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Home My WebLink AboutAGENDA REPORT 1990 0418 CC REG ITEM 08JPAUL W. LAWRASON, Jr. Mayor SCOTT MONTGOMERY Mayor Pro Tem ELOISE BROWN Councilmember CLINT HARPER, Ph.D. Councilmember BERNARDO M.PEREZ Councilmember LILLIAN KELLERMAN City Clerk MOORPARK TO: HONORABLE CITY COUNCIL IItMcj 0%-j STEVEN KUENY City Manager CHERYL J.KANE City Attorney PATRICK RICHARDS, A.I.C.P Director of Community Development R. DENNIS DELZEIT City Engineer JOHN V. GILLESPIE Chief of Police RICHARD T. HARE City Treasurer r FROM: RICHARD HARE, DEPUTY CITY y✓ DATE: April 11, 1990 ✓ SUBJECT: HEALTH INSURANCE RENEWAL BACKGROUND The City of Moorpark currently has health insurance coverage through Western Life. Our broker, Tolman & Wiker, was not able to forward the new rates for the next twelve month period to the City until this week. The new premiums for the period of May 1, 1990 to April 30, 1991 increased approximately 15 %. In addition, there were several changes in the plan itself. These changes included an expanded network of hospitals and physicians, of andincreasee doctor office co -pay provision, application to prescriptions and a required in- patient hospital and surgical services pre - authorization review. Staff also requested a quote for health insurance coverage from the Southern California Joint Powers Insurance Authority (the Authority) . The i�uthority's plan documents were received this week. TIIE� Authority's staff and contracted carrier representatives can meet with the City some time after the 19th of this month. A Western Life and Tolman & Wiker representative µi.11 also be available to meet with employees later th�..s -)nth. The City's agreement with PEAV; requires the review of the health insurance plan prior to �enewal, however, adequate time is not available to perfor.a a review and analysis of the two plans or to negotiate plan changes. An employee meeting was held on April 13th w i ith all available employees currently covered by the Wester,i Life plan to explain the plan changes proposed by Westerr, Life. Additionally, staff working with Tolman & Wiker c TntacteJ the Western Life Moorpark, California 93021 (805) 529 -6864 , 799 Moorpark Avenue p — underwriters in order to extend the current plan and the current premiums while we reviewed ol.an changes and rate changes. CONCLUSION Western Life has agreed to extend the same premium for May and June with the premium to be rEquoted for a twelve month period running from July 1, 199d:e to June 30, 1991. The plan changes would still take effect May 1, 1990, however, this will allow time for the review of the plan and alternative coverages during the next month, as well as, allow for analysis of the budget impacts of any rate increases prior to accepting a twelve month agreement with Western Life or the Insurance Authority. RECOMMENDATION: Staff recommends remaining with Western Life for another two months while options are reviewed, To do so, City Council must authorize the Cit)Y Manager to execute the necessary agreements with Western Life to extend the health insurance program for May and Jine. WESTERN LIFE INSURANCE COMPANY THE GROUP COMPANY WE.ST� EMPLO`IlsR RATE CHANGE° h,`)T1F "Lt,ATLON member AMEV-group Enclosed is your semi - annual illustration showirT and new premium to be effective cm the rata Effective with the rate change, your group in ut from the Med$ense provider network to the PHC`. 