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HomeMy WebLinkAboutMINUTES - 01161990 - 1.39 TO .. . BOARD OF SUPERVISORS �®039 FROM; Harry D . Cisterman , Director of Personnel Contra Costa DATE: January 3 , 1990 Cv`""`7 SUBJECT: 1st Choice Health, Plan Amendment SPECIFIC REQUEST(S) OR RECOMMENDATIONS) & BACKGROUND AND JUSTIFICATION RECOMMENDATION: Amend the 1st Choice Health Plan Document to include new benefit enhancements and to further clarify existing language. BACKGROUND: This amendment provides for new benefits and clarifies existing bene- fit language. The following information provides a summary of these changes and additions. I . NEW BENEFITS - EFFECTIVE AUGUST 1 , 1989 I • Provides annual required school or sports physicals • Provides coverage for allery shots performed by preferred providers Provides immunizations for adults 18 and over • Institutes a mandatory generic program and increases the co-payment when a generic equivalent has been approved by the member's physician II. NEW BENEFITS - EFFECTIVE JANUARY 1 , 1990 • Increases tha annual per member deductible .- Increases the annual family deductible • Increases the annual first level benefit payment III. NEW BENEFITS - EFFECTIVE JANUARY 1 ,1991 Increases the annual per member deductible • Increases the. annual per family deductible CONTINUED ON ATTACHMENT: d YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE S : YY ACTION OF BOARD ON 16 JNO APPROVED AS RECOMMENDED L OTHER VOTE OF SUPERVISORS 1 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. Originating Dept : Personnel Benefits Division JAN 16 1990 CC: County. Administrator ATTESTED Auditor-C o n t r o l l e r PHIL BATCHELOR, CLERK OF THE BOARD OF County Counsel SUPERVISORS AND COUNTY ADMINISTRATOR BY ,DEPUTY M382/7-83 `t ' January 3, 1990 Page Two IV. LANGUAGE CLARIFICATION CHANGES The following covered benefits remain unchanged. This amendment only clarifies the existing Plan Document language to be consistent with the brochure and/or case law. Part Two - Benefits • Private room charge payments • Licensed air ambulances Artificial limbs and eyes Prescription coverage for birth control pills • Licensed birthing centers and services of certified nurse midwives Pap smears and mammograms Part Three - Programs Affecting !Benefits Excludes infertility benefits • Excludes routine physicals except for annual pap and mammogram tests • Excludes cardiac rehabilitation program • Excludes allergy shots by non-preferred providers Part Six - Extension of Benefits Clarifies benefit coverage for totally disabled members Part Eight - Enrollment Specifies eligibility requirement for foster children Part Twelve - Continuation of; Benefits • Provides criteria for continued coverage for members who have a retire- ment application pending An exact copy of the 1st Choice amended Plan Document is available in the Clerk of the Board 's office for review. 1ST CHOICE THE CONTRA COSTA COUNTY SELF-FUNDED EMPLOYEES INDEMNITY HEALTH PLAN Effective: January 1, 1988 r TABLE OF CONTENTS Page PART ONE: DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 PART TWO: BENEFITS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 A. Determination of Covered Expense. . . . . . . . . . 8 B. Deductibles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 C. Payment Provisions. . . . . . . . . . . . . . . . . . . . . . . 10 D. Covered Expenses . . . . . . . . . . . . . . . . . . . . . . 13 PART THREE: PROGRAMS AFFECTING BENEFITS. . . .. . . . . . 26 A. Surgical Screening Second Opinion Program 26 B. Surgical Outpatient Procedure Incentive Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 C. Hospital Admissions Program. . . . . . . . . . . .. . 31 D. Prescription Drug Program. . . . . . . . . . . . . . . . 32 PART FOUR: UTILIZATION REVIEW. . . . . . . . . . . . . . . . . . . . 33 PART FIVE: EXCLUSIONS AND LIMITATIONS. . . .. . . . . . . . 34 PART SIX: EXTENSION OF BENEFITS. . . . . . . . . . . . . . . . . . 40 PART SEVEN: COORDINATION OF BENEFITS. . . . . : . . . . . . . 41 PART EIGHT: ENROLLMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . 47 PART NINE: MEDICARE ELIGIBLE MEMBERS. . . . . . . . . . . . . 51 PART TEN: SUBSCRIPTION CHARGES . . . . . . . . . . . . . . . . . . . 52 PART ELEVEN: TERMINATION. . . . . . . . . . . . . . . . . . . . . . . 52 PART TWELVE: CONTINUATION OF BENEFITS. . . . . . . . . . . . 53 PART THIRTEEN: SUBROGATION. . . . . . . . . . . . . . . . . . . . . . . 57 PART FOURTEEN: BINDING ARBITRATION. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . 58 PART FIFTEEN: GENERAL PROVISIONS. . . . . . . . . . . . . . . . . 59 1st Choice Diskette (see D.A.) A:\1st 12-1-89 PART ONE: DEFINITIONS A.) 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. B.) Ambulatory Surgical Center is a facility whose main function is the performance 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. C.) Child is a Subscriber's eligible child, stepchild, or legally adopted child, as provided in PART EIGHT B.2. D. ) 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. E. ) Covered Expense(s), whenever used in this Plan, has the meaning assigned to it in PART TWO. A. F. ) 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 and any other care which does not require the continuing services of medical personnel. G. ) Customary and Reasonable charge is an amount 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. H.) Effective Date is the date the Member's coverage under this Plan begins. I. ) 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. y J.) Family Member is a Subscriber's enrolled Spouse and each enrolled eligible Child. K. ) Foundation means the Alameda-Contra Costa Foundation for Medical Care, Inc. L. ) Home Health Agencies and Visiting Nurse Associations are home health care providers which are licensed according to state and local laws to provide skilled nursing, hospice care and other services on a visiting basis in the Member's home. They must be recognized as home health care providers under Medicare. M. ) 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. -2- N. ) 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 in Northern California. 