R-97-06-12-11G - 6/12/1997 1
Y
RESOLUTION NO. R-97-06-12-11G
WHEREAS, the City of Round Rock previously entered into a
Health Plan Document ("Plan Document" ) with Healthcare Benefits,
Inc. to provide City Employees with health care, and
WHEREAS, Healthcare Benefits, Inc. has submitted Amendment
Number Two to the Plan Document, and
WHEREAS, the City Council desires to enter into said
Amendment No. Two to the Document with Healthcare Benefits, Inc. ,
Now Therefore
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK,
TEXAS,
That the Mayor is hereby authorized and directed to execute on
behalf of the City Amendment Number Two to the Plan Document with
HealthCare Benefits, Inc. , to make the changes as more particularly
described in the attached Amendment Number Two.
RESOLVED this 12th day of June, 1997.
dZ41a,,Aj1
CHARLES CU PE ER, Mayor
City of Round Rock, Texas
ATTEST:
(�x r L.�F k X6.0-0 la44eL
JINNE LAND, City Secretary
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AMENDMENT NUMBER TWO
TO THE PLAN DOCUMENT OF
CITY OF ROUND ROCK
It is hereby agreed that the Plan Document describing the provisions of Plan Number 1169,
provided by City of Round Rock, the Plan Sponsor, is amended effective March 1, 1997, with
respect to all Covered Employees and their Covered Dependents, as follows:
SECTION VII - SCHEDULE OF BENEFITS, pages 26 thru 30, is deleted in its entirety and
substituted with the following:
SECTION VII-SCHEDULE OF MEDICAL BENEFITS
NETWORK BENEFIT NON-NETWORK BENEFIT
HOSPITAL SELECTION Any Physician or Hospital in the Any Physician or Hospital
AND Columbia St David's Health Network
PHYSICIAN SELECTION
Patient can choose non-PPO Physicians and Hospitals and receive Non-Network
benefits or select Preferred Providers at time of medical service and receive
increased Preferred Provider benefits
PREVENTIVE CARE
(routine physicals, mammograms, pap 100% coverage after$15 co-pay per 50% coverage; Deductible waived,
smears,well child care and immunizations visit; $250** maximum benefit per to a maximum benefit of$250**per
performed in a physician's office, Calendar Year Calendar Year
outpatient department of a hospital or an
independent facility)
INPATIENT HOSPITAL SERVICES*
Hospital room& board(semi-private), 80% coverage after $250 Annual 50%coverage after$250 Annual
intensive care,anesthesia and oxygen, Cash Deductible Cash Deductible
blood,drugs,diagnostic services,
Including x-ray,microscopic and
laboratory tests, radioactive therapy,
medical supplies,etc.
INPATIENT HOSPITAL SERVICES* 100% coverage after $250 Annual ---------
AT ROUND ROCK HOSPITAL Cash Deductible
FREESTANDING URGENT CARE 100% coverage after$15 co-pay per 80%coverage after$50 co-pay
CENTERS office visit — includes all charges per visit
related to office visit if billed by
Ph sician's office
* A$500 Pre-Certification Treatment Deductible will be applied if the Hospital confinement is not
pre-certified.
** Maximums include In and Out-of-Network
Amendment Two
Page 2
NETWORK BENEFIT NOW-NETWORK BENEFIT
OUTPATIENT HOSPITAL
Outpatient Surgery 80% coverage after $250 Annual 50%coverage after$250 Annual
Cash Deductible Cash Deductible
Outpatient Surgery at Round Rock 100% coverage after $250 Annual
Hospital Cash Deductible
Outpatient Diagnostic Testing and Other 80% coverage after $250 Annual 50%coverage after$250 Annual
Outpatient Services Cash Deductible Cash Deductible
Outpatient Diagnostic Testing and Other 100% coverage after $250 Annual
Outpatient Services at Round Rock Cash Deductible
Hospital
EMERGENCY TREATMENT
Hospital Emergency
Accident 80% coverage after $50 Emergency 80%coverage after$50 Emergency
Room Deductible — Deductible Room Deductible -— Deductible
waived if admitted to the hospital waived if admitted to the hospital
Sickness 80% coverage after $50 Emergency 80%coverage after$50 Emergency
Room Deductible — Deductible Room Deductible — Deductible
waived if admitted to the hospital waived if admitted to the hospital
PHYSICIAN SERVICES
In the Office 100% coverage after$15 co-pay per 50% coverage after $250 Annual
office visit — includes all charges Cash Deductible
related to office visit if billed by
Physician's office
All Other Physician Fees
(surgery,anesthesia,radiology,pathology, 80% coverage after $250 Annual 50% coverage after $250 Annual
diagnostic x-ray and lab, chemotherapy, Cash Deductible Cash Deductible
dialysis, physical therapy, radiation
there etc.
ALLERGY TREATMENT 80% coverage after $250 Annual 50% coverage after $250 Annual
(allergy testing and aller-gy in"ections Cash Deductible Cash Deductible
* A$500 Pre-Certification Treatment Deductible will be applied if the Hospital confinement is not
pre-certified.
