HomeMy WebLinkAboutMINUTES - 12151987 - 2.5 l �I
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CONTRA COSTA COUNTY
HEALTH SERVICES DEPARTMENT
ALCOHOL/DRUG ABUSE/MENTAL HEALTH
DIVISION
To: Phil Batchelor Date: November 16, 1987
From: !�
om: Mark Finucane, D'rector Subject: Revised Methadone Services
Health Services Department Contract
Background:
Contra Costa County began providing methadone maintenance and detoxification
services for heroin addicts in 1972. The services were directly provided by the
County until 1982 when the County decided to contract for the provision of these
services with California Health Associates, Inc. This decision to contract for
services was made in order to reduce County costs. A total of 180 maintenance
and 25 detoxification clients are presently served through clinics located in
Pittsburg and Richmond. The FY 1986-87 actual cost for this service was
$517,755 which represented 32% of the total drug budget of $1 ,575,690 as pre-
sented in the annual drug abuse services plan and budget for FY 1986-87.
After considerable study, the Health Services Department initiated an open com-
petitive bidding process in 1987 in order to achieve the following objectives:
. Reduce County cost of providing services from the present rate of $249 per
month per client to approximately $165 per month per client. The County
savings when applied to 180 clients per month are considerable.
• Significantly improve access to methadone services for County residents who
are unable to afford the $249 per month rate but are able to afford the rate
of $165 per month.
. Provide increased levels of prevention and counseling services for under-
served groups such as cocaine abusers, I.V. methamphetamine abusers,
pregnant substance abusers and others. These increased service levels would
be provided in West, Central , and East Contra Costa County.
• Improve the AIDS prevention and intervention services which are provided
through the methadone service provider.
. Improve services to pregnant addicts.
The bidding process initiated by the Health Services Department utilized a
Proposal Evaluation Committee to review proposals. This committee was comprised
of professionals in the drug abuse treatment field as well as members of the
Drug Abuse Advisory Board. Steps were taken to insure that the actual review
was completed in a fair and impartial manner.
y.
THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Adopted this Order on December 15, 1987 , by the following vote:
AYES: %upervisor Powers , Fanden, Schroder, Torlakson and McPeak
NOES: None
ABSENT: None.
ABSTAIN: None
SUBJECT: In the Matter of Adopting the )
Contra Costa County Self-Funded ) Resolution No. 87/759
Employees Indemnity Health Plan )
and Establishing a Self-Funded )
Health Plan Reserve Account. )
)
The Contra Costa County Board of Supervisors in all of its
capacities as the governing body of Contra Costa County and of the
Districts and Agencies of which it is also the governing body,
Resolves As Follows :
1, 1st Choice, The Contra Costa County Self-Funded Employees
Indemnity Health Plan, a copy of which is attached hereto, is
hereby adopted as a Board partially self-insured plan to provide
health and welfare benefits for its officers, employees, retirees,
and certain of their dependents .
2 . There is hereby established, and the County Auditor-
Controller is directed to maintain, a reserve account pursuant to
Government Code section 25263 and all other applicable legal
authority, for the purpose of providing the benefits of 1st
Choice, the Contra Costa County Self-Funded Employees Indemnity
Health Plan (hereinafter "Plan" ) , which shall be entitled "Health
Plan Self-Insured Trust Fund, " and which is hereinafter referred
to as the "reserve fund. "
3. There shall be deposited in said reserve fund:
a. Amounts appropriated for the self-insured health plan
program in the operating budgets of county
departments and board governed special districts at
times and in such amounts as specified by .the County
Administrator or his designee.
b. Contributions by Plan Subscribers in accordance with
Board approved rates deducted from payrolls or paid
by Subscribers.
C. Interest earned on investment of the reserve fund.
d. Any subrogation recoveries received by the County
under the Plan.
e. Any monies received from Blue Cross as a refund of
excess reserves.
Resolution 87/759
4 . Pursuant to Government Code section 31000. 8, the Auditor-
Controller and Treasurer-Tax Collector are authorized to make
disbursements from the reserve fund to:
a. Advance funds to a revolving trust fund which will be
in a separate bank checking account to be established
for payment of approved provider services performed
for Plan Members.
The amount of the revolving fund shall not exceed
$500, 000. 00 at any one time which sum this Board
determines to be sufficient and necessary to provide
for the payment of health benefit claims for a 30-
day period
b. Replenish the revolving trust fund periodically,
based on presentation of appropriate documentation
and approval of the Assistant County Administrator-
Director of Personnel or his designee.
5 . The Auditor-Controller and Treasurer-Tax Collector are
otherwise authorized tolmake disbursements from the reserve fund
to pay other lawfully incurred costs and expenses as may be
required to conduct the self-insured health plan program.
6. No advance or expenditures in excess of the funds
available in the reserve fund will be available.
7 . Program costs in excess of the amount available in the
reserve fund may be assessed equitably to the participating
agencies or as deemed appropriate by the County Administrator.
8. The County Administrator shall provide the Board of
Supervisors with a report of trust fund activities and its
financial condition on an annual basis .
9 . The provisions of this Resolution are effective from and
after January 1, 1988.
thereby certify that this is a true and correctcopy of
in action taken and enured on the n1nutes of the
Board of Supe visors on I e date shown.
ATTESTED: ( f.- ■� �{r-7
PHIL BATCHELOR, Clerk of the Board
of Supervisors and County Administrator
BY 0dMM AAM v , Deputy
Orig. Dept. : Personnel Department
cc: Auditor-Controller-Ken Corcoran
County Counsel
County Administrator
Treasurer/Tax Collector
Resolution No. 87/759
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1st Choice
THE
CONTRA COSTA COUNTY
SELF-FUNDED
EMPLOYEES INDEMNITY HEALTH PLAN
Effective : January 1 , 1988
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TABLE OF�CQNTENTS
Page
PART ONE: DEFINITIONS . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
PARTTWO: BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
A. Determination of Covered Expense . . . . . . . . . . . . . . . . . . . . . 8
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B. Deductibles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
C. Payment Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
D. Covered Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
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PART THREE: PROGRAMS AFFECTING BENEFITS . . . . . . . . . . . . . . . . . . . 21
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A. ; Surgical Screening Second Opinion Program . . . . . . . . . . . . 21
B. Surgical Outpatient Procedure Incentive Program . . . . . . 23
C. Hospital Admissions Program . . . . . . . . . . . . . . . . . . . . . . . . . . 25
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D. I Prescription Drugs Program . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
PART !FOUR: UTILIZATION REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
PART �FIVE: EXCLUSIONS AND LIMITATIONS . . . . . . . . . . . . . . . . . . . . . 28
PARTISIX: EXTENSION OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
PARTISEVEN: COORDINATION OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . 33
PART ', EIGHT: ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
PARTININE: MEDICARE ELIGIBLE MEMBERS . . . . . . . . . . . . . . . . . . . . . 1 42
PART TEN: SUBSCRIPTION CHARGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
PART ELEVEN: TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
PART; TWELVE: CONTINUATION OF BENEFITS . . . . . . . . . . . . . . . . . . . . . 44
PARTITHIRTEEN: SUBROGATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
PARTiFOURTEEN: ARBITRATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
PART, FIFTEEN: GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 48
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PART ONE: DEFINITIONS
1.) Accidental Injury is physical harm or disability which is the result of
a specific unexpected incident. The physical harm or disability must
have occurred at an identifiable time and place. Accidental Injury does
not include illness or infection, except infection of a cut or wound.
2.) Ambulatory Surgical Center is a facility whose main function is the per-
formance of surgical procedures by Physicians on an outpatient basis. It
must be licensed as an outpatient clinic according to state and local laws
and must meet all requirements of an outpatient clinic providing surgical
services.
3.) Child is a Subscribers eligible child, stepchild, or legally adopted
child, as provided in Part Eight B.2.
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4.) County.of Contra Costa or County means the County of Contra Costa and all
public agencies governed by the Contra Costa County Board of Supervisors.
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5. ) Covered Expense(s), whenever used in this Plan, has the meaning assigned
to it in PART TWO. A.
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6.) Custodial_Care is care provided primarily to meet the personal needs of a
Member. This includes help in walking, bathing or dressing. It also
includes preparing food or special diets, feeding, administration of
medicine which is usually self-administered any any other care which does
not require the continuing services of medical personnel.
7.) Customary and Reasonable charge is an amount payable for medical services,
determined by a Plan Administrator, and is a reasonable amount which
falls within the common range of fees billed by a majority of Physicians
for a procedure in a given geographic region, or which is justified based
on,
the complexity or the severity of treatment for a specific case.
8.) Effective Date is the date the Member's coverage under this Plan begins.
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9.) Experimental procedures are all procedures not generally provided as
treatment by the organized medical community in Northern California, and
those that are mainly .limited to laboratory and/or animal research.
10.) Family Member is a Subscriber's enrolled Spouse and each enrolled eligible
Child.
11.) Foundation means the Alameda-Contra Costa Foundation for Medical Care,
Inc.
12.) Home Health A encies and Visiting Nurse Associations are home health care
providers which are licensed according to state and local laws to pro-
vide skilled nursing, hospice care and other services on a visiting
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basis in the Member's home. They must be recognized as home health
care providers under Medicare.
13.) Hospital means a medical care facility which provides diagnosis, treatment
and care of persons who need acute inpatient hospital care under the
supervision of Physicians, and to which a Member is admitted pursuant to
arrangements made by a Physician. It must be licensed as a general acute
care hospital according to state and local laws and meet the accreditation
standards of the Joint Commission on Accreditation of Hospitals.
14.) Investigative procedures are experimental procedures that have
progressed to limited use on humans, but which are not widely accepted
as, proven and effective procedures within the organized medical community
ini Northern California.
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15.) Medically Necessary services or supplies are those which meet all the
following criteria, as determined by a Plan Administrator.
A.) Appropriate and necessary for the symptoms, diagnosis or treatment
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of a medical condition covered by the Plan, and
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BI.) Provided for the diagnosis or direct care and treatment of the medi
cal condition, and
C.) Within standards of good medical practice within the organized medi
cal community, and
D.) Not primarily for the convenience of the Member, the Member's
jPhysician or another provider, and
E.) The least expensive level of safe and adequate service or supplies
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which can appropriately be provided. For hospital stays, this
I means that acute care as a bed patient is needed due to the kind of
services the Member is receiving or the severity of the Member's
j condition, and that safe and adequate care cannot be received as an
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outpatient or in a less intensified medical setting.
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16.) Member means the Subscriber or a Family Member.
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17.) Mental, Nervous, and Substance Abuse Disorders are those conditions,
including drug or alcohol dependence, which are listed in the
international Classification of Diseases as diagnostic codes 290 to and
including 319.
18.) Yegptiated Rate is the fee Preferred Hospitals and Preferred Physicians
agree to accept as payment in full for covered services. Negotiated
Bates are determined by the Foundation.
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19.) Non-Preferred Hospital means a Hospital which has not entered into an
agreement with or through the Foundation at the time its services are
'rendered.
20. ) Non-Preferred Physician means a Physician who has not entered into an
A9 with or through the Foundation at the time the Physician's
services are rendered.
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21.) Non-Physician Provider means:
One of the following providers, when prescribed or referred by a
Physician, but only when the provider is licensed to practice where the
care is provided, is rendering a service within the scope of that
license, and is providing a service for which benefits are specified in
this Plan:
a.) An optometrist (O.D.)
b.) A podiatrist or chiropodist (D.P.M. , D.S.P. or D.S.C.)
c.) A psychologist
d.) A clinical social worker (C.S.W. or L.C.S.W.)
e.) A marriage, family and child counselor (M.F.C.C.)
f.) A physical therapist (P.T. or R.P.T.)
g.) A speech pathologist
h.) An audiologist
i.) An occupational therapist (O.T.R.)
22.) Physician means a doctor of medicine (M.D.) or a doctor of osteopathy
(D.O.) or a dentist who is licensed to practice medicine, osteopathy, or
dentistry where the care is provided.
23.) Plan means the County of Contra Costa Self-Funded Employees Indemnity
Health Plan, also known as "1st Choice."
24.) Plan Administrator means one or more individuals, organizations or firms
designated by the County of Contra Costa to provide administrative ser-
vices to the Plan.
25.) Preferred Hospital means a Hospital which has an Agreement in effect
with or through the Foundation and applicable to this Plan at the time
that the Hospital provides services covered under the Plan. Preferred
Hospitals have agreed to accept a Negotiated Rate as payment in full for
covered services.
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Preferred Hospitals have also agreed to participate in procedures
established to review the utilization of hospital services. Hospital
services determined to be unnecessary, according to these utilization
review procedures, are not covered by the Plan. It is the Member's
obligation to determine whether a Hospital is a Preferred Hospital. A
list of Preferred Hospitals is available to Members upon request to the
Plan Administrator.
26.) Preferred_Pharmacy means a Pharmacy which has a preferred pharmacy
agreement in effect with the County of Contra Costa at the time the
Pharmacy provides services or supplies covered under this Plan.
27.) Preferred Provider means a Preferred Hospital or Preferred Physician.
28.) Preferred_Physician means a Physician who has an Agreement in effect
with or through the Foundation and applicable to this Plan at the time
that the Physician's services covered under the Plan are rendered.
Preferred Physicians have agreed to accept the Negotiated Rate as
payment in full for covered services, but have reserved the right to
balance bill the Member if the Member has multiple health care coverage
which is applicable and the Preferred Physician reimbursement schedule
provides less than the. Physician's usual and customary fee. It is the
Member's obligation to determine whether a Physician is a Preferred
Physician. A list of Preferred Physicians is available to Members upon
request to the Plan Administrator.
29.) Residential Care Facility means a licensed institution that provides
room, board and treatment to persons suffering from Mental, Nervous, or
Substance Abuse Disorders, when Medically Necessary and prescribed by
a Physician.
30.) Skilled Nursing Facility means an institution that provides continuous
skilled nursing services. It must be licensed according to state and
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local laws and must be recognized as a Skilled Nursing Facility under
Medicare.
Skilled Nursing Facility also means a hospice facility conforming to
national hospice care standards if admission is directed by a physician
within the 6 month period prior to a Member's expected death.
Skilled Nursing_Faci�t does not include an institution, or part of
one, used mainly for (a) rest cures, (b) care of the aged, (c) care of
drug addicts or alcoholics, (d) custodial care, or (e) educational care.
31.) Special Care Units are special areas of a Hospital which have highly
skilled personnel and special equipment for acute conditions that require
special treatment and observation.
32.) Spouse means a Subscriber's spouse under a legally valid marriage be-
tween the subscriber and a person of the opposite sex.
33.) Subscriber is a person who meets all eligibility requirements of the
Plan and enrolls under the Plan.
34.) Totally Disabled Subscriber means a Subscriber who, because of illness
or injury, is unable to work for income in any job for which he or she
is qualified or for which he or she can become qualified by training or
experience, and who is in fact unemployed. A Totally Disabled Family
Member means a Family Member who is unable to perform all the activities
usual for a person of that age.
35.) Year means a twelve month, period starting each January 1 at 12:01 a.m.
Pacific Standard Time.
PART TWO: BENEFITS
The benefits provided by this Plan are payments for Covered Expenses incurred
by Members for Medically Necessary services or supplies for treatment of a
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covered illness, injury or condition. These benefits are subject to all pro-
visions of this Plan, which may limit benefits or result in benefits not being
payable.
A.) Determination of Covered Expense
1.) A Covered Expense is an expense incurred by a Member for a Medically
Necessary service or supply listed in section D. Covered Ex enses,
and provided or prescribed by a Physician or Hospital for a covered
illness, injury or condition. Expense is incurred on the date the
Member receives the service or supply for which the charge is made.
