HomeMy WebLinkAboutMINUTES - 12201994 - 1.68 TO BOARD OF SUPERVISORS
FROM . Allen Little, Fire Chief
H. George
o "
ra
By. Michaelg
Chief of Administrative Services r+ Costa
DATE:: December 6, 1994 C""' "J
SUBJECT: Employee Assistance (EAP) Contract for the
Contra Costa County Fire Protection District
SPECIFIC REQUEST(S) OR RECOMMENDATION(S ) & BACKGROUND AND JUSTIFICATION
RECOMMENDATION•
Authorize Chair, Board of Supervisors, to execute a contract with
Occupational Health Services Corporation for the period September 1, 1994, to
August 31, 1995, for the provision of an Employee Assistance Program to the
employees of the Contra Costa County Fire Protection District and four (4)
other Fire Districts in this County.
FINANCIAL IMPACT;
The total annual cost of providing the program from September 1, 1994, to
August 31, 1995, is $26, 317.20, apportioned among the five (5) Fire Districts
participating in the program as shown below:
Fire Protection District Cost
Contra Costa County $ 21,294. 00
Moraga 1,419. 60
Orinda 1,965. 60
Kensington 491.40
Rodeo-Hercules 1, 146. 60
$ 26,317.20
The contract amounts are included in the various Fire District budgets for FY
1994-95.
BACKGROUND/REASONS FOR RECOMMENDATION:
Through a contract with Occupational Health Services Corporation, the Contra
Costa County Fire Protection District has provided an Employee Assistance
Program (EAP) for its employees and their dependents. The EAP services
include a maximum of seven (7) individual private or group counselling
sessions per employee (includes dependents) per contract year and "critical
incident" debriefing sessions for emergency response personnel following
emotionally traumatic incidents encountered on the job. There is 24-hour
toll-free access to the program and it offers confidential and professional
counselling sessions on a variety of human problems.
CONTINUED ON ATTACHMENT: _ YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE 5): /9
ACTION OF BOARD ON 1 x and APPROVED AS RECOMMENDED OTHER
VOTE OF SUPERVISORS
A/ UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN
AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD
ABSENT' ABSTAIN: OF SUPERVISORS r)N TIE_ DATE SHOWN.
Contact: ATTESTED ®Ee --— - --
CC: County Administrator PHIL BATCHELOR. CLERK OF THE BOARD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
BY ,DEPUTY
\17Q7
.r.
�. (0 �
The Contra Costa County Fire Protection District initially contracted for the
EAP services for only its employees for the period September 1, 1988, through
August 31, 1989. The Orinda Fire Protection District subsequently requested
to be added to the Contra Costa County Fire Protection District's contract to
cover its employees at a cost substantially less than what would have been
charged had Orinda entered into a separate contract with Occupational Health
Services Corporation. Orinda was added to the Contra Costa County Fire
Protection District's contract effective December 1, 1988. Similarly, West
County Fire Protection District was added effective January 1, 1990; the
Riverview and Kensington Fire Protection Districts effective March 1, 1990;
Moraga Fire Protection District July 1, 1990; and Rodeo-Hercules Fire
Protection District September 1, 1990.
This new contract reflects the reorganization in the Fire Service which
occurred on 7-1-94 when the Oakley, Pinole, Riverview and West County Fire
Protection Districts were dissolved and their territory was annexed to the
Contra Costa County Fire Protection District. Since the contract amount
exceeds the $25, 000 threshold, the contract needs to be executed by the Chair
of the Board of Supervisors.
Contra Costa County Number
Standard Form 1/88 SHORT FORM SERVICE CONTRACT Fund/Org # 2020/7126 +
Account # 2310
1. Contract Identification. Other #
Department: Contra Costa County Fire Protection District
Subject: Employee Assistance Program
2. Parties. The County of Contra Costa, California (County), for its Department named above,
and the following named Contractor mutually agree and promise as follows:
Contractor: Occupational Health Services
Capacity: Corporation Taxpayer ID # 95-276?isn
Address: �'4_�e-t�-d$ 25 E. Sir Francis Drake Blvd.
-1ak��-s-6t---9 - Larkspur, CA 94939
3. Term. The effective date of this Contract is 9/1/94 and it terminates ._
8/31/95 unless sooner terminated as provided herein.
4. Termination. This Contract may be terminated by the County, at its sole discretion, upon
five-day advance written notice thereof to the Contractor, or cancelled immediately by
written mutual consent.
5. Payment Limit. County's total payments to Contractor under this Contract shall not exceed
$26,317.20
6. County's Obligations. In consideration of Contractor's provision of services as described
below, and subject to the payment limit expressed herein, County shall pay Contractor, upon
Contractor's submission of a properly documented demand for payment (County Demand Form D-
15) which shall be submitted not later than 30 days from the end of the month in which the
contract services were rendered, and upon approval of such demand by the head of the County
Department for which this Contract is made or his designee, as follows:
[Check one alternative only]
( ) hour; or
[x] a. FEE RATE: $2,193.10 per service unit: ( ) session, as defined below; or
(x) calendar mont-h (day, week or month)
NOT TO EXCEED a total of 12 service unit(s).
[ ] b. Payment in full after approval by the Department.
[x] c. As set forth in the attached Payment Provisions.
7. Contractor's Obligations. Contractor shall provide the following described services:
a. Employee Assistance Program Services as described in Attachment #1. Services shall
be rendered in compliance with Knox-Keene Health Care Service Plan Act of 1975,
Attachment #2.
8. 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.
9. 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, and that none shall be used, in
whole or in part, for religious worship or instruction.
10. Independent Contractor Status. This Contract is by and 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.
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Contra Costa County SHORT FOR14 SERVICE CONTRACT Number
11. Disputes. Disagreements between the County and Contractor concerning the meaning,
requirements, or performance of this Contract shall be subject to final determination in
writing by the head of the County Department for which this Contract is made or his designee
or in accordance with the applicable procedures (if any) required by the State or Federal
Government.
