Restated Health Plan Document & Summary Plan Description for Point of Service Copyright 2014
City of Dubuque Consent Items # 19.
ITEM TITLE: Restated Plan Document & Summary Plan Description for Point of
Service Health Care Plan
SUMMARY: City Manager recommending approval for the City Manager to execute the
Restated Plan Document and Summary Plan Description for the City's
health care plan that incorporates all of the amendments.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Approve
ATTACHMENTS:
Description Type
❑ Approval of Restated Plan Document and Summary for City's Health City Manager Memo
Plan-MVM Memo
❑ Staff Memo Staff Memo
❑ Plan Document&Summary Plan Description for POS Plan Supporting Documentation
THE CITY OF Dubuque
UBE I
erica .i
Masterpiece on the Mississippi 2007-2012-2013
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Restated Plan Document and Summary Plan Description for the City's
Health Plan
DATE: September 28, 2015
The City's Health Plan was adopted on May 1, 2004. Since that time, there have been
thirteen plan amendments.
Personnel Manager Randy Peck recommends City Council approval for the City
Manager to execute the Restated Plan Document and Summary Plan Description that
incorporates all the amendments.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
Mic ael C. Van Milligen
MCVM:jh
Attachment
cc: Barry Lindahl, City Attorney
Cindy Steinhauser, Assistant City Manager
Teri Goodmann, Assistant City Manager
Randy Peck, Personnel Manager
THE CITY OF � Dubuque
,TB UE � i
a
Mas torp ece on the Mississippi
pi aou •,otz•wn
TO: Michael C. Van Milligen, City Manager
FROM: Randy Peck, Personnel Manager
SUBJECT: Restated Plan Document and Summary Plan Description for the City's
Health Plan
DATE: September 21, 2015
The City's Health Plan was adopted on May 1, 2004. Since May 1, 2004, there have
been thirteen plan amendments. The plan amendments are summarized as follows:
Amendment I Effective Date --March 24 2007
This amendment brought the health plan into compliance with Federal and State
requirements related to qualified medical child support orders, mental health
parity, claims review procedures and continuation of coverage during military
leave. The amendment also modified the plan document to reflect the
employees contribution to the health insurance premium.
Amendment ll Effective Date - July 20 2007
This amendment added in-vitro fertilization to the medical plan.
Amendment III Effective Date - December 2 2008
This amendment modified the plan document to include language related to Iowa
House File 2539 that mandates health insurance coverage for dependent
children. The amendment also added domestic partner to the definition of
dependent and established July 1 as the anniversary date for the health plan.
Amendment IV Effective Date - March 19 2009
This amendment updated the plan document to allow for coverage of
contraceptive devices such as diaphragms, IUDs, Norplant and Depo-Provera.
These types of birth control are covered under our medical plan as they are
considered durable medical equipment. This amendment brought us into
compliance with the State of Iowa mandate. This amendment also modified
coverage for mammograms to provide mammograms every year for a woman 40
years of age or older.
Amendment V Effective Date - April 1 2009
In accordance with the State Children's Health Insurance Programs mandate,
this amendment allows employees and dependents to enroll in the health plan
within 60 days after they no longer meet the eligibility requirements for the State
Children's Health Insurance Program or Medicaid.
Amendment VI Effective Date - January 12 2010
This amendment incorporated the necessary changes as a result of State
mandates related to continuous coverage for dependents, coverage for oral
chemotherapy drugs, diabetic self-management training programs, psychiatric
medical coverage for children and coverage for artificial limbs.
Amendment VII Effective Date - August 7, 2010
This amendment implemented the provisions of the Mental Health Parity and
Addiction Equity Act.
Amendment VIII Effective Date - July 16, 2011
This amendment removed the lifetime maximum for out of network services,
updated the definition of dependent and stated that the health plan is "a
grandfathered plan". These changes brought us into compliance with certain
provisions of the Patient Protection and Affordability Care Act.
Amendment IX Effective Date — January 25, 2012
This amendment incorporated the necessary changes as a result of State
mandates related to lead screening for children and the appeal and expedited
external review process.
Amendment X Effective Date - August 31, 2012
This amendment defined the oral surgery benefit and amended the definition of
dependent to prevent a dependent from losing their eligibility when a plan
member enters military service.
Amendment XI Effective Date - March 21 2013
This amendment modified the schedule of benefits for physical therapy, speech
therapy, occupational therapy and respiratory therapy. The 60 visit lifetime cap
was modified to provide a cap of 30 visits per calendar year.
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Amendment XII Effective Date - March 5, 2014
This amendment modified the definition of"eligible active employee" to reflect the
twelve month Standard Measurement Period for eligibility for health insurance.
This change was required by the Affordable Care Act.
Amendment XIII Effective Date - September 8 2014
This amendment modified the definition of dependent and applied the lifetime
maximum to infertility treatment. These changes were required by the Affordable
Care Act.
The attached Restated Plan Document and Summary Plan Description incorporates all
of these amendments. The requested action is for the City Council to receive and file
and approve a motion authorizing you to sign the Restated Plan Document and
Summary Plan Description for the City's health plan.
3
THE CITY OF
Masterpiece an the Mississippi
PLAN DOCUMENT AND
SUMMARY PLAN DESCRIPTION
FOR
POINT OF SERVICE, PLAN
EFFECTIVE: MAY 1, 2004
RESTATED: JULY 1, 2015
TABLE OF CONTENTS
INTRODUCTION.................................................................................................................................................1
ELIGIBILITY, FUNDING, EFFECTIVE. DA'L'E AND TERMINATION PROVISIONS...........................2
OPENENROL,LMEN'l.........................................................................................................................................5
SCHEDULEOF BENEFITS................................................................................................................................7
MEDICALBENEFITS.......................................................................................................................................11
COVEREDSERVICES......................................................................................................................................11
COSTMANAGEMENT SERVICES................................................................................................................19
DEFINEDTERMS..............................................................................................................................................21
PIANEXCLUSIONS.........................................................................................................................................28
HOWTO SUBMIT A CLAIM...........................................................................................................................32
WHEN CLAIMS SHOULD 13E: FILED............................................................................................................32
CLAIMSREVIEW PROCEDURE...................................................................................................................33
COORDINATIONOF BENEFITS ...................................................................................................................38
THIRD PARTY RECOVERY PROVISION....................................................................................................40
GENERAL. PROVISIONS .................................................................................................................................41
CONTINUATIONOPTIONS............................................................................................................................42
RESPONSIBILITIES FOR PLAN ADMINISTRATION...............................................................................48
FUNDING "THF. PLAN AND PAYMENT BENEFITS....................................................................................49
CLERICALERROR...........................................................................................................................................49
STANDARDS FOR PRIVACY OF INDIVIDUAI..LN' INDEN'l'IFIABLF. HEALTH INFORMATION...49
COMPLIANCE WITH HIPAA EL.ECTRONIC.. SECURITYSTANDARDS ..............................................51
GENERAL, PLAN INFORMATION.................................................................................................................51
INTRODUCTION
This document is a description of City of Dubuque, Iowa Point of Service Plan(the Plan).No oral interpretations can
change this Plan. The Plan described is designed to protect Plan Participants against certain catastrophic health expenses.
Coverage under the Plan will take effect for an Eligible Employee and designated Dependents when the Employee and
such Dependents satisfy the waiting period and all the eligibility requirements of the Plan. The Employer fully intends to
maintain this Plan indefinitely. However, it reserves the right to terminate, suspend, discontinue or amend the Plan at any
time and for any reason. Changes in the Plan may occur in any or all parts of the Plan including benefit coverage,
deductibles, maximums, Copayments, exclusions, limitations, definitions,provisions, eligibility and the like.
Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no coverage at
all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, such as coordination
of benefits, subrogation, exclusions, timeliness of elections, Utilization Review or other cost management requirements,
lack of Medical Necessity, lack of timely filing of claims or lack of coverage. These provisions are explained in summary
fashion in this document; additional information is available from the Plan Administrator at no extra cost.
The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable for
expenses incurred before coverage began or after coverage terminated. An expense for a service or supply is incurred on
the date the service or supply is furnished.
If the Plan is terminated, amended, or benefits are eliminated, the rights of the Participants are limited to Covered Services
incurred before termination, amendment or elimination.
This document summarizes the Plan rights and benefits for covered Employees and their Dependents and is divided into
the following parts:
Eligibility,Funding, Effective Date and Termination. Explains eligibility for coverage under the Plan, funding of the
Plan and when the coverage takes effect and terminates.
Schedule of Benefits. Provides an outline of the Plan reimbursement formulas as well as payment limits on certain
services.
Benefit Descriptions. Explains when the benefit applies and the types of charges covered. !
Cost Management Services. Explains the methods used to curb unnecessary and excessive charges.
This part should be read carefully since each Participant is required to take action to assure that the maximum
payment levels under the Plan are paid.
Defined Terms. Defines those Plan terms that have a specific meaning.
Plan Exclusions. Shows what charges are not covered.
Claim Provisions. Explains the rules for filing claims.
Coordination of Benefits. Shows the Plan payment order when a person is covered under more than one plan.
Third Party Recovery Provision. Explains the Plan's rights to recover payment of charges when a Participant has a claim
against another person because of injuries sustained.
Continuation Options. Explains when a Participant's coverage under the Plan ceases and the continuation options which
are available.
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ELIGIBILITY,FUNDING,EFFECTIVE DATE
AND TERMINATION PROVISIONS
ELIGIBILITY
Eligible Active Employees. An Actively at Work Employee who accumulates 1,560 or more hours
during the 12-month Look Back Measurement Period established by the
Employer or a newly hired Employee who is expected to accumulate
1560 or hours in a 12-month Look Back Measurement Period.
Newly hired Eligible Employees, shall become eligible for coverage on
the first day of the month following thirty (30) days of continuous
employment. Any employee, who becomes eligible or maintains
eligibility as a result of accumulating 1,560 Eligible Hours or more
during the Look Back Measurement Period, shall become and/or
continue to be eligible January 15t through December 31 of the following
Calendar Year.
Enrollment Requirements. All Active Employees must make a written request to enroll and submit it to the City on an
approved form, within thirty(30) days of becoming eligible to do so. Active Employees are eligible for coverage on the
first(1St) day of the month following thirty(30) days of continuous employment. Active Employees and Dependents not
enrolled when first eligible may be enrolled at a later date during an open enrollment period if designated and as
determined by the City. An Employee or Dependent who loses coverage under Medicaid or SCHIP or who becomes
eligible for state assistance has a sixty(60) day enrollment period.
SPECIAL ENROLLMENT RIGHTS
Federal law provides Special Enrollment provisions under some circumstances. If an Active Employee is declining
enrollment for himself or herself or his or her dependents(including his or her spouse)because of other health insurance
or group health plan coverage, there may be a right to enroll in this Plan if there is a loss of eligibility for that other
coverage (or if the employer stops contributing towards the other coverage). However, a request for enrollment must be
made within 30 days after the coverage ends (or after the employer stops contributing towards the other coverage).
In addition, in the case of a birth, marriage, adoption or placement for adoption,there may be a right to enroll in this Plan.
However, a request for enrollment must be made within 30 days of the birth, marriage, adoption or placement for
adoption.
The Special Enrollment rules are described in more detail below. To request Special Enrollment or obtain more detailed
information of these portability provisions, contact the Plan Administrator, City of Dubuque, 50 West 13th Street,
Dubuque, Iowa, 52001, 563-589-4125.
SPECIAL ENROLLMENT PERIODS
The Enrollment Date for anyone who enrolls under a Special Enrollment Period is the first date of coverage.Thus,the
time between the date a special enrollee first becomes eligible for enrollment under the Plan and the first day of coverage
is not treated as a waiting period.
1. Individuals losing other coverage creating a Special Enrollment right.An Employee or Dependent who is
eligible,but not enrolled in this Plan, may enroll if loss of eligibility for coverage meets all of the following
conditions:
a. The Employee or Dependent was covered under a group health plan or had health insurance coverage at the
time coverage under this Plan was previously offered to the individual.
b. If required by the Plan Administrator, the Employee stated in writing at the time that coverage was offered
that the other health coverage was the reason for declining enrollment.
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C. The coverage of the Employee or Dependent who had lost the coverage was under continuation coverage
(other than through the City), but their continuation coverage was exhausted or the coverage of the
Employee or Dependent was terminated as a result of loss of eligibility for the non-continuation coverage or
because employer contributions towards the coverage were terminated. Coverage will begin no later than
the first day of the first calendar month following the date the completed enrollment form is received.
d. The Employee or Dependent requests enrollment in this Plan not later than 30 days after the date of
exhaustion of continuation coverage or the termination of non-continuation coverage due to loss of
eligibility or termination of employer contributions, described above. Coverage will begin no later than the
first day of the first calendar month following the date the completed enrollment form is received.
2. For purposes of these rules, a loss of eligibility occurs if one of the following occurs:
a. The Employee or Dependent has a loss of eligibility due to the plan no longer offering any benefits to a
class of similarly situated individuals(i.e.: part-time employees); or
b. The Employee or Dependent has a loss of eligibility as a result of legal separation, divorce, cessation of
dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan),
death,termination of employment, or reduction in the number of hours of employment or contributions
towards the coverage were terminated; or
C. If the Employee or Dependent lost the other coverage as a result of the individual's failure to pay premiums
or required contributions or for cause(such as making a fraudulent claim or an intentional misrepresentation
of a material fact in connection with the plan),that individual does not have a Special Enrollment right.
3. Dependent beneficiaries.If:
a. The Employee is a participant under this Plan(or is eligible to be enrolled under this Plan but for a failure to
enroll during a previous enrollment period), and
b. A person becomes a Dependent of the Employee through marriage, birth, adoption or placement for
adoption,
then the Dependent(and if not otherwise enrolled,the Employee)may be enrolled under this Plan. In the case of
the birth or adoption of a child,the spouse of the covered Employee may be enrolled as a Dependent of the covered
Employee if the spouse is otherwise eligible for coverage. If the Employee is not enrolled at the time of the event,
the Employee must enroll under this Special Enrollment Period in order for his eligible Dependents to enroll.
The Dependent Special Enrollment Period is a period of 30 days and begins on the date of the marriage, birth,
adoption or placement for adoption. To be eligible for this Special Enrollment,the Dependent and/or Employee
must request enrollment during this 30-day period.
The coverage of the Dependent and/or Employee enrolled in the Special Enrollment Period will be effective:
a. in the case of marriage, the first day of the first month beginning after the date of the completed request for
enrollment is received;
b. in the case of a Dependent's birth, as of the date of birth; or
C. in the case of a Dependent's adoption or placement for adoption, the date of the adoption or placement for
adoption.
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4. Medicaid and State Child Health Insurance Programs. An Employee or Dependent who is eligible,but not
enrolled in this Plan, may enroll if:
a. The Employee or Dependent is covered under a Medicaid plan under Title XIX of the Social Security Act or
a State child health plan(CHIP)under Title XXI of such Act, and coverage of the Employee or Dependent
is terminated due to loss of eligibility for such coverage, and the Employee or Dependent requests
enrollment in this Plan within 60 days after such Medicaid or CHIP coverage is terminated.
b. The Employee or Dependent becomes eligible for assistance with payment of Employee contributions to
this Plan through a Medicaid or CHIP plan(including any waiver or demonstration project conducted with
respect to such plan), and the Employee or Dependent requests enrollment in this Plan within 60 days after
the date the Employee or Dependent is determined to be eligible for such assistance.
If a Dependent becomes eligible to enroll under this provision and the Employee is not then enrolled, the Employee must
enroll in order for the Dependent to enroll.
Coverage will become effective as of the first day of the first calendar month following the date the completed enrollment
form is received unless an earlier date is established by the Employer or by regulation.
Effective Date of an Active Employee's Coverage. An Active Employee's coverage shall become effective on the date
he or she becomes eligible for coverage,provided the employee is Actively at Work as defined in this Plan.
Termination of an Active Employee's Coverage. The coverage of an Active Employee shall cease on the earliest of the
following dates:
1. The last day of the month the Active Employee as defined herein, ceases to be actively engaged in work with the
City as an Active Employee unless the former Active Employee is a Qualified Beneficiary or an early Retired
Employee and elects to continue coverage as specified herein;
2. The date the Plan is discontinued;
3. Thirty(30) days following the date the Active Employee enters the Armed Forces on full-time active duty;
4. The expiration of the period for which the last payment was made for coverage under the Plan; or
5. On 12/31 of each year, if the Active Employee who was not newly hired during the year, doesn't achieve 1,560 or
more of Eligible Hours during the Look Back Measurement Period established by the employer.
Dependents' Coverage — Enrollment Requirements. An Active Employee or Retired Employee must make written
request to the City on an approved form during the thirty (30) day period prior to the Active Employee's or Retired
Employee's Effective Date of coverage. Active Employees or Retired Employees not enrolling their eligible Dependents
for coverage when first eligible may enroll such Dependent(s) at a later date during an open enrollment period if
designated and as determined by the City.
If a Participant defined as a Dependent is also eligible for coverage as an Eligible Employee of this Plan, the following
election must be made: !
1. Both lawful spouses can be covered as an Eligible Employee under the health benefit plan; or
2. Both lawful spouses will be covered as an Eligible Employee and one spouse and eligible Dependent child(ren), if
any, will also be covered as a Dependent under the Plan for which the other spouse is covered as an Active
Employee or Retired Employee.