2.) In no event will Covered Expense exceed:
a.) As to a Preferred Hospital, Preferred Physician, or Preferred
Pharmacy, any charge for services in excess of the Negotiated
Rate.
b.) As to a Hospital, Physician, or Pharmacy which. is not
Preferred, any charge for services in excess of a Customary and
Reasonable charge.
c.) As to a Dentist treating an Accidental Injury to natural teeth,
any charge for services in excess of a Customary and Reasonable
charge.
d.) As to any other provider of covered services, any charge for
services in excess of a Customary and Reasonable charge.
B.) Deductibles
10 Each Member must pay the first $100.00 of Covered Expense incurred
during any Year before any benefits are provided by the Plan. After
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this $100.00 payment is made, no further deductible is required for
the rest of the Year.
2.) After a total of $300.00 in Covered Expense incurred in a Year has
been paid on account of the individual deductibles of a Subscriber
and the Family Members, any further individual deductibles of the
entire family will be considered to be satisfied for the remainder
of that Year.
3.) Covered Expense paid by a Member during the last quarter of a Year
and applied toward the deductibles for that Year is also applicable
toward the deductibles for the next succeeding Year.
4.) Waiver of deductibles.
The following services and supplies, if covered under the Plan, are
payable as Covered Expenses without prior payment of the $100 deduc-
tible amount:
a.) Preferred Provider services or supplies.
b.) Prescription Drugs and Medicines, subject, nevertheless, to the
co-payment requirements of the Prescription Drugs Program.
c.) Second Opinion Surgical Incentive Services and Procedures.
d.) Outpatient Surgery Incentive Services and Procedures.
e.) Routine radiology and laboratory examinations received within
14 days prior to a covered stay for inpatient care or out-
patient surgery, when they are needed for the illness, injury
or condition necessitating the stay and are provided and billed
by the Hospital or Ambulatory Surgical Center where the inpa-
tient care or outpatient surgery has taken place.
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C.) Payment Provisions
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Payment is provided as follows for Covered Expense incurred by a Member
after the deductibles have been paid or waived. All payments are subject
to the Customary and Reasonable charge determinations of a Plan
Administrator and to the Programs Affecting Benefits expressed in Part
Three, and are limited to the maximum amounts stated below.
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1.) First Level Payment
Until the Plan pays $1,600.00 in benefits for Covered Expense a
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iMember incurs in a Year:
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a.) Payment is provided for 50 percent of the Covered Expense
incurred by the Member for outpatient Non-Preferred Provider
services for Mental, Nervous, or Substance Abuse Disorders.
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b.) Payment is provided for 100 percent of the Covered Expense
incurred by the Member for Preferred Provider .services and
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supplies.
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c.) Payment is provided for 100 percent of the Covered Expense
incurred by the Member for Ambulatory Surgical Center Services,
and Physician services rendered in conjunction with Outpatient
Surgery Incentive Procedures.
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d.) Payment is provided for 100 percent of the Covered Expense
incurred by the Member for routine radiology and laboratory
examinations received within fourteen (14) days prior to a
covered stay for inpatient care or outpatient surgery, when
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they are needed for the illness, injury or condition necessi-
tating the stay and are provided and billed by the Hospital or
Ambulatory Surgical Center where the inpatient care or out-
patient surgery has taken place.
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e.) Payment is provided for 100 percent of the Covered Expense
incurred by the Member for services of a Physician rendering a
second surgical opinion in conjunction with procedures and for
hospital. and physician services rendered following the
obtaining of a second surgical opinion.
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f.) Payment is provided for 80 percent of the Covered Expense
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incurred by the Member for all other covered services, subject,
nevertheless, to the co-payment requirements of the
Prescription Drugs Program.
2.) Second Level Payment
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After the plan pays $1,600 in benefits for Covered Expense a Member
incurs in a Year:
a.) Payment is provided for 50 percent of the Covered Expense
incurred by the Member for outpatient services by a
Non-Preferred Provider for Mental, Nervous, or Substance Abuse
Disorders.
b.) Payment is provided for 80 percent of the Covered Expense
incurred by the Member for inpatient services by Non-Preferred
Providers for Mental, Nervous, or Substance Abuse Disorders.
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c.) Payment is provided for 100 percent of the Covered Expense
incurred by the Member for the rest of that Year for all other
covered services, subject, nevertheless, to the co-payment
requirements of the Prescription Drugs Program.
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3i) Pro ram Limitations
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As to Members who do not comply with the Surgical Screening Second
Opinion requirements or the Surgical Outpatient Procedure Incentive
Program requirements, payment will be provided for only 50 percent
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of the Covered Expense incurred on account of the services subject
to those programs, and as to Members who do not comply with the
Hospital Admissions Program, payment may be reduced or denied, sub-
ject further -to all deductible requirements and the First and Second
Level payment provisions.
4.) Maximum_Benefits
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a.) All benefits are limited to a .lifetime maximum of $1,000,000 in
payments per Member.
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b.) Benefits for outpatient visits for Mental, Nervous, and
Substance Abuse Disorders are limited to an aggregate of $1,250
in payments per year .
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c.) Benefits for all covered inpatient services for Mental,
Nervous, and Substance Abuse Disorders are limited to an aggre-
gate lifetime maximum of $50,000 in payments per Member.
5.) Time Limitations
Limitations on the number of visits or days of care allowed as a
Covered Expense are stated below under the Covered Expenses.
D.) Covered Expenses
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Ti he following are covered expenses, subject to the expressed limitations
of this Pian, only when Medically Necessary, and only when prescribed or
ordered by a Physician or Hospital or provided as emergency care:
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1 ) Hospital/Ambulatory Surgical Center
a.) Covered Services
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(1) Inpatient services and supplies provided by a Hospital,
including Special Care Units, except private room charges
over the prevailing two-bed room rate of the Hospital.
(2) Outpatient services and supplies provided by a Hospital.
(3) Outpatient services and supplies provided by an Ambulatory
Surgical Center in connection with surgery performed at
the Ambulatory Surgical ical Center.
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b.) Conditions of Service
(1) Services must be those which are regularly provided and
billed by the Hospital or Ambulatory Surgical Center.
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(2) Benefits are provided only for the services and number of
days required to treat the Member's illness, injury or
condition.
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2.) Skilled Nursing Facility
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a.) Covered Services
Inpatient services and supplies including hospice services pro-
vided by a Skilled Nursing Facility, except private room
charges over the prevailing two-bed room rate.
b.) Days Covered
Skilled Nursing Facility benefits are limited to 100 days of
care during each Skilled Nuring Facility stay and to an aggre-
gate of 100 days of Skilled Nursing Facility care per year.
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c.) Conditions of Service
(1) The Skilled Nursing Facility must be prescribed or
directed for the Member by a Physician.
(2) Services must be those which are regularly provided and
billed by the Skilled Nursing Facility.
(3) The services must be consistent with the illness, injury,
degree of disability and medical needs of the Member.
Benefits are provided only when required and only for the
number of days covered, to treat the Member's illness or
injury.
(4) The Member must remain under the active medical super-
vision of a Physician treating the illness or injury for
which the member is an inpatient in the Skilled Nursing
Facility.
3.) Home Health Care
a.) Covered Services, when Medically Necessary and prescribed by a
Physician
(1) Services of a registered nurse.
(2) Services of a licensed therapist for physical therapy,
occupational therapy or speech therapy.
(3) Services of a medical social service worker.
(4) Services of a health aide who is employed by (or under
arrangement with) a Home Health Agency or Visiting Nurse
Association. Health aide services must be ordered and
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supervised by a registered nurse employed by the Home
Health Agency or Visiting Nurse Association as pro-
fessional coordinator. These services are only covered if
the Member is also receiving the services listed in (1)
or (2) above.
(5) Hospice services for Members facing the last phase of an
incurable illness or injury under a hospice program con-
forming to national hospice care standards.
(6) Necessary medical supplies provided by the Home Health
Agency or Visiting Nurse Association.
b.) Number of_Visits_ Covered
Home Health Care services shall be provided for a period
beginning with the first visit, but not to exceed an aggregate
number of 100 visits per Year from all Home Health Care
providers.
c.) Conditions of Service
(1) The Member must be confined at home under the active medi-
cal supervision of the Physician ordering home health care
and treating the illness, injury or condition for which
the Member was confined.
(2) Services must be provided and billed by the Home Health
Agency or Visiting Nurse Association.
(3) Services must be Medically Necessary and consistent with
the illness, injury and degree of disability and medical
needs of the Member. Benefits are provided only for the
number of visits required to treat the Member's illness or
injury, or to provide hospice care.
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4.) Professional Services
a.) Services of a Physician.
b.) Services of an anesthetist.
c.) Services of a registered nurse when prescribed or directed by a
Physician.
5.) Additional Services and Supplies
a.) The following ambulance services in an emergency or prescribed
by a Physician:
(1) Base charge, mileage and non-reusable supplies of a
licensed ambulance company for ground service to transport
a Member to and from a Hospital or a Skilled Nursing
Facility.
(2) Monitoring, electrocardiograms (EKG's or ECG's), cardiac
defibrillation, cardiopulmonary resuscitation (CPR) and
administration of oxygen and intravenous (IV) solutions in
connection with ambulance service. An appropriately
licensed person must render the services.
b.) Outpatient diagnostic radiology and laboratory services.
c.) Radiation therapy, chemotherapy and hemodialysis treatment.
d.) Surgical implants, except in connection with cosmetic surgery.
e.) Artificial limbs or eyes. This includes services of an ortho-
tist and prosthetist in connection with evaluation or the
fitting of an orthotic or prosthetic device when those services
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are billed as part of the charge of the artificial limbs or
eyes.
f.) Rental or purchase of dialysis equipment, dialysis supplies and
rental or purchase of other medical equipment and supplies
which are:
(1) Ordered by a Physician, and
(2) Of no further use when medical need ends, and
(3) Usable only by the patient, and
(4) Not primarily for the Member's comfort or hygiene, and
(5) Not for environmental control, and
(6) Not for exercise, and
(7) Manufactured specifically for medical use.
Rental charges that exceed the reasonable purchase price of
medical equipment are not covered. A Plan Administrator
determines whether the item meets the above conditions.
g.) Blood transfusions, including blood processing and the cost of
unreplaced blood and blood products.
h.) Drugs and medicines approved for general use by the Food and
Drug Administration that are available only if prescribed by a
Physician. The drug or medicine must be dispensed by a
Physician or a licensed pharmacist.
i.) Injectable insulin prescribed by a Physician.
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6.) Dental Injury
Services of a Physician (M.D.) or Dentist (D.D.S.) treating an
Accidental Injury to natural teeth which occurs while the Member is
covered under this Plan. Services must be inititated within six
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months following the date of injury. Damage to natural teeth during
chewing or biting is not Accidental Injury.
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7.) Pregnancy and Maternity Care
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a.) Care for pregnancy, maternity, and abortion for a Member mother
and prenatal care of the mother's child for abnormal condition.
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b.) Routine nursery care of a Member mother's newborn Child.
8 1) Organ_ and Tissue _Transplants
All services previously described under this Section D. are provided
under the same terms and conditions stated above for. services in
connection with a non-experimental and non-investigative organ or
tissue transplant. The Plan provides coverage for:
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a.) A Member who receives the organ or tissue, and
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b.) A Member who donates the organ or tissue, and
c.) An organ or tissue donor who is not a Member, if the organ or
tissue recipient is a Member, but in such case, Benefits are
reduced by any amounts paid or payable by the donor's own
coverage.
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9.) Mental, Nervous, and Substance_Abuse Disorders
a.) Covered Services
(1) Physician prescribed inpatient Hospital or Residential
Care Facility services, limited to an aggregate number of
30 days during a Year for Mental, Nervous, and Substance
Abuse Disorders.
(2) Inpatient hospital visits by a Physician, during a covered
inpatient hospital stay limited to one (1) visit a day and
an aggregate number of 30 visits during a year for Mental,
Nervous, and Substance Abuse Disorders.
(3) Outpatient visits prescribed by a Physician limited to one
(1) visit a day and to an aggregate maximum of $1,250 in
payments per Year.
b.) Conditions of Service
(1) Services must be for treatment of a Substance Abuse
Disorder (such as drug or alcohol dependence) or a Mental
or Nervous Disorder which can be improved by standard
medical practice.
(2) The Member must be under the direct care and treatment of
a Physician for the condition being treated.
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(3) Inpatient services must be those which are regularly pro-
vided and billed by the Hospital.
(4) Inpatient Hospital benefits are provided only for the
number of days required to treat the member's illness,
injury or condition, up to an aggregate of 30 days during
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the Year for Mental, Nervous, and Substance Abuse
Disorders.
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10.") Well Baby Care
a.) Physicians' services for routine physical examinations of
Members including and until Member's second birthday.
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b.) Immunizations and laboratory services in connection with
covered services under section 10.a. above.
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11.) Chiropractic Services
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Subject to the Plan deductibles, chiropractic services performed by
California licensed chiropractors are covered under the Plan, to a
maximum of $300 in payments per year.
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12:1) Non-Physician Providers
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Non-Physician Provider services are covered when Medically Necessary
and prescribed by a Physician for a covered illness, injury or con-
dition.
13.) Optional Health Care For Children
Subscribers may elect in writing, to receive additional benefits for
comprehensive health care for eligible children beyond the age of
i two years as required by Section 10121 of the California Insurance
Code. Any Subscriber electing such optional benefits shall be
charged an additional subscriber charge.
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PART THREE: PROGRAMS AFFECTING BENEFITS
A.) Surgical �creeni _Second Opinion Program
Members who receive a Physician's recommendation for a non-emergency, non-
urgent surgical procedure .listed below, must consult as follows with the
Plan's Surgical Screening Program to receive payment of more than 5036 of the
Covered Expenses on account of such surgery.
1.) Surgical Procedures Requiring Second Opinion Surgical Screening
A 'Surgical Screening is required only for the following surgical
procedures:
a.) Arthroplasty - an operation on joint, such as knee, ankle or
elbow.
b.) Arthrotomy and/or Arthroscopy - opening and looking into a
joint with an instrument.
c.) Bunionectomy - an operation to remove an overgrowth of the bone
which occurs at the junction of the instep and the big toe.
a.) Cholecystectomy - removal of gall bladder.
e.) Colectomy - removal of all or part of the colon or large
intestine.
f..) Brain Surgery - of any type.
g.) Heart Surgery - coronary bypass, valve repair, etc.
h.) Hemorrhoidectomy (internal or external) - removal of
hemorrhoids or piles.
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i.) Herniorrhaphy - hernia repair, inguinal.
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j.) Hysterectomy - removal of uterus, partial or complete,
j.) Knee Surgery - any operation involving the knee.
k.) Laminectomy - removal of intervertebral disc.
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1.) Ligation and/or stripping of varicose veins - varicose vein
surgery.
m.) Mastectomy - partial or complete removal of breast.
n.) Ocular Surgery - of any type, including excision of cataracts.
o.) Podiatric Surgery
p.) Prostatectomy (all kinds) - removal of the prostrate gland.
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q.) Rhinoplasty - operation on the nose.
r.) Salpingectomy and/or Oophorectomy - removal of the ovary and/or
a fallopian tube.
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s.) Trans-Urethral Resection
t.) Tonsillectomy and/or Adenoidectomy - removal of the tonsils
and/or adenoids.
u.) Total knee or hip joint replacement.