0.) Medically Necessary services or supplies are those which meet all the following criteria, as determined by a Plan Administrator. 1.) Appropriate and necessary for the symptoms, diagnosis or treatment of a medical condition covered by the Plan, and 2.) Provided for the diagnosis or direct care and treatment of the medical condition, and 3.) Within standards of good medical practice within the organized medical community, and 4. ) Not primarily for the convenience of the Member, the Member's Physician or another provider, and 5. ) The least expensive level of safe and adequate service or supplies which can appropriately be provided. For hospital stays, this 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 condition, and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting. P.) Member means the Subscriber or a Family Member. Q.) 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. -3- R. ) Negotiated Rate is the fee Preferred Hospitals and Preferred Physicians agree to accept as payment in full for covered services. Negotiated Rates are determined by the Foundation. S.) 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. T. ) Non-Preferred Physician means a Physician who has not entered into an agreement with or through the Foundation at the time the Physician's services are rendered. U. ) Non-Physician Provider means: First: One of the following providers, when prescribed or referred by a physician, but only when a provider is licensed to practice where the care is provided, is rendering a service within e, the scope of that license, and is providing a service for which benefits are specified in this Plan: 1. ) A Physical Therapist (P.T. or R.P.T. ) 2. ) A Speech Pathologist 3. ) An Audiologist 4. ) An Occupational Therapist (O.T.R.) Second: One of the following, providers, 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: 5. ) An Optometrist (O.D.) -4- 6.) A Podiatrist or Chiropodist (D.P.M. , D.S.P. or D.S.C.) 7. ) A Psychologist 8.) A Clinical Social Worker (C.S.W. or L.C.S.W.) 9. ) A Marriage, Family and Child Counselor (M.F.C.C.) 10. ) A Certified Nurse Midwife V. ) 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. W. ) Plan means the County of Contra Costa Self-Funded Employees Indemnity Health Plan, also known as "1st Choice. " X. ) Plan Administrator means one or more individuals, organizations or firms designated by the County of Contra Costa to provide administrative services to the Plan. Y. ) 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. 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. -5- Z. ) 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. AA. ) Preferred Provider means a Preferred Hospital or Preferred Physician. BB. ) 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. CC. ) 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. DD. ) Skilled Nursing Facility means an institution that provides continuous skilled nursing services. It must be licensed according to state and local laws and must be recognized as a Skilled Nursing Facility under Medicare. -6- 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 Facility 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. EE.) 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. FF. ) Souse means a Subscriber's spouse under a legally valid marriage between the subscriber and a person of the opposite sex. GG. ) Subscriber is a person who meets all eligibility requirements of the Plan and enrolls under the Plan. HH. ) 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. II. ) Year means a twelve month period starting each January 1 at 12:01 a.m. Pacific Standard Time. -7- 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 covered illness, injury or condition. These benefits are , subject to all provisions 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 Expenses, 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. -8- B. ) Deductibles 1. ) Each Member must pay the first $100.00 through December 31 , 1989, $150.00 effective January 1, 1990 and $200.00 effective January 1, 1991 (the "deductible") of Covered Expense incurred during any Year before any benefits are provided by the Plan. After this deductible payment is made, no further deductible is required for the rest of the Year. 2.) After a total of $300.00 until December 31, 1989, $450.00 effective January 1, 1990 and $600.00 effective January 1, 1991 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 deductible amount: a. ) Preferred Provider services or supplies. b. ) Prescription Drugs and Medicines, subject, nevertheless, to the co-payment requirements of the Prescription Drugs Program. -9- 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 outpatient 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 inpatient care or outpatient surgery has taken place. C. ) Payment Provisions 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. 