Loading...
HomeMy WebLinkAboutAGENDA REPORT 1993 0616 CC REG ITEM 11DTO: FROM: DATE: AGENDA REPORT CITY OF MOORPARK The Honorable City Council Richard Hare, Deputy City Manager June 9, 1993 (CC. Mtg 6/16/93) ITEM - ,.,7 "ArX COIL,',. of 1G9 ACTION: �v RE: Consider Approval of Health Insurance Benefits • For Councilmembers and Staff Authorizing the City Manager to enter into agreements with United Insurance for Continuation of Employee Health Insurance Benefits, Standard Insurance for Long Term Disability and Employee Assistance Programs, and Blue Shield for Individual and Family Health Insurance Policies for Councilmembers Health Insurance Renewal New rates for our health insurance program went into effect on March 1, 1993. The rate increase was twelve percent making our monthly premium $565.44 per family. Due to the current Memorandum of Agreement with the City's employees, the total premium including the increase in premium for both employee and dependent coverage was paid for by the City, which costs an additional $61.63 per month. On June 30, 1993, the Memorandum of Agreement ends and the City is not contractually obligated to offer the same benefit. The health insurance program is one of the most significant benefits offered by the City to its employees and it is an important element in recruiting and retaining employees. It has been the City's objective for many years to maintain a competitive but cost effective employee benefit program. In an effort to control the escalating cost of health insurance, United Insurance the City's carrier, proposed several modifications to the benefit structure of the Health Insurance program which would lower the monthly premiums and reduce less cost effective utilization of services. The out of pocket cap for employees would remain $1,000 for employees using preferred providers, (PPG's) and $2,000 for employees who do not, (non -PPO). In particular these changes are designed to discourage the utilization of services outside of the preferred provider organization, frequent visits to the hospital, and higher utilization of doctor visits. The attached table outlines the options presented to the City Council by United Insurance as proposal A, B, and C. These proposals were discussed with the staff at a February general meeting. The City also appointed an ad hoc employee committee to look at these proposals as well as to discuss The Honorable City Council June 9, 1993 Page 2 future planning for health insurance benefits. In general, it is recognized that health insurance costs are a part of overall personnel costs, but there is strong sentiment on the part of employees to continue the current plan with the current set of benefits including payment of 100% of the premiums for dependent coverage. Budget & Finance Committee Review In addition to the options available to the Council as indicated in United proposals A, B, and C; the City Council could combine two of the proposals to lower the premiums and also decrease the impact on employees. The Budget & Finance Committee reviewed the proposals from United on 6/8/93 and recommended that Proposal A and Proposal B be combined, thereby, resulting in a twelve percent decrease in premium. Essentially, the premium would remain at the pre -March 1, 1993 level. City Employee Review Our Memorandum of Agreement (Section 701) requires the City to review health insurance plans with employees whenever changes in the Health Insurance Program are contemplated. The current Memorandum of Understanding requires the City to provide the same or comparable health insurance benefits through April 30, 1993. At this juncture, an alternative to the current plan can be implemented. The Deputy City Manager met with the employees in February to discuss the change in benefits and will be meeting again on June 14, 1993. United Insurance Deadline United Insurance originally provided us with a deadline of February 19, 1993 to accept the cost containment provisions that they proposed. As mentioned, we were not able to modify our plan due to our Memorandum of Agreement. Staff and our broker David Peters with Tolman & Wiker, have negotiated an extension with United Insurance which is very favorable to the City. United will allow us to notify them of our decision on 6/17/93 and the new rates will be retroactive to 6/1/93. In a further concession they have agreed to allow the rates to run for a full twelve months from that date. It is doubtful that we would be able to have any other opportunity to extend this matter and still receive the rate consideration. The Honorable City Council June 9, 1993 Page 3 Council Coverage Some other communities include their City Councilmembers in their health insurance programs or offer separate individual health insurance plans for Councilmembers and their dependents. Our broker has researched this matter and determined that Councilmembers and their family's, if rated separately, could be covered for the same cost as our group policy and still allow each Councilmember to decide whether or not they wanted coverage. Under proposal A, the estimated cost to the City for each Councilmember would be $218.14 and under proposal B would be $227.56. The premium would not exceed the current employee family rate. Placing a Councilmember and their family as part of the group plan would require enrollment of the councilmember as part of our payroll system and thereby add to the cost of the benefit because of additional payroll taxes and benefits required including part -time employee retirement. Long Term Disability Insurance (LTD) Our broker also reviewed our Long Term Disability Insurance Program due to difficulties we experienced with the administration of the current plan. The current plan requires complete disability during the qualifying period which impedes efforts to bring employees back to work on a part -time basis. The Standard Insurance Company of Portland, Oregon is one of the largest LTD companies in the country. It provides coverage to 50% of the cities in California and they offer a $6,000 maximum benefit versus a $3,000 benefit for a smaller premium. Their premium for employers with less than 1,000 employees is .49 percent of payroll. This compares to .54 percent of payroll which is our current premium. Employee Assistance Program (EAP) Associated with Standard's LTD Program is a proactive problem solving and preventative Employee Assistance Program. The establishment of an assistance program for all employees has been a standing objective. The Standard plan provides direct face -to -face and telephone referral and consultation services for problems and issues such as alcohol and drug abuse, divorce, family conflicts, legal, financial, and child care difficulties and much more. Standard's EAP services were organized in 1972 and currently they have 6,000 provider locations across the country. They contract with licensed psychiatrists, psychologists, social workers, marriage and family therapists and attorneys who Emfloyee_ June 11, 1993 RICHARD T. HARE Deputy City Manager City of Moorpark 799 Moorpark Avenue Moorpark, CA 93021 Dear Richard, WAYNE RR(1',KA'` PI&A I HANI)V KINSI ING MIKE MT REWI IHE R, (P( U I MIKE JOHNSON t DENNIS (ORI E SIEVEN(ARTER RICK TOOHI Y i DAVE PE lE RS, ( (U, (hl( ( (,RE(, ANDERSON BOB WIKF R, RE TIRE 7 A 1 At I I INNIA I (*1'( AA' r!N SIN( 1923 ACLY Below is a summary of three modifications which can be made to your group medical coverages, either individually or in any combination, that will provide the City of Moorpark with significant premium savings. 1. Raise the Non -PPO Deductible from $250 to $500: As you know, when an insured uses doctors, hospitals, labs, or clinics within the Preferred Provider Organization (PPO) he or she does not incur a deductible, and benefits are immediately paid at 90 %. Moreover, when using a preferred physician, office visits require only a $10 co -pay, again, with no deductible. If, however, an employee receives benefits outside of the Preferred Provider Organization, the insured must first pay a $250 deductible, after which benefits are paid at 80 %. By raising the Non -PPO deductible to $500, the insured would first incur a $500 deductible when using non - preferred providers, however, benefits would remain payable at 80 %. Incidentally, increasing the Non -PPO deductible would not affect the Preferred Provider office visit co -pay, i.e., when using a preferred physician, employees would still only be required to pay $10. 2. Add a $250 per Hospital Confinement Co -pay: Currently, when an employee is admitted to a hospital on an inpatient basis (overnight stay) there is no additional charge or co -pay required. By adding a $250 per confinement co -pay, employees would pay $250 each time they were admitted to a hospital on an inpatient basis. The $250 charge, however, would not be levied if they were treated on an outpatient basis (admitted and discharged the same day). The per confinement co -pay is applicable to both PPO and Non -PPO hospital confinements, and is charged per confinement (hospital stay), not per night. 3. Lower Non -PPO Percentage Payable from 80% to 70%: As mentioned above, if an employee receives benefits outside of the PPO, he or she incurs a deductible and then has benefits paid at 80% with a maximum out -of- pocket limit of $2,000 plus the deductible. (Expenses incurred inside the PPO are reimbursed at 90% with no deductible, and an out -of- pocket limit to the employee of $1,000). By lowering the Non -PPO percentage payable from 80% to 70 %, Non -PPO expenses would be paid at 70% with the out -of- pocket limit remaining at $2,000 plus the deductible. Please let your employees know that they may call me personally with any questions whatsoever. Sincerely, David M. Peters, CLU, ChFC 196 SO FIR STREET P 0 BOX 1388 . VENTURA. CA 93002 - PHONE: 805 653 7744 - 485 3504 - FAX 805 653 7762 Counct I -Pict.1 v Blue ,%field Preferred Plus Health Plan For Individuals And Families Summary of Benefits and Provisions TABLE OF CONTENTS Features of the Blue Shield Preferred Plus Plan .................. 1 Health Education and Wellness Program ....................... 1 Special Rates for Children ..... ............................... 1 More About Your Blue Shield Preferred Plus Plan ............... 2 Deductible Copayments Eligibility ..................... ..............................3 Changes in Your Family? ..... ............................... 3 Principal Benefits and Coverages .............................. 4 Services..................... ............................... 5 Managing Benefits with the Blue Shield Preferred Plus Program ....... ............................... 7 Preservice Benefits Determination and Certification Hospital Admission Hospital Inpatient Utilization Review Discharge Planning Principal Exclusions and Limitations on Benefits ................ 9 Pre - Existing and Waived Conditions Other Exclusions for the Blue Shield Preferred Plus Program Medical Necessity Exclusion .. ............................... 11 Definitions and Terms ....... ............................... 11 Transfer of Coverage ........... .............................12 Payment of Dues ............ ............................... 13 Provider Directories ......... ............................... 13 Features of the • Access to the Blue Shield Preferred Provider network: over Blue Shield 36,000 Physician Members, more than 270 Preferred Hospitals, Preferred Plus and 26,000 Participating Health Professionals across the state; Plan . Lifetime maximum benefits of $6,000,000 per covered individual; • Preventive Benefits which include Health Appraisal Examinations; • Prenatal Benefits; • Nationally recognized programs that can guide you to better health — HealthtracsMt and BabytracsMt; • Special rates for children with Preferred YouthCaresM 2; • Choice of deductible - $200, $500, $ 1,000 or $2,000 per Calendar Year, • Your maximum copayment, the amount you're responsible for after you've paid your deductible, is S2,000 per person and $4,000 per family in a Calendar Year when you use Preferred Providers: • All Preferred Providers have agreed to accept Blue Shield's payment allowance as payment for covered services. You are only responsible for the applicable deductible and copayments. Health Education The Blue Shield Preferred Plus Plan includes HealthtracsM, a And Wellness nationally recognized health education and wellness program. Program Following enrollment you will receive information from Blue Shield about the program and how to participate. In addition, the Blue Shield Preferred Plus plan includes