R-93-11-16-4A - 11/16/1993WHEREAS, the City of Round Rock has duly advertised for
bids for a third party administrator for a City health /dental self -
funded insurance program, and
WHEREAS, HealthCare Benefits, Inc., has submitted the lowest
and best bid, and
WHEREAS, the City Council wishes to accept the bid of
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 an agreement with HealthCare Benefits, Inc., for
a third party administrator for a City health /dental self- funded
insurance program, the terms of said agreement to be approved by
the City Manager and City Attorney.
RESOLVED this 16th day of November, 1993.
ATTEST:
I
11 141
LAND, City Secretary
KS/RESOLUTION
RS11163A
RESOLUTION NO. f ' ( 13" 1H - — c\
CHARLES CULP'PR Mayor
City of Round Rock, Texas
It is hereby agreed that the Out -of -Area Plan Document describing the provisions of the Plan
Number 1169, provided by City of Round Rock, the Plan Sponsor, is amended effective December
1, 1998 with respect to All Covered Employees, and their Covered Dependents, as follows:
The SIGNATURE PAGE, page 2, is deleted in its entirety and substituted with the following:
PLAN DOCUMENT NO.: 1169
PLAN SPONSOR: City of Round Rock
AMENDMENT NUMBER FOUR
TO THE PLAN DOCUMENT OF
CITY OF ROUND ROCK
PLAN SPONSOR'S PRINCIPAL LOCATION: Round Rock, Texas
PLAN EFFECTIVE DATE: December 1, 1993
PLAN ANNIVERSARIES: December 1, 1994 and each year thereafter
STOP LOSS CARRIER: Southland Life Insurance Company
The Plan Sponsor has established a self- funded Employee Welfare Benefit Plan pursuant to the
Employee Retirement Income Security Act of 1974, as amended, and the Plan Sponsor has
adopted this "PLAN DOCUMENT' (hereinafter "PLAN ") providing for certain medical benefits as
herein described for certain Employees and certain Dependents of such Employees of the Plan
Sponsor and other Participant Employers as herein listed.
The Plan Sponsor AGREES to pay, subject to all the provisions of this Plan, including any
amendments to this Plan, the benefits hereinafter described to the person or persons entitled to
such payments while covered hereunder.
The provisions of the following pages are a part of this Plan. Such provisions alone constitute the
agreement under which payments will be made and are a part of this "Plan" as fully as if recited
over the signatures hereto affixed.
IN WITNESS HEREOF, City of Round Rock has caused this Plan to be executed this 1st day of
December, 1998.
/nA yr,2
Title
7 -a -99
Date
WITNESSED BY:
465s7 city m, &ei
Title
Date
Amendment Number Four
Page 2
SECTION I - DEFINITIONS, page 6, is amended by the addition of the following:
Cosmetic, Reconstructive or Plastic Surgery means surgery that:
a. can be expected or is intended to improve the physical appearance of an Employee
or Dependent;
b. is performed for psychological purposes; or
c. restores form but does not correct or materially restore a bodily function.
SECTION VII - SCHEDULE OF BENEFITS, page 31, is amended by the addition of the following:
VISION CARE BENEFITS
Vision Care services are covered at 100% up to a maximum benefit of $200 per covered Person
per Calendar Year. The following services are covered:
(1) routine eye exams;
(2) Prescription lenses;
(3) Frames;
(4) Contact lenses; and
(5) Contact lens solution.
SECTION VIII - SPECIAL CONDITIONS, page 39, is amended by the addition of the following:
VISION CARE. Vision care is covered at 100% up to a maximum benefit of $200 per covered
person per Calendar Year. The following services are covered: routine eye exams, Prescription
lenses, Frames, Contact lenses and Contact lens solution.
SECTION IX - COMPREHENSIVE MEDICAL EXPENSE BENEFITS, page 45, Subsection 6,
COVERED MEDICAL EXPENSES, item af., is deleted in its entirety and substituted with the
following:
af. charges for Cosmetic, Reconstructive or Plastic Surgery are covered for the following:
a. treatment provided for the correction of defects incurred due to an Accidental Bodily
Injury sustained by the Employee or Dependent while covered under the Plan;
b. treatment provided for reconstructive surgery following cancer surgery while the
Employee or Dependent was covered under the Plan;
c. surgery performed on a newborn child for treatment or correction of a congenital
defect;
d. surgery performed on a Dependent child (other than a newborn child) under the age
of 19 for treatment or correction of a congenital defect other than conditions of the
breast; or
e. surgical reconstruction of a breast on which mastectomy surgery has been
performed or has not been performed. Surgical reconstruction of the breast means
the services or supplies necessary to restore or achieve breast symmetry.
Amendment Number Four
Page 3
SECTION VII - COMPREHENSIVE MEDICAL EXPENSE BENEFITS, page 22, Subsection,
COVERED MEDICAL EXPENSES, item 37., is deleted in its entirety and substituted with the
following:
37. charges for Cosmetic, Reconstructive or Plastic Surgery are covered for the following:
a. treatment provided for the correction of defects incurred due to an Accidental Bodily
Injury sustained by the Employee or Dependent while covered under the Plan;
b. treatment provided for reconstructive surgery following cancer surgery while the
Employee or Dependent was covered under the Plan;
c. surgery performed on a newborn child for treatment or correction of a congenital
defect;
d. surgery performed on a Dependent child (other than a newborn child) under the age
of 19 for treatment or correction of a congenital defect other than conditions of the
breast; or
e. surgical reconstruction of a breast on which mastectomy surgery has been
performed or has not been performed. Surgical reconstruction of the breast means
the services or supplies necessary to restore or achieve breast symmetry.
SECTION X- LIMITATIONS AND EXCLUSIONS APPLICABLE TO MEDICAL BENEFITS, page
47, item 9., is deleted in its entirety and substituted with the following:
9. any services provided for Cosmetic, Reconstruction or Plastic Surgery, except as provided
for under "COVERED MEDICAL EXPENSES ";
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 first day of December, 1998.
CITY OF ROUND ROCK
HEALTHCARE BENEFITS, INC.
By:/�
" . orizei epr• sentative
January 25, 1994
Linda Gunther
City of Round Rock
221 East Main
Round Rock, TX 78664
Re: Plan Document
Dear Linda:
Enclosed is the draft of your Plan Document. This Plan Document was effective December 1,
1993, and it replaces any prior Plan Documents. The Plan Document is a legal document and
should be reviewed by you and your attorney.
If there are any errors or omissions in the document, please indicate them on the enclosed copy
and return it to me. I will make the necessary changes and send you a corrected document.
If no corrections are necessary, please sign both copies of the document's signature page. One
copy of the executed signature page should be returned to our office to be placed in your
contract file, and the other should be kept with your copy of the document.
In addition, please sign the agreement below and return it to me with the executed signature
page.
Sincerely,
CA6 Querakc-.)
Jo Aldridge
Contract Specialist
JA:sb
Enclosure
I understand that the Plan Document is a legal document, and it has been reviewed by me and/or
an attorney. I understand that HealthCare Benefits, Inc. will not be held responsible for any
errors or • issions in the Plan Document.
1201 South Sherman Street, Suite 200 ❑ Richardson, Texas 75081 -4854 ❑ Telephone (214) 669.4660
Autho ' d . i. nature Title Date
A subsidiary of Blue Cross and Blue Shield of Texas, Inc.
%Q3 -i/- /6.4/,9
PLAN DOCUMENT NO.: 1169
PLANHOLDER: City of Round Rock
PLANHOLDER'S PRINCIPAL LOCATION: Round Rock, Texas
PLAN EFFECTIVE DATE: December 1, 1993
PLAN ANNIVERSARIES: December 1, 1994 and each year thereafter
STOP LOSS CARRIER: City of Round Rock
The Planholder has established a self - funded Employee Welfare Benefit Plan, and the Planholder
has adopted this "PLAN DOCUMENT" (hereinafter "PLAN ") providing for certain medical benefits
as herein described for certain Employees and certain Dependents of such Employees of the
Planholder and other Participant Employers as herein listed.
The Planholder AGREES to pay, subject to all the provisions of this Plan, including any
amendments to this Plan, the benefits hereinafter described to the person or persons entitled to
such payments while covered hereunder.
The provisions of the following pages are a part of this Plan. Such provisions alone constitute
the agreement under which payments will be made and are a part of this "Plan" as fully as if
recited over the signatures hereto affixed.
IN WITNESS HEREOF, City of Round Rock has caused this Plan to be executed this 1st day of
December, 1993.
SIGN P BY:
70.
2
WITNESSED BY:
Title
RESTATED
EMPLOYEE BENEFIT PLAN
(herein referred to as the "Plan ")
MASTER BENEFIT PLAN DOCUMENT
describing the
COMPREHENSIVE MEDICAL AND DENTAL PLAN
for the Employees of
CITY OF ROUND ROCK
This Restated Plan's
Effective Date is
December 1, 1993
Plan No. 1169
UST OF AFFILIATES OR SUBSIDIARIES
The Employees of a subsidiary or affiliated Company of the Planholder Covered under this Plan
are subject to the following conditions:
(1) Participation is not contrary to any applicable law; (2) the Planholder owns at least a majority
of the voting shares of stock and has legally enforceable control over the Corporate entity of
such Company, or the Planholder controlling financial interest in the non - corporate entity of such
Company; (3) the Company is not a fraternal group, club or organization of similar composition;
(4) the Planholder agrees to include the Company in this Plan; (5) the Planholder acts for or on
behalf of all Participants under the Plan; and (6) all such acts by the Planholder shall be binding
on the Participants.
Name of Subsidiaries
or Affiliates Effective Date
Employer Principal Location of Inclusion
City of Round Rock Round Rock, Texas December 1, 1993
3
TABLE OF CONTENTS
Page
Section I Definitions 5
Section II General Provisions 16
Section III Eligibility 18
Section IV Effective Dates of Coverage 19
Section V Termination Dates 22
Section VI Continuation of Coverage Provision 24
Section VII Schedule of Benefits 26
Section VIII Special Conditions 32
Section IX Comprehensive Medical Expense Benefits 40
Section X Limitations and Exclusions Applicable 46
to Medical Benefits
Section XI Comprehensive Dental Expense Benefits 50
Section XII Limitations and Exclusions Applicable 53
to Dental Benefits
Section XIII Dental Definitions 56
Section XIV Prescription Drug Program Benefits 59
Section XV Limitations and Exclusions Applicable 64
to Prescription Drug Program
Section XVI Claims 66
Section XVII Coordination of Benefits Provision 69
Section XVIII Additional Provisions as a Result 73
of Medicare /Medicaid
Section XIX Miscellaneous Medical Expense Provision 75
Section XX ERISA Information 77
4
SECTION I - DEFINITIONS
In this Plan:
1. Accidental Bodily Injury means only a bodily injury sustained accidentally and independently
of all other causes by an outside traumatic event or due to exposure to the elements, and
a non - occupational injury, as defined.
2. Actively at Work means the Employee is performing all the regular duties of his occupation
at an established business location of the Employer or another location to which he may
be required to travel to perform the duties of his employment. An Employee shall be
deemed actively at work on normal holidays or vacation days of the Employer if the
Employee is not totally disabled and if the Employee was "actively at work" on the last
preceding regular work day. In no event, will an Employee be considered actively at work
if he is not physically able to perform all of the regular duties of his employment or if he has
effectively terminated employment.
3. Alcohol Abuse Condition means a condition which is primarily alcoholism and is certified
to be such by a licensed Physician who is qualified to treat the condition.
4. Audiologist means a person who has received a master's or doctorate degree in audiology
from an accredited college or university and who is certified by the American
Speech- Language and Hearing Association. In states where there is a licensure
requirement, the Audiologist must be licensed by the appropriate state administrative
agency.
5. Calendar Year shall mean the period beginning on January 1st and ending on December
31st of each year. -
6. Certified Social Worker Advanced Clinical Practitioner means a person who is certified by
the Texas Department of Human Resources as a Certified Social Worker with the order of
recognition of Advanced Clinical Practitioner.
7. Claims Administrator means HealthCare Benefits, Inc.
8. Clinical Ecology means the inpatient or outpatient treatment of allergic symptoms by:
a. cytotoxicity testing (testing the result of food or inhalant by whether or not it reduces
or kills white blood cells);
b. urine auto injection (injecting one's own urine into the tissue of the body);
c. skin irritation by Rinkel method;
d. subcutaneous provocative and neutralization testing (injecting the patient with
allergen);
e. sublingual provocative testing (droplets of allergenic extracts are placed in mouth);
or
f. any other treatment not recognized as safe and effective by the American Academy
of Allergists and Immunologists.
9. Complications of Pregnancy means:
a. conditions requiring Hospital confinement (when the pregnancy Is not terminated)
whose diagnoses are distinct from pregnancy but are adversely affected by
pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac
decompensation, missed abortion and similar medical and surgical conditions of
comparable severity, but shall not include false labor, occasional spotting, Physician
prescribed rest during the period of pregnancy, morning sickness, hyperemesis
gravidarum, pre - eclampsia and similar conditions associated with the management
5
SECTION I - DEFINITIONS
of a difficult pregnancy, not constituting a nosologically distinct complication of
pregnancy; and
b. non - elective Cesarean section, ectopic pregnancy which is terminated and
spontaneous termination of pregnancy which occurs during a period of gestation in
which a viable birth is not possible.
10. Coordination of Benefits means a process by which two (2) or more group medical plans
covering the same person limit the aggregate benefits provided by all coverages to an
amount which does not exceed one hundred percent (100%) of the Allowable Expenses.
11. Covered Expenses means that coverage is provided only for any service or supply which
is necessary, meaning that it is broadly accepted professionally as essential to the
treatment of the disease or injury. Only that part of a charge which is reasonable is
covered. The reasonable charge for a service or supply is the lesser of (a) the charge
usually made for it by the provider who furnished it; and (b) the prevailing charge made for
it, in the same geographic area, by those of similar professional standing. Charges
incurred outside the United States or its territories will be calculated based on the usual and
customary fees applicable to the area in which the claims paying office is located. If usual
and prevailing charges for a service or supply cannot be determined because of the
unusual nature of the service or supply, the Plan Administrator will determine to what extent
the charge is reasonable, taking into account (a) the complexity Involved; (b) the degree
..of professional skill required; and (c) other pertinent factors. In the case of multiple
surgeries through the same incision or operative area for which there is not a unique single
reasonable charge, the reasonable charge for all procedures combined will be an amount
equal to the highest single procedures reasonable charge for the procedures performed
plus one -half (1/2) of the reasonable charge for each of the other procedures.
12. Covered Person means an eligible Employee or eligible Dependent who is covered
hereunder.
13. Custodial Care means care which consists of services and supplies, including room and
board and other institutional services, furnished to an individual primarily to assist him in
activities of daily living, whether or not he is disabled. These services and supplies are
Custodial Care regardless of the Physician or provider who prescribed, recommended or
performed them.
14. Deductible means the amount of Covered Expense that must be incurred by an Employee
and /or Dependent before benefits become payable by this Plan.
15. Dependent means one (1) or more of the following person(s):
a. an Employee's lawful licensed spouse (not divorced or legally separated);
b. an Employee's unmarried child or children who are less than nineteen (19) years of
age;
c. an Employee's unmarried child or children who are more than nineteen (19) years of
age but less than twenty -five (25) years of age, who are dependent upon the
Employee for support and who are full -time students at an accredited high school,
junior college, college, university or a licensed trade school. With respect to a junior
college, college or university, full -time attendance requires enrollment for credit of at
least twelve (12) hours per semester. With respect to a licensed trade school, full -time
attendance requires enrollment in a course requiring at least six (6) months to
complete and attendance of at least twenty (20) hours per week. If a Covered
Dependent, whose eligibility is based on his continuous attendance In an accredited
school as a full -time student, becomes ineligible because of failure to enroll as a
6
SECTION I - DEFINITIONS
full -time student, he will again become eligible to be a Covered Dependent on the
date he enrolls as a full -time student. However, in no event will a Dependent who has
enrolled as a full -time student again become eligible if such Dependent has not been
a full -time student for twelve (12) months or longer, until the date the Planholder
approves an Evidence of Good Health as it may require, without expense to the
Planholder; and
d. an Employee's unmarried child or children who were continuously covered prior to
attaining the limiting age under b. or c., above, who are mentally or physically
incapable of sustaining their own living and are still primarily dependent upon the
Employee for support. Such child or children must have been mentally or physically
incapable of earning their own living prior to attaining the limiting age under b. or c.,
above. Written proof of such incapacity and dependency, satisfactory to the
Planholder, must be furnished and approved by the Planholder within thirty -one (31)
days of the date the child or children have attained the limiting age of b. or c., above.
The Planholder may require at reasonable intervals, subsequent proof satisfactory to
the Planholder during the next two (2) year period following such date. After such two
(2) year period, the Planholder may require such proof, but not more often than once
each year.
The word "child" means, in addition to the Employee's own or lawfully adopted child, any
stepchild or any other child who for whom the Employee has obtained legal guardianship
and who resides with and who is dependent upon the Employee for more than one half of
his support, as defined by the Internal Revenue Code of the United States.
For the purpose of this Plan, the definition of Dependent does not include any person who
is a member of the armed forces of any country.
The Planholder reserves the right to require whatever documentation necessary to establish
such defined Dependent(s) satisfactorily to the Planholder.
An Employee may elect to be covered only as an Employee or as a Dependent, but not
both simultaneously. If and when a Covered Person terminates under the Plan as an
Employee or Dependent, such person shall have a right to continue coverage under either
definition which applies.
16. Dependent Coverage means an Employee's coverage under the Plan with respect to his
Dependents.
17. Dietary and Nutritional Services means the education, counseling or training of a Covered
Person (including printed material) regarding (a) diet, (b) regulation or management of diet,
or (c) the assessment or management of nutrition.
18. a. Drug means insulin and prescription legend drugs. A legend drug is (1) a Federal
Legend Drug - any medicinal substance which bears the legend, "Caution: Federal
law prohibits dispensing without a prescription," or (b) a State Restricted Drug - any
medicinal substance which may be dispensed by prescription only, according to state
law, and which is legally obtained from a licensed drug dispenser only upon a
prescription of a currently licensed Physician.
b. Generic Drug means a drug called by its chemical name. The brand name of any
drug is given to it by its original developer and is registered and protected under U.S.
SECTION I - DEFINf17ONS
by:
Patent and Copyright laws. When the patent expires on a drug, a generic equivalent
may be manufactured and sold as long as the Food and Drug Administration is
satisfied that the generic drug will have the same effectiveness as the brand name.
No generic drug is substituted for a brand name drug without a Physician's
authorization on the prescription.
19. Drug Abuse Condition means a condition which is primarily drug dependency and is
certified to be such by a licensed Physician qualified to treat the condition.
20. Durable Medical Equipment is equipment which (a) can withstand repeated use, (b) is
primarily and customarily used to serve a medical purpose, (c) generally is not useful to a
person in the absence of an illness or injury, and (d) is appropriate for use in the home.
All requirements of the definition must be met before an item can be considered to be
Durable Medical Equipment.
21. Effective Date means the date this Plan took effect, shown as the "Plan Effective Date" on
the cover page of this Plan, with respect to the Planholder. The "Effective Date" with
respect to any Participant Employers means the "Effective Date of Inclusion" for such
Participant Employer as shown on the "LIST OF AFFILIATES OR SUBSIDIARIES."
22. Emergency Care means services are rendered for the sudden onset of a medical condition
manifesting Itself by acute symptoms of sufficient severity that the absence of immediate
medical attention could reasonably result in:
a. permanently placing the Employee's and /or Dependent's health in jeopardy;
b. serious impairment of bodily functions;
c. serious and permanent dysfunction of any bodily organ or part; or
d. other serious medical consequences.
23. Employee means a person who is an active permanent full -time or part-time employee of
the Employer, who is regularly scheduled to work for the Employer in an
employee - employer relationship. The Director(s) of a Corporate Employer shall not be
deemed an Employee solely because of such directorship. Independent contractors and
any other such person(s) not considered an employee of the Planholder shall not be
deemed an Employee for the purpose of the Plan. An Employee must be scheduled to
work at least forty (40) hours per week for the Employer in order to be defined as a "full -
time" Employee or thirty (30) hours per week in order to be defined as a "part-time"
Employee.
24. Employer means the Planholder and any Participant Employers as defined herein.
25. Environmental Sensitivity means the inpatient or outpatient treatment of allergic symptoms
a. controlled environment;
b. sanitizing the surroundings, removal of toxic materials; or
c. use of special nonorganic, nonrepetitive diet techniques.
26. Evidence of Good Health means all medical information necessary for the Planholder to
determine that an Employee or Dependent is in good health and is eligible for coverage
under the Plan.
27. Experimental/Investigational means the use of any treatment, procedure, facility, equipment,
drug, device or supply not accepted as standard medical treatment of the condition being
treated, or any such items requiring Federal or other governmental agency approval not
8
SECTION I - DEFINfIIONS
granted at the time services are rendered. As used herein, "medical treatment' includes
medical, surgical or dental treatment. "Standard medical treatment" means the services or
supplies are in general use in the medical community in the United States, have been
demonstrated in peer reviewed literature to have scientifically established medical value for
alleviating, curing or improving the condition being treated, are appropriate for the Hospital
or Facility Other Provider in which they were performed, and the Physician or Professional
Other Provider had the appropriate training and experience to render the treatment or
procedure.
The Plan Administrator shall determine whether any treatment, procedures, facility,
equipment, drugs, devices or supplies are Experimental/Investigational and will consider the
guidelines and practices of Medicare, Medicaid and other government- financed programs
in making its determination. Although a Physician or Professional Other Provider may have
prescribed treatment, and the services or supplies may have been provided as the
treatment of last resort, the Plan Administrator still may determine such services or supplies
to be Experimental /Investigational within this definition.
28. Family and Medical Leave Act of 1993 requires employers with fifty (50) or more employees
to provide twelve (12) weeks of unpaid, approved leave due to the adoption or birth of a
child, to care for a spouse, child or parent with a serious medical condition, or because of
an employee's serious medical condition.
29. Generic Substituted Drug means a drug which costs less than the brand name drug
prescribed but is pharmaceutically and therapeutically equivalent to the brand name drug
prescribed.
30. Home Health Care Agency means a state licensed agency which is primarily engaged in
furnishing home nursing care and other therapeutic services in the home and which fully
meets each of the following requirements:
a. it is duly licensed, if such licensing is required, by the appropriate licensing authority
to provide skilled nursing and other therapeutic services;
b. it has its policies established by a professional group associated with the agency or
organization. This professional group must include at least one (1) Physician and at
least one (1) Registered Nurse (R.N.) to govern the services provided for full -time
supervision of such services by a Physician or Registered Nurse (R.N.);
c. it maintains a complete medical record on each individual; and
d. it has a full -time administrator.
31. Home Infusion Therapy means the administration of fluids, nutrition or medication (including
all additives and chemotherapy) by intravenous or gastrointestinal (enteral) infusion or by
intravenous injection in the home setting. Home Infusion Therapy shall include:
a. drugs and I.V. solutions;
b. pharmacy compounding and dispensing services;
c. all equipment and ancillary supplies necessitated by the defined therapy;
d. delivery services;
e. patient and family education; and
f. nursing services.
9
SECTION I - DEFINITIONS
Over- the - counter products which do not require a Physician's prescription, including but
not limited to standard nutritional formulations used for enteral nutrition therapy, are not
included within this definition.
32. Hospice means a licensed or certified agency that provides counseling and incidental
medical services, and may provide room and board to a terminally ill individual.