1.) First Level Payment Up to December 31, 1989 until the Plan pays $1,600.00 or $3,400.00 after January 1, 1990, 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 Non- Preferred Provider services for Mental , Nervous, or Substance Abuse Disorders. -10- b.) Payment is provided for 100 percent of the Covered Expense incurred by the Member for Preferred Provider services and supplies. 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. 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 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 inpatient care or outpatient surgery has taken place. e. ) Payment is provided for 100 percent of the Covered Expense incurred by the Member for services ofa 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. f. ) Payment is' provided for 80 percent of the Covered Expense incurred by the Member for all other covered services, except those provided limited coverage e.g. , allergy immunizations and, subject, nevertheless, to. the co-payment requirements of the Prescription Drugs Program. -11- 2. ) Second Level Payment Until December 31, 1989 the second -level payment is reached after the Plan pays $1,600.00 in benefits a Member incurs in a Year for Covered Expense arising from the services of a Non-Preferred Provider. On or after January 1, 1990, the second level payment is reached after the Plan pays .$3,400.00 in benefits a Member incurs in a Year for Covered Expense arising from the services of a Non-Preferred Provider. After the second level payment is reached coverage is as follows: 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. 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. 3.) Program Limitations 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 of the Covered Expense incurred -12- 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, subject further to all deductible requirements and the First and Second Level payment provisions. 4. ) Maximum Benefits a.) All benefits are limited to a lifetime maximum of $1,000,000 in payments per Member. b. ) Benefits for outpatient visits for Mental , Nervous, and Substance Abuse Disorders are limited to an aggregate of $1,250 in payments per year. c. ) Benefits for all covered inpatient services for Mental , Nervous, and Substance Abuse Disorders are limited to an aggregate 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 The following are covered expenses, subject to the expressed limitations of this Plan, only when Medically Necessary, and only when prescribed or ordered by a Physician or Hospital or provided as emergency care: -13- 1. ) Hospital/Ambulatory Surgical Center a. ) Covered Services (1) Inpatient services and supplies provided by a Hospital , including Special Care Units, however, private room charges over the prevailing two-bed room rate of the Hospital are not covered expenses unless medically necessary. (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 Center. b. ) Conditions of Service (1) Services must be those which are regularly provided and billed by the Hospital or Ambulatory Surgical Center. (2) Benefits are provided only for the services and number of days required to treat the Member's illness, injury or condition. 2.) Skilled Nursing Facility a.) Covered Services Inpatient services and supplies including hospice services provided by a Skilled Nursing Facility, -14- 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 Nursing Facility stay and to an aggregate of 100 days of Skilled Nursing Facility care per year. 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 . supervision of the Physician treating the illness or injury for which the Member is an inpatient in the Skilled Nursing Facility. -15- 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 supervised by a registered nurse employed by the Home Health Agency or Visiting Nurse Association as professional 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 conforming 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 -16- 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 medical 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. 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: -17- (1) Base charge, mileage and non-reusable supplies of a licensed ambulance company for ground service to transport a Member to and from Hospital or a Skilled Nursing Facility. (2) Base charge, mileage and non-reusable supplies of a licensed air ambulance company to transport a Member from point where first disabled to the nearest hospital providing adequate medical care. (3) 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 orthotist and prosthetist in connection with evaluation or the fitting of an orthotic or prosthetic device when those services are billed as part of the charge of the artificial limbs or eyes. -18- Provided, that benefits shall cover artificial limbs or eyes only when such devices are: (1) Affixed to the body externally (2) Required to replace all or any part of any limb or eye (3) Required to support or correct a defect or form or function of a permanently inoperative or malfunctioning limb or eye And further provided that benefits do not extend to the repair or replacement of prosthetic devices occasioned by misuse or loss. 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. -19- 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 for the medically necessary treatment of an injury or illness. Notwithstanding the above, birth control pills are a covered expense. i. ) Injectable insulin prescribed by a Physician. 