BabytracsM. This prenatal program is specifically designed to provide information that can help reduce the number of pre -term and low birthweight babies. Participation is voluntary. Special Rates The Blue Shield Preferred Plus plan has special rates for For Children children. This can save you money if you're a single parent, or allow you to provide greater (or lesser) coverage for your children than your group's health care plan. When you buy your child his or her own Blue Shield Preferred Plus YouthCare= Plan, you'll give your child access to more Preferred Providers than any other plan in the state. Please see the rate sheets for more details. More About Your Blue Shield provides 1000 of the Allowable Amount after you Blue Shield have paid the applicable deductible and maximum copayments in Preferred Plus a Calendar Year, up to a lifetime aggregate payment amount of Plan $6,000,000 per covered individual. Deductible With the Blue Shield Preferred Plus plan, you have a choice of deductible - $200, $500, $ 1,000, or $2,000 per Calendar Year. For families with 3 or more members, the total deductible is only twice the individual amount, regardless of family size. For subscribers enrolled in the $200 deductible plan, the deductible does not apply to Inpatient Hospital Services, Copayments Blue Shield Preferred Providers have agreed to accept Blue Shield's payment allowance as payment for covered services — non- preferred providers have not. There is a considerable difference in your out -of- pocket costs should you elect to go to non - preferred providers. Blue Shield pays for services performed by non - preferred providers at a significantly reduced percentage so you will have to pay more. You are also responsible for any charges that exceed Blue Shield's allowable amount. Services by Other Providers (see Definitions, Page 11) are paid at 80% of the amount billed or 80% of the amount charged by the majority of the same providers in the same area. Following are the maximum copayment amounts with the Blue Shield Preferred Plus plan each Calendar Year Preferred Any Combination of Provider Preferred/Non- Preferred Services Provider Services Per Person $2,000 $ 5,000 Per Family $4,000 $10,000 1Healthftw314 and Babytracsm are Service Marks of Healthtrac. Inc. WouthCa esM is a Service Mark of Blue Shield of Califomia N Copayments (continued) Charges for the following Services are not included in the total Calendar Year copayment calculations, and may cause a Subscriber's payment responsibility to exceed the maximums listed above: • Outpatient prescription drugs; • Services which are not covered; • Charges in excess of stated benefit maximums; • Services rendered for non - emergency inpatient and outpatient, inpatient mental, alcoholism, substance abuse and non - emergency complications of pregnancy. Eligibility If you are a California resident, under age 65, and meet the requirements stated on the application for coverage, you may apply for this plan. When your application is approved, you will be eligible to receive benefits of the plan you select. Your spouse (under age 65) and unmarried dependent children (under age 23) are also eligible for coverage. Changes in Newborn infants from the moment of birth and adopted children Your Family? from the date of placement in the subscriber's physical custody are automatically covered under the plan. Within 31 days of the birth or placement, the subscriber must submit a Subscriber Change Request to add the newborn or adopted child for coverage to continue past the 31 -day period. A new spouse may be enrolled in the plan once his or her application is approved and dues are paid. It is your responsibility to notify Blue Shield when a dependent becomes ineligible. 3 Principal Benefits Your eligibility for benefits stops once you become eligible for and Coverages Medicare benefits. At that time, you may apply for a Blue Shield plan which is designed to provide benefits that supplement Medi- care benefits. This is only a summary of the Blue Shield Preferred Plea plan for individuals and families. Please see the individual plan's Evidence of Coverage and Family Health Service Agreement for the exact terms and conditions of coverage. We will be pleased to furnish you a copy of the Health Service Agreement you require on request. No person has the right to receive the benefits of any Blue Shield plan for services furnished following termination of coverage. Benefits of the plan are available only for services furnished during the term it is in effect and while the individual claiming benefits is actually covered by the Agreement for the plan selected. Benefits may be modified during the term of your Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply for services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of any Blue Shield Agreement. The amount of coverage (what Blue Shield pays) and your copayment (what you pay) varies from benefit to benefit. The following chart shows many of the copayments, but it is only a summary. For the Blue Shield Preferred Plus plan, the copayments are shown for both Preferred and non- Preferred Providers. You will note that your copayment is significantly higher when non - Preferred Providers are used. In some cases, you will receive no benefits if non - Preferred Providers are used. 4 Services Physician — Inpatient Inpatient visits Blue Shield Pays with Preferred Providers Your Copayment With Preferred Providers Your Copayment With Non - Preferred Providers Physician and Other Outpatient Services 80% 20% 50% Office visits 80% 20% 50% Laboratory, x -ray, major diagnostic 80% 20% 50% Mammography, Papanicolaou's test 80% 20% Not Covered (Pap test) 5200 maximum Sigmoidoscopy age 50 and over every 5 years 80% 20% Not Covered Veneral Disease Tests 80% 20% Not Covered Physician — Inpatient Inpatient visits 80% 20% 50% Surgeon & assistants, anesthesiologists 80% 20% 50% pathologists, radiologists Preventive Coverage Health Appraisal Exam which includes: 80% up to a Balance Not Covered Routine Physical Examinations, 5200 maximum Vision/Hearing Testing (through age 16), per calendar year Immunization for adults Prenatal Care (Not subject to plan deductible) 80% up to a 20% Not Covered maximum of S750 Well Baby Care 80% 20% Not Covered (Through age 2, including