12. Access to Books and Records of Contractor, Subcontractor. Pursuant to Section 1861(v)(1)
of the Social Security Act, and any regulations promulgated thereunder, Contractor shall,
upon written request and until the expiration of four years after the furnishing of services
pursuant to this Contract, make available to the Secretary of Health and Human Services,
the Comptroller General , the County, or any of their duly authorized representatives, this
Contract and books, documents, and records of Contractor that are necessary to certify the
nature and extent of all costs and charges hereunder. Further, if Contractor carries out
any of the duties of this Contract through a subcontract, with a value or cost of $10,000
or more over a twelve-month period, such subcontract shall contain a clause to the effect
that upon written request and until the expiration of four years after the furnishing of
services pursuant to such subcontract, the subcontractor shall make available, to the
Secretary, the Comptroller General , the County, or any of their duly authorized
.representatives, the subcontract and books, documents, and records of the subcontractor that
are necessary to verify the nature and extent of all costs and charges hereunder. This
special condition is in addition to any and all other terms regarding the maintenance or
retention of records under this Contract and is binding on the heirs, successors, assigns
and representatives of Contractor.
13. Reporting Requirements. Pursuant to Government Code Sect ion 7550, Contractor shall include
in all documents or written reports completed and submitted to County in accordance with
this Contract, a separate section listing the numbers and dollar amounts of all contracts
and subcontracts relating to the preparation of each such document or written report. This
section shall apply only if the payment limit under this Contract exceeds $5,000.
14. Indemnification. The Contractor shall defend, indemnify, save, and hold harmless the County
and its officers and employees from any 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 services of the 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.
15. Legal Authority. This Contract is entered into under and subject to the following legal
authorities: California Government Code Sections 26227 and 31000.
16. Siqnatures. These signatures attest the parties' agreement hereto:
COu F O=NIA CALIFORNIA CONTRACTOR
B Designee By
Approved: County Administrator
Designate official capacity
By O�L 4 (2.... -) Designee
Recommmended\by Department
By ` kf,�ie— Designee [Form approved by County Counsel]
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Note to Contractor: For corporations (profit or nonprofit), the contract must be signed by two officers. Signature A oust be that
of the president or vice-president and Signature B nest be that of the secretary or assistant secretary (Civil Code Section 1190.1 and
Corporations Code Section 313).
PAYMENT PROVISIONS
a. Provides coverage for employees of the Contra Costa County, Moraga,
Orinda, Kensington and Rodeo-Hercules Fire Protection Districts.
b. Payment limit of $26,317.20 is apportioned as follows:
$21, 294. 00 to the Contra Costa County Fire Protection District
$ 1,419. 60 to the Moraga Fire Protection District
$ 1,965. 60 to the Orinda Fire Protection District
$ 491. 40 to the Kensington Fire Protection District
$ 1, 146.60 to the Rodeo-Hercules Fire Protection District
C. FEE RATE:
$ 1,774.50 per calendar month for the Contra Costa County Fire
Protection District.
$ 118.30 per calendar month for the Moraga Fire Protection District
$ 163 .80 per calendar month for the Orinda Fire Protection District
$ 40.95 per calendar month for the Kensington Fire Protection
District
$ 95. 55 per calendar month for Rodeo-Hercules Fire Protection
District
MHG(TBROWN.EAP
ATTACHMENT 11
SERVICES PROVIDED
Occupational Health Services Corporation (herein referred to as
Contractor) agrees to furnish personnel and services to the
Contra Costa Fire Protection District (herein referred as Sponsor) an "Employee
Assistance Program" for employees.
I. Contractor agrees to provide the following services during
the term of this Agreement at Contractor's designated office
locations or mutually agreed upon facilities and/or
locations:
A. Provision of direct one-to-one counseling by licensed
professional staff. Areas of counseling include, but
are not limited to, alcohol recovery services, drug
abuse treatment, marital and family counseling, legal
consultation, child care arrangement services, elder
care counseling, individual psychological counseling,
specialized children's service, psychiatric
consultation, psychological assessment, stress
reduction services, career counseling, step-parenting
services, conflict resolution counseling, grief
counseling, hypnotherapy, pregnancy counseling,
treatment of phobias, educational counseling,
neuropsychological screening and treatment of sexual
dysfunction. Telephone legal services shall be
rendered by licensed attorneys. Telephone financial
and credit counseling, child care and elder care
arrangement services shall be provided by qualified
contractor staff.
B. Contractor shall provide a maximum of seven (7)
Individual Private Sessions or Group Counseling
Sessions per Family Unit who has sought Progran
Services without referral by a supervisor of Sponsor
per contract period. Fees for any counseling sessions
exceeding seven (7) will become the financial
responsibility of the Subscriber or Dependent unless
otherwise arranged for by the Sponsor. Contractor
will, however, provide any number of counseling
sessions while this Agreement is in effect to identify
and evaluate personal, medical-behavioral problems and
to assess and address alternatives for the resolution
of such problems of Sponsor's Subscribers' who have
been referred to Contractor by a supervisor of Sponsor
as evidencing performance problems in their work or
occupation.
C. Twenty-four hour toll-free telephone access to the
Program for eligible employees and dependents. For
psychological emergencies, Contractor shall have
clinicians on call at all times.
D. One "critical incident" debriefing session for each
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affected individual or group to assist in the
prevention of post-traumatic stress response when a
firefighter as been exposed to emotionally traumatic
situations on the job.
E. Provision of high quality program materials including:
1. employee brochures
2 . Posters
3 . Periodic mailers
4 . Newsletter articles
5. Booklet on "Selecting Quality Childcare"
.6. Educational pamphlets
F. orientation of Sponsor's Enrollees to the Program by
means of written materials, briefing and training
session, and audio-visual presentations pertaining to
the purpose, scope, nature and use of the Program.
G. Training of Sponsor's supervisory and management staff
to develop the knowledge and skills necessary to
utilize effectively the. resources of the Program in the
exercise of their personnel management
responsibilities.
H. Provision of management consultation to Sponsor
relative to the development and integration of
organizational policies and procedures necessary for
effective implementation of Contractor's Program.
I. Provision to Enrollees of referrals to professional
community resources for treatment and/or assistance
outside of the scope of this Agreement as may be
appropriate. Payment of the fees for such treatment or
assistance shall not be the responsibility of
Contractor.