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A Member must contact the Plan Administrator and obtain a Surgical Second
Opinion Screening from the panel established by the Plan. If a Member
obtains a Second Opinion Surgical Screening, benefits are paid at 100
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percent of Covered Expense incurred for services rendered in connection
with that Surgical Screening.
2.) How_Benefits_In _Connection With The Surgery _Are Affected
a.) Payment Of Benefits When A Required Second Opinion Surgical
Screening Is Obtained
If a Member obtains a Second Opinion Surgical Screening when
required, benefits for the surgery are paid under, and in accordance
with PART TWO entitled "BENEFITS." Benefits are paid whether or not
the Second Opinion Surgical Screening confirms a need for the
surgery.
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3.) Reduction Of Benefits ForFailure_To_Obtain A Second Opinion
Surgical Screening
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When a Member fails to obtain a required Second Opinion Surgical
Screening for a surgical procedure listed above, benefits paid in
connection with that surgery are reduced to_50_percent of Covered
Expense incurred, subject to the benefits deductible and to all
japplicable limitations and terms of this Plan.
B.) Surgical O utpatient_Pro edure Incentive Program
Members who follow a Physician's recommendation for a non-emergency, non-
urgent'surgical procedure .listed below, must have the procedure carried out on
an outpatient facility basis in order to receive payment of more than 50% of
the Covered Expense benefits on account of such surgery.
f.) Surgical Procedures Requiring Outpatient Surgery Performance
f
a.) Arthoscopy
b.) Biopsy
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c.) Bronchoscopy
d.) Bunionectomy
e.) Dilation and Curettage
f.) Laryngoscopy
g.) Myringotomy
h.) Nasal Polypectomy
i.) Podiatric Surgery
j j.) Sigmoidoscopy
k.) Tendotomy
1.) Tonsillectomy and Adenoidectomy
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m.) Tubal Ligation
n.) Vasectomy
2.) How Benefits In Connection With The Surgery Are Affected
a.) Paymentof benefits when a required Outpatient Surgical Procedure is
performed_on_an outpatient basis.
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If a Member obtains surgical services on an outpatient basis on a listed
outpatient surgical procedure, benefits are paid at 100 percent of
Covered Expense incurred for services rendered in connection with that
Surgery.
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b.) Reduction of benefits for failure_to_have surgery performed on
an outpatient basis-on a listed outpatient surgical procedure.
When a' Member fails to obtain surgical services on an out-
patient basis for a surgical procedure listed above, hospital,
physician, and other benefits paid in connection with that
surgery are reduced to 50 percent of Covered Expense incurred,
subject to the benefits deductible and to all applicable limi-
tations and terms of this Plan.
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C.) Hospital Admissions Program
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Members must comply with the following procedures respecting hospital
admissions or benefits will be reduced as expressed below.
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1.1) Procedures required in connection with a Member's admission to a hos i-
al.
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a.) For any non-emergency, non-urgent, elective admission to any
Hospital, the Member and the attending Physician must fill out
a pre-certification form and send it to a Plan Administrator
prior to the scheduled admission date.
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b.) For an urgent admission to any Hospital, the Member, the
attending Physician, or the Hospital must notify a Pian
Administrator by telephone before or at the time that Member is
admitted to the Hospital, and confirm the notification in
writing within three days.
c.) For any emergency admission to any Hospital, the Member, the
attending .Physician, or the Hospital must notify a Plan
Administrator by telephone within 48 hours of the member's
admission to the Hospital and confirm the notification in
writing within three days.
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d.) A Plan Administrator will either approve or disapprove all
Hospital admissions for full benefit payments under this Plan
and advise the Member, the Hospital and the Plan Administrator
of the action taken.
2.j) How benefits in connection with a hos ital admission are affected
When A Plan Administrator does not receive a timely pre-certification
foi rm as to non-emergency, non-urgent or elective hospital admissions, or
timely telephone and written notice as to urgent or emergency hospital
admissions, and the ability of the Plan Administrator to determine the
appropriateness of the admission, the length of stay, or the care pro-
vided, is impeded on account of the lack of such notice, the Plan
Administrator may reduce the benefits payable and deny benefits in whole
or in part to the extent that the appropriateness of such services cannot
reasonably be determined. Benefits will not in any event be provided
unless such hospitalization is Medically Necessary.
D.) Prescription Drug Program
Prescription drugs and medicine referenced above in Part TWO, Section D.5.h.,
and provided by a Preferred Pharmacy, shall be covered in full and without
claim requirements when the Member makes a $2.00 co-payment to the Pharmacy
for each prescription drug or medicine and refill received. A list of
Preferred Pharmacies is available to Members upon request to a Plan
Administrator.
FI I
PART FOUR: UTILIZATION UT LI VIE O REVIEW
A.) The benefits of this Plan are provided only for services that are
Medically Necessary as determined by a Plan Administrator. The ser-
vices must be ordered by the attending Physician for the direct care and
treatment of a covered illness, injury or condition. Services must be
-26-
standard medical practice where received for the illness, injury or con-
dition being treated, and must be legal in the United States.
B.) All Hospital admissions are reviewed for Medical Necessity. That review
may be undertaken:
1.) Before or during a Hospital stay, or
2.,) Following discharge from the Hospital.
C.) All Hospital admissions are subject to a Plan Administrator's utiliza-
tion review program which includes; but is not limited to:
1.l) Pre-admission _Review to determine if a scheduled inpatient admission
is Medically Necessary. Pre-admission review is available and
required on all non-emergency, non-urgent, elective hospital
admissions.
2.) Admission Review to determine if any unscheduled admission is an
admission not subject to pre-admission review, and is Medically
Necessary.
3.1) Concurrent Review to determine if a continued Hospital stay is
Medically Necessary. The Member, the Member's attending Physician,
or the Hospital is responsible for initiating the appropriate utili-
zation review.
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4 ) Retrospective Review to determine after discharge, whether a
Hospital admission or stay was Medically Necessary.
D.) All claims for Physician or Hospital services are subject to final review
by a Plan Administrator. That review may result in a determination that
part, or all, of the Physician or Hospital services were not Medically
Necessary, and a reduction or denial of benefits.
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PART FIVE: EXCLUSIONS AND LIMITATIONS
This Plan does not provide benefits for or in connection with the following,
as; determined by 'the Plan Administrator:
A.) 1.) Services or supplies that are not Medically Necessary.
2.i1) All experimental or
investigative procedures.
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3.) All experimental organ transplants.
B.) Services received before the Member's Effective Date or during an inpa-
tient stay that began before the member's Effective Date;. and Services
received after the Member's coverage ends, except as expressly provided
under Extension of Benefits.
C.) Any charge for services of a Preferred Hospital, Preferred Physician, or
Preferred Pharmacy in excess of the Negotiated Rate.
D.) Any charge for services of a Non-Preferred Hospital, Non-Preferred
Physician, or Non-Preferred Pharmacy in excess of a Customary and
Reasonable charge.
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E.) Any charge for services of a dentist treating an Accidental Injury to
natural teeth in excess of a Customary and Reasonable charge.
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F.) Any charge for services of a Non-Preferred Anesthetist or for
Non-Preferred Outpatient Diagnostic Radiology and Laboratory services in
excess of a Customany and Reasonable charge.
G.) Services not specifically listed in this Plan as covered services.
H.) 1.) Services for which Member is not legally obligated to pay.
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2.) Services for which no charge is made to the Member.
3.) Services for which no charge is made to the Member in the absence of
insurance coverage, except services received at a non-governmental
charitable research Hospital. Such a Hospital must meet the
following guidelines:
a.) It must be internationally known as being devoted mainly to
medical research, and
b.) At least ten percent (10%) of its yearly budget must be spent
I
on research not directly related to patient care, and
c.) At least one-third of its gross income must come from donations
or grants other than gifts or payments for patient care, and
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d.) It must accept patients who are unable to pay, and
e.) Two-thirds of its patients must have conditions directly
related to the Hospital's research.
if benefits are recovered or can be recovered
I.) Work-related conditions, b f is ,
either by adjudication, settlement or otherwise, under any workers' com-
pensation, employee's liability law or occupational disease law, even if
the Member does not claim those benefits.
J.) 1.) Conditions caused by an act of war.
2.) Conditions caused by release of nuclear energy, whether or not the
result of war.
K.) Any services provided by a local, state or federal government agency,
excepting the County of Contra Costa.
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L.) Any services to the extent that a retired or disabled Member is
entitled to receive Medicare .benefits for those services, whether or not
Medicare benefits are actually paid. Any services for which payment may
bie obtained from 'any other local, state or federal government agency
(''except Medi-Cal).
M.) Professional services received from a person who lives in the Member's
Nome or who is related to the Member by blood or marriage.
N.) Inpatient room and board charges in connection with a Hospital stay pri-
marily for environmental change, physical therapy or treatment of chronic
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pain. Custodial Care or rest cures. Services provided by a rest home, a
Nome for the aged, a nursing home or any similar facility. Services pro-
vided by a Skilled Nursing Facility, except as expressly provided in
Skilled Nursing Facility under "BENEFITS."
i
O.) Inpatient room and board charges in connection with a hospital stay pri-
marily for diagnostic tests which could have been performed safely on an
oiutpatient basis.
P.) Hyperkinetic syndromes, learning disabilities, behavioral problems, men-
tal retardation or autism. Mental or Nervous Disorders or Substance
Abuse, except as expressly provided under "BENEFITS."
Q.) Braces, other orthodontic appliances or orthodontic services.
1
R.) Dental plates, bridges, crowns, caps or other dental prostheses, dental
services, extraction of teeth or treatment to the teeth or gums, except
as expressly provided for Dental Injury under "BENEFITS." Cosmetic den-
tal surgery or other services for beautification. -
S.) Hearing aids and routine hearing tests.
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—30—
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T.) Optometric services, radial keratotomy, eye exercise including orthop-
tics, routine eye examinations and routine eye refractions. Eyeglasses
or contact lenses.
U.) Outpatient occupational therapy, except by a Home Health Agency or
Visiting Nurse Association as expressly provided as in Home Health Care
under "BENEFITS."
V.) Outpatient speech therapy, except following surgery, injury or non-
congenital organic disease.
W.) Cosmetic surgery or other services for beautification.
X.) Services primarily for weight reduction or for the treatment of obesity
including morbid obesity.
Y.) Procedures or treatments to change characteristics of the body to those
of the opposite sex.
i
Z.) Sterilization reversal and services to induce pregnancy, including but
not limited to artificial insemination, ovum transplant, and in vitro
fertilization.
AA.) 1.) Orthopedic shoes (except when joined to braces) or shoe inserts, air
purifiers, air conditioners, humidifiers, exercise equipment and
supplies for comfort, hygiene or beautification.
i
21.) Health education services, nutritional counseling or food supple-
ments.
BB.) Routine physical examinations or tests which do not directly treat an
actual illness, injury or condition, including those required for
employment or by government authority. Notwithstanding this exclusion,
well-baby care is a covered expense as provided in Part Two, Section
19.10.
-31-
CC.)I'Any services or supplies for the treatment of an illness, injury or con-
dition causing the Member to be Totally Disabled on the effective date of
coverage.
i
DD.)!Holistic type medicine, smoking control or exercise programs.
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EE.) Acupuncture not administered by a Physician.
FF.) Any eye surgery solely for the purpose of correcting refractive defects
of the eye such as near-sightedness (myopia) and astigmatism.
I
GG.)!Telephone consultations with Physicians or Non-Physician Providers.
I
HH. Any service or supply relative to treatment of conditions caused by or
!attributed to the temporomandibular joint except for medically necessary
i
Itreatment arising from acute dislocations, fractures, neoplasms, rhema-
Itoid arthritis, ankylosing spondylitis or disseminated lupus erythemato-
Isus.
I1.) I Military service-connected injuries, diseases, conditions or disabili-
ties.
JJ.) Written medical reports requested by Member.
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PART SIX: EXTENSION OF. BENEFITS
t
A.) If a Member is Totally Disabled when coverage under the Plan ends and is
under the treatment of a Physician, the benefits of this Plan will con-
tinue to be provided for services treating the totally disabling illness
i
or injury for up to 12 consecutive months. No benefits are provided for
services treating any other illness, injury or condition.
B.) A Member confined as an inpatient in a Hospital or Skilled Nursing
Facility is considered Totally Disabled as long as the inpatient stay is
Medically Necessary.
-32-
C.) A Member who is not confined as an inpatient who wishes to apply for
total disability benefits must submit proof to the reasonable satisfac-
tion of the plan administrator of the total disability. The Plan must
receive this proof within 90 days of the date coverage ends. At least
once every 90 days while benefits are extended, the Plan must receive
proof to the reasonable satisfaction of the Plan Administrator that the
Member's total disability is continuing.
D.) ; Benefits to Totally Disabled Members are provided until any one of the
following occurs:
1.) The Member is no longer Totally Disabled, or
2.) The maximum benefits of this Plan per Year and per Member lifetime
maximum are paid, or
3.) The' Member becomes covered under another group health plan that pro-
vides coverage for the disabling illness or injury, or
4.) A period of 12 consecutive months has passed since the date the
Member's regular coverage ended.
PART ;SEVEN: COORDINATION OF BENEFITS
All of the benefits provided by this Plan are subject to the following provi-
sions and .limitations regardless of any other provisions of this Plan.
A. Definitions
1.) Other_ Plan means any other contract which provides full or partial
benefits or services for hospital, surgical, medical, vision or den-
tal care or treatments, for a Member, including, but not limited to:
(a) group, blanket or franchise insurance coverage; (b) group ser-
vice plan contract, group practice, group individual practice and
-33-
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other group prepayment coverages; and (c) any group coverage under
labor-management trusteed plans, union welfare plans, employer organ-
ization plans, employee benefit organization plans or self-insured
employee benefit plans. The term Other Plan refers separately to
each agreement, policy, contract or other arrangement for services
and benefits, and only to that portion of any such agreement,
policy, contract or other arrangement which reserves the right to
take the services and benefits of Other Plans into consideration in
determining its benefits.
2.) This Plan means the portion of this Plan providing the benefits that
i
are subject to this provision.
I
3.) Allowable Expenses means any necessary, reasonable and customary
item of Covered Expense which is at least partially covered under at
I
least one of the Other Plans covering the person for whom claim is
made.
4.) Claim Determination Period means a Year.
I
5.) Covered Individual means a Member covered for hospitalization,
surgical, medical, vision or dental services and benefits under both
this Plan and the Other Plan.
B.) Order of Benefits Determination
j 1.) This provision applies in determining the benefits of a Covered
Individual under this Plan for any Claim Determination Period if,
j for the Allowable Expenses incurred by that Covered Individual
during that period, the sum of (a) the benefits that would be pro-
j vided under this Plan without this provision, and (b) the benefits
that would be provided under all Other Plans without provisions
similar to this provision would exceed those Allowable Expenses.
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2.) Except as provided by Sections 3. and 4. below, the benefits payable
under this Plan for Allowable Expenses incurred by a Covered
Individual will be reduced to the extent that the sum of those
reduced benefits and all of the benefits provided for those
Allowable Expenses under all Other Plans will not exceed the total
of those Allowable Expenses. Benefits provided under any Other Plan
include the benefits that would have been provided had claim been
made for those benefits.
3.) If an Other Plan contains provisions coordinating its benefits with
those of this Plan and its rules require the benefits of this Plan
to be determined first, the stated benefits of this Plan will be
provided without reduction.
i
4.) The following rules determine the order of benefits payable by the
plans:
1.) The benefits of a plan which covers the Covered Individual
it
other than as a spouse or dependent shall be exhausted first.