immunizations) Hospital Services (non- emergency)t Semi - private room and board 80% 20% 50% of allowable of $600 /day Medically necessary services & supplies 80% 20% 50% of allowable of S600 /day (You Preferred Hospital copaytnent is based on the lesser of billed charges or the negotiated amount.) Hospital Services (emergency)t Semi - private room and board 80% 20% 20% Medically necessary services & supplies 80% 20% 20% Emergency Room 80% 20% 20% (Your Preferred Hospital copayment is baud on the lesser of billed charges or the negotiated amount.) Ambulance Surface (Up to $750 per trip maximum) 80% 20% 20% Air (Up to $3,500 per trip maximum) 80% 20% 20% Skilled Nursing Facility (SNF) Semi - private accommodations 80% up to 20% plus excess 20% plus excess (following transfer from hospital unless 100 daystyear over 100 days over 100 days Blue Shield gives written authorization) Family Planning 80% 20% Not Covered Pregnancy and Maternity Care Normal delivery Not Covered Not Covered Not Covered Complications of pregnancy (non -emergency) 80% 20% 50% of allowable of $600 /day Complications of pregnancy (emergency) 80% 20% 20% S Blue Shield Pays Your Copayment Your Copayment with Preferred With Preferred With Non - Preferred Providers Providers Providers Home Cam/Home Hospice Care Medically necessary visits by physician 80% 20% Medically necessary visits by approved 80% 20% home health agency [Combined Maximum ( Preferred /Non - Preferred) per Calendar Year = $10,0001 Facility Hospice Care Services of a licensed hospice 80% 20% (limited to six months per covered person) Prosthetic Appliances and Home Medical Equipment Such as artificial limbs, braces, 80% 20% oxygen, wheel chairs Physical Tberapy Physician's office, physical therapist's office, 80% 20% or hospital outpatient department At Home 80% 20% [Combined Maximum (Preferred /Non - Preferred) per Calendar Year = $1,0001 Psychiatric Caret Psychiatric care - Inpatient 80% 20% (limited to 15 days per Calendar Year) Psychiatric care - Outpatient Not Covered Not Covered Alcoholism/Substance Abuset Acute detoxification for alcoholism or narcotism (inpatient treatment limited to 3 days) Alcohol/drug abuse counseling, assessment. testing, telephone consultations Outpatient Prescription Drugs * (does not count toward plan deductible) Outpatient Prescription Drugs 80% Not Covered 20% Not Covered 50% 50% 20% 50% 50% 50% 50% of allowable of $175 /day' Not Covered 50% of allowable of 5175 /day * Not Covered 80% of allowed 20% of allowed 20% of allowed after initial after initial after initial $100 copsyment $100 cpayment $100 oopayment (of the lesser of the item's cost or the charge made by the majority of pharmacists in the area where the items are obtained) * These charges do not accumulate toward the maximum copayment amount. t See Deductible section on page 2. This chart, and the rest of this disclosure form, only briefly describe the benefits of these plans. The Health Service Agreement must be consulted to determine the exact terms and conditions of coverage. 6 Managing Benefits The Blue Shield Preferred Plus plan includes the Benefits with the Blue Shield Management Program, to help you identify the most appropriate and Preferred Plus Plan cost -effective course of treatment for which you may receive benefits. The program, which is designed to help control your health care coverage costs, is made up of the following components: Preservice Benefit Determination and Certification Taking this first simple step will tell you whether a procedure or treatment is a covered service -- before that service is provided. Let's say you are considering a plastic or reconstructive surgery procedure. When you or your physician call Blue Shield at 1 -800- 343 -1691, you'll find that medically necessary plastic surgery to correct a health condition may be covered, but plastic surgery for cosmetic purposes is not covered. Once you have this Preservice Benefit Determination, you and your physician make the final decision concerning treatment. Hospital Admission A. Notification Requirements At least five (S) business days prior to hospital admission for inpatient services (except for Emergency Services), you or your physician must call Blue Shield's Preadmission Review Unit at 1- 800 -343 -1691. If you are admitted for Emergency Services, Blue Shield must be notified within 24 hours or by the end of the first business day following admission. B. Preadmission Review Recommendations Ile Preadmission Review Unit will discuss the benefits available, review the medical information provided and may recommend that the services you need be obtained on an outpatient basis or advise that a second surgical opinion is required before a decision is made regarding treatment. Examples of procx hm that may be recommended to be performed on an outpatient basis if medical conditions do not warrant inpatient care are: Biopsy of Lymph Node Deep Axdlary Blepharoplasty (repair of drooping upper eyelids) Hernia Repair, inguinal Esophagogastroduodenoscopy with or without biopsy Excision of Ganglion Repair of Tendon Heart Catheterization Diagnostic Bronchoscopy Creation of Arterial Venous Shunts (for hemodialysis) Benefits Mangaaement ProdramsM is a Service Mark of Blue Shield of California 7 Examples of procedures for which a second surgical opinion may be required are: Cataract Extraction with or without Artificial Lens Implantation Tonsillectomy Andenoidectomy Hysterectomy Transurethral Resection, Prostate Cholecystectomy Coronary Artery Bypass Radical or Modified Mastectomy Laminectomy Surgery for Treatment of Morbid Obesity Non - emergency Cesarean Section Hospital Inpatient Utilization Review If you must be hospitalized, Blue Shield and your hospital's Utilization Review Committee will monitor your treatment to assure you receive the quality care you need. Depending upon your progress, your initial length of hospital stay may be extended or reduced. If inpatient care is determined to be no longer necessary, both you and your physician will be notified. Twenty -four hours after this notification, any charges for hospital services become your responsibility and will not be covered by these plans. Discharge Planning Together with your hospital's Utilization Review personnel and your physician, Blue Shield will evaluate