 Benefit Cost ..... .......... .......... .............. ............ ................. ........................ .... .................... ................ 8
6.3 Election Procedure.......................................................................................................................... 8
SECTION SEVEN - PLAN BENEFITS ....................................................................................................... 11
7.1 Benefit Options....................................................................................... ................. ..................... 11
7.2 Benefit Descriptions ......................................................................................................................11
7.3 Beneficiary Designation ................................................................................................................ 11
SECTION EIG HT - ADMINISTRATION ..... ............... ............................ ................... ......... .................. ........ 12
8.1 Appointment of the Plan Administrator ......................................................................................... 12
8.2 Powers and Responsibilities.........................................................................................................12
8.3 Allocation of Duties and Responsibilities ......................................................................................13
8.4 Expenses .... ......... ....... ....................... .......... ......... ........ ......... ............ .......... ........... ........ .............. 13
8.5 Liabilities ....................................................................................................................................... 13
8.6 Claims Procedures..... ............... ...... .......... ................ ............... ..... .............. .................. ................ 13
SECTION NINE - AMENDMENT, TERMINATION, AND MERGER.......................................................... 15
9.1 Amendment and Termination .......................................................................................................15
9.2 Successor Employer .....................................................................................................................15
9.3 Action by Redding......................................................................................................................... 15
SECTION TEN - MISCELLAN EOUS .. ........... ........ ...... ....... ..................... ...... ......... ............. ......... ............. 16
10.1 Non-guarantee of Employment........ ........ ............ ............. ....... ................................. .................... 16
10.2 Mailing Notices............. ................ ........................ ........... ........ ....... .... ....... ......... ........... ................ 16
10.3 Submitting Notices .......... ................. ................. ........... ...... ......... ................ .......... ........................ 16
10.4 Gender and Number ......................................... .......... ....... ......... ........................ ....... ..... .............. 16
10.5 Applicable Law.......... ................. ........................ ........ ............. ............................... ....................... 16
10.6 Consolidated Omnibus Budget Reconciliation Act of 1985..........................................................16
10.7 Family and Medical Leave Act. ..................................................................................................... 16
10.8 Official Document.......... ................. ...................... ............ .................. ........................................... 17
APPENDIX A - BENEFITS AND COSTS ..................... .............................................................................. 18
APPENDIX B - PARTICIPATION BARGAINING UNITS ......................................................................... 19
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SECTION ONE - ESTABLISHMENT AND PURPOSE
1.1 Establishment and Purpose
City of Redding (Redding) hereby establishes the City of Redding Section 125 Plan (Plan) to
provide taxable and nontaxable benefits to Employees and to permit those Employees to choose
which of the benefits they wish to receive. The Plan is intended to meet the requirements of
Section 125 of the I nternal Revenue Code of 1986 and is to be interpreted in a manner consistent
with the requirements thereof.
1.2 Original Effective Date
This plan shall take effect on June 1, 2006.
City of Redding Section 125 Plan
Effective June 1, 2006
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SECTION TWO - DEFINITIONS
As used herein, the following words and phrases shall have the following respective meanings when
capitalized:
2.1 Account
The Account established by Redding pursuant to Section 5.1 to which a Participant's Salary
Reduction Contributions are credited.
2.2 Affiliated Organization
Any organization which is affiliated with Redding organized under the laws of the State of
California.
2.3 Beneficiary or Beneficiaries
The covered dependent(s) of a Participant, or the individual(s) designated as beneficiary of a
Participant's benefit under the Plan pursuant to Section 7.3.
2.4 Code
The Internal Revenue Code of 1986, as it may be amended from time to time.
2.5 Employee
Any individual who is employed by Redding, or by any Affiliated Organization who has adopted
the Plan, and who meets the eligibility requirements specified in Section 3.1 and elects to
participate in the benefit plans described in Appendix A, other than a person who would be
treated as an employee by Redding under Section 414(n).
2.6 Employer
Redding, any predecessor or successor entity, and any other Affiliated Organization that shall
adopt the Plan with the consent of Redding.
2.7 Participant
Any Employee of Redding, who has met the eligibility requirements of Section 3.1 and who has
made benefit elections pursuant to a Salary Reduction Agreement in accordance with Section
4.2.
2.8 Plan
The City of Redding Section 125 Plan as set forth herein and as amended from time to time.
2.9 Plan Administrator
The person, persons or entity appointed by Redding pursuant to Section 8.1 to manage and
administer the Plan.
City of Redding Section 125 Plan
Effective June 1, 2006
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2.10 Plan Year
The period beginning on June 1 and ending on May 31 of the following calendar year.
2.11 Salary Reduction Agreement
The agreement between the Participant and Redding pursuant to Section 4.2 under which the
Participant elects between taxable and nontaxable benefits under the Plan.
2.12 Salary Reduction Contribution
The amount of compensation which a Participant elects to forego pursuant to a Salary Reduction
Agreement and which Redding contributes to the Plan for the purchase of benefits for the
Participant pursuant to Section 4.1.
2.13 Sponsor
City of Redding.
City of Redding Section 125 Plan
Effective June 1, 2006
Page 3
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SECTION THREE - ELIGIBILITY AND PARTICIPATION
3.1 Eligibility and Participation
Each Employee eligible to participate in the City of Redding Employee Group Health and Dental
Plan shall be eligible to participate in the Plan as of the later of June 1, 2006 or the first day of
employment with Redding, or upon the effective date upon which their respective bargaining unit
becomes eligible to participate in the Plan by making benefit elections pursuant to a Salary
Reduction Agreement in accordance with Section 4.2. The effective date of such benefit elections
shall be determined in accordance with the provisions of Section 4.2(d) and Section 6.
3.2 Cessation of Participation
A Participant shall cease to be a Participant as of the earliest of (a) the date on which the Plan
terminates, (b) the date on which his Salary Reduction Agreement under the Plan expires or is
terminated, or (c) the date on which he ceases to be an Employee.
3.3 Reinstatement or Former Participant
A former Participant whose participation in the Plan had ceased due to cessation of employment
with Redding, and who returns to employment, must meet Redding's then current entry guidelines
to participate in the Plan.
City of Redding Section 125 Plan
Effective June 1,2006
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SECTION FOUR - SALARY REDUCTION
4.1 Salary Reduction Contributions
With the consent of the Plan Administrator, Participants may elect each Plan Year to make Salary
Reduction Contributions, pursuant to a Salary Reduction Agreement, under the terms of Section
4.2, to purchase the benefits provided under Section 7.1 of this Plan.
4.2 Salary Reduction Agreement
(a) Nature of Agreement. The Salary Reduction Agreement shall be a legally binding
agreement (on a form prescribed by the Plan Administrator) under which the Participant
agrees to reduce the compensation otherwise payable to him thereafter by a specified
amount or, upon notice from the Plan Administrator, fails to decline coverage under the
Plan. The Salary Reduction amount may change within a Plan Year if any third party
insurance company providing the selected benefits adjusts the amount it charges for
such coverage. Redding agrees to apply the total amount of Salary Reduction
Contributions elected by the Participant toward the purchase of benefits elected under
Section 6.3. The Salary Reduction Agreement may take the form of a benefit election
form under the Plan.
(b) Agreement Election Period. With respect to any given Plan Year, a Participant may
enter into a Salary Reduction Agreement with Redding only during the Annual Election
Period provided for under Section 6.3(a).
(c) Timing of Salary Reduction. The reduction of a Participant's compensation that is used
for the purpose of providing benefits elected under Section 6 shall be done on a schedule
that is in accordance with the Participant's payroll period.
(d) Effective Date. A Participant's Salary Reduction Agreement shall be effective as soon
as practicable following the day the agreement is received in executed form by the Plan
Administrator, but not before the beginning of the Plan Year to which the Agreement
applies or the date of the commencement of the Participant's participation in the Plan.
(e) Amendment or Termination of Agreement. A Participant may amend or terminate his
Salary Reduction Agreement only at such time as he is permitted to change his benefit
election under Section 6.3(d). A Participant's amended Salary Reduction Agreement, if
consistent with Section 6.3(d), shall be effective as soon as practicable following the date
the amended agreement is received in executed form by the Plan Administrator, but not
before the earlier of the beginning of the Plan Year to which it applies or the occurrence
of an event specified in Section 6.3(d), provided that the amendment is on account of that
change. A Participant may amend his Salary Reduction Agreement during any Plan Year
only in the event of a status change or such other event as provided for by IRS
regulations.
(f) Transfer to Affiliated Organization; Termination of Employment. A Participant's
Salary Reduction Agreement shall automatically terminate if the Participant terminates
his employment with Redding or transfers to an Affiliated Organization which has not
adopted the Plan. If such Participant (or former Participant) subsequently returns to the
employment of Redding, the Participant shall, subject to the eligibility and participation
requirements set forth in Section 3.1, be permitted to execute a new Salary Reduction
Agreement and resume having Salary Reductions made on his behalf. A Participant's
Salary Reduction Agreement shall continue in effect (so long as it was not based on a
negative enrollment) if the Participant transfers to an Affiliated Organization which has
adopted the Plan.
City of Redding Section 125 Plan
Effective June 1, 2006
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4.3 Maximum Amount of Contributions
The amount of Salary Reduction Contributions permitted shall be limited to a maximum
determined by Redding each year.
4.4 Notification
Before making annual benefit elections, all Participants shall be notified of the maximum amount
of Salary Reduction Contributions they may elect to make.
4.5 Return or Recharacterization of Contributions
Notwithstanding any provision in this Plan to the contrary, in the event the Plan Administrator
determines that the Plan may be discriminatory under the Code, a Participant's Salary Reduction
Agreement may be: (a) disregarded to the extent necessary to prevent such discrimination and,
as a result, the amount of Salary Reduction Contributions which would otherwise have been
made pursuant to such Agreement may instead be paid directly to the Participant as additional
compensation; or (b) recharacterized as after-tax Employee Contributions, which are voluntary
nondeductible Employee contributions.
City of Redding Section 125 Plan
Effective June 1, 2006
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SECTION FIVE - PARTICIPANT ACCOUNTS
5.1 Establishment of Accounts
Redding shall create and maintain a bookkeeping account on behalf of each Participant who
elects to have Salary Reduction Contributions made to the Plan. Each Participant's Account shall
be divided into sub accounts which shall be established, as necessary, and credited with a
Participant's Salary Reduction Contributions for benefits provided under Section 7.1 of the Plan
and listed in Appendix A.
City of Redding Section 125 Plan
Effective June 1 J 2006
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SECTION SIX - BENEFIT ELECTIONS
6.1 Benefits Provided
A Participant may elect, pursuant to the procedures described in Section 6.3, to purchase
benefits under Section 7.1 of the Plan through Salary Reduction Contributions or with after-tax
Employee contributions.
6.2 Benefit Cost
The cost to Participants of any benefits provided under the Plan shall be determined by Redding,
regardless of the method of funding the Plan.
(a) Current Cost. The currently effective costs of the benefits provided under the Plan are
set forth in Appendix A to the Plan. Appendix A may be amended from time to time to
reflect, among other things, changes in the rates charged by third party insurance
companies.
(b) Cost Review. Each year, Redding shall review the costs of the benefits provided under
the Plan. Redding may at any time make changes to these costs at its discretion and
shall amend Appendix A to reflect such changes.
(c) Notification. Before making their annual benefit elections, all eligible Employees and
Participants shall be notified as to the currently effective costs of the benefits provided
under the Plan.
6.3 Election Procedure
(a) Annual Election Period. Each year, during the period beginning 30 days prior to the
first day of the new Plan Year, or, in the case of new Participant, during the period
beginning on his date of employment and ending on the first day on which he becomes
eligible to participate, each Participant shall complete an election form indicating which of
the benefits, or combination of benefits, provided, under Section 7.1 herein, he has
elected or, at the discretion of Redding, declined coverage under the Plan upon written
notice to Redding.
(b) Effective Period. An election made under Section 6.3(a) shall be effective only during
the Plan Year for which the election is made. Once made, such election. or a failure to
make such an election, shall be irrevocable as to the Plan Year to which it applies, except
as provided in Sections 6.3(d) and 6.3(i).
(c) Elections Irrevocable. All elections made by a Participant can be changed for the
following Plan Year during the Annual Election Period described in Section 6.3(a). Once
a Plan Year has commenced. a Participant shall not be permitted to revoke an election
which applies to that Plan Year or reallocate his Salary Reduction Contributions among a
different mix of benefits. except as provided in Section 6.3(d).
(d) Special Rule. Notwithstanding the foregoing, a Participant may revoke a benefit election
(including, but not limited to, an election not to receive benefits under the Plan) after the
Plan Year has commenced and make a new election with respect to the remainder of the
Plan Year if both the revocation and new election are on account of and consistent with a
Change in Status pursuant to Section 6.3(e).
(e) Change in Status. For purposes of this Plan. the following events shall constitute a
Change in Status:
City of Redding Section 125 Plan
Effective June 1, 2006
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1. Special Open Enrollment Rights. The exercise of enrollment rights provided for in
IRC Section 9801 (f) and corresponding regulations.
2. Legal marital status. Events that change Employee's legal marital status, including
marriage, death of Employee's spouse, divorce, legal separation, or annulment;
3. Number of dependents. Events that change the number of Employee's
Dependents, including birth, death, adoption, placement for adoption.
4. Employment status. Any of the following events that change the employment status
of the employee, the employee's spouse, or the employee's dependent: a termination
or commencement of employment; a strike or lockout; a commencement of or return
from an unpaid leave of absence; a change in worksite, and a change in employment
status with consequence that the individual becomes (or ceases to be) eligible under
the plan.
5. Dependent satisfies or Ceases to Satisfy Eligibility Requirements. Events that
cause an employee's dependent to satisfy or cease to satisfy the requirements for
coverage on account of attainment of age, student status, or any similar
circumstance.
6. Residence. A change in the place of residence of the employee, spouse or
dependent.
7. Judgment, Decree, or Order. Compliance with a judgment decree, or order resulting
from a divorce, legal separation, annulment, or change of custody including a
qualified medical child support order.
8. Entitlement to Medicare or Medicaid. Upon becoming entitled to Medicare or
Medicaid or loss of such entitlement.
9. Change in Coverage of Spouse or Dependent Under Other Employer's Plan. A
change under the plan of the spouse's, former spouse's, or dependent's employer, if:
i. a cafeteria plan or qualified benefit plan of the spouse's, former spouse's, or
dependent's employer permits participants to make an election change that would be
permitted under these Change in Status rules; or
ii. the cafeteria plan permits participants to make an election for a period of coverage
that is different from the period of coverage under the cafeteria plan or qualified
benefits plan of the spouse's, former spouse's or dependent's employer.
(f) Change in Benefit Cost. If the benefit plan expense under this Plan increases or
decreases during a Plan Year, then the Plan may automatically increase or decrease, as
the case may be, the required periodic contribution of all affected Participants for such
health insurance benefits. Alternatively, if the premium expense increases significantly,
the Plan Administrator may permit the affected Participants to either make corresponding
changes in their premium contribution or revoke their elections and, in lieu thereof,
receive on a prospective basis coverage under another health plan with similar coverage.
In addition, if the coverage under a health insurance benefit provided by an independent,
third party provider is significantly curtailed or cease during a Plan Year, affected
Participants may evoke their elections of such health insurance benefit and, in lieu there
of, elect to receive on a prospective basis coverage under another health plan with
similar coverage.
(g) Allocation of Salary Reduction Contributions. Election of benefits by a Participant in
accordance with Section 6.3(a) and 6.3(d) shall constitute authorization for the Plan
City of Redding Section 125 Plan
Effective June 1, 2006
Page 9
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Administrator to allocate the Participant's Salary Reduction Contributions made on behalf
of the Participant as necessary to purchase the benefits elected.
(h) Procedures. The Plan Administrator shall specify the procedures to be followed in the
distribution, completion and collection of the benefit election forms. The Plan
Administrator may specify any other administrative procedures deemed necessary to
implement and administer the Plan.
(h) Notification. Before making their annual benefit elections, all eligible Employees and
Participants shall be notified of any administrative procedures involved in the benefit
election process.
(i) Failure to Submit an Election Form. An Employee eligible to participate in the Plan but
failing to submit a completed election form to the Plan Administrator on or before the
specified due date for the first Plan Year for which he is eligible shall be deemed not to
be a Participant. Upon failure to submit a completed election form in subsequent Plan
Years, the Employee shall be deemed to have made the same election as was in effect
on the last day of the Preceding Plan Year. If the Employee is deemed to be a
Participant, he shall also be deemed to have agreed to a reduction of his compensation
for the Plan Year equal to the Participant's share of the costs of such insured benefits, as
set forth in Appendix A.
City of Redding Section 125 Plan
Effective June 1, 2006
Page 10
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SECTION SEVEN - PLAN BENEFITS
7.1 Benefit Options
Participants may elect, in accordance with the procedures outlined in Section 6.3, any of the
benefit options listed in Appendix A in which they are eligible to participate. Each year, Redding
shall review the benefits provided under the Plan. Redding may make changes to these benefits
at its discretion and shall amend Appendix A to reflect such changes and shall notify Employees
of such changes.
7.2 Benefit Descriptions
Detailed descriptions of each benefit offered under the Plan are contained in the separate written
plan of benefits.
7.3 Beneficiary Designation
The Participant shall designate the individual(s) who may receive benefits under the Plan due to
the Employee's status as a Participant as follows:
(a) Covered Dependents. Where applicable, the Participant shall designate his
dependent(s) who shall be covered under the Plan on a form provided by the Plan
Administrator, and shall provide such additional information regarding the covered
dependent(s) as deemed necessary by the Plan Administrator with regard to the benefit
coverage provided.
(b) Beneficiary. The Participant shall elect, on a form provided by the Plan Administrator,
the individual(s) who shall receive any benefit under the Plan upon the Participant's
death.
City of Redding Section 125 Plan
Effective June 1, 2006
Page 11
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SECTION EIGHT - ADMINISTRATION
8.1 Appointment of the Plan Administrator
Redding shall designate the Plan Administrator who shall administer Redding's Plan. Such Plan
Administrator may consist of an individual, a committee of two or more individuals, whether or
not, in either such case, the individual or any of such individuals are Employees of Redding, a
consulting firm or other independent agent, or Redding itself. The Plan Administrator shall be
charged with the full power and the responsibility for administering the Plan in all its details. If no
Plan Administrator has been appointed by Redding, or if the person designated as Plan
Administrator by Redding is not available to serve as such for any reason, Redding shall be
deemed to be the Plan Administrator of the Plan. The Plan Administrator may be removed by
Redding, or may resign by giving notice in writing to Redding, and in the event of the removal,
resignation, death or other termination of service by the Plan Administrator, Redding shall, as
soon as practicable, appoint a successor Plan Administrator, such successor thereafter to have
all of the rights, privileges, duties and obligations of the predecessor Plan Administrator.