33. Hospital means a short-term acute care facility which:
a. is duly licensed as a hospital by the state in which it is located and meets the
standards established for such licensing, and is either accredited by the Joint
Commission on Accreditation of Health Care Organizations or is certified as a hospital
provider under Medicare;
b. Is primarily engaged in providing inpatient diagnostic and therapeutic services for the
diagnosis, treatment, and care of injured and sick persons by or under the supervision
of Physicians for compensation from its patients;
c. has organized departments of medicine and major surgery and maintains clinical
records on all patients;
d. provides twenty -four (24) hour nursing services by or under the supervision of
Registered Nurses; and
e. is not, other than incidentally, a skilled nursing facility, nursing home, custodial care
home, health resort, spa or sanitarium, place for rest, place for the aged, place for the
treatment of alcohol abuse or drug abuse, hospice, place for the provision of
rehabilitative care, or a place for the treatment of pulmonary tuberculosis.
Hospital shall also mean, for the purpose of rehabilitation treatment, a free - standing
inpatient acute rehabilitation facility that is accredited by the Certified Accredited
Rehabilitation Facilities (CARF) or outpatient rehabilitation facility accredited by the Certified
Outpatient Rehabilitation Facilities (CORF). Sub -acute care facilities are not Included in this
definition.
Hospital shall also mean, for the purpose of alcohol or drug dependency treatment, a
facility or institution which provides a multi- disciplinary program for the treatment of alcohol
or other drug dependency pursuant to a written treatment plan approved and monitored
by a Physician, and which facility is also:
a. accredited as such a facility by the Joint Commission on Accreditation of Hospitals
sponsored by the A.M.A. and A.H.A.; •
b. affiliated with a Hospital, as defined above, under a contractual agreement with an
established system for patient referral;
c. licensed as an alcohol treatment program by the Texas Commission on Alcohol and
Drug Abuse, or the equivalent agency of another state, if any; and
d. certified as a drug dependency treatment program by the Texas Commission on
Alcohol and Drug Abuse in accordance with such standards, if any, as may be
adopted pursuant to subsection (c) of section 5.12 of the Texas Controlled Substance
Act, by the Executive Director of the Texas Commission on Alcohol and Drug Abuse.
For the purpose of this definition, Ambulatory Surgical Center shall mean, any public or
private state licensed and approved (whenever required by law) establishment with an
organized medical staff of Physicians, with permanent facilities that are equipped and
10
SECTION I - DEFINfIIONS
operated primarily for the purpose of performing surgical procedures and with continuous
Physician services and registered professional nursing services whenever a patient is in the
facility, and which does not provide service or other accommodations for patients to stay
overnight.
34. Hospital Admission means the period between the time of a Covered Person's entry into
a Hospital or Substance Abuse Facility as a bed patient, and the time of discontinuance of
bed patient care or discharge by the Physician, whichever occurs first. The day of entry,
but not the day of discharge or departure, shall be considered in determining the length of
a Hospital Admission. If a patient is admitted to and discharged from a Hospital within a
twenty -four (24) hour period, but is confined as a bed patient in a bed accommodation
during the period of time he is in the Hospital, the admission shall be considered a Hospital
Admission. "Bed Patient" means confinement in a bed accommodation of a Substance
Abuse Facility on a twenty -four (24) hour basis, or in a bed accommodation located in a
portion of a Hospital which is designed, staffed and operated to render acute, short-term
hospital care on a twenty-four (24) hour basis; the term does not include confinement in
a portion of the Hospital (other than a Substance Abuse Facility) designed, staffed and
operated to provide long -term institutional care on a residential basis.
35. Identification Card means the Prescription Drug Program Card issued to the Covered
Employee indicating pertinent information applicable to the coverage, including appropriate
Co- payment Amounts.
A 36. Incurred Date means the date on which a particular service or supply, which gives rise to
the expense or charge, is rendered or obtained.
37. Injury (or Non - Occupational Injury) means only Accidental Bodily Injury which does not arise
out of, and which is not caused by or contributed to or as a consequence of, any injury
which arises out of or in the course of any employment or occupation for compensation or
profit.
38. Intensive Care Unit or Cardiac Care Unit means only a separate, clearly designated service
area which is maintained within a Hospital and which meets all of the following tests:
a. it is solely for the treatment of patients who require special medical attention because
of their critical condition;
b. It provides within such area special nursing care and observation of a continuous and
constant nature not available in the regular rooms and wards of the Hospital;
c. it provides a concentration of special life- saving equipment immediately available at
all times for the treatment of patients confined within such area;
d. it contains at least two (2) beds for the accommodation of critically ill patients; and
e. it provides at least one (1) professional registered nurse who continuously and
constantly attends the patient confined in such area on a twenty -four (24) hour a day
basis.
39. Leave of Absence means the Employee has obtained an approved leave of absence from
the Employer as provided for in the Employer's company rules, policies, procedures and /or
practices.
40. Legend Drugs means drugs, biologicals, or compounded prescriptions which are required
by law to have a label stated "Caution- Federal Law Prohibits Dispensing Without a
Prescription," and which are approved by the U.S. Food and Drug Administration (FDA) for
a particular use or purpose.
11
SECTION I - DEFINmONS
41. Licensed Dietician means a person who is licensed by the Texas State Board of Examiners
of Dieticians. In states where there is a licensure requirement, the Licensed Dietician must
be licensed by the appropriate state administrative agency.
42. Licensed Professional Counselor means a person who is licensed by the Texas State Board
of Examiners of Professional Counselors. In states where there is a licensure requirement,
the Licensed Professional Counselor must be licensed by the appropriate state
administrative agency.
43. Medical Social Services means those social services relating to the treatment of a patient's
medical condition. Such services include, but are not limited to (a) assessment of the
social and emotional factors related to the patient's sickness, need for care, response to
treatment and adjustment to care; and (b) assessment of the relationship of the patient's
medical and nursing requirements to the home situation, financial resources and available
community resources.
44. Medically Necessary or Medical Necessity means those services or supplies covered
hereunder which are:
a. essential to, consistent with, and provided for the diagnosis or the direct care and
treatment of the condition, sickness, disease, injury or bodily malfunction;
b. consistent with standards of good medical practice;
c. not primarily for the convenience of the Employee and/or Dependent, the Physician,
or any other supplier;
d. the most economical supplies or levels of service that are appropriate for the safe and
effective treatment of the Employee and /or Dependent. When applied to
hospitalization, this further means that the Employee and /or Dependent requires acute
care as a bed patient due to his condition or due to the nature of the services
rendered and the Employee or Dependent cannot receive safe or adequate care as
an outpatient; and
e. not Experimental in nature at the time services or supplies are provided.
In determining Medical Necessity, the Plan Administrator may consider the views of the
state and national medical communities and the views and practices of Medicare, Medicaid
and other government - financed programs. Although a Physician may have prescribed
treatment, such treatment may not be Medically Necessary within this definition.
45. Mental or Nervous Disorder means a mental /emotional disease or disorder of any kind.
46. Nonparticipating Pharmacy means a Pharmacy which has not entered into an agreement
to provided a prescription drug benefits to Participants covered under the Plan.
47. Other Provider means a person or entity, other than a Hospital or Physician, that is licensed
where required to furnish to a Covered Person an item of service or supply described
herein as Covered Expenses. ''Other Provider" shall include:
a. Facility Other Provider - an institution or entity, only as listed:
(1) Crisis Stabilization Unit or Facility
(2) Home Health Agency
(3) Home Infusion Therapy Provider
(4) Hospice
(5) Psychiatric Day Treatment Facility
(6) Residential Treatment Center for Children and Adolescents
12
SECTION I - DEFINmONS
(7) Skilled Nursing Facility
(8) Substance Abuse Facility
(9) Therapeutic Center
b. Professional Other Provider - a person or practitioner, when acting within the scope
of his license and who is appropriately certified, only as listed:
(1) Audiologist
(2) Certified Social Worker - Advanced Clinical Practitioner
(3) Doctor of Chiropractic
(4) Doctor of Dentistry
(5) Doctor of Optometry
(6) Doctor of Podiatry
(7) Doctor of Psychology
(8) Licensed Dietician
(9) Speech - Language Pathologist
(10) Licensed Professional Counselor
48. Participant Employer means an Employer included in the "LIST OF AFFILIATES OR
SUBSIDIARIES."
49. Participating Pharmacy means an independent Pharmacy or a chain of Pharmacies which
has contracted to provided Pharmacy services to Participants covered under the Plan.
50. Personal Coverage means an Employee's coverage under this Plan with respect to himself.
51. Physician means a person, when acting within the scope of his license (other than a
Hospital resident or intern), who is a Doctor of Medicine (M.D.) or Doctor of Osteopathy
(D.O.). Such terms shall have the meaning assigned to them by the Texas Insurance Code.
52. Plan Administrator means the Employer.
53. Plan Month means a period commencing on the first day of any calendar month and
continuing until the same day of the next succeeding calendar month.
54. Plan Year means a period commencing on the Effective Date or any anniversary of the Plan
and continuing until the next succeeding anniversary.
55. Planholder means City of Round Rock.
56. Pre - Admission Testing includes preliminary x -ray and laboratory tests performed prior to
outpatient surgery, or in advance of a Hospital Admission involving surgery.
57. Pre-Existing Condition means any abnormal physical or mental condition, whether active
or inactive, including pregnancy, for which an Employee and /or Dependent was seen or
treated by a Physician during the twelve (12) month period immediately preceding the
effective date of coverage hereunder, including all deformities, ailments or prior injuries
which may thereafter become aggravated by subsequent injury.
58. Pregnancy shall include resulting childbirth, miscarriage or non - elective abortion, except
"Complications of Pregnancy" arising therefrom as defined herein.
59. Prescription Order means a written or verbal order from a Practitioner to a pharmacist for
a drug or device to be dispensed. Orders written by any Practitioners located outside the
United States to be dispensed in the United States are not covered under the Plan.
60. Prior Plan means the plan of medical benefits In effect for the Employees of the Planholder
prior to the Effective Date shown on the cover page of this Plan.
61. Prosthetic Appliances mean artificial devices which replace all or part of an absent body
organ (including contiguous tissue), or replace all or part of the function of a permanently
13
SECTION I - DEFINMONS
inoperative or malfunctioning body organ (excluding dental appliances and replacement of
cataract lenses).
62. Psychiatric Day Treatment Facility means an institution, other than a Hospital or Substance
Abuse Facility, which is appropriately licensed and accredited, to provide treatment for
individuals suffering from acute Mental and Nervous Disorders in a structured psychiatric
program which utilizes individualized treatment plans with specific attainable goals and
objectives appropriate to the patient and the treatment modality of the program, and which
is clinically supervised by a Doctor of Medicine (M.D.) who is certified in Psychiatry by the
American Board of Psychiatry and Neurology.
63. Room and Board means the Hospital's charge for:
a. room and linen service;
b. dietary service including meals, special diets and nourishments; and
c. general nursing service.
64. Second Surgical Opinion means a Physician's evaluation of the need for surgery which has
been recommended by another Physician.
65. Sickness or Illness (or Non - occupational Disease) means a disease which does not arise
out of, and which is not caused or contributed to by, or as a consequence of, any disease
which arises out of or in the course of any employment or occupation for compensation or
profit; however, if evidence satisfactory to the Planholder is furnished showing that the
Individual concerned is covered as an employee under any worker's compensation law,
occupational disease law or any other legislation of similar purpose, or under the Maritime
Doctrine of Maintenance, Wages and Cure, but that the disease involved is not covered
under the applicable law or doctrine, then such disease shall be regarded as a
"Non - occupational Disease" for the purpose of this Plan.
66. Skilled Nursing Facility means a duly licensed institution meeting the conditions of
participation for a Skilled Nursing Facility under Medicare, Title XVII, of the Federal Social
Security Act, as enacted and amended. Skilled Nursing Facility Confinement means a
continuous uninterrupted period of confinement to a Skilled Nursing Facility, as a registered
bed patient, for one (1) period of disability. In determining when one (1) period of disability
ends and a new one (1) begins, all Skilled Nursing Facility Confinements are considered
as having occurred during one (1) continuous period of disability unless acceptable
evidence is furnished that:
a. the latest Hospital confinement is due to causes entirely unrelated to the causes of
all previous confinements; or
b. for a related cause, the Employee has returned to work on a full -time basis for at least
one (1) full day (or the Employee's Dependent, if he is the individual concerned, has
been free of Hospital confinement for at least ninety (90) days).
67. Speech - Language Pathologist means a person who has received a master's or doctorate
degree in speech pathology from an accredited college or university, and who is certified
by the American Speech - Language and Hearing Association. In states where there is a
licensure requirement, the Speech - Language Pathologist must be licensed by the
appropriate state administrative agency.
68. Substance Abuse Facility means an institution appropriately licensed, and is a psychiatric
Hospital or rehabilitation Hospital approved by the Joint Commission on Accreditation of
Hospitals.
14
SECTION I - DEFINfIIONS
69. Surgical Procedure means:
a. the incision, excision, debridement or cauterization of any organ or part of the body,
and the suturing of a wound;
b. the manipulative reduction of a fracture or dislocation, or the manipulation of a joint
under general anesthesia, including application of a cast or traction;
c. the removal by endoscopic means of a stone or other foreign object from any part of
the body, or the diagnostic examination by endoscopic means of any part of the
body; _
d. the induction of artificial pneumothorax and the injection of sclerosing solutions;
e. arthrodesis, paracentesis, arthrocentesis and all injections into the joints or bursa;
f. obstetrical delivery, and dilatation and curettage; and
g. biopsy.
70. Total Disability means:
a. the complete inability of an Employee covered under the Plan to perform any and
every duty incident to the occupation in which the Employee was engaged
immediately prior to such total disability; or
b. with respect to a Dependent, the inability of the person to engage in the normal
occupational, domestic or social activities of a person of like age and sex who is in
good health.
A Covered Employee or Dependent with such a Total Disability shall be considered Totally
Disabled.
15
SECTION II - GENERAL PROVISIONS
1. THE PLAN
a. Entire Contract. The Plan and the applications of the Covered Persons, constitute the
entire contract of coverage under the Plan between the Planholder and the Covered
Persons.
b. Plan Description. The Planholder shall provide to Employees who are Covered
Persons, a Summary Plan Description containing the benefits of the Plan and the
rights and obligations of Covered Persons under the Plan.
c. Changes to Plan. The Plan may be changed by the execution of an amendment to
the Plan by the Planholder, at any time, without prior notice to or the consent of any
Covered Employee, or of any person entitled to receive payment of benefits under the
Plan. The Planholder shall provide to the Covered Employees, a summary of any
material change to the Plan, within two hundred and ten (210) days after the end of
the Plan Year in which the change is adopted.
d. Effect of Changes. All changes to the Plan shall become effective as of a date
established by the Planholder, EXCEPT that:
(1) no increase or reduction in benefits shall be effective, with respect to Covered
Expenses incurred prior to the date a change was adopted by the Planholder,
regardless of the effective date of the change; and
(2) no change shall become effective, with respect to any Covered Person who was
disabled on the effective date of such change, until the date such person
ceases to be disabled, and in the case of a Covered Employee, until such
Covered Employee is actively at work.
e. Termination of Plan. The Planholder may terminate the Plan at any time by providing
written notice to the Covered Employees. Such termination will become effective on
the date set forth in such notice.
f. Written Notice. Any written notice required under the Plan shall be deemed received
by a Covered Employee if sent by regular mail, postage prepaid, to the last address
of such Covered Employee on the records of the Planholder.
g. Texas Law. This Plan shall be interpreted and construed under the laws of the State
of Texas.
h. Waiver. The failure to strictly enforce any provision of the Plan shall not be construed
as a waiver of the provision. Rather, the right is reserved to strictly enforce each and
every provision of the Plan at any time, regardless of the prior conduct, and
regardless of the similarity of the circumstances or the number of prior occurrences.
i. Clerical Error /Delay. Clerical errors made on the records of the Employer, and delays
in making entries on such records, shall not invalidate coverage or cause coverage
to be in force or to continue in force. Rather, the effective dates of coverage shall be
determined solely in accordance with the provisions of the Plan, regardless of whether
any contributions with respect to Covered Person has been made, or have failed to
be made because of such errors or delays. Upon discovery of any such error or
delay, an equitable adjustment of any such contributions will be made.
j. Worker's Compensation. This Plan is not instead of, and does not affect any
requirement for coverage by worker's compensation insurance.
k. Gender. The use of masculine pronouns in the Plan shall apply to persons of both
sexes unless the context clearly indicates otherwise.
16
SECTION II - GENERAL PROVISIONS
I. Headings. The headings used in the Plan are for the purpose of convenience of
reference only. Covered Persons are advised not to rely on any provision because
of the heading. In all cases, the full text of the Plan Document will control.
m. Free Choice of Physician. Any Employee or Dependent covered hereunder will have
free choice of his Physician.
2. STATEMENTS
a. Not Warranties. Statements made by or on behalf of any person to obtain coverage
under the Plan shall be deemed representations and not warranties.
b. Misstatements on Application. If any relevant fact has been misstated by or on behalf
of any person to obtain coverage under the Plan, the true facts shall be used to
determine whether coverage is in force and the extent, if any, of such coverage.
Upon the discovery of any such misstatement, an equitable adjustment of any
contributions will be made.
c. Time limit for Misstatement. No misstatement made to obtain coverage under the
Plan shall be used to void the coverage of any person which has been in force for a
period of two (2) years, or to deny a claim for a loss incurred or disability
commencing after the expiration of such two (2) year period. The provisions of this
paragraph shall not apply if any such misstatement has been made fraudulently.
d. Use of Statements. No statement made by or on behalf of any person, shall be used
in any contest unless a copy of the written Instrument containing such statement has
been or is furnished to such person, or to any person claiming a right to receive
benefits with respect to such person.
17
SECTION III - ELIGIBILITY
1. ELIGIBLE CLASSES
All Employees of the Planholder and its Affiliates or Subsidiaries, as defined in section I
entitled "DEFINITIONS" are eligible for coverage under the Plan, subject to the following
classifications:
Classification Eligibility Period
Class I All Active Permanent eligible on the first of the month
Full -time and Part-Time following the date of employment
Employees
All full-time Employees regularly scheduled to work at least forty (40) hours per week are
eligible for coverage under the Plan. All part-time Employees regularly scheduled to work
— at least thirty (30) hours per week are eligible for coverage under the Plan.
If an Employee is hired on the first of the month, coverage shall be effective on the first of
the following month.
Each Employee who was covered under the Prior Plan, if any, will be eligible on the
Effective Date of this Plan. Any eligibility period or portion thereof satisfied under the Prior
Plan, if any, will be applied toward satisfaction of the eligibility period of this Plan.
2. ELIGIBILITY DATE
a. Personal Coverage
Each Employee will become eligible for coverage under the Plan on the day he
completes the eligibility period, if any, specified above. •
Each Employee who was covered under the Prior Plan, if any, will be eligible on the
Effective Date of this Plan. Any eligibility period or portion thereof satisfied under the
Prior Plan, if any, will be applied toward satisfaction of the eligibility period of this
Plan.
b. Each Employee will become eligible for the Dependent Coverage applicable to his
class on the latest of the following dates:
(1) the date of his eligibility for Personal Coverage;
(2) the date Dependent Coverage first becomes available under any amendment to
the Plan, if such Dependent Coverage was not provided under the Plan on the
Plan Effective Date; or
(3) the first date upon which he acquires a Dependent
In no event will any dependent child, as defined in the Plan, be covered as a
Dependent of more than one (1) Employee who is covered under the Plan.
18
SECTION IV - EFFECTIVE DATES OF COVERAGE
1. CONTRIBUTION BASIS
a.
b.
Contributory/Non - Contributory
(1) Personal Coverage
The Personal Coverage for which a full -time Employee is eligible is non-
contributory.
The Personal Coverage for which a part-time Employee is eligible is contributory.
(2) Dependent Coverage
The Dependent Coverage for which an Employee is eligible is contributory.
(3) COBRA Coverage
The COBRA Coverage for which an Employee is eligible is contributory.
Contribution Rate Structure
Contributions to this Plan, if applicable, will be based on the following classifications:
Employee Only Medical
Employee Only Dental
Employee Only Medical and Dental
Employee /Family Medical
Employee /Family Dental
Employee /Family Medical and Dental
Employee /Spouse Medical
Employee /Spouse Dental
Employee /Spouse Medical and Dental
Employee /Children Medical
Employee /Children Dental
Employee /Children Medical and Dental
2. EFFECTIVE DATES
(1)
(2)
(3)
19
COBRA Employee Only Medical
COBRA Employee Only Dental
COBRA Employee Only Medical and Dental
COBRA Employee /Family Medical
COBRA Employee /Family Dental
COBRA Employee /Family Medical and Dental
COBRA Employee /Spouse Medical
COBRA Employee /Spouse Dental
COBRA Employee /Spouse Medical and Dental
COBRA Employee /Children Medical
COBRA Employee /Children Dental
COBRA Employee/Children Medical and Dental
Coverage, for which an Employee is eligible under the Plan, will become effective on the
date specified below, subject to the conditions in subsection 4. of this section:
a. Coverage, Personal or Dependent, must be requested by the Employee on a form
furnished by the Planholder. When so requested, such coverage will become effective
as follows:
on the date the Employee becomes eligible provided the enrollment form is
received by the Employer on or before such date;
on the date the enrollment form is received by the Employer, provided it is within
thirty -one (31) days of the date of eligibility; or
If the request for coverage is made (i) more than thirty-one (31) days after the
date the Employee is eligible or (ii) after the coverage was voluntarily terminated
at the Employee's request, coverage will become effective following the
Employer's annual enrollment period and following the date Evidence of Good
Health statements are completed, if required, at no expense to the Employer,
and have been submitted and approved.
SECTION IV - EFFECTIVE DATES OF COVERAGE
3. ANNUAL ELECTION, REJECTION AND WITHDRAWAL OF COVERAGE
City of Round Rock has designated the month of November as annual enrollment period
during which Employees may enroll for coverage, make changes to coverage or withdraw
from the Plan. The coverage elected by an Employee may not be changed, except during
an annual enrollment period, unless this is a change in family status due to marriage,
divorce, death, birth, adoption, spouse's loss of employment or any other events the
Planholder determines will permit a change or revocation of an election. Any change in
family status must be reported to the Employer within thirty -one (31) days of the event
which caused the change. Evidence of Good Health approval is not required for changes
in family status due to marriage, divorce, death, birth, adoption, spouse's loss of
employment or spouse's employer eliminating health insurance.
If the Employee does not complete and return a new election form prior to December 1st
each year, the Employee will be treated as having elected to continue the benefit coverage
then in effect, for the following year.
4. CONDITIONS
a. If the Employee is not actively at work because of Sickness or Injury on the date his
Personal Coverage would otherwise become effective, the Employee's coverage will
not become effective until the first day he returns to active work.
b. If a Dependent is confined in a Health Care Facility or at home under medical care on
the date on which Dependent Coverage would otherwise become effective with
respect to such Dependent, coverage for such Dependent will not become effective
until the day following the date of discharge from the Health Care Facility or until the
Dependent is able to carry on the normal duties of a person in good health who is the
same sex and approximate age. Such deferral of coverage will not apply to a child
born while the Employee is covered hereafter. If a dependent child is born after the
effective date of an Employee's Personal Coverage hereunder, coverage shall take
effect from and after the moment of birth, to the extent of the benefits provided herein,
and any limitations of this Plan with respect to Pre - Existing Conditions or Congenital
defects shall not apply to such child. Coverage for such child shall continue for
thirty-one (31) days. After the thirty-one (31) day period, coverage shall continue only
if the Employee makes written application to the Employer for such child and agrees
to make any required contributions. For the purpose of this section, a Health Care
Facility is any institution providing mental or physical health care on an inpatient
basis.
c. If an Employee acquires a Dependent while the Employee is covered for Dependent
Coverage, coverage for the newly acquired Dependent shall be effective on the date
the Dependent becomes eligible provided application is made to the Employer within
thirty-one (31) days of the eligibility date and any required contributions are made.
d. Any reference in the Plan to an Employee's Dependent being covered means that
such Employee is covered for Dependent Coverage, except as may be provided
under b., above.
e. No Dependent Coverage will become effective for an Employee unless he is, or
simultaneously becomes, covered for Personal Coverage.
f. An Employee applying for Dependent Coverage under the Plan must apply for
coverage for all of his eligible dependents.