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 initiated within six months following the date of injury. Damage to natural teeth during chewing or biting is not Accidental Injury. 7.) Pregnancy and Maternity Care a. ) Care for pregnancy, maternity, and abortion for a Member mother in a hospital or licensed birthing center and prenatal care of the mother's child for abnormal condition. -20- (1) Includes services of certified nurse midwives. (2) Licensed birthing centers must: (a) Be licensed by the jurisdiction it is located in. (b) Be set up, equipped and run for labor, delivery and immediate postpartum care of mother and child. (c) Be run under the direction of an M.D. or D.O. specializing in obstetrics and gynecology. (d) Have a written agreement with an area hospital for immediate transfer in case of emergency. (e) Maintain written records on each patient admitted and each infant born at the center. (f) Accept only low risk pregnancies. •(g) Have diagnostic X-ray and laboratory equipment on site or available under a written agreement with an area medical facility. (h) Have equipment and trained personnel to handle medical emergencies. -21- b. ) Routine nursery care of a Member mother's newborn child. 8. ) 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: a. ) A Member who receives the- organ or tissue, and 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. 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 Substances 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. -22- (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. (3) Inpatient services must be those which are regularly provided 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 the Year for Mental , Nervous, and Substance Abuse Disorders. 10.) Well Babv Care a. ) Physicians' services for routine physical examinations of Members including and until Member's second birthday. b. ) Immunizations and laboratory services in connection with covered services under section 10.a. above. -23- 11.) Chiropractic Services 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. 12.) Non-Physician Providers Non-Physician Provider services are covered when Medically Necessary and prescribed by a Physician for a covered illness, injury or condition. 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 two years as required by Section 10121 of z the California Insurance Code. Any Subscriber electing such optional benefits shall be charged an additional subscriber charge. 14. ) Pap Smears and Mammograms Notwithstanding the exclusion of routine tests from covered benefits in PART FIVE (BB) below, laboratory and test fees for annual pap smears for female Members are covered expenses, however any separate office visit fee by the physician on. the same day as the pap smear is not a covered expense unless such visit is related to a Member's illness. Professional fees for screening or diagnostic mammography are covered expenses pursuant to Insurance Code section 10123.81: a baseline mammogram for women age 35-39, a mammogram for women 40 to 49 every two years or more, -24- . frequently on the recommendation of the women's physician, and a mammogram every year for women age 50 and over. 15.) Annual School or Sports Physical for Children Notwithstanding PART FIVE (BB) , any Member 18 years or younger shall be 100% covered for one required school or sports physical per year performed by a preferred provider. If the school or sports physical is performed by a non'- preferred on=preferred provider and the Member has not qualified for the second level of benefits described under PART TWO C.2. , 8010 of the reasonable and customary charge shall be a covered benefit. 16. ) Allergy Shots Services for allergy immunizations (shots) shall be covered at the rate of $5.00 per visit, limited to one visit per day, if the services are performed by a preferred provider. There is no coverage for allergy immunizations (shots) performed by non-preferred providers. 17. ) Adult Immunizations for Disease Prevention Notwithstanding PART FIVE (BB) , when medically indicated and consistent with accepted-medical practice, immunizations for adult members, 18 years and over, which are approved by the Federal Food..and Drug Administration ("FDA") for general use prior to January 1, 1988 and listed below are a covered benefit and will be paid at the rate of 100% if administered by a preferred provider and 800 of the reasonable and customary charge if administered by a non-preferred provider until the Member has qualified for the second level of benefits under PART TWO C.2. Approved immunizations: -25- Botulism Influenza Rabies Chickenpox Measles Rocky Mountain (rubeola) Spotted Fever Cholera Measles German Scarlet Fever (rubella) Crotaline Meningitis Smallpox (snakebite) Diphtheria Mumps Tetanus Gas gangrene Pertussis Tuberculosis Hemophilus Pneumococcal Typhoid Vaccine Hepatitis Polyvalent Typhus infectious Hepatitis B Polio Yellow Fever PART THREE:. PROGRAMS AFFECTING BENEFITS A. ) Surgical Screening 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 50% 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: -26- a. ) Arthroplasty - an operation on joint, such as knee, ankle or elbow. b. ) Arthrotomy and/or Arthroscopy of the knee - opening and looking into the knee 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. d.) Cholecystectomy - removal of gall bladder. e.) Colectomy - removal of all or part of the colon or large intestine. f.) Heart Surgery - coronary bypass, valve repair, etc. g.) Hemorrhoidectomy (internal or external) - removal of hemorrhoids or piles. h. ) Herniorrhaphy - hernia repair, inguinal. i. ) Hysterectomy - removal of uterus, partial or complete. j. ) Knee Surgery - any operation involving the knee. k. ) Laminectomy - removal of intervertebral disc. 1.) Ligation and/or stripping of varicose veins - varicose vein surgery. m.) Mastectomy - partial or complete removal of breast. -27- n.) Ocular Surgery - of any type, including excision of M cataracts. o.) Podiatric Surgery p. ) Prostatectomy (all kinds) - removal of the prostrate gland. q. ) Rhinoplasty - operation on the nose. r.) Salpingectomy and/or Oophorectomy - removal of the ovary and/or a fallopian tube. s.) Trans-Urethral Resection t. ) Tonsillectomy and/or Adenoidectomy - removal of the tonsils and/or adenoids. u. ) Total knee or hip joint replacement. 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 percent of Covered Expense incurred for services rendered in connection with that Surgical Screening. In the event that the first and second doctor's surgical opinions differ, Member may elect to obtain a third surgical opinion by consulting the Plan's Screening Program. -28- ' 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. 3.) Reduction Of Benefits For Failure To Obtain A Second Opinion Surgical Screening 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 applicable limitations and terms of this Plan. B. ) Surgical Outpatient Procedure 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. 1.) -Surgical Procedures Reguiring Outpatient Surgery Performance a. ) Arthroscopy -29- b.) Biopsy c. ) Bronchoscopy d. ) Bunionectomy e.) Dilation and Curettage f. ) Laryngoscopy g. ) Myringotomy h.) Nasal Polypectomy i. ) Podiatric Surgery j. ) Sigmoidoscopy k.) Tendotomy 1 . ) Tonsillectomy and Adenoidectomy m. ) Tubal Ligation n. ) Vasectomy 2. ) How Benefits In Connection With The Surgery Are Affected a.) Payment of benefits when a required Outpatient Surgical Procedure is Derformed on an outpatient basis. If a Member obtains surgical services on an outpatient basis on a listed outpatient surgical procedure, -30- benefits are paid at 100 percent of Covered Expense incurred for services rendered in connection with that Surgery. 3. ) 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 outpatient 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 limitations and terms of this Plan. C.) Hospital Admissions Program Members must comply with the following procedures respecting hospital admissions or benefits. will be reduced as expressed below. 1. ) Procedures required in connection with a Member's admission to a hospital . 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. b.) For an urgent admission to any Hospital , the Member, the attending Physician, or the Hospital must notify a Plan Administrator by telephone before or at the time -31- 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. 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. ) How benefits in connection with a hospital admission are affected. t;g When a Plan Administrator does not receive a timely pre- certification form 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 provided, 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 D.5.h. , and provided by_ a Preferred Pharmacy, shall be covered in . -32- full and without claim requirements when the Member makes a $2.00 co-payment to the Pharmacy for each generic prescription drug or medicine and generic refill received. In those cases in which there in no generic equivalent or the Member's physician indicates in writing that no generic substitution is permitted, the co- payment shall be $2.00. In those cases in which the Member otherwise refuses a generic substitution, the co-payment shall be $8.00. A list of Preferred Pharmacies is available to Members upon request of the Contra Costa County Personnel Department, Employee Benefits Division. PART FOUR: UTILIZATION REVIEW A. ) The benefits of this Plan are provided only for services that are Medically Necessary as determined by a Plan Administrator. The services must be ordered by the attending Physician for the direct care and treatment of a covered illness, injury or condition. Services must be standard medical practice where received for the illness, injury or condition 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 utilization review program which includes; but is not limited to: 1. ) Pre-admission Review to determine if a scheduled inpatient admission is Medically Necessary. Pre-admission review is -33- 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. ) 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 utilization review. 4. ) Retrospective Review to determine after discharge, whether a w 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 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. ) All experimental or investigative procedures. 3. ) All experimental organ transplants. B. ) Services received before the Member's Effective Date or during an in-patient stay that began before the Member' s Effective Date; and -34- 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. E. ) Any charge for services of a dentist treating an Accidental Injury to natural teeth in excess of a Customary and Reasonable charge. F. ) Any charge for services of a Non-Preferred Anesthetist or for Non- Preferred Outpatient Diagnostic Radiology and Laboratory services in excess of a Customary 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. 