8.2 Powers and Responsibilities
(a) Administration of the Plan. The Plan Administrator shall have all powers necessary to
administer this Plan, including the power to construe and interpret the Plan documents; to
decide all questions relating to an Employee's eligibility to participate in the Plan; to
determine the amount, manner, and timing of any payment of benefits or change of
accordance with Section 8.6 of the Plan; and to appoint or employ advisors, including
legal counsel, to render advice with respect to any of the Plan Administrator's
responsibilities under the Plan. Any construction, interpretation, or application of the Plan
by the Plan Administrator shall be final, conclusive and binding. All actions by the Plan
Administrator shall be taken pursuant to uniform standards applied to all persons similarly
situated. The Plan Administrator shall have no power to add to, subtract from or modify
any of the terms of the Plan, or to change or add to any benefits provided by the Plan, or
to waive or fail to apply any requirements of eligibility for a benefit under the Plan.
(b) Records and Reports. The Plan Administrator shall be responsible for maintaining
sufficient records to reflect the compensation of each Participant for purposes of
determining the amount of contributions that may be made by others on behalf of the
Participant under the Plan. The Plan Administrator shall be responsible for submitting all
required reports and notifications relating to the Plan to Participants or their Beneficiaries,
the Internal Revenue Service and the Department of Labor.
(c) Rules and Decisions. The Plan Administrator may adopt such rules as it deems
necessary, desirable or appropriate in the administration of the Plan. All rules and
decisions of the Plan Administrator shall be applied uniformly and consistently to all
Employees and Participants in similar circumstances. When making a determination or
calculation, the Plan Administrator may rely upon all such information so furnished,
including the Participant's, former Participant's or Beneficiary's current mailing address.
City of Redding Section 125 Plan
Effective June 1, 2006
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8.3 Allocation of Duties and Responsibilities
The Plan Administrator may, by written instrument, designate persons other than the Plan
Administrator to carry out any of its duties and responsibilities under the Plan. Any such duties or
responsibilities thus allocated must be described in the written instrument. If a person other than
an Employee of Redding is so designated, such person must acknowledge acceptance of the
allocated duties and responsibilities in writing. All such instruments shall be attached to, and
made part of, the Plan.
8.4 Expenses
Redding shall pay all expenses authorized and incurred by the Plan Administrator in the
administration of the Plan, unless, by agreement or common practice, the Plan Administrator
absorbs such expenses.
8.5 Liabilities
Redding agrees to indemnify any Employee, person or entity serving as the Plan Administrator or
as a member of a committee designated as Plan Administrator (including any Employee, person
or entity who formerly served as Plan Administrator or as a member of such committee) against
all liabilities, damages, costs and expenses (including attorneys' fees and amounts paid in
settlement of any claims approved by Redding) occasioned by any act or failure to act in
connection with the Plan, except where such act, or failure to act, is the result of willful neglect or
gross negligence on the part of such Employee, person or entity.
8.6 Claims Procedures
(a) Filing a Claim. Any Participant or Beneficiary under the Plan may file a written claim for
a Plan benefit with the Plan Administrator or with a person named by the Plan
Administrator to receive claims under the Plan. Notwithstanding any other language in
this Section 8.6, any claim which arises under any benefit program listed on Appendix A
shall not be subject to review under this Plan but rather shall be subject to review under
the provisions of the specific programs listed on Appendix A.
(b) Notice of Denial of Claim. In the event of denial or limitation of any benefit or payment
due to or requested by any Participant or Beneficiary under the Plan ("Claimant"), the
Claimant shall be given written notification containing specific reasons for the denial or
limitation of his benefit. The written notification shall contain specific reference to the
pertinent Plan provisions on which the denial or limitation of his benefit is based. In
addition, it shall contain a description of any other material or information necessary for
the Claimant to perfect a claim, and an explanation of why such material or information is
necessary. The notification shall further provide appropriate information as to the steps
to be taken if the Claimant wishes to submit his claim for review. This written notification
shall be given to a Claimant within 60 days after receipt of his claim by the Plan
Administrator or, within 120 days if special circumstances require an extension of time for
processing is required, written notice of the extension shall be furnished to the Claimant
prior to the termination of said sixty (60) day period, and such notice shall indicate the
special circumstances which make the postponement appropriate.
City of Redding Section 125 Plan
Effective June 1, 2006
Page 13
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(c) Right of Review. In the event of a denial or limitation of his benefit, the Claimant or his
duly authorized representative shall be permitted to review pertinent documents and to
submit to the Plan Administrator issues and comments in .writing. In addition, the
Claimant or his duly authorized representative may make a written request for a full and
fair review of his claim and its denial by the Plan Administrator; provided, however, that
such written request must be received by the Plan Administrator (or its delegate) within
sixty (60) days after receipt by the Claimant of written notification of the denial or
limitation of the claim. In appropriate cases, the Plan Administrator may waive the sixty
(60) day requirement.
(d) Decision on Review. A decision shall be rendered by the Plan Administrator within sixty
(60) days after the receipt of the request for review, provided that, where special
circumstances require an extension of time for processing the decision, it may be
postponed on written notice to the Claimant (prior to the expiration of the initial sixty (60)
day period) for an additional sixty (60) days, but in no event shall the decision be
rendered more than one hundred twenty (120) days after the receipt of such request for
review. Any decision by the Plan Administrator shall be furnished to the Claimant in
writing and shall set forth the specific reasons for the decision and the specific Plan
provisions on which the decision is based.
City of Redding Section 125 Plan
Effective June 1,2006
Page 14
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SECTION NINE - AMENDMENT, TERMINATION, AND MERGER
9.1 Amendment and Termination
The Plan may at any time and from time to time be amended, modified or terminated by written
instrument executed by a duly authorized representative of Redding. Any such amendment,
modification, or termination shall become effective on such date as Redding shall determine and
may apply to persons eligible to receive benefits or persons receiving benefits under the Plan at
the time thereof, or both, as well as to persons who otherwise would be eligible to receive
benefits in the future, provided, however, that no such amendment, modification, or termination
shall deprive any Participant of any benefits attributable to reduction in his compensation made
prior to the date of such amendment, modification, or termination.
9.2 Successor Employer
In the event of the dissolution, merger, consolidation, or reorganization of Redding, provision may
be made by which the Plan shall be continued by the successor employer, in which case such
successor employer shall be substituted for Redding under the Plan, as shall constitute an
assumption of Plan liabilities by the successor employer, and the successor employer shall have
all the powers, duties, and responsibilities of Redding under the Plan.
9.3 Action by Redding
Any action by Redding under this Plan shall be by any individual duly authorized by Redding to
take such action.
City of Redding Section 125 Plan
Effective June 1, 2006
Page 15
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SECTION TEN - MISCELLANEOUS
10.1 Non-guarantee of Employment
Nothing contained in this Plan shall be construed as a contract of employment between Redding
and any Employee, or as a right of any Employee to be continued in the employment of Redding,
or as a limitation of the right of Redding to discharge any of its Employees, with or without cause.
10.2 Mailing Notices
Notices, accountings and reports required to be given by the Plan Administrator may be given by
personal delivery or by mail, addressed to the party involved at the last address of such party
recorded on the general address files of the Plan Administrator. If given by mail, the date of
mailing shall be deemed to be the date as of which the same was given or furnished to the
addressee. Any notice required under the Plan may be waived in writing by the person entitled to
such notice.
10.3 Submitting Notices
All notices, designations and elections of Participants shall be submitted to the Plan Administrator
on forms and to the address specified by the Plan Administrator.
10.4 Gender and Number
Whenever used in the Plan, words in the masculine gender shall include masculine or feminine
gender, and unless the context otherwise requires, words in the singular shall include the plural,
and words in the plural shall include the singular.
10.5 Applicable Law
This Plan shall be construed and enforced in accordance with the laws of the State of California
to the extent not superseded by federal law.
10.6 Consolidated Omnibus Budget Reconciliation Act of 1985
Notwithstanding anything in the Plan to the contrary, to the extent required by Code Section
4980B and the Proposed Treasury Regulations thereunder (COBRA), a Qualified Beneficiary who
would lose health care coverage upon the occurrence of a qualifying event (as defined in Code
Section 4980B(f)(3)) shall be permitted to continue coverage under the Plan by electing to make
the applicable contributions, on an after-tax basis, in accordance with procedures established by
the Administrator that are consistent with COBRA. Redding shall provide notice to each covered
Employee and his Spouse of their rights under COBRA accordance with applicable law.
10.7 Family and Medical Leave Act
Notwithstanding anything in the Plan to the contrary, to the extent Redding is subject to the
provisions of the Family and Medical Leave Act (FMLA) and the regulations thereunder, an
Employee on leave of absence under FMLA may choose to continue coverage under the Plan by
making the applicable contributions in the following modes as permitted under the rules
established by the Administrator and in compliance with the FMLA regulations:
(a) Pre-payment made prior to the commencement of the FMLA period on a pre-tax or after-
tax basis; or
(b) Pay-as-you-go basis during the term of the leave on an after-tax basis or pre-tax basis to
the extent that the contributions are made from taxable compensation; or,
City of Redding Section 125 Plan
Effective June 1, 2006
Page 16
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e
(c) Catch-up option so long as the employer and the Participant have agreed in advance of
the coverage period that the Employer will recoup contributions on a pre-tax basis when
the Participant returns from FMLA leave.
An Employee on FMLA leave may also revoke an existing election for the remainder of the
coverage period (i.e., to the end of the Plan Year) or elect to be reinstated upon return from
FMLA leave.
Where FMLA leave spans two cafeteria Plan Years, the Employee on FMLA leave may only
make an election for the remainder of the Plan Year in which the FMLA leave begins.
10.8 Official Document
This document, together with all attachments and appendices, constitutes the entire Plan, and it
is the official Plan Document which sets forth in particularly the terms and conditions of the Plan.
Any discrepancy between the terms, condition or language contained in this Plan document and
the terms, conditions or language of other documents will be resolved in accordance with this
Plan Document. If there are differences in interpretations between this Plan Document and other
documents, the interpretation of this Plan Document shall prevail.
IN WITNESS WHEREOF, the undersigned authorized representative of Redding has executed this Plan
this 31st day of May ,20 06 ,on behalf of Redding to evidence the adoption of
the Plan as set forth herein.
For City Of.Reddi~ . ~
By: &w.4 ~
'Linda Jo on
Title: Director of Personnel
Date: May 31, 2006
City of Redding Section 125 Plan
Effective June 1, 2006
Page 17
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APPENDIX A
City of Redding
Section 125 Plan
Benefits & Costs
Effective Date: Effective June 1, 2006, the benefits and costs under the Plan are as follows:
Benefits: Benefits are available to Participants under the benefit plans sponsored by Redding. For
purposes of employees represented by a bargaining group, these benefits will be available as agreed
upon between Redding and the specific bargaining group. A copy of the City of Redding's Group Health
and Benefit Plan Summary is attached hereto.
Cost: The following schedule of contributions states the amount of premiums required to pay the cost of
the benefits elected by a Participant, subject to the limitations set forth in the City of Redding Section 125
Plan.
Bi-weekly Contributions: Up to 10% of the City's monthly composite rate of the City's health,
prescription, dental and vision programs. (As of June 1, 2006, the monthly amount is $106).
Full-time: Regular employees who work 40 hours per week.
Part-time: Regular employees who work a minimum of 20 hours per week up to a percentage which is
the ratio between hours regularly worked and 40 hours per week.
City of Redding Section 125 Plan
Effective June 1) 2006
Page 18
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APPENDIX B
City of Redding
Section 125 Plan
Participation Bargaining Units
Unit
1.
Part-time regular employees who
elect to participate
2.
Peace Officers Association of Redding
Effective Date
June 1, 2006
June 1, 2006
e
City of Redding Section 125 Plan
Effective June 1 t 2006
Page 19
e CITY OF REDDING e
GROUP HEALTH AND DENTAL PLAN DOCUMENT
RESTATED JULY 2003
TABLE OF CONTENTS
TO ALL EMPLOYEES, RETIREES AND CITY COUNCIL MEMBERS
COST CONTAINMENT IDEAS
PARTICIPATION IN THE PLAN
CLAIMS PROCEDURES
COVERED PERSONS
Description of Eligible Statuses
Waiting Period
Eligibility Dates of Coverage
Effective Dates of Coverage
Pre-Existing Conditions
Employee Responsibility With Respect to Dependent Eligibility
Required Employee Contributions
MANDATORY REVIEW PROVISIONS
Pre- Hospitalization/Surgical
Case Management Services
HIPP AA Privacy Act
MEDICAL BENEFITS
Schedule of Benefits
Outpatient Surgical Procedure List
Second Surgical and/or Third Opinion Benefits
Major Medical Benefits
Eligible Charges
GENERAL MEDICAL EXCLUSIONS AND LIMITATIONS
HOW OTHER COVERAGE AFFECTS BENEFITS UNDER THIS PLAN
Coordination of Benefits With Other Plans
Coordination Procedures
Medicare and Covered Employees
Third Party Liability Recovery Provision
4
5
6
7
8
8
8
9
9
10
11
12
13
13
14
15
19
19
23
24
24
25
33
38
38
39
39
42
e TABLE OF CONTENTS.
TERMINATION OF COVERAGE 44
Employee Coverage 44
Dependent Coverage 44
Re-Enrollment 45
CONTINUATION OF COVERAGE DURING LEAVES
Family Medical Leave Act
Extension of Coverage During Military Service
45
45
46
CONTINUATION OF MEDICAL BENEFITS WHEN COVERAGE ENDS
Due to Total Disability
Extension For Coverage for Developmentally Disabled
or Handicapped Dependent Children
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Conversion Privileges
47
47
47
47
53
DENTAL AND ORTHODONTIA BENEFITS
Schedule of Dental & Orthodontia Benefits
Pre- Treatment Estimates
Description of Dental Benefits
General Dental Exclusions and Limitations
Extension of Dental Benefits When Coverage Ends
Coordination of Benefits
Pre-Existing Conditions Limitations
Continuation of Coverage
54
54
54
55
56
58
58
58
58
GENERAL PLAN PROVISIONS AND ADMINISTRATION
Clerical Error
Amending and Terminating the Plan
Duties of the Plan Administrator
Important Plan Information
59
60
61
61
63
ADOPTION
65
DEFINITIONS
66
INDEX
77
. TO ALL EMPLO~S, RETIREES AND CITY COICIL MEMBERS
The City of Redding is pleased to offer this Plan for you and your eligible Dependents. The Plan is
periodically reviewed to assure we maintain an adequate and reasonably priced program. The City intends to
maintain this Plan indefinitely. However, it reserves the right to terminate, suspend, discontinue or amend the
Plan in whole or in part, at any time subject to collective bargaining.
This Plan is a self-insured Plan, the costs of the Plan are in direct proportion to claims paid. Therefore, it is
important that all participants become familiar with the Plan and use the Plan in an efficient manner to control
costs.
Important terms used throughout this Plan Document are defined in the Definitions section of this document.
When reading this booklet, consult the Definitions section to better understand the meanings of Capitalized and
Bolded terms.
The City, as the Plan Administrator, has selected Blue Cross to provide the Preferred Provider
Organization (PPO) Plan. Services rendered to participants by Blue Cross Preferred Providers (PPO) will be
subject to a discounted rate. Benefits furnished by Non-Participating Blue Cross Providers will be based on
Usual and Customary. Refer to the Schedule of Benefits for a full description of the benefits provided under
this Plan and their reimbursement levels. You may request a directory of PPO Providers in your area to assist
you with the selection of a provider.
IMPORTANT: Please read the Plan document thoroughly and become familiar with its provisions. After you
have read the Plan document, keep it with other valuable papers for future reference. If at any time you have
questions about this Plan, contact Managed Benefit Administrators (MBA) at 1-800-888-1801, or the Personnel
office.
4
e COST CONTAINMENT IDEI
As you access benefits under the Plan, consider the following health reminders to provide you and your
Dependents with additional savings.
A) Ask for Generic Drugs instead of Brand Drugs, if available.
B) Use Preferred Providers. Blue Cross has negotiated discounts with doctors, Hospitals, Physical
therapists, chiropractors, etc. If you do not have a Directory of Preferred Providers, call the Personnel
Office to request one. Using a Preferred Provider reduces your share of costs under the Plan.
C) If you have other insurance coverage, make sure you coordinate benefits between that insurance program
and this Plan. Send copies of claims to both companies for reimbursement.
D) Review your bills carefully. Make sure you are billed only for the services you have actually received. If
you discover a mistake, call the service provider and request a corrected statement.
E) Get second opinions on elective surgeries. The Plan pays for second opinions on surgery. A second
opinion is less costly than a surgery that you mayor may not need. Also, ask your doctor about the
possibility of Outpatient surgery as opposed to Inpatient surgery.
F) Make sure that the Treatment prescribed is the best one available for you. Do not be afraid to discuss
options with your Physician.
G) Be a comparative shopper for health and dental care services. Make sure that you are receiving the best
care at the most competitive price.
H) Become familiar with your benefit Plans. This knowledge will help you maximize your health care
dollar. Do not hesitate to contact the Claims Administrator at 1-800-888-1801 with questions.
I) Schedule on an annual basis Routine and Preventive Services. The Plan provides for preventative health
benefits such as: annual Physicals, mammograms, pap smears, prostrate Cancer Screening,
immunizations, cleanings etc. Refer to the Schedule of Benefits.
J) Emergency rooms should only be. used in the event of a Medical Emergency. A Medical Emergency is
a sudden onset of a condition with acute symptoms requiring immediate medical care, including but not
limited to the following conditions: heart attacks, cardiovascular incidents, poisonings, loss of.
consciousness or respiration, convulsions or other such acute medical conditions. There are several
health clinics in the area which can render non-acute services and are in the Blue Cross Preferred
Provider Organization (PPO) Plan. Remember that the Plan does NOT provide 100% coverage for
emergency room visits.
5
&TICIPATION IN THE PLANe
To assist the Claims Administrator in processing your claims, please follow the steps listed below in the order
in which they appear.
WHEN YOU HA VB A CLAIM:
STEP 1. Secure the proper claim form from your department or the Personnel Office. You should familiarize
yourself with these forms, and make sure that you have the correct form when filing a claim.
STEP 2. Fill out your portion of the claim form(s) completely and accurately. Sign where indicated.
STEP 3. Ask your doctor for a completed Physician's statement or an itemized bill which includes a
diagnosis. A statement indicating that a "balance is due" is not sufficient to process your claim.
STEP 4. If you or one of your eligible Dependents is confined to a Hospital, the Hospital must provide you
with a form and that form must be submitted directly to Blue Cross.
STEP 5. Attach all bills or receipts relating to the services provided. Make sure the bill clearly identifies what
services were performed and the charge for each service. Please keep copies of all documents sent to
the Claims Administrator.