20
SECTION IV - EFFECTIVE DATES OF COVERAGE
g. If an Employee specifically declines coverage, Personal or Dependent, and at a later
date such Employee requests to be covered hereunder, such coverage, Personal or
Dependent, will become effective on the first of the month following the Employer's
annual enrollment period and following the date Evidence of Good Health statements
have been completed, if required, at no expense to the Employer, and have been
submitted and approved. Evidence of Good Health will not be required if the request
for coverage is due to marriage, divorce, birth, adoption, spouse's loss of employment
or spouse's employer eliminating health insurance if such change is requested within
thirty -one (31) days of the qualifying event.
h. Any Employee who must furnish Evidence of Good Health as a condition to becoming
covered for Personal or Dependent Coverage, and whose employment or membership
within the eligible classes terminates without such evidence having been furnished,
shall continue to be subject to the same requirement if subsequently, he again
becomes an Employee within the eligible classes. Any Employee or Dependent who
was not covered under the Prior Plan, if any, and who was required to furnish
Evidence of Good Health under the Prior Plan, is required to furnish Evidence of
Good Health before becoming covered under this Plan.
i. No person may be simultaneously covered under the Plan as both an Employee and
as a Dependent.
j. When both spouses are Covered Employees under this Plan without Dependent
coverage and one spouse terminates active employment, the remaining Covered
Employee may enroll for Dependent coverage within thirty -one (31) days after the
other spouse's last day of active employment. Coverage is effective on the first of the
month following the end of employment. If you do not enroll your spouse within thirty -
one (31) days, Evidence of Good Health Statements must be submitted and approved
in order for such coverage to be effective.
k. Benefits payable on behalf of a Dependent previously covered under the Plan as an
Employee, shall not exceed the maximum benefits that would have been payable
during such period had the Dependent remained covered as an Employee.
I. Benefits payable on behalf of an Employee previously covered under the Plan as a
Dependent, shall not exceed the maximum benefits that would have been payable
during such period had the Employee remained covered as a Dependent.
m. Benefits payable on behalf of an Employee or Dependent covered under the Plan,
whose employment or coverage is terminated, and who is subsequently rehired or
reinstated at any time, shall be limited to the maximum benefits that would have been
payable had there been no interruption of employment or coverage.
n. Any benefits received prior to the Effective Date of the Plan will be applied to the
benefit maximum of the Plan as indicated in the "SCHEDULE OF BENEFITS."
21
SECTION V - TERMINATION DATES
1. PERSONAL COVERAGE
The Personal Coverage of any Employee covered under the Plan will terminate on the
earliest of the following dates:
a. the date of termination of the Plan;
b. the day of the Plan Month on or with respect to which the Employee requests that
such coverage be terminated, provided such request is made on or before such date;
c. the last day of the last period for which the Employee has made a contribution, in the
event of his failure to make, when due, any contribution for Personal Coverage to
which he has agreed in writing;
d. the date on which the Employee ceases to be eligible for such coverage under the
Plan;
e. the date the Participating Employer ceases to be a Participating Employer; or
f. the day of the Plan Month on which the termination of his employment occurs. If
termination of employment is due to:
(1) Sickness or Accidental Bodily Injury, an Employee's coverage may be continued
until the Employer stops such coverage, but in no event beyond twelve (12)
weeks from the date active work ceased due to Sickness or Accidental Bodily
Injury;
(2) temporary layoff or leave of absence, an Employee's coverage may be
continued for the number of months he was in the Plan, but not beyond the date
such Employee enters the military, naval or air forces of any country or
international organization, and in no event beyond twelve (12) weeks from the
date active work ceased.
Any maximum period of continuation permitted by this section may be extended at the
discretion of the Planholder in each individual case, provided that in so continuing an
Employee's coverage, the Employer acts in accordance with a plan which precludes
individual selection. The Plan will at all times be in compliance with the Family and Medical
Leave Act.
2. DEPENDENT COVERAGE
The Dependent Coverage of any Employee, with respect to any of his Dependents who are
covered under the Plan, will terminate on the earliest to occur of the following dates:
a. the date of termination of the Plan;
b. upon the discontinuance of Dependent Coverage under the Plan;
c. when such Dependent becomes covered for Personal Coverage under the Plan;
d. the date of termination of the Employee's Personal Coverage hereunder;
e. the last day of the last period for which the Employee has made a contribution, In the
event of his failure to make, when due, any contribution for Dependent Coverage to
which he has agreed in writing;
f. after the thirty -first (31st) day following the birth of a newborn child, with respect to
such child, unless prior to the expiration of such thirty -one (31) day period, the
Employer has been notified of the birth of such child and the Employee has agreed
to make any required contributions;
22
SECTION V - TERMINATION DATES
g. in the case of a child for whom coverage is being continued due to mental or physical
inability to earn his own living, the earliest to occur of:
(1) cessation of such incapacity;
(2) failure to furnish any required proof of the uninterrupted continuance of such
incapacity, or to submit to any required examination; or
(3) upon no longer being dependent on the Employee for his support.
h. on the date a dependent child marries, or in the case of a child, other than a child for
whom coverage is continued due to mental or physical inability to earn his own living,
the date on which the child attains the age of nineteen (19) years, or the age of
twenty - five (25) years in the case of a child who is regularly attending an accredited
high school, junior college, college, university or licensed trade school; or
i. the day immediately preceding the date such person ceases to be a Dependent, as
defined herein, except as may be provided for in g., above.
23
SECTION VI - CONTINUATION OF COVERAGE
CONSOLIDATED OMNIBUS RECONCILIATION ACT OF 1986 (COBRA)
If a Covered Employee's health coverage, including dental coverage if applicable, Is terminated
under the Plan for any of the "qualifying events" listed below, such Covered Employee shall have
the right to elect to continue coverage under the Plan without Evidence of Good Health.
QUALIFYING EVENTS
1. Death of the Covered Employee;
2. Termination (whether voluntary or involuntary) of the Covered Employee's employment (for
reasons other than gross misconduct), or a reduction in the number of hours of
employment;
3. Divorce of the Covered Employee;
4. Eligibility of the Covered Employee for Medicare;
5. A dependent child ceases to be an eligible Dependent under the terms and provisions of
the Plan.
If the Covered Employee is covered with respect to his Dependents on the date of such
qualifying event, he may elect to include his Covered Dependents, or such Covered Dependents
may elect to be covered. If an Employee does not elect to cover a dependent and at a later date
such Employee requests a dependent to be covered, such Dependent Coverage will become
effective on the first of the month following the date Evidence of Good Health Statements have
been completed, submitted, and approved at no expense to the Employer.
Notification of this privilege will be sent to the Covered Employee or Covered Dependent
following the qualifying event or the date the Planholder is notified of such qualifying event. The
necessary enrollment forms furnished by the Planholder must be completed and returned to the
Planholder within sixty (60) days from the date of receipt of such notice. The first contribution
must be paid to the Planholder within forty -five (45) days of such election.
If the qualifying event is termination of employment or a reduction in the number of hours of
employment, coverage shall be extended for a period of eighteen (18) months. For any other
qualifying event, coverage shall be extended for a period of thirty -six (36) months. Any such
continuation of coverage under the Plan shall be terminated earlier if:
a. the Planholder ceases to provide health coverage to any Employees;
b. the Covered Person fails to make, when due, the required contribution payment;
c. the Covered Person becomes covered under any other group health plan which does
not contain any exclusion or limitation with respect to any preexisting condition; or
d. the Covered Person becomes entitled to Medicare benefits.
Employees defined as disabled under the Social Security Act (SSA) at the time of the qualifying
event are entitled to an additional eleven (11) months of continued coverage under certain
circumstances. These circumstances include:
1. Employee must provide notice of SSA disability determination within sixty (60) days after
the date of determination and before the end of their eighteen (18) months of continued
coverage;
2. The continuation of coverage provision is effective for plan years beginning on or after
January 1, 1990;
24
SECTION VI - CONTINUATION OF COVERAGE
CONSOUDATED OMNIBUS RECONCILIATION ACT OF 1986 (COBRA)
3. Disability date is equal to or before the qualifying event; or
4. The extended coverage applies to the Employee only. Dependents' coverage terminates
at the end of eighteen (18) months.
Extended benefits terminate earlier if:
1. the Employee is no longer disabled:
a. if the Employee is determined by SSA to no longer be disabled, the extended
coverage is canceled the month beginning more than thirty (30) days after the final
determination date;
b. the Employee is responsible for notifying the plan administrator within thirty (30) days
of the final determination.
2. the Planholder ceases to provide health coverage to any Employees;
3. the Covered Person fails to make, when due, the required contribution payment;
4. the Covered Person becomes covered under any other group health plan which does not
contain any exclusion or limitation with respect to any preexisting condition; or
5. the Covered Person becomes entitled to Medicare benefits.
25
HOSPITAL SELECTION
AND
PHYSICIAN SELECTION
Any physician or hospital in the Td-
Med Network
Any physician or hospital
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 smears, well child care,
krim nations)
if the routine mammogram is
perforated outside the physician's
office, benefits are payable at 80%,
subject to the $250 Calendar Year
maximum for Preventive Care
100% coverage after $15 co -pay per
visit; $250 maximum per Calendar
Year for Preventive Care
50% coverage; deductible waived, to
a maximum of $250 per Calendar
Year for Preventive Care
INPATIENT HOSPITAL*
Hospital room & board (semi - private),
intensive care, anesthesia and
oxygen, blood, drugs, diagnostic
services, including x-ray, microscopic
and laboratory test, radioactive
therapy, medical supplies, etc.
80% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
OUTPATIENT HOSPITAL
Outpatient Surgery
Outpatient Diagnostic Testing and
Other Outpatient Services
80% coverage after $250 Calendar
Year deductible
80% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
EMERGENCY TREATMENT
Hospital Emergency
Accident
Sickness
80% coverage after $50 Emergency
Room deductible — deductible
waived if admitted to the hospital
80% coverage after $50 Emergency
Room deductible — deductible
waived if admitted to the hospital
80% coverage after $50 Emergency
Room deductible — deductible waived
if admitted to the hospital
80% coverage after $50 Emergency
Room deductible — deductible waived
if admitted to the hospital
FREE-STANDING URGENT CARE
CENTERS
100% coverage after $15 co-pay per
office visit — includes all charges
related to office visit if billed by
Physician's office .
80% coverage after $50 co-pay per
visit
SECTION VII - SCHEDULE OF BENEFITS
NETWORK BENEFIT
NON - NETWORK BENEFIT
*A $500 Pre - Certification Treatment Deductible will be applied if the Hospital confinement is not pre - certified.
26
PHYSICIAN SERVICES
In the Office
All Other Physician Fees
(surgery, anesthesia, radiology,
pathology, diagnostic x-ray and lab,
chemotherapy, dialysis, physical
therapy, radiation therapy, etc.)
100% coverage after $15 co -pay per
office visit — includes all charges
related to office visit if billed by
Physician's office
80% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
ALLERGY TREATMENT
(allergy testing and allergy injections)
80% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
MENTAL/NERVOUS DISORDERS
Inpatient Care*
Outpatient Physician Care
80% coverage after $250 Calendar
Year deductible to a maximum of
$25,000 per Lifetime
100% coverage after $15 co-pay per
visit to a maximum of 30 visits per
Calendar Year
50% coverage after $250 Calendar
Year deductible to a maximum of
$25,000 per Lifetime
50% coverage after $250 Calendar
Year deductible to a maximum of 30
visits per Calendar Year
SERIOUS MENTAL ILLNESS
Inpatient Care*
Outpatient Care
80% coverage after $250 Calendar
Year deductible
100% coverage after $15 co-pay per
visit
50% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
ALCOHOL AND DRUG ABUSE
Inpatient Care*
Outpatient Care
..
80% coverage after $250 Calendar
Year deductible
100% coverage after $15 co-pay per
visit
50% coverage after $250 Calendar
Year deductible
50% coverage after $250 Calendar
Year deductible
SECOND SURGICAL OPINIONS
100% coverage; deductible waived
100% coverage; deductible waived
CHIROPRACTIC SERVICES
Not Available
50% coverage after $250 Calendar
Year deductible to a maximum of
$500 per Calendar Year
SECTION VII - SCHEDULE OF BENEFITS
NETWORK BENEFIT
27
NON - NETWORK BENEFIT
*A $500 Pre - Certification Treatment Deductible will be applied if the Hospital confinement is not pre - certified.
SKILLED NURSING FACILITY
Room and Board (semi- private and
miscellaneous expenses)
80% coverage after $250 Calendar
Year deductible to a maximum of
$10,000 per Calendar Year
50% coverage after $250 Calendar
Year deductible to a maximum of
$7,000 per Calendar Year
HOME REALM CARE
80% coverage after $250 Calendar
Year deductible to a maximum of
$10,000 per Calendar Year
50% coverage after $250 Calendar
Year deductible to a maximum of
$7,000 per Calendar Year
HOSPICE CARE
80% coverage after $250 Calendar
Year deductible to a maximum of
$20,000 per Lifetime
50% coverage after $250 Calendar
Year deductible to a maximum of
$15,000 per Lifetime
OTHER COVERED EXPENSES
(durable medical equipment,
suppler home infusion therapy,
ambulance, etc.)
80% coverage after $250 Calendar
Year deductible
80% coverage after $250 Calendar
Year deductible
SECTION VII - SCHEDULE OF BENEFITS
NETWORK BENEFIT
*A $500 Pre - Certification Treatment Deductible will be applied if the Hospital confinement is not pre - certified.
28
NON - NETWORK BENEFIT
LIFETIME MAXIMUMS
OveraN Plan Madmum
MentaUNenroru Disorders
Hospice Care
$1,000,000
$25,000 -
$20,000
$1,000,000
$25,000
$15,000
CALENDAR YEAR MAXIMUMS
Outpatient Treatment of
Mental/Nervous Disorders
Home Health Care
Skilled Nursing Facility
Chiropractic Care
Preventive Care
30 visits
$10,000
$10,000
Not Available
$250
30 visits
$7,000
$7,000
$500
$250
ANNUAL CASH DEDUCTIBLE
Per Individual
(includes last quarter canyover)
Per Family
$250
$750
$250
$750
PLAN OUT -OF- POCKET
LIMITATION
Per Individual
(includes last quarter ova
$1,000
($5,000 at 80 %)
$5,000
($10,000 at 50 %)
PRESCRIPTION DRUG PLAN
CO- PAYMENT
Per Prescription
$5 (for Generic Drugs)
$10 (for Brand Name Drugs)
$5 (for Generic Drugs)
$10 (for Brand Name Drugs)
SECTION VII - SCHEDULE OF BENEFITS
NETWORK BENEFIT
NON - NETWORK BENEFIT
29
MAXIMUM BENEFIT
Preventive, Basic and Major Services Combined Per Calendar Year
Orthodontics Per Lifetime
$1,000
$1,000
ANNUAL CASH DEDUCTIBLE
Preventive Services
None
Basic and Major Services Combined
$50
Family Limit
$150
ORTHODONTIA DEDUCTIBLE
Per Person Per Lifetime
$50
BENEFIT PERCENTAGE PAYABLE
Preventive Services (routine exams, cleaning, fluoride, x-rays)
100%
Basic Services (extractions, fillings, oral surgery, periodontics)
80%
Major Services ( crowns, bridges, dentures, gold fillings)
50%
Orthodontic Services (braces covered to age 19)
50%
SECTION VII - SCHEDULE OF BENEFITS
DENTAL BENEFITS
30
SECTION VII - SCHEDULE OF BENEFITS
The City of Round Rock Health Plan pays scheduled amounts for Network hospital and physician
services for Covered Employees and their Dependents who reside in the Round Rock area
(within a fifty (50) mile radius). The Covered Person will pay co- payments for services received
at the specified Network providers. Contact the City of Round Rock Human Resources
Department for a current list of Network providers.
If the Covered Person chooses to use Non - Network providers when Network providers are
available, the amount the Covered Person must pay is significantly greater.
The Covered Person is encouraged to utilize Round Rock Hospital for inpatient hospital
confinements. If the services are available at Round Rock Hospital and the Covered Person
chooses to go elsewhere, Non - Network (fifty percent (50%)) benefits will apply. If the services
are not available at Round Rock Hospital, Network (eighty percent (80 %)) benefits will apply if
the Covered Person goes to St. David's Hospital. If the services are not available at Round Rock
Hospital and the Covered Person chooses to go to a hospital other than St. David's Hospital,
Non - Network (fifty percent (50 %)) benefits will apply.
Network benefits will apply to Non - Network providers /services under the following conditions:
1. the Covered Employee or Dependent lives outside a fifty (50) mile radius of the Round Rock
area;
2. medical services are not provided at Round Rock Hospital or St. David's Hospital; or
3. the Covered Employee or Dependent has a life- threatening emergency.
The Covered Person is strongly encouraged to utilize the Network providers as this will reduce
the Covered Person's cost and the Plan's cost. Before receiving non - emergency medical
services, be sure to contact the City of Round Rock Human Resources Department or contact
HealthCare Benefits, Inc. at (800) 522 -4422 to confirm benefits and providers.
31
SECTION VIII - SPECIAL CONDMONS
Alcohol and Drug Abuse Conditions. Benefits for Alcoholism and Drug Abuse treatment will be
payable as any other illness upon the diagnosis or recommendation of a physician. Treatment
must be recognized by the medical profession as appropriate and effective. This effective
treatment must be prescribed by the doctor and include monthly therapy sessions directed by
a physician and attendance, at least twice a month, at meetings devoted to therapeutic treatment.
Benefits are limited to three (3) series of treatment per lifetime. Treatment solely for detoxification
or primarily for maintenance care is not considered effective treatment; therefore, benefits are not
payable.
Chiropractic Care. Benefits are payable under the Plan for chiropractic care rendered by a
licensed Chiropractor (D.C.), as follows:
1. payable at fifty percent (50%); and
2. subject to a Calendar Year maximum of five hundred dollars ($500).
This includes all related exams, x -rays, modalities, manipulations and any other treatment.
Home Health Care. Benefits are payable under the Plan for Home Health Care as shown in the
"SCHEDULE OF BENEFITS." If the Covered Person's Physician certifies the need for such care
and establishes a course of treatment, the following necessary services and supplies are
covered:
1. part-time or intermittent nursing care by a Registered Nurse (R.N.), a Licensed Vocational
Nurse (LV.N.) or a Licensed Practical Nurse (L.P.N.);
2. part-time or intermittent home health aide services consisting primarily of caring for the
patient;
3. physical, occupational, speech and respiratory therapy provided by licensed therapists; and
4. supplies and equipment routinely provided by the Home Health Care Agency.
Benefits will not be provided for Home Health Care services for:
1. food or home delivered meals;
2. social case work or homemaker services;
3. services rendered primarily for custodial care; or
4. transportation services.
The maximum amount payable for Home Health Care is shown in the "SCHEDULE OF
BENEFITS."
Home Health Care expenses are subject to the Pre - Certification Treatment Plan requirements
described later in this section. If a Covered Person fails to obtain pre - certification of benefits, any
applicable penalties for non - compliance with the Pre - Certification Treatment Plan shall be
imposed.
Home Infusion Therapy. Benefits are payable under the Plan as specified In the "SCHEDULE OF
BENEFITS." If the physician certifies the Medical Necessity for such therapy, the following
necessary services and supplies will be covered:
1. prescription drugs and I.V. solutions;
32
SECTION VIII - SPECIAL CONDITIONS
2. pharmacy compounding and dispensing services;
3. equipment and ancillary supplies necessitated by the defined therapy;
4. delivery services;
5. patient and family education; and
6. nursing services.
Home Infusion Therapy expenses are subject to the Pre - Certification Treatment Plan requirements
described later in this section. If a Covered Person fails to obtain pre - certification of benefits, any
applicable penalties for non - compliance with the Pre - Certification Treatment Plan may be
imposed.
Hospice Care. Benefits are payable under the Plan for Hospice Care as specified in the
"SCHEDULE OF BENEFITS." If Hospice Care is furnished on an inpatient basis at a Hospice
Facility, or In the patient's home, and the attending Physician has certified that the patient is
terminally ill with one (1) year or less to live, the following necessary services and supplies are
covered:
1. room and board, and all routine services, supplies and equipment provided by the Hospice
Facility;
2. all usual nursing care by a Registered Nurse (R.N.), a Licensed Vocational Nurse (L.V.N.)
or a Licensed Practical Nurse (LP.N.); "
3. part-time or intermittent home health aide services which consist primarily of caring for the
patient;
4. physical, speech and respiratory therapy services provided by licensed therapists; and
5. homemaker and counseling services routinely provided by the Hospice.
Hospice Care is subject to the Pre -Certification Treatment Plan requirements described later in
this section. If a Covered Person fails to obtain pre - certification of benefits, any applicable
penalties for non - compliance with the Pre - Certification Treatment Plan shall be imposed.
Mental/Nervous Disorders. Benefits are payable under the Plan for treatment of MentaVNervous
Disorders as follows:
1. if a Covered Person is confined as a inpatient in a Hospital or Psychiatric Day Treatment
Facility, or as a full -time inpatient in a Mental Health Facility, for treatment of Mental /Nervous
Disorders, Covered Expenses Incurred during such Hospital Admission will be payable as
follows:
a. payable at the benefit percentage indicated in the "SCHEDULE OF BENEFITS "; and
b. subject to a lifetime maximum benefit of twenty -five thousand dollars ($25,000) for all
inpatient and outpatient treatment combined.
2. if a Covered Person is not confined in a Hospital or Mental Health Facility, Covered
Expenses for the outpatient treatment of Mental /Nervous Disorders will be payable as
follows:
a. up to thirty (30) visits per Calendar Year, payable at the benefit percentage indicated
in the "SCHEDULE OF BENEFITS "; and
33
SECTION VIII - SPECIAL CONDITIONS
b. subject to a lifetime maximum benefit of twenty -five thousand dollars ($25,000) for all
inpatient and outpatient treatment combined.
The benefits specified for outpatient treatment include only the expenses for counseling or
psychotherapy. Other related expenses, such as diagnostic x -ray and lab expenses, are not
included in this limitation.
Covered Expenses incurred for treatment of Mental /Nervous Disorders will not be applied to the
Co- Payment Limit of the Plan. Benefits for Serious Mental Illness, as described later in this
section, will be payable as any other Illness.
Newborn Care. Charges for the routine nursery and pediatric care of a newborn child are
covered during the hospital's admission during the delivery. These charges will be considered
expense of the child and will be subject to a separate deductible, coinsurance and any benefit
maximums shown in the "SCHEDULE OF BENEFITS." Routine pediatric well -baby care after a
newborn child is discharged from the Hospital will not be a Covered Expense, except as provided
for Preventive Care described later in this section.