your need for further care in another facility or in your home, and will let you know if benefits are available for the proposed treatment. The Benefits Management ProgramSM is simple to use, but it can only work to control and reduce your health care costs if it is used effectively. Blue Shield can be contacted at 1- 800 -343 -1691 for any questions regarding this program. To encourage you to use the program to your advantage we include the following incentive: If you do not follow Blue Shield recommendations regarding outpatient surgery, or if you do not obtain a second surgical opinion, you are responsible for an additional $500 deductible applied to your hospital charge after each admission. There is an additional $1,000 deductible for each psychiatric care hospital admission if you do not obtain Preadmission Review or fail to follow the Preadmission Review Unit recommendations. These amounts will be charged in addition to the required Calendar Year deductible, copayment, or amounts in excess of specified maximums and will not be included in the calculation of your maximum copayment amount. 8 Principal Exclusions and Limitations on Benefits Pre - Existing and Waived Conditions You will not be entitled to any benefits for ser- vices which are related to any condition, illness or injury, which is a e- Existing Condition as defined on page luntil after twelve (12) consecutive months of coverage. You are also not entitled to benefits for any conditions excluded by an endorsement (waiver) to the Health Service Agreement. Other Exclusions for the Blue Shield Preferred Plus plan Unless exceptions to the following exclusions are specifically made elsewhere in the Health Service Agreement for your plan, no benefits are provided for services and procedures which are: • experimental or investigational in name; for or incident to hospitalization or confinement in a health facility primarily to treat or cure chronic pain, except those benefits which would have been provided had the individual been treated on an Outpatient basis. For example, charges for room and board during such hospitalization are not a benefit; for Rehabilitation or Rehabilitative Care except for those Services for which benefits may be pre - approved in accordance with the Benefits Management Program; • for or incident to services rendered in a health facility primarily for custodial, maintenance or domiciliary care, rest, except as provided under the Facility Hospice Care benefit; or to control or change a person's environment, such as confinement in an eating disorders unit; • performed in a hospital by hospital officers, residents, interns and others in training; for or incident to hospitalization or confinement in a pain management center to treat or cure chronic pain; for cosmetic procedures or any resulting complications, except that benefits are provided for medically necessary services to treat complications of cosmetic surgery (e.g., infections or hemorrhages), but only upon review and approval by a Blue Shield physician consultant; • incident to a human organ transplant, except as provided in the Service Agreement; • for convenience items such as telephones, TVs, guest trays, and personal hygiene items; • for or incident to intersex surgery (transexual operations) or any resulting medical complications; • for or incident to sexual dysfunction, infertility or in vitro fertilization; • for or incident to the reversal of surgical sterilization, or any complications of these procedures; • for penile implant devices and surgery, any related services, or any resulting complications, except when medically necessary; • for callus, corn paring or excision, toenail trimming, and treatment (other than surgery) of chronic conditions of the foot, e.g., weak or fallen arches, flat or pronated foot, pain or cramp of the foot, bunions, muscle trauma due to exertion or any type of massage procedure on the foot; for dental care or services by oral surgeons, including hospitalization incident thereto, and services in connection with orthodontia for any condition; • for the treatment of hyperkinetic syndrome, learning disability, behavioral problems, mental retardation or autistic disease of childhood; • for or incident to acupuncture; • for spinal manipulation or adjustment; • for dental implants (endosteal, subperiosteal or transosteal); • for any procedure (e.g., vestibuloplasty) intended to prepare the mouth for dentures or for the more comfortable use of dentures; • for or incident to any injury arising out of, or in the course of, any employment for salary, wage or profit, if any such injury or disease is covered by any workers' compensation law, occupational disease law or similar legislation. However, if Blue Shield provides payment for such services it shall be entitled to establish a lien upon such other benefits up to the amount paid by Blue Shield for the treatment of such injury or disease; • performed by a close relative or by a person who ordinarily resides in the subscriber's or dependent's home; orthopedic shoes and other supportive devices for the feet, air conditioners, humidifiers, dehumidifiers, air purifiers, exercise equipment, or any other equipment not primarily medical in nature, including but not limited to spas, saunas and sun lamps; • for hemorrhoids, hernia, varicose veins, tonsils, adenoids, vasectomy, and tubal ligation or until after twelve (12) consecutive months of coverage; • for speech therapy services, except as specifically provided in the Home Care/Home Hospice Care benefit; • for or incident to occupational, vocational, educational, recreational, art, dance, music or reading therapy, weight control programs; or exercise programs; • for any condition, illness or injury defined as a PreExisting Condition (see Definitions, Page 12) until after twelve (12) consecutive months of coverage; • for routine eye refractions, surgery to correct refractive error, radial keratotomy; refractive keratoplasty; eye glasses; contact lenses or hearing aids; 10 • for or related to hospitalization primarily for x -ray, laboratory or any other diagnostic studies or medical observation; • related to pregnancy and vaginal delivery, except as provided in the Health Service Agree- ment; • in connection with private duty nursing & except as provided in