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 on research not directly related to patient care, and -35- c. ) At least one-third of its gross income must come from donations or grants other than gifts or payments for patient care, and 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. I. ) Work-related conditions, if benefits are covered or can be recovered, either by adjudication, settlement or otherwise, under any workers' compensation, 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. x 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. 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-be 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 home or who is related to the Member by blood or marriage. -36- N. ) Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, physical therapy or treatment of chronic pain. Custodial Care or rest cures. Services provided by a rest home, a home for the aged, a nursing home or any similar facility. Services provided by a Skilled Nursing Facility, except as expressly provided. in Skilled Nursing Facility under "BENEFITS." 0.) Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. P. ) Hyperkinetic syndromes, learning disabilities, behavioral problems, mental retardation or autism. Mental or Nervous Disorders or Substance Abuse, except as expressly provided under "BENEFITS." Q. ) Braces, other orthodontic appliances or orthodontic services. 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 dental surgery or other services for beautification. S. ) Hearing aids and routine hearing tests. T. ) Optometric services,, radial keratotomy, eye exercise including orthoptics, 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. " -37- V.) Outpatient speech therapy, except following surgery, injury or noncongenital 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. Z. ) Sterilization reversal and services to induce pregnancy or correct infertility, 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. 2. ) Health education services, nutritional counseling or food supplements. 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 D.10 and school or sports physicals as provided in PART TWO D.15. are covered expenses. Also notwithstanding this subparagraph, annual pap smear tests as provided under PART TWO D.14. and mammograms (as set forth in Insurance Code section 10123.51 or any later controlling statue) are covered expenses. . -38- f CC.) Any services or supplies for the treatment of an illness, injury or condition causing the Member to be Totally Disabled on the effective date of coverage. DD. ) Holistic or homeopathic type medicine, smoking .control . biofeedback or exercise programs, including cardiac rehabilitation programs. 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. GG. ) Telephone consultations with Physicians or Non-Physician Providers. HH. ) Any service- or supply relative to treatment of temporomandibular joint syndrome which is a disfunction of the temporomandibular joint (where the moveable jaw attaches to the skull in front of the ears) marked by a clicking or grinding sensation and pain in or about the ears. II. ) . Military service-connected injuries, diseases, conditions or disabilities. JJ. ) Written medical reports requested by Member. KK.) Desensitization Immunization administered by a non-preferred provider: allergy shots, -however, diagnostic allergy tests are a covered expense. -39- PART SIX: EXTENSION OF BENEFITS 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 continue to be provided for services treating the totally disabling illness 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. C. ) A Member who is not confined as an inpatient who wishes to apply for total disability benefits must submit proof to the reasonable satisfaction 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 provides 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. -40- E. ) The benefits payable during any extension of benefits are subject to all limitations and restrictions contained in this Plan document including any subsequent amendments. PART SEVEN: COORDINATION OF BENEFITS All of the benefits provided by this Plan are subject to the following provisions 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 dental care or treatments, for a Member, including, but not- limited to: a. ) group, blanket or franchise insurance coverage; b.) group service plan contract, group practice, group individual practice and other group prepayment coverages; and c. ) any group coverage under labor-management trusteed plans, union welfare plans, employer organization 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. -41- 2. ) This Plan means the portion of this Plan providing the benefits that are subject to this provision. 3. ) Allowable Expenses means any necessary, reasonable and customary item of Covered Expense which is at least partially covered under at least one of the Other Plans covering the person for whom- claim is made. 4. ) Claim Determination Period means a Year. 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 1. ) This provision applies in determining the benefits of a Covered Individual under this Plan for. any Claim Determination Period if, for the Allowable Expenses incurred by that Covered Individual during that period, the sum of (a) the benefits that would be provided 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. 