STEP 6. If you have any questions regarding Steps I - 5, contact the Claims Administrator at 1-800-888-
1801.
STEP 7. Forward all completed Inpatient and Outpatient Hospital Claim Forms to: .
Blue Cross
P.O. Box 1937
Rancho Cordova, CA 95741
Pre-Authorization Service: 1-800-274-7767
All other completed claim forms and related bills must be forwarded to the Claims Administrator at:
MBA
P.O. Box 873
Sacramento, CA 95812
6
e CLAIMS PROCEDURES e
NOTICE OF CLAIM. Written notice of a claim must be given to the Claims Administrator within twenty
(20) days of services provided. If this is not possible, written notice must be given as soon as it is reasonably
possible and within stated limits (see Proof of Service).
PROOF OF SERVICE. The Claims Administrator must be given written proof of service within ninety (90)
days after the date of such service. If it was not reasonably possible to give written proof in the time required,
the claim will not be reduced or denied solely for this reason if proof is filed as soon as reasonably possible. In
any event, proof of service must be given no later than one (I) year from date of service unless the claimant was
legally incapacitated. The Claims Administrator may require, as part of the proof, authorization to obtain
immediate medical and non-medical information.
7
e
COVERED PERSONS
e
Benefits for a Covered Person are determined by the Covered Person's status and by the terms of this Plan.
Any change in benefits as a result of a change in status will be effective on the date the change in status occurs.
A Covered Person will not be eligible to receive payment:
(1) for services and/or benefits for which such person is not eligible for; or
(2) in excess of the maximum amount provided under any benefit for which such person is covered.
DESCRIPTION OF ELIGIBLE STATUSES
Status I All Regular, Part-Time Regular and Job Share Employees and their eligible Dependents.
Status II Retired Employees, including covered Dependents, who were covered under this Plan on the day
immediately prior to retirement under the California Public Employees' Retirement System
(CaIPERS). Retired Employees and their covered Dependents are eligible for medical benefits.
Dental and Vision Benefits may be provided for retired Employees and their Dependents. **
Status III City Council Members and their eligible Dependents.
Independent contractors, seasonal or temporary Employees and their Dependents will not be considered
eligible for benefits under this Plan.
ELIGIBLE DEPENDENTS. Dependents eligible for coverage under the Plan are your spouse, unmarried
children up to age 19, and unmarried children up to age 24 if they are enrolled as full-time students. Eligible
children include stepchildren, foster children, legally-adopted children and children of adopting parents pending
adoption procedures. See definition of Dependent under Definitions for further clarification of eligibility.
WAITING PERIOD
There is no applicable waiting period to become eligible for medical benefits under the Plan. However, any
applicable Pre-Existing Conditions will apply to you and/or your Dependents upon enrollment in the Plan.
Pre-Existing Condition exclusions will be reduced by prior Creditable Coverage, as required by the Health
Insurance Portability Act (HIP AA) or other applicable legislation.
** May vary according to City Resolution or Collective Bargaining Agreement
8
e
COVERED PERSONS
e
ELIGIBILITY DATES OF COVERAGE
EMPLOYEE COVERAGE. An Employee becomes eligible for coverage provided by this Plan on the later of:
(1) the Plan's Effective Date; and
(2) on the first day of employment with the City; or
(3) when duly elected and upon taking the oath of office as a City Council Member.
If a former Employee is rehired or reinstated as a Covered Employee, he or she will be treated as a new
Employee for all provisions under this Plan.
DEPENDENT COVERAGE. A Dependent becomes eligible for coverage on the later of:
(1) the date the Employee becomes eligible for coverage; and
(2) the date the Employee first acquires a Dependent, through marriage, birth, adoption or placement for
adoption.
EFFECTIVE DATES OF COVERAGE
EMPLOYEE COVERAGE. Coverage for an Employee becomes effective on the date the Employee satisfies
eligibility requirements for his class and completes an enrollment form. See Eligibility Dates of Coverage.
DEPENDENT COVERAGE. Coverage for a Dependent will become effective on the date the Employee and
Dependent satisfy eligibility requirements under the Plan and make an election to be covered under the
Plan.
If an Employee acquires a new Dependent through marriage, birth, adoption or placement for adoption,
coverage for this Dependent will become effective on the date of the marriage, birth, adoption or placement for
adoption. A copy of the birth certificate, decree of adoption, or other supporting documentation may be
requested to enroll a new Dependent under the Plan.
NEWBORN CHILDREN COVERAGE. A newborn child of a Covered Employee who has Dependent
coverage is not automatically enrolled in this Plan. A Covered Employee must notify the Personnel Office
within 30 days of the child's birth in order for coverage to become effective from the date of birth.
SPECIAL ENROLLEE. The term "Special Enrollee" means an Employee or Dependent who is entitled to
and who requests Special Enrollment: (i) within 30 days of losing other health coverage; or (ii) for a newly
acquired Dependent, within 30 days of the marriage, birth, adoption or placement for adoption.
If an eligible Employee or Dependent declined coverage at the time of initial eligibility (and stated in writing at
that time that coverage was declined because of alternative health coverage) but subsequently loses coverage
under the other health Plan and makes application for coverage under this Plan within 30 days of the loss, such
individual shall be a Special Enrollee provided such person (a) was under a COBRA continuation provision
and the coverage under such provision was exhausted; or (b) was not under such a provision and either the
9
e
COVERED PERSONS
e
. EFFECTIVE DATES OF COVERAGE (Continued)
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 toward such coverage were terminated. Individuals who lose other coverage due to
nonpayment of premium or for cause (i.e. filing fraudulent claims) shall not be Special Enrollees. Coverage for
a Special Enrollee who had other coverage and then lost it shall begin as of the first day of the calendar month
following the enrollment request.
An eligible Employee, who acquires a new Dependent through marriage, birth, adoption or placement for
adoption shall be a Special Enrollee if the eligible Employee, Spouse, or newly acquired Dependent enrolls
within 30 days of acquiring the new Dependent. Coverage for a Special Enrollee shall begin as of the date of
the marriage, birth, or placement for adoption.
IT IS VERY IMPORTANT THAT EMPLOYEES NOTIFY THE PERSONNEL OFFICE WITHIN 30 DAYS OF
ACQUIRING A DEPENDENT(S), OR WHEN DEPENDENTS CEASE TO SATISFY THE ELIGIBILITY CRITERIA
FOR DEPENDENT COVERAGE UNDER THE PLAN A DEPENDENT WILL CEASE TO BE ELIGIBLE FOR
COVERAGE UNDER THE PLAN AS A RESULT OF A CHANGE IN THEIR STATUS. CHANGES IN STATUS ARE
DEFINED AS: MARRIAGE, DIVORCE, LEGAL SEPARATION, A DEPENDENT CHILD REACHING THE MAXIMUM
AGE FOR COVERAGE UNDER THE PLAN OR CEASING TO BE A FULL-TIME STUDENT, THE DEPENDENT'S
DEATH OR FAILURE TO SATISFY MENTAL OR PHYSICAL HANDICAP QUALIFICATIONS.
PRE-EXISTING CONDITIONS (APPLIES TO ALL COVERED PERSONS)
A Pre-Existing Condition is any medical condition, regardless of the cause of the condition, for which medical
advice, diagnosis, care, or Treatment was recommended or received by a licensed health care provider or
practitioner in the 90 day period immediately preceding an individual's becoming covered under this Plan.
Pregnancy, and genetic information with no related treatment is not considered a Pre-Existing Condition.
Treatment includes receiving services and supplies, consultations, diagnostic tests or prescribed medicines.
The Pre-Existing Condition does not apply to pregnancy, to a newborn child, to an adopted child or to a child
placed for adoption, who is covered under this Plan within 30 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 3D-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.
10
e COVERED PERSONS e
PRE-EXISTING CONDITIONS (Continued)
The prohibition on Pre-Existing Condition exclusion for newborn, adopted, or child placed for adoption, 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.
The length of the Pre-Existing Conditions limitation may be reduced or eliminated if a Covered Person has
Creditable Coverage from another health plan. A Covered Person may request a certificate of Creditable-
Coverage from his or her prior plan. If, after Creditable Coverage has been taken into account, there will still be
a Pre-Existing Condition limitation, that individual will be so notified.
Covered charges incurred under medical benefits for Pre-Existing Conditions are not payable unless incurred
90 days (if Treatment free), 6 consecutive months (if not Treatment free), or 12 months (if a Late Enrollee)
after the person's enrollment date. This time may be offset if the individual has Creditable Coverage from his
or her previous health plan.
Creditable Coverage will include coverage under: a self-insured employer group health plan; individual or
group health insurance indemnity or HMO plans, state or federal continuation coverage; individual or group
health conversion plans; Part A or Part B of Medicare; Medicaid; except coverage solely for pediatric vaccines;
the Indian health Service; the Peace Corps Act; a state health benefits risk pool; a public health plan; health
coverage for current and former members of the armed forces and their Dependents; medical savings accounts;
a health insurance for federal Employees and their Dependents.
EMPLOYEE RESPONSIBILITY WITH RESPECT TO DEPENDENT ELIGIBILITY
Employee acknowledges that Employee is responsible to insure that no ineli~ble Dependents of Employee
are receiving benefits under the City of Redding Group Insurance Benefit Plan as described herein. An
Employee who knowingly misrepresents Dependent eligibility to obtain City Group Insurance Benefits for an
ineligible person or who fails to notify the City of a Dependent's loss of eligibility under the Plan, will be .
subject to discipline up to and including termination of employment. The Employee will also be required to
refund to the City any Group Insurance Benefits rendered to ineligible Dependent(s) of the Employee.
OPEN ENROLLMENT
Once each Plan Year, the Plan Sponsor will hold an Open Enrollment period. This is a time when an
individual that does not enroll when first eligible to do so, or who allowed coverage to lapse may enroll. Note:
See Special I;nrollee for exceptions to this provision.
11
e COVERED PERSONS e
REQUIRED EMPLOYEE CONTRIBUTIONS
Employees and City Council Members do not contribute toward the cost of coverage unless the Employee
fails to be in a paid status for 20 hours per week or when the Employee is on leave, other than a leave as defined
by the Family Medical Leave Act (FMLA), or military leave. ** Part-Time Regular, Job Share and Retired
Employees may contribute toward the cost of the group insurance program pursuant to City Resolution or
Collective Bargaining Agreement. **
** May vary according to City Resolution or Collective Bargaining Unit Agreement.
12
e e
MANDATORY REVIEW PROVISIONS
PRE-HOSPITALlZATION/SURGlCAL
Treatment for a Covered Person's Illnesses or Injuries may include Inpatient Hospitalization Services. The
City as the Plan Administrator, has chosen Blue Cross to help assure that every Covered Person continues to
receive the high quality level of care Medically Necessary for Treatment. Blue Cross defines "Medically
Neces,sary" Inpatient care as:
(1) Non-emergency (elective) admission. As soon as the Covered Person is told he/she needs to be
admitted to a Hospital, or needs to have a scheduled surgical procedure, the provider and/or Covered
Person must phone Blue Cross prior to the admission or surgery. The phone number is listed on your
identification card.
(2) Emergency admission. In case of an emergency hospitalization, the call must be made within 72 hours,
or the next business day following the admission.
The person calling Blue Cross will need to provide the Covered Employee's social security number, patient's
name, address, date of birth, and the reason for hospitalization or surgery. The Covered Person is responsible
for informing the attending Physician of the requirements of the Pre.-Hospitalization Review Procedure.
The Blue Cross utilization management nurse will contact the Physician to discuss the proposed admission and
Treatment Plan. If the diagnosis and Treatment meet the criteria for Inpatient Hospital care, the utilization
management nurse and the patient's Physician will discuss the length of time required in the Hospital as well
as any alternative types of care appropriate for recovery.
NOTE: In no instance will prior authorization be required for an Inpatient pregnancy admission which does
not exceed 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
However, if or when the pregnancy confinement for the mother or newborn is expected to exceed these limits,
prior authorization for such extended confinement is required.
Blue Cross can arrange a Home Health Care program under the direction of the Covered Person's Physician.
The Home Health Care alternative may often be the most medically appropriate and cost effective' Treatment
for the Illness or Injury.
Penalty for Non-Compliance: If the above preauthorization requirements are not completed, an additional
deductible may be added to eligible Hospital charges. **
** May vary according to City Resolution or Collective Bargaining Agreement.
13
e e
MANDATORY REVIEW PROVISIONS
CASE MANAGEMENT SERVICES
In situations where extensive or ongoing medical care will be needed, the Utilization Management Organization,
Blue Cross of California, may, with the patient's and the City's consent, provide Case Management services.
Such services may include contacts with the patient, his family, the primary treating Physician, other caregivers
and care consultants, and the Hospital staff as necessary.
Blue Cross will evaluate and summarize the patient's continuing medical needs, assess the quality of current
Treatment, coordinate alternative care when appropriate and approved by the Physician and the City, review
the progress of alternative Treatment after implementation, and make appropriate recommendations to the
City. In order for a Covered Person to obtain medically appropriate care in a more economical and cost-
effective way, Blue Cross may recommend an alternative Plan of Treatment which includes services and/or
supplies not otherwise covered under this Plan. Benefits are provided for such an alternative Treatment Plan
on a case-by-case basis. The Plan Administrator has absolute discretion in deciding whether or not to offer to
substitute benefits for any Covered Person, which alternative benefits may be offered, and the terms of the
offer.
If the Plan elects to provide alternative benefits for a person in one instance, it will not be obligated to provide
the same or similar benefits for that period or other person in any other instance, nor will such election be
construed as a waiver of the City's right to administer the Plan thereafter in strict accordance with the
provisions of this Plan.
HIPAA PRIVACY RULES
Under the HIP AA Privacy Rules a Plan Sponsor has certain specific responsibilities. The Privacy Rules create
national standards for the protection of a person's individually identifiable health information. Individually
identifiable information is health information, including demographic information that is either created or
received by a health care provider, health plan, employer or health care clearinghouse. This information relates
to an individual's physical or mental health (past, present, or future), or the health care or payment for health
care of the individual. The Privacy Rules apply to information that may be transmitted by electronic media,
maintained in any electronic medium, or transmitted or maintained in any other form or medium.
The following describes those responsibilities and duties under the HIP AA Privacy Rules.
Disclosures bv the Plan to the Plan Sponsor. Under the Privacy Rules, a Plan Sponsor will:
1. Not use or further disclose information other than as permitted or required by Plan documents or by law;
14
!.NDATORY REVIEW PROVItONS
HIPAA PRIVACY RULES (Continued)
2. Ensure that any agents, including subcontractors, to whom it provides protected health information received
from the Plan, agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to
such information;
3. Not use or disclose the information for employment-related actions and decisions or in connection with any
other benefit or employee benefit Plan of the Plan Sponsor;
4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures
provided for herein of which it becomes aware;
5. Make available protected health information in accordance with the Privacy Rules which provide an
individual the right of access to inspect and obtain copies of protected health information about that
individual contained in a designated record set;
6. Make available protected health information for amendment and incorporation to protected health
information in accordance with the Privacy Rules;
7. Make available the information required to provide an accounting of disclosures in accordance with the
Privacy Rules;
8. Make its internal practices, books, and records relating to the use and disclosure of protected health
information received from the Plan available to the Secretary of the Department of Health and Human
Services or those acting under the authority or at the direction of the Secretary for purposes of determining
compliance by the Plan with the Privacy Rules;
9. If feasible, return or destroy all protected health information received from the Plan that the Plan Sponsor
.still maintains in any form and retain no copies of such information when no longer needed for the purpose
for which the disclosure was made. If 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; and
10. Ensure that the adequate separation required in accordance with the Privacy Rules is established. This will
provide for adequate separation from a group health Plan and Plan Sponsor. This separation must:
a. Describe the employee or classes of employees or other persons under the control of the Plan
Sponsor to be given access to the protected health information relating to payment under, health
care operations of, or other matters pertaining to the group health Plan in the ordinary course of
business.
b. Restrict the access to and use by such employees and other persons described above to the Plan
administration functions that the Plan Sponsor performs for the group health plan; and
15
e e
MANDATORY REVIEW PROVISIONS
HIPAA PRIVACY RULES (Continued)
c. Provide an effective mechanism for resolving issues of noncompliance by persons described
above in accordance with the Privacy Rules.
Disclosures bv Others to the Plan Sponsor. For purposes of conducting operations on behalf of the Plan, the
Plan Sponsor shall be entitled to receive protected health information from:
1. the Plan;
2. any business associate of the Plan;
3. any person or entity that contracts with such business associate;
4. any person or entity that contracts with the Plan Sponsor to provide services to or on behalf of the Plan;
5. any health insurer or health insurance issuer and HMO that provides health benefits coverage or services
to or on behalf of the Plan;
6. any health care clearinghouse that provides services to and on behalf of the Plan or with respect to Plan
participants; and
7. any other person or entity that maintains, or has the authority to direct the disclosure of, protected health
information related to any Plan participant.
Adequate Separation
Only those persons & classes of persons described below that are under the control of the Plan Sponsor shall be
given access to protected health information that is disclosed to or otherwise obtained by the Plan Sponsor.
This is provided that any employee or person under the control of the Plan Sponsor who receives protected
hea.lth information relating to payment, health care operations or other matters pertaining to the Plan in the
ordinary course of business shall be included and treated as such a person or as within the class of persons
described below:
(a) an officer or employee who serves as the Plan Administrator;
(b) an officer or employee who serves as a Plan fiduciary; and
(c) an officer or employee who performs functions related to the Plan, including but not limited to human
relations, audit, legal, accounting and systems personnel.
The persons and classes of persons described above shall be given access to and permitted to use protected
health information that is disclosed to or otherwise obtained by the Plan Sponsor solely for the purpose of Plan
administration functions that the Plan Sponsor performs for the Plan.
16
t!NDATORY REVIEW PROVI'ONS
HIPAA PRIVACY RULES (Continued)
Any person or class of persons described above who obtains access to or uses protected health information in a
manner that is contrary to the requirements of the Privacy Rules shall be subject to the Plan Sponsor's
disciplinary policies and procedures up to and including termination of employment. Regardless of whether a
person is disciplined or terminated, the Plan reserves the right to direct that the Plan Sponsor, and upon receipt
of such direction, the Plan Sponsor shall modify or revoke any person's access to or use of protected health
information.
Permitted Use and Disclosure of Protected Health Information. The Plan Sponsor is and shall be entitled
to use and disclose any protected health information obtained in accordance with the Privacy Rules and any
other information that may reasonably be deemed to be protected health information, regardless of the source of
such information, that comes into the possession of the Plan Sponsor, only for the following:
(a) to provide and conduct administrative functions related to payment and health care operations for
and on behalf of the Plan;
(b) to audit payments for claims incurred under the Plan;
(c) to request proposals for services to be provided to or on behalf of the Plan; and
(d) to investigate fraud or other unlawful acts related to the Plan and committed or reasonably suspected
to have been committed by a Plan participant.