2.) When the Covered Individual is the child of the Subscriber, the
plan of the parent whose birthday falls earlier in the calendar
year pays before the plan of the parent whose birthday falls
later in the calendar year, except that:
iia.) if said birthdays of parents are the same, the plan which
has covered a child for the longest period of time will
pay first;
b.) if the parents are separated or divorced and the parent
with custody of the child has not remarried, the plan
which covers the child as a dependent of the parent with
custody pays first;
c.) if the parents are divorced and the parent with custody of
the child has remarried, a plan which covers the child as
-35-
a dependent of the parent with custody pays before a plan
which covers the child as a dependent of the stepparent,
and a plan which covers the child as a dependent of the
stepparent pays before a plan which covers the child as a
dependent of the parent without custody;
d.) regardless of (b) and (c) above, if there is a court
decree which establishes a parent's financial respon-
sibility for the child's health care expenses, a plan
which covers the child as a dependent of that parent pays
first;
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e.) if any other plan does not have provision for child bene-
fit payment priority, as set forth above, then this plan
will determine the order of payment with respect to
children.
5.) If rules (1) and (2) of subsection 4. ) above do not establish an
_ order of benefit priority, then the benefits of the plan which has
covered the Covered Individual for the longer period of time shall
pay first except that:
a.) If a plan covers a person for whom claim is made as a laid off
or retired employee, or as his or her dependent, the benefits
of that plan will pay after those of a plan that covers such
person as an employee who is not laid off or retired, or as his
or her dependent.
b.) If any other plan does not have a provision like that in (a),
this exception will not apply to that plan.
6.) In no event shall the Covered Individual recover under this Plan and
all Other Plans combined, more than the total Customary and
Reasonable actual expense of the services covered by this Plan.
-36-
' 7.) Rights reserved by the County: For the purposes of coordination of
benefits, the County and the Plan Administrator:
a.) May release to or obtain from any other organization or indi-
viduals any claim information, and any Covered Individual
claiming benefits under this Plan shall furnish the County or
the Plan Administrator with any information which it may
jrequire.
b.) Have the right, if any overpayment is made under this Plan
because of failure to report other coverage or for any other
reason, to recover such excess payment from any Covered
Individual to whom, for whom, or with respect to whom such
payments were made.
c.) May release medical information under the conditions of
I
Sections 56.11 and 56.20(c) of the California Civil Code.
C.) ! Responsibility for Timely Notice
iThe Plan is not responsible for payment to Members or other insurers
under coordination of benefits unless timely information has been pro-
vided by the Member or the other insurer regarding the application of
this provision.
D.) Reasonable Cash Value
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When an Other Pian provides benefits in the form of services rather than
cash payment, the Customary and Reasonable cash value of services pro-
vided will be considered to be a benefit paid. The Customary and
Reasonable cash value of any service provided to the Covered Individual
by any service organization will be considered expense incurred by that
individual, and the liability of the Plan will be reduced accordingly.
-37-
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E.) Facility of Payment
Whenever payments which should have been made under this Plan have been
made under any Other Plan, the Plan will have the right to pay to that
Other Plan any amount this Plan Administrator determines to be warranted
to; satisfy the intent of this provision. Any amount so paid will be con-
sidered to be benefits paid under this Plan, and with that payment the
Plan will fully satisfy its liability under this provision.
i
F.) Right of Recovery
Whenever payments for covered benefits have been made by this Plan and
those payments are more than the maximum payment necessary to satisfy the
intent of this provision, regardless of who was paid, the Plan has the
right to recover the excess amount from any persons to or for whom those
payments were made, or from any insurance company, service plan or any
i
other organization or persons.
PART EIGHT: ENROLLMENT
A.) Eligibility to Subscribe
The following persons may enroll as Subscribers to the Plan for them-
selves and for their eligible Family Members:
1.) Permanent and provisional employees of Contra Costa County.
2.1) Retired employees of Contra Costa County receiving a retirement
allowance from the Contra Costa County Employee's Retirement ti
Association who were subscribers to the Plan immediately prior to
their retirement and who elected in writing to continue as subscri-
bers to the plan after retirement; the surviving spouses of such
retired employees, who are receiving a retirement allowance; and the
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children of deceased retired employees who were Members at the time
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of the retired employee's death, or were conceived within 9 months
prior to the time of the retired employee's death.
3.) Retired employees of Contra Costa County receiving a retirement
allowance from the Contra Costa County Employee's Retirement
Association who:
a.)• Were subscribers to any Contra Costa County offered Health Plan
immediately prior to their retirement, and
b.) Elected to continue as subscribers to such Health Plan after
retirement, and
c.) Enroll as Subscribers to the Plan;
and the surviving spouses of such retired employees who are receiving
a retirement allowance.
Provided:
4.) A Subscriber must agree to and pay in full on behalf of the
Subscriber and the Family Members such subscription charges as are
required by any Resolution or Order of the Contra Costa County Board
of Supervisors.
5.) A dependent child who is eligible as an employee of Contra Costa
County cannot be covered as a Family Member.
' 6.) Retirees do not have vested rights to participate in health benefit
plans offered by the County for its employees or to receive any
County or Retirement System subvention for any part of the cost of
health benefits. Such participation and such subvention is at the
sole discretion of the Board of Supervisors or the Retirement
Association and is subject to modification or termination.
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B.) Eligible Members
i _ _
The following persons may be enrolled as the eligible Family Members of a
Subscriber.
1;) The Subscriber's Spouse.
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2i) The Subscriber's Child, which includes a natural or legally adopted
i
child of either a Subscriber or the spouse, a foster child entirely
supported by the Subscriber or the spouse and for whom the
Subscriber or the spouse is the legal guardian, provided in all
cases that the child is dependent, unmarried, and under the age of
1 25. Proof of eligibility either by a court order or a copy of a
U.S. income tax return of the Subscriber or the spouse showing
dependency of the child, may be required. For dependents aged 19 to
25 a statement may be required to verify that the child is legally
dependent in accordance with Internal Revenue Service requirements.
Attainment of the limiting age shall not terminate coverage of a
child while the child is and continues to be both (a) incapable of
self-sustaining employment by reason of mental retardation or physi-
cal handicap and (b) chiefly dependent upon the Subscriber for sup-
port and maintenance, provided the proof of such incapacity and
dependency is furnished to the Plan Administrator by the Subscriber
within 31 days of the child's 25th birthday and annually thereafter,
if required by the Plan Administrator.
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C.) Application for Enrollment
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11.) Subscribers must file a written application with the County within
31 days of becoming eligible for coverage hereunder and as to Family
it
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Members, within 31 days of marriage or the acquiring of children or
birth of a child; or during any open enrollment period.
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2.) Every Subscriber must notify the County in writing of any change in
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their medical coverage status during the open enrollment period held
annually by the County.
3.) Retirees must file a written election to continue as Subscribers to
the plan prior to their retirement, except as provided in Part
EIGHT, A.3. ; and must notify the County immediately in writing of
any change in their medical coverage status.
D.) [ Commencement of Coverage
--
,'After fulfilling the conditions of enrollment, and if payment of all
required charges have been made, coverage shall commence as follows:
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l.) For a Subscriber enrolled on the Effective Date of this Plan and for
the eligible Family Members, if coverage is elected. therefor,
coverage shall commence as of the Effective Date of this Plan.
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12.) For a Subscriber enrolled subsequent to the Effective Date of the
Plan and for the eligible Family Members, if coverage is elected
therefor, coverage shall commence on the first day of the month
following the month in which the enrollment application is accepted
by the County, except that no such coverage shall commence prior to
March 1, 1988, . and except in the case of new employees, enrollment
applications will be accepted only during open enrollment periods.
I
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3.) For a Family Member, other than a newborn child, who becomes eli-
gible after the Subscriber has been enrolled, coverage shall com-
mence on the effective date of eligibility, providing written
I application for the addition of such Family Member is filed with the
jCounty and all required charges are paid within 31 days of marriage
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or legal adoption. Otherwise coverage may be obtained only as pro-
vided in Section.D.2., upon open enrollment.
4.) For child born while the Subscriber is covered hereunder, coverage
shall commence from the date of birth. If written application for
the addition of such child is not filed with the County and all
required charges are not paid within 31 days of the date of birth,
such coverage will terminate at the end of the 31 day period
following the date of birth, subject to re-instatement as provided
in Section D.2. upon open enrollment.
PART NINE: MEDICARE ELIGIBLE MEMBERS
A.) Members who become eligible for Medicare benefits must notify the Contra
Costa County Personnel Office, Employee Benefits Division, in writing of
such eligibility at least 60 days prior to the Member's 65th birthday or
within 60 days of the Member's otherwise becoming eligible for Medicare.
Failure to notify the Contra Costa County Personnel Office Employee
Benefits Division of Medicare eligibility known to a retired Member will
jresult in the termination of that Member's membership.
B.) 'Medicare eligible Subscribers employed by Contra Costa County and the
Medicare eligible spouses and dependent children of Subscribers employed
by Contra Costa County must file a written election with the Contra
Costa County Personnel Office, Employee Benefits Division, and the Social
;Security Administration either to receive Medicare benefits or the Plan
benefits as their primary health coverage. Such election must be filed
no later than 30 days prior to the Member's or Family Member's 65th
birthday. County employed Members who elect Medicare coverage as their
!primary health coverage shall be ineligible for Plan benefits until
the Member elects the plan as their primary health coverage upon the next
open enrollment period. When County employed Subscribers elect to
i receive Medicare benefits as their primary health coverage, the Family
, Members based on such Subscriber's membership shall also be ineligible
'for 'Plan benefits.
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C. Medicare eligible Subscribers not employed by Contra Costa County and the
Medicare eligible spouses and dependent children of Subscribers not
employed by Contra Costa County, must as a condition of continued mem-
bership in the Plan, file a written election with the Contra Costa County
Personnel Office Employee Benefits Division and the Social Security
Administration to receive Medicare coverage as their primary health
coverage, in which case the Plan shall continue to provide those Members
such coverage within the provisions of the Plan as is in addition to the
health benefits provided by Medicare. Failure to file such a written
election will result in the termination of that Member's membership in
the Plan.
PART TEN: SUBSCRIPTION CHARGES
The Contra Costa County Board of Supervisors shall determine and may modify at
its discretion the monthly charges required for subscription to the Pian by
classes of Subscribers and the proportion, if any, of those charges payable by
the County. The balance of the monthly charges are payable by the Subscribers
by payroll deduction or by the eleventh of the month for each insured month.
PART ELEVEN: TERMINATION
A.) This Plan may be terminated in full by Contra Costa County after thirty
days prior written notice mailed to the Plan Subscribers at their last
address of record.
B.) This Plan may be terminated as to any Member by Contra Costa County after
thirty days prior written notice mailed to the Member at the Member's
last address of record, ,as follows:
1 ) Upon termination of the Plan.
2 ) Upon failure of the Subscriber or Member to meet the Plan's eligi-
bility and Medicare requirements.
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3.) Upon failure of the Subscriber to pay any required subscription
charge on or before the due date for such payment.
41) Upon the County's receipt of the Subscriber's written notice of
termination.
PART TWELVE: CONTINUATION OF BENEFITS
Subject to payment of the required subscription charges, a Subscriber or
PaY 9 P g
Family Member may continue his or her health benefits that would otherwise
terminate due to failure of the Subscriber to continue to meet the Plan's eli-
gibility requirements, as described below.
A.) Employee Continuation
An employee may elect to continue his or her health benefits, and his or
her dependent health benefits, for a maximum of 18 months from the date
such benefits would otherwise terminate due to:
1.j) Termination of employment for any reason other than termination for
gross misconduct, or
2.I) A reduction of hours worked.
B.) Dependent Continuation
An employee's covered Family Members may elect to continue their health
benefits for a maximum of 36 months from the date such benefits would
otherwise terminate due to:
1. The employee's death;
2 ) Divorce or legal separation from the employee;
3:) The employee's eligibility for Medicare; or
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4.) A dependent Child becoming ineligible under the terms of this Plan.
C.) Length of Continued Coverage
The maximum length of time each person may elect to continue his or her
health benefits is based on the first event for which he or she becomes
entitled to continued coverage.
Continued benefits will terminate on the earlier of:
1.1) The end of the 18 or 36 month continuation period stated above;
2). The date the County ceases to provide any group health plan to
I any employee;
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3;) The date a charge required for the continued benefits is due but not
paid;
4.) The date the person becomes covered under any other group health
plan;
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5.) The date the person becomes entitled to benefits under Medicare; or
6�.) For a divorced Spouse, the date he or she remarries and becomes
covered under any other group health plan.
D.) Notice of Conti zjuation_Privilege
The Subscriber or Family Member must notify the County Personnel Office
of:
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1'.) The date of his or her divorce or legal separation; or
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2.) The date his or her dependent child is no longer eligible under the
terms of this Plan.
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The County Personnel Office will notify each employee and Family Member
of! his or her right to continue the benefits under this Plan within 30
days after the County Personnel Office receives notice that an employee
or Family Member is entitled to continue his or her health benefits.
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E.) Election to Continue_Health-Benefits
The employee or Family Member must elect to continue his or her health
benefits within 60 days from the later of:
11) The date his or her benefits would otherwise terminate; or
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2s) The date he or she receives notice from the Plan Administrator.
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Unless stated otherwise, an election by an Employee or Spouse will be
considered an election by all Family Members entitled to continue health
benefits.
F.) Required-Charices
J
The amount of charges required to continue Pian benefits will be stated
on the notice from the County. This amount will be determined by the
County Personnel Office and will not exceed 102% of the entire amount
('employer and employee portion) of the subscription charges for a person
or family not on continuation.
The required charges must be paid monthly on or before the due date
sI ated in the notice. However, if continued benefits are elected after
the date coverage would otherwise terminate under this Plan, the required
charges for the period prior to the date of the election must be paid
within 45 days after the election.
Continued health benefits will start on the date benefits under the Plan
would otherwise terminate.
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PART THIRTEEN: SUBROGATION
A.) Subrogation Right_of_the_County
The benefits of this Plan are available to a Member who is injured by the
act or omission of another person, firm or corporation. If the Member
receives benefits under this Plan for treatment of such injuries, the
County shall be subrogated to the rights of the Member or the personal
representative of a deceased to the extent of all payments made by the
Plan Administrator for such benefits.
As a condition of receiving such benefits the Member assigns to the
County of Contra Costa any rights the Member or the Member's personal
representative may have against any person or entity, including, but not
.by way of limitation, any Workers' Compensation carrier or Board; and the
Member or Member's personal representative shall furnish the County in
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writing the name and address of the party who caused the injuries and the
facts of the accident and shall cooperate fully with the County and do
nothing to prejudice the County's subrogation rights.
I
B.) Collection by Member or Representative
Any sums collected by or on behalf of a Member or the Member's personal
representative by legal action, settlement, or in any manner, on account
of .the benefits provided, shall be payable to the County. When reason-
able collection costs and reasonable legal expenses have been incurred
in recovering sums which benefit both the Member and the County, whether
incurred in an action for damages or otherwise, there shall be an
equitable apportionment of such collection costs and legal expenses.
PART FOURTEEN: BINDING ARBITRATION
A.) Any dispute between a Member and the County of Contra Costa regarding any
decision or action under the Plan by the Plan Administrator or the County
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or' otherwise with respect to any of the terms, conditions, or benefits of
this Plan, must be submitted to binding arbitration unless the dispute is
subject to the jurisdiction of the small claims court. This arbitration
is begun by the Member making written demand for arbitration on the Plan
Administrator not later than one year after the decision, action, or
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occurrence upon which the demand is based.