the Home Care/Home Hospice Care benefit; • for alcoholism or narcotism, except that this exclusion shall not apply to services rendered in a hospital for a period not to exceed three (3) days when confinement is certified by the attending physician as medically necessary by reason of the person's acute condition or except as specifically provided in the Service Agree- ment; • for telephone consultations for any purpose, whether between the Physician or other pro- vider and the Person or Person's family, or involving only Physicians or other providers; • related to telephone psychiatric consultations or for psychological evaluation or testing, or testing for intelligence or learning disabilities; • for which the person is not legally obligated to pay or for services for which no charge is made to the person; • not specifically listed as a benefit. Medical Necessity Exclusion All services must be Medically Necessary. The fact that a physician, hospital or other provider may prescribe, order, recommend or approve a service or supply does not, in itself, make it Medically Necessary, even though it is not spe- cifically listed as-an exclusion or limitation. Blue Shield may limit or exclude benefits for services which are not Medically Necessary. Definitions and Terms Some Definitions and Terms you should know (please consult the Health Service Agreement for the plan you select for exact terms and conditions of coverage). Allowable Amount 1. For Physicians: (a) An amount determined by Blue Shield, based upon Billed Charge data for the same or similar services submitted to Blue Shield during a period of time determined by Blue Shield, which physicians who have contracted with Blue Shield are obligated to accept as payment -in -full for the services provided; or (b) If an amount is not determined as described in subparagraph (a) above, the amount Blue Shield determines is appropriate considering the particular circumstances and services provided and which Physicians who have contracted with Blue Shield are obligated to accept as payment -in- full. 2. For Alternate Care Services Providers: An amount that Blue Shield determines is appropriate considering the services provided and which such providers who have contracted with Blue Shield are obligated to accept as payment -in- full. Allowed Charge: The amount Blue Shield allows for covered services. It is based on the type of provider and the specific service. Copayment: The applicable percentage of the Allowable Amount for covered services that a subscriber pays after the deductible is met. Calendar Year. A period beginning at 12:01 am. on January 1 and ending at 12:01 am. on January 1 of the next year. Deductible: The initial allowed charge for covered services and supplies which a subscriber pays from his or her own pocket. Hospital (either 1, 2 or 3 below): 11 1. A licensed institution primarily engaged in providing, for compensation from patients, medical, diagnostic and surgical facilities for care and treatment of sick and injured persons on an inpatient basis, under the supervision of an organized medical staff, and which provides 24- hour -aday musing service by registered nurses. A facility which is principally a rest home or nursing home or home for the aged is not included. 2. A psychiatric Hospital accredited by the joint Commission on Accreditation of Healthcare Organizations. 3. A "Psychiatric health facility" as defined in Section 1250.2 of the Health and Safety Code. Other Providers - (Preferred Plan): 1. Independent Practitioners - licensed vocational nurse; licensed practical nurse; registered nurse; licensed psychiatric nurse; certified nurse anesthetist; certified nurse midwives; individual certified orthotist; prosthetist or prosthetist-orthotist; licensed occupational therapists; inhalation and ent.erostomal therapists; licensed speech therapists or pathologists; certified acupuncturist; dental technicians; laboratory technicians; and drugless practitioners. Health Care Organizations - nurses registry, approved surgi- centers; licensed mental health, freestanding public health, rehabilitation, hemodialysis and physician directed outpatient clinics; enuresis control centers; portable x -ray companies; lay -owned independent lab; blood banks; speech and hearing centers; dental labs; dental supply companies; nursing homes; ambulance companies; Easter Seal Society; American Cancer Society; Catholic Charities; and Skilled Nursing Facilities. Participating Provider: A Physician Member, Preferred Hospital, Alternate Care Services Provider, or other provider of health care that has contracted with Blue Shield to furnish services and to accept Blue Shield's payment as payment -in -full for covered services, except for applicable deductibles, copayments, or amounts in excess of benefit dollar maximums specified. Physician: A licensed Doctor of Medicine, clinical psychologist, research psychoanalyst, dentist, clinical social worker, optometrist, chiropractor, podiatrist, audiologist, marriage, family and child counselor, or registered physical therapist. Physician Member.• A Doctor of Medicine who has enrolled with Blue Shield, has agreed to furnish services to persons covered by Blue Shield, and has agreed to accept Blue Shield's payment as payment -in -full for covered services, except for applicable deductibles, copayments or amounts in excess of benefit dollar maximums specified. Pre- Existing Condition: An illness, injury or condition which existed during the twelve (12) months prior to the effective date of coverage if during that time (1) any professional advice or treatment, or any medical supply (including but not limited to prescription drugs or medicines) was obtained for that disability; or (2) there was the 12 symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment. Preferred Hospital: A hospital under contract to Blue Shield which has agreed to furnish services and accept reimbursement at negotiated rates, and which has been designated as a Preferred Hospital by Blue Shield. Preferred Provider: A Physician Member, a Preferred Hospital, or other Participating Provider. Skilled Nursing Facility: A facility licensed by the California State Department of Health as a "Skilled Nursing Facility" or any similar institution licensed under the laws of any other state, territory, or foreign country. Transfer of Coverage 1 If you move out -of -state to an area served by another plan in the Blue Cross/Blue Shield system and have your dues billed to the new address, your coverage will be transferred to the plan serving your new address. 