Required Uses and Disclosures of Protected Health Information. The Plan Sponsor shall be required to use
and/or disclose protected health information:
(a) to an individual when requested under and as required by the Privacy Rules ~n order to provide an
individual with access to his or her own protected health information;
(b) to an individual when requested under and required by the Privacy Rules in order to provide an
individual with an accounting of disclosures of that individual's protected health information; and
( c) when required by the Secretary of the Department of Health and Human Services or those acting
under the authority or at the direction of the Secretary to investigate or determine the Plan's
compliance with the Privacy Regulations.
Prohibited Uses and Disclosures. The Plan Sponsor shall not be entitled to use or disclose protected health
information for any purpose for which use and disclosure is not expressly allowed under the Privacy Rules.
This includes:
(a) using or disclosing protected health information other than as permitted or required under applicable
federal or state law; or in a manner inconsistent with the Privacy Rules; and
17
MAIATORY REVIEW PROVISIO'S
HIPAA PRIVACY RULES {Continued}
(b) taking adverse employment action against any Plan participant who is an employee of Plan
Sponsor, except with respect to any fraud or unlawful act related to the Plan and committed or
reasonably suspected to have been committed by such person.
Minimum Necessary. The Plan Sponsor must make reasonable efforts when using, disclosing or requesting
protected health information to limit the protected health information to the minimum necessary to achieve the
purpose of the use or disclosure. This will not apply:
(a) for treatment purposes, but will apply for health care operations and payment;
(b) communications between treating physicians and medical personnel, including case management
services, as long as the communications are necessary to render appropriate and adequate medical care;
(c) in situations where an authorization has been received; and
(d) for disclosures required under workers' compensation programs.
18
e MEDICAL BENEFITS e
SCHEDULE OF BENEFITS
All benefits described in this Schedule of Medical Benefits are subject to the exclusions and limitations
described more fully herein including, but not limited to, the Plan Administrator's determination that: care and
Treatment is Medically Necessary; that charges are Usual and Customary; that services, supplies and care
are not Experimental and/or Investigational. (The meaning of these capitalized items are in the Definitions
section of this document.)
MAXIMUM BENEFITS
LIFETIME MAXIMUM BENEFIT PER COVERED PERSON (PPO or NON-PPO)
While covered under the City's Plan:
Maximum Lifetime Benefit Per Covered Person
(All Disabilities)
$1,000,000**
or $2,000,000* *
Within the above maximum are the following Lifetime benefit Maximums per person:
Temporomandibular Joint Dysfunction Syndrome (TMJ)
Inpatient Mental or Emotional Conditions
(Limited to 90 Days per Calendar Year)
$1,000*
180 Days
Inpatient Alcoholism and/or Drug Dependency
(Limited to 30 Days per Calendar Year)
CALENDAR YEAR MAXIMUM BENEFITS PER PERSON. Within the above Lifetime maximums are the
following Calendar Year maximums per person:
60 Days
Outpatient Benefit for Mental or Emotional conditions, Alcohol and/or
Drug Dependency 36 visits per Calendar Year
Inpatient Benefit for Mental or Emotional conditions
(Limited to 180 Days per Lifetime)
90 days per Calendar Year*
Inpatient Benefit for Alcoholism and/or
Drug Dependency
(Limited to 60 days per Lifetime)
Home Health Care
30 days per Calendar Year*
100 Visits per Calendar Year
Skilled Nursing Facility
Physical Therapy Alternatives
Annual Physical (age 6 and older)
140 Days per Calendar Year
$650 per Calendar Year
$250 per Calendar Year
*lncluded in Maximum Lifetime Benefit ** May vary according to City Resolution or Collective Bargaining Agreement.
19
e . MEDICAL BENEFITS e
. SCHEDULE OF BENEFITS (Continued)
DEDUCTIBLE
Each Calendar Year
per individual
per family maximum
$100 or $200 **
$300 or $600 **
BENEFIT PERCENTAGE FOR FIRST $5,000 OF ELIGIBLE CHARGES PER CALENDAR YEAR.
The percentages payable for PPO facilities are of the contracted charge. The Non-PPO percentages are of
Usual and Customary fees.
HOSPITAL EXPENSES
(Deductible Waived)
PPO
NON-PPO **
Daily Room & Board (registered bed patient) and
miscellaneous charges-Non-PPO limited to Hospital's average
semi-private room charge
Intensive Care Unit - (Non-PPO limited to 3 times
the semiprivate room charge)
100%
100% **
100%
100% **
PHYSICIAN CHARGES
(Subject to Deductible)
Includes Psychiatric visits for medication management
80%
80% or 70% **
MENTAL OR EMOTIONAL CONDITIONS, ALCOHOLISM AND DRUG DEPENDENCY
Wh~n Hospital confined, (see definition of Hospital), up to
90 days per Calendar Year or 180 days Lifetime for mental
or emotional condition
and 30 days per Calendar Year or 60 days Lifetime for
Alcoholism and Drug Dependency
100%
100% **
100%
100% **
NOTE: Two days of partial confinement will be considered as one day of
confinement. Partial Treatment means Treatment of at least 3 hours
but no more than 12 hours in any 24-hour period.
(a) Eligible Charges incurred on an Inpatient basis (Same as any Illness) subject to Plan limits as
set forth in the Schedule of Benefits.
(b) Eligible Charges incurred on an Outpatient basis subject to Plan limits as set forth in the
Schedule of Benefits.
** May vary according to City Resolution or Collective Bargaining Unit Agreement.
20
e MEDICAL BENEFITS tit
SCHEDULE OF BENEFITS (Continued)
EMPLOYEE ONLY - The Deductible is waived for the first twelve (12) visits per Calendar Year,
which are payable at 100%. After the first twelve (12) visits per Calendar Year, the Deductible is
applied, and all subsequent visits are payable at 80%, up to the Plan maximum. - Maximum of 36 visits
per Calendar Year.
DEPENDENTS - The Deductible is waived for the first six (6) visits per Calendar Year, which are
payable at 50%. After the first six (6) visits per Calendar Year, the Deductible is applied, and all
subsequent visits are payable at 80%, up to the Plan maximum. Maximum of 36 visits per Calendar
Year.
NEWBORN CARE
PPO
NON-PPO **
Nursery care in the Hospital
Discharge Physician visit (Subject to Deductible)
100%
80%
100%
80% or 70% **
WELL BABY CARE (BIRTH THROUGH AGE 5)
For Physician services and immunizations - after deductible
80%
80% or 70% **
**May vary according to City Resolution or Collective Bargaining Agreement.
PRESCRIPTION DRUG PLAN
The Plan Administrator has selected Pharmaceutical Care Network (PCN) as its prescription benefit manager.
Covered Persons must use a PCN pharmacy for the following copays to apply.
All eligible Prescription Drugs and medicines will be reimbursed through the Prescription Drug Plan with
the following co-payments:
1. Retail:
Generic Drugs $5.00
Brand Name Drugs $15.00
The above co-payments apply to a maximum 34 days supply.
2. Mail order:
Generic Drugs $7.50
Brand Name Drugs $22.50
The mail order co-payments apply to a maximum 90 days supply and are available for long term maintenance
drugs (e.g., blood pressure medication, insulin, allergy medication, etc.). There are no annual Deductibles with
the Prescripti~n Drug Plan.
21
e MEDICAL BENEFITS e
SCHEDULE OF BENEFITS (Continued)
If a Generic Drug is not available, a Brand Name Drug may be substituted according to the following co-
payment schedule: 1) $8.50 which applies to the retail Prescription Drug Plan, or 2) $12.75 which applies to
the mail order Prescription Drug Plan.
Any family member who has primary coverage elsewhere should NOT use the City's Prescription Drug
benefit as primary. These individuals should make purchases and submit claims to their primary carrier first.
The receipt documentation of what the primary carrier paid and a claim form would then be processed through
the City's Claims Administrator to coordinate the benefits. (See Coordination of Benefits section.)
COST CONTAINMENT BENEFITS (Deductible Waived)
Outpatient Surgery (for facility, radiologist,
pathology and anesthesiologist)
PPO
NON-PPO **
100%
100% or 70% **
Second Surgical Opinions
100%
100% or 70% **
Home Health Care (prior DR approval required)
One visit per day, 100 visits per Calendar Year.
80%
80% or 70% **
First $150 of Diagnostic (DXL) X-ray and Lab expenses
per Illness per Calendar Year
100%
100% or 70% **
First $150 of annual Cancer Screening per calendar
year
100%
100% or 70% **
Charges made by a Hospital for Inpatient Services
(includes charges by an outside Physician for
radiology, pathology and anesthesiology services
performed while the Covered Person is Inpatient)
100%
100%
OTHER MEDICAL EXPENSES (Subject to Deductible)
Physician
Other services and supplies
PPO
80%
80%
NON-PPO **
80% or 70% **
80% or 70% **
OTHER BENEFIT PROVISIONS
Skilled Nursing Facilities 140 days
PPO
80%
NON-PPO **
80% or 70% **
Birthing Centers 100% 100% ** .
** May vary according to City Resolution or Collective Bargaining Agreement.
Waiver of Insured Percentage. If a Covered Person incurs $5,000 of Eligible Charges which are payable at
less than 100% during a Calendar Year in excess of the Deductible(s), Eligible Charges subsequently
incurred during that Calendar Year and the next following Calendar Year will be paid at 100% of Usual and
Customary fees. **
22
e MEDICAL BENEFITS tit
SCHEDULE OF BENEFITS (Continued)
Charges incurred for Treatment of mental or emotional conditions and alcoholism and drug dependency will
not count toward the $5,000 of Eligible Charges, nor be payable at 100% after the $5,000 has otherwise been
incurred.
Any covered charges payable at 100% will not count toward this $5,000.
Charges incurred and processed through the Prescription Drug Plan do not count toward the $5,000 amount.
** May vary according to City Resolution or Collective Bargaining Agreement.
OUTPATIENT SURGICAL PROCEDURE LIST
Ambulatory (same day/Outpatient) surgery is performed for many types of procedures which do not have pre-
determined medical indication for Hospital admission.
The list below is a representative sample of some of the surgeries routinely done on an Outpatient basis. You
should check with your Physician to see if any needed surgery can be performed on an Outpatient basis.
Adenoidectomy
Arthroscopy
Breast Biopsy
Capsulectomy
Capsuloplasty
Carpal Tunnel Release
Cataract Extraction
Cystoscopy
Dilation & Curettage
Exostectomy
Gastroscopy
Hemorrhoidectomy
Herniorrhaphy
Iridectomy
Ligament Repair
Simple Mastoidectomy
Meniscectomy
Myringoplasty
Metatarsal Ostectomy
Pilonidal Cyst Removal
Prostate Biopsy.
Tonsillectomy
Tubal Ligation
Varicocele Excision
Vasectomy
Removal of adenoids
Examination of the interior of a joint usually the knee through an
arthroscope
Surgical removal of tissue or lump for diagnosis
Removal of a capsule from a joint
Surgical repair of a joint capsule
Removal of Fibrous tissue from the tendons and nerves of wrist to
relieve pressure
Removal of the lens from the eye
Operation or biopsy of the bladder or urinary through a cystoscope
Expansion of the uterus for scraping the uterine wall
Removal of a one spur
Examination of the interior of the stomach through a gastroscope
Removal of hemorrhoids
Surgical repair of a hernia
Removal of part of the iris from the eye
Repair of an injured or abnormal collateral ligament
Removal of part of the temporal bone
Removal of cartilage from a joint, usually the knee
Repair of a perforated eardrum
Repair of a bone or part of a bone from the foot
Removal of a cyst from tissue in anal area
Removal of tissue from prostate
Removal of tonsils
Female sterilization
Removal of a varicose vein from the testicle
Male sterilization
23
e
MEDICAL BENEFITS
e
SECOND SURGICAL and/or THIRD OPINION BENEFITS
When surgery is Medically Necessary and advised by a Physician, a Covered Person may get a Second
Surgical Opinion. Benefits for the Second Surgical Opinion will be payable for Covered Medical Benefits
incurred for such second opinion, on a Outpatient basis, but only for:
1. Physician's charges; and
2. Related diagnostic testing
The Physician who provides the second opinion must be one who:
1. treats the type of condition for which surgery is advised; and
2. is not scheduled to do the surgery; and
3. has no business or financial relationship with the original Physician recommending or performing the
surgery.
If the second Physician disagrees with the first Physician, benefits will be payable for the cost of a third
opinion, subject to the same conditions as listed above.
A Second Surgical Opinion is an evaluation of the need for surgery by a second Physician (or a third Physician
if the opinions of the Physician recommending surgery and the second Physician are in conflict), including the
Physician's exam of the patient and diagnostic testing.
The Covered Person may choose any Physician for the Second Surgical Opinion. If the first and second
opinions differ, the Plan provides for full payment of Eligible Charges for a third final surgical opinion.
Covered Persons retain the choice to either have, or not have, the recommended surgery, regardless of what a
second or third Physician recommends. THE ULTIMATE DECISION TO HAVE SURGERY OR NOT
REMAINS WITH THE COVERED PERSON.
Benefits for the cost of a second opinion, and a third opinion, where necessary, are payable as shown in the
Schedule of Benefits.
MAJOR MEDICAL BENEFITS
DEDUCTIBLE. The Deductible is an amount of Eligible Charges that a Covered Person must incur before
Major Medical Benefits are payable. The Deductible will be met when Eligible Charges equal the individual
Deductibie shown in the Schedule of Benefits.
The Covered Person must meet a new Deductible each Calendar Year. A Calendar Year begins on January
1 st and ends on December 31 st of that same year. Eligible Charges not incurred until October, November or
December of the preceding year which were applied to the Deductible of the previous Calendar Year will
carry over and be applied to the Deductible for the current Calendar Year.
24
e MEDICAL BENEFITS e
MAJOR MEDICAL BENEFITS (Continued)
The Deductible will be applied separately to each Covered Person's Eligible Charges except when the Family
Deductible (shown on the Schedule of Benefits) has been met by the Family Unit. In the event that the Family
Deductible is met, all members of the Family Unit will continue to receive benefits during that Calendar Year
period; and no further Deductible will be required during that Calendar Year.
BENEFIT PERIOD. A Covered Person's Benefit Period begins when the Covered Person has incurred,
during the Calendar Year, Eligible Charges equal to the Deductible. A Covered Person's Benefit Period
ends on the earliest of the following dates:
(1) the last day of the Calendar Year;
(2) the day such Covered Person's coverage provided by the Plan ends; or
(3) the day the Maximum Benefits under the Plan are paid.
BENEFIT. The Plan will pay Medical Benefits if, during a Benefit Period, a Covered Person incurs charges
which:
(1) are not excluded by the terms of the Plan; and
(2) are not paid under any other terms of the Plan.
The amount of Benefit to be paid will be equal to:
ELIGIBLE CHARGES
Only charges incurred by a Covered Person while covered under this Plan may be considered Eligible
Charges. A charge is considered to be incurred on the date a service is performed or a purchase is made. .
Eligible Charges are the actual. charges (but not more than the Usual and Customary charges) incurred for an
Illness or Injury for one or more of the following:
(1) Room and board and routine nursing services for each 24 hour period of admittance and confinement in
a Hospital or Free-Standing Chemical Dependency Treatment Center.
(2) Intensive or cardiac care room and board if Medically Necessary.
(3) Medical services and supplies furnished by a Hospital.
(4) Anesthetics and their use.
25
e e
MEDICAL BENEFITS
ELIGIBLE CHARGES (Continued)
(5) Fees of Physicians for medical Treatment including, but not limited to, fees for surgical procedures.
(6) Services of a registered nurse (R.N.) or licensed practical nurse (L.P.N.) for private duty nursing.
(7) Services of a licensed Physical therapist.
(8) X-rays (other than dental), laboratory tests, and other diagnostic services which:
(a) are performed as a result of definite symptoms of an Injury or Illness; or
(b) reveal the need for medical Treatment.
(9) X-ray and radiation therapy.
(10) The transport of a Covered Person:
(a) within the continental United States and Canada;
(b) by means of a professional ambulance service or regularly scheduled airline or railroad service;
and
(c) to or from the nearest Hospital qualified to provide Medically Necessary Treatment.
(11) Medical supplies as follows:
(a) Drugs and Medications
(i) which are approved by the Food and Drug Administration;
(ii) which require the written prescription of a Physician; and
(iii) which must be dispensed by a participating pharmacist of the Prescription Drug Plan
network.
(b) Blood or other fluids
(c) Artificial limbs and eyes to replace natural limbs and eyes. In addition, repair and adjustment of
prosthetic devices, when Medically Necessary.
(d) Contact lenses or lenses for standard glasses only if required promptly after and because of
cataract surgery.
( e) Casts, splints, trusses, braces, crutches and surgical dressings.
(f) Rental of (or purchase of, if more cost effective) hospital-type equipment including but not
limited to wheel chair, Hospital bed, iron lung, oxygen and kidney dialysis equipment.
(12) Charges for services performed in an Outpatient Surgical Center.
(13) Room and board charges for each day of confinement in a Skilled Nursing Facility determined to be
Medically Necessary, up to a maximum of 140 days per Calendar Year, if:
26
e MEDICAL BENEFITS tit
ELIGIBLE CHARGES (Continued)
(a) The Covered Person is admitted to the Skilled Nursing Facility by a Physician; and
(b) The Covered Person is under the active medical supervisiori of a Physician; and
(c) The services rendered are consistent with the Illness, Injury, degree of disability and medical
needs of the Covered Person.
No payment will be made for Skilled Nursing Facility confinement:
(a) For charges which are excluded from coverage by the terms of the Plan; or
(b) To the extent that the charges are paid under any other terms of the Plan.
Room and board charges: charges made by a Skilled Nursing Facility for the cost of room, meals and services
(such as general nursing services) provided to all Inpatients on a routine basis, and is limited to the lesser of the
facility's regular semi-private room rate.
(14) Services of a licensed speech therapist when speech loss is due to a congenital defect for which
corrective surgery has been performed or an Illness or an Accident, except a mental, psycho neurotic, or
personality disorder.
(15) Second Surgical Opinion.
(16) Newborn Care: A newborn child is a Covered Person at the time of birth provided the Covered
Employee notifies the Personnel Office within 30 days of the child's birth.
Newborn Care includes:
(a) Hospital charges for room and board, services and supplies;
(b) Charges related to circumcision
( c) Routine newborn discharge examination
Also see Well Baby Care
(17) Allergy shots and allergy testing. Allergens payable on a monthly basis.
(18) Acupuncture by an acupuncturist licensed to perform such service by the state in which he or she
practices, and who is practicing within the scope of license.
(19) Abortion, when Medically Necessary.
(20) Elective sterilization.