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B.) This arbitration will be held before a designated neutral arbitrator
appointed by the county medical association of the county in which the
services were provided. If the county medical association declines or is
unable to appoint an arbitrator, the arbitration will be conducted
according to the rules of the American Arbitration Association.
C.) Any dispute regarding a claim for damages or other matter within the
jurisdiction of the small claims court will be resolved in such court.
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D.) THE ARBITRATION FINDINGS WILL BE FINAL AND BINDING.
PART FIFTEEN: GENERAL PROVISIONS
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A.) Workers'—Compensation
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The Plan does not affect any requirement for workers' compensation. It
also does not replace workers' compensation. Members must notify the Plan
Administrator of any workers' compensation application filed on the
Member's behalf.
B.) Protection f Coverage
The coverage of any Member under this Plan may not be canceled while:
10 This Plan is still in effect, and
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2.) The Member is still eligible and in compliance with the Medicare,
Subrogation, and Coordination of Benefits requirements of this Plan,
and
3.) The Member's subscription charges are paid.
C.) Clerical and Administrative Errors
Clerical and Administrative errors of the Plan do not deprive any Member
of his or her coverage. Also, clerical and administrative errors of the
Plan do not create, authorize, or continue coverage or benefits which
would not otherwise be provided by the Plan.
D.) ProvidiM of_Care
The Plan is not responsible for providing any type of hospital, medical
or similar care. Also, the Plan isnot responsible for the quality of
any type of hospital, medical or similar care received.
E.) Non-Regulation of Providers
Benefits provided under this Plan do not regulate the amounts charged by
providers of medical care.
F. Benefits Not_Transferable
Only eligible Members are entitled to receive benefits under this Plan.
The right to benefits cannot be transferred.
G.) Independent Contractors
All providers are independent contractors. The Plan is not liable for
any claim or demand for damages connected with any injury resulting from
any treatment.
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H.) Medical Neck
In addition to any other provision in this Plan respecting Medical
necessity, the benefits of this Plan are provided only for services that
are Medically Necessary. The services must be ordered by the attending
Physician for the direct care and treatment of a covered illness, injury
or condition. They must be standard medical practice where received for
the illness, injury, or condition being treated and must be legal in the
United States. When an inpatient stay is necessary, services are limited
to those which could not have been performed before admission.
I.) Expense in Excess of Benefits
The County is not liable for any expenses the Member incurs in excess of
the benefits of this Plan.
J.) Area of Service
The benefits of this Plan are provided for covered services received by a
Member anywhere in the world.
K.) Payment to Providers
Plan benefits are paid directly to Preferred Hospitals, Preferred
Physicians, and Preferred Pharmacists. The Plan may in its discretion
pay other providers of service directly when the Member assigns benefits
in writing. These payments fulfill the obligation of the Plan to the
Member for these services.
L.) Notice of Claim
Properly completed claim forms itemizing the services received and the
charges must be sent to the Plan by the Member or the provider of ser-
vice. These claim forms must be received by the Plan within 6 months of
the date services are received. The Plan is not liable for the benefits
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of this Plan if claims are not filed within this time period. Claim
forms must be used; canceled checks or receipts are not acceptable.
M.) Right of _Recovery
When the amount paid by the Plan exceeds the amount for which the Plan is
liable, the County of Contra Costa has the right to recover the excess
amount. This amount may be recovered from the Member, the person to whom
payment was made, or any other plan.
N.) Free Choice of Hospital_and_Physician
THIS PLAN DOES NOT INTERFERE WITH THE RIGHT OF A MEMBER ENTITLED
TO HOSPITAL BENEFITS TO SELECT THE HOSPITAL. THAT PERSON MAY
CHOOSE ANY PHYSICIAN WHO HOLDS A VALID PHYSICIAN AND SURGEON'S
CERTIFICATE AND WHO IS A MEMBER OF, OR ACCEPTABLE TO, THE ATTENDING
STAFF AND BOARD OF DIRECTORS OF THE HOSPITAL WHERE SERVICES ARE
RECEIVED. HOWEVER, BENEFITS PAYABLE ACCORDING TO THE TERMS OF
THIS PLAN WILL BE DIFFERENT FOR EACH OF THE FOLLOWING CATEGORIES:
PREFERRED HOSPITALS, PREFERRED PHYSICIANS, HOSPITALS WHICH ARE
NOT PREFERRED AND NON-PREFFERED PHYSICIANS.
O.) Member_ Duties
When a Member is a Child, the duties of that Member under this Plan must '
be carried out by the Subscriber.
P.) Plan Administration
1.) The Contra Costa County Administrator may promulgate rules or regu-
lations which shall govern the interpretation and administration of
the Plan.
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2.) Open enrollment in the Plan shall be permitted only during periods
determined from time to time by the Contra Costa County
Administrator and re-enrollment may be required from time to time as
determined by the Contra Costa County Administrator.
3.) Each Member shall be deemed to have assented to all of the terms and
conditions of the Plan.
4.) This Plan may be amended or terminated by the County.
5.) Any notice or other communication required or permitted under the
Plan, if directed to the County, shall be sent to the Plan
Administrator and if directed to a Member shall be sent to the
Member by first class mail to the Member's last known address as it
appears on the records of the Plan Administrator or the County's
Director of Personnel.
Q.)
Conversion
This Plan shall offer its Members the conversion coverage required, if
any, by Insurance Code section 12670 et seq.
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,2 / 5 T3 (1)
THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Adopted this Order on December 15, 1987 , by the following vote:
AYES: Supervisors Powers, Fanden, Schroder, Torlakson and McPeak
NOES: None
ABSENT: None
ABSTAIN: None
SUBJECT: In the Matter of )
Implementation of 1st ) 87/760
Choice, The Contra Costa )
County Self-Funded Employees )
Indemnity Health Plan. )
Upon the recommendation of the County Administrator and for
the purpose of implementing 1st Choice, The Contra Costa County
Self-Funded Employees Indemnity Health Plan, IT IS BY THE BOARD
ORDERED:
1. The agreement between the County of Contra Costa and the
Alameda-Contra Costa. Foundation for Medical Care, -Inc. , for
Preferred Hospital and Physician services to Plan Members, a copy
of which is attached hereto as Exhibit A, is approved and the
Assistant County Administrator/Director of Personnel is authorized
to execute the agreement on behalf of Contra Costa County.
2 . The Assistant County Administrator/Director of Personnel
is authorized to negotiate contracts with Stateco Administrative
Services and Pacific Peer Review, Inc. , to provide claims review,
adjustment, payment, and administrative services for the Plan,
effective from January 1, 1988 and . to execute such contracts upon
approval by the Board of Supervisors .
3 . Upon approval of a contract with Stateco Administrative
Services, that agency may execute and deliver checks in payment of
Plan health benefit claims from the Self-Insured Health Plan
Revolving Trust Fund, as provided under Government Code section
31000 . 8.
4 . The Assistant County Administrator/Director of Personnel
is authorized to negotiate contracts for the Plan with Pharmacies
in the form attached hereto as Exhibit B, effective from or after
January 1, 1988, and. to execute such contracts upon approval by
the Board of Supervisors .
5 . The Assistant County Administrator/Director of Personnel
is authorized and directed to take all actions necessary or
advisable to comply with state or federal laws or regulations
concerning operation of 1st Choice, the Contra Costa County Self-
Funded Employees ' Indemnity Health Plan.
6. Persons eligible to enroll as Plan Subscribers on
January 1, 1988 and. who, prior to that time, were subscribers to a
Contra Costa County offered Blue Cross health plan, may enroll as
Plan Subscribers effective January 1, 1988; and the Assistant
County Administrator/Director of Personnel may enroll such persons
as Subscribers effective January 1, 1988 until March 1, 1988,
subject to their right to disaffirm such enrollment and their
right to elect other coverage upon open enrollment.
Orifi Dept.: personnel jhereby certify that this Isatrue and correct copy of
CC: County Counsel an action taker, and entered on the nilnutes of the
County Administrator Board of Su f Isors on t e date shown.
Auditor/Controller-Keri Corcoran U \ A
Treasurer/Tax Collector ATTESTED: 1 14�T I W
PHIL BATCHELOR, Clerk of the Board
of Supervisors and County.Administrator
LO
87/760
By , Deputy
t A
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THE FOUNDATION/CONTRA COSTA COUNTY AGREEMENT
THIS AGREEMENT (.the "Agreement") is effective on January 1, 1988, between the
Alameda-Contra Costa Foundation for Medical Care, Inc. (The Foundation) and Contra
Costa County (The County).
I. RECITAL
1.1. The Foundation intends by entering into this Agreement to make
it possible for Covered Individuals of The County to have access
to health care services through the Participating Physician and
Hospital network of The Foundation and to enjoy the benefits of
the Agreements between health care providers and The Foundation.
II. DEFINITIONS
2.1 "Covered Individuals" means an employee or a retired employee of The
County or his/her dependents covered under the Self Funded Plan of
Contra Costa County.
2.2 "Covered Services" means Hospital Services and Medical Services which
are available under the Health Plan.
2. 3 "Health Plan" means those benefits available to Eligible employees
and their dependents provided by the self funded plan through the
County.
2.4 "Hospital Services" means those acute care inpatient and outpatient
services provided by a Participating Hospital which are covered under
the Health Plan.
2.5 "The Alameda-Contra Costa Foundation for Medical Care, Inc.", (The "--
Foundation) means. the California corporation which has agreements with
participating Physicians and Hospitals which is authorized to act as
agent for Participating Physicians and Hospitals in executing this
Agreement.
2. 6 "Medical Services" means those services provided by a Participating
Physician that are covered under the Health Plan.
2. 7 "Participating Hospital" means a hospital which has entered into an
agreement with The Foundation to provide Hospital Services at agreed
upon rates and conditions.
2.8 "Participating Physician" means a physician who has. entered into an
agreement with. The Foundation, to provide Medical Services at agreed
upon rates and conditions.
C��G►10 0 0� Q
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III. RELATIONSHIP OF THE PARTIES
3.1 The Foundation and The County are independent of. one another.
Nothing in this Agreement shall be deemed to create a
relationship of employer and employee or principal and agent
or any relationship other than that of independent parties
contracting with each other solely for the purpose of
carrying out the provisions of this Agreement. Neither the
Foundation nor The County is authorized to represent the other
for any purpose.
3.2 Nothing in this Agreement shall be deemed to create any rights
or remedies in any third party.
IV. RESPONSIBILITIES OF PARTICIPATING PHYSICIAN AND HOSPITAL
4.1 Physician and Hospital shall provide Medically necessary Services
to Covered Individuals pursuant to their respective Agreements with
The Foundation.
4.2 Participating Physician and Hospital agree to participate in an
approved Pre-Admission and Concurrent Utilization Review Program
as established by The County and to accept the determinations
thereunder.
V. RESPONSIBILITIES OF THE COUNTY
5.1 The County, through its authorized payor, will pay Participating
Physician pursuant to all applicable provisions of The Physicians
Agreement with The Foundation for Covered Medical Services rendered
to Covered Individuals, and agrees to reimburse Participating Physicians
on an automatic assignment basis. A current copy of the Participating
Physicians Agreement is attached to and made a part of this Agreement
as Exhibit A.
5.2 The County agrees to identify Participating Physicians and Participating
Hospitals on informational materials provided to Covered Individuals.
5. 3 The County, through its authorized payor, will pay Participating Hospitals
pursuant to all applicable provisions of the Hospital's Agreement with
The Foundation. A copy of a model "Hospital Service Agreement" is
attached ;to and made a part of this Agreement as Exhibit B. The "Per
Diems" and "Discounts" differ with each Hospital. A copy of reimbursement
methodology and updated information will be provided to the County by
The Foundation, provided 1) that Participating Hospitals will be paid at
Hospital Service Agreement rates whether or not the admitting physician is
a Participating Physician, and 2). that Participating Hospitals will be paid
at Hospital Service Agreement rates for pre-operative work for scheduled
surgical admissions, notwithstanding any contrary provisions in any
agreements between said Hospitals and The Foundation.
MEN nW
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VI. REIMBURSEMENT
6.1 Participating Physician agrees to accept as payment in full for
Medical Services those amounts determined in accordance with
CRVS conversion factors set forth in Schedule A attached hereto
and made a part hereof (the "Maximum Fee Schedule"). The County
will have use of those rates for a period of one year (12 months)
from the effective date of this Agreement. New rates will become
effective on the subsequent anniversary date of the Agreement.
6. 2 Participating Physician agrees that the only charges for which
a Covered Individual shall be liable and shall be billed by
Participating Physician shall be for services not covered by
the Health Plan, co-insurance, co-payments and deductibles required
by the Health Plan.
6. 3 Providers may appeal the claim determination of The County. Such
appeals are to be submitted to The Foundation for its review and
recommendation.
6.4 The County agrees to reimburse Participating Hospitals at those
rates in force on the effective date of the Agreement. The County
will have use of those rates for a period of one year (12 months)
from the effective date of this Agreement. New Hospital rates will
become effective on the subsequent anniversarydate of the Agreement.
VII. PREADMISSION REVIEW
7.1 Preadmission Review will be provided by an organization acceptable
to the County- and The Foundation.
VIII. RECORDS
8.1 Participating Physician and Hospital shall maintain and retain records
concerning Covered Individuals receiving Medical Services in accordance
with prudent record-keeping procedures and as required by law.
8.2 Participating Physician and Hospital agree to allow The County or its
representative, upon reasonable notice, and during regular business
hours, to review and make copies of files and records maintained
concerning Covered Individuals which relate ' to this Agreement,
including but not limited to medical records and other records relating to
billing, payment and assignment of benefits.
8. 3 The County, its representative and Participating Physician and Hospital
agree to take reasonable precautions to keep confidential and to prevent
the unauthorized disclosure of confidential records relating to Covered
Individuals.
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IX. INSURANCE
9.1 The Foundation shall maintain policies of comprehensive
general liability and professional liability insurance
in amounts necessary to insure it and its employees against
damages related to the performance by employees of The Foundation
under this Agreement.
9.2 The County shall be self insured in amounts necessary to insure
it and its employees against damages related to the performance
by employees of The County under this Agreement.
9.3 Each party shall indemnify the other and hold it harmless from
any loss, liability, damage, claim or .cost arising out of the
act or omission of any employee, officer or agent of the
indemnifying party in connection with this Agreement.
X. INFORMATION AND EDUCATION
10.1 The Foundation agrees to provide updated listings of Participating
Physicians and Hospitals and to assist The County in the education
of its covered individuals as to the utilization of their services.
10.2 The Foundation also agrees to solicit the Participation of Physicians
who are not now Participating members of The Foundation.
XI. TERM AND TERMINATION
11.1 The initial term of this Agreement shall be one year beginning with
the effective date hereof and thereafter this Agreement shall
continue in effect for successive one-year terms unless terminated
as provided in Section 11.2 of the Agreement.
11.2 Either party may terminate this Agreement at the expiration of the T
current one-year term by giving at least 60 days. wxitten noticeprior
to the date of such- expiration. Notwithstanding the termination of this
Agreement, all obligations and rights hereunder shall continue-
with-respect to the period before termination and as otherwise provided
in .this Agreement.
11.3 The Foundation may amend the Fee Schedules, pursuant to Exhibits, A and .R.
for any succeeding term by giving notice to The County together with..a
copy of the amendment no later than .9.0.. days prior to the expiration of
the then current term.
5 -
XII. MONTHLY ADMINISTRATIVE FEE
12.1 Within fifteen (15) days following the end of each month during
which this Agreement is in effect, The County shall pay to The
Foundation a monthly administration fee of $. 75 per employee
covered by the County.Self Funded Plan.