Dependents' Effective Date of Coverage.
1. Dependents enrolled for coverage on the Eligible Employee's Effective Date of coverage shall become covered
on that date;
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2. Newly acquired Dependents are covered on the date of acquisition provided they are enrolled within thirty (30)
days of such acquisition, if however, the Eligible Employee is already enrolled for Dependent coverage, the
Dependent will be enrolled automatically;
3. A newborn child is included in family coverage at the time of birth and is eligible for Plan benefits only if the
Eligible Employee enrolls such newborn child within thirty(30) days from the date of the newborn child's date of
birth if the Eligible Employee is not already enrolled for Dependent coverage; and
4. Dependents not enrolled when first eligible (within the time period set forth herein) may be enrolled during an
open enrollment period if designated, and as determined by the City.
Termination of Dependent's Coverage. The coverage of any Dependent will terminate on the earliest of the following
dates:
1. The date of termination of the Eligible Employee's coverage, unless such Dependent is a Qualified Beneficiary
and elects to continue coverage as specified in the Continuation of Coverage section;
2. The last day of the month in which the Dependent ceases to qualify as a Dependent,unless such Dependent is a
Qualified Beneficiary and elects to continue coverage as specified in the Continuation of Coverage sections;
a. Effective July 1, 2010 a Dependent child who is receiving coverage under the Plan as a Full-Time Student,
may take up to a one year Medically Necessary Leave of Absence and continue receiving coverage under
the Plan. A"Medically Necessary Leave of Absence" is a leave of absence or change in enrollment status
that:
i. Commences while the Dependent child is suffering from a serious Illness or Injury;
ii. Is Medically Necessary; and
iii. Causes the Dependent child to loss full-time student status for purposes of the Plan.
The treating Physician must certify in writing that a leave of absence due to the child's serious Illness or
Injury is Medically Necessary and must provide a copy of the written certification to the Human
Resources Department.The child's coverage may terminate prior to the end of the one year Medically
Necessary Leave of Absence for the reasons stated in the Summary Plan Description.
3. The date the Plan is discontinued; or
4. The expiration of the period for which the last payment was made for coverage under the Plan.
Continuous Coverage for Dependents. Coverage continues for a child of an Employee who so elects if they meet
the definition of an eligible Dependent.
OPEN ENROLLMENT
Every December 1, the annual open enrollment period, Employees and their Dependents who are Late Enrollees will be
able to enroll in the Plan. In the event of a Plan change, the Plan Administrator may designate an additional open
enrollment period or periods.
Benefit choices for Late Enrollees made during the open enrollment period will become effective January 1 of the next
following year.
Plan Participants will receive detailed information regarding open enrollment from their Employer.
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QUALIFIED MEDICAL CHILD SUPPORT ORDERS
It is the intent of the Plan to comply with the regulations pertaining to Qualified Medical Child Support Orders
(QMCSO). The Participants must present a copy of the Order for review and acceptance by the Plan Administrator. Only
Orders which meet the requirements of a QMCSO will be honored by the Plan to enroll any eligible Dependents outside
of a Special Enrollment Period. The Employee will be required to elect Family Coverage and pay any applicable
contribution for said coverage.
The Child Support Performance and Incentive Act of 1988 (CSPIA)require the Employer to take certain actions to help
enforce state administrative and court orders for medical child support.
The Employer adopts the following procedures to determine whether medical child support orders qualify and thus are to
be carried out. The Employer may modify or terminate these procedures to satisfy legal requirements.
A Qualified Medical Child Support Order(QMCSO) establishes a child's right to receive benefits for which a Plan
Participant or Qualified Beneficiary for continuation of coverage is eligible, and which the Plan has determined meets the
requirements to be a Qualified Medical Child Support Order.
To qualify, a medical child support order must:
1. Specify the name and last known mailing address of the Participant and the name and mailing address of each
child covered by the order; and,
2. Include a reasonable description of the type of coverage to be provided by the Plan to each child, or the manner in
which such type of coverage is to be determined; and
4. Specify each period to which such order applies; and,
5. Specify each plan to which such order applies.
A QMCSO must not require the Plan to provide any type or form of benefit or any option not otherwise provided under
the Plan, except to meet requirements of Section 1908 of the Social Security Act(relating to enforcement of state laws
regarding child support and reimbursement of Medicaid).
Upon receiving a medical child support order,the Plan Administrator shall:
Promptly notify in writing the Participant, each child covered by the order, and each representative for these
parties of the receipt of the medical child support order. The notice shall include a copy of the order and these
QMCSO procedures for determining if the order is qualified;
Permit the child to designate a representative to receive copies of notices sent to the alternate recipient regarding
the medical child support order;
Within a reasonable time after receiving a medical child support order, determine if it is qualified and notify the
Participant and child(ren) subject of the order; and
Once the order is determined to be qualified, ensure the child is enrolled according to Plan terms and the order
and is otherwise treated by the Plan as a covered beneficiary for reporting and disclosure purposes. As such, the
Plan will distribute to the child a copy of the Summary Plan Description(SPD)and any subsequent material
modifications adopted by the Plan Sponsor.
In the event the Plan receives a state administrative or court medical child support order under CSPIA requiring the
Employer to withhold Employee contributions for group health coverage for a child, the Employer will determine
whether the Employee is covered or eligible under the Plan, and whether the child may be eligible under the Plan.
After the Employer determines the Employee is subject to income withholding to pay for the child's coverage, the
Employer will notify the Plan Administrator. The Plan Administrator will then notify the Employee, the child and the
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child's custodial parent(when that this not the Employee)that coverage is or will become available. The Plan
Administrator will furnish the custodial parent a description of the coverage available,the Effective Date of the
coverage and any forms, documents or other information needed to put such coverage into effect, as well as
information needed to submit claims for benefits.
The Plan Administrator will provide the appropriate enrolment information to the Employer,who will.then determine
whether Employee contributions are available to pay for the child(ren)'s coverage. If such funds are available,the Plan
Sponsor will withhold such contributions from Employee income and notify the Employee to that effect.
SCHEDULE OF BENEFITS
Verification of Eligibility
800-747-8900 or 563-556-8070
Call either of these numbers to verify eligibility for Plan benefits before the charge is incurred.
All benefits described in this Schedule are subject to the exclusions and limitations described more fully herein including,
but not limited to, the Plan Administrator's determination that: services and supplies are Medically Necessary; that charges
are Usual, Customary&Reasonable; that services, supplies and care are not Experimental and/or Investigational. The
meanings of these capitalized terms are in the Defined Terms section of this document.
This Plan makes provision for In-Network Benefits and Out-of-Network Benefits. Service and/or Supplies received from
Providers designated as In-Network Providers will be payable according to the In-Network Benefits of the Plan. A list of
In-Network Providers will be provided to Plan Participants, at no cost, and updated as needed. A copy can be received
from either the Plan Administrator or Claims Administrator upon request. If a Participant is referred to an Out-of-
Network Provider by an In-Network Provider with the approval of the Plan Medical Director, such services will also be
considered In-Network Benefits. Emergency services are payable as stated herein in the Schedule of Benefits.
A Point of Service Managed Care Organization is similar to a health maintenance organization but Participants are not
restricted solely to using the In-Network Providers.
Deductibles/Copayments payable by Plan Participants
Deductibles/Copayments are dollar amounts that the Participant may be required to pay before the Plan pays.
A deductible is an amount of money that is paid once a Calendar Year per Participant applicable under Out-of-Network
benefits. Typically, there is one deductible amount per Participant and it must be paid before any money is paid by the
Plan for any Covered Services. Each January 1st, a new deductible amount is required. However, covered expenses
incurred in, and applied toward the deductible in October,November and December will be applied to the deductible in
the next Calendar Year as well as the current Calendar Year.
A Copayment is a smaller amount of money that is paid each time a particular service is utilized. Typically, there may be
Copayments on some services and other services will not have any Copayments. The Copay amounts for In-Network
services would not be applied to the Out-of-Network deductible, but would be applied to the annual out-of-pocket
maximum.
Precertification of Services
Pre-Certification should be obtained for the following non-emergency services before Medical and/or Surgical services
are provided. Pre-Certification is required prior to receiving non-emergency Out-of-Network Hospital Services or
a $250 penalty will apply. This penalty does not apply to the annual out-of-pocket maximum.
Hospitalizations
Outpatient CAT Scans/PET Scans
In-patient Substance Abuse/Mental Disorder treatments
Skilled Nursing Facility stays
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Home Health Care Services
Hospice Care Plan
Durable Medical Equipment over$500
Orthotic Appliances
Out-patient surgical procedures performed in a Hospital or free-standing Facility
Organ transplant
Morbid obesity program
Infertility treatment—Lifetime maximum of$15,000 applies
Out-patient diabetic program
Stop smoking program
Oral Surgical Procedures
Plastic surgery or cosmetic surgery, when Medical Necessary
Spinal Manipulation/Chiropractic services for In-Network coverage
Weight control program
In-vitro fertilization
SCHEDULE OF BENEFITS
In-Network Out-of-Network
Eligible Benefits are those services Benefits are available from the
and/or supplies ordered by and provider of your choice.
received from an In-Network Reimbursements are based on
Physician or Provider. Eligible care allowable charges, which means
and services received from an Out-of- services covered by the Plan and
Network Physician or Provider when Usual, Customary&Reasonable
an In-Network Physician and the Plan allowances.
Medical Director have authorized such
care in advance, will be paid as In-
Network.
LIFETIME MAXIMUMS
Overall Lifetime Maximum Unlimited Unlimited
Transplants None Not Covered
Infertility $15,000 per Participant for Treatment Not Covered
Calendar Year Deductible— None/person $250/person
Applied before benefits are None/family $750/family
payable as follows:
You pay the Copay amounts as noted
as follows:
Annual out-of-pocket maximums
(includes deductible and $400/person $750/person
Copayments). In-Network and $1,200/family $2,250/family
Out-of-Network annual out-of-
pocket maximums are combined.
PHYSICIAN'S SERVICES
Service In-Network Out-of-Network
Acute/Urgent Care Visits $25 Copay, then 100% 70% after deductible
Doctor's Office Visits $15 Copay, then 100% 70% after deductible
Routine Annual Adult Physical $15 Copay, then 100% 70% (deductible waived)
Exam
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Service In-Network Out-of-Network
Routine Pediatric Exam(including $15 Copay, then 100% 70% (deductible waived)
well child)
Routine Annual OBGYN Exam $15 Copay, then 100% 70% (deductible waived)
Home Visits $15 Copay, then 100% 70% after deductible
Immunization/Injections 70% (the deductible will be waived on
Immunizations and injections for 100% Immunizations/Injections for well-
travel are not covered child care from birth through age 7.)
Hospital Visits
Pre-Certification is required, or 70% after deductible
$250 penalty will apply, which 100%
cannot be counted toward the
annual out-of-pocket maximum.
Eye Exam-
Hearing Exam- °
Children(under age 18) $15 Copay, then 100%
-once every 12 months Adult(18 70% after deductible
and over)
- once every 24 months
Eyeglasses/Contact Lenses after 100%limited to one(1) set of frames up to a maximum of$95.
Cataract Surgery
Chiropractors $15 Copay-with an authorized 70% after deductible
Referral
Infertility Services (Treatment is $15 Copay, then 100%, some
subject to $15,000 Lifetime limitations; 50% Copay on some Not covered
Maximum) services
Routine Mammogram 100% (deductible waived) 70% (deductible waived)
Ages 35-39-one baseline
Ages 40 & over-annually
Emergency Care—Physician
-of-Service Area—80%of Usual,
Services 100% Out
Customary&Reasonable charges.
Chemotherapy drugs 100% 100%
Intravenous, injectable and oral) J
Out-patient Cardiac Rehabilitation 100%; up to 18 visits
Weight Control Program 100%limited to a Lifetime payment of$30 by the Plan
Stop Smoking Program 100%
CT/PET/MRI 100% 70%after deductible
HOSPITAL SERVICES
Room and Board
Pre-Certification is required, or $400 copay per admission—Copay— 70% after deductible for semi-private
$250 penalty will apply, which then 100% for semi-private room room.
cannot be counted toward the
annual out-of-pocket maximum.
Miscellaneous Services 100% 70% after deductible
Ambulance 100% if to nearest facility 70% after deductible,if to nearest
facility
- 9 -
Service In-Network Out-of-Network
Skilled Nursing Care—limited to 100% 70% after deductible
100 days per calendar year
Emergency Room Care
Notification is required, or$250 $100 Copay,then 100% (waived if Out-of Service Area—80% of Usual,
penalty will apply, which cannot admitted, then$400 Copay applies Customary&Reasonable charges.
be counted toward the annual out- instead).
of-pocket maximum.
Blood Transfusions 100% 70% after deductible
MENTAL HEALTH & SUBSTANCE ABUSE SERVICES
Hospital $400 Copay per admission 70%after deductible
Pre-Certification is required or a
$250 penalty will apply, which
cannot be counted toward the
annual out-of-pocket maximum.
100% for semi-private room 70% after deductible
In-patient Physician
Office Visit $15 Copay 70% after deductible
SURGERY—PHYSICIAN 100% 70%after deductible
SAME DAY SURGERY $25 Copay, then 100% 70%after deductible
PHYSICAL THERAPY,
SPEECH THERAPY,
OCCUPATIONAL THERAPY,
or RESPIRATORY THERAPY
In-patient—unlimited treatments
Out-patient—30 visits per calendar 100% 70% after deductible
year for all outpatient therapies
combined. Additional visits may be
eligible if deemed medically
necessary; subject to pre-
certification by the Participant.
X-RAY& LABORATORY
In Hospital 100% 70%after deductible
In Office 100% 70%after deductible
Radiation 100% 70%after deductible
MATERNITY& OBSTETRICAL
Physician Services (Global Care) 100% 70% after deductible
$400 per admission Copay, then 100%
Hospital Services - only one Copay applies for both 70% after deductible
mother and baby.
HOME HEALTH CARE
SERVICES 100% 70% after deductible
DURABLE MEDICAL 100% 70% after deductible
EQUIPMENT
10 -
*The Copay amounts for In-Network services would not be applied to the Out-of-Network deductible,but
would be applied to the annual out-of-pocket maximum.
MEDICAL BENEFITS
Medical Benefits apply when Covered Services are incurred by a Participant for care of an Injury or Illness and while the
Participant is covered for these benefits under the Plan.
DEDUCTIBLE
Deductible Amount.This is an amount of Covered Services for which no benefits will be paid and is applied to the Out-
of-Network benefits. Before benefits can be paid in a Calendar Year a Participant must meet the deductible as stated
herein in the Schedule of Benefits, if applicable.
Deductible Three Month Carryover. Covered expenses incurred in, and applied toward the deductible in October,
November and December will be applied toward the deductible in the next Calendar Year.
Family Unit Limit.When the maximum amount as stated herein in the Schedule of Benefits has been incurred by
members of a Family Unit toward their Calendar Year deductibles, the deductibles of all members of that Family Unit
will be considered satisfied for that year.
BENEFIT PAYMENT
Each Calendar Year,benefits will be paid for the Covered Services of a Participant that are in excess of the deductible and
any Copayments, as applicable. Payment will be made at the rate as stated herein under reimbursement rate in the
Schedule of Benefits. No benefits will be paid in excess of the Maximum Benefit Amount or any listed limit of the Plan.
OUT-OF-POCKET LIMIT
Covered Services are payable at the copayment amounts and coinsurance percentages as stated herein each Calendar Year
until the out-of-pocket limit as stated herein in the Schedule of Benefits is reached. Then, Covered Services incurred by a
Participant will be payable at 100% (except for the charges excluded) for the rest of the Calendar Year.
When a Family Unit reaches the out-of-pocket limit, Covered Services for that Family Unit will be payable at 100%
(except for the charges excluded) for the rest of the Calendar Year.
COVERED SERVICES
Covered Services are the contracted rates or Usual, Customary&Reasonable Charges, whichever is applicable, that are
incurred for the following services and supplies. These charges are subject to the benefit limits, exclusions and other
provisions of this Plan. A charge is incurred on the date that the service or supply is performed or furnished.
Emergency Services. Benefits are available for care that is required for conditions which meet the definition of
Emergency Services and will be payable as stated herein in the Schedule of Benefits.The Participant should notify Health
Choices prior to treatment unless (a) a delay in obtaining care would seriously impair or endanger the Participant's health
or cause serious dysfunction of any bodily organ or part; (b)the Participant, if an adult, is in shock or has been
unconscious so as to be incapable of rational, independent judgment concerning the medical treatment or service rendered;
(c)the Participant, if a minor has been alone or without the presence of an adult of his/her family or his/her legal guardian
from the onset of the Medical Emergency.
If the Participant was not able to contact Health Choices prior to seeking care,the Participant should do so within 48
hours after receiving care or as soon as reasonably possible. Payment for emergency room services and associated
Physician Services will be as stated herein in the Schedule of Benefits.
Notification is required for non-emergency Out-of-Network Hospital Services or a $250 penalty will apply. This
penalty does not apply to the annual out-of-pocket maximum.