Pre-Certification Treatment Plan. A Covered Person shall be required to obtain pre - certification
of benefits for:
1. all inpatient Hospital Admission;
2. all inpatient surgical operation;
3. all Skilled Nursing Facility Confinement;
4. all Home Health Care;
5. all Hospice Care; and
6. all Home Infusion Therapy.
If pre - certification of benefits is not obtained, all related Covered Expenses will be subject to the
Pre - Certification Treatment Deductible specified In the "SCHEDULE OF BENEFITS."
Pre - Certification of benefits establishes in advance that services are Medically Necessary. The
Planholder shall not be obligated to pay for any expense, whether or not a Covered Expense,
which is determined to be not Medically Necessary. Pre - Certification ensures that the pre -
certified care will not be denied on the basis of Medical Necess Pre - Certification does not
guarantee payment for a claim. Any benefits payable under the Plan shall continue to be subject
to other contractual requirements such as PreExisting Conditions limitations and eligibility of the
Covered Person at the time services are rendered.
Inpatient Certification. Using the Plan wisely affords the maximum amount of benefits
available. For Inpatient Hospital Admissions, this means the Covered Employee or
Dependent, or the Covered Person's Physician must notify the Pre - Certification Department
at the appropriate telephone number shown on the Employee Identification Card, prior to
each Hospital Admission. In a case of a medical emergency, the Pre - Certification
Department must be notified within forty -eight (48) hours of the admission or as soon
thereafter as reasonably possible.
34
SECTION VIII - SPECIAL CONDfIIONS
Pre - Certification of a hospital admission does not guarantee payment of a claim but does
ensure that payment for the covered room and board charges for the approved
length -of -stay will not be denied on the basis of Medical Necessity.
Second Surgical Opinion. The Pre - Certification Department may require a Covered Person
to obtain a Second Surgical Opinion before the Hospital Admission can be certified. In
such a case, the guidelines for obtaining a Second Surgical Opinion, described later in this
section, must be followed. The Pre - Certification Department must be notified when a
required Second Surgical Opinion has been obtained in order to complete the pre -
certification of benefits request.
Length-of-Stay and Discharge Planning. At the time notification of a Hospital Admission is
received, a length-of-stay will be assigned for the admission, provided it is determined to
be a Medically Necessary Hospital Admission. The assigned length -of -stay will be based
on the diagnosis and facts as presented by the attending Physician. If during the
subsequent Hospital Admission, a longer length -of -stay is anticipated, the Physician must
notify the Pre - Certification Department to obtain approval for any additional Medically
Necessary days of confinement. If a Covered Person remains in the hospital beyond the
number of days determined to be Medically Necessary by the Pre - Certification Department,
the charges for the days determined to be not Medically Necessary will not be covered
under the Plan.
During the Hospital Admission, a case coordinator will monitor the admission and work with
the Hospital discharge planner to make sure that benefits are administered appropriately
for any Medically Necessary follow -up care. If the Covered Person no longer needs
inpatient Hospital care, the discharge planning process may help make arrangements for
alternate care.
Required Extended Care Certification. Pre - Certification of benefits also applies to services
for any Extended Care, which includes the services of a Skilled Nursing Facility, a Hospice,
or a Home Health Care Agency. In order for Extended Care benefits to be provided, pre —
certification must be obtained by having the attending Physician submit a treatment plan
on a Pre - Certification Review Form. If Extended Care is to follow a Hospital Admission as
discussed previously, the discharge planning process will assist the pre - certification
process.
The Pre - Certification Review Form must be completed (1) before the start of Extended Care;
(2) every thirty (30) days for recertification of Extended Care; or (3) when the treatment plan
is altered. If the Extended Care is to begin in less than one (1) week, the attending
Physician should call the Pre - Certification Department at the appropriate telephone number
shown on the Employee Identification Card.
Information will be reviewed by the Pre - Certification Department prior to the start of
Extended Care. A certification letter will be sent to both the Covered Employee or
Dependent, and the provider of service indicating benefit approval or denial of services
requested. Certification will be made by telephone to the provider of service if Extended
Care is scheduled to begin within seventy -two (72) hours after approval or denial of
35
SECTION VIII - SPECIAL CONDr71ONS
services. No payment will be made for charges incurred when the corresponding treatment
plan has been previously denied based on the information submitted.
Large Case Management. As an extension of discharge planning, the Plan provides the
flexibility to allow exceptions to the contractual provisions of your coverage in certain cases
of catastrophic illness or injury. Such decisions will only be made after establishing the
cost effectiveness of Medically Necessary services, and with the understanding and
agreement of the Covered Employee and /or Dependent, and the attending Physician. This
type of catastrophic large case management will be initiated by the case coordinator in
appropriate situations.
Pre - Existing Conditions. No benefits will be provided for treatment of a Pre - Existing Condition
as defined herein. Treatment of a Pre - Existing Condition shall include any Illness or Injury, for
which:
1. medical expenses were incurred;
2. medical treatment was recommended;
3. medical treatment was received;
4. drugs were prescribed; or
5. a Physician was consulted during the twelve (12) month period immediately prior to the
effective date of coverage under the Plan.
This exclusion will cease to apply if a Covered Person completes twelve (12) consecutive months
of coverage under the Plan. This exclusion will not apply to any Covered Person who was
covered under the Prior Plan.
Any time accumulated toward satisfaction of the Pre - Existing Condition limitation under the
previous City of Round Rock Benefit Plan will be counted toward the satisfaction of the Pre -
Existing Condition limitation of the Plan.
Pregnancy. Charges in connection with pregnancy, childbirth, miscarriage or elective abortion
are covered under the Plan for Employees and Dependents on the same basis as any other
illness.
Prescription Drug Card Program. Out -of- Hospital Prescription Drugs must be purchased from
a licensed pharmacist with the Prescription Drug Card furnished to a Covered Person as part of
the Plan. The Prescription Drug Card Program is designed with a dual deductible provision
which provides the option to pay a lesser co- payment amount when a brand name prescription
can be substituted with a "generic" prescription. Prescriptions purchased using the Prescription
Drug Card may not exceed a thirty (30) day supply, but may be refilled as necessary each thirty
(30) days while the Covered Person is covered under the Plan.
Prescription Mall Order Program. Maintenance Prescriptions are medications prescribed for long-
term or chronic conditions such as high blood pressure, arthritis, ulcers, etc. A Maintenance
Prescription may be filled over a thirty (30) day supply, but limited to a ninety (90) day supply.
Maintenance Prescriptions are filled by Caremark, Inc. Forms for ordering mail order prescription
drugs are available through your Employer.
36
SECTION VIII - SPECIAL CONDMONS
Preventive Care. Benefits will be provided for Physician's expenses incurred for immunizations,
routine well -child care incurred out -of- hospital, routine physical examinations, routine
mammograms and routine annual pap smears. Injections for allergies are not considered
"immunizations" under this benefit.
Benefits will be payable at the benefit percentage indicated in the "SCHEDULE OF BENEFITS,"
with no deductible, up to a Maximum Benefit of two hundred fifty dollars ($250) per Calendar
Year. The Maximum Benefit applies separately to each individual family member.
Psychiatric Day Treatment Facility. Charges for a Psychiatric Day Treatment Facility are covered
the same as for an inpatient treatment of Mental /Nervous Disorders, subject to the same benefits
as specified in the "SCHEDULE OF BENEFITS" and under this section entitled "SPECIAL
CONDITIONS." If the following conditions are met, benefits will be payable for a Psychiatric Day
Treatment Facility:
1. A Physician who is certified in Psychiatry by the American Board of Psychiatry and
Neurology must certify that the Psychiatric Day Treatment Facility services are being
provided in lieu of a Hospital Admission; and
2. The Psychiatric Day Treatment Facility is accredited by the Program for Psychiatric
Facilities, or its successor, of the Joint Commission on Accreditation of Hospitals.
Second Surgical Opinion. As part of the Pre - Certification Treatment Plan, a Covered Person may
be required to obtain a second or third surgical opinion whenever surgery is proposed. The cost
of obtaining the opinion of a surgeon, who is not the Physician scheduled to perform the surgery
or the Physician who originally recommended the surgery, including any required outpatient tests
to confirm that the surgery is Medically Necessary, will be considered a Covered Expense and
will be payable at one hundred percent (100%) of the reasonable and customary charges
incurred, without the application of any deductible, provided the following conditions are met:
1. each opinion is provided by a Physician who is currently qualified to perform the surgery
in question;
2. each Physician rendering an opinion is in practice independent of any other Physician
providing an opinion; -
3. no reimbursement is sought for redundant tests or x -rays; and
4. no charges are submitted for Hospital Admission to obtain a surgical opinion.
If all of the foregoing conditions are not met, the Plan will not pay for the second or third surgical
opinions. If the first and second opinion conflict, payment will be made for the reasonable
charge for a third opinion. If the first two opinions agree, subsequent opinions are covered
subject to the regular Annual Cash Deductible and co- payment provisions of the Plan. To be
covered for this benefit, the second or third surgical opinion must be recommended by the Pre -
Certification Department and must be obtained within ninety (90) days of the original opinion.
The Pre - Certification Department must be notified after any such recommended second or third
opinion has been obtained, in order to complete the pre - certification of benefits.
When a Covered Person does not secure a recommended Second Surgical Opinion, or fails to
notify the Pre - Certification Department when such second or third opinion has been obtained,
any applicable penalties of the Pre - Certification Treatment Plan may be imposed.
37
SECTION VIII - SPECIAL CONDfnONS
Serious Mental Illness. Benefits for Serious Mental Illness will be payable on the same basis as
any other illness for any of the following primary diagnoses:
1. Schizophrenia;
2. Paranoid and other psychotic disorders;
3. Bipolar disorders (mixed, manic and depressive);
4. Major depressive disorders (single episode or recurrent); and
5. Schizo-affective disorders (bipolar or depressive).
Skilled Nursing Facility. Benefits are payable for the confinement of a Covered Person in a
Skilled Nursing Facility as specified in the "SCHEDULE OF BENEFITS," and subject to the
following:
1. the Room and Board and Miscellaneous Service limits specified in the "SCHEDULE OF
BENEFITS;
2. the confinement must be recommended by a Physician;
3. the confinement must be necessary for the treatment of or leading to the recovery from an
Accidental Bodily Injury or Illness; and
4. the confinement must be for other than Custodial Care.
If all of the foregoing conditions are met, benefits will be provided for the following eligible
expenses:
1. room and board, and all routine services, supplies and equipment provided by the Skilled
Nursing Facility;
2. all usual nursing care by a Registered Nurse (R.N.), a Licensed Vocational Nurse (L.V.N.)
or a Licensed Practical Nurse (L.P.N.); and
3. physical, occupational, speech and respiratory therapy services provided by licensed
therapists.
Skilled Nursing Care Facility confinements are subject to the Pre - Certification Treatment Plan
requirements described earlier in this section. If a Covered Person fails to obtain pre - certification
of benefits, any applicable penalties for non - compliance with the Pre - Certification Treatment Plan
may be imposed.
Sterilization. Benefits are payable under the Plan for charges incurred as a result of voluntary
sterilization on the same basis as an Illness.
Temporomandibular Joint Disorders. The Plan provides benefits for treatment of TMJ Disorders
to include initial diagnostic visit, x -rays of the joint, injection into the joint and surgical repair of
the temporomandibular joint.
Transplants. Benefits provided to a Covered Person in cases involving human organ or tissue
transplant are subject to the following special conditions and provisions. When Hospital or
Physician's medical care and services are required for any type of human organ or tissue
transplant from a living donor (to a transplant recipient), which requires surgical removal of the
donated organ or tissue, coverage under the Plan is available only under the following
circumstances:
38
SECTION VIII - SPECIAL CONDffiONS
1. When only the transplant recipient is a Covered Person, the benefits of the Plan will be
provided to the donor to the extent that benefits are not provided to the donor under any
other available coverage.
2. When only the donor is a Covered Person, the donor will receive benefits for care and
services necessary to the extent such benefits are not provided to the donor under any
other coverage available. Benefits will not be provided to any recipient who is not a
Covered Person.
3. When the transplant recipient and the donor are both Covered Persons, benefits will be
provided for both in accordance with their respective Covered Expenses.
Benefits available in the case of human organ or tissue transplant are also subject to the
following conditions:
1. Benefits will be provided only when the Hospital and Physician customarily bill for the
medical care and services involved in the human organ or tissue transplant.
2. Under no circumstances will benefits be available for any "personal service" fee, organ or
tissue fee, or any other similar change or fee.
3. Only those necessary Hospital and Physician's medical care and service expenses, with
respect to the donation, will be considered for benefits.
4. Benefits will be provided only for Covered Expenses relating to non - experimental organ and
tissue transplants up to the Lifetime Maximum Benefit shown in the "SCHEDULE OF
BENEFITS."
39
SECTION DC - COMPREHENSIVE MEDICAL EXPENSE BENEFITS
1. BENEFITS PAYABLE
If because of Non - occupational Sickness or Non - occupational Accidental Bodily Injury, a
person, while covered for benefits under this section, incurs covered medical expenses in
excess of the Annual Cash Deductible, and /or the Pre - Certification Treatment Deductible,
when applicable, the Plan will provide benefits as specified in this section. The benefit
percentage payable, any applicable benefit maximums, and the Comprehensive Medical
Expense Maximum Lifetime Benefit are specified in the "SCHEDULE OF BENEFITS." In the
event, a Covered Person is confined in a Hospital on December 31st, the benefit
percentage payable which is in effect on December 31st, will continue to be payable until
the date the Covered Person is discharged from the Hospital.
2. DEDUCTIBLE AMOUNT
The Deductible Amount is made up of the Annual Cash Deductible and /or the
Pre - Certification Treatment Deductible specified In the "SCHEDULE OF BENEFITS."
The Annual Cash Deductible will be deducted from the expenses covered under this section
before benefits are computed under this section, unless the "SCHEDULE OF BENEFITS'
indicates otherwise. The Pre - Certification Treatment Deductible will be waived If all
requirements of the Pre - Certification Treatment Plan are met.
The Annual Cash Deductible applies separately to each Covered Person in each Calendar
Year, subject to the following conditions:
a. When two (2) or more covered family members are injured in the same accident, only
one (1) Annual Cash Deductible will be applied during the same Calendar Year to the
expenses directly resulting from Injuries sustained in such accident.
b. Covered Medical Expenses incurred during any one (1) Calendar Year, and applied
toward satisfaction of a covered family member's Annual Cash Deductible, will be
accumulated toward the Family Umit specified in the "SCHEDULE OF BENEFITS."
When such Family Limit has been satisfied, the Annual Cash Deductible will be waived
for Covered Expenses incurred by any covered family member during the same
Calendar Year.
c. Covered Medical Expenses incurred by a Covered Family Member in the last three (3)
months of any Calendar Year, and applied toward satisfaction of his Annual Cash
Deductible for that Calendar Year, may also be used toward satisfaction of his Annual
Cash Deductible in the next Calendar Year. Such Covered Expenses may be used
toward satisfaction of the Family Umit for the Calendar Year in which they are
Incurred, but will not be used to satisfy any portion of the Family Umit for the following
Calendar Year.
The Plan reserves the right to allocate the Annual Cash Deductible to any covered Medical
Expenses and to apportion the benefits to the Covered Employee or Dependent and any
assignees.
40
SECTION IX - COMPREHENSIVE MEDICAL EXPENSE BENEFITS
3. CO PAYMENT LIMIT
The Co- Payment Limit Is included in the Plan to help control the amount of out -of- pocket
expenses a Covered Employee must pay for himself and for each of his Covered
Dependents. Provided all of the provisions specified in the Plan are met, a Covered
Employee's out -of- pocket expense shall not exceed one thousand two hundred and fifty
dollars ($1,250) per covered family member using Network providers or five thousand two
hundred and fifty dollars ($5,250) per covered family member using Non - Network providers.
The following out -of- pocket expenses will be used to satisfy the Co- Payment Limit of the
Plan:
a. eligible expenses used to satisfy the Annual Cash Deductible of two hundred and fifty
dollars ($250);
b. eligible expenses used to satisfy the one thousand dollar ($1,000) (20% of $5,000)
Employee portion of medical co- payment if using Network providers; and
c. eligible expenses used to satisfy the five thousand dollar ($5,000) (50% of $10,000)
Employee portion of medical co payment if using Non - Network providers.
The following out -of- pocket expenses will not be used to satisfy the Co- Payment Limit of
the Plan:
a. any non - covered expenses;
b. any expenses for hospital room and board in excess of the limits shown in the
"SCHEDULE OF BENEFITS ";
c. any expenses for treatment of Mental /Nervous Disorders; or
d. any additional Deductible amount charged or any expenses determined to be not
Medically Necessary when a Covered Person fails to comply with the requirements
of the Pre - Certification Treatment Plan.
4. MAXIMUM LIFETIME BENEFIT
The Maximum Lifetime Benefit, as shown in the "SCHEDULE OF BENEFITS," applies
separately to each Covered Person. The total payments under this section shall not exceed
that maximum, whether or not a Covered Person is continuously covered under the Plan.
If the "SCHEDULE OF BENEFITS" contains a separate lifetime maximum for any specified
condition, the above provisions will also apply to that maximum. In addition, any separate
lifetime maximum is a part of, and not in addition to, the Comprehensive Medical Expenses
Maximum Lifetime Benefit.
5. EXTENDED BENEFITS
If a Covered Person is totally disabled on the date his coverage terminates under the Plan,
except due to exhaustion of the Comprehensive Medical Expenses Maximum Lifetime
Benefit, Comprehensive Medical Expense Benefits will be provided as if the coverage had
not terminated, up to the earliest to occur of the time limits shown below. Payment will be
made only for Covered Expenses incurred as a direct result of the Accidental Bodily Injury
or Sickness which caused such Total Disability.
41
SECTION IX - COMPREHENSIVE MEDICAL EXPENSE BENEFITS
Time Limits:
The coverage of any Covered Person will terminate on the earliest of the following dates:
a. the end of the total disability;
b. the end of twelve (12) weeks; or
c. the date the Covered Person becomes covered, with respect to such disability, under
any other group coverage or prepayment plan.
6. COVERED MEDICAL EXPENSES
Covered Expenses, as defined in the section entitled, "DEFINITIONS," will be such of the
following charges as are made to the Covered Person for Hospital services, surgical
procedures, Physician charges, and medical services and supplies, provided such charges
and services are usual and customary charges and services. Such Covered Expenses will
be payable by the Plan at the applicable Benefit Percentage Payable and subject to the
Annual Cash Deductible as shown in the "SCHEDULE OF BENEFITS." The following types
of Covered Expenses are covered under this section:
a. the actual charges made to the Covered Person by a Hospital for room and board,
up to the limits specified in the "SCHEDULE OF BENEFITS ";
b. the actual charges made to the Covered Person by a Hospital for an Intensive Care
Unit or Cardiac Care Unit, up to the limits specified in the "SCHEDULE OF BENEFITS';
c. the actual charges made to the Covered Person by a Hospital for the following
miscellaneous services, up to the limits, if any, specified in the "SCHEDULE OF
BENEFITS ":
(1) all approved drugs and medicines for use in the Hospital;
(2) use of operating, delivery, recovery and treatment rooms and equipment;
(3) radiation services, including diagnostic x -rays, x -ray therapy, radiation therapy
and treatment;
(4) clinical and pathological laboratory examinations"
(5) electrocardiograms and electroencephalograms;
(6) physical and occupational therapy;
(7) intravenous solutions;
(8) oxygen and oxygen therapy, plus use of the equipment;
(9) dressings, ordinary splints, plaster casts and sterile supplies;
(10) anesthetics and the administration thereof by the Hospital's employee;
(11) services for the emergency room physician, provided such services are billed
by the Hospital.
(12) processing and administering of blood and blood plasma, including the
supplying of blood or plasma, unless it is donated or replaced; and
(13) admission kits and I.D. bracelets.
d. the hospital's charges for room, board and miscellaneous fees based on the
contracted allowances with Tri -Med Physicians Hospital Organization. Such
contracted allowances may exceed the actual billed charges;
e. charges for a Skilled Nursing Facility, as specified in the "SCHEDULE OF BENEFITS,"
and under the section entitled, "SPECIAL CONDITIONS ";
42
SECTION IX - COMPREHENSIVE MEDICAL EXPENSE BENEFITS
f. professional licensed ambulance service as follows:
(1) ground transportation when Medically Necessary and used locally to or from the
nearest Hospital qualified to render treatment;
(2) air ambulance where air transportation is medically indicated to transport a
Covered Person to the nearest facility qualified to render treatment (excluding
commercial flights); and
(3) "CARE" and "LIFE" flights in a life threatening situation.
g. charges made by a Physician for professional services, regardless where rendered,
and including surgical procedure charges for performing an operation, and charges
of an assistant surgeon, not to exceed twenty -five percent (25 %) of the reasonable
and customary charges allowed for the surgeon;
h. anesthesia and its administration by a licensed anesthesiologist or certified registered
nurse anesthetist (C.R.N.A.);
i. radiation services, including diagnostic x -rays and interpretation, x -ray therapy,
radiation therapy and treatment;
j. clinical and pathological laboratory examinations and professional interpretation of
their results;
k. electrocardiograms and electroencephalograms;
I. charges for outpatient allergy testing;
m. services of an Audiologist to restore loss or correct an impaired hearing function;
n. services of a Speech- Language Pathologist for restoratory or rehabilitative speech
therapy, provided the therapy is for speech loss or impairment due to a Sickness or
Accidental Bodily Injury, surgery on account of Sickness or Accidental Bodily Injury,
or impairment due to a congenital anomaly, provided such loss or impairment is not
due to a functional nervous disorder;
o. services of a Licensed Dietician, when recommended by a Doctor of Medicine (M.D.)
or Doctor or Osteopathy (D.O.) except services which are otherwise excluded under
the Plan;
p. physical therapy and physical rehabilitative occupational therapy (when consisting of
traditional physical therapy modalities), if such treatment is prescribed by a Physician
and performed by a qualified licensed physical therapist or qualified licensed
occupational therapist;
q. services of a private duty Registered Nurse (R.N.), a Licensed Vocational Nurse
(L.V.N.) or a Licensed Practical Nurse (L.P.N.), when prescribed by a Physician and,
in addition, subject to the following:
(1) The nurse cannot be related to the Covered Person, by blood or marriage, or
a person who resides in the Covered Person's home. Only Medically Necessary
care prescribed by a Physician is covered by the Plan. No benefits will be
provided for custodial care and services that are not medical treatment requiring
the skills of a Registered Nurse (R.N.), a Licensed Vocational Nurse (LV.N.) or
a Licensed Practical Nurse (L.P.N.). The fact that such care has been
prescribed or recommended by a Physician does not always mean the services
are Medically Necessary or reimbursable.
(2) Services of a private -duty nurse require prior written approval in order for
benefits to be provided. Only upon examination of the actual services rendered,
can a determination of the Medical Necessity of such services be made.