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 -42- 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. 4. ) The following rules determine the order of benefits payable by the plans: a. ) The benefits of a plan which covers the Covered Individual other than as a spouse or dependent shall be exhausted first. b. ) 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: (1) if said birthdays of parents are the same, the plan which has covered a child for the longest period of time will pay first; (2) 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; (3) if the parents are divorced and the parent with custody of the child has remarried, a plan which covers the child as a dependent. of the parent with custody pays before a plan which covers the -43- 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; (4) regardless of (2) and (3) above, if there is a court decree which establishes a parent's financial responsibility for the child's health care expenses, a plan which covers the child as a dependent of that parent pays first; (5) if any ,other plan does not have provision for child benefit payment priority, as set forth above, then this plan will determine the order of payment with respect to children. c. ) If rules a. and b.. 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: (1) 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. (2) If any other plan does not have a provision like that in (a) , this exception will not apply to that plan. -44- d. ) 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. e. ) Rights reserved by the County: For the purposes of coordination of benefits, the County and the Plan Administrator: (1) May release to or obtain from any other organization or individuals 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 require. (2) 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. (3) May release medical information under the conditions of Sections 56.11 and 56.20(c) of the 7-California Civil Code. C. ) Responsibility for Timely Notice The Plan is not responsible for payment to Members or other insurers under coordination of benefits unless timely information has been provided by the Member or other insurer regarding the application of this provision. -45- D. ) Reasonable Cash Value When an Other Plan provides benefits in the form of services rather than cash payment, the Customary and Reasonable cash value of services- provided 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. 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 considered to be benefits paid under this Plan, and with that payment the Plan will fully satisfy its liability. under this provision. ' 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 other organization or persons. -46- PART EIGHT: ENROLLMENT A.) Eligibility to Subscribe The following persons may enroll as Subscribers to the Plan for themselves and for their eligible Family Members: 1.) Permanent and provisional employees of Contra Costa County. 2.) Retired employees of Contra Costa County receiving a retirement allowance from the Contra Costa County Employee's Retirement Association who were subscribers to the Plan immediately prior to their retirement and who elected in writing to continue as subscribers to the plan after retirement; the surviving spouses of such retired employees, who are receiving a retirement allowance; and the children of deceased retired employees who were Members at the time 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 . HealthrPlan 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. -47- 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. B. ) Eligible Family Members The following persons may be enrolled as the eligible Family Members of a Subscriber. 1. ) The Subscriber's Spouse. 2. ) The Subscriber's Child,.which includes a natural or legally adopted 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 25. Nevertheless, foster children who-.are eligible for Medi-Cal coverage are not eligible for coverage under this Plan. Pursuant to Insurance Code section 10121, immediate coverage is available to each newborn child of a Member and to any minor child placed in the physical custody of a Member for adoption. For a natural or legally adopted child, proof of eligibility either by a court adoption order and a copy of a -48- U.S. income tax return of the Subscriber or the spouse showing dependency of the child, may be required. For a foster child, proof of eligibility requires a copy of a Social Service Foster Care Agreement and a letter from Social Service verifying that the child is not eligible for Medi-Cal coverage. 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 physical handicap and (b) chiefly dependent upon the Subscriber for support 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. C.) Application for Enrollment 1. ) Subscribers must file a written application with the County within 31 days of becoming eligible for coverage hereunder and as to Family Members, within 31 days of marriage or the acquiring of children or birth of a child; or during any open enrollment period. 2. ) Every Subscriber must notify the County in writing of any .change in 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 -49- 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: 1.) 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. 2. ) 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. 