(21) Organ transplants. In the event of a direct transplant of a natural organ or organs from a living donor to
the Covered Person, the covered medical expenses of the donor which are incurred as a direct result of
and within three (3) months of the transplant will be considered expenses incurred by the recipient of the
27
tit MEDICAL BENEFITS e
ELIGIBLE CHARGES (Continued)
organ( s) to the extent that the benefits are not provided under any other group benefit plan. Any fee or
charge made by the donor for such organ( s) will not be considered a covered medical expense.
(22) Prosthetic devices incident to a mastectomy determined in consultation between the attending Physician
and Covered Person.
(23) Temporomandibular Joint Syndrome (including all myofacial dysfunction syndromes and other
associated disorders) up to the limits as shown in the Schedule of Benefits.
(24) Home Health Care provided by a Home Health Care Provider for the maximum number of visits as
shown on the Schedule of Benefits, if:
(a) The Covered Person requires, on an intermittent basis, nursing services, therapy or other
services provided by a Home Health Care Provider.
(b) The Covered Person is Totally Disabled and is essentially confined to the home;
(c) The Covered Person would otherwise have been confined as an Inpatient in a Hospital or a
Skilled Nursing Facility;
(d) The Covered Person is examined by the attending Physician prior to the commencement of
such Treatment; and at least once every sixty (60) days thereafter; and
( e) The Plan of Treatment including Home Health Care is:
(i) established in writing by the attending Physician prior to the commencement of such
Treatment; and
(ii) certified by the attending Physician at least once every month.
Eligible Home Health Care services will not include;
(1) custodial care;
(2) meals or nutritional services;
(3) housekeeper services;
(4) services or supplies not specified in the Home Health Care Plan;
(5) services of a relative of the Covered Person;
(6) services of any social worker;
(7) transportation services;
(8) care for tuberculosis, alcoholism or drug addiction;
(9) care for the deaf or blind; or
28
e MEDICAL BENEFITS.
ELIGIBLE CHARGES (Continued)
(10) care for senility or mental deficiency or mental illness.
A visit by a member of a home health care team and four (4) hours of home health aide services will each be
considered one home health care visit.
(25) Birthing Centers: Alternative Birthing Center and like terms me~s an institution which is not a
Hospital, but a place where births take place following nonnal, uncomplicated pregnancies. Such
centers must be:
(a) Constituted, licensed and operated as set forth in the laws that apply, where required;
(b) Equipped with those items needed to provide low-risk maternity care;
(c) Adequately staffed with personnel who are qualified and, where required, licensed and who:
(i) provide care at childbirth and;
(ii) are practicing within the scope of their training and experience, and
(d) Equipped and ready to initiate emergency procedures in life threatening events to mother and
baby. The definition of a Medical Emergency is: a" sudden onset of a condition with acute
symptoms requiring immediate medical care, for example, includes such conditions but is not
limited to, heart attacks, cardiovascular incidents, poisonings, loss of consciousness or
respiration, convulsions or other such acute medical conditions.
( e) Transportation to/from Birthing Centers is not a covered benefit.
(26) Oral Surgery (limited to the following procedures):
(a) excision of tumors or cysts from the mouth;"
(b) osseous surgery, except when required for the Treatment of periodontal disease;
(c) excision of exostoses of the jaws and hard palate (provided that this procedure is not done in
preparation for dentures);
(d) Treatment of fractures of the facial bones;
( e) external incision and drainage of cellulitis;
(f) incision of accessory sinuses, salivary glands or ducts.
(27) Infertility testing. Covered Expenses are limited to Physician, X-ray and laboratory examinations
perfonned solely for the purpose of diagnosing sickness or Injury.
(28) Services for the Treatment of mental and emotional disorders and/or chemical dependency (alcoholism
or drug abuse) are payable on the same basis as for any other Illness, subject to the Plan Maximums and
Limitations as shown on the Schedule of Benefits.
29
e MEDICAL BENEFITS e
ELIGIBLE CHARGES (Continued)
In addition to psychotherapy services by a Physician, individual counseling services will be covered if
provided by a practitioner licensed to perform such services and practicing within the scope and
limitation of such license.
(29) Cancer Screening:
(a) Upon referral of the patient's Physician, and based on the Physician's determination of
frequency, payment will be made for routine Pap Smears, mammograms and prostate Cancer
Screening.
(b) Cancer Screening benefits, including Physician's visits, will be covered at 100% of Usual and
Customary, with no Deductible, up to $150 per person per Calendar Year. Additional Cancer
Screening benefits will be covered at 80% after the Deductible.
(30) Personal Case Management. In order for a Covered Person to obtain medically appropriate care in a
more economical and cost-effective way, Blue Cross may recommend an alternative Plan of Treatment
which includes services and/or supplies not otherwise covered under this Plan. Benefits are provided for
such an alternative Treatment Plan on a case-by-case basis. The Plan Administrator has absolute
discretion in deciding whether or not to offer to substitute benefits for any Covered Person, which
alternative benefits may be offered, and the terms of the offer. The Plan's substitution of benefits in a
particular case in no way commits the Plan to do so in another case or for another Covered Person.
Also, it does not prevent the Plan Administrator from strictly applying the expressed benefits,
limitations and exclusions of this Plan at any other time or for any other Covered Person.
(31) Massage Therapy:
(a) When Medically Necessary and recommended by a licensed Physician and
(b) Performed by a Registered Physical Therapist (RPT).
(32) Physical Therapy Alternatives:
(a) Subject to a $650 per year limit on reimbursement for this program.
(b) A doctor's prescription is required for participation in this program and must be certified by a
Physician at least annually.
(c) Such alternative to Physical therapy, such as Treatment by a Certified Massage Therapist
(CMT), is in lieu of the more traditional Physical therapy and will not be in addition to such
therapeutic activities.
(33) Chiropractic care - performed by a Physician and limited to 30 visits within a Calendar Year.
30
e MEDICAL BENEFITS e
ELIGIBLE CHARGES (Continued)
(34) Well Baby Care (birth through age 5) - benefits covered at 80% after annual Deductible for Physician
services and immunizations.
(35) Annual Physical for member age 6 and older, one per Calendar Year up to $250, covered at 80% after
annual Deductible.
(36) Post Mastectomy - When provided in a manner determined in consultation between the attending
Physician and patient, services and supplies will cover the following (Pursuant to the Women's Health
and Cancer Rights Act, effective October 21, 1998):
Reconstruction of the breast on which a mastectomy has been performed; surgery and reconstruction of
the other breast to produce symmetrical appearance; breast prostheses; and physical complications of all
stages of mastectomy, including lymphedermas.
(37) Maternity and Neonatal Benefits - Expenses related to pregnancy and birthing are covered according to
the following schedule:
(a) Prenatal care of the mother (if a Covered Employee or Covered Dependent) and fetus is treated as
any other Illness or Injury covered under the Plan.
(b) Inpatient care for the mother (if a Covered Employee or Covered Dependent) and newborn child
is provided for a minimum of 48 hours following a vaginal delivery, or a minimum of 96 hours
following a cesarean section. The mother's or newborn's attending Physician, after consulting with
the mother, may discharge the mother or her newborn earlier than 48 hours (or 96 hours as
applicable).
(c) The attending Physician need not seek authorization from the Plan to prescribe a length of
Inpatient stay for the mother (if a Covered Employee or Covered Spouse) or newborn not in
excess of 48 hours (or 96 hours as applicable).
(38) Birth Control Benefits - Expenses related to birth control are covered according to the following
schedule and will be reimbursed through the Prescription Drug Plan:
(a) Prescriptions for oral contraceptives are covered the same as all other eligible Prescription
Dru~.
(b) Diaphragms are covered as follows: the pharmacy dispenses one diaphragm for one co-payment.
(c) Other contraceptive devices are covered as an alternative method for medical reasons only when
approved with prior authorization based on the Physician's recommendation.
(d) Prescriptions for the following contraceptives are covered with the following limits: 1) Proven
Kit, limited to 2 in 25 days with a maximum of 4 fills per Calendar Year, or 2) Plan B
(morning after pill), limited to 2 in 25 days with a maximum of 4 fills per Calendar Year.
These limits apply to both retail and mail order.
31
e MEDICAL BENEFITS e
ELIGIBLE CHARGES (Continued)
(e) Eligible Birth Control Benefits will not include injectable contraceptives.
(39) Smoking/tobacco cessation. Enrollment and completion in a smoking/tobacco cessation program or
behavior modification program is covered once per Lifetime when approved with prior
authorization based on the Physician's recommendation. Covered Treatments include:
(a) Zyban (bupropion), limited to one 12-week course once per Lifetime.
(b) Nicotine transdermal patches (e.g., Nicoderm, Habitrol), limited to one 12-week course once per
Lifetime.
32
e e
GENERAL MEDICAL EXCLUSIONS AND LIMITATIONS
(1) Abortion. Services, supplies, care or Treatment in connection with an abortion unless the life of the
mother is endangered by the continued pregnancy.
(2) 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.
(3) Court mandated. No benefits will be paid for services that are provided due to a court order, except as
identified under Definition of Dependent.
(4) Cosmetic Surgery. Care, services or Treatment as a result of Cosmetic Surgery except as provided for:
(a) the result of post-mastectomy, requiring reconstruction of the breast on which a mastectomy has been
performed or requiring surgery and reconstruction of the other breast to produce symmetrical
appearance which is determined while the Covered Person is covered under the Plan; or
(b) the result from an Accident, an infection or other disease which occurs while the Covered Person is
covered under the Plan; or
(c) the result of congenital disease, developmental condition or anomaly in a covered Dependent child
which has resulted in a functional defect, provided the disease, condition or an anomaly occurs or
manifests itself while the child is covered under the Plan.
(5) Custodial care. No benefits will be paid for services which are custodial in nature or primarily consist of
bathing, feeding, homemaking, moving the patient or acting as a companion or sitter.
(6) Drugs - Poison. No benefits will be paid for losses which are due to:
(a) the voluntary taking of drugs, except those taken as prescribed by a Physician;
(b) the voluntary taking of poison; or
( c) the voluntary inhaling of gas.
(7) Excess Charges. The part of an expense for care and Treatment of an Injury or Illness that is in excess
of Usual and Customary charges.
(8) Exercise program. Exercise programs for Treatment to any condition, except for Physician supervised
cardiac rehabilitation, occupational or Physical therapy covered by this Plan.
(9) Experimental or not Medically Necessary. Care and Treatment that is either Experimental/Invest-
igational or not Medically Necessary according to the American Medical Association or the Food and
Drug Administration.
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
33
GENERAL ME'ICAL EXCLUSIONS AND LIlITATIONS
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 claims 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:
(a) 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
(b) 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
( c) 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
(d) 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.
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.
(10) Eye care. Radial keratotomy or other eye surgery to correct near sightedness. Also, routine eye exams,
lenses and exams for their fitting. This exclusion does not apply to aphakic patients and soft lenses or sclera
'shells intended or used as corneal bandages.
(11) Government agencies. Benefits will not be paid for charges incurred for Hospital confinement, services,
Treatments or supplies furnished by the United States or a foreign government agency for a disability
related to military service.
(12) Hair loss. Care and Treatment for hair loss including wigs, hair transplant or any drug that promises hair
growth, except for wigs after chemotherapy.
(13) Hearing aids and exams. Charges for services or supplies in connection with hearing aids or exams for
their fitting.
(14) Illegal drugs or medications. Services, supplies, care or Treatment to a Covered Person for Injury
orlllness.
(15) Infertility. Care and Treatment for Infertility, artificial insemination or in vitro fertilization.
34
e .
GENERAL MEDICAL EXCLUSIONS AN'LIMITATIONS
(16) Learning Disabilities. No benefits will be paid for charges incurred for special education or training
for learning disabilities.
(17) Legal Duty. Coverage is provided only for Treatment for which the Covered Person has legal duty to
pay. This Plan will not create such a duty to pay.
(18) Limit of medical Treatment. Benefits will only be paid for charges by a Physician who is present and
consults with the Covered Person. Benefits will not be paid for services of a registered nurse (R.N.),
licensed practical nurse (L.P.N.), or licensed Physical therapist:
(a) who usually resides in the same household with the Covered Person; or
(b) who is related by blood, marriage or legal adoption to the Covered Person or to be the Covered
Person's spouse.
(19) Non-occupational coverage. No benefits will be provided for losses which result from an Illness or
Injury:
(a) which arises out of or in the course of employment with any Employer who is eligible to obtain
coverage under Workers' Compensation, or occupational disease law;
(b) or which the Covered Person is eligible for benefits under any Workers' Compensation law or
occupational disease law; or
(c) for which the Covered Person is paid a Workers' Compensation benefit or occupational disease law
benefit.
(20) Not sp~cified as covered. Services, Treatments and supplies, which are not specified as, covered under
this Plan.
(21) Orthoptics or visual training. No benefits will be paid for charges incurred for orthoptics and/or visual
training.
(22) Other. Benefits will not be paid for charges not listed under "Eligible Charges."
(23) 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, nonprescription drugs, first aid supplies and non Hospital
adjustable beds.
(24) Physician's direct care. Benefits will be paid only for Eligible Charges incurred by a Covered Person
under the direct care of a Physician.
(25) Pre-Existing Conditions. Charges are subject to the limitations as defined under the Pre-Existing
Conditions section.
(26) Riot - Felony. No benefits will be paid for losses which are due to taking part in a riot or civil
disturbance, or while committing or attempting to commit a felony.
35
GENERAL M!ICAL EXCLUSIONS AND LlITATIONS
(27) Routine care. Charges for routine or periodic examinations, preventive medical care, unless such care is
specifically covered in the Schedule of Benefits.
(28) Routine foot care. No benefits will be paid for charges incurred for routine foot care (unless Medically
Necessary); Treatment of flat foot conditions and the prescription of supportive devices for such
conditions; Treatment of weak, strained or flat feet, metatarsalgia; or bunions (unless performing an open
cutting operation).
(29) Self-Inflicted. Any loss due to intentionally self-inflicted Injury or Illness, while sane or insane.
(30) Sex changes. Care, services or Treatment for non-congenital transsexualism, gender dysphoria or sexual
reassignment or change.
(31) Sleep disorder. Care and Treatment for sleep disorders unless deemed Medically Necessary. Claims
Administrator will submit documentation to an independent Physician for review and determination.
Medically Necessary care and Treatment is recommended or approved by a Physician, is consistent with the
patient's condition or accepted standards of good medical practice; is medically proven to be effective
Treatment of the conditions; is not performed mainly for the convenience of the patient or provider of medical
services; is not conducted for research purposes; and is the most appropriate level of services which can be
safely provided to the patient.
(32) Smoking/tobacco cessation. Care and Treatment for smoking/tobacco cessation programs unless such
care is specifically listed under Eligible Charges. Covered Treatments do NOT include:
(a) Nicotine gum;
(b) Nicotine nasal spray; or
(c) Nicotine oral inhaler.
(33) Surgical sterilization reversal. Care and Treatment for reversal of surgical sterilization.
(34) Teeth and gums. No benefits will be paid under the Plan for Treatment of teeth, gums, alveolar process
supplies used in such Treatment or for dental appliances. This exclusion does not apply to:
(a) Surgical services, if performed on an Outpatient basis, for the removal of impacted teeth; and
(b) Major Medical Benefits for expenses incurred for Treatment of Injury to natural teeth, including the
replacement of such teeth or setting of a jaw fractured or dislocated in an Accident. Expenses must be
incurred:
(i) as a result of an Accident which occurs while the Covered Person's coverage under the Plan
is in effect; and
(ii) within twelve (12) months after such Accident.
36
GENE~ MEDICAL EXCLUSIONS A LIMITATIONS
(c) Oral surgery, as specified under "Eligible Charges"
(35) Temporomandibular Joint Syndrome (TMJ). All diagnostic and Treatment services related to the
Treatment of jaw joint problems including TMJ syndrome, except as specified as covered under the
Schedule of Benefits.
(36) Travel, transport or accommodations. Charges for travel, transport or accommodations, whether or not
recommended by a Physician, except for ambulance charges as defined as a Covered Expense.
(37) Vitamins. No benefits will be paid for charges incurred for vitamins or dietary supplements.
(38) War. No benefits will be paid for losses which are due to revolt, war or any act of war, whether
declared or not.
(39) Weight control. No benefits will be paid for services or supplies for weight reduction by diet control or
behavior modification, with or without medication.
37
HOW OTHER COVE~GE AFFECTS BENEFITS Ul'l'ER THIS PLAN
COORDINATION OF BENEFITS WITH OTHER PLANS
All health care benefits provided under the Plan are subject to Coordination of Benefits as described below,
unless specifically stated otherwise.
If a person is covered under more than one plan, the total benefits could pay for more than 100% of the covered
charges under the plans. To prevent benefit payments exceeding the total allowable expenses, the Coordination
of Benefits (COB) provision is included. It coordinates all the benefits provided by this Plan with similar
benefits payable under any other medical or dental plan.
In this section, the term "plan" means any health care and dental coverage or similar arrangement, which
provides medical or dental care benefits on an insured or uninsured basis. It includes, but is not limited to:
(1) Group or blanket insurance;
(2) Hospital or medical service pre-payment plans;
(3) Hospital reimbursement-type plans which permit the Covered Person to elect indemnity benefits at the
time of claim;
(4) Hospital or medical service organizations on an individual basis having a provision in effect similar to
this provision;
(5) A licensed Health Maintenance Organization (HMO);
(6) Any coverage under Labor-Management-Trustee plans, union welfare plans, employer organization
plans, or Employee benefit organizations plans;
(7) Federal government plans or programs, including Medicare .
(8) Any coverage required or provided by law. This does not include Medicaid or any benefit Plan like it
that, by its terms, does not allow coordination.
(9) Any coverage for students which is sponsored by, or provided through, a school or other educational
institution;
(10) "No Fault" auto insurance; or
(11) Group automobile insurance.
Each policy, contract or other Plan for benefits or services will be considered a separate plan. A Plan may
include a Coordination of Benefits provision (or similar provision) on some, but not all, of its benefits or
services. The benefits or services subject to the Coordination of Benefits provision will be considered a separate
Plan from the benefits of services not subject to a Coordination of Benefits provision.
ALLOWABLE EXPENSE. In this section, the term "allowable expense" means any Usual and Customary
charge covered in full or in part under more than one plan. When this Plan is secondary (i.e. when this Plan
38
. e .
HOW OTHER COVERAGE AFFECTS BENEFI~ UNDER THIS PLAN
COORDINATION OF BENEFITS WITH OTHER PLANS(Cont;nued)
pays after the benefits of another plan), "allowable expense" will include any Deductible or coinsurance
amounts not paid by the other plan. No more than 100% of allowable expenses will be paid by all plans
together. In no event will an "allowable expense" include an expense incurred when the person's coverage is not
in effect under this Plan. When a Plan provides benefits in the form of services, rather than cash payment, the
reasonable cash value of the services will be considered a benefit paid.