K. Provision of wellness seminars at a mutually agreed
upon fee, if requested by the Sponsor.
L. Provision of quarterly statistical evaluation to
Sponsor of Enrollee utilization of Contractor's
Program.
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ATTACHMENT #2
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
FOR
EMPLOYEE ASSISTANCE PLAN
PROVIDED BY
OCCUPATIONAL HEALTH SERVICES
IMPORTANT PROVISIONS
THIS COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM ("EVIDENCE OF
COVERAGE") CONSTITUTES ONLY A SUMMARY OF THIS PLAN. THE GROUP
AGREEMENT BETWEEN OCCUPATIONAL HEALTH' SERVICES ("OHS") , AND THE
EMPLOYER THAT HAS SPONSORED YOUR PARTICIPATION IN THIS PLAN
("EMPLOYER") MUST BE CONSULTED TO DETERMINE THE EXACT TERMS AND
CONDITIONS OF COVERAGE. YOU MAY REQUEST TO SEE THE GROUP AGREEMENT
FROM EMPLOYER.
Not all words and terms used in this Evidence of Coverage have their
usual meanings and some have meanings that limit their application.
Please refer to the "Definitions" Section to understand the meanings
of these words and terms.
By enrolling or accepting services under this plan, Members are
obligated to understand and abide by all terms, conditions and
provisions of the Group Agreement and this Evidence of Coverage.
If this Evidence of Coverage has been issued to an existing OHS
group, then it replaces the former Evidence of Coverage, effective
upon the date set forth in the Group Agreement. Read this Evidence
of Coverage as benefits may have changed from those stated within
the Evidence of Coverage for the previous period of coverage.
This Evidence of Coverage, the Group Agreement and benefits of this
plan are subject to amendment in accordance with the provisions of
the Group Agreement without the consent or concurrence of Members.
The services described in this Evidence of Coverage are Covered
Services only if and to the extent they (1) are provided by
Participating Providers, and (2) have obtained Prior Authorization
of coverage and referral by OHS. This plan will not pay charges for
services and supplies provided by non-Participating Providers.
Members are obligated to inform OHS as to any change in residence
and any circumstance which may affect entitlement to coverage or
eligibility under this plan. Members must also immediately disclose
to OHS whether they have filed a workers' compensation claim, or
were injured by a third party.
Health, legal and certain other types of professionals are required
under law to treat their client's problems confidentially. Common
exceptions to confidentiality include mandatory reporting of child
abuse, elder abuse, persons dangerous to themselves or others. OHS
will preserve the confidentiality of patient-related records in its
possession in accordance with the requirements of applicable federal
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and state laws. OHS will only release patient-related records in
accordance with applicable federal and state laws.
2
INTRODUCTION
Recognizing that personal problems can adversely impact one's
effectiveness at work, Employer has contracted with OHS to provide
its Employees and their enrolled Family Members coverage under this
plan for counseling and treatment for certain marital and family
problems, alcoholism and drug dependency, financial and credit
concerns, emotional problems, stress, childcare, eldercare,
interpersonal conflicts, situational life problems, federal tax
problems, and legal problems. All of us encounter some of these
problems at some time in our lives. These problems not only affect
our mood and behavior, they frequently affect others close to us.
Employer encourages its Employees and their enrolled Family Members
to use this plan. The specific benefits of this plan are set forth
in the section entitled "Covered Services" below and in the attached
Benefits Schedule.
There is no claim form submission requirement for Covered Services.
Claims for Covered Services are submitted directly by the
Participating Providers and are processed by OHS or an agent or
independent contractor of OHS.
You are required to take an active part in ensuring the success of
your plan. Read this Evidence of Coverage as it will help you
understand your responsibilities and benefits as a Member. If you
have any questions regarding this plan, please contact OHS at (800)
227 -1060.
HOW TO USE THIS PLAN
For counseling services to be covered under of this plan, you must
obtain Prior Authorization of coverage and a referral from OHS.
This means that you must contact OHS at (800) 227-1060 to request
that the service be approved for coverage before it is rendered and
to receive the name and telephone number of the Participating
Provider selected by OHS to assist you with your problems. Members
may call OHS 24 hours a day, 365 days a year. Prior Authorization
of coverage will be denied if the requested services are not
Medically/Psychologically Necessary or otherwise not covered under
this plan.
PARTICIPATING PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHICH
PROVIDERS SERVICES MAY BE OBTAINED IN ORDER TO BE COVERED UNDER THIS
PLAN.
Members may not self refer to any non-Participating Provider or
Participating Provider. Instead, OHS will refer the Member to a
Participating Provider selected by OHS who will assist the Member
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with his or her problems (in most cases, this referral takes place
after OHS consults with the Member's attending Participating
Provider, if any) . If after seeing the Participating Provider a
Member is dissatisfied with the provider, OHS will provide a
referral to its selection of another Participating Provider. In
order to be covered under this plan, all Covered Services must be
authorized by OHS, provided by Participating Providers, and all
referrals to Participating Providers must be arranged by OHS.
Participating Providers include psychiatrists, psychologists,
clinical social workers, marriage, family and child counselors,
alcohol and drug counselors, tax professionals, legal professionals,
financial professionals, and childcare/eldercare coordinators. OHS'
roster of Participating Providers is subject to change as new
providers contract with OHS and some Participating Provider
contracts are terminated. This plan does not and cannot guarantee
the initial or continued availability of any particular
Participating Provider.
COVERED SERVICES
THIS SECTION DESCRIBES THE SERVICES THAT THIS PLAN COVERS. SEE THE
ATTACHED BENEFITS SCHEDULE FOR A DESCRIPTION OF CERTAIN BENEFIT
LIMITATIONS. SEE ALSO THE "EXCLUSIONS AND LIMITATIONS" SECTION FOR
A DESCRIPTION OF BENEFIT LIMITATIONS AND SERVICES AND SUPPLIES THAT
ARE NOT COVERED UNDER THIS PLAN.
o Counseling for marriage, family and relationship problems. The
American family and the stresses upon it have changed dramatically
in the last few decades. A great number of marriages end in
dissolution. Single-parent and dual-career families are
commonplace. Today's relationships have conflicts and stresses that
were unknown to many of us during our upbringing. This plan covers
the services of a Participating Counselor to help a family analyze
and resolve the stresses that can lead to disharmony and breakup.
o Counseling for alcohol and drug abuse. There are no innocent
bystanders in the life of an alcohol or drug-dependent individual.