3. ) For a Family Member, other than a newborn child, who becomes eligible after the Subscriber has been enrolled, coverage shall commence on the effective date of eligibility, providing written application for the addition of such Family Member. .is filed with the County and all required charges are paid within 31 days of marriage or legal adoption. Otherwise coverage may be obtained only as provided 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 -50- 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 result 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 receive Medicare benefits as their primary health coverage, the Family Members based on such Subscriber's membership shall also be ineligible for Plan benefits. -51- 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 membership 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 Plan 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. -52- 2. )- Upon failure of the Subscriber or Member to meet the Plan's eligibility and Medicare requirements. 3. ) Upon.failure of the Subscriber to pay any required subscription charge on or before the due date for such payment. 4.) 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 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 eligibility 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. ) _ Termination of employment for any reason other than termination for gross misconduct, or r= 2. ) 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: -53- 1. ) The employee's death; 2.) Divorce or legal separation from the employee; 3. ) The employee's eligibility for Medicare; or 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. ) 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 any employee; 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 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. -54- a D.) Notice of Continuation Privilege The Subscriber or Family Member must notify the County Personnel Office of: 1.) The date of his or her divorce or legal separation; .or 2.) The date his or her dependent child is no longer eligible under the terms of this Plan. 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. 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: 1.) The date his or her benefits would otherwise terminate; or 2. ) The date he or she receives notice from the Plan Administrator. 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 Charges The amount of charges required to continue Plan benefits will be stated on the notice from the County. This amount will be -55- u 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 stated 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. G. ) Continuation Pending Adjudication of Retirement Benefits. 1. ) When a retirement application to the Contra Costa County Employees' Retirement Association is pending with respect to an employee, and the benefits provided above have expired, an. employee or the employee's retirement benefit claimant , survivor dependent, may receive additional continued health benefits until such time as the Board of Retirement has made a determination on the retirement application, provided: a. ) The employee or the survivor notifies the County Personnel Office of their election to receive additional continued health coverage hereunder, within 30 days from the date the coverage provided above expires; and b. ) The employee or the survivor pays 1001. of the cost of such continued health benefits, as determined by the County, monthly. -56- 2. ) If the retirement benefits are denied, the coverage shall terminate at the end of the month in which the Board of Retirement determination is made. 3.) If retirement benefits are granted, coverage shall continue upon such terms and conditions as are available to retirees. 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 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. 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 reasonable collection costs and reasonable legal -57- 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 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 occurrence upon which the demand is based. 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. D. ) THE ARBITRATION FINDINGS WILL BE FINAL AND BINDING. -58- + PART FIFTEEN: GENERAL PROVISIONS A.) Workers' Compensation 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. of Coverage The coverage of any Member under this Plan may not be canceled while: 1.) This Plan is still in effect, and 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 orh'er 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. ) Providing of Care The Plan is not responsible for providing any type of hospital, medical or similar care. Also, the Plan is not responsible for -59- 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. H. ) Medical Necessity 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 -60- 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 service. 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 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. -61 i 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-PREFERRED PHYSICIANS. 0. ) 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 l.) The Contra Costa County Administrator may promulgate rules or regulations which shall govern the interpretation and administration of the Plan. 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. -62- 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 22670 et seq. -63-