When this Plan is secondary, "allowable expense" shall not include any amount that is not payable under the
primary Plan as a result of a contract between the primary Plan and a provider of service which such provider
agrees to accept a reduced payment and not to bill the patient for the difference between the provider's
contracted amount and the provider's regular billed charge. "Allowable expense" also shall not include any
amount that is not payable under the primary Plan because a Covered Person did not adhere to the provisions
of that Plan which are intended to reduce unnecessary medical care or make medical services available at a
reduced cost, and full benefits would have been payable had the Covered Person adhered to the Plan
provisions. Examples include but are not limited to: penalties, increased Deductibles, and/or decreased co-
insurance amounts incurred under the primary Plan for failure to comply with such Plan provisions as pre-
admission certification, second surgical opinion, or preferred provider requirements, including charges by a non-
Plan provider, if the primary Plan restricts coverage to a limited list of providers.
Regardless of whether this Plan is primary or secondary under this COB provision, if a Covered Person
receives covered services from a prepaid Plan of any type provided by another employer, this Plan will only
reimburse the Covered Person for any co-payments required by the plan, and only if such co-payments are
required of every person covered by the plan. Except for these specified co-payments, this Plan will not
consider any other charges made by the prepaid Plan as "allowable expenses' under this Plan. For the purposes
of this section, the term "prepaid plan" shall include health maintenance organizations, individual practice
associations and any other such programs that the Plan Administrator deems to be essentially similar to such
prepaid arrangements.
COORDINATION PROCEDURES
If a Covered Person is covered under more than one plan, this Coordination of Benefits section will apply.
This section will be used to determine the amount of benefits payable under this Plan for a Covered Person for
any Calendar Year. One Plan is the primary plan, and all the other plans are secondary, in the order described
below. The primary Plan pays its benefits first, without taking the other
plans into consideration. The secondary plans then pay benefits up to the extent of their liability, after taking
into consideration the benefits provided by the other plans. Benefits under other plans include benefits, which a
Covered Person could have received, if such benefits had been claimed.
39
HOW OTHER COvPRAGE AFFECTS BENEFITS AER TmS PLAN
COORDINATION PROCEDURES(Continued)
(1) If a Plan has no Coordination of Benefits provision (or similar provision), it is automatically the primary
plan. This Plan will always pay its benefits AFTER such Other Planes). This Plan's liability will be the
lesser of: I) its normal liability ; or 2) total Allowable Expenses minus benefits paid by the Other Plan (s).
(2) If the planes) have a Coordination of Benefits provision, a Plan is primary, ifit covers the person as an
Employee, and secondary, if it covers the person as a Dependent.
(3) A Plan is primary, if it covers a person as an active Employee or a Dependent of an active Employee, and
secondary, ifit covers a person as a retired or laid-off Employee.
(4) When a child is covered as a Dependent and the parents are not legally separated or divorced, these rules
will apply:
(a) 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;
(b) 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.
(5) When a child's parents are divorced or legally separated, these rules will apply:
(a) The Plan covering the child as a Dependent of the parent with legal custody of the child will be
the primary plan.
(b) If the parent with legal custody has not remarried, the Plan covering the child as a Dependent of
the other parent will be the secondary plan.
( c) Ifthe parent with legal custody has remarried, the Plan covering the child as a Dependent of the
spouse of such parent will be the secondary plan, and the Plan covering the child as a Dependent
of the other natural parent will be the tertiary plan.
(d) Not withstanding a, b, or c above, if a court decree sets the obligation for medical expenses of
such child, the Plan which covers the child as a Dependent of the parent with such obligation
will be the primary plan.
(6) If a Plan is "No Fault" auto insurance, it is the primary plan.
(7) If coverage is provided under this Plan as a result of the Consolidated Onmibus Budget Reconciliation Act
- COBRA (as amended), this Plan will pay its benefits last after all other plans have paid their benefits.
40
HOW OTHER CLRAGE AFFECTS BENEFI,fUNDER TIDS PLAN
COORDINATION OF BENEFITS WITH OTHER PLANS(Cont;nued)
(8) If the primary Plan is still not established under (1), (2), (3), (4), (5), (6) or (7) above then the Plan that
covers such person for the longest, continuous period of time will be the primary plan.
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. In the event this Plan pays benefits that should be paid by another benefit plan, as described
in the Coordination of Benefits section, 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 to the overpayment from the source to which it was paid.
MEDICARE AND COVERED EMPLOYEES
For active Employees and their Dependents, age 65 and older, who choose to participate in this Plan, the Plan
will pay primary to Medicare (in the absence of any other Plan which would be primary under the Coordination
of Benefits Provision of this Plan) and Plan benefits will be the same as for active Employees and their
Dependents under age 65.
The limited circumstances when Medicare will be primary and this Plan will be secondary include:
I) w}1en the claimant has end-stage renal disease and has been entitled to secondary Medicare benefits for the
statutory 3D-month waiting period, or
2) when a claimant is a retired Employee or a Dependent of a retired Employee. When this Plan is secondary
to Medicare, Eligible Expenses will not include amounts which a Covered Person is not legally required
to pay due to Medicare's "limiting charge" amounts.
41
HOW OTHER COvLGE AFFECTS BENEFITS tlDER THIS PLAN
THIRD PARTY RECOVERY PROVISION
RIGHT OF SUBROGATION AND REFUND. When this provision applies. The Covered Person may incur
charges for treatment of an injury, sickness or other condition which is caused by the act or omission of a third
party or another party, the third party may be responsible for payment. In such circumstances, the Covered
Person may have a claim against that third party, 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 or dental expenses. This lien shall remain in effect
until the Plan is repaid in full.
The Covered Person:
(I) 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.
Amount subject to subrogation or refund. The Covered Person agrees to recognize the Plan's rights to
Subrogation and reimbursement. These rights provide the Plan with a priority over any 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.
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. However, 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.
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.
42
HOW OTHER CLRAGE AFFECTS BENEFr'UNDER THIS PLAN
THIRD PARTY RECOVERY PROVISION(Continued)
Defmitions:
"Recovery" means monies paid to the Covered Person by way of judgment, settlement, or otherwise to
compensate for all losses caused by the Injuries or sickness whether or not said losses reflect medical or dental
charges covered by the Plan.
"Subrogation" means the Plan's right to pursue the Covered Person's claims for medical or dental charges
against the other person.
"Refund" means the Plan's right to pursue the Covered Person's claims for medical or dental charges against
the other person.
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, homeowner's Plan,
renter's Plan, medical malpractice Plan or any liability Plan.
43
TfRMINATION OF COVERAG'
EMPLOYEE COVERAGE
An Employee's Coverage will terminate on the earliest of these dates (except in certain circumstances, a
Covered Employee may be eligible for COBRA continuation coverage as set forth in the section on COBRA):
(1)
(2)
the date this Plan is terminated;
the end of the period for which the last required Employee contribution (if any) for the Employee's
Coverage has been paid;
the date such Covered Employee ceases to be in an Employee status eligible for coverage under the
Plan; or
. (3)
(4)
the last day of the month in which such Covered Employee's employment with the City terminates.
Ceasing active work is deemed termination of employment unless the Covered Employee is disabled due to
Illness or Injury. In that event, coverage may be continued during the disability provided any required
Employee contributions are made by such Covered Employee.
Employees who are in a non-pay status will be retained for coverage under this Plan subject to all applicable
Federal or State laws, City rules and collective bargaining agreements.
If a Covered Employee is absent from work due to a labor dispute, coverage will terminate immediately.
The Plan Administrator will not discriminate unfairly among Employees in similar situations.
A Covered Employee's coverage for any specific benefit will terminate on the earlier of:
(1) the date coverage for such benefits ends; or
(2) the date the Covered Employee ceases to be eligible for such benefit.
DEPENDENT COVERAGE
A Covered Employee's Dependent Coverage will cease for all of the Covered Employee's Dependents on
the earliest of:
(1) the date the Covered Employee's coverage terminates;
(2) the date this Plan is terminated;
(3) the date Dependent Coverage is discontinued under this Plan;
(4) the date the Covered Employee ceases to be in an Employee class eligible for Dependent Coverage;
(5) the end of the period for which the last required Employee contribution for the Employee's Dependent
coverage has been paid. However, in the case of a child covered pursuant to a Qualified Medical Child
Support Order (QMCSO), the Employee must provide proof that the child support order is no longer in
effect or that the Dependent has replacement coverage which will take effect immediately upon
termination; or
44
~ERMINATION OF COVERA!E
DEPENDENT COVERAGE(Cont;nued)
(6) the date the Covered Employee no longer has any Dependents.
Dependent Coverage for a Dependent will cease on the date such person ceases to be a Dependent as defined
in this Plan (See Definitions).
When coverage under this Plan ceases, Covered Persons will receive a certificate of coverage that will show
the period of coverage under this Plan. Please contact the Plan Administrator for further details.
RE-ENROLLMENT
If a person who is covered under this Plan as an Employee or as a Dependent continues such coverage under
COBRA and subsequently becomes eligible again for coverage under this Plan while continuation coverage is
still in force, credit will be given under this Plan for any Pre-Existing Conditions limitation, Individual
Deductible, and Individual Co-insurance Maximums which have been satisfied while this Plan was previously
in force and/or during COBRA. This will be true ONLY if there has been no break between former coverage
under this Plan, COBRA, and subsequent coverage under this Plan. In all other respects, such person will be
treated as any other new Employee or Dependent.
45
CONTINU'ION OF COVERAGE DURIN'LEA VES
FAMILY AND MEDICAL LEAVE ACT
Continuation during Family and Medical Leave (FMLA): Regardless of the established leave policies
mentioned above, this Plan shall at all times comply with the Family ~d 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.
EXTENSION OF COVERAGE DURING MILITARY SERVICE (USERRA)
Regardless of an Employer's established termination or leave of absence policies, the Plan will at all times
comply with the regulations of the Uniformed Services Employment and Reemployment Rights Act (USERRA)
for an Employee or Dependent entering military service. These rights include up to 18 months of extended
health care coverage upon payment of the entire cost of coverage plus a reasonable administration fee.
Additional information concerning USERRA can be obtained from the Personnel office. (See COBRA
Continuation Coverage)
46
CONTINUJION OF BENEFITS WHEN C!,ERAGE ENDS
. DUE TO TOTAL DISABILITY
A Covered Person's Medical Benefits may end because of Total Disability. In that event, the Covered
Person's coverage will be extended, for the disabling condition only, until the earlier of the following:
(1) the date this Plan is terminated;
(2) the date maximum benefits under this Plan have been paid;
(3) the date the individual is no longer Totally Disabled;
(4) the date the individual becomes covered without limitation as to the disabling condition under any other
group Plan;
(5) the date the individual becomes eligible for Medicare; or
(6) in any event, no longer than three (3) months from the date coverage would otherwise have ended.
EXTENTION OF COVERAGE FOR DEVELOPMENTALLY DISABLED OR HANDICAPPED
DEPENDENT CHILDREN
If an already covered Dependent child attains the age which would otherwise terminate his status as a
Dependent, and:
· if on the day immediately prior to the attainment of such age the child was a covered Dependent under the
Plan;
· at the time of attainment of such age the child is incapable of self-sustaining employment by reason of
. mental retardation, cerebral palsy, epilepsy, other neurological disorder; physical handicap, or disability
which results from injury, Accident, congenital defect.or sickness;
· the child's condition has been diagnosed by a Physician as a permanent or long-term dysfunction or
condition; and such child is primarily Dependent upon the Employee for support and maintenance; then
the child's status as Dependent will not terminate solely by reason of having attained the limiting age and
he will continue to be considered a covered Dependent under the Plan so long as he remains in such
condition, and otherwise conforms to the definition of Dependent.
The Employee must submit to the Plan Administrator proof of the child's incapacity within 30 days of the
child's attainnient of such age, and thereafter as it may be required by the Plan Administrator, but not more
frequently than once a year, after the two-year period following the child's attainment of such age.
CONSOLIDATED OMNIBUS BUDGET RECONCLIATION ACT (COBRA)
A federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), requires that most
Employers sponsoring a group health Plan offer Employees and their families covered under their health Plan
47
e e
CONTINUATION OF BENEFITS WHEN COVERAGE ENDS
CONSOLIDATED OMNIBUS BUDGET RECONCLIATION ACT (COBRA)(Cont;nued)
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.
COBRA Continuation Coverage Defined. 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 an event that results 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).
"Qualified Beneficiary". In general, a "Qualified Beneficiary" is:
(i) 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.
(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.
The term "Covered Employee" incliJdes 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., City Council Member).
48
e .
CONTINUATION OF BENEFITS WHEN COVERAGE ENDS
CONSOLIDATED OMNIBUS BUDGET RECONCLIATION ACT (COBRA)(Continued)
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.
Each Qualified Beneficiary (including a child who is born 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.
Qualifying Event Defined. A Qualifying Event is any of the following if the Plan provides 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 II 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, and 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
continuations of the COBRA law are also met.
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 ofFMLA leave and the applicable maximum coverage period is
49
e.:, e
CONTINUATION OF BENEFITS WHEN COVERAGE ENDS
CONSOLIDATED OMNIBUS BUDGET RECONCLIATION ACT (COBRA)(Continued)
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 form 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.
Election period. 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 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 that date
that is 60 days after the later of the date of the Qualified Beneficiary would lose coverage on account of the
Qualifying Event or the date notice is provided to the Qualified Beneficiary of her or his right to elect COBRA
continuation coverage.
Notification Responsibility. 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 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.
Waiver of Coverage. 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 60-day 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, form 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.
Termination of Coverage. 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:
50
CONTINU~ON OF BENEFITS WHEN CtERAGE ENDS
CONSOLIDATED OMNIBUS BUDGET RECONCLIATION ACT (COBRA){Cont;nued)
(i) The last day of the applicable maximum coverag~ 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) (i) 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.
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 non-COBRA 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.
Maximum coverage periods. The maximum coverage periods are based on the type of 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 hour of
employment, the maximum coverage period ends 18 months after the Qualifying Eventjf there is
not a disability extension and 29 months after the Qualifying Event if there is a disability
extension.
51
"t , .
CONTINUATI~ OF BENE;iTS WHEN COvluGE ENDS
CONSOLIDATED OMNIBUS BUDGET RECONCLIATION ACT (COBRA)(Continued)
(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.
Extension of coverage period. If a Qualifying Event that gives rise to an I8-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.
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 II 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 electing COBRA coverage and
before the end of the original I8-month maximum coverage.
52
CONTINU~ION OF BENEFITS WHEN C!,ERAGE ENDS
CONSOLIDATED OMNIBUS BUDGET RECONCLIATION ACT fCOBRA)(Continued)
Payment requirements. 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 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 terminate 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. The Plan is also permitted to allow for payment at other intervals. .
Timely Payment. 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.
Conversion after COBRA. 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.
CONVERSION PRIVILEGE
If coverage for you or your Dependents should terminate under the Plan, a conversion coverage option may be
available. Check with your Employer for details of current conversion options at the time coverage terminates.
If coverage under this Plan terminates, participants may be eligible to purchase a conversion policy on
an individual basis. Application must be made within 31 days of the date group coverage terminates.
Rules governing this purchase are established by the insurance carrier contracted to provide such
services. All details concerning this policy will be furnished upon request.
53
DEN~L & ORT~6DONTIA BENE'TS
SCHEDULE OF BENEFITS (Emolovees and Deoendents)
COVERED EXPENSES
Dentist's Usual and Customary fees is the 90th percentile for listed procedures and services.
NOTE: Some Retired Employees and their Dependents may be eligible for dental benefits. **
CASH DEDUCTIBLE EACH CALENDAR YEAR
Preventive- Diagnostic
Basic & Major (combined)
Orthodontia
NONE
$25
NONE
PERCENTAGE OF COVERED EXPENSES PAYABLE
Preventive - Diagnostic (Part A)
Basic (Part B)
Major Restorative (Part C)
Orthodontia (Adult and child)
100%
80%
80%
50%
MAXIMUM PAY ABLE
Calendar Year Maximum
$1,500 or $2,000**
Orthodontia, while covered under this Plan
$2,000
WAITING PERIOD
There is no benefit payable for Part C - Major Restorative - services or supplies provided during an
individual's first six (6) months of coverage under this Plan.
**
May vary according to City Resolution or Collective Bargaining Agreement.
PRE-TREATMENT ESTIMATE OF MAJOR RESTORATIVE CHARGES
The City believes a patient has a right to know the amount of benefits payable under a dental Plan for a course
of dental Treatment before it begins. If a patient expects charges for services and supplies to exceed $200, the
dentist may first submit to the Claims Administrator a Pre-Treatment plan, which lists the charges for the
course of Treatment. The Claims Administrator in turn, will set out on the form the amount of benefits
payable under the Plan and return it to the dentist.
54
Dt-TAL & ORTHODONTIA BEIFITS
DESCRIPTION OF DENTAL BENEFITS
DENTAL EXPENSE. The Plan will pay benefits for covered dental expenses incurred by a Covered Person
while covered under this Plan. The benefits are described below.
The Plan will pay benefits for the portion which is in excess of the Cash Deductible. Payment will be made at
the Percentage Payable rate for the Covered Dental Expense up to the applicable Maximum Amount as shown
in the Schedule of Dental Benefits.
Dental Expense is deemed to be incurred on the date on which the services or supplies which cause the expense
is rendered or obtained.
COVERED DENTAL EXPENSE. The term "Covered Expense" means only expenses incurred for the
services and supplies listed below which are authorized by a dentist, and which in the geographical area where
the expense is incurred, are the Usual and Customary services and supplies provided for the condition being
treated. Covered Dental Expense will not exceed the Usual and Customary charges for the services and
supplies in such geographical area.
A dental procedure will be deemed to have commenced on the date the Covered Dental Expense is incurred,
except as follows:
(1) For installation of prosthesis, other than a bridge or crown, on the date the impression was made;
(2) For a crown, bridge or gold restoration, on the date the tooth or teeth are first prepared;
(3) For endodontic Treatment, on the date the pulp chamber is opened.
PART A - DIAGNOSTIC AND PREVENTIVE SERVICES AND SUPPLIES.
(1) Cleaning and scaling of teeth, but not more than once in a six (6) month period.
(2) Diagnostic services to determine necessary care, including
(a) full mouth X-rays;
(b) bite-wing X-rays;
(c) routine oral examinations, but not more than once in a six (6) month period;
(3) Fluoride application to teeth, but not more than once in a six (6) month period;
(4) Emergency palliative Treatment for relief of dental pain on a day for which no other benefit, other than
for X-rays, is payable;
(5) Sealants.
55
DEN~ & ORT~ODONTIA BENE~S
DESCRIPTION OF DENTAL BENEFITS(Cont;nued)
PART B - BASIC
(1) Oral surgery, including (a) extractions; (b) cutting procedures in the mouth; (c) tooth implantation; and
(d) Treatment of fractures and dislocations of the jaw.