XIII. REPRESENTATION AND WARRANTIES: OPINION OF COUNSEL
13.1 Representations and Warranties
On behalf of the Participating Physician and Hospital, The
Foundation warrants to the County that (a) Participating
Physician is a physician duly licensed to practice medicine
in the State of California and that Participating Hospital is
duly licensed and accredited as required by the State of
California. Further, Participating Physician and Hospital will
maintain such license and all other licenses required by law
during the term of this Agreement, and (b) this Agreement has
been duly executed and delivered by authorized agent for
Participating Physician and Hospital, and constitutes a legal,
valid and binding obligation of Participating Physicians and
Hospitals.
13.2 Attorney Fees
In the event of any suit to enforce any provision of this Agreement,
or as a result of the alleged b.reach. of any provision of this
Agreement, the prevailing party shall recover reasonable attorney
fees.
XIV. GENERAL PROVISIONS
14.1 Notice of Actions: Changes in Status
Participating Physician and Hospital shall promptly notify
The Foundation and The Foundation shall promptly notify The
County in writing of the commencement of any action or proceeding
with respect to any licenses, the initiation of any proceeding
or investigation relating by the California Department of Health
Services or by the United States Department of Health and Human
Services or any change in certification or accreditation by any
association or organization.
- 6 -
14.2 Evidence of License
Participating Physician and Hospital shall furnish to The
Foundation upon request satisfactory evidence of the licenses,
certifications and accreditation referred to in Article XIII.
14. 3 Waiver of Breach
Waiver of breach of any provision of this Agreement shall not
be deemed a waiver of any other breach of the same or a different
provision.
14.4 Notices
Any notices or other communication under this Agreement shall
be in writing and shall be considered given when delivered or
mailed first class to the parties at the following address (or
such other address as party may specify by notice to the other) :
(. i) if to The Foundation, to:
The Foundation
6230 Claremont Avenue
Oakland, California 94618
Attention: Executive Director
Phone: (415) 654-5383, Ext. 6450
(ii) if to The County, to:
County of Contra Costa
Employee Benefits Division
651 Pine Street, 3rd Floor
Martinez, California 94553
14.5 Entire Agreement
This Agreement together with the Exhibits, Schedules and Agreements
attached hereto constitutes the entire Agreement between the parties
and may not be modified or amended except by a written instrument
executed by both parties hereto.
14.6 Non-Assignability
This Agreement is not assignable.
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14. 7 Governing Law
This Agreement shall be construed and enforced in
accordance with the laws of the State of California.
14.8 Headings
The headings of articles and sections contained in this
Agreement are for reference purposes only and shall not
affect in any way the meaning or interpretation of this
Agreement.
THE FOUNDATION THE COUNTY
By:
Tit e Title
/- i- 14
.s
PHYSICIAN AGREEMENT
ALAMEDA-CONTRA COSTA FOUNDATION FOR MEDICAL CARE
6230 CLAREMONT AVENUE - OAKLAND, CALIFORNIA 94618
The parties to this Agreement are the Alameda-Contra Costa Foundation for Medical Care, a California non-
profit public benefit Corporation, hereinafter referred to as 'Foundation' and
hereinafter referred to as 'Physician%
(Name of Physician Please Print or type)
AGREEMENT
A. FOUNDATION AGREES:
(1) To provide access to agreements, contracts and medical policy guidelines entered into or adopted
by the Foundation.
(2) To require all third party payors, directly or indirectly through the Foundation, to provide
identification cards and eligibility information.
(3) To establish review programs and procedures which recognize local community standards;
(4) To administer payment to Physicians in accordance with third party payor contracts, and
applicable policies and procedures.
(5) To require as a part of the reciprocity agreement with other foundations that peer review
denials of Physician be reviewed by Foundation before denials are issued.
B. PHYSICIAN AGREES:
(1) To be bound by the Articles of Incorporation, Bylaws, guidelines, policies and procedures entered
Into or adopted by Foundation. .
(2) That Physician will directly bill the Foundation within sixty days, after completion of services
and provide sufficient information in billing to allow the Foundation proper evaluation with respect to
eligibility and medical necessity of services rendered to patients and to be compensated by the responsible
third party payor pursuant to the reimbursement schedule(s) utilized by Foundation.
(3) Physician will accept payments pursuant to Foundation reimbursement schedule and Explanation
of Benefits (EOB) as payment in full from the responsible third party payor-for services rendered pursuant
to this Agreement except as applies to the conditions outlined In Items 4 and/or 5.
(4) That physicians will not bill patients amounts not paid by the third party payor until the
Explanation of Benefits (EOB) statement explaining. amounts which are the patient's responsibility, Is
received from Foundation or other Foundations maintaining reciprocity agreements with Alameda-Contra
Costa Foundation.
(5) In the event the patient has multiple coverage and Foundation's reimbursement schedule amounts `
to less than Physician's usual and customary fee, Physician may balance-bill the patient for the difference
between Foundation's allowance and the Physician's usual and customary fee as specified by the Explanation
of Benefits (EOB). - -�
(6) That Physician and/or professional practitioner employed by Physician is duly licensed by the
State of California.
m Physician shall allow name(s), specialty(ies), address(es), telephone number(s), languages(s) to
be listed in the Alameda-Contra Costa Foundation directory of participating members. In the event this
Agreement Is terminated for any reason, Physician's name, etc., notwithstanding such termination, may be
retained for some period of time on Foundation's directory list, but such listing shall not constitute a
reinstatement of physician or a renewal or continuation of this Agreement.
(8) To notify Foundation within one working day by telephone, followed up in writing, of any
policy(s) and/or procedure(s) which obstruct the provision of health care and where, in the opinion of the
Physician, such policy(s) and/or procedure(s) carry potential negative consequences for Physician's patient.
C. BOTH PARTIES AGREE:
(1) That In performing obligations under this Agreement, the Physician Is , and shall remain at all
times, an independent contractor and not an employee or agent of the Foundation. Further, that patients to
whom services are rendered, for which Physician Is compensated pursuant to this Agreement, shall not be
third party beneficiaries of the obligation assumed by either party under this Agreement.
(2) That this agreement is personal in nature and cannot be assigned by the Physician or Foundation.
Subject to such restriction all of the terms, provisions, and obligations of this Agreement shall be binding
upon and shall inure to the benefit of the parties hereto and their respective heirs, representative,
successor, and assigns. M o lu Q
FEE SCHEDULE AGREEMENT
ALAMEDA-CONTRA COSTA FOUNDATION FOR MEDICAL CARE
FOUNDATION STANDARD BUSINESS
The following fees are not intended to establish fees to be charged by member or non-member physicians.
Physicians are to bill their usual and customary charges. The Foundation will reimburse according to the fee
schedule listed below.
ACKNOWLEDGEMENTS
Foundation and Physician acknowledge that the fee schedule has been established by an independent third
party, and unless an independent third party changes the schedule as listed, the fee schedule will be in effect
from July 1, 1987 through June 30, 1988.
Physician agrees to utilize the 1979 California Standard Nomenclature or CPT to bill Foundation-related
services. The Foundation agrees to reimburse Physicians utilizing the 1974 Relative Value Studies (RVS)
with revisions as adopted by third party payors conducting business in Alameda-Contra Costa Counties (or
an independent third party).
Physician agrees, according to the Physician's Agreement with the Foundation, to accept the following fee
schedule:
1974 RVS Sections Reimbursement Schedule
Medicine $ 6.50
Surgery 155.00
Anesthesia 33.00
Radiology/Nuclear Medicine 13.50
Professional Component 1.75
Pathology 1.40
Maternity-Global Fee
Procedure 59400 (Normal Delivery) 1,600.00
Procedure 59501 (C-Section) 2,000.00
Physician name
(Please Print or Type) Alameda-Contra Costa Foundation
for Medical Care, Inc.,
By
SIGNATURE Eugene R. Draper,
Executive Director
DATE DATE
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ALAMEDA-CONTRA COSTA FOUNDATION FOR MEDICAL CARE
HOSPITAL SERVICE AGREEMENT
THIS AGREEMENT is made this day of ,
198 , by and between the ALAMEDA-CONTRA COSTA FOUNDATION FOR
MEDICAL CARE, a California non-profit corporation ( "Foundation" )
and a hospital
licensed under t e laws of California Hospital" ) .
I. GENERAL
A. Hospital agrees to render services to Patients as set
forth in this Agreement. Foundation will encourage third party
payors to use financial incentives for Patients that utilize
Hospital 's services and will encourage Patients and Physicians to
judiciously utilize the services of contracting hospitals.
II. DEFINITIONS
A. "Patient" means any person and/or dependent who is
covered under a health plan offered by an insurer, hospital or
health care service plan, trust, self-insured group, employee-
welfare plan or other third party payor contracting with
Foundation.
B. "Inpatient Services" means any service ordered by a
licensed physician or other licensed health professional and
normally provided by Hospital on its premises or at another `
location by contract to a hospitalized Patient, and which is
included in Hospital' s proposal. These services include but are
not limited to the following: - -'
1. Room and board. For the purposes of this
agreement, the characterization of a service as either medical,
surgical, ICU or other shall be determined by the licensure
classification of the inpatient bed which the patient is
occupying on the day the services were required, providing that
the bed level is medically appropriate to the patient 's
diagnostic and medical need.
2. Medical, nursing, surgical, pharmacy, and
dietary services;
3. Diagnostic and therapeutic services required
by Patients, excluding physicians ' services except as may be
included by the hospital in its proposal.
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4. Use of Hospital facilities, medical social
services furnished by Hospital, and drugs, biologicals, supplies,
appliances and equipment required by hospitalized Patient;
5. Transportation services required in providing
inpatient services to hospitalized Patients, excluding trans-
portation prior to admission and transportation following release
from Hospital ;
6. Services rendered by Hospital prior to admis-
sion to Hospital, such as outpatient services for a medical
admission or emergency services, if these services are related to
a condition for which the Patient is admitted to Hospital and are
rendered within a 24 hour period prior to 12:01 a.m. of the day
of Patient 's admission to Hospital, shall be deemed rendered
during the Patient 's first acute care day of stay. Pre-operative
work for scheduled surgical admissions are not included. These
are to be billed separately and in addition to the per diem set
forth in Exhibit "C" or as these may be amended pursuant to
.Section V of this Agreement.
7. Administrative services, excluding the cost of
utilization review performed by the Foundation or its agents
pursuant to this Agreement, as required to provide inpatient
services.
C. "Day of Stay" means a day of service in which a
patient occupies an inpatient acute care bed at 12:00 midnight or
where a patient is admitted and discharged within the same day.
D. "Payor" means any primary third party payor of
health care costs, including insurers, hospital or health care
service plans, trusts, self-insured plans, and employee welfare
benefit plans contracting with Foundation.
E. "Per Diem" - Is the daily allowance for Inpatient
Services described in "B" above and other services, as set forth
under Column 1 of Exhibit "C" or as these may be amended pursuant
to Section V of this Agreement.
F. "Charge Threshold" - Is the amount of daily
hospital billed charges, as set forth under Column 2 of
Exhibit "C", or as may subsequently be adjusted, pursuant to
Section V. of this Agreement and which will be used to activate
the payment of the "High Intensity Per Diem". The "Charge
Threshold" and "High Intensity Per Diem" will apply to those
instances of extraordinary utilization of hospital resources
which generate charges significantly in excess of the "Per Diem".
G. "High Intensity Per Diem" - Is the higher payment
level as set forth under Column 3 of Exhibit "C" or as these may
be amended pursuant to Section V of this Agreement and will apply
to those instanceswhere the daily hospital billed charges exceed
the "Charge Threshold" as described above in F. This amount will
be 125% of the applicable "Per Diem" (Column 1) , as shown on
Exhibit "C" Column 31 or as subsequently adjusted, pursuant to
Section V of .this Agreement.
III . HOSPITAL SERVICES
A. For Patients admitted by Foundation participating
physicians, Hospital shall accept payment specified in
Exhibit "C" or as these may be amended pursuant to Section V of
this Agreement as payment in full for inpatient services rendered
during each acute care day of stay, less any co-insurance or
deductible specified in the third party payor's contract with the
Patient, and less any coordination of benefit reimbursement.
When Foundation 's coverage is primary the base for coordination
of benefits reimbursement shall be the applicable inpatient
services per diem rate (s) specified in Exhibit "C" or as these
may be amended pursuant to Section V of this Agreement and not
Hospital 's normal rates. When Foundation 's coverage is not pri-
mary, Hospital 's usual rates shall be used for calculation of
coordination of benefits reimbursement. Patients are responsible
for any services or supplies not covered by third party payors
pursuant to Section VI of this Agreement.
B. For Patients admitted by physicians who are not
members of Foundation, Hospital will be reimbursed at payment
_ levels specified in Exhibit "C" or as these may be amended pursu-
ant to Section V of this Agreement but may bill the Patient for
the difference in that payment and its usual and customary
charge. The base for coordination of benefits in these instances
will be Hospital 's usual and customary charge and not the per
diem rate(s).
C. Hospital may bill the Patient or other responsible
party at normal rates for services rendered which are not covered
by the per diem rate or for which Hospital is not otherwise com-
pensated pursuant to this Agreement as set forth in Section VI.
D. Hospital shall, at its expense, maintain appro-
priate facilities to provide hospital services for which
compensation is paid under this Agreement ; provide organizational
and administrative capabilities needed to carry out its duties
under this Agreement; and comply with all applicable statutes and
regulations.
E. Hospital shall provide hospital services for which
it is compensated pursuant to this Agreement in the same manner
as it provides services to other persons and shall not discrim-
inate against any Patient in an_y ner, including admission
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practices, placement in special or separate wings or rooms, pro-
vision of special or separate meals, or waiting time for surgical
procedures. Notwithstanding the foregoing, Hospital may refuse
to render services to a Patient if the payor responsible for
reimbursement for these services has failed to substantially
comply with the terms of its agreement with Foundation regarding
payment to Hospital. Hospital may demand adequate financial
assurances before again rendering services to a Patient for which .
such payor is responsible. Hospital ' s obligation to provide
hospital services shall be subject to and dependent upon the
availability of appropriate Hospital facilities and services.
F. Notwithstanding any other provision of this
Agreement, the Foundation shall provide Hospital with notice of
its intent to contract with a Payor, which is not an insurance
company or is an insurance company but is rated by Best 's Ratings
as below B, at least 15 days prior to the date upon which the
contract is to be executed. Such notice shall include informa-
tion concerning the financial viability and appropriate licen-
sure, if required. If Hospital fails to disapprove within 15
days of receipt of such notice and information, Hospital shall be
bound by this agreement. Hospital shall have no obligation under
this agreement with respect to such Payors which it has
disapproved.
IV. REPRESENTATIONS AND WARRANTIES
A. Hospital represents and warrants that it is
licensed as a general acute care hospital in accord with the
licensing provisions of Div. 2, Chapter 2, of the California
Health and Safety Code, §§1250 et seq. and the licensing regula-
tions established by the State Department of Health Services
(Title 22, California Administrative Code).
B. When Foundation does not administer payment, it
shall include as an integral part of agreements with third party
payors a clause stating that payment of bills for inpatient or
outpatient services shall be made within not more than 30 days of
receipt of bill from the Foundation. As billing agent,
Foundation agrees to transmit all claims with proper
identification and information to the responsible third party
payor within 10 days of receipt of bill from the Hospital.
C. The Foundation agreement with third party payors
shall specify that calculation of benefits, co-insurance,
deductibles, or other co-payments (if any) be based upon the
rates set forth in Exhibit C of this agreement for Patients
admitted by Foundation participating physicians. For Patients
admitted by non-participating physicians, calculation of all
co-payments shall be based upon the Hospital 's usual and
customary charges.