4E WesternCare network consists of numerous hosp' t (primary care and specialists) in the Southerr. illustrating the comprehensive network is enc;. rc -1,3n benefits, current premiums d3 i di_cated. Cl -,c irog ?am will automatically change e r -)Car( provider network. The PHCS <,n i '_h(,usands of physicians �'' -rr =a area- A provider directory the are giving you advanced notice 'so that you h3° the provider network changes. Your employees wi current providers they are now , ,Is nq are in t.,,E' several that are not in the PHCS network. It are advised of this so that -, if tiney want to r(c to change their choice of physicians and hosFita Enhanced benefits will only be paid as of yMr r ` me t > inform your employees of :>F 1- >1. <;a;;ed to find that many of the eeslso a.network. However, there are {er. important ive enhanced benefits they have time _> before the rate change date. f' -fiance date if the PHCS network providers are used. Pre- admission authorization is another very ml)c-tant rate change date. All hospital admissions wi,il- WesternCare used Private Healthcare Systems td authorization review service for the greater S)l;Chern quality provider network and prompt, efficieit rre-authorization change to be effective on your re ire 3Se admis.sionma thorization. (PHCS) pre-ad California area. PHCS offers a for hospital stays. Enclosed are handouts for each of your insured the plan changes and a review of the pre- admi,s important that these are distributed immediatEl mpioyees which include highlights of an authorization process. It is very s� that Everyone is aware of the changes. Just prior to your rate change date, we will lac will include details on the plan changes, alone new ID cards, and a preferred provider direc:t,1 NEED TO TURN IN THEIR MED$ENSE III CARDS TO "O'. nailing new employee packets which with new certificate schedule pages, Your agent has received a copy of this noti,,e Y coverage options and plan changes. Or, you car noted below to have any questions answered DI options. We appreciate the opportunity of ir.s look forward to providing contin.3ed service + d can provide more information about one of the toll -free numbers call on quotation on alternate plan inca yo7.ir employee benefit program and of !L , ..,.n GROUP OPERATIONS DEPARTMENT Toll Free: 1- 800 - 328 -1001 Ext. 5275 (Clar ,Ca.-e 1`' -49) Customer Seri, i , E + (: r que t ions Ext. 4066 (C]a:,s.cCare V-49) Group Underwri I f_r proposals on alternative plans MEDRLVR . DOC R E f F 1 V F D APR � 0 190 P.O. Box 64271 St. Paul, Minnesota 55164 itN it MOO p'atE Oualit y... because we care Telephone (612) 738 -4000 WESTERN LIFE INSURANiE COMPANY' DATE: 03/22/90 RATE CHANGE NOTI� ATION GROUP NAME: CITY OF MOORPARK POLICY NUMBER: 9000133444 EFFECTIVE DATE OF RATE CHANGE: 05/01/90 LENGTH OF RATE PERIOD: 06 MONTHS CURRENT RATE-) COVERAGE EMPLOYEE AD +D INSURANCE $100 EMPLOYEE MEDICAL