(2) Treatment of the gums and supporting structures ofthe teeth.
(3) Space maintainers, up to age nineteen (19).
(4) Root canal therapy and other endodontic Treatment.
(5) General anesthetics and their administration.
(6) Antibiotics and therapeutic injections administered by a dentist.
(7) Restorations for teeth broken down by decay or Injury.
PART C - MAJOR RESTORA TIVE
(1) Full or partial dentures, fixed bridges, or the addition of teeth to an existing denture.
(2) Repair and rebasing of existing dentures which have not been replaced by a new denture.
(3) Crowns and gold restorations for teeth broken down by decay or Injury.
ORTHODONTIA SERVICES
(1) Installations of orthodontic appliances and all orthodontic Treatments concerned with the reduction or
elimination of an existing malocclusion and conditions resulting from that malocclusion through
correction of abnormally positioned teeth.
(2) Diagnostic services, including examinations, study models, radiographs and all other diagnostic aids
used to determine orthodontic needs only once in any five (5) year period, commencing with the date of
the initial visit to the dentist or Physician.
GENERAL DENTAL EXCLUSIONS AND LIMITATIONS
Benefits are not payable for:
(1) Replacement of defective or lost crown inserted while covered until five (5) years have elapsed from the
date of insertion.
(2) Temporary crowns or gold foil restorations.
(3) Appliance replacement performed less than five (5) years after a placement or replacement which was
performed while covered, except as specified.
56
DITAL & ORTHODONTIA BE_FITS
GENERAL DENTAL EXCLUSIONS AND LIMITATIONS(Continued)
(4) Replacement at any time of dentures or bridges which can be made serviceable.
(5) Denture adjustments during the first six (6) months following denture placement performed by the same
or associated dentist or Physician who provided or repaired the appliance.
(6) Replacement and/or repair of any appliance used during the course of orthodontia Treatment.
(7) Orthodontia Treatment rendered within five (5) years after the completion of a course of orthodontia
Treatment.
(8) Dental care which is provided solely for the purpose of improving appearance, when form and function
of the teeth are satisfactory and no pathological condition exists.
(9) Services, supplies or Treatment covered under the Medical Benefits, except when necessary due to
Accidental Injury which occurred while covered.
(10) Tooth implants.
(11) Personalizing dental service by added restorations to artificial teeth, precision attachments, implant
dentures, use of magnets, or similar procedures.
(12) Charges incurred for dental services, which were ordered or started before coverage began, including but
not limited to the installation, manufacture or fitting of dental restorations (fillings, inlays, crowns,
bridgework and dentures).
(13) Expenses related to services or supplies of the type normally intended for sport or home use.
(14) Charges for replacement of bridges or dentures lost, misplaced or stolen.
(15) Splinting for periodontal purposes and/or other appliances or restorations whose primary purpose is to
stabilize periodontally involved teeth.
(16) Education or training.
(17) Services or supplies that are experimental or do not meet accepted standards of medical or dental
practice.
(18) Charges for failure to keep a scheduled visit or charges for completion of forms.
(19) Personal hygiene, comfort or convenience items.
(20) Treatment of Temporomandibular Joint Dysfunction Syndrome (TMJ). TMJ Treatment is covered
under Medical Benefits.
(21) Charges that are limited or excluded under the provision "General Exclusions and Limitations."
(22) Dental care provided by a Dentist:
57
DENtL & ORTHODONTIA BENEIrS
GENERAL DENTAL EXCLUSIONS AND LIMITATIONS(Continued)
(a) who usually resides in the same household with the Covered Person; or
(b) who is related by blood, marriage or legal adoption to the Covered Person or to the Covered
Person's spouse.
EXTENSION OF DENTAL BENEFITS WHEN COVERAGE ENDS
Dental charges incurred by a Covered Person after his or her dental benefits are terminated will be eligible for
payment only under the following condition, and only if the procedure is completed in the thirty-one (31) days
following the date of termination of this Plan:
(1) the service involves an appliance or change in an appliance for which the impression was taken prior to
the date of termination; or
(2) the service involves a crown, bridge or gold restoration for which the tooth was prepared prior to the
date of termination; or
(3) the service involves root canal therapy for which the pulp chamber was opened prior to the date of
termination.
Payment will be made under this Extension of Dental Benefits only to the extent the Covered Person is not
entitled to payment from any other Plan which provides dental coverage.
COORDINA TION OF BENEFITS
Dental Benefits are subject to the Coordination of Benefits Provision as outlined in this Plan Document.
PRE-EXISTING CONDITIONS LIMITATIONS - (DENTAL)
The Pre-Existing Conditions Limitations found elsewhere in this Plan Document will not apply to Dental
Benefits.
CONTINUATION OF COVERAGE
The COBRA continuation coverage provisions outlined in this Plan apply to covered participants under this
Plan. Please refer to the COBRA Continuation Coverage section for more information.
58
GENERAL'LAN PROVISIONS AND AD~NISTRATION
PLAN DOCUMENT. The City will issue to each Covered Employee a Plan Document. The Plan Document
will state:
(1) the benefits provided;
(2) to whom benefits will be paid; and
(3) limitations or requirements to the Plan that may apply to the Covered Person.
STA TEMENTS. In the absence of fraud, all statements made by a Covered Person are representations and not
warranties. No such statement will be used to contest the coverage provided by the Plan unless:
(1) it is a written statement; and
(2) a copy of such statement is furnished to the Covered Person or the Covered Person's beneficiary, if
any.
MISSTATEMENT OF AGE. If a Covered Person's age has been misstated, the amount of benefit will be that
which would have been payable based upon the person's correct age.
FUTURE OF THE PLAN. Although the City of Redding intends to continue this Plan, the City reserves the
right to amend or terminate the Plan at any time subject to collective bargaining.
LEGAL ACTIONS. No legal action to recover any benefits may be brought before sixty (60) days after the
required written proof of loss has been given. No legal action may be brought more than three (3) years after
written proof of loss is required to be given.
PHYSICAL EXAMINATION. The Employer, at its expense, may have a Covered Person examined as often
as reasonably necessary while any claim is pending.
RIGHTS OF REVIEW AND APPEAL. If a claim is partially or wholly denied for any reason, the Covered
Employee will be notified in writing. The written denial will give:
(1) specific reasons for the denial with references to the Plan provisions; and
(2) a description and need for any other material pertinent to the claim.
If a claim is not processed within ninety (90) days .of receipt by the Claims Administrator, a Covered
Employee, Retiree and Council Member may proceed to the Review Procedure, as if the claim had been .
denied.
REVIEW PROCEDURES. A Covered Employee, Retiree or Council Member may request a review of the
claim denial by making written request to the Plan Administrator within sixty (60) days of receipt of the denial
notice. This written notice for review should:
(I) state the reason why the Covered Person feels the claim should not have been denied; and
59
GENERAL P!N PROVISIONS AND ADMI~TRATION
(2) include any additional documentation which the Covered Person may determine pertinent and submit
for consideration.
DECISION ON REVIEW. The Plan Administrator will make a full and fair review of the claim and give final
written notice of its decision within sixty (60) days (120 days under special circumstances) after the request is
received. The written notice on the review will include specific reasons for the decision and include references
to the Plan provisions on which the decision was based.
ARBITRA TION. If, by mutual agreement of the City and the Covered Person, any issue raised in the appeal of
a claim is such that such issue should be resolved by arbitration, the appeal shall be submitted to the American
Arbitration Association pursuant to its rules. The decision of the arbitrator(s) shall be binding and final on the
City and the Covered Person, with the costs of the arbitration to be borne by the party or parties as determined
by the arbitrator(s). In the event the City determines to submit the appeal for arbitration, it shall notify the
Covered Person within sixty (60) days after the request for appeal is received, and the time within which final
determination of the appeal is rendered shall be extended as necessary to comply with the rules of the American
Arbitration Association.
PLAN IS NOT AN EMPLOYMENT CONTRACT. Participation in this Plan by any Employee of the City
should not be construed as anything but participation in one particular benefit offered by the City. Participation
in the Plan does not bind the City to any contractual obligation or ~ployment obligation with the Employee,
other than to the terms of the Plan documents.
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.
60
GENERA"LAN PROVISIONS AND ADINISTRATION
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).
RESPONSIBILITIES FOR PLAN ADMINISTRATION
PLAN ADMINISTRA TOR. The City of Redding Group Health and Dental Plan is the benefit Plan of the
City of Redding, the Plan Administrator. An individual may be appointed by the City to be Plan
Administrator and serve at the convenience of the City of Redding. If the Plan Administrator resigns, dies or
is otherwise removed from the position, the City shall appoint a new Plan Administrator as soon as reasonably
possible.
(1) To decide disputes which may arise relative to a Plan participant's rights.
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
The Plan Administrator shall have all necessary power to carry out the full administration and management of
the Plan. The Plan Administrator's powers shall include, but are not limited to:
(A) To interpret the Plan, including the right to remedy possible ambiguities, inconsistencies or
omissions;
(B) To enforce all provisions of the Plan;
(C) To make changes in the Plan when necessary;
(D) To decide all questions of eligibility;
(E) To decide all questions of benefits;
(F) To decide the proper management of benefit claims;
(0) To obtain from every Employee the necessary forms and documents that allow participation in
the Plan;
(H) To obtain from every Participant the necessary forms and documents that allow either continued
participation or termination in the Plan;
61
GENERAL P!N PROVISIONS AND ADMIJtTRATION
DUTIES OF THE PLAN ADMINISTRATOR(Condnued)
en To contract with any and all insurance companies or other suppliers to provide benefits under the
Plan;
(1) To notify each Participant in writing of any amendment of the Plan, of any proposed amendment
of the Plan, of the termination of any benefit of the Plan, and of the termination of the Plan;
(K) To provide guidance for Employees and participants as to questions of participation, benefits, or
personal objectives in connection with the Plan;
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 for 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 of 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:
(a) 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;
(b) 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
(c) in accordance with the Plan documents to the extent that they agree with existing laws.
GENDER AND NUMBER: Wherever any words are used in the masculine, feminine or neuter gender, they
shall be interpreted to be applicable to all cases where they would apply. Wherever used in this document, the
singular shall mean the plural and the plural shall mean the singular except where context requires otherwise.
62
GENERAL4tLAN PROVISIONS AND AD&STRATION
IMPORTANT PLAN INFORMATION
This Plan has been prepared to furnish you with information regarding the benefits to which you and your
eligible Dependents are entitled under the CITY OF REDDING GROUP HEALTH AND DENTAL BENEFIT
PLAN in which you have enrolled. If you have any questions concerning the Plan or the information and
provisions of coverage, please contact the Claims Administrator or the Personnel Office.
1) NAME OF PLAN:
City of Redding Group Health and Dental Plan
2) NAME AND ADDRESS OF EMPLOYEES:
City of Redding
777 Cypress Avenue
Redding, CA 96001.;.2718
(530) 225-4065
3) PLAN SPONSOR/PLAN ADMINISTRATOR/AGENT FOR LEGAL PROCESS:
City of Redding
777 Cypress Avenue
Redding, CA 96001-2718
(530) 225-4065
Federal Identification Number: 94-6000401
The Plan Administrator has delegated to MBA ministerial functions and non-discriminatory claims functions.
The address of MBA is:
P.O. Box 873
Sacramento, CA 95812
Federal Identification Number: 68-0231274
Toll Free (In or Out of California): (800) 888-1801 Customer Service
Fax Number 916-635-6288
4) TYPE OF PLAN:
Employee Welfare Benefit Plan
Plan Number: 502
5) ELIGIBILITY REQUIREMENTS:
Eligibility requirements for Employee and Dependent status are as defined in this Plan Document.
63
GENERAL P!.N PROVISIONS AND ADMIrlTRATION
6) DESCRIPTION OF PLAN:
The Plan is self-funded. Plan benefit provisions are described in this Plan Document.
7) PLAN YEAR ENDS:
December 31
8) PLAN EFFECTIVE DATE:
July 1, 1995 Restated January 1, 1996 and January 1, 1998 and July 1,2003.
64
&PTION OF THE PLAN DOCtLENT
Adoption
The City of Redding hereby adopts this Plan Document as the written description of its welfare benefit Plan ,
(the "Plan "). This Plan Document replaces any prior statement of the Plan and is effective on the date shown
below.
Purpose of the Plan
The purpose of the Plan is to provide certain benefits for eligible Employees and City Council Members and
their eligible Dependents. The benefits provided by the Plan are as listed in the Schedule of Medical Benefits
and the Schedule of Benefits for the Dental Plan.
Conformity with Law
If any provision of this Plan is contrary to any law to which it is subject, such provision is amended to conform
to such law.
Acceptance of the Plan Document
IN WITNESS WHEREOF, the City of Redding has caused this instrument (page 1- inclusive) to be executed,
effective as of July 1,2003.
City of Redding
By:
M~~
Personne 1rector
Title:
Date:
September 9. 2003
65
It
DEFINITIONS
e
. As used in this Plan, the following words and phrases shall have the meanings indicated:
A CCIDENT means Physical harm or disability, which is the result of a specific unexpected incident caused by
an outside force. The physical harm or disability must have occurred at an identifiable time and place.
BIRTHING CENTER means a part of a Hospital or a free-standing institution which provides care by a
certified nurse midwife with Physician backup or by a Physician and nurse(s) with specialized training to
monitor labor, delivery and post-partum care. A Hospital Birthing Center must have discounted rates as
compared with the regular Hospital delivery room charges.
BRAND NAME PRESCRIPTION DRUG (BRAND NAME DRUG) is a Prescription Drug that has been
patented and is only produced by one manufacturer.
CALENDAR YEAR means January 1 through December 31 of that same year.
CANCER SCREENINGS means services and supplies provided in connection with routine tests to detect
cancer.
CASE MANA GEMENT occurs in situations where extensive or ongoing medical care will be needed. At such
times, the Utilization Management Organization, Blue Cross of California, may, with the patient's and the
City's consent, provide Case Management services. Such services may include contacts with the patient, his
family, the primary treating Physician, other caregivers and care consultants, and the Hospital staff as
necessary. As a result of these contacts, Blue Cross may recommend an alternative Plan of Treatment which
includes services and/or supplies not otherwise covered under this Plan. Benefits are provided for such an
alternative Treatment Plan on a case-by-case basis. The Plan Administrator has absolute discretion in
deciding whether or not to offer to substitute benefits for any Covered Person, which alternative benefits may
be 'offered, and the terms of the offer. The Plan's substitution of benefits in a particular case in no way commits
the Plan to do so in another case or for another Covered Person. Also, it does not prevent the Plan
Administrator from strictly applying the expressed benefits, limitations and exclusions of this Plan at any other
time or for any other Covered Person.
CITY means the City of Redding.
CITY COUNCIL MEMBER is an officer elected by the citizens of the City of Redding, and becomes eligible
for benefits under this Plan upon taking the oath of office.
CLAIMS ADMINISTRATOR refers to the agency contracted by City of Redding to administer claims.
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
DEFINITIONS (continued)
CONTRIBUTORY COVERAGE means coverage, which requires an Employee contribution.
66
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DEFINITIONS
e
COSMETIC SURGERY means surgery performed for the purpose of improving appearance rather than for
restoring bodily function.
COVERED EMPLOYEE means an Employee for whom the coverage provided by this Plan is in effect.
COVERED EXPENSE is the expense you incur for a covered service or supply, but not more than the
maximum amounts described in this Plan document. Expense is incurred on the date you receive the service or
supply.
COVERED PERSON means a Covered Employee, Retiree or City Council Member or Dependent for whom
the coverage provided by this Plan is in effect.
CREDITABLE COVERAGE means prior health care coverage, such as coverage under a group health Plan,
COBRA, HMO, an individual health insurance policy, Medicaid or Medicare. Creditable Coverage does not
include coverage consisting solely of dental or vision benefits.
DEDUCTIBLE. The Deductible is an amount of Eligible Charges that a Covered Person must incur before
Major Medical Benefits will be payable. The Deductible will be met when Eligible Charges equal the
individual Deductible shown in the Schedule of Benefits.
DEPENDENT means a person who:
(I) meets the definition of a Dependent of the Covered Employee, Retiree or City Council Member under
the provisions ofthe Internal Revenue Code (IRS) of the United States; AND
(2) is a Covered Employee's, Retiree's, City Council Member's:
(a) legal spouse (unless the spouse is legally separated from the Covered Employee, Retiree or City
Council Member), as recognized under the laws of the state where the Covered Employee lives;
(b) unmarried child less than 19 years of age;
(c) unmarried child from 19 years of age up to the age of 24 and a full:-time. s~dent (equivalent to 12
semester units or 36 quarter units) at an accredited school.
(d) unmarried child meeting all of the following conditions:
(i) totally and permanently disabled and unable to earn a living (proof of such disability must be
submitted to the Plan Administrator within thirty (30) days of the date coverage would have'
ended due to the child's age);
(ii) primarily Dependent upon the Covered Employee, Retiree, or City Council Member for
primary support; and
(iii) covered under the Plan on the day prior to the day coverage would have ended due to the
child's age.
(e) a natural born or legally adopted child. A child who is in the process of being adopted is considered
a legally adopted child if the Plan Administrator receives legal evidence of both: the intent to
67
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DEFINITIONS
e
(t) adopt and that the Covered Employee or spouse has either the right to control the health care of the
child or assumed a legal obligation for full or partial financial responsibility for the child in
anticipation of the child's adoption.
(g) a step-child or grandchild, or any other child related to the Covered Employee through
blood or marriage, who resides in the Covered Employee's household in a regular parent-
child relationship, and is primarily Dependent upon the Covered Employee, Retiree or City
Council Member for support and maintenance; or
(h) a foster child who resides in the Covered Employee's, Retiree's or City Council Member's
household in a regular parent-child relationship and qualifies as an exemption under the Internal
Revenue Service Code (IRS).
A Dependent is further defined as a person who meets the definition of a Dependent of an Employee under the
provisions of the Internal Revenue Service (IRS) and who also meets the above outlined criteria. The following,
which is based on IRS Code 152 and legal opinion are to assist in clarifying this issue:
. Generally, a child is an eligible Dependent of the custodial parent, the parent having custody for a
greater portion of the Calendar Year.
. A child can be an eligible Dependent of the non-custodial parent, if the legal custodial parent waives
his/her right to claim the child on his/her Federal tax forms. An IRS waiver is required in this instance.
. When a court document stipulates the parents have joint custody of a child, the child is an eligible
Dependent of both parents if each parent provides 50% of the child's support and maintenance. An IRS
waiver is not required in this instance.
. In the case of a legal multiple support agreement, the child can be an eligible Dependent of the non-
custodial parent, if the other parties to the agreement have waived their right to claim the child as a
Dependent on their Federal tax forms. An IRS waiver is required in this instance.