2. The new plan must offer you at least its group conversion plan. This is a type of plan normally provided to subscribers who leave a group and apply for new coverage as individuals. 3. Conversion plans provide coverage without a medical examination or health statement. 4. If you accept the conversion policy, the new plan will credit you for the length of your enrollment in this plan toward any of its own waiting periods. Any physical or mental conditions covered by this plan will be covered by the new plan without a new waiting period if the new plan offers this feature to others carrying the same type of coverage. Transfer of Coverage (continued) 5. The required dues amount and benefits available from the new plan may vary significantly from this plan. 6. In addition, the new plan may offer other types of coverage outside the transfer program which may: (a) require a medical examination or health statement to exclude coverage for pre - existing conditions, and (b) not apply time enrolled in this plan's waiting period. Payment Of Dues Dues are billed and payable every three months. The bill will tell you the date the payment is due. Payments should be sent to: Blue Shield of California P.O. Box 8502 Ukiah, CA 95482 Provider Directories Blue Shield Provider Directories are published periodically. While we try to make sure they are as up to date as possible, they are subject to change. To be certain you have the latest direc- tory, please call any of the Sales offices listed in this brochure. All of these numbers are operational Monday through Friday between 9 am. and 4 p.m. 13 BLUE SHIELD OF CALIFORNIA PREFERRED PLUS Underwritten by the California Physicians, Insurance Corporation Utilizing the Blue Shield of California Preferred Providers Prepared for QUARTERLY DUES * $200 DEDUCTIBLE Major Medical .......... ............................... $1,317.00 $500 DEDUCTIBLE Major Medical .......... ............................... $ 981.00 $1,000 DEDUCTIBLE Major Medical .......... ............................... $ 756.00 $2,000 DEDUCTIBLE Major Medical .......... ............................... $ 528.00 * Dues are due and payable in QUARTERLY amounts. Rates are based on the subscribers age and number of dependents insured on the plan with the subscriber. The monthly dues can be paid by automatic draft deduction from the subscribers bank account if so desired. i Application for any Blue Shield health plan is subject to the review of medical history of the subscriber and all dependents. BLUE SHIELD OF CALIFORNIA PREFERRED PLUS Underwritten by the California Physicians' Insurance Corporation Utilizing the Blue Shield of California Preferred Providers Prepared for QUARTERLY DUES * $200 DEDUCTIBLE MajorMedical .......... ............................... $ 993.00 $500 DEDUCTIBLE Major Medical .......... ............................... $ 753.00 $1,000 DEDUCTIBLE Major Medical .......... ............................... $ 495.00 $2,000 DEDUCTIBLE Major Medical .......... ............................... $ 372.00 * Dues are due and payable in QUARTERLY amounts. Rates are based on the subscribers age and number of dependents insured on the plan with the subscriber. The monthly dues can be paid by automatic draft deduction from the subscribers bank account if so desired. Application for any Blue Shield health plan is subject to the review of medical history of the subscriber and all dependents. BLUE SHIELD OF CALIFORNIA PREFERRED PLUS Underwritten by the California Physicians' Insurance Corporation Utilizing the Blue Shield of California Preferred Providers Prepared for QUARTERLY DUES * $200 DEDUCTIBLE Major Medical .......... ............................... $1,116.00 $500 DEDUCTIBLE MajorMedical .......... ............................... $ 915.00 $1,000 DEDUCTIBLE MajorMedical .......... ............................... $ 654.00 $2,000 DEDUCTIBLE Major Medical .......... ............................... $ 501.00 * Dues are due and payable in QUARTERLY amounts. Rates are based on the subscribers age and number of dependents insured on the plan with the subscriber. The monthly dues can be paid by automatic draft deduction from the subscribers bank account if so desired. Application for any Blue Shield health plan is subject to the review of medical history of the subscriber and all dependents. STANDARD INSURANCE COMPANY LONG TERM DISABILITY INSURANCE PLAN B SCHEDULE OF INSURANCE Class: All Eligible COST BENEFIT FORMULA 66 2/30 of the first $9,000 of monthly earnings, reduced by deductible income. Maximum Monthly Benefit $6,000 No. of 37 Benefit Waiting Period 90 Days Maximum Benefit Period To Age 65 + ADEA Total Percent Covered Covered Monthly Payroll X Payroll = Premium $111,923 .490 $548 243222 -2- 930409 STANDARD INSURANCE COMPANY PLAN FEATURES * All benefits are Guarantee Issue. * Plan reflects 100% Employer contribution. * Partial Disability includes automatic indexing of Predisability Earnings while disabled to help offset inflation. * A Return to Work Incentive for Partially Disabled Members is included. * A lump sum Survivors Benefit, equal to 3 times the LTD Benefit without reduction by Deductible Income, is included. * No alcohol or drug restrictions. * This plan provides a 2 year Own Occ, unless otherwise indicated. Partial Disability, zero -day residual and 80% Own Occ /80% Any Occ income protection are included. During the Own Occ Period there is no limit on earnings from another occupation. * $100 Minimum LTD Benefit. * ADEA standard grading with 1 year benefit at age 69 or older. * A 3/12 Preexisting Condition Exclusion applies. * Final rates will be guaranteed for 3 year(s). * Own Occ Income Protection to Age 65 applies to Managers, Directors, Administrators and Office employees. Partial Disability, zero -day residual and 80% income protection are included. May earn up to 800 of Indexed Predisability Earnings in another occupation and still qualify for a LTD benefit. -- Increase rate by a factor o 1.03 243222 -2- 930409 Feature LTD Standard Reliance