43
SECTION IX - COMPREHENSIVE MEDICAL EXPENSE BENEFITS
r. charges for Hospice Care as specified in the "SCHEDULE OF BENEFITS" and under
the section entitled "SPECIAL CONDITIONS;
s. charges for Home Health Care as specified In the "SCHEDULE OF BENEFITS" and
under the section entitled "SPECIAL CONDITIONS ";
t. charges for Home Infusion Therapy as specified in the "SCHEDULE OF BENEFITS"
and under the section entitled "SPECIAL CONDITIONS;
u. charges for Mental /Nervous Disorders or Serious Mental Illness as specified in the
"SCHEDULE OF BENEFITS" and under the section entitled "SPECIAL CONDITIONS;
v. charges for the treatment of Alcohol and /or Drug Abuse Conditions as specified in the
"SCHEDULE OF BENEFITS" and under the section entitled "SPECIAL CONDITIONS;
w. services of a Certified Social Worker- Advanced Clinical Practitioner or Licensed
Professional Counselor;
x. charges for drugs and medications:
(1) in a Hospital, drugs, medicines, dressings and supplies furnished by the
Hospital; and
(2) other than in a Hospital, insulin and prescription legend drugs, which are
approved by the Food and Drug Administration, which require the written
prescription of a Physician and which must be dispensed by a licensed
pharmacist according to guidelines established under the Prescription Drug
Program provided as part of the Plan.
y. for birth control implants and their insertion and removal;
z. the initial supply of artificial limbs or eyes, trusses, braces or crutches, not to include
replacement of such except due to a change in medical condition;
aa. rental, or purchase at the Planholder's option, of Durable Medical Equipment, as
defined, to include:
(1) equipment for the administration of oxygen,
(2) a wheelchair or hospital type bed, and
(3) other mechanical equipment for the treatment of respiratory paralysis.
If a Covered Person must rent Durable Medical Equipment for an extended period of
time, the Plan reserves the right to pay for the rental monthly, not to exceed the
purchase price.
ab. charges for Prosthetic Appliances, excluding dental appliances, Medically Necessary
for the alleviation or correction of conditions arising out of Sickness or Accidental
Bodily Injury sustained, or surgery occurring, while covered hereunder (replacement
of such appliances shall not be a Covered Expenses unless the replacement is
necessitated by a physical change in the body which necessitates its replacement,
or unless the replacement Is necessitated by growth of a person who had previously
received the prosthesis);
ac. charges for the initial pair of eyeglasses or contact lenses prescribed as part of
postoperative treatment for intraocular surgery, or due to Accidental Bodily Injury, not
to include replacement of such, provided treatment is received within six (6) months
from the date of the accident or date of surgery;
ad. charges for the following medical supplies: colostomy bags, catheters, oxygen, and
syringes and needles for the treatment of allergies or diabetes;
44
SECTION IX - COMPREHENSIVE MEDICAL EXPENSE BENEFITS
ae. surgical dressings, ordinary splints, plaster casts and sterile supplies;
af. surgical implants prescribed by a Physician as the result of a medically necessary
mastectomy performed while covered under the Plan;
ag. routine Preventive Care as specified in the section entitled "SPECIAL CONDITIONS";
ah. charges for human organ transplants as specified in the "SCHEDULE OF BENEFITS"
and under the section entitled "SPECIAL CONDITIONS ";
al. charges for the treatment of Temporomandibular Joint (TMJ) disorders as specified
in the section entitled "SPECIAL CONDITIONS'; and
aj. charges for dental expenses are covered for:
(1) treatment of fractures and traumatic dislocations of the jawbone;
(2) cutting procedures in the oral cavity for tumors or cysts of the jawbone; and
(3) treatment necessitated by Accidental Bodily Injury to sound natural teeth, except
that no such treatment received more than twelve (12) months from the date of
Injury is covered.
For other dental work or oral surgery requiring hospitalization, only Hospital charges are
Covered Expenses.
In the event that dental work or oral surgery is considered a Covered Expense under both
Comprehensive Medical Expense Benefits and Dental Expense Benefits, benefits will be
• provided under the section of the Plan which provides the greater benefits.
45
SECTION X - LIMITATIONS AND EXCLUSIONS APPLICABLE TO MEDICAL BENEFITS
This section applies to all medical benefits provided by the Plan.
The Plan does not cover any disability or any charge for care or services for the following:
1. any services or supplies provided in connection with an occupational sickness or an injury
sustained in the scope of and in the course of employment whether or not benefits are, or
could upon proper claim be, provided under the Worker's Compensation Law;
2. for benefits that are provided, or would have been provided had the Covered Person
enrolled, applied for, or maintained eligibility for such care and service benefits under Title
XVIII of the Federal Social Security Act of 1965 (Medicare), including any amendments
thereto, or under any federal law or regulation, except as provided in the sections entitled
"COORDINATION OF BENEFITS" and "ADDITIONAL PROVISIONS AS A RESULT OF
MEDICARE/ MEDICAID';
3. for Hospital care and services or supplies, to the extent it shall be established upon review
of a claim submitted hereunder, that:
a. the Covered Person's condition does not require (1) constant direction and
supervision of a Physician, (2) constant availability of licensed nursing personnel, and
(3) immediate availability of diagnostic therapeutic facilities and equipment found only
in the hospital setting; or
b. the primary cause of such confinement was for rest cure or custodial type care
consisting of daily routine personal maintenance, administration of medication on
schedule, preparation of diet and assistance in ambulation.
4. for Hospital care and services rendered after the patient has been discharged from the
Hospital by the attending Physician, or for Hospital care and services when a registered
bed patient is absent from the Hospital;
5. for Hospital expense or Physician's charges relating to non - emergency Friday or Saturday
admissions, unless surgery or treatment is performed the day of or the day after admission
(treatment is defined as specialized treatment that necessitates Hospital Admission);
6. provided to a Covered Person, for which the provider of service customarily makes no
direct charge, or for which the Covered Person is not legally obligated to pay, or for which
no charges would be made in the absence of this coverage, except services or supplies
for treatment of mental illness or mental retardation provided by a tax supported institution
in the State of Texas, (this Plan will not create such duty to pay);
7. in excess of the usual and customary charges and services;
8. for any expenses due to any Pre - Existing Condition. A Pre - Existing Condition is any illness
or injury:
a for which medical expenses were incurred;
b. for which medical treatment was recommended;
c. for which medical treatment was received;
d. for which drugs were prescribed; or
e. for which a Physician was consulted during the twelve (12) month period immediately
prior to the effective date of coverage under the Plan.
Coverage will be available for such conditions on the date on which a Covered Person
completes twelve (12) consecutive months of coverage under the Plan.
46
SECTION X - LIMITATIONS AND EXCLUSIONS APPLICABLE TO MEDICAL BENEFITS
This exclusion shall not apply to a Covered Person who was covered under the Prior Plan.
Any time accumulated toward satisfaction of the Pre - Existing Condition limitation under the
previous City of Round Rock Benefit Plan will be counted toward the satisfaction of the Pre -
Existing Condition limitation of the Plan.
9. for cosmetic surgery or complications of cosmetic surgery, except for treatment of
Accidental Bodily Injury which was sustained while the Person was covered under the Plan
and provided such treatment is received within six (6) months from the Injury, or for the
correction of a congenital anomaly in a child who was covered under the Plan from birth;
10. the result of intentionally self - inflicted injuries or illnesses, whether sane or insane;
11. caused or contributed to by the Covered Person's commission or attempted commission
of a crime, or being engaged in an illegal occupation;
12. in connection with a Covered Person's participation in a riot or insurrection;
13. the result of an act of war, declared or undeclared, or any type of military conflict, nor loss
caused by any means for disease contracted or injuries sustained In any country while such
country is at war, or while en route to or from any such country at war;
14. for travel and accommodations in, or outside the United States and its territories, whether
or not recommended by a Physician;
15. rendered by a member of the Covered Person's family or close relative, including a person
related by blood or marriage to the Covered Person;
16. for custodial and sanitaria care and services, or for rest cures;
17. for treatment by hypnosis, except as part of the Physician's treatment of a mental illness,
or when hypnosis is used in lieu of an anesthetic;
18. for care and treatment of Mental /Nervous Disorders in excess of the limits specified in the
"SCHEDULE OF BENEFITS" and under the section entitled "SPECIAL CONDITIONS ";
19. for psychiatric or psychological services in the nature of family counseling or marriage
counseling, or any self therapy to another Psychiatrist or Doctor in Psychology as part of
training, or any services of a Master of Science in Social work who is not a Certified Social
Worker- Advanced Clinical Practitioner or Licensed Professional Counselor, as defined;
20. for any Medical Social Services, except services provided for treatment of Alcohol or Drug
Abuse Conditions, or as an eligible expense of a Skilled Nursing Facility Confinement or
a part of Hospice Care, or Home Health Care;
21. for educational and recreational therapy or for occupational therapy services which do not
consist of traditional physical therapy modalities, except as provided for under treatment
of Alcohol or Drug Abuse Conditions, or as an eligible expense of a Skilled Nursing Facility
or Home Health Care;
22. services or supplies rendered to any Covered Employee or Dependent in connection with
a voluntary Interruption of pregnancy, unless the voluntary Interruption of the pregnancy is
Medically Necessary, where the life of the Covered Employee or Dependent would be
endangered if the fetus were carried to term, or the pregnancy is the result of a criminal act
such as rape or incest or if a fetal or chromosomal abnormality exists which was diagnosed
prior to the abortion. Benefits for treatment of complications, arising from or as a result of
any voluntary interruption of a pregnancy shall be payable on the same basis as an Illness;
23. any services or supplies provided for reduction of obesity or weight, including surgical
procedures, even if the Covered Person has other health conditions which might be helped
by a reduction of obesity or weight;
47
SECTION X - LIMITATIONS AND EXCLUSIONS APPLICABLE TO MEDICAL BENEFITS
24. any services or supplies which are not Medically Necessary and essential to the diagnosis
or direct care and treatment of a sickness, injury, condition, disease or bodily malfunction;
or any Experimental /Investigational services and supplies;
25. any services or supplies provided for treatment of adolescent behavior disorders, including
conduct disorders and oppositional disorders;
26. any charges resulting from failure to keep a scheduled visit while a Physician or any
charges for completion of any insurance form;
27. for infertility testing and treatment, artificial insemination, in vitro fertilization and other direct
attempts to induce pregnancy, including drug therapy;
28. for reversal of sterilization procedures or surgery;
29. expenses incurred for:
a. weak, strained or flat feet;
b. instability or imbalance of the foot;
c. tarsalgia, metatarsalgia, bursitis or bunion, except surgery requiring the cutting and
suturing of tendons, ligaments or bones; or
d. toenails or superficial lesions of the foot, including but not limited to corns, callouses
and warts, except for removal of nail matrix or root.
30. for care and services received for the analysis and adjustment of spinal subluxation, or for
the diagnosis and treatment by manipulation of the skeletal structure for other than
fractures and dislocations of the extremities, in excess of the limits specified for Chiropractic
Care in the "SCHEDULE OF BENEFITS" and under the section entitled "SPECIAL
CONDITIONS";
31. for any services or supplies rendered primarily for:
a. Environmental Sensitivity Testing or treatment which includes (1) controlled
environment, (2) sanitizing the surroundings, or removal of toxic materials, (3) use of
special nonorganic, nonrepetitive diet techniques; or
b. Clinical Ecology testing or treatment which includes (1) cytotoxicity testing (testing the
result of food or inhalant by whether or not it reduces or kills white blood cells); (2)
urine auto injection (injecting one's own urine into the tissue of the body); (3) skin
irritation by Rinkel Method; (4) subcutaneous provocative and neutralization testing
(injecting the patient with allergen); (5) sublingual provocative testing (droplets of
allergenic extracts are placed in mouth); or (6) any other treatment not recognized as
safe and effective by the American Academy of Allergists and Immunologists.
32. for meridian therapy (acupuncture);
33. for, or in conjunction with, chelation therapy, except for treatment of acute metal poisoning;
34. for services or supplies rendered to a Covered Person for Dietary and Nutritional Services,
except for a nutritional assessment program provided by a Licensed Dietician during a
Hospital admission, which has been recommended by a Physician and which has been
approved by the Plan Administrator;
35. for treatment of nicotine use or addiction;
36. treatment of myopia, and other errors of refraction, orthoptics or visual training, radial
keratotomy, unless such treatment is made necessary as a result of Illness or Injury;
37. for eye exercises, eyeglasses, contact lenses, or hearing aids, or for the fitting or
examination of such, except as required due to intraocular surgery of Accidental Bodily
Injury sustained while the person is covered under the Plan. However, no charges are
48
SECTION X - LIMITATIONS AND EXCLUSIONS APPLICABLE TO MEDICAL BENEFITS
payable for treatment received more than six (6) months from the date of surgery or the
date of the Injury;
38. for any services or supplies rendered for gender reassignment or to improve or restore
sexual function, unless such treatment is made necessary as a result of Illness or Injury;
39. for orthopedic shoes, unless attached to a brace, supports and other foot support devices,
including casting or impressions, regardless of whether store bought or specially built for
the patient;
40. for the purchase of air conditioners, dehumidifiers, humidifiers, and air purifiers, whether or
not recommended by a Physician;
41. for dentistry of any kind, except where specifically provided as a Covered Expense;
42. for examinations or tests for checkup purposes which are not incident and necessary to the
treatment of an Injury or Sickness, except as specifically shown under "Preventive Care" in
the section entitled "SPECIAL CONDITIONS';
43. for immunizations, except when required as a result of an Accidental Bodily Injury, or except
as specifically shown under "Preventive Care" in the section entitled "SPECIAL
CONDITIONS ";
44. for the routine nursery and pediatric care of a newborn child, except as specifically shown
under "Newborn Care" in the section entitled "SPECIAL CONDITIONS ";
45. charges for drugs and medicines incurred out -of- hospital, except as provided under the
Prescription Drug Program;
46. for any benefits that are not payable due to the application of any deductible or co- payment
provisions contained herein;
47. for any services or supplies furnished to a Covered Person prior to his effective date, or
subsequent to his termination date of coverage under the Plan;
48. incurred more than six (6) months prior to the date a claim for benefits is filed;
49. for care and treatment of temporomandibular joint (TMJ) syndrome except as specified in
the section entitled "SPECIAL CONDITIONS ";
50. any expenses incurred for orthognathic surgery (surgery to correct congenital or
development maxillofacial deformities of the mandible and maxilla) after the Covered
Person's nineteenth (19th) birthday; or
51. not specifically listed as a Covered Expense.
49
SECTION XI - COMPREHENSIVE DENTAL EXPENSE BENEFITS
1. BENEFITS PAYABLE
If a Covered Person incurs Covered Dental Expenses in excess of the Annual Cash
Deductible shown in the section entitled "SCHEDULE OF BENEFITS," the Plan will pay the
benefits specified in this section. The applicable benefits payable shall not exceed any
Maximum Benefit shown In the "SCHEDULE OF BENEFITS ".
2. BENEFIT PERCENTAGE PAYABLE
The percentage of benefits payable for usual and customary charges incurred in excess of
the Annual Cash Deductible, when applicable, is shown in the "SCHEDULE OF BENEFITS."
3. DEDUCTIBLE AMOUNT
The Deductible Amount is the Annual Cash Deductible specified in the "SCHEDULE OF
BENEFITS" The Annual Cash Deductible will be deducted from the expenses covered
under this section before benefits are computed under this section, unless the "SCHEDULE
OF BENEFITS" indicates otherwise.
The Annual Cash Deductible applies separately to each Covered Person in each Calendar
Year; subject to the following:
a. Covered Dental Expenses incurred during any one (1) Calendar Year, and applied
toward satisfaction of a covered family member's Annual Cash Deductible, will be
accumulated toward the Family Limit specified in the "SCHEDULE OF BENEFITS."
When such Family Limit has been satisfied, the Annual Cash Deductible will be waived
for Covered Dental Expenses incurred by any covered family member during the same
Calendar Year.
b. Covered Dental Expenses incurred by any Covered Person in the last three (3)
months of any Calendar Year, and applied toward satisfaction of the Annual Cash
Deductible for that year, may also be used toward satisfaction of the Annual Cash
Deductible in the next Calendar Year. Such Covered Dental Expenses may be used
toward satisfaction of the Family limit for the Calendar Year in which they are
incurred, but will not be used to satisfy any portion of the Family Limit for the following
Calendar Year.
The Plan reserves the right to allocate the Annual Cash Deductible to any Covered Dental
Expenses and to apportion the benefits to the Covered Person and any assignees.
The Lifetime Deductible for orthodontia specified in the "SCHEDULE OF BENEFITS" will be
deducted from covered orthodontia expenses before benefits are computed.
4. MAXIMUM BENEFITS
Benefits payable to any Covered Person for covered dental expenses incurred for
Preventive, Basic and Major Services shall not exceed any Maximum Benefit specified in
the "SCHEDULE OF BENEFITS" The Orthodontic Services Lifetime Maximum is also
specified in the "SCHEDULE OF BENEFITS."
50
SECTION XI - COMPREHENSIVE DENTAL EXPENSE BENEFITS
5. LIMITATIONS FOR LATE APPLICANTS
If an Employee request Dental Benefits for himself or for any Dependents more than thirty-
one (31) days after the date on which the Employee is first eligible, no Majort9r Orthodontic
Services will be covered for the first twelve (12) months of coverage under the Plan.
PRE - TREATMENT PLAN
If a Covered Person anticipates dental treatment in an amount estimated to be three
hundred dollars ($300) or more, a Pre Treatment Plan should be submitted prior to the
commencement of treatment. This will enable the Covered Person to estimate in advance
his share of the cost.
A Pre Treatment Plan is a written report prepared by the dentist showing the recommended
programs and the estimated cost, An approved Pre Treatment Plan will be subject to
amendments to the Plan, and eligibility of the Covered Person at the time services are
rendered. Any such approved Pre Treatment Plan will only be applicable for a period of six
(6) months from the approval date.
7. COVERED DENTAL EXPENSES
a. Preventive Services. Benefits are payable at one hundred percent (100 %) of eligible
charges, with no deductible, for the following expenses:
(1)
(2)
(3)
(4)
(5)
(6)
routine oral examinations and scaling and cleaning of teeth, but not more than
twice in any Calendar Year;
topical application of fluoride solutions up to age nineteen (19);
space maintainers for missing primary teeth;
emergency treatment for pain;
diagnostic x - rays and laboratory procedures; and
dental x -rays, including full mouth x -rays, but not more than once in any thirty-six
(36) consecutive months, supplementary bitewing x -rays, but not more than
twice in a Calendar Year, and any other dental x -rays required for the diagnosis
of a condition.
b. Basic Services. After satisfaction of the Annual Cash Deductible, benefits are payable
at eighty percent (80 %) of eligible charges for the following expenses:
(1) extractions;
(2) amalgam, silicate, acrylic, synthetic porcelain and composite filling restorations
to restore diseased or accidentally broken teeth;
(3) general anesthetics administered for oral or dental surgery when Medically
Necessary;
(4) treatment of periodontal and other diseases of the gums and tissues of the
mouth;
(5) endodontic treatment, including root canal therapy;
(6) injection of antibiotic drugs by the attending Dentist;
(7) repair or recementing of crowns, inlays, onlays, bridgework or dentures, or
relining or rebasing of dentures more than six (6) months after the installation
51
SECTION XI - COMPREHENSIVE DENTAL EXPENSE BENEFITS
(8)
(
of an initial or replacement denture but not more than once In any thirty-six (36)
consecutive months;
oral surgery; and
sealants up to the age of nineteen (19) years.
c. Major Services. After satisfaction of the Annual Cash Deductible, benefits are payable
at fifty percent (50 %) of eligible changes incurred for the following expenses:
(1) the first installation of fixed bridgework including inlays and crowns as
abutments;
(2) the first installation of partial or full removable dentures including precision
attachments and any adjustments during the six (6) month period following
installation;
(3) replacement of an existing partial or full removable denture or fixed bridgework
by a new one, or the addition of teeth to an existing partial removable denture
or bridgework if satisfactory evidence is presented that:
(a) the replacement or addition of teeth is necessary to replace one (1) or
more teeth extracted after the existing denture or bridgework was installed;
(b) the existing denture or bridgework was installed at least five (5) years prior
to its replacement, and the existing denture or bridgework cannot be fixed;
or
(c) the existing denture is a temporary denture which cannot be made
permanent, and replacement is made within twelve (12) months after the
temporary one was installed.
Normally, dentures will be replaced by dentures, but If a professionally adequate
result can be achieved only with bridgework, the bridgework will be a Covered
Dental Expense.
(4) inlays, onlays, gold - fillings or crown restorations to restore diseased or
accidentally broken teeth, but only when the tooth, as a result of extensive
caries or fracture, cannot be restored with an amalgam, silicate, acrylic, synthetic
porcelain or composite filling restoration.
d. Orthodontic Services. After satisfaction of the Ufetime Deductible for orthodontia,
benefits are payable at fifty percent (50 %) of eligible expenses Incurred for orthodontic
diagnostic procedures and treatment consisting of surgical therapy and
functional /myo- functional therapy, including related oral examinations, surgery and
extractions. Orthodontic Services are payable monthly over the course of treatment,
and cease upon termination of coverage. This benefit Is limited to Covered Persons
under nineteen (19) years of age.
52
SECTION XII - LIMITATIONS AND EXCLUSIONS APPLICABLE TO DENTAL BENEFITS
1. RESTORATIVE
a. Gold, baked porcelain restorations, crowns and jackets. If a tooth can be restored
with a material like amalgam, payment of the applicable percentage of the charge for
that procedure, will be made toward the charge for another type of restoration
selected by the Covered Person and the Dentist. The rest of the charge will be the
responsibility of the Covered Person.
b. Reconstruction. Payment, based on the applicable percentage, will be made toward
the cost of procedures necessary to eliminate oral disease and to replace missing
teeth. Appliances or restorations necessary to increase vertical dimension or restore
the bite are considered optional. Their cost will be the responsibility of the Covered
Person.
2. PROSTHODONTICS
a. Partial Dentures. If a cast chrome or acrylic partial denture will restore the dental arch
satisfactorily, payment of the applicable percentage of the cost of that procedure, will
be made toward a more elaborate or precision appliance that the Covered Person
and Dentist may choose to use. The rest of the cost will be the responsibility of the
Covered Person.
b. Complete Dentures. If, in the provision of complete denture services, the Covered
Person and the Dentist decide on personalized restorations or specialized techniques
as opposed to standard procedures, payment of the applicable percentage of the
cost of the standard denture services will be made toward that treatment. The rest
of the cost wit be the responsibility of the Covered Person.
c. Replacement of Existing Dentures. Replacement of an existing denture will be a
covered dental expense only if the existing denture is unserviceable and cannot be
fixed. Payment, based on the applicable percentage, will be made toward the cost
of services which are necessary to fix the appliance. Replacement of prosthodontic
appliances will be a covered dental expense only if at least five (5) years have lapsed
since the date of the Initial installation of that appliance.
3. PROOF OF CLAIM
The Plan reserves the right, at its discretion, to accept or to require verification of any
alleged fact or assertion pertaining to any claim for covered dental expenses. As part of
the basis for determining benefits payable, the Plan Administrator may require submission
of x-rays and other appropriate diagnostic and evaluative materials. When these materials
are unavailable, and to the extent that verification of covered dental expenses cannot
reasonably be made by the Plan Administrator based on the information available, benefits
for the course of treatment may be for a lesser amount that which otherwise would have
been payable.
4. EXTENDED BENEFITS AFTER TERMINATION
If coverage terminates during a period when a Covered Employee or Dependent is incurring
covered dental expenses, benefits will be payable as provided under the Plan for covered
dental expenses incurred as follows:
53
SECTION XII - LIMITATIONS AND EXCLUSIONS APPLICABLE TO DENTAL BENEFITS
a. charges for dentures will be payable if the impression was taken prior to termination
of benefits and the dentures are installed within two (2) months following such
termination;
b. charges for fixed bridgework, crowns and gold restorations will be payable if the tooth
was prepared prior to termination of benefits, and the bridge, crown or gold
restoration is placed within two (2) months following such termination; and
c. charges for endodontics, including root canal therapy, will be payable if the tooth was
opened prior to termination of benefits, and the expenses in connection with the
endodontic treatment are incurred within two (2) months following such termination.