- 11 -
1. Hospital Care. The medical services and supplies furnished by a Hospital or Ambulatory Surgical Center or a
Birthing Center when Medically Necessary and when Pre-Certification authorization is granted (except in case of
Emergency Services). Covered Services for room and board will be payable as stated herein in the Schedule of
Benefits. Elective admissions must be approved in advance by the Plan.
Room and Board, special diets, medications, general nursing care, and other services are covered when a
Participant occupies a semi-private room or in a special care unit.
If the Participant occupies a private room for reasons other than the fact that the Illness or Injury requires a private
room, based upon certification by the Attending Physician, the difference between the Hospital's most frequent
rate for a semi-private room (two or more beds) and its rate for a private room shall be paid by the Participant.
Room charges made by a Hospital having only private rooms will be paid on the average rate for a semi-private
room in a Hospital in the same area. Personal comfort or convenience items are not covered.
Other Hospital services covered on an In-patient or Out-patient basis are:
a. Operating and recovery rooms;
b. Medical and surgical supplies;
C. Anesthesia supplies and services;
d. Nursing care and related services;
e. Oxygen and its administration;
f. Surgical dressings, casts and splints;
g. X-ray and laboratory services and other diagnostic tests;
h. Radiation therapy;
i. Chemotherapy;
j. Administration of blood,blood plasma and blood plasma expanders; and
k. Labor and delivery rooms.
Pre-Certification is required for Hospital Services. Pre-Certification is required for Out-of-Network
Hospital services, or a $250 penalty will apply. This penalty does not apply to the annual out-of-pocket
maximum.
2. Coverage of Pregnancy. Services and supplies of Pregnancy are covered the same as any other Illness.
Any Hospital length of stay in connection with childbirth for the mother or newborn child will not be restricted to
less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, this
does not prohibit the mother's or newborn's attending Physician, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours(or 96 hours as applicable).
Only one Copayinent is applied for both mother and newborn, unless one stays after the other is discharged; in
which case, a Copayment is charged for the mother and newborn separately.
Coverage will be continued for a Participant in the second or third trimester of Pregnancy:
a. If the Plan terminates its contract with an In-network Provider for continued care from the Physician. The
Participant may continue to receive such treatment or care through postpartum care related to the
- 12 -
childbirth and delivery. Payment for Covered Services and benefit levels shall be according to the terms
and conditions of the Plan.
b. If an involuntary change in health plans is made, the Participant may request that the new Plan cover the
services of the Participant's Physician who is an Out-of-Network Provider under the new Plan.
Continuation of such coverage shall continue through postpartum care related to the childbirth and
delivery. Payment for Covered Services and benefit levels shall be according to the terms and conditions
of the new Plan.
If the contract of an In-Network Physician terminates for cause, coverage shall not be provided for health care
services to a Participant following the date of termination.
3. Nursing Facility Services. Services in a Nursing Facility will be covered in lieu of hospitalization when Nursing
Services are Medically Necessary, ordered by a Physician, and approved by the Plan Medical Director. Covered
Services for a Participant's care in these facilities is limited to the covered daily maximum as stated herein in the
Schedule of Benefits.
Care which is designed essentially to assist an individual to meet his/her daily living activities is not covered.
4. Physician Care. The professional services of a Physician for office visits, home visits and visits to a Nursing
Facility, consultations, In-patient visits in a Hospital, surgical services when needed to care for an Illness and
accidental Injury. Surgical treatment of morbid obesity, organ transplantation, cosmetic procedures needed as a
result of an Illness or Injury or any plastic surgery is available only when Medically Necessary and ordered by a
Physician and approved in writing by the Plan Medical Director.
5. Home Health Care Services and Supplies. Charges for Home Health Care services and supplies are covered
only for services and supplies of an Injury or Illness when Hospital or Skilled Nursing Facility confinement would
otherwise be required. The diagnosis, services and supplies must be certified by the attending Physician, approved
by the Plan Medical Director prior to the services being provided, and be contained in a Home Health Care Plan.
Services are provided for the services and supplies of a Participant under a home care plan established by a
Physician and approved by the Plan Medical Director prior to the services being provided.
Listed below are services and supplies covered for the treatment of an unstable medical condition:
a. Part-time or intermittent home nursing care by or under the supervision of a registered or licensed
practical nurse;
b. Home Health Care aide services that are provided on a part-time or intermittent basis and are skilled in
nature. They must be Medically Necessary as part of the home care plan. They must consist solely of
caring for the patient. Must be supervised by a registered nurse or medical social worker;
C. Physical, respiratory, occupational or speech therapy;
d. Medical supplies, drugs that are not covered under any other City drug program, Physician and laboratory
services to the extent such items would be covered under this Plan if the Participant had been hospitalized
and such items and services are prescribed by a Physician and authorized by the Plan Medical Director.
Disposable items are not covered;
e. Nutritional counseling. A registered dietician must give or supervise these services. They must be
Medically Necessary as part of the home care plan; and
f. A registered nurse (R.N.), Physician extender or medical social worker must assess the need for a home
care plan, and its development. The attending Physician must ask for or approve this service.
g. Home Health Care Services shall not be covered unless ordered by a Physician, and approved by the Plan
- 13 -
Medical Director:
i. Hospitalization or confinement in a facility providing skilled nursing care would otherwise be
required if Home Health Care Services were not provided; and
ii. Necessary services and supplies are not available without causing undue hardship from a
Participant's spouse, children, parent(s), grandparent(s), brother(s), sister(s), their spouses, or
other persons residing with the Participant.
Home Health Care Services must be provided or coordinated by a Plan approved agency which shall be
licensed under the applicable State Law or a Medicare certified Home Health Care Agency or certified
Rehabilitation Facility.
Services rendered by the Participant's spouse, children, parent(s), grandparent(s), brother(s), sister(s),
their spouses or any other person residing in the Participant's home, will not be reimbursed by the Plan.
When reviewing the certified statements of the Physicians as to the appropriateness and Medical
Necessity of the services prescribed, the Plan may apply the same review criteria and standards which are
utilized by the Plan for other purposes.
6. Hospice Care Services and Supplies. Charges for Hospice Care Services and Supplies are covered only when
the attending Physician has diagnosed the Participant's condition as being terminal, determined that the Participant
is not expected to live more than six months and placed the Participant under a Hospice Care Plan.
Hospice services should be recommended by a Physician and approved by the Plan Medical Director. Covered
Services for Hospice Care Services and Supplies are payable as stated herein in the Schedule of Benefits.
7. Other Medical Services and Supplies. These services and supplies not otherwise included in the items above are
covered as follows:
a. Professional ambulance service by air or ground, when Medically Necessary, to and from the nearest
institution having the facilities required to treat the Illness or Injury involved. Professional ambulance
services furnished in connection with Emergency Services required to treat a life threatening condition do
not require Pre-Certification.
b. Periodic physical examinations.
C. Well child care, visual acuity tests,breast and pelvic examinations, therapeutic injections administered
during a visit to a Physician. Coverage for visual tests and refractions to determine the need for glasses
for individuals eighteen(18)years of age and over is limited to one examination every twenty-four(24)
months. Coverage for lead screening is limited to individuals through age six (6). Coverage for
Participants seventeen(17)years of age or under is limited to one refraction every twelve(12)months.
d. Audiometry tests, pap smears, hormone or allergy shots. There is no Copayment for these services unless
there is a charge for an office visit in addition to these services.
e. Allergy testing. If the Participant is seen by a Physician in addition to the allergy testing, the Participant is
liable for two (2) Copayments. All allergy testing done on the same day will be subject to one
Copayment.
f. Anesthesia; in connection with a Medically Necessary surgery or medical services covered by the Plan;
drawing,processing, and storing of blood and blood products when utilized by a Participant.
g. Phase II Out-patient cardiac rehabilitation subject to the limits in the Schedule of Benefits provided
services are rendered:
i. Under the supervision of a Physician;
- 14 -
ii. In connection with a myocardial infarction (heart attack), coronary occlusion or coronary bypass
surgery, onset of angina pectoris, heart valve surgery, onset of decubital angina, onset of unstable
angina, and percutaneous transluminal angioplasty;
iii. Participant must begin an exercise program immediately following his/her Hospital confinement
for one of the conditions as stated herein.
A new benefit period is available following subsequent period of hospitalization for any of the conditions
listed above. No other benefits for Out-patient cardiac rehabilitation services are available under this
contract. Coverage is listed in the Schedule of Benefits. The Participant is liable for the balance of any
charges.
h. Radiation or chemotherapy and treatment with radioactive substances. The services and supplies of
technicians are included.
i. Eyeglasses for aphakic (post-op cataract)patients. Coverage is limited to one(1) set of frames to a
maximum of$95. Eyeglasses and contact lenses are covered for up to twelve (12)months post-
operatively and will be replaced during this twelve (12)month period as long as there is a change in the
prescription.
j. Durable Medical Equipment, Orthotic Devices and Prosthetic Appliances when authorized by a Physician
and approved by the Plan Medical Director. Covered duplicate appliances or prostheses,repairs and
replacements are not covered unless Medically Necessary. Payment will be made only for the least
expensive equipment or appliance which will meet the Participant's needs as determined by the
Participant's Physician and the Plan Medical Director.The expense of any equipment or appliance
beyond the basic equipment will be at the Participant's expense. Glucose monitors and strips for diabetes
mellitus are covered. Pre-Certification is recommended if price is over$500.
k. Infertility Services are provided if in a time period established by an In-Network OB/GYN Physician, the
Participant is not able to conceive. For the diagnostic phase (the Copay for Physician services and any
appropriate Hospital Copayments) shall apply. This may include, but is not limited to:
i. History and physical examination;
ii. Education about Infertility;
iii. Instruction on basal body temperature monitoring and discussion of optimal coital practice;
iv. Semen analysis and other preliminary studies (except sperm washing and sperm penetration);
V. Endometrial biopsy;
vi. Hysterosalpingogram; and
vii. Diagnostic laparoscopy.
All Covered Services required to treat Infertility have a 50% Copay and do not apply to the Out-of-Pocket
Maximum. These services may include the following:
i. All cycle monitoring including ultrasound and appropriate lab;
ii. Subsequent laparoscopies;
iii. Tuboplasty and other microsurgery for tubal pathology;
iv. Sonogram;
V. LH lab tests and any other necessary lab tests;
vi. Ovulation induction with IV GnRH; and
vii. In-vitro fertilization(Pre-Certification is required)
viii. Embryo transfers;
ix. Any ovum or embryo transfers
X. Sperm washing and sperm penetration tests;
xi. Artificial insemination;
xii. Surgical procedures for male Participants
Infertility treatment for the following services are not covered(including Hospital costs):
- 15 -
i. Reversal of sterilization and related procedures where there is no disease process
involved;
ii. Surrogate parenthood;
iii. Adoption;
iv. Over the counter LH kits;
V. Devices for male Infertility or impotence; and
vi. Injectable Infertility drugs administered or dispensed in a Physician's office, clinic or
Hospital Out-patient department.
1. X-ray and Laboratory services.
in. Substance Abuse Services. Office visits, inpatient and outpatient services. It is the intent of the Plan to
adhere to the Mental Health Parity Act and cover Substance Abuse services the same as any other Illness.
n. Mental health services. Office visits,inpatient and outpatient services. It is the intent of the Plan to adhere
to the Mental Health Parity Act and cover Mental Disorders the same as any other Illness.
o. Dental services are limited to those which are determined by the Plan to be necessary to provide
stabilization and treatment of an acute accidental Injury to Sound Natural Teeth. If a Physician
recommends, and the Plan approves hospitalization of a Participant for a dental procedure,
whether covered or not covered, because of a specific no-dental physiological condition, the
Hospital services, supplies and anesthesia will be covered.
LIMITATION: The Plan will pay fifty percent (50%) of the dentist's charges which are UCR as
determined by the Plan, for treatment in connection with Injury to Sound Natural Teeth or
surrounding soft tissues. The participant will be liable for the remaining charges. Services and
treatment must be initiated within seventy-two (72) hours of the date of the accident or Injury
and completed within ninety (90) days from the date of the accident or Injury. If the Participant
is physically unable to initiate treatment within seventy-two (72) hours of the accident or Injury,
the treatment must be started within seventy-two (72) hours of the date the Physician certifies
that the Participant is physically able to begin such treatment. In such cases, care must be
completed within ninety (90) days of the date of the Physician's certification. The ninety (90)
day period for completion of the services may be extended if the person providing the service
indicates that there is a medical reason for additional time to finish the services and the Plan
approves the extension.
P. Organ transplant. Heart, lung, liver, kidney, bone marrow, corneal,heart/lung,pancreas,kidney/pancreas
and liver transplants, and re-transplants, and all related services and supplies, including procurement,
when the services are ordered or recommended by an In-Network Physician, and approved by the Plan
Medical Director prior to the time the transplant is performed. The transplant must be performed at a
designated Transplant Facility. Re-transplant means the re-transplant of the same human organ, human
tissue or bone marrow performed within one(1)year of the date of the initial transplant procedure.
A Participant is eligible for coverage for up to two (2)transplants of different organs per Lifetime.
Multiple organ transplants performed at the same time are considered to be one procedure.
q. Mammograms are covered when Medically Necessary, e.g.: because of family history, abnormality in
prior x-rays or examination. When there is no condition which indicates the need for a mammogram, such
examinations are limited to:
i. One baseline mammogram for any woman who is thirty-five(35)through thirty-nine(39)years
of age.
ii. A mammogram every year for any woman who is forty(40) years of age or older.
- 16 -
r. Reconstructive Mammoplasty. Reconstructive mammoplasties will be considered Covered Services.
Coverage for the treatment of breast cancer as mandated under the Women's Health and Cancer Act of
1998 including:
i. Reconstruction of the breast on which a mastectomy has been performed,
ii. Surgery and reconstruction of the other breast to produce a symmetrical appearance, and
iii. Coverage of prostheses and physical complications during all stages of mastectomy, including
lymphedemas,
iv. In a manner determined in consultation with the attending Physician and the patient.
Any plastic surgery is only available when Medically Necessary and ordered by a Physician and approved
in writing by the Plan Medical Director. Post-mastectomy surgical bras and lymphedema sleeves are
covered.
S. Spinal Manipulation/Chiropractic services. To be covered as an In-Network benefit you must have a
Referral from an In-Network M.D. or D.O. and approval of the Plan Medical Director and use an In-
Network Doctor of Chiropractor(D.C.).
t. A weight control program is covered, as defined in the Schedule of Benefits, if prescribed by a Physician
and approved by the Plan Medical Director.
U. Out-patient diabetic education programs designed to enable diabetes mellitus patients to gain an
understanding of the diabetic disease process and the daily management of diabetic therapy when ordered
by a Physician. Such program must be approved by the Plan Medical Director.
i. The Physician managing the individual's diabetic condition certifies that such services are needed
under a comprehensive plan and care related to the individual's diabetic condition to ensure
therapy compliance or to provide the individual with necessary skills and knowledge to
participate in the management of the Participant's condition.
ii. The diabetic self-management training and education program is certified by the Iowa
Department of Public Health. The department shall consult with the American Diabetes
Association, Iowa Affiliate, in developing the standards for certification of diabetes education
programs as follows:
Initial training shall cover up to ten (10) hours of initial Out-patient diabetes self-management training
within a continuous twelve (12) month period for each Participant that meets any of the following
conditions:
i. A new onset of diabetes.
ii. Poor glycemic control as evidenced by a glycosylated hemoglobin of nine and five-tenths (5110)
or more in ninety(90) days before attending the training.
iii. A change in treatment regimen from no diabetes medications to any diabetes medication, or from
oral diabetes medication to insulin.
iv. High risk for complications based on poor glycemic control; documented acute-episodes of severe
hypoglycemia or acute severe hyperglycemia occurring in the past year during which the
individual needed third-party assistance for either emergency room visits or hospitalization.
V. High risk based on documented complications of a lack of feeling in the foot or other foot
complications such as foot ulcer or amputation,pre-proliferative or proliferative retinopathy or
prior laser treatment of the eye, or kidney complications related to diabetes, such as
macroalbuminuria or elevated creatinine.
vi. Participants who receive the initial training shall be eligible for a single follow-up training
session of up to two (2) hours each year.
- 17 -
V. Sexual counseling services limited to those techniques commonly used by Physicians for conditions
considered to be producing significant physical or mental problems. The Plan will pay fifty percent(50%)
of the allowable amount.
W. A stop smoking program is covered, as defined in the Schedule of Benefits, if prescribed by a Physician
and approved by the Plan Medical Director.
X. Family planning, counseling, information on birth control. Contraceptive devices such as diaphragms,
IUDs and Norplant(and their insertion and removal), and Depo Provera for birth control.
Y. Terminally Ill Patient. Coverage will be continued for a Participant who is undergoing a specified course
of treatment for a terminal Illness or related condition:
i. If the Plan terminates its contract with an In-Network Provider. The Participant may continue to
receive treatment for the terminal Illness or a related condition, from the Participant's Physician
with the recommendation of the treating Physician, for a period of up to ninety(90)days.