Friends, coworkers, supervisors and family members are all involved
and affected to some degree. This plan covers the services of a
Participating Substance Abuse Counselor to assist a Member in
resolving chemical dependency problems by assessing the problem,
intervening, breaking denial, arranging for appropriate treatment,
and motivating the individual to sustain sobriety and lifelong
recovery.
o Counseling for emotional, personal and stress-related concerns.
This plan covers the services of a Participating Mental Health
Counselor to help resolve a broad range of emotional, personal and
stress-related concerns, from everyday stresses and worries to mood
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swings, depression, anxiety reactions and phobias.
o Counseling for financial and credit problems. In a "buy now, pay
later" world, it's easy to suddenly find oneself in financial
trouble. This plan covers the services of a Participating Financial
Counselor to help get the Member's finances back under control,
analyze spending habits and patterns, develop a realistic,
personalized budget, and to educate the Member on available credit
rights and options.
o Counseling for childcare matters. Childcare problems can produce
frustration, concern and guilt. They can interfere with a parent's
routine, causing missed time from work and canceled plans. This
plan covers the services of a Participating Counselor to help a
Member assess the Member's childcare needs and to identify and
evaluate appropriate childcare options.
o Counseling for eldercare matters. Getting the help required to
care for an aging relative can be a difficult and confusing process
for concerned family members. This plan covers the services of a
Participating Counselor to help a Member explore and utilize
available resources to resolve problems with elder living
arrangements, nutrition, health care, legal rights, and Social
Security, Medicare and Medicaid benefits.
o Counseling for legal problems. In the past, only the most
privileged had routine access to legal advice. Today, legal counsel
is frequently a necessity for the average citizen. This plan
covers the services of a Participating Legal Counselor to provide
legal consultation to Members with legal questions in areas of
family law, consumer issues, landlord-tenant disputes, personal
injury, .contracts and criminal matters.
o Counseling for federal tax problems. Few events in life cause as
much worry and preoccupation as dealing with the Internal Revenue
Service under potentially adverse circumstances. To Members who are
faced with federal tax problems, this plan covers the services of a
Participating Tax Counselor to provide tax consultation for:
o Unpaid federal taxes, penalties and interest.
o IRS audits.
o Unfiled, past-due federal tax returns.
o Any other problem with the IRS that you or your family members
have unsuccessfully attempted to resolve.
o Counseling for pre-retirement planning. Whatever retirement
means to you, be it a time to get away from it all or a chance to
develop personal interests, how those years are spent will depend on
what is done to prepare for them. This plan covers the services of a
Participating Retirement Counselors to provide information on topics
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relevant to persons of any age who are planning for retirement.
Members will be provided information about the range of situations
that they are likely to encounter in retirement, and they will be
given guidance on how to plan ahead for quality retirement.
o Counseling for organizing life's affairs. In our complex lives,
paperwork can become overwhelming, and leaving a legacy of
disorganized records and vital documents can be a time-consuming and
emotional burden to surviving loved ones. To simplify life, to
prepare for emergencies, and to ease the burden on family members
who may need to make important decisions in your absence, this plan
covers the services of a Participating Counselor to address these
needs. The counselor will teach you how to create an organized
legacy. This benefit can also be used for Members who need to
arrange "final details" for a friend or family member, or for
Members who need suggestions and support about getting life back
together after the loss of a loved one.
Extended Benefits
This plan provides extended benefits for a Member who is totally
disabled on the date his or her coverage under this plan ceases
because either OHS or Employer discontinues the Group Agreement for
all Employees. The extended benefits are subject to all terms and
conditions of the Group Agreement, exclusions and limitations set
forth in this Evidence of Coverage, and the following conditions:
o For the purposes of this benefit, the Member is considered
totally disabled when confined in a hospital, or, when because of
injury or illness, an Employee is prevented from engaging in any
occupation for compensation or profit, or, in the case of a Family
Member, is prevented from performing substantially all regular and
customary activities usual for a person of his or her age and family
status.
o Covered Services shall be furnished solely in connection with the
condition which has caused total disability and for no other
condition, illness or injury. Extended benefits shall be provided
only when the Member is under treatment of a Participating Provider,
and when written certification of the disability and the cause
thereof has been furnished to OHS within 30 days from the date
coverage is terminated. Proof that total disability continues must
be furnished at least every 30 days during the period of extended
benefits.
o Extended benefits shall be provided for the shortest of the
following periods: (1) Until total disability ceases; (2) For a
maximum period of 12 consecutive months; (3) Until coverage without
limitation as to the disabling condition is available to the Member
under any replacement plan; or (4) the Member moves out of
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California or any other pertinent terminating event occurs, as
specified in the Group Agreement or this Evidence of Coverage.
EXCLUSIONS AND LIMITATIONS
COVERED SERVICES ARE SUBJECT TO THE CONDITIONS, EXCLUSIONS AND
LIMITATIONS SET FORTH IN THE AGREEMENT, ELSEWHERE IN THIS EVIDENCE
OF COVERAGE, THE BENEFITS SCHEDULE, AND THE FOLLOWING (NOTE:
FACILITY AND ALL OTHER CHARGES RELATED TO, OR AS A FOLLOW-UP TO
SERVICES AND SUPPLIES THAT ARE SPECIFIED AS EXCLUDED OR BEYOND THE
LIMITATIONS SET FORTH IN THIS EVIDENCE OF COVERAGE ARE LIKEWISE
EXCLUDED) :
1. General exclusions and limitations. This plan does not cover:
o investment advice (nor does OHS loan money or pay bills) ;
o legal representation in court, preparation of legal
documents, or advice in the areas of labor law, taxes, patents or
immigration;
o tax representation or preparation services; or
o services of a Participating Provider that are not authorized
by OHS, or that are beyond the maximum number of Sessions covered
under this plan as set forth in the attached Benefits Schedule.
o Psychoanalysis and treatment for Chronic mental health
conditions is excluded.
o Inpatient treatment of any kind.
o Medical transportation.
o Treatment that OHS determines to be for medical, organic,
endocrine, metabolic, or physiological disorders.
o Services and supplies determined by OHS to be for for the
treatment of mental retardation, autism, congenital mental
abnormalities, developmental and learning disorders, functional
nervous disorders or chronic deficiencies of mental ability.