5. The Plan does not cover any services which are:
a. dental treatment received from a dental or medical department maintained by the
Employer, a mutual benefit association, labor union, trustee or similar type of group;
b. dental treatment required as a result of intentionally self - inflicted injury, war or
engaging in a riot or insurrection;
c. broken appointments or completion of claim forms or pre- treatment forms required by
the Planholder;
d. dietary planning, plaque control or oral hygiene instruction;
e. installation of an initial prosthodontic appliance when such charges are incurred for
replacement of congenitally missing teeth, or replacement of teeth all of which were
lost while the individual was not covered under the Plan;
f. replacement of an existing prosthodontic appliance unless:
(1) replacement is necessitated by the extraction of additional natural teeth while
covered under the Plan;
(2) the existing appliance is at least five (5) years old and cannot be made
serviceable, and twelve (12) months have lapsed since the effective date
coverage; or
(3) the replacement appliance is made necessary as the result of an initial
placement of an opposing denture while covered.
g. any expenses incurred for treatment rendered after the date of termination of an
individual's coverage, except as specked under subsection 4. of this section, entitled
"EXTENDED BENEFITS AFTER TERMINATION ";
h. any expenses incurred for treatment rendered due to an occupational cause;
i. any care, services, supplies or treatment rendered on an experimental or research
basis, which Is not recognized as a generally accepted dental practice;
j. any expenses in excess of the usual and customary charge for the service or supply
or any supply or service that is not reasonably necessary for the dental care of the
covered person;
k. treatment other than by a duly licensed Dentist or a Physician, except treatment by
a Dental Hygienist, technician or laboratory by or under the direction of a Dentist or
Physician;
I. any care or services for which the provider customarily makes no charge to a
Covered Person;
m. any care or service rendered by a member of the Covered Person's family or close
relative, including a person related by blood or marriage to the Covered Person;
n. any care or service covered in whole or in part under any other section of the Plan;
54
SECTION XII - LIMITATIONS AND EXCLUSIONS APPLICABLE TO DENTAL BENEFfTS
o. temporary restorations, except if temporary restoration is part of a course of treatment,
the maximum benefit for a permanent restoration shall include the fee for temporary
restoration;
p. any duplicate prosthetic device or any other duplicate appliance including
replacement of lost, missing or stolen prosthetic devices;
q. implantology;
r. night guards for bruxism;
s. appliances, restorations or special equipment used to increase vertical dimension,
reconstruct occlusion or correct or treat temporomandibular joint dysfunction or TMJ
pain syndromes;
t. charges for care or treatment of occlusion by adjustment, appliance, or restoration,
except for orthodontics and osseous surgery;
u. any expense incurred prior to becoming covered or any dental work in progress at
the time a patient becomes covered under the Plan or any treatment of a congenital
or developmental malformation existing when the person became covered under the
Plan;
v. any charges in excess of the charges customarily made when alternate services or
supplies are customarily available for such treatment, beyond the charge for the least
expensive service or supply resulting in professionally adequate treatment;
w. services and supplies that are cosmetic in nature, including charges for
personalization or characterization of dentures;
x. any charges incurred more than six (6) months prior to the date the claim for benefits
is filed; or
y. any item which is not listed as a Covered Expense.
55
SECTION XIII - DENTAL DEFINrrIONS
1. Abutment means a tooth or root that retains or supports a fixed bridge or a removal
prosthesis.
2. Acid Etch means the etching of a tooth with a mild acid to aid in the retention of composite
filling material.
3. Acrylic means plastic materials used in the fabrication of dentures and crowns and
occasionally as a restorative filling material.
4. Amalgam means a metal alloy usually consisting of silver, tin, zinc and copper, combined
with liquid pure mercury and used as a restorative material in operative dentistry.
5. Anesthesia means: local - the condition produced by the administration of specific agents
to achieve the loss of pain sensation in a specific location or area of the body; general -
the condition produced by the administration of specific agents to render the patient
completely unconscious and without pain sensation.
6. Appliance means a device used to provide function, therapeutic (healing) effect or space
maintenance, or as an application of force to teeth to provide movement or growth
changes, as in Orthodontics. Fixed - one that is attached to the teeth by cement or by
adhesive materials and cannot be removed by the patient. Removable - one that can be
taken in and out of the mouth by the patient. Prosthetic - used to provide replacement for
a missing tooth.
7. Bitewing means a type of dental x -ray film that has a central tab or wing upon which the
teeth close to hold the film in position. They are commonly called decay detecting x -rays
because they show decay better than other x -rays.
8. Bridgework or Prosthetic Appliance means: fixed - pontics or replacement teeth retained
with crowns or inlays cemented to the natural teeth, which are used as abutments; fixed
removable -one which the dentist can remove but the patient cannot; removable - a partial
denture retained by attachments which permit removal of the denture, normally held by
clasps.
9. Caries means a disease of progressive destruction of the teeth from bacterially produced
acids on tooth surfaces.
10. Composite means tooth colored filling material primarily used in the anterior teeth.
11. Course of Treatment means a planned program of one or more services or supplies,
whether rendered by one or more dentists, for the treatment of a dental condition
diagnosed by the attending dentist. The course of treatment begins on the date a dentist
first renders a service to correct or treat the diagnosed dental condition.
12. Crown means: natural crown - the portion of a tooth covered by enamel; artificial crown
(cap) - restores the anatomy, function and esthetics of the natural crown.
13. Dental Hygienist means a person who has been trained to clean teeth and provide
additional services and information on the prevention of oral disease.
14. Dentist means a Doctor of Dental Surgery (D.D.S.) or a Doctor of Medical Dentistry (D.M.D.),
who holds a lawful license authorizing the person to practice dentistry in the locale in which
the service is rendered.
15. Denture means a device replacing missing teeth. The term usually refers to full or partial
dentures but it actually means any substitute for missing natural teeth.
16. Endodontic Therapy means treatment of diseases of the dental pulp and their canals.
17. Emergency Palliative Treatment means any dental procedures necessary to alleviate (but
not cure) acute pain or temporarily alleviate (but not cure) conditions requiring the
immediate attention of a dentist to prevent irreparable harm to the Covered Person.
18. Fluoride means a solution of fluorine which is applied to the teeth for the purposes of
preventing dental decay.
56
SECTION XIII - DENTAL DEFINr1lONS
19. Implant means a device surgically inserted into or onto the jaw bone. It may support a
crown or crowns, a partial denture or complete denture, or may be used as an abutment
for a fixed bridge.
20. Impression means a negative reproduction of a given area. It is made in order to produce
a positive form or cast of the recorded teeth and or soft tissues of the mouth.
21. Incurred Date means:
a. for an appliance or modification of an appliance, the date the impression is taken;
b. for a crown, bridge or gold restoration, the date the tooth is prepared;
c. for root canal therapy, the date the pulp chamber is opened; and
d. for all other services, the date the service is received.
22. Inlay means a restoration, usually of castmetals, made to fit a prepared tooth cavity and
then cemented into place.
23. Malocclusion means an abnormal contact and /or position of the opposing teeth when
brought together.
24. Occlusion means the contact relationship of the upper and lower teeth when they are
brought together.
25. Onlay means a cast restoration that covers the entire chewing surface of the tooth.
26. Orthodontics means the branch of dentistry primarily concerned with the detection,
prevention and correction of abnormalities in the positioning of the teeth in relationship to
the jaws.
27. Palliative means an alleviating measure. To relieve but not cure.
28. Partial Denture means a prosthesis replacing one or more, but less than all, of the natural
teeth and associated structures. It may be removable or fixed, on one or both sides of the
mouth.
29. Pedodontics means the specialty of children's dentistry.
30. Periodontics means the science of examination, diagnosis and treatment of diseases
affecting the supporting structures of the teeth.
31. Pontic means the part of a fixed bridge which is suspended between the abutments and
which replaces a missing tooth or teeth.
32. Prophylaxis means the removal of tartar and stains from the teeth. The cleaning of the
teeth by a dentist or dental hygienist.
33. Rebase means a process of refitting a denture by replacement of the entire denture -base
material, without changing the occlusal relations of the teeth.
34. Reline means to resurface the tissue -borne areas of a denture with new material.
35. Restoration is a broad term applied to any inlay, crown, bridge, partial denture or complete
denture that restores or replaces loss of tooth structure, teeth or oral tissue. The term
applies to the end result of repairing and restoring or reforming the shape, form and
function of part or all of a tooth or teeth.
36. ' Root Canal Therapy means the complete removal of the pulp tissues of a tooth, sterilization
of the pulp chamber and root canals, and filling these spaces with a sealing material.
37. Scaling means the removal of calculus (tartar) and stains from teeth with special
instruments.
38. Sealant means a resinous agent applied to the grooves and pits of teeth to reduce decay.
39. Silicate means a relatively hard and translucent restorative material that is used primarily
In the anterior teeth.
40. Splinting means stabilizing or immobilizing teeth to gain strength and /or facilitate healing.
57
SECTION XIII - DENTAL DEFINfI ONS
41. Topical means painting the surface of teeth, as in fluoride treatment, or application of an
anesthetic formula to the surface of the gum.
42. Vertical Dimension means the degree of jaw separation when the teeth are in contact.
58
SECTION XIV - PRESCRIPTION DRUG PROGRAM BENEFITS
1. BENEFITS PAYABLE
a. Payment of benefits to the Pharmacy dispensing the drugs or to the Covered
Employee, as the Claims Administrator may elect, shall constitute full discharge of all
responsibility to the Covered Employee on account of benefits available to any
Covered Person under the Plan;
b. The rights and benefits of the Plan shall not be assignable, either before or after
Covered Drugs are dispensed or delivered;
c. It is understood and agreed that the allowances for drugs dispensed by a Pharmacy
are not intended to and do not fix the value of the services of the Pharmacy nor in
any way relate or regulate such value; that such Pharmacy is privileged to make its
regular charges and that the stipulated amounts are merely to apply as credits
thereon; and
d. Any benefits payable to the Covered Employee shall, if unpaid at his death, be paid
to the Covered Employee's estate.
2. COVERED PERSON/PHARMACY RELATIONSHIP
The choice of a Pharmacy is made solely by a Covered Person. The Plan does not
dispense drugs but only makes payment for Covered Drugs purchased by Covered Person.
Neither the Plan nor the Claims Administrator is liable for any act or omission by any
Pharmacy, and they do not have any responsibility for a Pharmacy's failure or refusal to
dispense drugs to a Covered Person.
3. PARTICIPATING PHARMACIES
a. When any Covered Person, while covered under the Plan, shall obtain Covered Drugs
at a Participating Pharmacy, upon:
(1) presentation of a current valid Identification Card;
(2) payment to the Pharmacy of the appropriate Co- Payment Amount for the drugs
received; and
(3) providing a valid Prescription Order and the necessary recipient information and
signatures required by the Pharmacy, the Plan will provide benefits to the
Participating Pharmacy equal to the contractually agreed to Reasonable Charge
amount remaining for the Covered Drugs dispensed.
b. If Covered Drugs are obtained from a Participating Pharmacy by a Covered Person
while covered under the Plan, prior to the Covered Employee's receipt of an
Identification Card, the Plan will reimburse the Covered Employee for the amount paid,
less the appropriate Co- Payment Amount.
c. If Covered Drugs are obtained from a Participating Pharmacy by a Covered Person
while covered under the Plan, after the Covered Employee's receipt of an Identification
Card, and the Covered Person does not comply with the requirements specified
above, at the time the Covered Drug is dispensed, the Plan will reimburse the
Employee an amount equal to the billed Pharmacy charge, less the appropriate
Co- Payment Amount, up to the amount the Plan would have paid the Participating
Pharmacy under the Claims Administrator's contractual arrangement with the
59
SECTION XIV - PRESCRIPTION DRUG PROGRAM BENEFITS
Pharmacy. The Claims Administrator will provide documentation of its determination
of the benefit amount upon request of the Covered Employee.
4. NONPARTICIPATING PHARMACIES
When any Covered Person, while covered under the Plan, shall obtain Covered Drugs at
a Nonparticipating Pharmacy, the Plan will pay benefits equal to eighty percent (80%) of the
billed charge (but not more than eighty percent (80 %) of the Average Wholesale Price) plus
a dispensing fee less the appropriate Co- Payment Amount. The Claims Administrator will
provide documentation of its determination of the benefit amount upon request of the
Covered Employee.
5. IJMITATIONS ON QUANTITIES DISPENSED
a. Covered Drug benefits, except as provided below, shall be limited to no more than
a thirty (30) calendar day supply on any occasion when a Prescription Order is
dispensed; and
b. Covered Drugs for the treatment of chronic conditions are covered under the Plan
when prescribed and dispensed in amounts not to exceed the amounts indicated
below on any occasion when such Prescription Order is dispensed. If the dosage
quantities allowed below, for a particular Covered Person results in an amount to be
dispensed that is less than a thirty (30) calendar day supply, a thirty (30) calendar day
supply would be permitted.
(1) Ninety (90) calendar day supply quantities:
Oral contraceptive medications which are Legend Drugs
(2) One hundred (100) individual dose quantities:
(3)
Anticoagulants
Antifungal Agents
Covered Prenatal Vitamins
Urinary and Intestinal Anti- infectives
Two hundred (200) individual dose quantities:
Antiarthritic Drugs
Anticholinergic and Parasympatholytic Agents
Anticonvulsants
Antidiabetics
Antihistamines
Cardiac Drugs
Diuretics
Hormones
Hypotensive Agents
Thyroid Preparations
60
SECTION XIV - PRESCRIPTION DRUG PROGRAM BENEFITS
c. Benefits for injectable insulin shall be limited to no more than four (4) ten (10) cc vials
on any occasion when the insulin is dispensed under a Prescription Order.
d. The quantity of disposable syringes and needles covered for self- administered
injections shall be limited on each occasion dispensed to amounts appropriate to the
dosage amounts of covered injectable drugs actually prescribed and dispensed, but
cannot exceed one hundred (100) syringes and needles on any occasion dispensed.
e. Payment for benefits covered under the Plan may be denied when drugs are
dispensed or delivered in a manner intended to circumvent, or having the effect of
circumventing, the quantity limitations described above, such as obtaining multiple
refills for the same Prescription Order prior to the original supply being consumed. _
6. CO- PAYMENT LIMIT
The benefits of the Plan shall be available for Covered Drugs dispensed by a Participating
Pharmacy after application of one (1) of the following Co- Payment Amounts as applied for
in the Schedule, if any:
a. Generic Substituted Drugs
If a Co- Payment Amount is applied for under "Generic Substituted Drug Co- Payment
Amount," this Co- Payment Amount shall apply to each covered Generic Substituted
Drug dispensed.
b. Other Covered Drugs and Devices
If a Co- Payment Amount is applied for under "Other Drug Co- Payment Amount," this
Co- Payment Amount shall apply to each Covered Drug dispensed other than Generic
Substituted Drugs.
The Co- Payment Amounts described above, as applied for, will be shown on the
Identification Card. The Covered Person is obligated to pay the appropriate Co- Payment
Amount to the Pharmacy before benefits under the Plan will apply.
7. IDENTIFICATION CARD
a. Identification Cards for each Covered Employee will be provided to the Employer for
issuance to the Covered Employee. Where coverage applied for is other than for an
individual Covered Employee, two (2) cards will be provided.
b. The Identification Card is required to be presented to Participating Pharmacies in
order for a Covered Person to receive full program benefits. The card will contain
information needed by the Participating Pharmacy to identify the Covered Person.the
group and the coverage applied for. Participating Pharmacies are not permitted to
file claims for reimbursement under the Plan unless the card is presented at the time
Covered Drugs are received from the Pharmacy.
c. When coverage for any Covered Employee Is terminated, or the Plan is terminated or
canceled by the Employer, for any reason, the Employer will immediately notify the
Claims Administrator in writing and will recover from the Employee any Identification
Cards issued to Covered Persons which have not expired as of the Employee's
61
SECTION XIV - PRESCRIPTION DRUG PROGRAM BENEFITS
termination date or the Plan termination date, as indicated by the "valid through" date
shown on the card, to prevent their further use.
d. In the event any Covered Person fails to surrender the card upon termination or
cancellation of coverage and continues to make use of the Identification Card, the
Employer will assist the Claims Administrator in recovering any benefits paid out in
"good- faith" payments to Participating Pharmacies honoring an Identification Card
showing a current "valid through" date. Such assistance shall include providing a
current address or location to which cease and desist letters and collection notices
could be sent and otherwise using the Employer's good offices to locate the
Employee or former Employee.
e. If the Employer fails to provide the written notice of termination or cancellation as
specified above, prior to the effective date of cancellation or termination (including
terminations resulting from default in premium payments) and if the Employer fails to
recover unexpired Identification Cards, the Employer shall be responsible for any
"good- faith" payments made to Participating Pharmacies honoring an Identification
Card showing a current "valid through" date.
8. UNAUTHORIZED, FRAUDULENT, IMPROPER OR ABUSIVE USE OF IDENTIFICATION
CARDS
a. The unauthorized, fraudulent, improper or abusive use of Identification Cards issued
to a Covered Employee and his Covered Dependents shall include, but not be limited
to:
(1) Use of Identification Card prior to effective date (the "valid" date);
(2) Use of Identification Card after expiration date (the "through" date);
(3) Obtaining prescription drugs or other benefits which are not covered under the
Plan;
(4) Obtaining prescription drugs or other benefits for persons not covered under the
Plan;
(5) Obtaining Covered Drugs for resale or for use by any person other than the
person for whom the Prescription Order is written, even though the person is
otherwise covered under the Plan;
(6) Obtaining Covered Drugs without a Prescription Order or through the use of a
forged or altered Prescription Order;
(7) Obtaining quantities of prescription drugs in excess of Medically Necessary or
prudent standards of use or in circumvention of the quantity limitations of the
Plan;
(8) Obtaining prescription drugs using Prescription Orders for the same drugs from
multiple Practitioners;
(9) Obtaining prescription drugs from multiple Pharmacies through use of the same
Prescription Order.
b. Improper use of Identification Cards by a Covered Person can result in, but is not
limited to, the following sanctions being applied to all Covered Persons covered under
the Planholder's coverage:
(1) Denial of benefits;
62
SECTION XIV - PRESCRIPTION DRUG PROGRAM BENEFITS
(2) Cancellation of coverage under the Plan for all Covered Person covered under
the Planholder's coverage;
(3) Limitation on the use of Identification Card to one designated Participating
Pharmacy of the Planholder's choice;
(4) Recoupment from the Planholder or Covered Person of any benefit payments
made;
(5) Pre - approval of drug purchases for all Covered Persons covered under the
Planholder's coverage;
(6) Notice to proper authorities of potential violations of law or professional ethics.
63
SECTION XV - LIMITATIONS AND EXCLUSIONS APPLICABLE TO PRESCRIPTION DRUG
PROGRAM
This section applies to all prescription drug benefits provided by the Plan.
The Plan does not cover any charge for:
a. drugs which do not by law require a Prescription Order from a Practitioner (except
injectable insulin); and drugs, Insulin, or covered devices for which no valid
Prescription Order is obtained;
b. devices or durable medical equipment of any type (even though such devices may
require a Prescription Order), such as, but not limited to, contraceptive devices,
therapeutic devices, artificial appliances, or similar devices (except disposable
hypodermic needles and syringes for self - administered injections);
c. administration or injection of any drugs;
d. vitamins (except those vitamins which by law require a Prescription Order and for
which there is no non - prescription alternative);
e. drugs dispensed in a Practitioner's office or during confinement while a patient in a
hospital, or other acute care institution or facility, including take -home drugs; and
drugs dispensed by a nursing home or custodial or chronic care institution or facility;
f. covered drugs, devices, or other Pharmacy services or supplies provided or available
in connection with an occupational illness or an injury sustained in the scope of and
in the course of employment whether or not benefits are, or could upon proper claim
be, provided under the Workers' Compensation law;
g. covered drugs, devices, or other Pharmacy services or supplies for which benefits are,
or could upon proper claim be, provided under any present or future laws enacted by
the Legislature of any state, or by the Congress of the United States, or the laws,
regulations or established procedures of any county or municipality, or any
prescription drug which may be properly obtained without charge under local, state,
or federal programs, unless such exclusion is expressly prohibited by law; provided,
however, that the exclusions shall not be applicable to any coverage held by the
Covered Person for prescription drug expenses which is written as a part of or in
conjunction with any automobile casualty insurance policy;
h. any services provided or items furnished for which the Pharmacy normally does not
charge;
i. drugs for which the Pharmacy's usual and customary charge to the general public Is
less than or equal to the amount of Co- Payment provided under the Plan;
j. contraceptive devices, contraceptive materials, infertility medication, and fertility
medication (except oral contraceptive medications which are Legend Drugs);
k. any prescription antiseptic or fluoride mouthwashes, mouth rinses, or topical oral
solutions or preparations; and any Retin -A or pharmacologically similar topical drugs
for Participants age twenty -five (25) and older;
I. drugs required by law to be labeled: "Caution— Limited by Federal Law to
Investigational Use," or experimental drugs, even though a charge is made for the
drugs;
m. covered drugs dispensed in quantities in excess of the amounts stipulated in the Plan,
or refills of any prescriptions in excess of the number of refills specified by the
Practitioner or by law, or any drugs or medicines dispensed more than one (1) year
following the Prescription Order date;
64
SECTION XV - LIMITATIONS AND EXCLUSIONS APPUCABLE TO PRESCRIPTION DRUG
PROGRAM
n. legend drugs which are not approved by the U.S. Food and Drug Administration
(FDA) for a particular use or purpose or when used for a purpose other than the
purpose for which FDA approval is given;
o. fluids, solutions, nutrients, or medications (including all additives and chemotherapy)
used or intended to be used by intravenous or gastrointestinal (enteral) infusion or
by intravenous injection in the home setting;
p. drugs prescribed and dispensed for the treatment of obesity or for use in any
program of weight reduction, weight loss, or dietary control;
q. drugs the use or intended use of which would be illegal, unethical, imprudent,
abusive, not Medically Necessary, or otherwise improper;
r. drugs obtained by unauthorized, fraudulent, abusive, or improper use of the
Identification Card;
s. drugs used or intended to be used in the treatment of a condition, sickness, disease,
injury, or bodily malfunction which is not covered under the Employer's health care
plan, or for which benefits have been exhausted;
t. rogaine, minoxidil or any other drugs, medications, solutions or preparations used or
intended for use in the treatment of hair Toss, hair thinning or any related condition,
whether to facilitate or promote hair growth, to replace lost hair, or otherwise; and
u. any smoking cessation prescription drug products, including, but not limited to,
nicotine gum or nicotine patches.