Payment for Covered Services and benefit levels are as stated herein.
ii. If an involuntary change in health plans is made. The Participant may request that the new Plan
cover the services of the Participant's Physician who is an Out-of-Network Provider under the
new Plan. Such coverage will continue if the Participant is undergoing a specified course of
treatment for a terminal Illness or a related condition. Continuation of such coverage shall
continue for up to ninety(90) days. Payment for covered services and benefit levels are as stated
herein.
in. If the contract of an In-Network Physician terminates for cause, coverage shall not be provided
for health care services to a Participant following the date of termination.
Z. Hemodialysis treatments when provided to a Participant as an In-patient in a Hospital or as an Out-patient
in a dialysis center.
aa. Immunizations and injections. Immunizations and injections required for travel are not covered. Hepatitis
B vaccine is covered only when the Participant is under age twenty-one(21) and has been exposed to
hepatitis or for well-child care and the immunization has been ordered by a Physician. It is not covered if
required by an employer, school or any other third party.
bb. Oxygen therapy and other inhalation therapy and related items for home use as authorized by a Physician.
cc. Cosmetic or reconstructive surgery which is determined by the Plan Medical Director to be Medically
Necessary and which meets the following criteria:
i. To correct a birth defect or deformity which occurred or was present at the time of birth(e.g. cleft
lip, cleft palate, club foot).
ii. To correct disfigurement as a result of accident.
iii. To correct disfigurement as a result of Illness or prior surgical procedure when such
disfigurement impedes physiological functioning.
iv. To revise or change the stricture, configuration, or relationship with contiguous structure of any
feature of the human body which would be considered by the average prudent observer to be
within the range of"normal"and acceptable variation for age and ethnic origin and, in addition, is
performed for a condition which is judged by competent medical opinion to be without potential
jeopardy to physical or mental health.
Surgery performed for the primary purpose of improving a Participant's personal appearance or for
- 18 -
psychological reasons which does not improve physiological function of the area of the body involved is
not covered.
dd. Out-patient short-term therapy including, but not limited to physical, respiratory, speech and occupational
therapy which the Plan expects to result in significant improvement in the condition by the end of thirty
(30)visits. Therapy sessions are limited to thirty(30), for all Out-patient therapies combined per calendar
year. Additional visits may be eligible if deemed medically necessary; subject to pre-certification by the
Participant. Treatments for In-patient therapy are unlimited. Speech therapy is limited to therapy
required to restore speech after an accident or Illness and subject to limits as stated herein.
ee. Routine patient care costs in all phases of an approved cancer clinical trial. Referral to an approved
clinical trial must be provided by two oncologists and the cancer trial must be sponsored by the NIH,the
FDA,the Department of Defense, or the Department of Veterans Affairs.
ff. Oral Surgical Procedures which are determined by the Plan to be Medically Necessary and meet
applicable guidelines for surgery will be covered the same as any other Illness. Such procedures include,
but are not limited to the following: disease of the facial bones, trauma to the soft and hard tissue
structures of the face and oral cavity, treatment of a jaw disorder commonly known as TMJ, correcting
facial deformities present at birth or later which are not considered cosmetic, diseases and the corrections
of malpositions of the human teeth, alveolar process, gums, jaw, or associated structures, removal of
tumors; and/or treatment of congenital lip or cleft palate(excluding orthodontia).
LIMITATION: The Plan will not pay for oral surgery related to the removal or repair of teeth, except as
specifically listed as covered as part of an acute accidental injury to Sound.Natural Teeth. Surgery that is
dental in nature involves the teeth and is not covered by the Plan. Tooth extraction and/or excision of
impacted or non-impacted wisdom teeth are not covered by the Plan.
8. Psychiatric Medical Institution for Children(PMIC). Coverage for PMIC shall be included and paid the same
as any other mental health Illness under the Plan. Care must be Medically Necessary as defined in the Plan. Pre-
Certification, as with any other in-patient admission is required.
COST MANAGEMENT SERVICES
Cost Management Services Phone Number
Health Choices: 800-747-8900 or 563-556-8070
Please refer to the Employee ID card for the Cost Management Services phone number.
Any reduced reimbursement due to failure to follow cost management procedures will not accrue toward the 100%
maximum out-of-pocket payment.
UTILIZATION REVIEW
Utilization Review is a program designed to help insure that all Participants receive necessary and appropriate health care
while avoiding unnecessary expenses.
The program consists of:
1. Pre-Certification should be obtained for the following non-emergency services before Medical and/or Surgical
services are provided.
Hospitalizations
Outpatient CAT Scans/PET Scans
In-patient Substance Abuse/Mental Disorder treatments
Skilled Nursing Facility stays
Home Health Care Services
- 19 -
Hospice Care Plan
Durable Medical Equipment over$500
Orthotic Appliances
Out-patient surgical procedures performed in a Hospital or free-standing Facility
Organ transplant
Morbid obesity program
Infertility treatment—Lifetime maximum of$15,000 applies
Out-patient diabetic program
Stop smoking program
Oral Surgical Procedures
Plastic surgery or cosmetic surgery, when Medical Necessary
Spinal Manipulation/Chiropractic services for In-Network coverage
Weight control program
In-vitro fertilization
Pre-Certification is required prior to receiving non-emergency Out-of-Network Hospital Services or a
$250 penalty will apply. This penalty does not apply to the annual out-of-pocket maximum.
2. Retrospective review of the Medical Necessity of the listed services provided on an emergency basis;
3. Concurrent review,based on the admitting diagnosis, of the listed services requested by the attending Physician;
and
4. Certification of services and planning for discharge from a Medical Care Facility or cessation of medical
treatment.
The purpose of the program is to determine what charges may be eligible for payment by the Plan. This program is not
designed to be the practice of medicine or to be a substitute for the medical judgment of the attending Physician or other
health care provider.
If a particular course of treatment or medical service is not Pre-Certified, it means that either the Plan will not pay for the
services or the Plan will not consider that course of treatment as appropriate for the maximum reimbursement under the
Plan. The patient is urged to find out why there is a discrepancy between what was requested and what was Pre-Certified
before incurring charges.
SECOND AND/OR THIRD OPINION PROGRAM
Certain surgical procedures are performed either inappropriately or unnecessarily. In some cases, surgery is only one of
several treatment options. In other cases, surgery will not help the condition.
In order to prevent unnecessary or potentially harmful surgical treatments,the second and/or third opinion program fulfills
the dual purpose of protecting the health of the Plan's Participants and protecting the financial integrity of the Plan.
Benefits will be provided for a second(and third, if necessary) opinion consultation to determine the Medical Necessity of
an elective surgical procedure. An elective surgical procedure is one that can be scheduled in advance; that is, it is not an
emergency or of a life-threatening nature.
While any surgical treatment is allowed a second opinion, the following procedures are ones for which surgery is often
performed when other treatments are available.
Appendectomy Hernia surgery Spinal surgery
Cataract surgery Hysterectomy Surgery to knee, shoulder,
elbow or toe
- 20 -
Cholecystectomy Mastectomy surgery Tonsillectomy and
(gall bladder removal) adenoidectomy
Deviated septum Prostate surgery Tympanotomy
(nose surgery) (inner ear)
Hemorrhoidectomy Salpingo-oophorectomy Varicose vein ligation
(removal of tubes/ovaries)
CASE MANAGEMENT
Case Management is a program whereby a case manager nurse monitors patients and explores, discusses and recommends
coordinated and/or alternate types of appropriate Medically Necessary care. The case manager nurse consults with the
patient, the family and the attending Physician in order to develop a plan of care for approval by the patient's attending
Physician and the patient.This Plan of care may include some or all of the following:
-- personal support to the patient;
-- contacting the family to offer assistance and support;
-- monitoring Hospital or Skilled Nursing Facility;
-- determining alternative care options; and
-- assisting in obtaining any necessary equipment and services.
Case Management occurs when this alternate benefit will be beneficial to both the patient and the Plan.
The case manager nurse will coordinate and implement the Case Management program by providing guidance and
information on available resources and suggesting the most appropriate treatment plan.The Plan Administrator, attending
Physician,patient and patient's family must all agree to the alternate treatment plan.
Once agreement has been reached, the Plan Administrator will direct the Plan to reimburse for Medically Necessary
expenses as stated in the treatment plan, even if these expenses normally would not be paid by the Plan.
Note: Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient and
family choose not to participate.
Each treatment plan is individually tailored to a specific patient and should not be seen as appropriate or
recommended for any other patient, even one with the same diagnosis.
DEFINED TERMS
The following terms have special meanings and when used in this Plan will be capitalized.
Anniversary Date is July 1.
Active Employee is an Employee who is hired by the Employer and who has begun to perform the duties of his or her job
with the Employer and also meets the definition of Eligible Employee.
Actively at Work means, an Active Employee who has physically reported to work for the City at his/her regular place of
employment and regular job.
Acute Care visit is any service received at an Acute Care center within a clinic, a free-standing Urgent Care facility, a
walk-in facility, an Urgent Care facility attached to a Hospital, or a student health center at a college or university.
Ambulatory Surgical Center is a free standing or hospital-based facility,with an organized professional staff,that provides
surgical services to patients who do not require an inpatient bed.
- 21 -
Birthing Center means any freestanding health facility,place,professional office or institution which is not a Hospital or
in a Hospital, where births occur in a home-like atmosphere. This facility must be licensed and operated in accordance
with the laws pertaining to Birthing Centers in the jurisdiction where the facility is located.
Calendar Year means January 1 st through December 31 st of the same year.
Certified Registered Nurse Anesthetist means a registered nurse(R.N.) licensed under Chapter 152, code of Iowa, or
similar laws in other states, and certifies by the Council of Certification of Nurse Anesthetists.
City means the City of Dubuque, Iowa.
Claims Administrator means the person, firm, and/or company designated by the City to provide claims payment
services for the Plan.
Copay/Copayment means the amount of medical expense incurred for Covered Services that shall be paid by the
Participant before payment of certain Covered Services by the Plan would commence.
Covered Services means the description of the services set forth in the Covered Services section.
Custodial Care means the type of care,wherever furnished,which is designed essentially to assist an individual to meet
his or her daily living activities and is of a nature that does not require the continuing attention and assistance of licensed
medical or trained paramedical personnel. Examples of Custodial Care include but are not limited to:
a. Services which constitute personal care such as assistance in walking, getting in and out of bed, aid in bathing,
dressing, feeding and other forms of assistance with normal bodily functions;
b. Preparation of special diets;
C. Supervision of medication which can usually be self-administered.
Dependent means:
a.. A covered Employee's spouse and children from birth to 26 years of age. A Dependent child is not required to
reside with the Employee,be a Full-time student or be unmarried.
b. A child 26 years of age or older and unmarried and a Full-time student in attendance (as defined by the
institution) at an educational institution which maintains a regular faculty and curriculum and has a regularly
organized body of students in attendance.
The term child shall also include a stepchild, a legally adopted child, or a child placed in the home for adoption.
The term child shall also mean one who is at least nineteen(19) years of age and who is totally and permanently disabled,
either physically or mentally, so as to be incapable of earning his/her own living and is dependent upon the Eligible
Employee for his/her support, and who became totally and permanently disabled before attaining age nineteen(19) and
while covered by this Plan.Notification and proof of such incapacity must be submitted to the City or its designated agent
within thirty-one(3 1) days of the date the Dependent child's coverage would otherwise terminate and proof may
subsequently be required from time to time.
Detoxification is the gradual reduction of the toxic properties of alcohol and/or other addictive drugs to prevent serious
withdrawal complications. Signs and symptoms may include delirium tremens, convulsions or hallucinations.
Durable Medical Equipment means Medically Necessary equipment which is not otherwise excluded under the Plan and
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.
Examples of Durable Medical Equipment include,but are not limited to: wheelchairs, Hospital beds, and respirators,but
do not include items such as batteries, air conditioners,humidifiers, dehumidifiers, air purifiers, exercise equipment, and
other convenience items. Equipment must be obtained from an In-Network medical equipment supplier.
- 22 -
Effective Date is the first day of coverage or, if there is a waiting period,the first day of the waiting period.
Eligible Employee means a person who is an Active Employee of the Employer,who when hired is expected to
accumulate 1,560 or more Eligible Hours during a 12-month Look Back Measurement Period or an Employee who
accumulates 1,560 or more Eligible Hours during the 12-month Look Back Measurement Period established by the
Employer, or a Retired Employee not eligible for Medicare.
Eligible Hours for the purposes of calculating benefits eligibility under this policy Eligible Hours shall include:
each hour for which an Employee is paid, or entitled to payment, for the performance of duties for the Employer; and each
hour for which an employee is paid, or entitled to payment by the Employer on account of a period of time during which
no duties are performed due to vacation,holiday, Illness, incapacity(including disability), layoff,jury duty,military duty
or leave of absence during the specified Look Back Measurement Period established by the Employer.
Employer is City of Dubuque.
Event means an incident resulting in a change of status of an Employee or dependent including marriage,birth, legal
adoption,placement for adoption, divorce, death of spouse, loss of spouse's employment, loss of coverage under an
individual policy, loss of coverage under Medicaid or SCHIP, or loss of coverage under a Group Health Plan provided the
Employee or dependent declined enrollment under the Plan in writing when initially eligible to enroll because of either:
a. COBRA continuation coverage in effect and such coverage has since been exhausted(this does not include
declining to pay the required premium when due for such coverage); or
b. Coverage under another Group Health Plan or Insurance Coverage which has terminated as a result of:
i. Loss of eligibility for such coverage; or
ii. Employer contribution toward such coverage has terminated.
Experimental and/or Investigational means a Drug, device, medical treatment or procedures which are experimental or
investigative; a drug, device, medical treatment or procedure is experimental or investigative if:
a. The drug or device cannot be lawfully marketed with approval of the U.S Food and Drug Administration and
approval for marketing has not been given at the time the drug or device is furnished; or
b. The drug, device,medical treatment or procedure, or the patient informed consent document utilized with the
drug, device,treatment or procedure, was not reviewed and approved by the treating facility's Institutional
Review Board or other body serving a similar function, and if federal law requires such review or approval; or
C. Reliable evidence shows that the drug, device, medical treatment or procedure is the subject of ongoing phase I or
phase II clinical trials, in the research, experimental, study or investigative arm of ongoing phase III clinical trials,
or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its
efficacy as compared with a standard means of treatment or diagnosis; or
d. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment
or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its
toxicity, its safety its efficacy or its efficacy as compared with a standard means of treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the
written protocol(s)use by the treatment facility of the protocol(s)utilized by other facilities studying substantially the
same drug, device, medical treatment or procedure; or the written informed consent document used by the treating facility
or by other facilities studying substantially the same drug, device, medical treatment or procedure.
Family Unit is the covered Employee or Retiree and the family members who are covered as Dependents under the Plan.
Freestanding Substance Abuse Facility (FSAF) A state licensed facility approved by the Plan to provide inpatient and
outpatient treatment for mental health and/or chemical dependency.
Genetic Information means information about genes, gene products and inherited characteristics that may derive from an
individual or a family member. This includes information regarding carrier status and information derived from laboratory
- 23 -
tests that identify mutations in specific genes or chromosomes,physical medical examinations, family histories and direct
analysis of genes or chromosomes.
Home Health Care Agency means an agency which:
a. Is state licensed, certified or approved, or certified under Medicare and the Plan; and
b. Has policies which are established and reviewed by health care professionals, including at least one Physician and
registered nurse(R.N.); and
C. Keeps clinical records on each patient; and
d. Has been approved by the Claims Administrator or Plan Medical Director prior to obtaining services.
Home Health Care Services means a program of Skilled Nursing Services planned and established for a Participant by a
Physician, furnished in a Participant's home or usual place of residence,provided that such Skilled Nursing Services are
furnished by a Home Health Care Agency approved by Medicare and accepted by the Plan.
Hospice Agency is an organization where its main function is to provide Hospice Care Services and Supplies and it is
licensed by the state in which it is located, if licensing is required, is certified by Medicare and meets the standards
established by the National Hospice Organization.
Hospice Care Plan is a plan of terminal patient care that is established and conducted by a Hospice Agency and is
designed to meet the special needs of a dying person and his/her Family Unit, during the final Illness.
Hospital means a lawfully operated institution for the services and supplies of sick and injured persons, including
Licensed Ambulatory Surgical Centers, Community Mental Health Centers, and Birthing Facilities, which have organized
facilities for diagnosis and treatment, medical supervision, major surgery, and twenty-four (24) hour per day nursing
services by registered nurses (R.N.) and is not, other than incidentally, a nursing home or a place for rest, the aged,
treatment of pulmonary tuberculosis or nervous and Mental Disorders. A Hospital must be duly licensed by the state of its
situs.
Illness means a bodily disorder, disease,physical Sickness or Mental Disorder. Illness includes Pregnancy, childbirth,
miscarriage or complications of Pregnancy.
In-Network means services or supplies provided by a Physician,Hospital, Ambulatory Surgical Center, Hospice, Home
Health Care Agency,Nursing Facility, Medical Equipment Supplier,Pharmacy, Laboratory or any other provider of
health services, which has entered into an agreement to provide health care services to Participants of the Plan(or through
a contractual relationship with the Claims Administrator on behalf of the Plan) and is listed in the Plan's Provider
Directory or for whom the Plan has issued a Referral for services.
In-patient as used in this Plan shall mean a Participant who,while confined in a Hospital, is assigned to a bed in any
department of the Hospital other than its Out-patient department and from whom a charge for room and board is made by
the Hospital.