DED $300 FAMILY MEDICAL DED 80% COINSURANCE TO $5,000 PCS DRUG BENEFIT 5/7 COPAY WESTERN DRUG BENEFIT PREGNANCY PAID AS A SICKNESS LIFE INSURANCE FOR EMPLOYEE RENEWAL RATES COVERAGE EMPLOYEE AD +D INSURANCE $100 EMPLOYEE MEDICAL DED $300 FAMILY MEDICAL DED 80% COINSURANCE TO $5,000 PRE - ADMISSION AUTHORIZATION PCS DRUG BENEFIT 5/7 COPAY WESTERN DRUG BENEFIT PREGNANCY PAID AS A SICKNESS LIFE INSURANCE FOR EMPLOYEE_ * MAJOR MEDICAL COVERAGE INCLUDES WESTERN ARE CITY OF MOORPARK 799 MOORPARK AVE MOORPARK EMPLOYEE A !43-78 DEPENDENT 228.59 30 EMPLOYEE DEPENDENT .06 166.08 258.71 ;4 TOLMAN AND WIKER INC 790 E SANTA CLARA ST CA 93021 P 0 Box 1388 VENTURA CA 93002 505 48 PAGE 01 WESTERN LIFE INSURANCE COMPANY THE GROUP COMPANY ��►71 Ei�1V member AMEV -group WELCOME TO THE NEW PHCS WESTERNCARE NETWORK!! Effective May 1, 1990, our new PHCS westernC'are physician and hospital network will replace your current Med$ense provider network. The PHCS WesternCare network consists of numerous hospitals and thousands of physicians (primary care and specialists) in the Southern California area. Western Life has expanded their- WesternCare Preferred Provider network in Southern California. Private Healthcare Systems Ltd. (PHCS) is a nationally proven Preferred Provider network. Your employer has been given some of the new directories which list your new preferred providers. To receive enhanced benefits after May 1 1990 you must use the physicians and hospitals shown in the new listing. PLAN CHANGE HIGHLIGHTS Network of Hospitals & New PHCS /'4esternCare -� Physicians Nationa., Doctor Office Visit Co -pay $10 Prescriptions Deductibl applies, (If the PCS card option is 80% - c.,v.�rage included in your plan, this does not apply.) In- Patient Hospital and 1000; pre authorization Surgical Services required nor all hospital conf ineme ,ts Current Regional $3, $5, $7, $10 No deductible, 80% Coverage 100% when admitted by Med$ense physician to a Med$ense facility. WesternCare requires that ALL hosp.ita, admissions be pre - authorized. But, it's easy!! All you need to �jo s give your doctor the completed pre - admission form. He will call the toll -free number, 1- 800 - 225 -5548, to obtain pre - admission authorization Failure to obtain re- authorization will result in a reduction in benefits. For emergency admissions, the doctor must call w.Lth n one working day.' Within the next few weeks you will re�ieive a new insurance packet with your new ID cards, and all the detailLs of your new coverage with PHCS WesternCare. AT THAT TIME YOU MUS".' RFTURN YOUR MED$ENSE ID CARD TO YOUR EMPLOYER. Please see your employer -f you have -zy questions. WELCOME.DH P O. Box 64271 St. Paul, Minnesota 55164 Telephone (612) 738 -4000 Quality... because we care A PRESENTATION FOR THE CITY OF MOORPARK SOUTHERN CALIFORNIA JOINT POWERS INSURANCE AUTHORITY AND CAL - SURANCE BENEFIT PLANS, INC. 2790 SKYPARK DRIVE, SUITE 200 TORRANCE, CALIFORNIA 90505 (213) 530 -x,525 APRIL 6, 1990 THE CAL -SURANCE GROUP CITY OF MOORPARK I. OPERATION OF SCJPIA EMPLOYEE. BENEFIT PROGRAM A. PARTICIPATION B. ENROLLMENT C. CLAIM PROCESSING II. FINANCIAL OPERATION OF SCJPIA EMPLOYEE BENEFIT