EIggT Q
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D. Participating Hospitals: From the date of this
Agreement through December 31, 1986, Foundation agrees that only
those hospitals listed on Exhibit E will be Participating Hospi-
tals. The exception to amend this list is as follows: in the
event that the Agreement is not signed or is cancelled with any
of the hospitals listed in Exhibit E, the Foundation reserves the
right to reopen negotiations with other hospitals whose most
recent discharge data set demonstrates a 20% patient population
derived from the planning area in which the hospital that cancel-
led or did not sign an agreement is located.
E. Outpatient Surgery: If Foundation and Hospital
contract for outpatient surgery, the rates or schedules will be
listed on Exhibit .C, Appendix 1 or as these may be amended
pursuant to Section V of this Agreement. Foundation will urge
insurance carriers, employers and employee groups to provide a
financial incentive to encourage utilization of these services.
If Foundation and Hospital do not contract for out-
patient surgery, payment will be made for those services, after
retrospective review, at the rate schedule provided in the
Patient 's contract. Any difference between the Hospital charge
and the payment will be the Patient's responsibility.
F. Other Outpatient Patient Services: If Foundation
and Hospital contract for other outpatient services, other than
outpatient surgery, those rates shall be listed on Exhibit C,
Appendix 2 or as these may be amended pursuant to Section V of
this Agreement. Foundation shall urge insurance carriers,
employers and employee groups to provide a financial incentive to
encourage utilization of these services.
If Foundation and Hospital do not contract for out-
patient surgery, payment will be made for other outpatient
Patient services, after retrospective review, at the rate
schedule provided in the Patient contract. Any difference
between the Hospital charge and the payment will be the Patient's
responsibility.
G. Notice of Balance Billing: Participating Hospitals
not contracting for outpatient surgery and/or other outpatient
services agree to advise the Patient, in advance of services,
that they do not contract for the services and that the Patient
may be balance billed.
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V. COMPENSATION
A. The Hospital payment rates for Foundation contract-
ing payors shall be as shown on Exhibit "C" or as these may be
amended pursuant to Section V of this Agreement and shall be
effective as of the date this agreement is signed, for a •period
of 12 months. Thereafter new rates may be established quarterly
beginning three months from the effective date of this agreement
and shall apply to contracts with payors which become effective
or are renewed during the applicable quarter. Such rates shall
remain in effect during the term of the contract or contracts
with payors, to which they apply or a minimum of 12 months from
their effective date. Hospital must notify Foundation 60 days in
advance of the effective date of any proposed quarterly rate
changes.
B. The term of this Agreement is extended for 12
months from the effective date of each new quarterly per diem
agreement.
C. Renegotiation of the rates set forth in Exhibit "C"
or as these may be amended pursuant to Section V of this
Agreement may be commenced by either party upon 90 days written
notice to, the other party, subject to acceptance by third party
payors. If agreement on new per diem rate(s) cannot be reached,
the current rate (S) shall continue in effect until the parties
have agreed or the Agreement is terminated.
D. The payable amount for covered inpatient services
will be calculated pursuant to the rates set forth on
Exhibit "C", or as these may be amended pursuant to Section V of
this Agreement. JThe Foundation or Payor shall reimburse
Hospital, on an assigned basis, at the applicable "per diem" as
set forth in Exhibit "C" - column 1 or as these may be amended _
pursuant to Section V of this Agreement except in those instances
in which Hospitals averaged daily billed charges, for the entire
stay, exceed the "charged threshold" as set forth in Exhibit C -
column 2, Foundation or the Payor will reimburse the Hospital at
the "high intensity per diem" as set forth in the Exhibit "C" -
column 3 or as these may be amended pursuant to Section V of this
Agreement.
E. Performance of all terms and conditions of this
Agreement is a condition precedent to reimbursement. Hospital is
entitled to payment for services rendered for which it has con-
tracted pursuant to this Agreement prior in time to an occurrence
or event which terminates the obligation of a third party payor
to make payment for services rendered by Hospital. Reimbursement
of Hospital is subject to the terms and conditions of the payor' s
contract with the Patient. The Foundation may not issue payment
for services or benefits not covered by the payors contract..
These non-covered services are the Patients ' responsibility.
Foundation shall keep Hospital informed about terms and provi-
sions of all its contracting payors ' health plans in relation to
covered and non-covered benefits.
VI. BILLINGS
A. . Hospital shall forward billings to Foundation or
the responsible Payor as specified on Patient identification card
within 30 days of the Patient 's discharge with extensions to 120
days allowed for cause.
B. Hospital may bill the Patient or other responsible
party, subsequent to billing the Foundation or the Payor, but
only for the portion of the charges for services rendered for
which the Patient or other party is responsible pursuant to the
Patient 's contract with the Payor.
C. When Foundation administers payments for a third
party payor, Foundation shall make payment to Hospital of all
bills properly rendered to it within an average of 15 working
days.
D. Hospital shall use its customary billing form and
procedures. Billings shall include identifying Patient infor-
mation and itemized records of services and charges even though
reimbursement is limited to the inpatient services per diem
rate(s) under Exhibit "C" and appendices or as these may be
amended pursuant to Section V of this Agreement. Foundation
shall notify Hospital of Patient 's responsibility for non-covered
services when payment is made.
E. Hospital agrees that it shall not bill the Payor,
Patient or Other Responsible Party for services and/or days of
stay which are determined not medically necessary, pursuant to
the "Utilization Review Procedures" established under Exhibit "D"
of this Agreement. However, Hospital may bill the Patient or
Other Responsible Party directly for such services rendered or
for days of stay. providing Patient or Other Responsible Party
has acknowledged responsibility and has been informed that these
services are not covered by the third party payor's contract with
the hospitalized Patient and/or that certain days of stay have
been determined not medically necessary. The responsibility for
notification of the patient and obtaining the proper acknowledge-
ment is (1) Hospitals, if delegated or (2) East Bay PRO's, if
non-delegated. Foundation will accept documentation showing that
notice was given or that reasonable efforts to give notice were
made. Foundation and its contracting Payors shall not retro-
actively deny payment for any admission with prior authorization.
MEN W
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VII. SERVICE LOCATION
All services rendered by Hospital for which it is com-
pensated hereunder shall be rendered within the facilities of
Hospital, or at other facilities to which Hospital has access to
or contractual agreements with. Those specific services must be
included in the hospitals proposal as set forth in Exhibit "C" or
as these may- be amended pursuant to Section V of this Agreement.
VIII. STAFF MEMBERSHIP AND PRIVILEGES
A. Hospital shall not deny medical staff membership or
clinical privileges unless denial is based upon reasonable
criteria or upon individual qualifications as determined by pro-
fessional and ethical criteria, uniformly applied to all
applicants or members.
B. Hospital shall not use participation in Foundation
to establish admitting privileges which allow professional
providers who are not Foundation participating physicians to
admit Patients on a basis different than that of participating
physicians.
IX. REVIEW PROCEDURES
A. Hospital will participate in the utilization review
program and procedures described in Exhibit "D, " attached and
incorporated by reference. Hospital will cooperate with
Foundation and the review coordinator or review team to implement
the utilization review program and will furnish pertinent
hospital records required to implement the utilization review
program while maintaining patient confidentiality.
B. Hospital shall not be paid for .services rendered or
for days of stay which are determined to be not medically neces-
sary pursuant to the utilization review procedures as set forth
in Exhibit "D. " There shall be no medical necessity retrospec-
tive audits or disallowances based on lack of medical necessity
for any previously authorized days or services under this
Agreement.
X. HOSPITAL - FOUNDATION - PATIENT RELATIONS
A. Foundation and Hospital will maintain liaison to
provide maximum benefits to Patients at the most reasonable cost
consistent with quality standards of hospital care.
B. Hospital, through its Medical Staff, shall monitor
medical care rendered in Hospital and take appropriate action,
including initiation of disciplinary proceedings, for Medical
-8-
Staff members whose actions are contrary to its Medical Staff 's
By-Laws.
C. . Foundation agrees that it shall not intervene in any
way or manner with the rendition of Hospital Services by
Hospital, it being understood and agreed that the traditional
relationships between Hospital and Patient, Physician and
Patient, and .Physician and Hospital, shall be maintained.
XI. INSURANCE AND INDEMNIFICATION
A. Hospital shall, at its expense, maintain policies
of comprehensive general liability and professional liability
insurance in amounts necessary to insure it and its employees
against liability for damages directly or indirectly related to
the performance of Hospital services provided hereunder, the use
of any property and facilities provided by Hospital, and
activities performed by Hospital in connection with this
Agreement, or shall otherwise make and maintain appropriate
arrangements to assume full financial responsibility for such
damages.
B. Each party shall indemnify the other and hold it
harmless from any loss, liability, damage, claim or cost arising
out of the act or omission of any employee, officer or agent of
the indemnifying party in connection with this Agreement.
XII. INDEPENDENT RELATIONSHIP
No provision of this Agreement is intended to create
nor shall be deemed or construed to create any relationship be-
tween Foundation and Hospital other than that of independent
entities contracting with each other to effectuate the provisions
of this Agreement. Neither of the parties hereto, nor any of --
their respective employees, shall be construed to be the agent,
employee or representative of the other.
XIII. RECORDS AND CONFIDENTIALITY
Foundation shall have the right upon request to inspect
at mutually convenient times all books and records (including any
accounting, administrative, and medical records) maintained by
Hospital pertaining to payments and/or claims for services ren-
dered for which Hospital is compensated under this Agreement.
Foundation and Hospital agree that all Patient medical records
shall be treated as confidential to the extent necessary to com-
ply with all state and federal laws and regulations regarding the
confidentiality of patient records. Except as otherwise provided
herein, Hospital shall not be required to disclose the hospital
records of any Patient to whom services are rendered for which
Hospital is compensated pursuant to this Agreement. Hospital
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shall not be prevented from disclosing such information contained
in the records of any Patient when such request is for the pur-
pose of meeting any obligations Foundation may have pursuant to
the utilization review program described in Exhibit "D, " upon
written request of Foundation pursuant to a valid order of a
competent jurisdiction, or as otherwise provided. by law. All
patient medical records shall be treated as confidential in the
same manner as other medical records of persons to whom Hospital
renders services.
XIV. LISTING OF HOSPITAL
Foundation may list the name, address, telephone number
and, subject to approval by Hospital, a description of the facil-
ities and service's of Hospital in Foundation roster of
participating hospitals. Foundation may not list the rates
established hereunder in the roster, but may provide rate infor-
mation for actuarial purposes.
XV. TERM OF AGREEMENT
A. This Agreement shall become effective on
, 198 and shall continue until
This Agreement shall be extended for 90 day intervals with each
new annual negotiated rate as described in paragraph V.A. of this
Agreement.
B. Either party may terminate this Agreement with cause
upon 60 days written notice or without cause upon 90 days written
notice, except where termination is for cause and the cause is
resolved within the notice period. Notification shall state the
effective date of termination and if for cause the grounds for
termination.
C. Termination shall have no effect upon the rights and
obligations of the parties arising out of any transactions occur-
ring prior to the effective date of termination. When a Patient
is an admitted inpatient of Hospital as of the date of termina-
tion of this Agreement, Foundation shall require contracting
payors to reimburse Hospital directly or through Foundation for
services rendered during the period the Patient remains as an
inpatient of Hospital, or until benefits are exhausted provided
Hospital continues to abide by the applicable terms of this
Agreement relative to the provisions of such Hospital services to
said Patient.
XVI. NOTICES
Any notice required to be given pursuant to the terms
and provisions hereof, unless otherwise indicated herein, shall
M o fl� a
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be in writing and shall be sent by certified mail, return receipt
requested, postage prepaid, to Foundation at:
Alameda-Contra Costa Foundation for Medical Care
Attention: Executive Director
6230 Claremont Ave
Oakland, California 94618
and to Hospital at:
XVII. ASSIGNMENT
A. The parties recognize that their duties and interests
under this Agreement are personal in nature, and that they shall
remain primarily .responsible for any duty or interest under this
Agreement which they may delegate, transfer, assign, or otherwise
vest in third parties. Any attempt by either party to otherwise
transfer, assign, or delegate a duty or interest in this
Agreement shall at the time constitute a present material breach
of this Agreement. >
B. Notwithstanding the foregoing, Hospital shall have
the right to assign this Agreement and to delegate all rights,
duties and obligations hereunder, in whole or in part, to any
parent, affiliate, successor or subsidiary organization and shall
have the right to assign this Agreement and to delegate all
rights, duties and obligations hereunder to any person, firm or
entity who acquires the capital stock of Hospital or a substan-
tial portion of its assets. Such assignments or delegations
shall not constitute a material breach of this Agreement. - �
XVIII. DISPUTE RESOLUTION
Hospital and Foundation agree to meet and confer in
good faith to resolve disputes arising under this Agreement. If
the parties cannot resolve a dispute in this manner, it shall be
referred to a mediation committee composed of three hospital
representatives selected by Hospital from participating Hospitals
and three representatives of the Foundation selected by
Foundation. The mediation committee shall meet promptly and
shall provide its recommendations after hearing from the
parties. Disputes which are not resolved by mediation shall be
resolved by arbitration conducted by the members of the mediation
committee and a seventh neutral individual who shall not be
affiliated with any of the parties and who shall be selected with
the consent of the six members of the mediation committee.
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XIX. INVALIDITY OR UNENFORCEABILITY
The invalidity or unenforceability of any terms or
provisions hereof shall in no way affect the validity or enforce-
ability or any other term or provision.
XX. MODIFICATIONS
A. It is the express intention ofboth FOUNDATION and
HOSPITAL that the terms of this totally integrated writing shall
comprise the entire Agreement between the parties and it shall
not be subject to rescission, modification, or waiver, except as
defined in a subsequent written instrument executed by both
parties hereto.
B. Informal toleration by either party of defective
performance of any independent covenant in this Agreement shall
not be construed as a waiver of either the right to performance
or the express conditions which have been set forth in this
Agreement.
IN WITNESS WHEREOF, the undersigned have executed this
Agreement as of the day and year first above written.
ACCMA FOUNDATION FOR MEDICAL CARE
By
Executive Director
HOSPITAL
By
Title:
11 ' X11 " " 11 7
REVISED EXHIBIT "C"
COMPENSATION RATES
SINGLE RATE
I. Iraatient Per Diem Rate - $
1
II. Psychiatric Per Diem Rate - $
III. Outpatient Services Payment Rate - $
IV. Outpatient Surgical Packzge Rate - $
*AREA ADJUSTIENT FACTOR
MULTIPLE RATES X PER DIEM
(1) (2) (3)
Charge High Intensity
Service Per Diem Threshold Per Diem
. I. Yedical/Surgical Rate $ 620.00 * $ 995.00 $� 775.00
i
II. Intensive Care Unit Rate $ 19250.00 * $ 2,006.00 $ 19563.00
III. Coronary Care Unit Rate $ 1,2500.00 * $ 2,006.00 $ 1,563.00
IV. Burn Care Unit Rate $ $ S
V. OB (Including Newborn) Rate $ srr Brt.nw
VI. Psychiatric Rate $ $ $
VII. Boarder Baby Rate $ 350.00 * $ 562.00 $ 438.00
%'ITI. Outpatient Services Rate $ SEE ATTACHED $ -- $ --
--
I?;. Outpatient Surgical Rate $ SEE ATTACHED $ $
Other Services Per Diem:
1. OB - Normal Delivery 1 Dav $ 925.00 * $ 1,484.00 $ 1,156.00
2. 2 Dav $ 1,550.00 * $ 2,487.00 S 1,938.00
3. OB - C Section 4 Dav $ 2,200.00 * $ 3,531.00 $ 2,750.00
4, additional Days $ 750.00 * S 1,204.00 S 938.00
[X (I Number
Fund/Ord #
Account #
1st CHOICE PHARMACY SERVICE CONTRACT
1. Contract Identification.
Department: Personnel Department
Subject: Pharmacy Services To 1st Choice, The Contra Costa
County Self Funded Employees Indemnity Health Plan
2 . Parties. The County of Contra Costa, California (County) , for
its Department named above, and the following named Contractor
mutually agree and promise as follows:
Contractor:
Capacity: Taxpayer ID#
Address:
3. Term. The effective date of this Contract is
and it continues to June 30 next ensuing and from year to year
thereafter unless sooner terminated as provided herein.