Infertility means incapable of producing offspring.
Injury means an accidental physical Injury to the body caused by unexpected external means.
Intensive Care Unit is defined as a separate, clearly designated Service Area which is maintained within a Hospital
solely for the services and supplies of patients who are critically ill. This also includes what is referred to as a"coronary
care unit" or an "acute care unit." It has: facilities for special nursing care not available in regular rooms and wards of the
Hospital; special lifesaving equipment which is immediately available at all times; at least two beds for the
accommodation of the critically ill; and at least one registered nurse(R.N.) in continuous and constant attendance 24
hours a day.
Late Enrollee means an Employee or Dependent who enrolls under the Plan other than during the first 31-day period in
which the individual is eligible to enroll under the Plan or during a Special Enrollment Period.An Employee or
Dependent who loses coverage under Medicaid or SCHIP has 60 days from date coverage ended in which to enroll in the
Plan.
- 24 -
Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations. Lifetime is understood to
mean while covered under this Plan. Under no circumstances does Lifetime mean during the lifetime of the Participant.
Look Back Measurement Period means the period of time used for calculating benefits eligibility. Subsequent years will
follow the same Look Back Measurement Period timeframe for the upcoming benefits Plan Year.
Once per year just prior to Benefits Open Enrollment for the coming year(typically held in November), the Employer will
review payroll data from the Look Back Measurement Period to determine benefits eligibility for the upcoming Calendar
Year. 1,560 of Eligible Hours or more must be achieved to qualify for benefits for those employed during the entire Look
Back Measurement Period.
Medical Emergency means those covered In-patient and Out-patient services that are furnished by a provider that is
qualified to furnish such service and are needed to evaluate or stabilize a medical condition manifesting itself by acute
symptoms of sufficient severity, including severe pain,that a prudent layperson,who poses an average knowledge of
health and medicine, could reasonably expect that absence of immediate medical attention to result in one of the
following: (a)Placing the health of the individual or, with respect to a pregnant woman, the health of the woman and her
unborn child in serious jeopardy; (b) Serious impairment to bodily function; or(c) Serious dysfunction of any bodily
organ or part.
Medically Necessary means a service or supply which is appropriate and consistent with the diagnosis of a particular
condition, in accord with accepted standards of community practice and could not have been omitted without adversely
affecting the person's condition or the quality of medical care. A service or supply is Medically Necessary if.
a. It is medically required and medically appropriate for diagnosis and treatment of the Participant's Illness or
Injury;
b. It is consistent with professionally recognized standards of health care determined within the State of Iowa and
given at the right time and in the right setting; and
C. It does not involve costs that are excessive in comparison with alternative services that would be effective for
diagnosis and treatment of the Participant's Illness or Injury.
Medicare is the Health Insurance For The Aged and Disabled program under Title XVIII of the Social Security Act of
1965, as amended.
Mental Disorder means any disease or condition,regardless of whether the cause is organic, that is classified as a Mental
Disorder in the current edition of International Classification of Diseases,published by the U.S. Department of Health and
Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by
the American Psychiatric Association.
Named Fiduciary means City of Dubuque which has the authority to control and manage the operation and
administration of the Plan.
No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining fault in
connection with automobile accidents.
Nursing Facility means an institution that at the time the Participant is admitted:
a. Is licensed under Chapter 135, Code of Iowa, or licensed under laws of other states similar to Chapter 135;
b. Provides continuous Skilled Nursing Services as ordered by a Physician on a twenty-four (24) hour basis
furnished by a registered nurse(R.N); and
C. Is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics, or place for the treatment of
pulmonary tuberculosis or nervous and Mental Disorders.
Out-of-Network means any Hospital, Ambulatory Surgical Center, Nursing Facility, Hospice, Home Health Agency,
pharmacy, laboratory, Psychiatric Facility, Physician, medical equipment supplier, individual, organization or agency
which furnishes health care services but does not have a contractual relationship for the provision of health care services
or supplies to Participants whose charges shall be payable at the Usual, Customary&Reasonable amount.
- 25 -
Out-patient Care and/or Services is treatment including services, supplies and medicines provided and used at a
Hospital under the direction of a Physician to a person not admitted as a registered bed patient; or services rendered in a
Physician's office, laboratory or X-ray facility, an Ambulatory Surgical Center, or the patient's home.
Partial Hospitalization is an Out-patient program specifically designed for the diagnosis or active treatment of a Mental
Disorder or Substance Abuse when there is reasonable expectation for improvement or when it is necessary to maintain a
patient's functional level and prevent relapse; this program shall be administered in a facility which is licensed to provide
Partial Hospitalization services, if required,by the state in which the facility is providing these services.Treatment lasts
less than 24 hours,but more than four hours, a day and no charge is made for room and board.
Participant is an Employee,Retired Employee or Dependent who is covered under this Plan.
Physician means a Doctor of Medicine licensed under Chapter 148, Code of Iowa, an Osteopathic Physician licensed
under Chapter 150, code of Iowa, an Osteopathic Physician and surgeon licensed under Chapter 150A, code of Iowa, or a
person licensed as a Physician, surgeon, psychologist (Ph.D.) or podiatrist under laws of other states similar to Chapters
148, 150, 150A or 154B, Code of Iowa, an oral surgeon, licensed Physical therapist, a Doctor of Dentistry, a Doctor of
Chiropractor, or a Physician assistant or an advanced registered nurse practitioner(R.N.).
Plan means City of Dubuque, Iowa Point of Service Plan, which is a benefits Plan for certain employees of City of
Dubuque and is described in this document.
Plan Medical Director means a Physician designated by the Plan or Claims Administrator to evaluate appropriate
utilization of health services by Plan Participants.
Plan Participant is any Employee,Retired Employee, Continuation Coverage Participant or Dependent, if any, who is
covered under this Plan.
Plan Year shall be a twelve(12)month period beginning on July 1 of one year and ending on June 30 of the following
year.
Pre-Certification/Pre-Certified is the Plan Administrator's determination that: services and supplies is Medically
Necessary; that charges are Eligible Charges; that services, supplies and care are not Experimental and/or Investigational.
Pregnancy is childbirth and conditions associated with Pregnancy, including complications.
Prescription Drug means any of the following: a Food and Drug Administration-approved drug or medicine which,
under federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without prescription";
injectable insulin; hypodermic needles or syringes,but only when dispensed upon a written prescription of a licensed
Physician. Such drug must be Medically Necessary in the treatment of an Illness or Injury.
Prosthetic Appliances means an artificial device which replaces all or part of a body organ or replaces all or part of the
function of a permanently inoperative or malfunctioning body organ. Examples of prosthetic devices would include
cardiac pacemakers,prosthetic lenses,breast prostheses (including a surgical brassiere) for post mastectomy patients, and
urinary collection and retention system in case of permanent urinary incontinence. Colostomy(and other ostomy)bags
are covered as prosthetic devices. It does not include devices such as artificial limbs or temporary devices used before
artificial limbs are fitted or devices used in the fitting of such limbs, artificial or mechanical hearts, eyeglasses, hearing
aids, orthopedic shoes, arch supports, trusses, or examinations for the prescription or fitting of such devices, disposable
underpants, diapers, and rubber sheets.
Psychiatric Facility means a facility which is devoted in whole or has a discrete portion thereof devoted to the treatment
of mental or nervous conditions.
Qualified Beneficiary means an individual who, on the date before a Qualifying Event, is a Dependent of an Active
Employee or early Retired Employee. The term"Qualified Beneficiary" also means an individual who, on the date before
a Qualifying Event is an Active Employee.
- 26 -
A newborn child, adopted child or a Qualified Beneficiary or a child placed for adoption with a Qualified Beneficiary who
was not a covered employee will be entitled to the same continuation coverage period available to the Qualified
Beneficiary,however, such child shall not become a Qualified Beneficiary.
A newborn child, adopted child or child placed for adoption with a Qualified Beneficiary who was a covered employee
shall become a Qualified Beneficiary in his/her own right and shall be entitled to benefits as a Qualified Beneficiary. A
Qualified Beneficiary must notify the City within thirty-one(3 1) days of the child's birth, adoption or placement for
adoption in order to add the child to the continuation coverage.
Qualifying Event. "Qualifying Event"means any of the following:
a. Termination of coverage due to the death of an Active Employee or early Retired Employee;
b. Termination of coverage due to the voluntary or involuntary termination of employment (other than by reason of
gross misconduct)or reduction in hours of an Active Employee;
C. Termination of coverage due to an Active Employee's change in status,to a classification not covered by the
Plan;
d. The divorce or legal separation of an Active Employee or early Retired Employee from his/her spouse;
e. An Active Employee's or early Retired Employee's commencement of entitlement to Medicare coverage; or
f. A Dependent child ceasing to be a Dependent child as defined herein.
Quality Assurance Programs are programs designed by the Claims Administrator not only to assess the quality of care
delivered to Participants but to alter professional and organizational behavior so as to remedy deficiencies and to improve
performance.
Referral means an authorization given by an In-Network Physician and approved by the Plan Medical Director for a
Participant to receive Medically Necessary services from an Out-of-Network Provider. Such Referral must be made in
advance of the rendering of services. A Referral is not required when a Participant needs Emergency Services due to a
Medical Emergency outside the Service Area. If possible a Referral should be requested from an In-Network Physician
prior to seeking care for Emergency Services in.the Service Area. Other limitations, exclusion and conditions of this Plan
are not affected by this Referral and still apply.
Rehabilitation Facility means a facility that is recognized by the Plan and licensed or certified to perform rehabilitative
health care services by the state or jurisdiction where services are provided. Services of such a facility must also be
among those covered by the Plan.
Rehabilitative Care means a procedure for re-education or functional restoration of a disabled body system or part and
will be considered a Covered Service if Medically Necessary as determined by the Claims Administrator.
Retired Employee means an Active Employee as defined herein, who subsequently loses eligibility because of retirement
and who elects to continue coverage under the applicable Self-Payment Provisions for Retired Employees described
herein. In order to be covered under the Plan, the Retired Employee or their Dependent(s) may not be eligible for
Medicare.
Service Area means the geographic area defined by the Claims Administrator or the Plan and within which a Participant
must reside or work at the time of enrollment. The Service Area may change. A Participant may request a description of
the most recently approved Service Area from the Claims Administrator.
Sickness is a Participant's Illness, disease or Pregnancy(including complications).
Skilled Nursing Services means nursing services prescribed and certified to by the attending Physician, and furnished
under the direction of a registered nurse(R.N.) on a twenty-four(24)hour a day basis as a result of an Illness or Injury
requiring continuous Skilled Nursing Services and related medical services,but not requiring Hospital care.
Sound Natural Teeth mean teeth which have not been weakened by disease process or previous dental treatment.
Special Enrollment Period means the 31-day time period following the date that an Event as defined herein has
occurred. An Employee or dependent who loses coverage under Medicaid or SCHIP or who becomes eligible for state
- 27 -
assistance has a 60 day Special Enrollment Period.
Spinal Manipulation/Chiropractic Care means skeletal adjustments,manipulation or other treatment in connection with
the detection and correction by manual or mechanical means of structural imbalance or subluxation in the human body.
Such treatment is done by a Physician to remove nerve interference resulting from, or related to, distortion,misalignment
or subluxation of, or in,the vertebral column.
Substance Abuse means alcohol or drug usage resulting in the need for medical treatment. It is further a pattern of
compulsive drug use characterized by an overwhelming involvement with a drug or drugs. This includes the securing of
its supply by any means, a tendency towards increasing dosage over a period of time, and a psychological and usually
physical dependence on its effects. The condition often includes a deterioration of a Participant's health, accompanied by
interference with the social, family, or economic functioning of the Participant as well as a tendency to relapse after
withdrawal exists.
Substance Abuse Facility or Licensed Treatment Center mean facilities licensed under Chapter 125, Code of Iowa, or
similar laws in other states,which provide treatment for Substance Abuse and which have been certified as being in
compliance with regulations of the Iowa Department of health, or similar regulations in other states.
Temporomandibular Joint (TMJ) syndrome is the treatment of jaw joint disorders including conditions of structures
linking the jaw bone and skull and the complex of muscles, nerves and other tissues related to the Temporomandibular
Joint. Services and supplies shall include, but are not limited to orthodontics, crowns, inlays,physical therapy and any
appliance that is attached to or rests on the teeth.
Terminally Ill Patient means a patient whose Physician certifies that such patient is terminally ill and who is expected to
live six (6)months or less.
Total Disability(Totally Disabled)means the same condition as defined by the Social Security Act.
Transplant Facility means a facility which has entered into an agreement with Claims Administrator to render approved
organ transplant services. The Transplant Facility to be used by the particular Participant will be determined by Claims
Administrator and may or may not be located within a Participant's geographic area.
Urgent Care visit is any service received at an Acute Care center within a clinic, a free-standing Urgent Care facility, a
walk-in facility, an Urgent Care facility attached to a Hospital, or a student health center at a college or university.
Usual, Customary & Reasonable means those amounts/charges for Medically Necessary services, supplies and
treatment, which do not exceed the general level of charges made by others of similar standing in the locality where the
charge is incurred and which are within the maximum amounts allowed by the fee schedule, which is utilized by the
Claims Administrator as determined by the City. This Plan shall utilize the national database for the Claims Administrator
at the 80`x'percentile, in determining UCR.
Utilization Review refers to a program adopted by the Plan to review and monitor Hospital admissions and In-patient and
Out-patient services to determine the medical necessity of such services.
PLAN EXCLUSIONS
If any services or supplies are not specifically addressed in this Document,whether as an Exclusion or as a
Covered Service,it is not assumed that such services or supplies are covered under this Plan.
1. Acupuncture,Hypnotism, or Biofeedback. Services or supplies related to the performance of acupuncture,
hypnotism, or biofeedback.
2. Appliances or Orthotics.Dentures, corrective appliances, orthotics for the feet, orthopedic shoes, arch supports,
trusses or examinations for the prescription or fitting thereof, and support stockings and garments regardless of
their intended use(except post-mastectomy surgical bras and lymphedema sleeves).
- 28 -
3. Bereavement. Bereavement counseling or services of volunteers or clergy.
4. Blood. Blood,blood plasma, blood serum, if replaced.
5. Certified Registered Nurse R.N. Services or supplies furnished by a certified registered nurse(other than a
Certified Registered Nurse Anesthetist)which are not private duty nursing services as stated herein.
6. Cochlear Implants.Diagnostic analysis of cochlear implants, cochlear device implantation, programming and
subsequent reprogramming are not covered under the Plan.
7. Complications of non-covered treatments. Care, services or treatment required as a result of complications
from a treatment not covered under the Plan are not covered.
8. Cosmetic. Services or supplies for cosmetic or beautifying purposes, including cosmetic, or plastic surgery
procedures performed primarily for psychological reasons or as a result of the aging process, except as to improve
functional capacity of the body or to correct a congenital disease or anomaly, which has resulted in a functional
defect or it is for reconstructive surgery following a mastectomy as stated in the Covered Services section.
9. Counseling. Services or supplies for marital, family or other counseling or other training services unless
otherwise covered herein.
10. Custodial Care. Services or supplies provided mainly as a rest cure, maintenance or Custodial Care.
11. Dental. Services or supplies for dental care, dental surgery, dental treatment, dentures or for dental appliances
except as defined in the Covered Services section.
12. Developmental Delay. Speech therapy and other therapies and treatment for developmental delay. (Therapy
required to restore speech after an accident or Illness is covered.)For behavioral training therapy; for hearing
therapy; for residential education therapy; for vocational counseling.
13. Educational or vocational testing. Services for educational or vocational testing or training. Services or supplies
for recreational, vocational testing or training, or educational therapy or forms of non-medical self-help or self-
cure.
14. ESW(Extracorporeal Shock Wave). Services, therapy or supplies related to ESW are not covered under the
Plan.
15. Excess charges.The part of an expense for services and supplies of an hijury or Illness that is in excess of the
Usual, Customary&Reasonable Charge.
16. Exercise programs,materials or equipment. Exercise or fitness programs,health education materials or
equipment for treatment of any condition, except for Physician-supervised cardiac rehabilitation, occupational or
physical therapy, or weight control programs covered by this Plan.
17. Experimental or not Medically Necessary. Experimental and/or Investigational means a Drug, device,
medical treatment or procedures which are experimental or investigative; a drug, device, medical treatment or
procedure is experimental or investigative if:
a. The drug or device cannot be lawfully marketed with approval of the U.S Food and Drug Administration
and approval for marketing has not been given at the time the drug or device is furnished; or
b. The drug, device,medical treatment or procedure, or the patient informed consent document utilized with
the drug, device,treatment or procedure,was not reviewed and approved by the treating facility's
Institutional Review Board or other body serving a similar function, and if federal law requires such
review or approval; or
C. Reliable evidence shows that the drug, device,medical treatment or procedure is the subject of ongoing
phase I or phase II clinical trials, in the research, experimental, study or investigative arm of ongoing
phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose,its toxicity,
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its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis; or
d. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical
treatment or procedure is that further studies or clinical trials are necessary to determine its maximum
tolerated dose, its toxicity, its safety its efficacy or its efficacy as compared with a standard means of
treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific
literature; the written protocol(s)use by the treatment facility of the protocol(s)utilized by other facilities
studying substantially the same drug, device, medical treatment or procedure; or the written informed consent
document used by the treating facility or by other facilities studying substantially the same drug, device, medical
treatment or procedure.