Standard Guarantee Issue Amount All benefits guarantee same issue. Benefit Waiting Period 90 days same Maximum Monthly Benefit Plan A $3,000 $3,000 Plan B $6,000 Definition of Disability Own Occ Income 5 year own Protection to Age 65 occupation; any occupation applies to Managers, thereafter. Contract Directors, does mention partial Administrators, disability after the and Office Employees. elimination period. Partial disability, However, no mention zero -day residual and of 80% earnings test. 80% income protection are included. May earn up to 80% of Indexed Predisability Earnings in another occupation and still qualify for a LTD benefit. Partial Disability Yes. Benefit waiting No, claimant must be Definition period can be served totally disabled during while partially the elimination period disabled. in order to be eligible for partial disability. Return to Work Incentive Provisions: Percentage of work earnings used to reduce LTD benefit: First 12 months return No reduction until 50% offset of work earnings work work earnings plus LTD benefit exceed 100% of indexed predisability earnings. After the first 12 50% 50% months return to work Return to work Standard does not Reliance Standard employment have to approve a must approve a claimant's claimant's return to work employment rehabilitative prior to acceptance of employment partial disability benefit. LTD Feature Standard Reliance Standard Index Predisability Increase by lesser of Not mentioned in Earnings 10% or CPI (W) after contract. each year of disability. No limit of adjustments. Never decreases. Temporary Recovery: Days of Temporary Recovery permitted during Benefit Waiting Period without requiring start of New Benefit Waiting Period. 5 days for each 30 days 7 days total of Benefit Waiting Period. Proposed plan has 15 days. Survivor Benefit Paid in a lump sum Not mentioned in equal to three times contract. the maximum LTD benefit (non- integrated), other option available; payment to estate optional. Specific Indemnity Benefit Not available If the insured suffers any one of the losses listed in the contract from an accident resulting in an injury, Reliance Standard will pay a guaranteed minimum number of monthly payments. See contract for details P. 10. Employee Assistance See brochure for Not available Program features and cost. Progn-1 111 l FA Pi High /igil ts oe tandard has made arrangements to offer an Employee Assistance Program to our bong 'Perm Disability (LTD) policyowners. As one of the nation's leading underwriters of LTD, we recognize that an employee's personal problems may interfere with their effectiveness at work. These prob- lems (such as alcohol and drug abuse, di- vorce, family conflicts, financial, legal, and child care difficulties) can result in absentee- ism and poor job performance. Additionally, if left unattended, these problems can deterio- rate into long term disabilities. An Employee Assistance Program helps employees confront their problems before the problems explode into catastrophes. Standard is offering a reliable mechanism which re- duces absenteeism, the cost of health care, and may reduce the number of LTD claims, while simultaneously contributing to the less tangible but all- important benefit of a more productive and motivated workforce. For managers and supervisors, the EAP provides immediate access to high quality, pro- fessional consultation to assist in handling the difficult personnel issues that confront man- agement today. For employees and their families, the EAP means the opportunity to resolve problems of adult life in a non — threatening, confidential environment. (l;; u; '),"., iii,..., . i ' l;, Occupational Health Services, Inc. (OHS) will provide EAP services. OHS, founded in 1972, has more than 20 years experience and currently covers more than two million people nationwide. OHS has become one of the na- tion's largest and most respected EAP provid- ers, serving business, industry, government agencies, public utilities and education institu- tions large and small.. 24 —hour toll —free number • Unlimited access 24— liours /day, 365 days/ year • On —line translation in 140 languages • "I'IY for the hearing impaired • Licensed counselors to respond to crisis calls Assessment, consultation and referral for: Clinical Issues • Substance abuse • Marital /family problems • Psychological distress and psychiatric dis- orders • Emotional, personal and stress — related concerns Other issues • Financial matters • Organizing life's affairs (pre —post death) • Pre— retirement counseling • Legal issues • Federal tax collection and audit problems • Childcare and eldercare consultation Accessible specialized provider network • Nearly 6,000 provider locations nationwide. • Licensed psychiatrists, psychologists, so- cial workers, marriage and family thera- pists and attorneys who have all passed a credo ntialing process. You 71 Stay u,ith Standard Supervisor's consultation service for re- ferral of troubled employees • Dedicated management consultation unit • On —site critical incident response (Addi- tional fee) Program materials • Brochures • Posters • Paycheck stuffers • Newsletter articles • Educational pamphlets • Booklets Employee orientation • Employee orientation video • Professional on —site sessions (Additional fee) Quarterly EAP utilization reports for groups with more than 200 employees Training seminars for management/super- visors Professional on —site sessions (Additional fee) Educational and Wellness Seminars Programs on a wide variety of topics (Additional fee) Telephone Assessment and Referral $1.15 per employee per month* (Does not include childcare or eldercare con- sultation) In— person Service Face —to —face assessment and referral for all clinical services, plus telephone consulta- tion and referral for all other services. Up to 3 in— person sessions per incident. $1.75 per employee per month* Program materials and supervisory con- sultation are available under both options at no additional charge. *Groups over 1,000 lives will be individually underwritten by OHS. If you select this feature, you will enter into a separate agreement with OHS. This agreement will provide more details concern- ing OHS's services. S INSURANCE COMPANY PORTIAND. ORFGON Dedicated to Excellence SI 13 -7049 Yo01 Stav with .Standard 2