PROGRAM A. DEPOSIT RATES B. RETROSPECTIVE PREMIUM ARRANGEMENT C. INTERNAL STOP -LOSS POO HNG ARRANGEMENT D. SPECIFIC STOP -LOSS ARRANGEMENJ E. CONTINGENCY EQUITY RESIRVE III. BENEFITS OF SCJPIA EMPLOYEE BENEFIT PROGRAM A. MEDICAL B. DENTAL C. VISION D. LIFE TI--iE CAL-- SURANCE GROUP SCJPIA EMPLOYEE BENEFIT PLAN PARTICIPANTS LA VERNE LIFE, MEDICAL )ENTAL , `.'ISION LAKEWOOD LIFE, MEDICAL iENTAL, JISION CAMARILLO LIFE, MEDICAL BELL GARDENS LIFE, MEDICAL )ENTA1 MAYWOOD LIFE, MEDICAL ° ENTAI LOMA LINDA LIFE HAWAIIAN GARDENS LIFE, MEDICAL ) ENTAL, VISION SEEACA LIFE, MEDICAL. LAWNDALE LIFE, ) ENTAL, VISION ARTESIA LIFE, MEDICAL, [)ENTAL, VISION IMPERIAL LIFE, MEDICAL, ':)ENTAL, VISION LOMITA VISION RANCHO PALOS VERDES LIFE, MEDICAL, DENTAL. MISSION VIEJO LIFE, MEDICAL, DENTAL, VISION PICO RIVERA )ENTAL, VISION SCJPIA LIFE, MEDICAL, ')ENTAL., VISION LA HABRA HEIGHTS DENTAL., VISION CITY OF COMMERCE MANAGED HEALTH NETWORK (MHN) DANA POINT LIFE, MEDICAL, DENIAL, VISION ROLLING HILLS ESTATES LIFE, MEDICAL, )ENIAI SAN JUAN CAPISTRANO LIFE, MEDICAL TEMPLE CITY LIFE I. THE OPERATON OF THE SCJPIA EMPLOYEE BENEFIT PROGRAM HOW TO ENTER THE PROGRAM Members enter the program by council approval of specified resolution (agreeing, as well to a minimum of tiree years in the plan) and submitting an enrollment card for each el igible employee. Upon entering the program, the following mats i,il will be presented to the member: 1. Summary Pl an Des _-r' i i or 2. Certificates of Jf In,uran::e 3. Identification Carl 4. Claim Forms 5. Other Admi ni strat. i v, Forms PLAN PROVISICINS EliaibiIit The following are eligible to parti ipat:e in the programs made available by a SCJPIA member: 1. Full -time employees, according to �rre members requirements, but no less than 30 hours per week. 2. Retiree coverage is not necessary ri order to participate in the program, but may be elected by a member for its retirees. Life insurance would not be available_ i coverage is offered to full - time employees. 3. Elected official may also be covere by a member, at its option. Dependents are eligible until age 19, r up to age 23, if unmarried, and attending an accredited colle(le r r.nlvE-S ity as a full -time student. New employees are covered after a wait: �g period as determined by the member city. SCJPIA ADMINISTRATIVE AERVICES CLAIM SERVICES HELLER ASSOCIATES - ENROLLMENT YES - ELIGIBILITY YES - MEDICAL, DENTAL, CLAIMS ADJUDICATION YES - CLAIMS ADMINISTRATION MANAGEMENT RfPOR_ YES - QUALITY CONTROL YES - INTEGRATION W /REINSURERS YES GENERAL ADMINISTRATION SERVICES - LIST BILLINGS YES - RECONCILIATION OF LIST BILLING YE:S - COMPLETE PREMIUM COLLECTIONS AND A(COUNT RECEIVABLES YE:S - GENERATION OF ELIGIBILITY REPORTS f(JR OTHER VENDORS SUCH AS VSP, PCS AND MHN YES - MAINTENANCE OF RECORDS AND FILE')- YES II. FINANCIAL OPERATION OF SCJPIA EMPLOYEE BENEFIT PROGRAM SCJPIA 7/89 - 7/90 RATE: SUMMARY COVERAGE SCJPIA LIFE /AD &D $.38/$1,000 (W / ")AFETY) S.34/$1,000 ( W/ OU' SAFE r-Y ) MEDICAL PPO EPO EMPLOYEE $145.97 $138 19 EMPLOYEE + 1 316.14 302 22 EMPLOYEE + 2 OR MORE 422.19 401 68 DENTAL FEE FOR SERVICE PREPAID EMPLOYEE $18.63 $ 9 41 EMPLOYEE + 1 32.56 16 45 EMPLOYEE + 2 OR MORE 46.54 23 51 SOUTHERN CALIFORNIA JOINT POWERS INSURANCE AUTHORITY VISION SERVICE PLAN! DEDUCTIBLE $ 0 $ 5.00 $ 7.50 $10.00 $15.00 $20.00 $25.00 PLAN A (Exam every 12 months - Lenses every 24__rionths__ Frames every -4 months.) 