65
SECTION XVI - CLAIMS
1. Claims Procedure. The procedures outlined below must be followed to obtain payment of
benefits under the Plan for themselves and their Covered Dependents.
a. Notice of Claim. Within six (6) months after the date a loss occurs or commences,
written notice must be submitted to the Planholder, which identifies the person whose
condition, sickness or injury is the basis of a claim.
b. Claim Forms. Claims forms for submitting proof of loss will be furnished by the
Claims Administrator upon receipt of notice of a claim. If such forms are not furnished
within fifteen (15) days after receipt of a notice of claim, a Covered Person may use
any written form as a claim form, to submit a proof of loss which includes information
indicating the occurrence, character and extent of the loss for which a claim is made.
c. Proof of Loss. A completed claim form, together with the original bills for medical
expenses incurred and /or the attending Physician's statement of charges, must be
submitted to the Claims Administrator within six (6) months from the date a loss
occurs or commences. In the case of a claim for benefits for a continuing loss, for
which periodic payments are provided under the Plan, a claim form must be submitted
to the Planholder within ninety (90) days after the termination of the period for which
the Planholder is liable.
d. Limitation of Liability. The Planholder shall not be obligated to pay any benefits under
the Plan for any claim, if the proof of loss for such claim was not submitted to the
Claims Administrator within the period provided in paragraph c., above, unless it is
shown that (1) it was not reasonably possible to have submitted the proof of loss
within such period, and (2) the proof of loss was submitted as soon as it was
reasonably possible. In no event, will the Planholder be obligated to pay benefits for
any claim if the proof of loss for such claim is not submitted to the Claims
Administrator within six (6) months from the date a loss occurs or commences, except
In the case of legal incapacity of the Covered Employee and /or Dependent.
e. Physical Examinations. The Planholder reserves the right to have a Physician of its
own choosing examine the person of any Covered Person whose condition, sickness
or injury is the basis of a claim. All such examinations shall be at the expense of the
Planholder. This right may be exercised when and as often as the Planholder may
reasonably require during the pendency of a claim. The opportunity to exercise this
right shall be a condition for obtaining payment of benefits for the claim.
f. Autopsy. The Planholder reserves the right to have an autopsy performed upon any
deceased Covered Person whose condition, sickness or injury is the basis of a claim.
This right may only be exercised where not prohibited by law.
2. Payment of Claims.
a. lime of Payment
(1) Medical Expense Reimbursement. Benefits for incurred medical expenses which
are covered under the Plan, will be paid immediately upon receipt of proper
written proof of Toss by the Claims Administrator.
(2) Periodic Payments. Payment of accrued periodic payments for continuing
losses which are covered under the Plan, will be made immediately upon receipt
of proper proof of loss by the Claims Administrator, and the applicable time
period thereafter.
66
SECTION XVI - CLAIMS
b. Payment of Benefits.
(1) To Employee. All benefits under the Plan are payable to the Covered Employee
whose sickness or injury, or whose Covered Dependent's sickness or Injury is
the basis of a claim.
(2) Death or Incapacity of Employee. In the event of the death or incapacity of a
Covered Employee, and in the absence of written evidence to the Plan of the
qualifications of a guardian for his estate, the Plan may, in its sole discretion,
make any and all such payments to the individual or institution which, in the
opinion of the Plan, is or was providing the care and support of such Employee.
(3) Assignments. Benefits for medical expenses covered under the Plan may be
assigned by a Covered Employee to the person or institution rendering the
services for which the expenses were incurred. No such assignment will bind
the Planholder unless it is in writing and unless it has been received by the
Claims Administrator prior to the payment of the benefit assigned. The Claims
Administrator will not be responsible for determining whether any such
assignment is valid. Payment of benefits which have been assigned will be
made directly to the assignee unless a written request not to honor the
assignment, signed by the Covered Employee and the assignee has been
received before the proof of loss is submitted.
c. Discharge of Liability. Any payment made in accordance with the provisions of this
section shall fully discharge the liability of the Planholder to the extent of such
payment.
d. Subrogation Rights. Unless otherwise prohibited by law, when benefits are paid as
or for an Employee or Dependent under the terms of the Plan, the Plan shall be
subrogated to the extent of the amount of such payment, to all the rights, powers,
privileges, and remedies of the Employee or Dependent against any person
responsible, at law or in equity, for the Toss or expense for which the benefits were
paid. "Any person responsible" shall include any person legally obligated for payment
for the loss or expense, whether by contract, settlement, or judgement of a court of
competent jurisdiction. The Covered Employee shall cooperate fully with the Plan
Administrator in enforcing the subrogation rights.
e. Act of Third Parties. No benefits are payable under the Plan to or for a person
covered under the Plan when the Injury or Illness to the Covered Person occurs
through the act or omission of another person. However, the Plan may elect to
advance payment for medical care expenses incurred for an Injury or Illness, or a
disability incurred as a result of an Injury or Illness, for which a third party may be
liable. In that event, the Covered Person must sign an agreement with the Planholder
to reimburse the Plan in full for any sums advanced to cover such expenses.
f. Recovery of Payment. The Planholder reserves the right to deduct from any benefits
properly payable under the Plan, the amount of any payment which has been made:
(1) in error; or
(2) pursuant to a misstatement contained in a proof of loss; or
(3) pursuant to a misstatement made to obtain coverage under the Plan within two
(2) years after the date such coverage commences; or
(4) with respect to an ineligible person; or
67
SECTION XVI - CLAIMS
g.
in anticipation of obtaining a recovery in subrogation if a Covered Person fails
to comply with the provisions of paragraph 2.d., above; or
pursuant to a claim, for which benefits are recoverable under any policy or act
of law providing coverage for occupational injury or disease, to the extent that
such benefits are recovered. This provision (6) shall not be deemed to require
the Planholder to pay benefits under the Plan in any such instance.
Such deductions may be made against any claim for benefits under the Plan by a
Covered Employee or by any of his Covered Dependents, if such payment is made
with respect to such Covered Employee or any person covered or asserting coverage
as a Dependent of such Covered Employee.
Legal Action. No action at law or inequity shall be brought under this Plan prior to
the expiration of sixty (60) days after proper written proof of loss has been furnished
in accordance with the requirements of the Plan. No such action shall be brought
after the expiration of three (3) years after the time written proof of loss is required to
be furnished in accordance with the requirements of the Plan.
(5)
(6)
68
SECTION XVII - COORDINATION OF BENEFITS PROVISION
The purpose of the Medical benefits described in this Plan is to help pay Medical bills. It is not
intended that the Employee receive benefits greater than the bill. This Coordination of Benefits
Provision is Included to help keep the cost of the benefits at a reasonable level and, at the same
time, to provide coverage up to one hundred percent (100 %) of the Allowable Expenses to any
person covered under more than one (1) plan. If any person is covered under one (1) or more
plans, as defined below, the Medical benefits payable under the Plan for expenses incurred
during any one (1) Calendar Year will be the lesser of the regular benefits of the Plan, or reduced
benefits, which when added to the benefits of the other plans, will equal one hundred percent
(100%) of the Allowable Expenses.
1. Definitions
a. 'Plan" means any Plan providing benefits or services for medical or dental care and
treatment, for which benefits or services are provided by (i) group, blanket or
franchise insurance coverage; (ii) Blue Cross, Blue Shield, group practice and other
prepayment coverage; (iii) any coverage under labor- management trusteed plans,
union welfare plans, employer organization plans or employee benefit organization
plans; and (iv) any coverage under governmental programs, other than the Medical
Assistance Act of 1967 (Texas), and any coverage required or provided by statute.
The term "Plan" shall also mean any mandatory automobile reparations insurance
(no- fault) providing benefits under a medical expense reimbursement provision for
hospital, medical, dental or other health care services and treatment because of
Accidental Bodily Injuries arising out of a motor vehicle accident, and any other
medical and disability benefits received under any automobile policy where and to the
extent that coordination of such benefits is permitted by law.
The term "Plan" shall be construed separately with respect to each policy, contract or
other arrangement for benefits or services, and separately with respect to that portion
of any such policy, contract or other arrangement which reserves the right to take the
benefits or services of other Plans into consideration in determining its benefits and
that portion which does not.
b. "This Plan" means that portion of this Plan which provides the benefits that are subject
to this Provision.
(Note: Any benefits provided under this Plan that are not subject to this Provision,
constitute another Plan.)
c. "Allowable Expenses" means any necessary, reasonable and customary item of
expense, at least a portion of which is covered under at least one (1) of the Plans
covering the person for whom claim is made or services provided.
When a Plan provides benefits in the form of services rather than cash payments, the
reasonable cash value of each service rendered shall be deemed to be both an
Allowable Expense and -a benefit paid.
d. This Plan shall be considered the Primary Plan for any Covered Drugs for which
benefits are available under the Prescription Drug Program.
69
SECTION XVII - COORDINA11ON OF BENEFITS PROVISION
e. "Claim Determination Period" means Calendar Year.
2. Effect on Benefits
a. This Provision shall apply in determining the benefits as to a person covered under
this Plan for any Claim Determination Period if for the Allowable Expenses incurred
as to such person during such period, the sum of:
(1) the benefits that would be payable under this Plan In the absence of this
Provision; and
(2) the benefits that would be payable under all other Plans in the absence therein
of provisions of similar purpose to this Provision;
would exceed the Allowable Expenses.
b. As to any Claim Determination Period with respect to which this Provision is
applicable, the benefits that would be payable under this Plan in the absence of this
Provision for the Allowable Expenses incurred as to such person during such Claim
Determination Period, shall be reduced to the extent necessary so that the sum of
such reduced benefits and all the benefits payable for such Allowable Expenses under
all other Plans, except as provided in item c. of this subsection 3., shall not exceed
the total of such Allowable Expenses. Benefits payable under another Plan include
the benefits that would have been payable had a claim been duly made therefor.
c. If:
(1) another Plan which is involved in item b. of this subsection 3. and which
contains a provision coordinating its benefits with those of this Plan would,
according to its rules, determine its benefits after the benefits of this Plan have
been determined; and
(2) the rules set forth in item d. of this subsection 3., would require this Plan to
determine its benefits before such other Plan;
then, the benefits of such other Plan will be ignored for the purpose of determining
the benefits under this Plan.
d. For the purpose of item c. of this subsection 3., the rules establishing the order of
benefits determination are:
(1) a Plan without a coordinating provision will always be the primary Plan;
(2) the benefits of a Plan which covers the person on whose expenses claim is
based other than as a dependent, shall be determined before the benefits of a
Plan which covers such person as a dependent;
(3) the benefits of a Plan which covers the person on whose expenses claim is
based as a dependent of a person whose date of birth, excluding year of birth,
occurs earlier in a Calendar Year, shall be determined before the benefits of a
Plan which covers such a person as a dependent of a person whose date of
birth, excluding year of birth, occurs later in a Calendar Year. If either Plan does
not have the provisions of this paragraph regarding dependents, which results
70
SECTION XVII - COORDINATION OF BENEFITS PROVISION
either in each Plan determining its benefits before the other, or in each Plan
determining its benefits after the other, the provisions of this paragraph shall not
apply, and the rules set forth in the Plan which does not have the provisions of
this paragraph shall determine the order of benefits, except that in the case of
a person for whom claim is made as a dependent child,
(a) when the parents are separated or divorced and the parent with custody
of the child has not remarried, the benefits of a Plan which covers the child
as a dependent of the parent with custody of the child, will be determined
before the benefits of a Plan which covers the child as a dependent of the
parent without custody;
(b) when the parents are divorced and the parent with custody of the child
has remarried, the benefits of a Plan which covers the child as a
dependent of the parent with custody, shall be determined before the
benefits of a Plan which covers the child as a dependent of the stepparent,
and the benefits of a Plan which covers the child as a dependent of the
step - parent will be determined before the benefits of a Plan which covers
the child as a dependent of the parent without custody.
Not withstanding subparagraphs (a) and (b) of this paragraph, when the parents are
divorced or separated and there is a court decree which would otherwise establish
financial responsibility for the medical, dental or other health care expenses with
respect to the child, the benefits of a Plan which covers the child as a dependent of
the parent with such financial responsibility shall be determined before the benefits
of any other Plan which covers the child as a dependent.
(4) when paragraphs (1), (2) and (3), above, do not establish any order of benefits
determination, the benefits of a Plan which has covered the person on whose
expenses claim is based for a longer period of time, shall be determined before
the benefits of a Plan which has covered such person the shorter period of time,
except that:
(a) the benefits of a Plan covering the person on whose expenses claim is
based as a laid -off or retired employee or as a dependent of such person,
shall be determined after the benefits of any other Plan covering such
person as an employee other than as alaid -off or retired employee, or
dependent of such person; and
(b) 11 either Plan does not have a provision regarding laid off or retired
employees, and as a result, each Plan determines its benefits after the
other, then the provisions of subparagraph (a) of this paragraph do not
apply.
(5) When this Provision operates to reduce the total amount of benefits otherwise
payable as to a person covered under this Plan during any Claim Determination
Period, each benefit that would be payable in the absence of this Provision shall
be reduced proportionately, and such reduced amount shall be charged against
any applicable benefit limit of this Plan.
71
SECTION XVII - COORDINATION OF BENEFITS PROVISION
3. Right to Receive and Release Necessary Information
For the purpose of determining the applicability of, and implementing the terms of this
Provision or any provision of similar purpose of any other Plan, the Planholder may, without
the consent of or notice to any person, release to or obtain from any other insurance
company or other organization or individual, any information, with respect to any person,
which the Planholder deems to be necessary for such purposes. Any person claiming
benefits under this Plan shall furnish to the Planholder such information as may be
necessary to implement this Provision.
4. Facility of Payment
Whenever payments, which should have been made under this Plan in accordance with this
Provision, have been made under any other Plan, the Planholder shall have the right,
exercisable alone and in its sole discretion, to pay over to any organization making such
payments, any amounts it shall determine to be warranted in order to satisfy the intent of
this Provision, and amounts so paid shall be deemed to be benefits paid under this Plan
and, to the extent of such payments, the Planholder shall be fully discharged from liability
under this Plan.
5. Right to Recovery
Whenever payments have been made by this Plan, with respect to Allowable Expenses In
a total amount, at any time, in excess of the maximum amount of payment necessary at that
time to satisfy the intent of this Provision, the Planholder shall have the right to recover
such payments, to the extent of such excess, from among one or more of the following, as
the Planholder shall determine: any person to or for or with respect to whom such
payments were made, any other insurance companies, and /or any other organizations.
6. Medium of Payment
All payments made by or to this Plan in connection with the benefits of Covered Persons
shall be made in lawful money of the United States, which, at the time of payment, is legal
tender for public and private debts.
72
SECTION XVIII - ADDITIONAL PROVISIONS AS A RESULT OF MEDICARE/MEDICAID
APPUCABLE TO ACTIVE EMPLOYEES AND THEIR SPOUSES
AGES SIXTY FIVE (65) AND OVER
In accordance with the Tax Equity Fiscal Responsibility Act of 1982 (TEFRA), and the
Consolidated Omnibus Reconciliation Act of 1986 (COBRA) including any amendments thereto,
an active employee (age sixty -five (65) or over) may, at the option of such employee, elect or
reject coverage under this Plan. If such employee elects coverage under this Plan, the benefits
of this Plan shall be determined before any benefits provided by Medicare.
APPUCABLE TO SPOUSES AGES SDCTY -FIVE (65) AND OVER
OF EMPLOYEES UNDER AGE SIXTY-FIVE (65)
In accordance with the Deficit Reduction Act of 1984 ( DEFRA), spouses who are ages sixty-five
(65) and over, may elect or reject coverage under this Plan even if the employee is not yet
sixty-five (65). If such spouse elects coverage under this Plan, then the benefits of the Plan shall
be determined before any benefits provided by Medicare.
APPLICABLE TO DISABLED PERSONS UNDER AGE 65
The benefits of the Plan will be determined before the benefits of Medicare for any Covered
Person who is under age sixty -five (65), and who is disabled (by Social Security Definition).
APPUCABLE TO ALL OTHER COVERED PERSONS
EUGIBLE FOR MEDICARE
For the purposes of this Plan, if any Covered Person Is eligible for Medicare, such person shall
be considered as having 'full Medicare coverage." The term "full Medicare coverage" means
coverage for all the benefits provided under Medicare, Part A, and under the voluntary portion
of Medicare, Part 8.
When a Covered Person becomes eligible for Medicare benefits, benefits will be provided in
addition to Medicare's benefits, in accordance with the "COORDINATION OF BENEFITS
PROVISION" of the Plan, for that portion of the Covered Expenses which is not payable by
Medicare, unless any nonpayment by Medicare is due to a failure to enroll for Medicare coverage
or to apply for Medicare benefits.
Medicare shall be considered a "Plan" under the "COORDINATION OF BENEFITS PROVISION,"
and benefits payable by Medicare shall be determined before the benefits of the Plan.
APPUCABLE TO MEDICARE SERVICES FURNISHED TO
E.S.R.D. (END STAGE RENAL DISEASE) BENEFICIARIES
WHO ARE COVERED UNDER EMPLOYEE GROUP HEALTH PLANS
For the purpose of this Plan, if any Covered Person is eligible for Medicare benefits because of
E. S. R. D., the benefits of the Plan will be determined before the benefits of Medicare for an
initial period of up to eighteen (18) months.
73
SECTION XVIII - ADDmONAL PROVISIONS AS A RESULT OF MEDICARE/MEDICAID
APPLICABLE TO ALL COVERED PERSONS
ELIGIBLE FOR MEDICAID
For the purpose of this Plan, if any Covered Person is also a Medicaid recipient, any benefits for
services or supplies under the Plan will not be excluded solely because benefits are paid or
payable for such services or supplies under the Medical Assistance Act of 1967 (Medicaid), as
amended. Any benefits available under the Plan will be payable to the Texas State Department
of Human Resources to the extent required by the provisions of Chapter 783, Acts of the 66th
Legislature, 1979.
74
SECTION XIX - MISCELLANEOUS MEDICAL EXPENSE PROVISION
Effect of Coverage under a Health Maintenance Organization Plan.
1. Each Employee in an eligible class, who has elected coverage under any Health
Maintenance Organization Plan (herein referred to as "HMO Plan ") offered by an employer,
shall be excluded from coverage as provided by this Plan, except Dental Expense Benefits
(if provided), subject to this section with respect to himself and his eligible Dependents,
immediately on and after the effective date of any coverage under such HMO Plan.
2. Each Employee in an eligible class, who resides in an HMO Plan enrollment area and who
is a covered individual under such HMO Plan as offered by an employer, may elect
coverage for himself and his covered Dependents under the Plan annually during an open
enrollment period determined in advance by the Planholder. Any coverage elected during
the open enrollment period will become effective on the Plan Anniversary next following the
open enrollment period, without Evidence of Good Health statements or other restrictions
as to waiting periods or Pre - Existing Conditions. Any coverage elected will become
effective on the first of the month following the Planholder's open enrollment period and
following the day membership in the qualified HMO Plan is terminated without Evidence of
Good Health or other restrictions as to waiting periods or Pre - Existing Conditions, provided
the Employee applies for such coverage and agrees to make any required contributions
within thirty -one (31) days of the date coverage is terminated under the HMO Plan.
3. Each Employee in an eligible class, who is covered under an HMO Plan when he changes
residence out of the HMO Plan enrollment area, or when the HMO Plan discontinues
operations for financial or other reasons, may elect to change to coverage under this Plan
for himself and his Covered Dependents. Any such coverage under the Plan will become
effective as follows:
a. with respect to an Employee who makes written request prior to or within thirty
(31) days following his change in residence or the date the HMO discontinues
operations, on the later to occur of:
(1) the date he makes written request, or
(2) the date of his change in residence or such discontinuance of operations,
without Evidence of Good Health or other restrictions as to waiting periods or Pre -
Existing Conditions, or
b. with respect to an Employee who makes written request after thirty-one (31) days
following his change in residence or the date the HMO discontinues operations, on
the first of the month following the Planholder's open enrollment period, and only if
and when the Planholder approves Evidence of Good Health statements submitted
by the Employee at his own expense.
4. Those portions of the Plan which provide extensions of benefits to Covered Persons by
reason of disability, will cease to apply on and after the effective date of any change in
coverage to an HMO Plan. However, if coverage is not provided for a covered family
member under the HMO Plan on the date coverage would otherwise become effective,
because the family member is confined in a Hospital not affiliated with the Health
Maintenance Organization, and if the Employee submits satisfactory proof to the Planholder
75
SECTION XIX - MISCELLANEOUS MEDICAL EXPENSE PROVISION
that the HMO Plan contains an extension of benefits provision applicable to disability, then
coverage for such confined family member may be extended under this Plan for the same
length of time and for the same conditions an extension is provided under the HMO Plan,
but not beyond the earliest to occur of (a) the end of a ninety (90) day period commencing
the date coverage would otherwise become effective, or (b) cessation of confinement, or
(c) the date this Plan terminates.
5. All of the coverage provided under this Plan is subject to the provisions of this section, and
no coverage is afforded under this Plan for any charge for a service rendered or a supply
furnished under an HMO Plan.
6. An Employee who has elected coverage for himself under an HMO Plan, may not cover his
Dependents under this Plan, nor may such an Employee be covered under this Plan if the
Employee has coverage for his Dependents under an HMO Plan.
7. If an Employee's Dependent has elected membership in a qualified HMO Plan as an
employee of another employer, no benefits are payable under this Plan for treatment of any
injury or illness of any such Dependent, to the extent that such Dependent is entitled to
coverage, services or treatment as a result of membership in the HMO Plan, regardless of
whether such coverage, services or treatments are received through the qualified HMO.
8. If an Employee and his Dependent(s) are covered under an HMO Plan, such Dependent(s)
may, in the event of the death of such Employee, elect to change to coverage under this
Plan, provided such Employee was in an eligible class at the time of death and provided
such Dependent(s) is eligible. Any such coverage under this Plan will become effective as
follows:
a. with respect to a Dependent who makes written request within thirty -one (31) days
following the death of such Employee, on the date he makes written request, without
Evidence of Good Health or other restrictions as to waiting periods or Pre - Existing
Conditions, or
b. with respect to a Dependent who makes written request after thirty-one (31) days
following the death of the Employee, on the first of the month following the
Planholder's open enrollment period, and only if and when the Planholder approves
Evidence of Good Health statements submitted by the Dependent at his own expense.
76
SECTION XX - PLAN INFORMATION
1. PLAN NAME: City of Round Rock
Employee Benefit Plan
2. PLANHOLDER: City of Round Rock
3. TYPE OF PLAN: Welfare Benefit Plan
4. FINANCING OF THE BENEFIT PLAN -
The Planhoider pays the cost of benefits provided by the Plan partially from its general
funds and partially from funds contributed by Employees.
5. ADMINISTRATION
The Plan is administered directly by the Planholder. The Plan Year for the Group Health
Plan ends on November 30th.
Records for the Group Health Plan are kept on a Plan Year basis.
6. GENERAL INFORMATION
Primary responsibility for administration of the Group Health Plan is placed with the
designated Planholder. The Planholder may allocate responsibilities for the operation and
administration of the Plan as he deems appropriate.
The Group Health Plan is subject to administration or termination as determined appropriate
by the Planholder.
7. EMPLOYEE GROUPS COVERED
Employees of City of Round Rock (Employer Identification Number 74- 6017485), and of the
Participant Employers, who meet the Plan's eligibility requirements and elect to be governed
by the Plan are covered by the Plan described in this booklet. A complete list of covered
units Is available from the Planholder.
8. PLAN NUMBER
The Planholder has assigned Plan Number 1169 to the Plan. The Planholder is:
City of Round Rock
221 East Main Street
Round Rock, TX 78664
(512) 255 -3612
77
1
HBI- ASA/11 -93
ADMINISTRATIVE SERVICES AGREEMENT
ADMINISTRATIVE SERVICES AGREEMENT
THIS AGREEMENT is made and entered into by and between HealthCare Benefits, Inc., a corporation
organized, existing and doing business under and by virtue of the laws of the State of Texas (hereinafter
referred to as "Contractor") and CITY OF ROUND ROCK (hereinafter referred to as "Purchaser ").
WITNESSETH:
WHEREAS, Contractor is in the business of providing independent third -party administration of employee
welfare benefit programs; and
WHEREAS, Purchaser desires to engage the service of a third -party administrator for a welfare benefit
program (hereinafter referred to as "Benefit Program ") to be provided to Purchaser's employees and their
eligible dependents (hereinafter collectively referred to as "Participants"); and
WHEREAS, Contractor is willing to provide such services to Purchaser and other parties on an independent
contract basis.