. When a court has ordered an Employer to enroll Employee's child iri its group health insurance
program pursuant to California Family Code Section 3761, said child wQuld be eligible to be claimed as
a Dependent for group insurance purposes.
If there is a court order requiring the non-custodial parent to provide health insurance for his/her child, only
the parent is legally bound by that court order.
In all cases, eligibility is based upon the fact that a child is eligible to be claimed as a Dependent on Federal
tax forms. Group insurance eligibility is not affected even if the Employee chooses not to actually claim the
child on Federal tax forms, so long as the child is eligible to be claimed.
DURABLE MEDICAL EQUIPMENT means equipment that is used by a Covered Person for the therapeutic
Treatment of an active Illness or Injury. Such equipment will not be covered under the Plan ifit could be
68
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DEFINITIONS
e
useful to a person in the absence of an Illness or Injury and could be purchased without a Physician's
prescription.
ELIGIBLE CHARGES are charges incurred by a Covered Person while covered under this Plan. A charge is
considered to be incurred on the date a service is performed or a purchase is made. Eligible Charges are the
actual charges (but not more than the Usual and Customary charges) incurred for an Illness or Injury for any
ofthe reasons outlined in the section titled "Eligible Charges."
EMPLOYEE means a person:
(1) whose employment with the City is:
(a) on a regular basis and who works at least 20 hours per week for the City;
(b) the person's principal occupation; and
(c) for regular wage or salary;
(2) who is a member of an Employee status which is eligible for coverage under this Plan; and
(3) for the purpose of this Plan, the Mayor of the City and City Council Members will be considered to be
Employees upon election and taking the oath of office; and
(4) a retired Employee who was covered under this Plan on the day before his or her retirement under the
Public Employees' Retirement System (PERS) will be considered to be an Employee; and
(5) who is a permanent resident of the United States.
Employee does not include a person who:
(1) performs service of a recognized profession, including but not limited to, an attorney or an accountant;
and
(2) is paid on a basis other than regular wage or salary.
EMPLOYER is City of Redding.
EXCESS CHARGES. The part of an expense for care and Treatment of an Injury or Illness that is in excess
of Usual and Customary charges.
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.
69
;;.
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DEFINITIONS
e
~
FAMILY MEDICAL LEAVE ACTis Federal law requiring employers with more than 50 employees to provide
eligible workers with up to 12 weeks of unpaid leave each year for birth, adoptions, foster care placements, and
illnesses of employees and their families.
FAMILY UNIT means a Covered Employee and persons covered under this Plan as a Covered Employee's
Dependents.
FREE-STANDING CHEMICAL DEPENDENCY TREATMENT CENTER means a place, which meets all
of the following requirements:
(1) it is accredited by the Joint Commission on Accreditation of Hospitals or is licensed by the appropriate
state licensing authority as a chemical dependency Treatment center;
(2) it is operated chiefly for the Treatment of chemical dependency;
(3) it provides only Treatment that is directly under the supervision of a Physician; and
(4) it provides 24-hour nursing service by graduate nurses (R.N.).
GENERIC PRESCRIPTION DRUG (GENERIC DRUG) is a pharmaceutical equivalent of one or more
Brand Name Drugs and must be approved by the Food and Drug Administration as meeting the same standards
of safety, purity, strength, and effectiveness as the Brand Name Drug.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) is Federal legislation
designed to improve portability and accessibility to health insurance when changing jobs by restricting certain
preexisting condition limitations.
HOME HEALTH CARE PROVIDER means a home health agency or a visiting nurses' association which
meets all of the following requirements;
(1) is licensed by the state;
(2) meets the Medicare qualifications for a home health care agency;
(3) meets the standards of the applicable area-wide health care Planning agency;
(4) provides skilled nursing services and other services on a visiting basis in the patient's home;
(5) is responsible for administering a home health care program; and
(6) supervises the delivery of a home health care program as prescribed and approved in writing by the
patient's attending Physician.
HOSPITAL means a place, which meets all of the following requirements:
(1) it is accredited as a general Hospital by the Joint Commission on Accreditation of Hospitals;
(2) it is open at all times;
(3) it is operated chiefly for the Treatment of sick or injured persons as Inpatients;
70
e
DEFINITIONS
e
(4) it has a staff of one or more Physicians available at all times; and
(5) it includes areas designed for diagnosis and major surgical procedures. Or if it is chiefly a place for the
Treatment of mentally ill or developmentally disabled, it has an agreement by contract or otherwise,
with an accredited Hospital to perform surgery which may be required.
The term "Hospital" does not include:
(1) a convalescent, nursing, rest, or Skilled Nursing Facility; or
(2) a facility chiefly operated for Treatment of the aged, drug addicts or alcoholips.
ILLNESS means a non-occupational disorder of the body or mind, a non-occupational disease, pregnancy,
childbirth, miscarriage or complications of pregnancy. All lllnesses which are due to the same cause or to a
related cause or causes will be deemed to be one lllness.
INFERTILITY is the presence of a condition recognized by a Physician as a cause of Infertility; or the
inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual
relations without contraception.
INJURY means a non-occupational bodily Injury caused by an Accident and which results directly from the
. Accident and independently of all other causes.
INPATIENT means confined as a registered bed patient in a Hospital, Skilled Nursing Facility, or Free-
Standing Chemical Dependency Treatment Center. It does not include observation room services. These
facilities must meet the definition of "Hospital".
LA TE ENROLLEE means an eligible person who enrolls under the Plan other than when first eligible or
durfng a Special Enrollment period. A Special Enrollment period can occur if an individual with other health
coverage loses that coverage or if a person becomes a Dependent through marriage, birth, adoption, or
placement for adoption.
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 meant to be while covered under this Plan and does not mean during the Lifetime of the
Covered Person.
MEDICAL EMERGENCY is a sudden onset of a condition with acute symptoms requiring immediate medical
care, for example, includes but is not limited to, such conditions as heart attacks, cardiovascular incidents,
poisonings, loss of consciousness or respiration, convulsions or other such acute medical conditions.
MEDICALLY NECESSARY means services or supplies determined to be:
1. Appropriate and necessary for the diagnosis or Treatment of the medical condition;
71
e
DEFINITIONS
e
..
2. Provided for the diagnosis or direct care and Treatment of the medical condition;
3. Within standards of good medical practice within the organized medical community;
4. Not primarily for your convenience, or for the convenience of your Physician or another provider; and
5. The most appropriate supply or level of service, which can safely be provided. The most appropriate
service or supply must satisfy the following requirements:
a. There must be valid scientific evidence demonstrating that the expected health benefits from the
service or supply are clinically significant and produce a greater likelihood of benefit for you
with the particular medical condition being treated than other possible services or supplies; and
b. The service or supply is no more likely to be harmful to you than other services or supplies that
could be prescribed under the same circumstances; and
c. For Hospital stays, acute care as an Inpatient is necessary due to the kind of services you are
receiving or the severity of your condition, and safe and adequate care cannot be received by you
as an Outpatient or in a less intensified medical setting.
The Plan Administrator has the discretionary authority to determine whether care or Treatment
is Medically Necessary.
MEDICARE means the medical benefits provided by Title XVIII of the Social Security Act, as amended.
NEWBORN CARE means coverage of a newborn child who is covered at the time of birth. It includes coverage
for Hospital charges for room and board, services and supplies; charges related to circumcision, and the
Physician charges for the newborn discharge examination.
NON-CONTRIBUTORY COVERAGE means coverage paid entirely by the Employer.
NON-PREFERRED PROVIDER ORGANIZATION (NON-PPO) means a provider which does not have an
agreement with Blue Cross to accept a reduced rate for services. Services provided would be subject to Usual
and Customary.
OPEN ENROLLMENT refers to a time when an individual that does not enroll when first eligible to do so, or
who allowed coverage to lapse may enroll.
OUTPATIENT means receiving medical services, but not confined as a registered bed patient in a Hospital,
Skilled Nursing Facility, or Free-Standing Chemical Dependency Treatment Center. It may include
observation room services. These facilities must meet the definitions of Hospital.
OUTPATIENT SURGICAL CENTER OR AMBULATORY SURGICAL CENTER means any public or
private establishment which;
(I) has an organized medical staff of Physicians;
72
e
DEFINITIONS
e
(2) has permanent facilities that are equipped and operated primarily for the purpose of performing surgical
procedures;
(3) provides continuous Physician services and registered professional nursing services while patients are in
the facility; and
(4) does not provide services or other accommodations for patients to stay overnight.
PHYSICAL means an annual Physical or tests, including complete Physical examinations and checkups, when
performed by a Physician. It excludes vision and hearing exams and exams required by employment or
government authority.
PHYSICIAN means a medical practitioner who:
(1) is a legally qualified Physician or surgeon (or is a professional person deemed by state law to be the
same as a legally qualified Physician); and
(2) is acting within the lawful scope of his /her license.
Physician does not include a person who:
(1) is the Covered Person receiving Treatment; or
(2) is related by blood, marriage or legal adoption to the Covered Person or the Covered Person's spouse
receiving Treatment.
Examples of a Physician are: 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, 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.
PLAN means the Plan of Group Medical and Dental benefits as described in this Summary Plan Description,
and shall also be deemed to include the previous Plan of Group Medical and Dental benefits.
PLAN ADMINISTRA TOR refers to the City of Redding.
PLAN SPONSOR refers to the party that establishes and maintains the plan, which is the City of Redding.
PLAN YEAR is the l2-month period beginning on either the effective date of the Plan or on the day following
the end of the first Plan Year.
PRE-EXISTING CONDITION is defined as any medical condition, regardless of the cause of the condition,
for which medical advice, diagnosis, care or Treatment was recommended or received by a licensed health care
73
"',
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DEFINITIONS
e
provider or practitioner in the 90 day period immediately preceding an individual's becoming covered under this
Plan. Neither genetic information nor pregnancy constitutes a Pre-Exis~g Condition for these purposes.
PREFERRED PROVIDER ORGANIZATION (PPO) means a provider which has an agreement with Blue
Cross to accept a reduced rate, subject to Plan benefits and exclusions.
PRESCRIPTION DRUG means any of the following: an approved drug or medicine; injectable insulin and
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 Illness or Injury and approved by the Food and Drug
Administration.
RECOVERY means monies paid to the Covered Person by way of judgement, settlement, or otherwise to
compensate for all losses caused by the Injuries or sickness whether or not said losses reflect medical or dental
charges covered by the Plan.
REFUND means the Plan's right to pursue the Covered Person's claims for medical or dental charges against
the other person.
SKILLED NURSING FACILITY means a place, or a distinct part of a place, which meets all of the following
criteria;
(1) it is licensed according to state and local laws.
(2) its chief purpose is to provide skilled nursing Treatment to a Covered Person who is recovering from
an Illness or Injury.
(3) it includes areas for medical Treatment.
(4) it provides 24-hour-a-day nursing service under the full-time supervision of a Physician or a graduate
registered nurse (R.N.).
(5) it maintains daily health records for each patient.
(6) it has an agreement, which provides for the services of a Physician.
(7) it has a suitable method for providing drugs and medicines to patients.
(8) it has an arrangement with one or more Hospitals for the transfer of patients.
(9) it has an effective utilization review Plan.
(10) its functions are developed with the advice and review of a skilled group, which includes at least one
Physician.
(11) it is not solely a place for:
(a) rest, rehabilitation, or custodial care;
74
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DEFINITIONS
e
(b) the aged;
(c) drug addicts;
(d) alcoholics; or
(e) those who are developmentally disabled or who have mental di~orders.
SPECIAL ENROLLMENT. The term "Special Enrollee" means an Employee or Dependent who is entitled
to and who requests Special Enrollment: (i)within 30 days of losing other health coverage; or (ii) for a newly
acquired Dependent, within 30 days of the marriage, birth, adoption or placement for adoption.
If an eligible Employee or Dependent declined coverage at the time of initial eligibility (and stated in writing at
that time that coverage was declined because of alternative health coverage) but subsequently loses coverage
under the other health Plan and makes application for coverage under this Plan within 30 days of the loss, such
the individual shall be a Special Enrollee provided such person (a) was under a COBRA continuation
provision and the coverage under such provision was exhausted; or (b) was not under such a provision 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 toward such coverage were terminated. Individuals who lose other coverage due to
nonpayment of premium or for cause (i.e. filing fraudulent claims) shall not be Special Enrollees. Coverage for
a Special Enrollee who had other coverage and then lost it shall begin as of the first day of eligibility provided
they apply within 30 days.
An eligible Employee, spouse or newly acquired Dependent who seeks to enroll in the Plan as a result of the
acquisition of a new Dependent through marriage, birth, adoption or placement for adoption shall be a Special
Enrollee if the eligible Employee, spouse, or newly acquired Dependent enrolls within 30 days of the
acquisition of the new Dependent. Coverage for such Special Enrollee shall begin as of the date of the
adoption, birth, placement for adoption or marriage.
SUBROGATION means the Plan's right to pursue the Covered Person's claims for medical or dental charges
against the other person.
TOTAL DISABILITY means an Injury or Illness which:
(1) with respect to a Covered Employee, prevents the Covered Employee from performing the normal .
duties of his or her occupation; and who is in fact not performing work of any kind for wage or profit;
and
(2) with respect to a Dependent, prevents the Dependent from performing the normal activities of a healthy
person of the same age and sex.
.75
-:
e
DEFINITIONS
e
TREATMENT means services provided that are Medically Necessary based on medical advice, diagnosis, or
care by a licensed health care provider or practitioner. Treatment includes receiving services and supplies,
consultations, diagnostic tests or prescribed medications.
USUAL AND CUSTOMARY means the ordinary charge made by a person, group, or other entity which
provides services, Treatments, or materials. It does not include any charge, which the Plan Administrator
finds to be more than the general level of charges made:
(1) by others who provide such services, Treatments, or materials;
(2) for an Illness or Injury of comparable severity and nature to the Illness or Injury being treated; or
(2) to persons of similar income or net worth in the area where the Covered Person normally resides. The
term "area" means a county or such greater area as is required to obtain a typical cross section of others
who provide such services, Treatments, or materials to persons of similar income or net worth. The Plan
Administrator has the discretionary authority to determine whether a charge is Usual and Customary.
WELL BABY CARE means routine medical care provided by a Physician for an infant from birth through age
5.
76
e
INDEX
TOPIC
Abortion
Accident
Alcoholism
Allergy Testing
Ambulance
Annual Physical
Arbitration
Birth Control
Birthing Center.
Cancer Screening
Chemical Dependency
Chiropractic
Claims Appeals
Claims Procedures
COBRA
COBRA - Disabled Persons
Contributory Coverage
Conversion - Medical
Coordination of Benefits - Dental
Coordination of Benefits - Medical
Cosmetic Surgery
Cost Containment Benefits
Covered Employee
Covered Person
Creditable Coverage
Deductible
Definitions
Dental - Diagnostic Services
Dental - Orthodontia
Dental - Preventative Services
Dental- Restorative Services
Dependent
Drug Dependency
Durable Medical Equipment
Effective Dates of Coverage
Eligible Charges
Emergency Room
Emotional Conditions
Employee Contributions
77
e
PAGE
27, 33
27,33,36,47,57,66,71
19,20,23,28,29
27
26,37
5,19,31,59, 73
60
34
22,29,66
5,22,30,66
25,29, 70-72
30, 73
59
7
40,44,45,47-53,58,66,67,75
47
66, 72
453
38-41,58
38-41
33,67
5
9,13,27,31,41,44,46,48-50,52,53,59
67,68,70,75
8-14,19,21,22,24-28,30,33-36,38,39,
41-45,47,55,58-60,68,69,71,73-76
8, 11, 67
13,20-25,31,39,54,67
4, 8, 19, 43, 45, 66-76
54-58
54-58
55-56
56
8-11, 13,33,40-41,44-52,63,67-68, 71, 75
23,25,29
68
9,10
20,23-33,35-37,67,68,71
5
19,20,23,29
44
.,
.
e
II
TOPIC
Exclusions - Dental
Exclusions - Medical
Extension of Benefits
Eye Glasses
Family Unit
General Plan Provisions
Hearing Aids
Home Health Care Provider
Hospital
Illness
Infertility Testing
Injury
Inpatient
Labor Dispute
Laboratory Tests
Late Enrollee
Legal Action
Limitations - Dental
Limitations - Medical
Massage Therapy
Mastectomy
Maternity
Maximum Benefits
Medicare
Medically Necessary
Mental Conditions
Neonatal
Newborn
Non-Contributory Coverage
Non-Occupational Coverage
Surgery
Orthodontia Benefit
Other Group Plans - (See Coordination of Benefits)
Out of Pocket (Waiver of Insured Percentage)
Outpatient
Outpatient Surgical Center
Overpayment
Physical
INDEX
78
e
PAGE
56-58
33-37
48,52,58
26
25, 70
59-62
34
13,19,22,28,29,70
6,13,20,22,23,25-28,34,38,66,70-72
13,20,22,25-29,31,33-36,44,68-76
29, 71
25,26,31,33,36,42,57,69,71,74-76
5,6,13,19,20,22,28,31,71,72
44
26,29
11,71
59
58
29, 30, 33-37
30
28,31,33
27,31
19,25,47
11,38,41,47,49,52,67,70,72
13,24,26,30,33,36,71,74,76
19,20,23,29,33,34,47
31
9, 10, 13,21,27,31, 72
72
35
29,56
54-58
28,47
22
5,6,19,20,22-26,36,72
26, 72
41, 60
31,59,73
e
TOPIC
Physician
Physical Therapy
Plan
Plan Administrator
Post-Mastectomy
Preferred Provider Organization (PPO)
Pre-Existing Conditions - Dental
Pre-Existing Conditions - Medical
Pre- Hospitalization
Pregnancy
Prescription Drug Plan
Pre- Treatment Estimate - Dental
Preventive Services
Proof of Service
Review Procedures
Re-Enrollment
Schedule of Benefits - Dental
Schedule of Benefits - Medical
Second Surgical Opinions
Skilled Nursing Facility
Smoking Cessation
Subrogation
Termination of Coverage
Total Disability
Treatment
Usual and Customary
Vitamins
Waiting Period
Weight Control
Well Baby Care
X-Rays
INDEX
79
,"
e
.
PAGE
13,14,20-24,28,30,31,33-36,47,57,
66, 71-74, 76
19,30,33,35,73
4-11, 13-21 23-26,28-31, 33-76
4,13,16, 19,21,30,34,39,41,45,47
48,52,59-63,66,72,76
28,31,33
4,5,39
58
8, 10, 11,35,45,46,51, 74
13
13,31, 71, 74
21,23,26
54
5,55
4
59
45
54
19-23
22, 24, 27, 39
19,22,26-28,70,72,74
32,36
42, 75
44,45,50
75
5, 10-14, 18-20,23,25-29,30,33-37,
42,54-57,68-76
20,22,25,33,38,54,55,69,76
31
8,46,54
37
21,27,31, 76
22,26,29,55