3 -RATE BASIS Employee Only 8.81 7.91 7.40 7.00 6 16 5.48 4.69 Employee + 1 15.59 13.90 13.05 12.31 10 85 9.54 8.30 Employee + 2 22.15 19.77 18.53 1".5) 15 42 13.50 11.81 2 -RATE BASIS Employee Only 8.81 7.91 7.40 '.0[ 6 16 5.48 4.69 Employee With Dependents 18.98 17.97 16.83 15.8 14 01 12.37 10.73 COMPOSITE 17.06 15.20 14.24 13.41 1:.86 10.39 9.10 $15.00 $20.00 $25.00 DEDUCTIBLE $ 0 $ 5.00 $ 7.50 $10.0C' PLAN B (Exam every 12 months - Lenses every- 12. months _ F =rames every 24 months.) 3 -RATE BASIS Employee Only 9.38 8.36 7.85 7.4ir 6.50 5.76 5.03 Employee + 1 16.50 14.74 14.01 13.28 11.69 10.23 8.93 Employee + 2 23.50 21.02 19.94 18 7 16.55 14.58 12.60 2 -RATE BASIS Employee Only 9.38 8.36 7.85 7 4'! 6.50 5.76 5.03 Employee With Dependents 21.30 19.10 18.08 7 11).08 1' >.08 13.28 11.41 COMPOSITE 18.08 16.16 15.37 i4 4, 1.1.82 11.19 9.72 DEDUCTIBLE $ 0 $ 5.00 $ 7.50 $10.00 $15.00 $20.00 $25.00 PLAN C (Exam - Lenses - Frames every 12 month_ 3 -RATE BASIS Employee Only 11.30 10.28 9.72 9. a 8.19 7.34 6.49 Employee + 1 20.28 18.13 17.17 16.:8 14.69 13.10 11.69 Employee + 2 28.81 25.82 24.40 23,8 20.90 18.70 16.55 2 -RATE BASIS Employee Only 11.30 10.28 9.72 9. 8.19 7.34 6.49 Employee With Dependents 26.10 23.33 22.15 21. 3 18.98 16.95 15.08 COMPOSITE 22.14 19.83 18.76 1�. 7 '6.10 14.46 12.82 SCJPIA INTERNAL STOP -LOSS POOLING SINGLE CLAIM INCREMENT $ 0 to $2,500 $2,501 to $5,000 $5,001 to $10,000 $10,001 and Over TO SCJPIA MEMBER (Retained s...oss) 100` 40, 20. None TO SCJPIA POOL None 60% 80% 100% Maximum member retained loss per cause„ prior to retro calcula- tion = $4,500 Retro exposure allocated based upon total deposit funding for the account period. SPECIFIC STOP -LOSS STOP -LOSS LEVEL: $100,000 MONTHLY PREMIUM RATE: $12.33 Per Employee ;Included in deposit funding rates) The $100,000 "specific" provides reimbursement to SCJPIA on any single claim that exceeds the $100,000 point, for the portion of the claim that exceeds $100,000 to a maximum reimbursement of $1,000,000. CONTINGENCY EQUITY RESERVE This is one -time charge equal to 15% of total annual deposits. This charge can be paid through a "retr, call" or surpluses. III. BENEFITS OF SCJPIA EMPLOYEE BENEFIT PROGRAM CJP9 SUMMARY OF MEDICAL BENEFIT; BENEFIT DESCRIPTION - - - - - - - - - OPTION I NON- NETWORK (PPO) _ — -- -- - - OPTION II (EPO) -(1) _ _NETWORK _._ --- NETWORK ONLY For care by any Licensed hospital or For care by l censc,�? For care by CappCare CappCar« hosp=tai licensed hospital or physician physi( i:- physician LIFETIME MAXIMUM $1,000,000 S1,)0(" l $1,000,000 ANNUAL PLAN DEDUCTIBLE $200 Individual; $200 irxa °✓iduat; $400 Family $403 Farr .y No Deductible EMERGENCY ROOM DEDUCTIBLE $25 per occurrence $25 bcr curr ence $25 co-payment HOSPITAL CARE 70% to $1,000 out -of- 90% to $ •000 out -ct- 100% pocket (does not pocket V goes riot include deductible) include ieductible) HOME HEALTH SERVICES 100%, after deductible 