NOW, THEREFORE, for and in consideration of the mutual promises, covenants and Agreements hereinafter
set forth, the parties hereto agree as follows:
SECTION ONE
OBLIGATION OF PURCHASER
1.01 Purchaser shall furnish Contractor with a detailed description of the Benefit Program to be
administered.
1.02 Purchaser, in consultation with Contractor, shall determine the administrative practices and
procedures to be followed in the processing and payment of claims.
1.03 Purchaser shall provide to Contractor a complete and current listing of all Participants
eligible to receive benefits prior to their date of eligibility -- making timely changes to the
listing on a periodic basis.
1.04 Purchaser shall obtain the consent of Participants for the release of confidential medical
information required for administration and to process claims for the payment of fees for
medical services rendered to patients, including any fees for mental or emotional health
services performed by professionals, as may be required by state or federal law.
1.05 Purchaser shall establish and maintain a suitable banking arrangement to effectuate the
provisions of Section Six herein.
1.06 At Contractor's request, or at Purchaser's option, Purchaser shall make the final
determination of eligibility of Participants to receive benefits and any special issues ansing
in the course of administration.
1
1.07 Purchaser shall designate in wnting a contact person who will be empowered to act on behalf
of Purchaser with regard to the terms of the Agreement and with whom Contractor can
coordinate and resolve all questions arising in the course of administration.
SECTION TWO
OBLIGATION OF CONTRACTOR
2.01 Contractor shall administer Purchaser's Benefit Program in accordance with the benefit plan
description provided and the administrative practices and procedures established.
2.02 Contractor shall provide or arrange for suitable facilities, equipment and personnel necessary
for proper administration of the Benefit Program.
2.03 Contractor shall, upon request, assist Purchaser is establishing appropnate banking
arrangements for program administration.
2.04 Contractor shall provide standard administrative materials, including enrollment forms,
participant and provider claim forms and two identification cards for each participant in the
Benefit Program on the Effective Date of the Plan.
2.05 Contractor shall, upon request, assist Purchaser in incorporating the Benefit Program
description and design into a plan document and booklet for Participants. The Contractor
will provide one benefit booklet per participant enrolled in the Benefit Program on the
Effective Date of the Plan. The cost of reprinting additional benefit booklets shall be the
obligation of the Purchaser.
2.06 Contractor shall provide claims processing services to include:
a. Review and validation of all claims submitted for payment;
b. Determination of benefits in accordance with the specification of the Benefit
Program;
c. Coordination of benefits with other plans, where appropriate;
d. Preparation and mailing of explanation of benefit forms; and
e. Preparation and mailing of claim drafts drawn on Purchaser's bank account as
provided in Section Six herein.
2.07 Contractor shall establish liaison with Purchaser's designee, providers and Participants, as
required, to obtain and follow -up on additional service information, to verify eligibility of
Participants and to assist in resolving claims problems.
2
2.08 Contractor shall provide periodic written reports to include:
a. Monthly check reconciliation report;
b. Monthly benefit experience reports; and
c. Those reports specified in Item Four of the current Exhibit to this Agreement, if any.
d. Utilization reports, to include, claims incurred, claims paid and discounted services.
e. Estimates of incurred but unpaid claim liabilities.
f. Assistance with preparation of the Summary Plan Description, SummaryAnnual
Report, and other matters that are required for reporting and disclosure under Title
I, Part I of the Employees Retirement Income Security Act of 1974.
2.09 Contractor will provide Purchaser copies of specific claim payment drafts upon request.
2.10 Contractor shall evaluate late applicants for evidence of good health on behalf of Purchaser.
2.11 Contractor shall maintain current individual benefit records on all Participants and shall
maintain the confidentiality of any medical information contained in such records.
2.12 Contractor shall prepare IRS form 1099 reports on medical provider fees.
2.13 Contractor shall keep Purchaser informed with respect to non - routine "shock" claims and
matters of general interest, including recurring administration problems, local situations
meriting review and possible misuses of benefits.
2.14 Contractor shall refer to Purchaser any claim or class of claims Purchaser may specify for
consideration and final decision, to include:
a. Claims for services which do not appear to qualify for payment under the Benefit
Program;
b. Claims in which there is a question on the amount of payment due;
c. Claims involving any matter in controversy; and
d. Those claims or classes of claims specified in Item Three of the current Exhibit to
this Agreement, if any.
2.15 Contractor shall assist Purchaser in the analysis and resolution of disputed chims, provided,
however, that such assistance shall in no way include or be considered to include or
constitute legal advice or opinions.
2.16 Underwriting services will not be provided unless specifically identified in Item Two of the
Exhibit to this Agreement, if any. Any such services provided will include required
certifications by a qualified actuary.
2.17 Contractor shall also provide those services specified in Item Two of the current Exhibit to
this Agreement, if any.
3
2.18 Assist in complying with any and all State and Federal statues, rules or regulations,
including ERISA.
2.19 All files, records and reports prepared and maintained by the Contractor pursuant to this
agreement shall be the property of the Purchaser, but the right of possession of such files,
and reports shall be and remain with the Contractor during the term of this agreement. All
files, records, and reports shall be made available for review and inspection during normal
business hours. Within fifteen (15) working days of completion of duties under this agree-
ment, all such files, and reports shall be transferred to the Purchaser on request and in
exchange for its receipt.
SECTION TIIREE
RELATIONSFIIP OF PARTIES
3.01 Contractor shall not be construed, represented or held out to be a partner, associate, joint
venturer or employee of Purchaser nor shall the Contractor be construed, represented or held
out to be an agent of the Purchaser or agent of any insurance company. Contractor shall at
all times have the status of an independent contractor.
3.02 Contractor shall, upon request, assist purchaser in obtaining Stop Loss Reinsurance. If Stop
Loss reinsurance is purchased, Contractor shall not be responsible for claims not timely filed
and not included within the Stop Loss coverage. Contractor shall attempt to assist Purchaser '
in encouraging providers to file claims timely but Contractor assumes no responsibility for _
the timely filing of such claims, and Purchaser commits not to sue contractor regarding any
claims arising out of Stop Loss reinsurance coverage so purchased.
3.03 Contractor is not a statutory fiduciary of Purchaser's Benefit Program nor is Contractor a
plan administrator withrn the meaning of the Employee Retirement Income Security Act of
1974, Public Law 93 -406.
3.04 This Agreement is not a contract of insurance, and Contractor is not an insurer or underwriter
of Purchaser's liability under the Benefit Program. Purchaser has and retains the ultimate
responsibility for payment of claims and other expenses under the Benefit Program.
4
SECTION FOUR
TERM AND TERMINATION
4.01 The term of this Agreement shall be for the period of one (1) year commencing on the
Effective Date specified herein and shall continue in full force and effect from year to year
thereafter unless terminated as provided herein.
4.02 This Agreement may be terminated as follows:
a. By either party on any anniversary of the Effective Date of this Agreement
following thirty (30) days' prior written notice to the other;
b. By Contractor upon Purchaser's failure to fund the bank account as provided for in
Paragraph 6.02 of Section Six below;
c. By Purchaser, upon thirty (30) day's prior written notice.
d. By both parties on a mutually agreeable date.
e. By Purchaser, upon Contractor's breach of any provision of this Agreement, after
f. upon (30) thirty days written notice and failure to cure such breach.
4.03 If this Agreement is terminated by Purchaser, except as provided in Paragraph 4.02, (a), (b)
or (d), above, Purchaser agrees to pay to Contractor a termination fee in an amount equal to
twice the average of the monthly administration fee due for all months immediately
preceding termination. Such termination fee is due and payable within thirty (30) days after
notice of termination, or immediately upon termination if no notice is given, and is in
addition to any monthly administration fee, or portion thereof, or any other monies due and
payable to Contractor under this Agreement.
4.04 If this Agreement is terminated for cause by Purchaser under Paragraph 4.02 (a), (b), (d) and
(e), above, the Purchaser shall not be liable for any termination fees or changes. Moreover,
Purchaser may withhold from the current administration fee due Contractor, the costs
incurred by Purchaser in attempting to gain Contractor's performance of the Agreement
4.05 If this agreement is terminated, the Contractor shall complete the processing of all requests
for benefits payments under the plan that were received by Contractor on or before the date
of termination and which are due and payable prior to termination, but shall not include:
A. The processing of any requests if the Purchaser has not provided funds for
the benefits payment.
B. Process request for benefit payments presented to the Contractor after the
date of termination.
C. Issue benefit check after termination date.
5
SECTION FIVE
ADMINISTRATION FEES AND REIMBURSEMENT
5.01 Purchaser agrees to pay Contractor a monthly administration fee which shall be due and
payable in full on or before the first (1st) day of each month at its home office in Richardson,
Texas, during the term of this Agreement.
a. In the event payment of the monthly administration fee is not paid by the twentieth
(20th) day of the month, Contractor may suspend its performance under this
Agreement upon ten (10) days notice to the Purchaser until such fees and late
charges are paid.
b. After the twentieth (20th) day of the month, a late charge may be assessed each day
for late payment of all monies owed to Contractor by Purchaser under this
Agreement. The late charge shall be charged as interest and equal to ten percent
(10 %) of the past - due amount owed, or the maximum amount permitted by state
law, whichever is less.
c. After the thirty-first (31st) day the Contractor may terminate this Agreement for
non - payment of fees.
5.02 The amount of the administration fee shall be determined in accordance with the
specifications contained in Item One of the current Exhibit to this Agreement, if any.
5.03 The administration fee shall be subject to change by Contractor upon (90) ninety days prior
written notice to purchaser, as follows:
a. On each anniversary of the Effective date of this Agreement
b. On the implementation date of any changes in the Benefit Program which would
increase Contractor's cost of administration;
c. On any date that increased expenses are incurred by Contractor because of changes
imposed by governmental entities -- limited to increases sufficient to recover the
additional expenses; or
d. On any date that Benefit Program enrollment changes by an amount equal to ten
percent (10 %) or more of total enrollment.
5.04 Purchaser shall reimburse Contractor for the direct cost of any special supplies or forms
provided by Contractor for Purchaser- -such reimbursement to be in addition to the monthly
administration fee.
6
5.05 Purchaser will reimburse Contractor for any taxes imposed or adjudged due by any lawful
authority with respect to the Benefit Program or its administration. In the case of imposition
of such tax liability, Purchaser may elect to terminate this Agreement uponthirty (30) days'
prior written notice without incurring liability for termination fees or charges.
SECTION SIX
CLAIMS PAYMENT AND BANKING ARRANGEMENT
6.01 Purchaser shall establish a bank account on which Contractor shall write drafts for the
payment of Benefit Program claims and expenses. Purchaser agrees and is obligated to
arrange for sufficient funds to be available in such account to cover all drafts validly issued
against the account. Contractor shall notify Purchaser, simultaneous with the release of
checks, the amount that is required to be deposited by Purchaser to cover the checks issued.
6.02 Contractor shall have the right to terminate this Agreement upon notice to Purchaser in the
event that Purchaser fails to fund such account within three (3) banking days after notice is
given by Contractor and received by Purchaser, that such funds are required to be deposited.
6.03 Notice by Contractor, as contemplated in paragraph 6.02, above, shall be sufficient if given
by telephone, fax or by United States mail, delivery services or personal delivery to
Purchaser's designee or the signatory to this Agreement at the telephone number or address
specified in Item Five of the current Exhibit to this Agreement, if any. Any telephonic
notice given will be confirmed in writing within twenty -four (24) hours.
SECTION SEVEN
NOTICES
7.01 All notices given under in this Agreement, unless otherwise provided for herein, must be in
writing and shall be deemed to have been given for all purposes when personally delivered
and received or when deposited in the United States mail, first -class postage prepaid,
certified or registered, return receipt requested and addressed to the parties as set forth in
Item Five of the current Exhibit to this Agreement, if any.
7
SECTION EIGHTS
GENERAL PROVISIONS
8.01 ASSIGNMENT. No part of this Agreement, or any rights, duties or obligations described
herein, shall be assigned or delegated without the prior express written consent of both
parties, except for the use of a third party for printing and mailing services. Contractor's
acquisition and use of facilities, services, supplies, equipment and the use of temporary
personnel on site shall not constitute an assignment under this Agreement; provided,
however, that the supervision of all services provided under this Agreement will be
performed by Contractor's regular employees.
8.02 GOVERNING LAW. This contract shall be governed by and shall be construed in
accordance with the laws of the State of Texas, and venue for any cause related to this
Agreement shall be in Williamson County, Texas.
8.03 MODIFICATION. This Agreement shall not be amended or modified in any manner except
by an instrument in writing executed by the parties.
8.04 CAPTIONS. Captions appearing in this Agreement and its Exhibits, if any, are provided for
convenience only and in no way define, limit, construe or describe the scope of sections or
paragraphs to which they are inserted.
8.05 GENDER AND MODE. The use herein of a personal pronoun in the masculine or feminine
gender or in the singular or plural mode, shall be deemed to include the opposite gender or
mode unless the context clearly indicates the contrary.
8.06 EXHIBIT. "Exhibit" means the attached document(s) setting out certain particulars of this
Agreement, or any replacement document(s) mutually agreed to by the parties.
8.07 LEGAL CONSTRUCTION. Should any provision(s) contained in this Agreement be held
to be invalid, illegal or otherwise unenforceable, the remaining provisions of the Agreement
shall be construed in their entirety as if separate and apart from the invalid, illegal or
unenforceable provision(s), subject to renegotiation by the parties if a material change in the
terms of the Agreement were to result.
8.08 ENFORCEMENT. Any delay or inconsistency in the enforcement of any part of this
Agreement shall not constitute a waiver of any rights with respect to the enforcement of this
Agreement at any future date, nor shall it limit any remedies which may be sought in any
action to enforce any provision of this Agreement.
8.09 FORCE MAJEURE. Neither party shall be liable for any failure to perform its obligations
under this Agreement if prevented from doing so by a cause or causes beyond its
commercially reasonable control, including, but not limited to, acts of God or nature, fires,
floods, storms, earthquakes, riots, strikes and wars or restraints of government.
8
8.10 ENTIRETY. This Agreement and any Exhibits or amendments and advertisement for bids
shall constitute the entire Agreement between the parties and shall supersede any and all
prior Agreements or understandings, either oral or in writing, between the parties respecting
the subject matter herein.
8.11 DISCLOSURE STATEMENT. Purchaser acknowledges that a disclosure of all payments
to be made to Contractor has been made to Purchaser and such disclosure statement is
incorporated herein by reference.
IN WITNESS HEREOF, the parties hereto have executed this Agreement for an Effective Date of December
1,1998.
•
OR CIT OF • : ROCK, P ' CHASER:
;11 Er � /
1... /i
Tit 'W
9
(Date)
FOR HEALTHCARE BENEFITS, INC., CONTRACTOR:
EXIIIBIT NUMBER ONE
Specifications For
ADMINISTRATIVE SERVICES AGREEMENT
Between
HEALTHCARE BENEFITS, INC. (CONTRACTOR)
and
CITY OF ROUND ROCK (PURCHASER)
These specifications are to apply beginning with the Effective Date of the Agreement between the parties to
which this Exhibit is attached and shall continue in force and effect until the Agreement is terminated or this
Exhibit is superseded in whole or in part by a later executed exhibit.
ITEM ONE
ADMINISTRATION FEE
As provided in Paragraph 5.02 of Section Five of the Agreement, for the first (1st) year this Agreement is
in effect, the monthly administration fee shall be an amount equal to twelve and 50 /100 dollars ($12.50)
multiplied by the number of Employees enrolled in the Benefit Program on the first (1st) day of each month.
This fee includes repricing and administration of St. David's PPO as well as Vision administration. The
monthly Hospital Pre - Certification fee shall be an additional amount equal to one and 80/100 dollars ($1.80)
multiplied by the number of Employees enrolled in the Benefit Program on the first (1st) day of each month.
The monthly Dental Administration fee shall be an additional amount equal to two and 25/100 dollars ($2.25)
multiplied by the number of Employees enrolled in the Benefit Program on the first (1st) day of each month.
ITEM TWO
OTHER SERVICES
As provided in Paragraph 2.17 of Section Two of the Agreement, the following additional services shall be
furnished:
A. Inpatient Certification Program will be administered by Blue Cross Blue Shield of Texas, Inc. acting
as agent of Contractor.
B. Prescription Drug Program by arrangement with Blue Cross Blue Shield of Texas, Inc. acting as
agent of Contractor to provide benefits substantially the same as its insured Prescription Drug
Program. Your billing will include applicable dispensing fees, discounted pricing and one and
50 /100 dollars ($1.50) per prescription filled payable to the drug card company.
C. Dental Administration.
1
As provided in Paragraph 2.14d of Section Two of the Agreement, the following special claims handling
procedures shall be followed: None.
ITEM THREE
SPECIAL CLAIMS PROCESSING
ITEM FOUR
OTHER REPORTS
As provided in Paragraph 2.08c of Section Two of the Agreement, the following additional reports shall be
furnished: None.
ITEM FIVE
NOTICE ADDRESS
As provided in Paragraph 7.01 of Section Seven of the Agreement, notice to Contractor shall be delivered
or mail to:
HealthCare Benefits, Inc.
1001 E. Campbell
Richardson, TX 75081
HealthCare Benefits, Inc.
P. O. Box 833889
Richardson, TX 75083 -3889
Written notice to Purchaser shall be delivered or mailed to:
CITY OF ROUND ROCK
221 East Main Street
Round Rock, TX 78664
Fax notice to Purchaser shall be made to the following number:
(512) 255-6676
Y OF 0 ! 1 ROCK, PURCHASER:
(Date)
FOR HEALTHCARE BENEFITS, INC., CONTRACTOR:
'2/1
2
(Date)
Purchaser shall designate in writing a contact person who will be empowered to act on behalf of
Purchaser with regard to the terms of the Agreement and with whom Contractor can coordinate and
resolve all questions arising in the course of administration.
�I Y O RO
iii iip
Tit
ROCK, PURCHASER:
CONTACT PERSON
(Date)
DESIGNATED PERSON EMPOWERED TO ACT ON BEHALF OF PURCHASER:
(Date)
1
The agent and/or HealthCare Benefits, Inc. will contract with or represent the insurance carrier in
conjunction with the sale of certain group insurance polices. This disclosure does not limit the agent's
ability to recommend the products of other insurance companies or other funding organizations, but is
intended to disclose the financial interest of the parties as to the Employee Benefit Plan. HealthCare
Benefits, Inc. is a wholly -owned subsidiary of Blue Cross Blue Shield of Texas, Inc. As requested by the
Purchaser, HealthCare Benefits, Inc. has solicited bids from Stop Loss Carriers, Life Carriers, etc., and
the Purchaser, after reviewing the proposals, has selected certain coverage. The relationship and dealings
of those companies are on file with the State Board of Insurance. If insurance is purchased through an
insurance company, HealthCare Benefits, Inc. may contract to facilitate the payment of insurance
premiums, claims and eligibility and may receive compensation for its services, but HealthCare Benefits,
Inc. is not an agent of the insurance company and does not receive commissions.
The following persons or companies are entitled to commissions as agents on the insurance contract
issued to you:
Product: Administration
Name of Broker: Keith Carmichael Commission: n/a
Product: Stop Loss
Name of Broker: Keith Carmichael Commission: 15%
HealthCare Benefits, Inc., in addition to its administrative charge as indicated in the Administrative
Services Agreement, is entitled to the following payments and marketing allowances for its services:
Product: Stop Loss
Y OF ' 0 ROCK, PURCHASER:
v
EMPLOYEE BENEFIT PLAN
DISCLOSURE FORM
For
CITY OF ROUND ROCK
Administrative Charge: n/a
(Date)
2
The undersigned acknowledges receipt of the information contained herein prior to any purchase and
approves the proposed transaction on behalf of the plan without receiving, either directly or indirectly,
any personal compensation in connection with the purchase of policies under this Plan.
FOR HEALTHCARE BENEFITS, INC., CONTRACTOR:
Health efits, Inc.
.3
ate)
3
AMENDMENT
to the
ADMINISTRATIVE SERVICES AGREEMENT
between
CITY OF ROUND ROCK
(Purchaser)
and
HEALTHCARE BENEFITS, INC.
(Contractor)
The Agreement is amended as follows:
1. Wherever in the Agreement the name Blue Cross and Blue Shield of Texas, Inc. appears, it shall
now read Blue Cross and Blue Shield of Texas, a division of Health Care Service Corporation, a
mutual legal reserve company, an independent licensee of the Blue Cross and Blue Shield
Association.
2 SECTION FOUR of the Agreement is amended by deleting the wording of Paragraph 4.01 iu its
entirety and substituting the following:
4.01 The term of the Agreement shall be for the periods set forth below commencing on the
Effective Date specified herein and shall continue in full force and effect from year to
year thereafter unless the Agreement is terminated as provided herein.
Period Dates
First December 1, 1998 througlNovember 30, 1999
Second December 1, 1999 through November 30, 2000
Third December 1, 2000 through November 30, 2001
Fourth December 1, 2001 through November 30, 2002
The Agreement may be renewed for two (2) additional periods not to exceed twelve (12)
months each, provided both parties agree in writing.
3. SECTION FOUR of the Agreement is amended by adding a new Paragraph 4.02 f:
EBIATY OFRR
£ By Purchaser at the end of Purchaser's fiscal year if the City Council of the Purchaser
does not appropriate sufficient moneys to allow the Purchaser to meet its obligations
under this Agreement during the Purchaser's next fiscal year. The Purchaser may
terminate the Agreement by giving the Contractor written notice of the termination and
paying the Contractor any fees which are due and have not been paid at or before the end
of the Purchaser's then current fiscal year. The Purchaser will use its best efforts to give
the Contractor not less than sixty (60) days written notice of termination prior to the end
of the Purchaser's fiscal year.
f
4. SECTION FOUR of the Agreement is amended by deleting the wording of the first sentence of
Paragraph 4.03 in its entirety and substituting the following:
If this Agreement is terminated by Purchaser, except as provided in Paragraph 4.02 a, b
or d, above, Purchaser agrees to pay Contractor a termination fee in an amount equal to
two times the average of the monthly administration fee due to Contractor for all the
months since the last anniversary date up to and including the month of termination.
5. SECTION SIX of the Agreement is amended in Paragraph 6.01 to change the word "drafts" to
"checks" wherever the word "drafts" appears.
6. SECTION SIX of the Agreement is amended in Paragraph 6.02 to change the phrase "within
three (3) banking days" to "within three (3) business days ".
7. The Agreement is amended by adding the following new SECTION NINE entitled
INDEMNIFICATION AND HOLD HARMLESS.
9.01 Contractor shall indemnify and hold harmless Purchaser, its officers, directors,
employees, and agents, against any and all liability, obligations, risks, expenses, costs,
damages, losses, or judgments (including reasonable attorney's fees) arising out of or in
any way connected with any negligent acts or omissions of Contractor in the performance
of the duties and responsibilities of Contractor under this Agreement.
9.02 Purchaser shall indemnify and hold harmless Contractor, its officers, directors,
employees, and agents, against any and all liability, obligations, risks, expenses, costs,
damages, losses or judgments (including reasonable attorney's fees) arising out of or in
any way connected with any negligent acts or omissions of Purchaser in the performance
of the duties and responsibilities of Purchaser under this Agreement.
8. - EXHIBIT NUMBER ONE of the Agreement is amended by changing the Purchaser's fax
number in ITEM FIVE from (512) 255 -6676 to (512) 218- 5493.
This Amendment to the Agreement will be effective 1711/9R-11 /an /oo
CHASE : FOR CONTRACTOR:
e
ame
mAyo,)
Title
'1- as -99
Date
RBI-CITY OFRR
President
Title
7/6/99
Date