18. Eye care. Eyeglasses or eye refractions (except as specifically as stated herein as covered); surgery for correction
of refraction such as but not limited to: radial keratotomy or other eye surgery to correct refractive disorders..
19. Foot care. Services and supplies related to routine foot care.
20. Foreign travel. Care, treatment or supplies out of the U.S. if travel is for the sole purpose of obtaining medical
services.
21. Government coverage. Care, treatment or supplies furnished by a program or agency funded by any federal,
state, or local government body. This does not apply to Medicaid or when otherwise prohibited by law. The City,
through its designated agent, reserves the right to review and waive this exclusion on a case-by-case basis if the
services provided are Medically Necessary. Services and supplies for a Participant covered under this Plan to the
extent that the Participant is entitled to have any part of the cost thereof paid by Medicare, even though the
Participant does not enroll in Medicare or waives or fails to claim Medicare benefits.
22. Hair loss. Services and supplies for hair loss including wigs, artificial hair pieces, hair transplants or any drug that
promises hair growth, whether or not prescribed by a Physician.
23. Hearing aids and exams. Cochlear implants. Charges for services or supplies in connection with hearing aids
or exams for their fitting. Diagnostic analysis of cochlear implants, cochlear device implantation,programming
and subsequent reprogramming.
24. Hospital admission for Physical, Speech or Occupational Therapy. Services or supplies furnished when
admission to a Hospital or Nursing Facility is primarily for, or the services consist primarily of physical therapy,
occupational therapy, diagnostic evaluations, other than pre-admission testing.
25. Illegal acts. Charges for services received as a result of Injury or Illness caused by or contributed to by engaging
in an illegal act or occupation or commission of, or attempt to commit a felony.
26. Immunizations. Immunizations required only for travel or when ordered or required by a third party.
27. Impotence. Care, treatment, services, supplies or medication in connection with treatment for male Infertility or
impotence.
28. Infertility. Services or supplies except as specifically stated herein as covered.
29. Long Term Physical, Speech,or Occupational Therapy. Long term physical therapy, occupational therapy, or
speech therapy services which are not expected to result in significant improvement in the condition.
30. No obligation to pay. Charges for any services, treatment, supplies or accommodations for which the Participant
is not obligated to pay, is not billed or would not have been billed, except for the fact that the Participant was
covered under this Plan.
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31. Not specified as covered.Non-traditional medical services,treatments and supplies which are not specified as
covered under this Plan.
32. Nutritional supplements.
33. Occupational. Services or supplies provided in connection with the treatment of Illness or Injury arising out of or
in the course of a Participant's employment for which an employer is required to furnish any Hospital, Skilled
Nursing Services, Care Services or Physician's services or benefits (including Worker's Compensation benefits)
or is liable for damages to the Participant,or to the Participant's personal representative,under any applicable
federal, state,municipal or other law, even though the Participant has elected to waive or has failed to claim rights
to such services,benefits or damages; or services provided in connection with the treatment of Illness or Injury
when the Participant has received or has a right to receive any payment for such services from or on behalf of his
employer.
34. Occupational therapy. Supplies related to occupational therapy except as stated herein as Covered Services.
35. Organ Transplant. Services and supplies related to organ transplantation involving mechanical or animal organs;
expenses related to the purchase of an organ other than expenses for procurement of an organ; services and
supplies related to donation of any organ if provided under the coverage of a donor; or services or supplies
furnished in connection with the transportation of a living organ transplant donor.
36. Personal comfort items. Personal comfort items or other equipment, such as, but not limited to, air conditioners,
air-purification units, humidifiers, dehumidifiers, electric heating units, orthopedic mattresses,blood pressure
instruments, scales, elastic bandages or stockings,non-Prescription Drugs and medicines, and first-aid supplies,
non-Hospital adjustable beds and other personal convenience equipment which would be useful to a person in the
absence of Illness or Injury. Motor vehicles, lifts for wheel chairs and scooters, and stair lifts.
37. Prescription Drugs and Medications.
38. Relative giving services. Services or supplies furnished by a Physician to a Participant of the Physician's
immediate family.
39. Residential living. Structured residential living programs designed to teach trauma victims independent living
skills.
40. Reversal of sterilization. Services and supplies for the reversal of surgical sterilizations, including but not limited
to: vasectomy or tubal litigation or for Infertility when the Infertility of a Participant or a Participant's
reproductive partner is the result of a voluntary sterilization.
41. Routine care. Charges for routine or periodic examinations or screening examinations, except as specifically as
stated herein as covered.
42. Services before or after coverage. Care, treatment or supplies for which a charge was incurred before a
Participant was covered under this Plan or after coverage ceased under this Plan.
43. Sex changes. Services or supplies related to counseling for Participants suffering from gender identification
problems and services or supplies related to the performance of gender transformation procedures.
44. Sex determination.Non-medical amniocentesis exclusively for sex determination, alpha-feta protein tests,
holistic medicine, cytotoxin testing, and hair analysis.
45. Smoking cessation. Services and supplies for smoking cessation programs, including smoking deterrent patches,
except for stop smoking program as defined as covered.
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46. Substance Abuse Center. Services or supplies furnished in a facility for the treatment of Substance Abuse
licensed under Chapter 125, Code of Iowa, if that facility has not been certified as being in compliance with
regulations of the Iowa Department of Health, or similar regulations in other states.
47. Travel or accommodations. Charges for travel or accommodations, whether or not recommended by a
Physician.
48. War. Services and supplies which are required to treat an Injury suffered due to any act of war, declared or
undeclared,when the Participants is on active or reserve duty in the military of any country.
HOW TO SUBMIT A CLAIM
Benefits under this Plan shall be paid only if the Plan Administrator decides in its discretion that a Participant is
entitled to them.
When a Participant has a Claim to submit for payment that Participant must:
1. Obtain an itemized billing from the Physician.
2. Keep a copy for your own records. ALL BILLS MUST SHOW:
- Name of Plan
- Employee's name
- Name of patient
- Name, address,telephone number of the provider of care
- Diagnosis
- Type of services rendered, with diagnosis and/or procedure codes
- Date of services
- Charges
3. Send the above to the Claims Administrator at this address:
Health Choices
1605 Associates Drive, Suite 10IDubuque, Iowa 52002
800-747-8900 or 563-556-8070
Many Physicians will automatically file your bill with the Claims Administrator. If this service is available, take
advantage of it.
WHEN CLAIMS SHOULD BE FILED
Claims should be filed with the Claims Administrator within 90 days of the date charges for the service were incurred.
Benefits are based on the Plan's provisions at the time the charges were incurred. Claims filed later than that date may be
declined or reduced unless:
1. It's not reasonably possible to submit the claim in that time; and
2. The claim is submitted within one year from the date the service was incurred. This one year period will not apply
when the Participant is not legally capable of submitting the claim.
A request for Plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair review. If a
claim is wholly or partially denied, the Claims Administrator will furnish the Plan Participant with a written notice of this
denial. This written notice will be provided within 90 days after receipt of the claim. The written notice will contain the
following information:
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I. The specific reason or reasons for the denial;
2. Specific reference to those Plan provisions on which the denial is based;
3. A description of any additional information or material necessary to correct the claim and an explanation of why
such material or information is necessary; and
4. Appropriate information as to the steps to be taken if a Plan Participant wishes to submit the claim for review.
A Plan Participant will be notified within 90 days of receipt of the claim as to the acceptance or denial of a claim and if
not notified within 90 days,the claim shall be deemed denied.
If special circumstances require an extension of time for processing the claim, the Claims Administrator shall send written
notice of the extension to the Plan Participant.The extension notice will indicate the special circumstances requiring the
extension of time and the date by which the Plan expects to render the final decision on the claim. In no event will the
extension exceed a period of 90 days from the end of the initial 90-day period.
CLAIMS REVIEW PROCEDURE
Claims and Appeal Process
Following is a description of how the Plan processes Claims for benefits. A claim is defined as any request for a Plan
benefit, made by a claimant or by a representative of a claimant that complies with the Plan's reasonable procedure for
making benefit claims. The times listed complies with the Plan's reasonable procedure for making benefit Claims. The
times listed are maximum times only. A period of time begins at the time the Claim is filed. Decisions will be made
within a reasonable period of time appropriate to the circumstances. "Days"means calendar days.
There are different kinds of Claims and each one has a specific timetable for approval, payment, request for further
information, or denial of the Claim. If you have any questions regarding this procedure,please contact the Plan
Administrator.
The definitions of the types of Claims are:
Urgent Care Claim
A claim involving Urgent Care is any Claim for medical care or treatment where using the timetable for a non-Urgent
Care determination could seriously jeopardize the life or health of the claimant; or the ability of the claimant to regain
maximum function; or in the opinion of the attending or consulting Physician, would subject the claimant to severe pain
that could not be adequately managed without the care or treatment that is the subject of the Claim.
A Physician with knowledge of the claimant's medical condition may determine if a Claim is one involving Urgent Care.
If there is no such Physician, an individual acting on behalf of the Plan applying the judgment of a prudent layperson that
possesses an average knowledge of health and medicine may make the determination.
In the case of a Claim involving Urgent Care, the following timetable applies:
Notification to claimant of benefit determination 72 hours
Insufficient information on the claim, or failure to follow the Plan's procedure for filing a Claim:
Notification to claimant, orally or in writing 24 hours
Response by claimant, orally or in writing 48 hours
Benefit determination, orally or in writing 48 hours
Ongoing courses of treatment, notification of:
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Reduction or termination before the end of treatment 72 hours
Determination as to extending course of treatment 24 hours
If there is an adverse benefit determination on a Claim involving Urgent Care, a request for an expedited appeal may be
submitted orally or in writing by the claimant. All necessary information, including the Plan's benefit determination on
review, may be transmitted between the Plan and the claimant by telephone, facsimile, or other similarly expeditious
method.
Pre-Service Claim
A Pre-Service Claim means any Claim for a benefit under this Plan where the Plan conditions receipt of the benefit, in
whole or in part, on approval in advance of obtaining medical care. These are, for example, Claims subject to Pre-
Certification. Please see the Cost Management section of this booklet for further information about Pre-Service Claims.
In the case of a Pre-Service Claim, the following timetable applies:
Notification to claimant of benefit determination 15 days
Extension due to matters beyond the control of the Plan 15 days
Insufficient information on the Claim:
Notification of 15 days
Response by claimant 45 days
Notification, orally or in writing, of failure to follow
Plan's procedures for filing a Claim 5 days
Ongoing courses of treatment:
Reduction or termination before the end of the treatment 15 days
Request to extend course of treatment 15 days
Review of adverse benefit determination 30 days
Post-Service Claims
A Post-Service Claim means any Claim for a Plan benefit that is not a Claim involving Urgent Care or a Pre-Service
Claim; in other words, a Claim that is a request for payment under the Plan for covered medical services already received
by the claimant.
In the case of a Post-Service Claim, the following timetable applies:
Notification to claimant of benefit determination 30 days
Extension due to matters beyond the control of the Plan 15 days
Insufficient information on the Claim:
Notification of 15 days
Response by claimant 45 days
Review of adverse benefit determination 60 days
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Notice to claimant of adverse benefit determinations
Except with Urgent Care Claims, when the notification may be orally followed by written or electronic notification within
three days of the oral notification, the Plan Administrator shall provide written or electronic notification of any adverse
benefit determination. The notice will state, in a manner calculated to be understood by the claimant:
1. The specific reason or reasons for the adverse determination.
2. Reference to the specific Plan provisions on which the determination was based.
3. A description of any additional material or information necessary for the claimant to perfect the Claim and an
explanation of why such material or information is necessary.
4. A description of the Plan's review procedures, incorporation any voluntary appeal procedures offered by the Plan,
and the time limits applicable to such procedures.
5. A statement that the claimant is entitled to receive,upon request and free of charge,reasonable access to, and
copies of, all documents, records, and other information relevant to the Claim. "You and your Plan may have
other voluntary alternative dispute resolution.options, such as mediation. One way to find out what may be
available is to contact your local U.S. Department of Labor Office."
6. If the adverse benefit determination was based on an internal rule, guideline,protocol or other similar criterion,
the specific rule, guideline,protocol, or criterion will be provided free of charge. If this is not practical, a
statement will be included that such a rule, guideline,protocol, or criterion was relied upon in making the adverse
benefit determination and a copy will be provided free of charge to the claimant upon request.
Appeals
When a claimant receives an Adverse Benefit Determination, the claimant has 180 days following receipt of the
notification in which to appeal the decision. A claimant may submit written comments, documents, records, and other
information relating to the Claim.
At any time during the appeal process,the Participant has the right to allow an authorized representative to act on their
behalf.
The appeal procedure shall be used to resolve any adverse determination regarding any Pre-Service claim, Post Service
Claim or Urgent Care Claim according to the following time frames:
1. Urgent Care Claims-The Plan will notify you of the decision of your appeal no later than seventy-two (72)hours.
If you request an expedited appeal of this benefit denial, all necessary information, including the Plan's decision
via telephone and followed up in writing is required.
2. Pre-Service Claims-The Plan will notify you of the decision of your appeal within a reasonable period of time
appropriate to medical circumstances but not later than fifteen(15) days after the Plan receives your appeal.
3. Post-Service Claims-The Plan will notify you of the decision of your appeal within a reasonable period of time
but not later than thirty(30)days after the Plan receives your appeal.
A document,record, or other information shall be considered relevant to a Claim if it:
1. Was relied upon in making the benefit determination;
2. Was submitted, considered, or generated in the course of making the benefit determination, without regard to
whether it was relied upon in making the benefit determination;
- 35 -
3. Demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that
benefit determinations are made in accordance with Plan documents and Plan provisions have been applied
consistently with respect to all claimants; or
4. Constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment options or
benefit.
The review shall take into account all comments, documents,records, and other information submitted by the claimant
relating to the Claim, without regard to whether such information was submitted or considered in the initial benefit
determination. The review will not afford deference to the initial Adverse Benefit Determination and will be conducted by
a fiduciary of the Plan who is neither the individual who made the Adverse Benefit Determination nor a subordinate of
that individual.
If the Participant,the Participant's authorized representative or the Plan is not satisfied with the decision at the appeal
level according to Iowa Regulations,the Participant,the Participant's authorized representative or the Plan has the right to
file a written grievance.
Grievance Process
Upon receipt of a written request for the grievance process,the Plan shall notify the Participant filing the grievance of the
Participant's right to appear in person before the Grievance committee to present written or oral information and to
question those people responsible for making the detennination that resulted in the grievance. Such notice shall inform the
Participant in writing of the time and place of the meeting at least seven(7) days before the meeting.The grievance
committee shall consist of five(5)persons. The Claims Administrator Staff and/or Plan Medical Director shall be ex-
officio and non-voting members of the committee. Each party to the complaint and/or their representatives shall be heard
by the grievance committee. Each party may present their case as to why the original decision was rendered and why that
decision should be sustained or rejected. Upon conclusion of the presentation or arguments, the grievance committee shall
have seven(7) days in which to deliberate and issue their recommendation to the city or its designated agent.If the
claimant so requests, he or she will be provided, free of charge,reasonable access to, and copies of, all documents,
records, and other information relevant to the Claim.
If the recommendation of the grievance committee is to uphold the denial and the denial is related to an issue of medical
necessity, appropriateness, health care setting, level of care, effectiveness of the health care service or treatment or
rescission of coverage and the Participant(or the Participant's authorized representative) or the Plan decline to accept the
grievance committee's recommendation, that party shall have four(4)months after receipt of the decision of the City or
its designated agent based on the recommendation of the grievance committee in which to file a formal written request for
an External Review.
Standard External Review Process
Plan Participants are entitled to an external review after the internal appeals/grievance process has been exhausted. An
external review can be filed on any matter relating to an adverse determination or final adverse determination for the
denial of coverage based on medical necessity, appropriateness,health care setting, level of care, effectiveness of the
health care service or treatment or rescission of coverage. The decision will be reviewed by independent health care
professionals who have no association with the Plan. The external review entity shall be an entity certified as meeting the
criteria established by the Iowa Insurance Division. The Plan will adhere to the rules adopted by the Iowa Insurance
Division, and as may be amended from time to time,regarding external reviews.
In order to be eligible for external review: (1) the Plan Participant must have been covered at the time the service or
treatment was proposed; (2) the covered Participant must have been denied coverage based on a final adverse
determination by the Plan and that the proposed services or treatment does not the definition of medical necessity, care or
services are not deemed appropriate for the diagnosis,the health setting or level of care is not considered appropriate for
the diagnosis, the health setting or level of care is not considered appropriate of the standard of care and/or the denial is
based upon the lack of effectiveness of an otherwise benefit; and(3) the covered Participant or the covered Participant's
treating provider acting on behalf of the covered Participant, must have exhausted all internal appeal mechanisms
provided under this Plan.
- 36 -
In order to request an external review, the Participant or the Participant's authorized representative shall send a request for
an external review in writing,by mail, fax or electronic submission including a copy of the Plan's written notice
containing the final adverse determination within four(4)months of receipt of the final coverage decision from the Plan to
the commissioner at the Division of Insurance, 330 Maple Street, Des Moines, IA 50319; telephone 515-281-5705;
facsimile 515-281-3059; iid.marketregulation@iid.iowa.gov.