100%, r de- ductitle 100% HOSPITAL PRE - ADMISSION TESTING 90%, no deductible 90% n;) "eductible 100% PHYSICIAN SERVICES 70% subject to 90% dedu<tible subject $5.00 deductible to deducrible (in- co-payment, 100X thereafter patient), 100% after a $5.00 co payment fo, preterret providers only (ouv patient) ACCIDENTAL INJURY BENEFIT 100% of the first $500 100% o^ e 'i -st $ "S70 $25 Co- payment SURGEON FEES 70% subject to 90% subje,_t °o 100% deductible deductib - NURSING CARE 70% subject to 90% subp t *o 100% deductible deductib. EMERGENCY 70% subject to 90X 90% s s e r to ubj TRANSPORTATION deductible 100X SERVICES rb X -RAY AND LABORATORY 70% subject to 90% EXAMS deductible subje to 100% dedtx:tibI RADIATION THERAPY 70% subject to 90% :yubje to deductible 100% dedu.tiol ANESTHETICS 70% subject to 90% ruble to deductible dedtx:tibl 100% MEDICAL SUPPLIES 70% subject to 90% deductible sub)e to 100% dedu(I it) l PRESCRIPTION DRUGS $3.00 Generic $3.00 Generic (PCs) $7.00 Brand $7.00 Brand (includes Oral Contraceptive. (Includes Oral Contraceptives) (1)No benefits are paid in or out of the service area without prior approvac. Tpecific exceptions paid at 80% to $1,000 out of pocket (not including deductible); $200 calendar year deduc, !e incicxie Genuine emergency care. Services not available in network (prior approval). Medical services for eligible dependents living outside se-vi -( crea and l ,ing away from the insured. - - - - - - - - - - OPTION I (PPO)_,_ -. -.- _ -- - - OPTION li (EPO) -(1) COST CONTAINMENT NON - NETWORK NETWORK NETWORK ONLY OUT- PATIENT SURGERY 70% subject to 90% suoyt tc 100 %; must call deductible; must call dedt.ictvb e•; must -a 1- 800 - Capping 1- 800 - Capping 1- B00 - �oirg PREADMISSION REVIEW 70% subject to 90% sub',-rct tc 100 %; must call deductible; must call deductib e; mcst ca',. 1-800- Capping 1- 800-Capping 1-800 C,i oirig TEMPOROMANDIBULAR 70% subject to 90% suo, ::t tt 100 %; $1,000 lifetime JOINT DYSFUNCTION deductible; $1,000 deduct it: e; $',000 maximum Lifetime maximum lifet,m, naxirxrr RADIAL KERATOMY 50% subject to 50% sub ect to 50%; $1,500 lifetime deductible; $1,500 deduct e; 41,500 Lifetime lifetrr• PODIATRY 50% subject to 90% sub ect to $5.00 co- payment, 100% deductible; $1,000 deduct, >le (in- thereafter lifetime patient ; 100% after a $5.0( a co paymert for pre ?erred provide s only (out patien, CHIROPRACTIC 80% subject to 80% sut;,ect :0 80% subject to deductible; $1,000 deduct ole; $1,00C deductible; $1,000 calendar year cal end, yea• calendar year PREVENTIVE CARE Not Covered Ccrvere Covered Well -Baby Care Not Covered $`.ou - Paymment $5.00 Co- Payment (Thru Age 2) (PPO c Y) Immunizations Not Covered S ".OU Payment $5.00 Co- Payment (Children Through (PPC c v) Age 12) Routine Physical Not Covered 90% cc M1 maximum $100 90% to a maximum $100 (One Every 5 Years) (PPC ( 'Y) Annual Pap Tests Not Covered $5.00 (tr office $5.00 per office visit vrsi r'PO only) Mammography Not Covered 90%; r deductiole 90 %; no deductible (':)PC Y PRESCRIPTION DRUGS $3.00 Generic $3.00 Generic (PCs) $7.00 Brand $7.00 Brand (includes Oral Contraceptive. (Includes Oral Contraceptives) (1)No benefits are