2. Non-Medically/Psychologically Necessary services and supplies
are excluded.
3 . Services and supplies rendered by non-Participating Providers
are excluded.
4 . Prior Authorization. Any services and supplies provided without
Prior Authorization of coverage are excluded. If the Member fails
to obtain Prior Authorization, OHS will not overturn the resulting
denial on the basis of whether the service or supply would have been
covered had the Member requested Prior Authorization. All
communications by OHS granting Prior Authorization of coverage are
conditioned upon the Member's eligibility for coverage at the time
the Covered Services are received. If subsequent to OHS'
communication of Prior Authorization OHS discovers that the Member
was not eligible for coverage, OHS will deny coverage accordingly.
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5. Medications, medical supplies and medical equipment are
excluded.
6. Workers' Compensation, insurance and third party liability
recoveries. Services and supplies that are otherwise covered under
this plan are excluded to the extent that a Member realizes a
recovery from any source, including settlements and recoveries
derived from workers' compensation, a liable third party, or from
other insurance coverage (e.g. , homeowners' insurance, underinsured
and uninsured motorists insurance) . Coverage for any condition
caused by another person's negligence or intentional act or omission
is excluded. This plan will, however, advance the benefits of this
plan, subject to an automatic lien against the recovery for the
usual, customary and reasonable value.
7. Fitness for duty opinions are excluded.
8. Medical records. Charges associated with copying or
transferring medical records are excluded.
9. Mid-year plan changes. Benefits under this plan that are
subject to annual benefit limitations, will not be increased, even
when a Member becomes covered under two separate OHS plan contracts
during the same annual period.
10. Coordination of benefits. This plan does not coordinate
benefits with any other plan that may be maintained by a Member.
11. Ongoing treatment for substance abuse disorders.
12 . Ongoing treatment for psychiatric conditions of patients
requiring psychotropic medications.
13 . Ongoing treatment for any psychiatric or mental disorder listed
in the DSM-III-R.
14. Psychological or educational assessment and testing.
UTILIZATION REVIEW
This plan includes prior, concurrent and retrospective review of
certain proposed courses of treatment to determine whether the
proposed treatment is Medically/Psychologically Necessary and the
services are covered under this plan. The determination of the
reviewer or professional review organization is not a substitute for
the independent judgment of the treating physician as to the course
of treatment. Utilization review decisions that are not consistent
with a treating physician's determination do not preclude treatment
but do determine OHS' coverage for such treatment.
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ELIGIBILITY PROVISIONS
The Group Agreement specifies the eligibility prerequisites and
terms and conditions of eligibility under this plan.
COMMENCEMENT OF COVERAGE
The Group Agreement specifies the time and the conditions under
which coverage shall start.
BENEFIT CHANGES
OHS will notify Employer at least 30 days in advance of any changes
in benefits.
TERMINATION PROVISIONS
THE FOLLOWING DESCRIBES SOME OF THE USUAL TERMINATION PROVISIONS,
BUT YOU SHOULD ASK EMPLOYER IF THERE ARE ANY DIFFERENT PROVISIONS IN
THE GROUP AGREEMENT.
Employer can terminate this plan:
o By giving 60 days' written notice of termination to OHS prior to
the annual renewal date of this plan.
OHS can terminate a Member's coverage in any of the following
events:
o If prepayment fees are not paid according to the Agreement,
termination will be effective on midnight of the last day of the
month for which prepayment fees were last received by OHS.
o If a Subscriber ceases to be eligible according to the provisions
listed in the Group Agreement, coverage will be terminated for the
Subscriber and any enrolled Family Members effective on midnight of
the last day of the month in which loss of eligibility occurred.
o If a Family Member ceases to be eligible according to the
provisions listed in the Group Agreement, coverage will be
terminated only for that person effective on midnight of. the last
day of the month in which loss of eligibility occurred.
o On midnight of the last day of the month in which a Member no
longer works or maintains a permanent residence within California,
coverage will be terminated for the Subscriber and any enrolled
Family Members effective on midnight of the last day of the month in
which such event occurred.
o If, in the determination of OHS, a Member refuses to establish
and maintain relationships with a Participating Provider to assure
continuity of care and appropriate use of Covered Services,
termination will be effective after 15 days' notice from OHS.
o If, in the determination of OHS, a Member's behavior is
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disruptive, unruly, abusive or uncooperative to the extent that the
ability of OHS or the Member's attending Participating Provider to
manage the care of the Member is significantly impaired, or if the
Member threatens the life or well-being of an employee of OHS or a
Participating Provider, termination will be effective after 15 days'
notice from OHS.
o If a Subscriber makes a material false statement as to his or her
health status or that of any of his or her Family Members, or
obtains or attempts to obtain Covered Services by means of deception
or false, misleading or fraudulent information, acts or omissions,
OHS may terminate coverage immediately upon notice.
If a Member's coverage is terminated under this plan by OHS and the
Member has reason to believe that the termination was based upon the
Member's health status or requirements for health care services, the
Member may request a review of the termination by the California
Commissioner of Corporations.
Upon notice of termination of the Group Agreement by either OHS or
Employer, Employer is responsible for providing notice of same to
each Subscriber.
MEMBER'S LIABILITY FOR PAYMENT
When a Member receives Covered Services from a Participating
Provider, the Member is responsible for payment for non-Covered
Services or benefits in excess of specified limitations. If OHS
does not pay a Participating Provider for Covered Services, you will
not be liable to the provider for any sums owed by OHS. If you
receive services and supplies from a non-Participating Provider, you
will be responsible for payment.