4. Termination. This Contract may be terminated by either party
by giving thirty ( 30 ) days advance written notice thereof to
the other, or may be canceled immediately by written mutual
consent.
5. County' s Obligations. County shall make to the Contractor
those payments described in the Payment Provisions attached
hereto which are incorporated herein by reference, subject to
the Service Plan and the Conditions of this Contract.
6. Contractor' s Obligations . Contractor shall provide those
services and carry out that work described in the Service Plan
attached hereto which is incorporated herein by reference,
subject to all the terms and conditions contained or
incorporated herein.
7 . Conditions . This Contract is subject to the Conditions
attached hereto, which are incorporated herein by reference.
8. Project. This Contract implements in whole or in part the
following described Program, the provisions of which are
incorporated herein by reference:
Provision of Preferred prescription pharmacy services to
Members of lst Choice, The Contra Costa County Self-Funded
Employees Indemnity Health Plan.
9 . Legal Authority. This Contract is entered into under and
subject to the following legal authorities : Government Code
section 25263.
10 . Signatures. These signatures attest the parties ' agreement
hereto:
COUNTY OF CONTRA COSTA, CALIFORNIA
ATTEST: Phil Batchelor, Clerk
BOARD OF SUPERVISORS of the Board of Supervisors and
County Administrator
By By
Chairman Designee Deputy
CONTRACTOR
By By
(Designate official business (Designate official business
capacity A. ) capacity B. )
Note to Contractor: For corporations (profit or nonprofit) , the
contract must be signed by two officers . Signature A must be that
of the president or vice-president and Signature B must be that of
the secretary or assistant secretary (Civ. Code, § 11909 .1 and
Corp. Code, § 313 ) .
Service Plan
1. Contractor agrees to:
a. Provide to members of lst Choice, the Contra Costa County
Self-Funded Employees Indemnity Health Plan (hereinafter
"1st Choice" ) , prescription drugs and medicines except as
limited below upon the member' s presentation of a
prescription, or refill request, proof of membership in
lst Choice, and a co-payment of $2. 00 .
b. To substitute generic drugs whenever and wherever
permitted in accordance with state and federal laws and
regulations .
Contractor will only dispense generic drugs approved by
the United States Food and Drug Administration and which
are available nationally through the majority of wholesale
drug companies. Contractor may not select a generic
substitute for LANOXIN OR DILANTIN.
c. Collect the $2. 00 co-payment from the member for each
prescription or refill filled by Contractor under this
Contract.
d. Not require any payment from lst Choice members , other
than the above-referenced co-payment, for prescriptions
covered under this Contract.
e . Submit claims on a Universal claim form, a copy of which
is attached as exhibit 1 to County through its
lst Choice' s plan administrator no later than two months
after the date of service.
f. Allow County and its lst Choice plan administrator to
audit prescriptions and cost records on ten working days
notice to contractor. County shall have the right to - _
recover from Contractor any over charges discovered.
g. Maintain all required state and local licenses which
relate to the service Contractor provides.
h. Maintain confidentiality of all patient information
obtained pursuant to this Contract including but not
limited to the identity of persons served under this
Contract, their records or services provided to them.
2 . County agrees to:
a. Provide Contractor with updated lst Choice membership
lists on a monthly basis.
b. Pay Contractor for its services as specified in the
Payment Provisions .
rY `
C. Provide members with a list designating Contractor as a
preferred pharmacy provider.
d. Provide all 1st Choice members with an identification card
which can be presented to Contractor at the time a
prescription is offered for filling.
3. Covered Drugs and Medicines under this Agreement:
a. Shall include:
1. Only those drugs and medicines which meet all of the
following conditions :
aa) require a prescription by a licensed physician,
licensed dentist or licensed podiatrist,
bb) are prescribed by a licensed physician,
licensed dentist or licensed podiatrist, and
cc) are approved for use in the United States by
the U.S. Food and Drug Act or its successor.
2 . Injectable insulin and insulin syringes and needles .
3. Oral contraceptive pills .
b. Exclusions:
1. Drugs and medicines not required for the treatment of
an injury or illness except for oral contraceptive
pills.
2 . Drugs dispensed for smoking control or cessation.
3. Diaphragms.
4 . Drugs or medicines obtained for administration in a
hospital.
5 . Therapeutic devices and appliances, including support
garments .
6. Immunization agents, blood plasma and biological sera.
7 . Any prescriptions which the 1st Choice member is
entitled to receive without charge under any workers '
compensation laws.
8. Any portion of a single prescription or refill of a
maintenance drug or medicine or injectible insulin
which exceeds a 34 day supply or a 100 unit dosage,
whichever is greater.
L3 217 B,
Payment Provisions
1. In addition to the $2 . 00 member' s co-payment retained by the
Contractor, County or its plan administrator shall pay to
Contractor the cost plus $4 . 05 for each prescription or refill
filled under this Contract and for which a claim is properly
submitted. Cost shall be calculated as the average wholesale
price of the prescription or refill less 100 . Average
wholesale prices shall be determined by the pharmaceutical
industry "Redbook" and the current Redbook supplement.
2 . Contractor shall submit payment demands to 1st Choice ' s plan
administrator on Universal claim forms, attached as Exhibit 1,
no later than two months after the date claimed prescription
services are rendered.
3. County maintains the right to withhold payment for any
prescription services provided which are insufficiently
documented on the Universal claim form submitted.
4. All properly completed and submitted payment demands received
by the plan administrator on or before the 25th day of any
month shall be paid by a check issued on the first day of the
next successive month.
FEW QUI B,
CONDITIONS
( 1st Choice Pharmacy Service Contract)
1. Compliance with Law. Contractor shall be subject to and
comply with all Federal , State and local laws and regulations
applicable with respect to its performance under this Contract,
including but not limited to, licensing, employment and purchasing
practices ; and wages , hours and conditions of employment, including
nondiscrimination.
2 . Records. Contractor shall keep and make available for
inspection and copying by authorized representatives of the
County, the Contractor' s regular business records and such
additional records pertaining to .this Contract as may be required
by the County.
Retention of Records . The Contractor shall retain all
documents pertaining to this Contract for five years or for four
years from the date of submission of Contractor' s final payment
demand or final Cost Report, whichever is later; and for any
further period that is required by law or written direction from
the County. Upon request, Contractor shall make these records
available to authorized representatives of the County.
3 . Entire Agreement. This Contract contains all the terms
and conditions agreed upon by the parties . Except as expressly
provided herein, no other understanding, oral or otherwise,
regarding the subject matter of this Contract shall be deemed to
exist or to bind any of the parties hereto.
4 . Subcontract and Assignment. This Contract binds the
heirs , successors , assigns and representatives of Contractor. The
Contractor shall not enter into subcontracts for any work
contemplated under this Contract and shall not assign this
Contract or monies due or to become due, without the prior written
consent of the County Administrator or his designee .
5 . Independent Contractor Status . This Contract is by and µ
between two independent contractors and is not intended to and
shall not be construed to create the relationship between the
parties of agent, servant, employee, partnership, joint venture or
association.
6. Nondiscriminatory Services . Contractor agrees that all
goods and services under this Contract shall be available to all
qualified persons regardless of age, sex, race, religion, color,
national origin, or ethnic background, or handicap.
7 . Indemnification. The Contractor shall defend,
indemnify, save and hold harmless the County and its officers and
employees from and all claims, costs and liability for any
damages , sickness , death , or injury to person(s ) or property,
including without limitation all consequential damages , from any
cause whatsoever arising directly or indirectly from or connected
with the operations or servicesofthe Contractor or its agents,
servants , employees or subcontractors hereunder, save and except
claims or litigation arising through the sole negligence or sole
willful misconduct of the County or its officers or employees.
Contractor will reimburse the County for any expenditures ,
including reasonable attorneys fees, the County may make by reason
of the matters that are the subject of this indemnification, and
if requested by the County will defend any claims or litigation to
which this indemnification provision applies at the sole cost and
expense of the contractor.
8 . Insurance. During the entire term of this Contract and
any extension or modification thereof , the Contractor shall keep
in effect insurance policies meeting the following insurance
requirements :
a. Liability Insurance. The Contractor shall provide
comprehensive liability insurance, including coverage for owned
and non-owned automobiles, with a minimum combined single limit
coverage of $500, 000 for all damages , including consequential
damages , due to bodily injury, sickness or disease, or death to
any person or damage to or destruction of property, including the
loss of use thereof, arising from each occurrence. Such insurance
shall be endorsed to include the County and its officers , agents ,
and employees as additional insureds as to all services performed
by Contractor under this agreement. Said policies shall
constitute primary insurance as to the County, and its officers,
agents , and employees, so that other insurance policies held by
them or their self-insurance program(s ) shall not be required to
contribute to any loss covered under the Contractor' s insurance
policy or policies.
b. Workers' Compensation. The Contractor shall provide
workers ' compensation insurance for its employees .
C. Certificate of Insurance. The Contractor shall
provide the County with (a) certificate(s ) of insurance evidencing
liability and worker' s compensation insurance as required herein
no later than the effective date of this Contract. If the --
Contractor should renew the insurance policy(ies) or acquire
either a new insurance policy(ies ) or amend the coverage afforded
through an endorsement to the policy at any time during the term
of this Contract, then Contractor shall provide (a) current
certificate(s ) of insurance.
d. Additional Insurance Provisions . The insurance
policies provided by the Contractor shall include a provision for
thirty ( 30 ) days ' written notice to County before cancellation or
material change of the above-specified coverage.
9 . No Third-Party Beneficiaries. Notwithstanding mutual
recognition that services under this Contract may provide some aid
or assistance to persons other than the parties, it is not the
intention of either the County or Contractor that such individuals
occupy the position of intended third-party beneficiaries of the
obligations assumed by either party to this Contract.
SUBMIT CLAI`A TO: .
M • ��. ..•� OTHER THIRD PARTY
YE COVERA
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Cartity to,at d accept the toms NaDot, 1 also toddy that I have re- r vA'.'.� COS,
cared the pre{aiption(e)that ere shown below.
PATIENT/AUTHORIZED REPRESENTATIVE: `"t r•;i.' D!SP.
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ear XLIOl r� �` ® • • L � , � _ — '
MERV
. THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Adopted this Order on December 15, 1987 by the following vote:
AYES: Supervisors Powers, Fanden, Schroder, Torlakson and 'McPeak
NOES: None
ABSENT: None
ABSTAIN! None
SUBJECT: 761
In the Matter of ) Resolution No. 87/
)
Establishing Subscription )
Charges for lst Choice, The )
Contra Costa County Self- )
Funded Employees ' Indemnity )
Health Plan. )
The Contra Costa County Board of Supervisors in all of its
capacities as the governing body of Contra Costa County and of the
Districts and Agencies of which it is also the governing body,
Resolves at follows :
1. The Subscription Charges for 1st Choice, The Contra Costa
County Self-Funded Employees ' Indemnity Health Plan, from January
1, 1988 until further order of the Board are:
A. For individual Subscriber coverage only, $133.62 per
month or any part thereof.
B.. For Subscriber and Family Member coverage, without
regard to the number of persons covered, $338.88 per month or any
part thereof.
2. The 1st Choice Plan monthly subscription charges payable
by the County or Districts and Agencies governed by the Board on
behalf of employees" and retirees are:
A. For individual Subscriber coverage, $130.89, except
for employees represented by United Professional Firefighters,
Local 1230 in which case thelamount shall be $124 . 29.
B. For Subscribers and Family Member .coverage, $313.88,
except for employees represented by United Professional
Firefighters, Local 1230 in which case the amount shall be
$293 .88.
3 . Medicare rates for employees, including retirees , covered
in this Resolution shall be as follows: for Employee Only on
Medicare by taking the monthly Part B Medicare premium withheld
from Social Security: payments for one enrollee; for Employee and
Dependent(s ) with one member on Medicare by taking the Employee
and Dependent(s ) rate for the option selected and subtracting the
monthly Part B Medicare premium withheld from Social Security
payments for one enrollee;. for Employee and Dependent(s ) with two
members on Medicare by taking the Employee and Dependent(s ) rate
for the option selected and subtracting the monthly Part B
Medicare premium withheld from Social Security payments for two
enrollees.
I
87/761
4 . The additional subscription charges .for the Optional
Health Care for Children benefit under the lst Choice Plan shall
be $125. 00 °per month payable by the Subscriber.
5 . The County and Districts or Agencies governed by the
Board shall also pay $1:23 per month for employees only to provide
the life insurance benefits which accompany health benefits and
$3. 22 per month for employees and retirees on account of health
plan administrative costs .
6. The 1st Choice Plan monthly subscription charges fo'r
Subscribers and for their Family Members not payable by the County
or by Districts or agencies governed by the Board are payable by
the Subscribers, as a condition of continued coverage, if not
otherwise paid, within thirty days after notice of the balance due
is mailed to the Subscriber at their last address of record.
1 hereby certify that this Is a true and correct copy of
an action taken and entered on INN r.11huies of the
Board of Supe isors on the date shown.
ATTESTED: lil-U-
PHIL BATCHELOR, CIerA of tho Board
of Supervisors and County Administrator
b
By , Deputy
Orig. Dept. : Personnel Dept.
cc: Auditor-Controller-Ken Corcoran
County Counsel
County Administrator
Treasurer/Tax Collector
i
Resolution No. 87/ 761
f
A�m"����.
TO: BOARD OF SUPERVISORS
FROM: Harry D. Cisterman, Director of Personnel Contra
December 3, 1987 Costa
DATE: , County
SUBJECT: Cancellation of Blue Cross, IPM and Lifeguard Health Plans
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
Recommendation
IT IS ORDERED that the Director of Personnel is AUTHORIZED to cancel the
IPM and Lifeguard health plan contracts effective March 1, 1988 and Blue Cross
Prudent Buyer health plan contract effective January 1 , 1988.
Background
This action is necessary because of the minimal enrollment in these
plans and the administrative costs to retain them as options.
Fiscal Impact
Currently enrolled IPM/Lifeguard members will be offered alternate
health plan options with minimal fiscal impact.
CONTINUED ON ATTACHMENT: ,. YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S): p
ACTION OF BOARD ON December 15 , 1987 APPROVED AS RECOMMENDED x OTHER
i
VOTE OF SUPERVISORS
" I HEREBY CERTIFY THAT THIS IS A TRUE
X UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN
AYES. NOES'. AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.
CC: Personnel Department ATTESTED _ 4oNS-t 1r
County Administrator PHIL BATCHELOR. CLERK OF THE BOARD OF
Auditor/Controller SUP VISORS ApI D COUNTY ADMINISTRATOR
Tr asurer /Tax Collector p
County Counsel BY �,L�, r„�a Deputy