paid in or out of the service area without prior approvac. Tpecific exceptions paid at 80% to $1,000 out of pocket (not including deductible); $200 calendar year deduc, !e incicxie Genuine emergency care. Services not available in network (prior approval). Medical services for eligible dependents living outside se-vi -( crea and l ,ing away from the insured. - - -- - - - - - - - OPTION I (PPO). , - -- - OPTION (I (EPO) - ALL MENTAL AND NERVOUS /SUBSTANCE ABUSE BENEFITS ARE PROVIDED THROUGH MANAGED HEALTH NETWORK (MHN) MANAGED HEALTH NETWORK IN- PATIENT MENTAL Coverage is 100% at contracting MHN fac tid es up to Coverage is 100% at HEALTH AND CHEMICAL a maximum of 30 days per year, $50•;)00 lifetime contracting MHN DEPENDENCY maximum. Alternate care facititie, (intensive out- facilities up to a patient treatment) is also covereca Subject t� a maximum of 30 days per $250 deductible and 2 episodes ne, i4eTlme year, $50,000 lifetime maximum. Alternate care facilities (intensive out - patient treatment) is also covered. Subject to a $250 deductible and 2 episodes per lifetime. OUT- PATIENT MENTAL 1 5 Visits: $ 0 HEALTH AND CHEMICAL 5 10 Visits: $10 5 Visits: $0 DEPENDENCY 11 - 15 Visits: $20 4 10 visits: $10 Balance: $30 11 - 15 Visits: $20 (No Maximum) Balance: $30 (No Maximum) The above schedule is based upon using one of their The above schedule is providers. If you use a non - contracting provider, reimbursement is 'h based u Pon using one made up to the amount aid to a contracting provider, to $750 If their providers. a subscriber family unit calendar year maximum benefit you use a non - contracting provider, reimbursement is made up to h the amount paid to a contracting provider, to a $750 subscriber family -unit calendar year maximum benefit. SCJPIA DENTAL BENEFITS ANNUAL DEDUCTIBLE FEE - FOR - SERVICE PREPAID SAFEGUARD INDIVIDUAL $50 N/A FAMILY MAXIMUM $100 N/A PLAN PAYS PREVENTIVE CARE 100 %, NO )EDUCTIBIE 100% (EXAMS, CLEANING, FLUORIDE, ETC.) BASIC CARE 80% CO- PAYMENTS RANGE (FILLINGS, FROM 0 TO $35 EXTRACTIONS, ROOT CANAL, ETC.) MAJOR CARE 50% CO- PAYMENTS RANGE (DENTURES, CROWNS, FROM $80 TO $125 BRIDGES) ANNUAL INDIVIDUAL MAXIMUM $1,000 ORTHODONTIA NOT COVERID FULL BANDED - $1,350 PARTIAL BANDED - $ 675 ORTHODONTIA COVERAGE (OPTIONAL) LIFETIME MAXIMUM $1,000 DEDUCTIBLE $50 COINSURANCE 50% OF REASONABLE AND CUSTOMARY CHARGES SOUTHERN CALIFORNIA JOINT POWERS INSURANCE AUTHORITY PLAN A EXAM Every 12 Months LENSES Every 24 Months FRAMES Every 24 Months VISION SERVICE PLAN SUMMARY IF BENEFITS Ever, 12 Months; Ever, 12 Mont.ns Ever. 24 Montns Member Doctor DEDUCTIBLE 0 - $25 Deductible MAXIMUM EXAMS 100% Every 12 or 24 Months LENSES 100% Every 12 or 24 r1onths FRAMES 100% Every 12 or 24 Months CONTACT LENSES 100% Necessary $130 Elective C Every 12 Months Every 12 Months Every 12 Months Non - Member Doctor 0 - $25 Deductible $40 $30 - $125 $45 $250 Necessary $130 Elective CONTACT LENSES Necessary: Contact lenses are furnished under the VSP plan when the VSP panel doctor obtains prior approval for any ' the following conditions: 1. Following cataract surgery. 2. To correct extreme visual acuity [roblems that cannot be corrected with spectacle lenses. 