CONTINUATION OF GROUP COVERAGE
In accordance with the Consolidated Omnibus Budget Reconciliation
Act ("COBRA") , a Member who loses coverage under this plan is
entitled under certain conditions to elect to continue group
coverage if Employer is not exempted under COBRA. Generally, COBRA
requires all employers of 20 or more employees to offer to continue
group health coverage for up to 18 months to employees and their
Dependents who lose coverage due to termination of employment
(except for gross misconduct) or reduction in hours worked, and for
up to 36 months to Dependents who lose coverage due to the death of
the Employee, divorce or legal separation from the Employee or to
children who no longer qualify as covered Dependents. "Extended"
coverage of up to 29 months is available to certain COBRA
beneficiaries who are disabled at the time of their qualifying event
and entitled to Social Security disability benefits. Continuation
of group coverage rights under COBRA continue until either the
exhaustion of the previously mentioned maximum continuation periods
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or a "terminating event" occurs (e.g. , termination of all group
plans provided by Employer, failure of the Member to pay monthly
prepayment fees when due, the Member is or becomes covered under any
other group plan without limitation as to the totally disabling
condition, or the Member is or becomes entitled to Medicare
coverage) .
Benefits of the continuation plan are identical to this group plan.
The cost of the coverage will be 102% of the applicable group rate
(including any portion previously paid by Employer) during the
period of basic COBRA coverage and 150% of the applicable group rate
during the period of "extended" coverage (i.e. , 19th through 29th
month) .
UNDER COBRA, ALL NOTIFICATION AND OTHER COMPLIANCE RESPONSIBILITIES
ARE THE SOLE OBLIGATION OF EMPLOYER. Please consult Employer with
your questions regarding continuation of group coverage. Employees
should receive notice from Employer's plan administrator of their
eligibility for group continuation coverage if a qualifying event
occurs. This notice should be sent the Employee's Family Members in
the event of the Employee's death. Failure of a Subscriber or
affected Family Member to notify Employer within 60 days of a
divorce, legal separation or a Dependent child's loss of eligibility
will result in loss of eligibility for group continuation coverage.
Employer must notify OHS of the occurrence and related date of any
qualifying event within 30 days of the incidence thereof. If the
Member fails to provide such notice, then the Member shall not be
entitled to elect continuation coverage under this plan.
COBRA coverage will begin at the time group coverage ends if the
Member applies and pays the required prepayment fees within 60 days
after receiving notice of eligibility for continuation coverage or
the date of loss of coverage, whichever is later. Electing Members
will be billed for coverage on a monthly basis. Payment is due on
the first day of each coverage month. Coverage will be canceled on
midnight of the last day for which payment was last made if
prepayment fees are not received within 30 days of the due date.
GRIEVANCE PROCEDURES
General
As a condition of enrollment and a contractual term of the Group
Agreement and this Evidence of Coverage, Members are required to
submit all grievances through OHS' internal grievance procedures.
OHS' internal grievance procedures are required to be completed
before the Member may file for arbitration, as specified below, for
final and binding resolution of the grievance. (Note: For the
purposes of these procedures, "grievances" , "appeals" and
"complaints" are not distinguished) .
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How to File a Grievance
If after discussion with OHS a Member is dissatisfied with the
result of OHS' initial determination regarding a claim, request for
Prior Authorization of coverage or problem of any other nature
related to this plan, the Member may appeal in writing to OHS within
30 calendar days of the date of OHS' notice of its determination.
Any further appeal of OHS' response to a first or second step appeal
must also be in writing and submitted to OHS within 30 calendar days
of the date of OHS' notice of its determination as to the prior
step. If the Member is still dissatisfied with OHS' determination,
and the Member wishes to further appeal, a petition for arbitration
must be filed with the arbitrator (as described below) within 30
calendar days of the date of OHS' notice of its final determination.
APPEALS RECEIVED MORE THAN 30 CALENDAR DAYS AFTER THE DATE OF ANY
OHS DETERMINATION WILL NOT BE CONSIDERED AND NO FURTHER INTERNAL OR
EXTERNAL RESOLUTION IS AVAILABLE.
Members are encouraged to call OHS at (800) 227-1060 to discuss the
grievance but all appeals must be made in writing and mailed to OHS
at 125 East Sir Francis Drake Boulevard, Suite 300, Larkspur,
California, 94939-1860, Attention: Director of Quality Management.
If you require assistance, OHS will assist you in writing the
complaint. Written appeals must be made and signed by the affected
Member (unless incapacitated or a minor) and include any additional
information that the Member wishes OHS to consider and an itemized
statement as to the amount in dispute. OHS will respond with its
determination within 30 calendar days following its receipt of an
appeal, unless the Member is notified that additional time is
required.
Details of Procedures for Grievance Resolution
o First Step - Internal Review
Problems with eligibility, commencement of coverage, re-enrollment,
access to providers, delivery of care, cost of care,
Medical/Psychological Necessity, Covered Services or any other
matter should be directed in writing by the Member to OHS.
In the case of a grievance concerning a Participating Provider, OHS
will, upon receipt of a written grievance, conduct an investigation
of the matter and implement appropriate disciplinary or corrective
action if it determines that action is necessary. However, the
findings of, and any actions resulting from, such peer review will
not be disclosed to the grievant as they are privileged and
protected from disclosure under law. No further steps of internal
appeal are available for provider related grievances.
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o Second Step - Internal Review
If you do not agree with OHS' determination made on a first step
appeal, you may request in writing that your case be reconsidered.
o Third Step - Internal Grievance Committee Hearing
The final internal level of appeal available to you for resolution
of a grievance is a hearing by OHS' Grievance Committee. Although
the make-up of the Committee is subject to change at OHS'
discretion, it is currently comprised of three administrative
personnel of OHS. Hearings are usually scheduled within 30 days of
written request. OHS will assist you in scheduling the hearing.
This step is only available for disputes where the amount in
controversy equals or exceeds $1, 000. Disputes under this amount
may only be finally decided by arbitration as set forth below.
Members are allowed to appear with, and have information offered by
third parties, including attorneys, but not insurance brokers or
persons having a conflict of interest with OHS. However, unless
incapacitated or a minor, the affected Member must appear in person
and be principally responsible for the presentation of their
grievance and for direct response to questions by the Committee.
The hearing is conducted as an informal administrative hearing --
formal rules of evidence and discovery which are common to legal
hearings do not apply. In some cases, OHS may require the hearing
to be conducted by telephonic conference.