** Maximums include In and Out-of-Network
Amendment Two
Page 3
NETWORK BENEFIT NO14 NETWORK BENEFIT
MENTAL/NERVOUS DISORDERS
Inpatient Care* 80% coverage after $250 Annual 50% coverage after $250 Annual
Cash Deductible to a Maximum Cash Deductible to a Maximum
Lifetime Benefit of$25,000** Lifetime Benefit of$25,000**
Outpatient Physician Care 100% coverage after$15 co-pay per 50% coverage after $250 Annual
visit to a maximum of 30**visits per Cash Deductible to a maximum of
Calendar Year 30**visits per Calendar Year
SERIOUS MENTAL ILLNESS
Inpatient Care* 80%coverage after$250 Annual 50%coverage after$250 Annual
Cash Deductible Cash Deductible
Outpatient Care 100%coverage after$15 co-pay per 50%coverage after$250 Annual
visit Cash Deductible
ALCOHOL AND DRUG ABUSE
Inpatient Care* 80%coverage after$250 Annual 50%coverage after$250 Annual
Cash Deductible Cash Deductible
Outpatient Care 100%coverage after$15 co-pay per 50%coverage after$250 Annual
visit Cash Deductible
SECOND SURGICAL OPINIONS 100%coverage; Deductible waived 100%coverage; Deductible waived
CHIROPRACTIC SERVICES Not Available 50% coverage after $250 Annual
Cash Deductible to a maximum of
$500 per Calendar Year
SKILLED NURSING FACILITY*
Room and Board(semi-private and 80% coverage after $250 Annual 50% coverage after $250 Annual
miscellaneous expenses) Cash Deductible to a maximum of Cash Deductible to a maximum of
$10,000**per Calendar Year $7,000**per Calendar Year
Room and Board(semi-private and 100% coverage after $250 Annual ---
miscellaneous expenses)at Round Rock Cash Deductible to a maximum of
Hospital $10,000** per Calendar Year
HOME HEALTH CARE* 80% coverage after $250 Annual 50% coverage after $250 Annual
Cash Deductible to a maximum of Cash Deductible to a maximum of
$10,000**per Calendar Year $7,000**per Calendar Year
HOSPICE CARE* 80% coverage after $250 Annual 50% coverage after $250 Annual
Cash Deductible to a Maximum Cash Deductible to a Maximum
Lifetime Benefit of$20,000** Lifetime Benefit of$15,000**
* A$500 Pre-Certification Treatment Deductible will be applied if the Hospital confinement is not
pre-certified.
* Maximums include In and Out-of-Network
Amendment Two
Page 4
NETWORK BENEFIT NON-NETWORK BENEFIT
OTHER COVERED EXPENSES
(durable medical equipment,supplies, 80%coverage after$250 Annual 80%coverage after$250 Annual
home infusion therapy%ambulance,etc.) Cash Deductible Cash Deductible
OTHER COVERED EXPENSES 100%coverage after$250 Annual
PROVIDED BY ROUND ROCK HOSPITAL I Cash Deductible
* A$500 Pre-Certification Treatment Deductible will be applied if the Hospital confinement is not
pre-certified.
** Maximums include In and Out-of-Network
Amendment Two
Page 5
NETWORK BENEFIT NON-NETWORK BENEFIT
LIFETIME MAXIMUMS"
Overall Plan Maximum $1,000,000 $1,000,000
Mental/Nervous Disorders $25,000 $25,000
Hospice Care $20,000 $15,000
CALENDAR YEAR MAXIMUMS"
Outpatient Treatment of 30 visits 30 visits
Mental/Nervous Disorders
Home Health Care $10,000 $7,000
Skilled Nursing Facility $10,000 $7,000
Chiropractic Care Not Available $500
Preventive Care $250 $250
ANNUAL CASH DEDUCTIBLE
Per Individual $250 $250
(includes last quarter carryover)
Per Family $750 $750
PLAN OUT-OF-POCKET LIMITATION
Per Individual
(includes last quarter carryover) $1,000 $5,000
$5,000 at 80% $10,000 at 50%
PRESCRIPTION DRUG PLAN
CO-PAYMENT
Per Prescription $5 (for Generic Drugs) $5(for Generic Drugs)
$10 for Brand Name Drugs) $10 for Brand Name Drugs)
* A$500 Pre-Certification Treatment Deductible will be applied if the Hospital confinement is not
pre-certified.
*" Maximums include In and Out-of-Network
Amendment Two
Page 6
Payment of the Administration Fee for the coverage provided by the Plan, as amended, for
coverage periods beginning on and after the effective date of this amendment, shall constitute
acceptance of the terms of this amendment by the Employer.
This amendment shall be attached to and form a part of the Plan and shall not be held to alter or
affect any of the terms of such Plan other than as specifically stated.
Dated at Round Rock, Texas,this 1 st day of March, 1997.
CITY OF ROUND ROCK
By.
Authorized Re sentative
HEALTHCARE BENEFITS, INC.
Authorized Representative
DATE: June 10. 1997
SUBJECT: City Council Meeting, June 12, 1997
ITEM: 11. G. Consider a resolution approving Amendment Number 2 to the Health Plan
Document for the City of Round Rock.
STAFF RESOURCE PERSON: Joanne Land / David Kautz
This amendment to the Health Plan document formalizes changes made as of March 1 and
includes access to the Columbia/St. David's Network, which includes Round Rock Hospital, St.
David's Hospital, Austin Diagnostic Medical Center, South Austin Medical Center, Bailey Square
Surgical Center and an additional 500 physicians.
This amendment also provides for 100% coverage of inpatient and outpatient surgeries,
diagnostic procedures, semi-private room and board, and intensive care at Round Rock Hospital
after a $250 deductible is met.