1. Within one(1) business day of receipt of the request for external review,the Insurance Commissioner shall send a
copy of the request to the Plan.
2. Within five (5)business days of receipt of the request from the commissioner, the Plan shall complete a
preliminary review to certify the Participant meets the criteria established under Iowa Code Chapter 514J.
3. Within one(1)business day after receipt of the notice from the Plan that a request for external review is eligible
or upon determination by the commissioner that a request is eligible, the commissioner shall do the following:
a. Assign an Independent Review Organization(IRO)randomly from a list maintained by the commissioner
and notify the Plan of the name of the assigned IRO.
b. Notify the Participant and the Participant's authorized representative of the selected IRO and the right to
submit additional information to the IRO in writing within five(5)business days.
4. Within five(5)business days after receipt of the notice from the commissioner,the Plan shall provide to the IRO
the documents and any information used in making the final adverse determination.
5. The IRO shall submit written notification within forty-five(45) days from the date of receipt of the request to
uphold or reverse the final adverse determination to the Participant or the Participant's authorized representative,
the Plan and the commissioner.
Expedited External Review Process
To request an expedited review, the Participant or the Participant's authorized representative may make an oral or written
request to the commissioner at the Division of Insurance, 330 Maple Street, Des Moines, IA 50319; telephone 515-281-
5705; facsimile 515-281-3059; iid.marketreegulations(a iid.iowa.gov for an expedited external review when the following
have been received:
1. A final Adverse Benefit Determination that involves a medical condition for which the time for completion of an
internal review of a grievance committee involving a final adverse determination would seriously jeopardize the
life or health of the covered person or would jeopardize the Participant's ability to regain maximum function.
2. A final adverse determination that concerns an admission, availability of care, continued stay, or health care
service for which the Participant received Emergency Services and has been discharged from a facility.
Upon receipt of a request for an expedited external review, the commissioner shall immediately send written notice of the
request to the Plan. Immediately upon receipt of notice of a request for an expedited external review,the Plan shall
complete a preliminary review to determine if the request meets the eligibility requirements set forth under Iowa Code
Chapter 514J.Upon receipt of the notice from the Plan that a request is eligible for expedited external review or upon
determination by the commissioner that a request is eligible, the commissioner shall immediately assign an IRO from an
approved list of IRO's maintained by the commissioner. The commissioner shall immediately notify the Plan and the
Participant or the Participant's authorized representative of the name of the assigned IRO. Upon receipt of the notice of
the assigned IRO, the Plan shall immediately provide or transmit all necessary documents used to make the final adverse
determination electronically,by telephone or facsimile or any other available expeditious method. As expeditiously as the
covered person's medical condition or circumstances require,but not more than 72 hours after the date of receipt of an
eligible request,the IRO shall do all of the following:
1. Make a decision to uphold or reverse the final adverse determination.
2. Notify the Participant or the Participant's authorized representative, the Plan and commissioner of its decision.
An external review decision is binding for the Plan except to the extent that the Plan has other remedies available under
applicable Iowa law.
A Participant or Participant's authorized representative may appeal the external review decision made by the IRO by
filing a petition for judicial review in either Polk County district court or in the district court in the county in which the
Participant resides. The petition must be filed within fifteen (15) days after the issuance of the review decision. The Plan
shall follow and comply with the decision of the court on appeal.
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COORDINATION OF BENEFITS
Coordination of the benefit plans. Coordination of benefits sets out rules for the order of payment of Covered Services
when two or more plans --including Medicare--are paying. When a Participant is covered by this Plan and another plan,
or the Participant's spouse is covered by this Plan and by another plan or the couple's Covered children are covered under
two or more plans,the plans will coordinate benefits when a claim is received.
The plan that pays first according to the rules will pay as if there were no other plan involved.The secondary and
subsequent plans will pay the balance due up to 100% of the total allowable expenses.
Benefit plan.This provision will coordinate the Covered Services of a benefit plan. The term benefit plan means this Plan
or any one of the following plans:
1. Group or group-type plans, including franchise or blanket benefit plans.
2. Group practice and other group prepayment plans.
3. Group service plans.
4. Other plans required or provided by law. This does not include Medicaid or any benefit plan like it that, by its
terms, does not allow coordination.
5. No-Fault Auto Insurance, by whatever name it is called,when not prohibited by law.
6. Any coverage under labor management trusteed plans,union welfare plans, employer organization plans or
employee benefit organization plans.
Allowable charge.For a charge to be allowable it must be a Usual, Customary&Reasonable Charge and at least part of
it must be covered under this Plan.
In the case of HMO (Health Maintenance Organization) or other In-Network only plans: This Plan will not consider any
charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an HMO or
network plan is primary and the Participant does not use an HMO or network provider, this Plan will not consider as an
allowable charge any charge that would have been covered by the HMO or network plan had the Participant used the
services of an HMO or network provider.
In the case of service type plans where services are provided as benefits,the reasonable cash value of each service will be
the allowable charge.
Automobile limitations. When medical payments are available under vehicle insurance,the Plan shall pay excess
benefits only,without reimbursement for vehicle plan deductibles. This Plan shall always be considered the secondary
carrier regardless of the individual's election under PIP (personal Injury protection) coverage with the auto carrier.
Benefit plan payment order. When two or more plans provide benefits for the same allowable charge,benefit payment
will follow these rules.
1. Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision will be
considered after those without one.
- 38 -
2. Plans with a coordination provision will pay their benefits up to the Allowable Charge:
a. The benefits of the plan which covers the Participant directly(that is, as an employee,member or
subscriber) ("Plan A") are determined before those of the plan which covers the Participant as a
Dependent("Plan B").
b. When a child is covered as a Dependent and the parents are not separated or divorced,these rules will
apply:
i. The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined
before those of the benefit plan of the parent whose birthday falls later in that year;
ii. If both parents have the same birthday, the benefits of the benefit plan which has covered the
parent for the longer time are determined before those of the benefit plan which covers the other
parent.
C. When a child's parents are divorced or legally separated, these rules will apply:
i. This rule applies when the parent with custody of the child has not remarried. The benefit plan of
the parent with custody will be considered before the benefit plan of the parent without custody.
ii. This rule applies when the parent with custody of the child has remarried.The benefit plan of the
parent with custody will be considered first. The benefit plan of the stepparent that covers the
child as a Dependent will be considered next. The benefit plan of the parent without custody will
be considered last.
iii. This rule will be in place of items (i) and(ii) above when it applies. A court decree may state
which parent is financially responsible for medical and dental benefits of the child. In this case,
the benefit plan of that parent will be considered before other plans that cover the child as a
Dependent.
iv. If the specific terms of the court decree state that the parents shall share joint custody,without
stating that one of the parents is responsible for the health care expenses of the child, the plans
covering the child shall follow the order of benefit determination rules outlined above when a
child is covered as a Dependent and the parents are not separated or divorced.
V. For parents who were never married to each other, the rules apply as set out above as long as
paternity has been established.
d. The benefits of a benefit plan which covers a Participant as an Employee who is neither laid off nor
retired are determined before those of a benefit plan which covers that Participant as a laid-off or Retired
Employee. The benefits of a benefit plan which covers a Participant as a Dependent of an Employee who
is neither laid off nor retired are determined before those of a benefit plan which covers a Participant as a
Dependent of a laid off or Retired Employee. If the other benefit plan does not have this rule, and if, as a
result,the plans do not agree on the order of benefits,this rule does not apply.
e. The benefits of a benefit plan which covers a Participant as an Employee who is neither laid off nor
retired or a Dependent of an Employee who is neither laid off nor retired are determined before those of a
plan which covers the Participant as a COBRA beneficiary.
f. If there is still a conflict after these rules have been applied, the benefit plan which has covered the patient
for the longer time will be considered first.When there is a conflict in coordination of benefit rules, the
Plan will never pay more than 50% of allowable charges when paying secondary.
3. Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare is to be the
primary payer, this Plan will base its payment upon benefits that would have been paid by Medicare under Parts A
and B, regardless of whether or not the Participant was enrolled under both of these parts.
4. If a Plan Participant is under a disability extension from a previous benefit plan,that benefit plan will pay first and
this Plan will pay second.
- 39 -
Claims determination period. Benefits will be coordinated on a Calendar Year basis. This is called the claims
determination period.
Right to receive or release necessary information. To make this provision work, this Plan may give or obtain needed
information from another insurer or any other organization or Participant. This information may be given or obtained
without the consent of or notice to any other Participant. A Participant will give this Plan the information it asks for about
other plans and their payment of allowable charges.
Facility of payment.This Plan may repay other plans for benefits paid that the Plan Administrator determines it should
have paid. That repayment will count as a valid payment under this Plan.
Right of recovery.This Plan may pay benefits that should be paid by another benefit plan. In this case this Plan may
recover the amount paid from the other benefit plan or the Participant. That repayment will count as a valid payment
under the other benefit plan.
Further,this Plan may pay benefits that are later found to be greater than the allowable charge. In this case, this Plan may
recover the amount of the overpayment from the source to which it was paid.
THIRD PARTY RECOVERY PROVISION
RIGHT OF SUBROGATION AND REFUND
When this provision applies. The Participant may incur medical or dental charges due to Injuries which may be caused
by the act or omission of a Third Party or a Third Party may be responsible for payment. hi such circumstances, the
Participant may have a claim against that Third Party, or insurer, for payment of the medical or dental charges. Accepting
benefits under this Plan for those incurred medical or dental expenses automatically assigns to the Plan any rights the
Participant may have to Recover payments from any Third Party or insurer. This Subrogation right allows the Plan to
pursue any claim which the Participant has against any Third Party, or insurer, whether or not the Participant chooses to
pursue that claim. The Plan may make a claim directly against the Third Party or insurer,but in any event, the Plan has a
lien on any amount Recovered by the Participant whether or not designated as payment for medical expenses. This lien
shall remain in effect until the Plan is repaid in full.
The Participant:
1. Automatically assigns to the Plan his or her rights against any Third Party or insurer when this provision applies;
and
2. Must repay to the Plan the benefits paid on his or her behalf out of the Recovery made from the Third Party or
insurer.
Amount subject to Subrogation or Refund.The Participant agrees to recognize the Plan's right to Subrogation and
reimbursement. These rights provide the Plan with a 100%, first dollar priority over any and all Recoveries and funds paid
by a Third Party to a Participant relative to the Injury or Illness, including a priority over any claim for non-medical or
dental charges, attorney fees, or other costs and expenses. Accepting benefits under this Plan for those incurred medical or
dental expenses automatically assigns to the Plan any and all rights the Participant may have to recover payments from
any Responsible Third Party. Further, accepting benefits under this Plan for those incurred medical or dental expenses
automatically assigns to the Plan the Participant's Third Party Claims.
Notwithstanding its priority to funds,the Plan's Subrogation and Refund rights, as well as the rights assigned to it, are
limited to the extent to which the Plan has made, or will make,payments for medical or dental charges as well as any
costs and fees associated with the enforcement of its rights under the Plan.The Plan reserves the right to be reimbursed
for its court costs and attorneys' fees if the Plan needs to file suit in order to Recover payment for medical or dental
expenses from the Participant. Also, the Plan's right to Subrogation still applies if the Recovery received by the
Participant is less than the claimed damage, and, as a result, the claimant is not made whole.
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When a right of Recovery exists,the Participant will execute and deliver all required instruments and papers as well as
doing whatever else is needed to secure the Plan's right of Subrogation as a condition to having the Plan make payments.
In addition, the Participant will do nothing to prejudice the right of the Plan to Subrogate.
Conditions Precedent to Coverage.The Plan shall have no obligation whatsoever to pay medical or dental benefits to a
Participant if a Participant refuses to cooperate with the Plan's reimbursement and Subrogation rights or refuses to execute
and deliver such papers as the Plan may require in furtherance of its reimbursement and Subrogation rights. Further, in the
event the Participant is a minor, the Plan shall have no obligation to pay any medical or dental benefits incurred on
account of Injury or Illness caused by a responsible Third Party until after the Participant or his authorized legal
representative obtains valid court recognition and approval of the Plan's 100%, first dollar reimbursement and
Subrogation rights on all Recoveries, as well as approval for the execution of any papers necessary for the enforcement
thereof, as stated herein.
Defined terms: "Participant"means anyone covered under the Plan, including minor Dependents.
"Recover," "Recovered," "Recovery" or"Recoveries" means all monies paid to the Participant by way of judgment,
settlement, or otherwise to compensate for all losses caused by the Injury or Illness, whether or not said losses reflect
medical or dental charges covered by the Plan. "Recoveries" further includes,but is not limited to,recoveries for medical
or dental expenses, attorneys' fees, costs and expenses,pain and suffering, loss of consortium, wrongful death, lost wages
and any other recovery of any form of damages or compensation whatsoever.
"Refund" means repayment to the Plan for medical or dental benefits that it has paid toward services and supplies of the
Injury or Illness.
"Subrogation" means the Plan's right to pursue and place a lien upon the Participant's claims for medical or dental charges
against the other person.
"Third Party" means any Third Party including another person or a business entity.
Recovery from another plan under which the Participant is covered.This right of Refund also applies when a
Participant Recovers under an uninsured or underinsured motorist plan(which will be treated as Third Party coverage
when reimbursement or Subrogation is in order), homeowner's plan,renter's plan, medical malpractice plan or any
liability plan.
Rights of Plan Administrator.The Plan Administrator has a right to request reports on and approve of all settlements.
GENERAL PROVISIONS
Proof of Claim. Proof of claim forms, as well as other forms, and method of administration and procedure will be solely
determined by the Plan.
Workers' Compensation. The benefits provided by this Plan are not in lieu of and do not affect any requirement for
coverage by Workers' Compensation insurance laws or similar legislation.
Titles. Titles of provisions are for convenience of reference only and are not to be considered in interpreting this Plan.
Disclaimer. None of the benefits provided by the Plan are guaranteed by the Plan or any other individual or entity other
than through a stop-loss policy issued by an insurance carrier. The benefits may be provided only from amounts in the
Plan collected and available for such purpose.
Gender. Wherever any words are used in this Plan Document in the masculine gender, they should be construed as
though they were also used in the feminine gender in all situations where they would so apply; wherever any words are
used in the Plan in the singular form they should be construed as though they were also in the plural form in all situations
where they would so apply, and vice versa.
Submission of Falsified or Fraudulent Claims. All claims submitted to the Claims Administrator shall be honest,
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accurate and as complete as possible. If the Claims Administrator finds at any time, that there has been an intentional
falsification of any document submitted in support of a claim, either by use of forgery or intentionally inaccurate
information or any other fraudulent means whatsoever, it shall have the right to immediately terminate coverage and/or
refuse to honor any claim which is related to the falsified or fraudulent information. The coverage to be terminated, if the
Claims Administrator so determines, shall be that of the employee and Dependents who are related to the person
submitting the false or fraudulent claim.
No Vested Rights. No covered individual or any other person shall have any vested right to any benefit provided by the
Plan.
CONTINUATION OPTIONS
CONTINUATION OF COVERAGE PROVISION
A Qualified Beneficiary may continue coverage under the health plan. This opportunity for a temporary extension of
health coverage (called "continuation coverage") in certain instances where coverage under the Plan would otherwise end.
This notice is intended to inform Plan Participants and beneficiaries, in summary fashion, of the rights and obligations
under the continuation coverage provisions. Complete instructions, as well as election forms and other information,will
be provided by the Plan Administrator to Plan Participants who become Qualified Beneficiaries.
Note: Special rights apply to employees who have been terminated or experienced a reduction of hours and who qualify
for a trade readjustment allowance or alternative trade adjustment assistance under a federal law called the Trade Act of
1974. These employees must have made petitions for certification to apply for TAA on or after November 4, 2002.
The employees, if they do not already have continuation coverage, are entitled to a second opportunity to elect
continuation coverage for themselves and certain family members, but only within a limited period of 60 days or less and
only during the six months immediately after their group health plan coverage ended.
Any employee who qualifies or may qualify for assistance under this special provision should contact his or her Plan
Administrator for further information.
What is continuation coverage? Continuation coverage is group health plan coverage that an Employer must offer to
certain Plan Participants and their eligible family members (called"Qualified Beneficiaries") at group rates for up to a
statutory-mandated maximum period of time or until they become ineligible for continuation coverage, whichever occurs
first. The right to continuation coverage is triggered by the occurrence of one of certain enumerated events that result in
the loss of coverage under the terns of the Employer's Plan(the "Qualifying Event"). The coverage must be identical to
the Plan coverage that the Qualified Beneficiary had immediately before the Qualifying Event, or if the coverage has been
changed,the coverage must be identical to the coverage provided to similarly situated active employees who have not
experienced a Qualifying Event(in other words, similarly situated non-continuation beneficiaries).
Who is a Qualified Beneficiary? In general, a Qualified Beneficiary is:
1. Any individual who, on the day before a Qualifying Event, is covered under a Plan by virtue of being on that day
either a covered Employee, the spouse of a covered Employee, or a Dependent child of a covered Employee. If,
however, an individual is denied or not offered coverage under the Plan under circumstances in which the denial
or failure to offer constitutes a violation of applicable law, then the individual will be considered to have had the
Plan coverage and will be considered a Qualified Beneficiary if that individual experiences a Qualifying Event.