Written requests for a hearing must be made directly by the affected
Member (unless the Member is incapacitated or is a minor) . Written
requests by the treating physician or other Participating Provider
will not be considered unless signed also by the Member. The
written request should include all information that the Member
wishes OHS and the Committee to consider. Information submitted
after the hearing will not be considered in the review process. The
written request must also contain an itemized statement as to the
amount of money in dispute. If the Member does not attend the
scheduled hearing, the Committee will decide the question on the
basis of the information presented at that time. Requests for
rescheduling of a scheduled hearing date will ordinarily only be
considered if made at least ten days prior to the scheduled hearing
date.
o Final Step - Neutral, Binding Arbitration
If the Member does not agree with OHS' final determination, the
Member may, within 30 days of OHS' notice of its final
determination, file a petition for neutral, binding arbitration in
accordance with the California Arbitration Act (California Code of
Civil Procedure Section 1280, et seq. ) .
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Arbitration is the final process for the resolution of any dispute
arising out of or relating to this Evidence of Coverage or the
Agreement, whether involving a claim in tort, contract or otherwise,
involving Subscribers, Family Members (whether a minor or an adult) ,
the heirs-at-law or personal representatives of a Subscriber or
Family Member, and OHS (including any of its agents or employees) .
Members must settle all such disputes by neutral, binding
arbitration according to the terms and conditions set forth here.
By enrolling in this plan, Members waive their constitutional right
(or any other such right) to a trial before a jury or judge
regarding such disputes, and any other right they may have to have
such disputes resolved in any manner other than as set forth here.
Judgment upon the award rendered by the arbitrator(s) may be entered
in any court having proper jurisdiction. The decision of the
arbitrator shall be final and binding. Each party is responsible
for their own attorney fees and for an equal share of the costs of
arbitration. The power of the arbitrator shall be limited to the
determination of the interpretation of the terms of the Group
Agreement and the Evidence of Coverage only and the arbitrator
expressly does not have the power to grant any other relief or award
or determine any change, modification, alteration, addition or
subtraction from any contractual provisions. Section 1281.2 (c) of
the California Code of Civil Procedure which allows a court to order
any case to trial if the case involves a party not privy (i.e. ,
bound by contract) to this provision, is expressly waived.
How to Initiate Arbitration Proceedings
OHS is available to instruct Members how to initiate arbitration
proceedings. Generally, these arbitration proceedings are initiated
by the Member: (1) filing a petition in the Superior Court in the
county where the Agreement is to be performed (usually, the county
where the Member resides) or was made requesting that arbitration be
ordered, and (2) serving a copy of the petition and a written notice
of the time and place of the hearing thereof and any other papers
upon which the petition is based upon OHS' agent for service of
process at its principal place of business.
Medical, Legal and Behavioral Health Malpractice Disputes
Any dispute alleging medical, legal and behavioral health
malpractice, that is as to whether any services or supplies covered
under this Evidence of Coverage were unnecessary or unauthorized by
the Member or were improperly, negligently or incompetently
rendered, will be determined by submission to arbitration as
provided by California law, and not by a lawsuit or resort to court
process except to the extent California law provides for judicial
review of arbitration proceedings. ANY SUCH LEGAL ACTIONS SHALL NOT
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INCLUDE OHS AND SHALL INCLUDE ONLY THE PROVIDER SUBJECT TO THE
ALLEGATION. BY ENROLLING IN THIS PLAN, MEMBERS WAIVE THEIR RIGHT TO
BRING ANY LEGAL ACTION AGAINST OHS, OR TO JOIN OHS AS A PARTY IN ANY
LEGAL ACTION, REGARDING SUCH DISPUTES.
INDEPENDENT CONTRACTOR RELATIONSHIP
ALTHOUGH OHS IS SUBJECT TO THE REQUIREMENTS OF THE KNOX-KEENE HEALTH
CARE SERVICE PLAN ACT REGARDING, AMONG OTHER THINGS, ITS MONITORING
OF THE QUALITY OF CARE RENDERED BY PARTICIPATING PROVIDERS, THE
RELATIONSHIP BETWEEN OHS AND PARTICIPATING PROVIDERS IS THAT OF AN
INDEPENDENT CONTRACTOR RELATIONSHIP. EXCEPT FOR CERTAIN COUNSELORS
PROVIDING CHILDCARE, ELDERCARE AND FINANCIAL COUNSELING WHO ARE
EMPLOYED BY OHS, PARTICIPATING PROVIDERS ARE NOT AGENTS OR EMPLOYEES
OF OHS, NOR IS OHS AND ITS EMPLOYEES AND AGENTS AN EMPLOYEE OR AGENT
OF ANY PARTICIPATING PROVIDER. OHS AND PARTICIPATING PROVIDERS ARE
NOT AUTHORIZED TO REPRESENT THE OTHER FOR ANY PURPOSES, NOR ARE THEY
NOR ANY OF THEIR RESPECTIVE OFFICERS, AGENTS OR EMPLOYEES TO BE
CONSTRUED TO BE THE OFFICER, AGENT OR EMPLOYEE OF THE OTHER.
PARTICIPATING PROVIDERS MAINTAIN THE PROVIDER-PATIENT RELATIONSHIP
WITH MEMBERS AND ARE SOLELY RESPONSIBLE TO MEMBERS FOR ALL OF THE
SERVICES THEY PROVIDE TO MEMBERS. IN NO EVENT SHALL OHS BE LIABLE
FOR THE NEGLIGENCE, WRONGFUL ACTS OR OMISSIONS OF PARTICIPATING
PROVIDERS.
