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HomeMy WebLinkAboutMINUTES - 04141992 - 1.64 r_ 1 , s4 TO: BOARD OF SUPERVISORS Contra FROM: Joseph J. Tonda, Risk Manager . Costa County DATE: April 14, 1992 o'.' ::(W. (()L. SUBJECT: lst Choice Health Plan - Amendment to Plan Document SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION RECOMMENDATION Amend the 1st Choice Health Plan, the self-funded employees' indemnity health plan, effective April 1, 1992 to comply with the agreement as negotiated between the County and the Contra Costa County Health Care Coalition as follows: I . Add to Part Two: Benefits, Section C, Payment Provisions (page 13) add as follows: Subsection 4, Maximum Benefits.. Benefits for outpatient physical therapy visits are limited to an aggregate of 50 visits per calendar year per Member. Add to Part Five: Exclusions and Limitations (page 39) , add as follows: Subsection LL. Benefits for outpatient physical therapy visits are limited to an aggregate of 50 visits per calendar year per Member. II. Amend Part Two: Benefits, Section D. 14, Pap Smears and Mammograms (page 24) to read as follows: 14. Notwithstanding the exclusion of routine tests from covered benefits in Part Five (BB) below, laboratory, test and office visit fees for annual pap smears for female members are covered expenses. Professional fees for screening or diagnostic mammography are covered expenses pursuant to Insurance Code Section 10123 . 81: a baseline mammogram for women age 35 through 39, a mammogram for women 40 through 49 every two years or more frequently on the recommendation of the woman' s physician, and a mammogram every year for women age 50 and over. CONTINUED ON ATTACHMENT: X YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF ARD OMMI E APPROVE OTHER SIGNATURE(S): ACTION OF BOARD ON q 9 z APPROVED AS RECOMMENDED X OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS(ABSENT �� ) AND CORRECT COPY OF AN ACTION TAKEN AYES: '!NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. CC: Risk Management (Benefits Div. ) ATTESTED County Administrator PHIL BATCHELOR,CLERK OF THE BOARD OF County Counsel SUPERVISORS AND COUNTY ADMINISTRATOR Auditor-Controller BY DEPUTY M382 (10/88) III . Add Part Two: Benefits, Section D, Covered Expenses, Subsection 18, y: 19 and 20 (page 26) to read as follows: 18. Non-Preferred Provider Emergency Room Physician and Radiologist. a. Services provided by a non-preferred emergency room physician shall be fully covered when the services are provided at a preferred provider hospital subject to a $25 co-payment by the Member. The $25 co-payment does not apply to the Member' s annual out-of-pocket expense until the annual out-of-pocket limit is reached. b. Services provided by a non-preferred radiologist shall be fully covered when the services are provided at a preferred provider hospital subject a $25 co-payment by the Member. The $25 co-payment does not apply to the Member' s annual out-of-pocket expense until the annual out-of-pocket limit is reached. 19. Routine Vision Examinations. Services of a Physician (M.D. ) or licensed Optometrist (O.D. ) for routine vision .examination shall be fully covered subject to a $10 co-payment by the Member: for Members 0 through 17 and 40 or over, every twelve months, and every twenty-four months for Members age 18 to 39. 20. Diabetic Training Programs. Diabetic training programs prescribed by the treating physician for diabetes treatment is a covered expense limited to a lifetime maximum of $300 in payments per Member under the preferred/non-preferred provider provisions of the Plan. IV. Amend Part Three: Programs Affecting Benefits, Section D, Prescription Drug Program (page 32) to read as follows: D. Prescription Drug Program 1 . Prescription drugs and medicine referenced in Part Two D. 5.h. , and provided by a preferred pharmacy, shall be covered in full and without claim requirements when the Member makes a $2. 00 co-payment to the pharmacy for each generic prescription drug or medicine and generic refill received. In those cases in which there is no generic equivalent or the Member' s physician or Member requests a brand name prescription drug, the co-payment shall be $5. 00. A list of Preferred Pharmacies is available to Members upon request of the Contra Costa County Employee Benefits Division. 2. Prescription drugs and medicine referenced in Part Two D. 5.h. and provided by a non-preferred pharmacy, shall be reimbursed when the Member or pharmacy submits a claim for each prescription drug or medicine refill received. Payment is provided for 80 percent of the covered expense incurred by the Member. 3 . Injectable drugs referenced in Part Two D. 5.h. , excluding insulin, shall be covered limited to a 50 percent co-payment for each injectable drug prescribed. V. Amend Part Five: Exclusions and Limitations, Section AA.2 (page 38) to read as follows: 2. Health education services, nutritional counseling or food supplements. Notwithstanding this exclusion, diabetic training programs prescribed by the treating physician for diabetes treatment is a covered expense as set forth in Part Two, Section D. 20 above, limited to a lifetime maximum of $300 in payments per Member. - 2 - 1 VI . Amend Part Five: Exclusions and Limitations, Section BB (page 38 ) to read as follows: 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 office visit and 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. VII. Amend Part Five: Exclusions and Limitations, Sections D,. F (page 35) and T (page 37) are amended as follows: 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. Notwithstanding this limitation, non-preferred emergency room physician services are covered expenses as provided in Part Two, Section D. 18 .a. F. Any charge for services of non-preferred anesthetist or for non-preferred outpatient diagnostic radiology and laboratory services in excess of a customary and reasonable . charge. Notwithstanding this limitation, non-preferred radiologists services are covered expenses as provided in Part Two, Section D. 18.b. T. Optometric services . except as provided in Part Two, Section D. 19, radial keratotomy, eye exercise including orthoptics, eyeglasses, contact lenses or frames. BACKGROUND The proposed amendments are necessary to make the plan document consistent with the agreements negotiated between the County and the Health Care Coalition. FISCAL IMPACT Except for the vision examination benefit, the amended benefit changes are not expected to have any significant fiscal impact to the plan. The vision examination costs will be dependent upon plan utilization. Plan expenses will be paid from the 1st Choice Trust Fund. 3 -