3. Certain conditions of anisometrop :. 4. Keratoconus. When the VSP Panel Doctor receives prior approval for such cases, they are fully covered by VSP and are IN LIEU OF ALL OTHER BENEFITS. CONTACT LENSES ONCE FURNISHED UNDER THI'7 PLAN AS DESCRIBED ABOVE CAN BE REPLACED ONLY WITH PRIOR AUTHORIZATION `'Y VSP, BUT IN NO EVENT MORE FREQUENTLY THAN EVERY TWENTY -FOUR (24) MONTHS. Elective: When covered persons choose contact lenses for reasons other than those mentioned above, VSP will make an allowance toward their costs equivalent, under the VSP program, to a standard eye examination, spectacle lenses, and frame IN LIEU OF ALL OTHER 11- NEFITS VISION SERVICE PLAN ELECTIVE CONTACT i_ENS PROGRAM BENEFITS Persons covered under this additional benefit are entitled to contact lenses for "cosmetic" purposes, as opposed to extreme "necessary" conditions. A condition is deemed "necessary" when the visual problem is so acute that it cannot be corrected with spectacle lenses such a,; following cataract surgery. Persons seeking services under this additional benefit from a panel doctor are fully covered for the initial fitting period of up to 90 days, which may be extended, at the discretion of the VSP doctor. The patient pays a $50 deductible whether they are prescribed regular, soft or multi -focal contact lenses. Because the elective contact lens program is an additional benefit, the patient is still eligible for spec.ta +'e lenses and frames under the standard SCJPIA Vision Service Plan. Exclusions under this additional benefit include orthokeratology, replacement of lost or damaged lenses, modifications of lenses, routine maintenance, such as polishing, cleaning, etc. Refitting fter the initial fitting will be the responsibility of the patient. COST The cost to add the contact lens benE ^flt is as follows: Rate Structure Rates Two Tier:. Employee $1.80 Employee + Dependents (laml y) $5.10 Three Tier: Employee $1.80 Employee + 1 Dependent 53.90 Employee + 2 or More Depenc -rit s $5.60 Composite Rate $4.35 The above rates are additional costs wh h reed to be applied to the standard VSP Plan rates. LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT EMPLOYEES EMPLOYERS MAY OFFER A FLAT AMOUNT OF BENEFI WITH A $10,000 MINIMUM OR MULTIPLE OF SALARY. GUARANTEE ISSUE AMOUNTS ARE SUBJEC TO REVIEW BY BEST LIFE. DEPENDENTS TWO PLANS ARE AVAILABLE PLAN I Spouse $1,000 Child (14 Days to 6 Months) $ 100 Child (6 Months to 19 Years) $1,000 PLAN II S� ous(' $1,500 Ckld (14 Days to 6 Months) $ 100 :r ld (6 Months to 19 Years) $1,000 SUPPLEMENTAL GROUP LIFE ADDITIONAL LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE IS AVAILABLE TO EMPLOYEES AT LOW TERM RATES IN INCREMENTS OF $10,000.. SUBJECT TO AN EVIDENCE OF INSURABILITY STATEMENT. EMPLOYEE RATES DEPENDENT ON WHETHER THE MEMBER CITY ELECTS !0 INCLUDE THEIR FIRE AND POLICE, THE FOLLOWING RATES WILL APPLY (WHICH INCLUDES A COMPREHENSIVE GUARANTEE MEDICAL CONVERSION POLICY): INCLUDI`AG EXCLUDING FIRE & OL `CE FIRE AND POLICE PER 1,000 OF INSURANCE $ 3)� S .34 DEPENDENT RATES PLAN I PLAN II $ .48 PER DEPENDENT UNIT 63 PER DEPENDENT UNIT s \scjpia \jpiamas.089