EMPLOYER IS NOT THE AGENT OR REPRESENTATIVE OF OHS NOR IS OHS LIABLE
FOR ANY ACTS OR OMISSIONS OF EMPLOYER, ITS AGENTS OR EMPLOYEES. OHS
AND EMPLOYER ARE INDEPENDENT CONTRACTORS IN RELATION TO ONE ANOTHER
AND NO JOINT VENTURE, PARTNERSHIP, EMPLOYMENT, AGENCY OR OTHER
RELATIONSHIP IS CREATED BY THE AGREEMENT. NEITHER OHS NOR EMPLOYER
ARE LIABLE FOR ANY ACT, NEGLIGENCE OR OMISSION OF THE OTHER, NOR
EACH OTHER'S AGENTS OR EMPLOYEES. NEITHER OHS NOR EMPLOYER IS
AUTHORIZED TO REPRESENT THE OTHER FOR ANY PURPOSES. NONE OF THE
PARTIES TO THE AGREEMENT NOR ANY OF THEIR RESPECTIVE OFFICERS,
AGENTS OR EMPLOYEES SHALL BE CONSTRUED TO BE THE OFFICER, AGENT OR
EMPLOYEE OF ANY OTHER PARTY.
PUBLIC POLICY
OHS permits Members to participate in establishing its public policy
through its Public Policy Committee, the findings and
recommendations of which are regularly reported to OHS' governing
Board of Directors. A minimum of 51% of the seats on the Committee
are dedicated to enrollees of OHS (which can include enrollees
enrolled in other plans with OHS) . For the purposes of this
paragraph, "public policy" means acts performed by OHS and its
employees to assure the comfort, dignity and convenience of Members
who rely on Participating Providers to provide Covered Services.
RIGHT TO RECEIVE AND RELEASE INFORMATION
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As a condition of enrollment in this plan and a condition precedent
to the provision of benefits under this plan, OHS, its agents,
independent contractors and Participating Providers shall be
entitled to release to, or obtain from, any person, organization or
government agency, any information and records, including patient
records of Members, which OHS requires or is obligated to provide
pursuant to legal process, federal, state or local law in the
administration of this plan.
REGULATION
OHS is subject to the requirements of the California Knox-Keene
Health Care Service Plan Act and its implementing regulations. Any
provisions required to be in this Evidence of Coverage or in the
Group Agreement by either of these sources of law shall bind OHS
whether or not provided in this Evidence of Coverage or the Group
Agreement.
NON-ASSIGNABILITY OF BENEFITS
The coverage and benefits of this plan may not be assigned without
the prior written consent of OHS, which consent may be withheld for
any reason. OHS reserves the right to make payment of benefits, at
its sole discretion, directly to the attending provider or to the
Member.
DEFINITIONS
(Note: All defined terms are capitalized within this Evidence of
Coverage)
Agreement: Includes the Group Agreement between OHS and Employer,
this Evidence of Coverage, the Group Application, the Notice of
Acceptance, the Member's enrollment form, and any addenda,
endorsements or amendments thereto.
Chronic: Designating a mental health condition which OHS determines
to show little or slow positive change, or reasonable prognosis for
positive change.
Covered Service: A counseling service that is authorized for
coverage by OHS and specified as being covered in this Evidence of
Coverage.
Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised ("DSM") : A listing of diagnostic categories and
criteria which provides guidelines for making diagnoses of mental
and substance abuse disorders. The DSM is a widely accepted basis
for describing the presence and type of these disorders. A DSM
16 -
diagnosis of mental or substance abuse disorder is a minimum
requirement for the demonstration of Medical/Psychological
Necessity. The diagnosis must be contained in the most recent
edition of the DSM.
Dependent: Those individuals in a Subscriber's Family Unit who meet
the criteria of the definition of dependent as used in the Internal
Revenue Code and Regulations of the United States, subject to any
Employer prerequisites to the contrary described in the Group
Agreement.
Employee: An individual whose employment or affiliation status with
Employer meets the eligibility prerequisites set forth in the Group
Agreement.
Family Member: Any individual of a Subscriber's Family Unit who
meets all applicable eligibility requirements and Employer
prerequisites specified within the Group Agreement.
Family Unit: A unit comprised of a Subscriber and each person whose
eligibility for Covered Services is based upon such person's
relationship with, or dependency upon, such Subscriber.
Medically/Psychologically Necessary: Covered Services which are
necessary and appropriate for treatment of a Member's symptoms and
behaviors that demonstrate the presence of a mental or substance
abuse disorder as described in the DSM. The terms "necessary" and
"appropriate" as used in this paragraph are determined according to
professionally recognized standards of practice. Attending
Participating Providers are exclusively responsible for making all
medical determinations and treatment decisions. However, payment
for Covered Services rendered will be conditioned on OHS' subsequent
review and determination as to consistency with these standards and
OHS' medical policies. The fact that a Participating Provider may
prescribe, order, recommend or approve a service, supply or
admission does not, in itself, make it Medically/Psychologically
Necessary or make the charge an allowable Covered Service even
though it is not specifically listed as an exclusion or limitation.
Member: An Employee, Dependent, Subscriber or Family Member who
meets all applicable eligibility requirements specified within the
Agreement, is enrolled under this plan and for whom the required
prepayment fees have been received and accepted by OHS.
Participating Provider: A physician, psychiatrist, psychologist,
clinical social worker, marriage, family and child counselor,
alcohol and drug counselor, tax professional, legal professional,
financial professional, childcare coordinator, or other type of
health care provider, having a written agreement with OHS, or an
independent practice association or medical group which contracts
- 17 -
with OHS, to provide Covered Services to Members. Certain
counselors providing childcare, eldercare and financial counseling
are employed by OHS.
Prior Authorization: Approval for coverage from OHS prior to the
Member obtaining Covered Services. Requests for Prior Authorization
will be denied if not Medically/Psychologically Necessary, if in
conflict with OHS' medical policies, or otherwise not covered under
this plan.
Session: Any in-person or telephone consultation with a
Participating Provider for Covered Services under this plan.
Subscriber: An Employee enrolled under this plan who is responsible
for payment of Copayments and any applicable prepayment fees to OHS
and whose employment or other status, except family dependency, is
the basis for eligibility under this plan.
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BENEFITS SCHEDULE FOR
EMPLOYEE ASSISTANCE PLAN
This Benefits Schedule summarizes the benefit limitations
requirements of this plan.
Benefit limitations. A maximum of 7 sessions are covered under this
plan per family unit per contract period. OHS will count one of
your Sessions used if you fail to cancel an appointment at least 24
hours in advance, unless the appointment is missed because of an
emergency that prevents you from giving such notice of cancellation.
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