2. Any child who is born to or placed for adoption with a covered Employee during a period of continuation
coverage. If,however, an individual is denied or not offered coverage under the Plan under circumstances in
which the denial or failure to offer constitutes a violation of applicable law,then the individual will be considered
to have had the Plan coverage and will be considered a Qualified Beneficiary if that individual experiences a
Qualifying Event.
3. A covered Employee who retired on or before the date of substantial elimination of Plan coverage which is the
result of a bankruptcy proceeding under Title 11 of the U.S. Code with respect to the Employer, as is the spouse,
42 -
surviving spouse or Dependent child of such a covered Employee if, on the day before the bankruptcy Qualifying
Event, the spouse, surviving spouse or Dependent child was a beneficiary under the Plan.
An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is attributable to a period in
which the individual was a nonresident alien who received from the individual's Employer no earned income that
constituted income from sources within the United States. If, on account of the preceding reason, an individual is not a
Qualified Beneficiary,then a spouse or Dependent child of the individual is not considered a Qualified Beneficiary by
virtue of the relationship to the individual.
Each Qualified Beneficiary(including a child who is born to or placed for adoption with a covered Employee during a
period of continuation coverage)must be offered the opportunity to make an independent election to receive continuation
coverage.
What is a Qualifying Event? A Qualifying Event is any of the following if the Plan provided that the Plan Participant
would lose coverage (i.e., cease to be covered under the same terms and conditions as in effect immediately before the
Qualifying Event)in the absence of continuation coverage:
1. The death of a covered Employee.
2. The termination(other than by reason of the Employee's gross misconduct), or reduction of hours, of a covered
Employee's employment.
3. The divorce or legal separation of a covered Employee from the Employee's spouse.
4. A covered Employee's enrollment in the Medicare program.
5. A Dependent child's ceasing to satisfy the Plan's requirements for a Dependent child(e.g., attainment of the
maximum age for dependency under the Plan).
6. A proceeding in bankruptcy under Title 11 of the U.S. Code with respect to an Employer from whose
employment a covered Employee retired at any time.
If the Qualifying Event causes the covered Employee, or the spouse or a Dependent child of the covered Employee,to
cease to be covered under the Plan under the same terms and conditions as in effect immediately before the Qualifying
Event(or in the case of the bankruptcy of the Employer, any substantial elimination of coverage under the Plan occurring
within 12 months before or after the date the bankruptcy proceeding commences),the individuals losing such coverage
become Qualified Beneficiaries under continuation coverage if all the other conditions of the continuation coverage are
also met. Any increase in contribution that must be paid by a covered Employee, or the spouse, or a Dependent child of
the covered Employee, for coverage under the Plan that results from the occurrence of one of the events listed above is a
loss of coverage.
The taking of leave under the Family and Medical Leave Act of 1993 ("FMLA")does not constitute a Qualifying Event.
A Qualifying Event occurs, however, if an Employee does not return to employment at the end of the FMLA leave and all
other continuation coverage conditions are present. If a Qualifying Event occurs, it occurs on the last day of FMLA leave
and the applicable maximum coverage period is measured from this date (unless coverage is lost at a later date and the
Plan provides for the extension of the required periods, in which case the maximum coverage date is measured from the
date when the coverage is lost.)Note that the covered Employee and family members will be entitled to continuation
coverage even if they failed to pay the employee portion of premiums for coverage under the Plan during the FMLA
leave.
What is the election period and how long must it last? An election period is the time period within which the Qualified
Beneficiary can elect continuation coverage under the Employer's Plan. A Plan can condition availability of continuation
coverage upon the timely election of such coverage. An election of continuation coverage is a timely election if it is made
during the election period.The election period must begin not later than the date the Qualified Beneficiary would lose
coverage on account of the Qualifying Event and must not end before the date that is 60 days after the later of the date the
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Qualified Beneficiary would lose coverage on account of the Qualifying Event or the date notice is provided to the
Qualified Beneficiary of her or his right to elect continuation coverage.
Is a covered Employee or Qualified Beneficiary responsible for informing the Plan Administrator of the
occurrence of a Qualifying Event? In general,the Employer or Plan Administrator must determine when a Qualifying
Event has occurred. However, each covered Employee or Qualified Beneficiary is responsible for notifying the Plan
Administrator of the occurrence of a Qualifying Event that is:
1. A Dependent child's ceasing to be a Dependent child under the generally applicable requirements of the Plan.
2. The divorce or legal separation of the covered Employee.
The Plan is not required to offer the Qualified Beneficiary an opportunity to elect continuation coverage if the notice is
not provided to the Plan Administrator within 60 days after the later of. the date of the Qualifying Event, or the date the
Qualified Beneficiary would lose coverage on account of the Qualifying Event.
Is a waiver before the end of the election period effective to end a Qualified Beneficiary's election rights? If, during
the election period, a Qualified Beneficiary waives continuation coverage,the waiver can be revoked at any time before
the end of the election period. Revocation of the waiver is an election of continuation coverage. However, if a waiver is
later revoked, coverage need not be provided retroactively(that is, from the date of the loss of coverage until the waiver is
revoked). Waivers and revocations of waivers are considered made on the date they are sent to the Employer or Plan
Administrator, as applicable.
When may a Qualified Beneficiary's continuation coverage be terminated? During the election period, a Qualified
Beneficiary may waive continuation coverage. Except for an interruption of coverage in connection with a waiver,
continuation coverage that has been elected for a Qualified Beneficiary must extend for at least the period beginning on
the date of the Qualifying Event and ending not before the earliest of the following dates:
1. The last day of the applicable maximum coverage period.
2. The first day for which Timely Payment is not made to the Plan with respect to the Qualified Beneficiary.
3. The date upon which the Employer ceases to provide any group health plan(including successor plans)to any
Employee.
4. The date, after the date of the election,that the Qualified Beneficiary first becomes covered under any other Plan.
5. The date, after the date of the election,that the Qualified Beneficiary first enrolls in the Medicare program(either
part A or part B, whichever occurs earlier).
6. In the case of a Qualified Beneficiary entitled to a disability extension,the later of:
a. 29 months after the date of the Qualifying Event, or(ii) the first day of the month that is more than 30
days after the date of a final determination under Title II or XVI of the Social Security Act that the
disabled Qualified Beneficiary whose disability resulted in the Qualified Beneficiary's entitlement to the
disability extension is no longer disabled,whichever is earlier; or
b. The end of the maximum coverage period that applies to the Qualified Beneficiary without regard to the
disability extension.
The Plan can terminate for cause the coverage of a Qualified Beneficiary on the same basis that the Plan terminates for
cause the coverage of similarly situated non-continuation beneficiaries, for example, for the submission of a fraudulent
claim.
What are the maximum coverage periods for continuation coverage? The maximum coverage periods are based on
the type of the Qualifying Event and the status of the Qualified Beneficiary, as stated herein.
44 -
1. In the case of a Qualifying Event that is a termination of employment or reduction of hours of employment, the
maximum coverage period ends 18 months after the Qualifying Event if there is not a disability extension and 29
months after the Qualifying Event if there is a disability extension.
2. In the case of a covered Employee's enrollment in the Medicare program before experiencing a Qualifying Event
that is a termination of employment or reduction of hours of employment, the maximum coverage period for
Qualified Beneficiaries other than the covered Employee ends on the later of:
a. 36 months after the date the covered Employee becomes enrolled in the Medicare program; or
b. 18 months (or 29 months, if there is a disability extension) after the date of the covered Employee's
termination of employment or reduction of hours of employment.
3. In the case of a bankruptcy Qualifying Event,the maximum coverage period for a Qualified Beneficiary who is
the retired covered Employee ends on the date of the retired covered Employee's death. The maximum coverage
period for a Qualified Beneficiary who is the spouse, surviving spouse or Dependent child of the retired covered
Employee ends on the earlier of the date of the Qualified Beneficiary's death or the date that is 36 months after the
death of the retired covered Employee.
4. In the case of a Qualified Beneficiary who is a child born to or placed for adoption with a covered Employee
during a period of continuation coverage, the maximum coverage period is the maximum coverage period
applicable to the Qualifying Event giving rise to the period of continuation coverage during which the child was
born or placed for adoption.
5. In the case of any other Qualifying Event than that described above,the maximum coverage period ends 36
months after the Qualifying Event.
Under what circumstances can the maximum coverage period be expanded? If a Qualifying Event that gives rise to
an 18-month or 29-month maximum coverage period is followed,within that 18- or 29-month period,by a second
Qualifying Event that gives rise to a 36-month maximum coverage period, the original period is expanded to 36 months,
but only for individuals who are Qualified Beneficiaries at the time of both Qualifying Events. In no circumstance can the
continuation coverage maximum coverage period be expanded to more than 36 months after the date of the first
Qualifying Event.
How does a Qualified Beneficiary become entitled to a disability extension? A disability extension will be granted if
an individual (whether or not the covered Employee)who is a Qualified Beneficiary in connection with the Qualifying
Event that is a termination or reduction of hours of a covered Employee's employment, is determined under Title I1 or
XVI of the Social Security Act to have been disabled at any time during the first 60 days of continuation coverage. To
qualify for the disability extension,the Qualified Beneficiary must also provide the Plan Administrator with notice of the
disability determination on a date that is both within 60 days after the date of the determination and before the end of the
original 18-month maximum coverage.
Can a Plan require payment for continuation coverage? Yes.For any period of continuation coverage, a Plan can
require the payment of an amount that does not exceed 102% of the applicable premium except the Plan may require the
payment of an amount that does not exceed 150% of the applicable premium for any period of continuation coverage
covering a disabled Qualified Beneficiary that would not be required to be made available in the absence of a disability
extension. A group health plan can terminate a Qualified Beneficiary's continuation coverage as of the first day of any
period for which timely payment is not made to the Plan with respect to that Qualified Beneficiary.
Must the Plan allow payment for continuation coverage to be made in monthly installments? Yes. The Plan is also
permitted to allow for payment at other intervals.
What is Timely Payment for payment for continuation coverage? Timely Payment means payment that is made to the
Plan by the date that is 30 days after the first day of that period. Payment that is made to the Plan by a later date is also
considered Timely Payment if either under the terms of the Plan, covered Employees or Qualified Beneficiaries are
allowed until that later date to pay for their coverage for the period or under the terms of an arrangement between the
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Employer and the entity that provides Plan benefits on the Employer's behalf,the Employer is allowed until that later date
to pay for coverage of similarly situated non-continuation beneficiaries for the period.
Notwithstanding the above paragraph, a Plan cannot require payment for any period of continuation coverage for a
Qualified Beneficiary earlier than 45 days after the date on which the election of continuation coverage is made for that
Qualified Beneficiary. Payment is considered made on the date on which it is sent to the Plan.
If Timely Payment is made to the Plan in an amount that is not significantly less than the amount the Plan requires to be
paid for a period of coverage, then the amount paid will be deemed to satisfy the Plan's requirement for the amount to be
paid,unless the Plan notifies the Qualified Beneficiary of the amount of the deficiency and grants a reasonable period of
time for payment of the deficiency to be made. A "reasonable period of time" is 30 days after the notice is provided. A
shortfall in a Timely Payment is not significant if it is no greater than the lesser of$50 or 10%of the required amount.
Must a Qualified Beneficiary be given the right to enroll in a conversion health plan at the end of the maximum
coverage period for continuation coverage? If a Qualified Beneficiary's continuation coverage under a group health
plan ends as a result of the expiration of the applicable maximum coverage period, the Plan must, during the 180- day
period that ends on that expiration date,provide the Qualified Beneficiary with the option of enrolling under a conversion
health plan if such an option is otherwise generally available to similarly situated non-continuation beneficiaries under the
Plan. If such a conversion option is not otherwise generally available, it need not be made available to Qualified
Beneficiaries.
CONTINUATION DURING MILITARY LEAVE, FAMILY AND MEDICAL LEAVE,LEAVE OF ABSENCE
OR TEMPORARY LAYOFF
Continuation of Coverage During Military Leave. It is the intent of the Plan to comply with the Uniformed Services
Employment Act of 1994 (USERRA). If any part of this Plan is found to be in conflict with this Act,the conflicting
provision shall be null and void. All other benefits and exclusions of this Plan will remain effective to the extent there is
no conflict with this Act.
USERRA provides for continuation of health coverage to a covered Employee and covered Dependents during a period of
active service or training with any of the Uniformed Services. These rights apply only to Employees and their
Dependents covered under the Plan immediately before leaving for military service. A covered Employee may elect to
continue coverage in effect at the time the Employee is called to active service as follows:
1. The maximum period of coverage of a person under such an election shall be the lesser of:
a. The 24-month period beginning on the date on which the person's absence begins; or
b. The day after the date on which the covered Employee's fails to apply for or return to a position
of employment as follows:
i. For service of less than 31 days, no later than the beginning of the first full regularly
scheduled work period on the first full calendar day following the completion of the
period of service and the expiration of eight hours after a period allowing for the safe
transportation from the place of service to the covered Employee's residence or as soon
as reasonably possible after such eight hour period;
ii. For service of more than 30 days but less than 181 days, no later than 14 days after the
completion of the period of service or as soon as reasonably possible after such period;
iii. For service of more than 180 days,no later than 90 days after the completion of the
period of service.
iv. For a covered Employee who is hospitalized or convalescing from an Illness or Injury
incurred in or aggravated during the performance of service in the uniformed services, at
the end of the period that is necessary for the covered Employee to recover from such
Illness or Injury. Such period of recovery may not exceed two(2) years.
2. A Covered Person who elects to continue health plan coverage may be required to pay up to 102% of the full
contribution under the Plan, except a person on active duty for 30 days or less cannot be required to pay more
than the Employee's share, if any, for the coverage.
- 46 -
3. Continuation cannot be discontinued merely because activated military personnel receive health coverage
as active duty members of the Uniformed Services, and their family members are eligible to receive
coverage under the Military Health System, TRICARE.
"Uniformed Services" shall include fulltime and reserve components of the United States Army,Navy, Air Force,
Marines, Coast Guard, Army National Guard,the commissioned corps of the Public Health Service and any other
category of persons designated by the President in time of war or emergency.
Covered Employees called to a period of active service in the Uniformed Service are encouraged to check with
the Plan Administrator for a more complete explanation of your rights and obligations under USERRA.
If the Covered Employee wishes to elect this coverage or obtain more detailed information, contact the Plan Administrator
City of Dubuque, 50 West 13th Street, Dubuque,Iowa, 52001, 563-589-4125. The Employee may elect USERRA
continuation coverage for the Employee and their Dependents. Only the Employee has election rights.Dependents do not
have any independent right to elect USERRA health plan continuation.
Continuation--Family and Medical Leave Act. Active Employees shall be entitled to benefits under the Plan during a
family or medical leave in accordance with the provisions of the Family and Medical Leave Act of 1993, as may be
amended.
Continuation under Leave of Absence or Temporary Layoff. During any period for which an Active Employee is
granted by the City an approved leave of absence or incurs a temporary layoff and on a basis precluding individual
selection, such Active Employee will continue to be an Active Employee under the terms of the Plan for the leave of
absence or layoff period approved by the City. Contributions will be required from the Active Employee to continue
coverage if the leave is not covered under the Family and Medical Leave Act. Coverage will terminate under this
provision upon expiration of approved leave of absence, when layoff is no longer considered temporary, or when the
required contributions are not remitted in a timely manner. Upon termination of coverage under this provision, former
Active Employees may then elect to continue coverage as specified under the Continuation Coverage section. For
purposes of this provision, leave of absence will include military leave/reserve call-ups.
CONTINUATION FOR RETIRED EMPLOYEES
Continuation for Retired Employees—Self-Payment Provisions.
1. Those Eligible. Retired Employees as stated herein and their eligible Dependents are entitled to participate under
the Continuation section or under any other continuation of coverage Plan sponsored by the City.
a. A Retired Employee receiving a pension benefit from the Iowa Public Employee Retirement System
(IPERS) or Municipal Fire Police Retirement System of Iowa(MFPRSI), as a result of his/her disability
or formal retirement; or
b. A Retired Employee who is receiving a Social Security Disability Benefit.
2. Application for Coverage. The Retired Employee's request for permission from the City to participate in the
Plan may be filed with the City within thirty(30) days prior to the date eligibility as an Active Employee
terminates due to retirement.
3. Self-Payment. The first payment(which will include payment for all months since coverage terminated)must be
received by the City within forty-five(45) days of the date the Retired Employee elected to continue coverage
under the Self-Payment Provisions for Retired Employees. Each subsequent payment is due by the twenty-fifth
(25) day of the month preceding the month for which coverage is intended, and shall be considered timely if
received within thirty(30)days of the due date. If payment is not received in a timely manner coverage will
terminate retroactive to the last day of the month for which coverage was paid.
4. Termination of Coverage. Coverage for a Retired Employee shall terminate on the earliest of the following
dates:
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a. The expiration of the period for which the last monthly payment was made timely for coverage under the
Plan;
b. The last day of the month in which the Retired Employee is no longer receiving or entitled to receive a
pension benefit from the Iowa Public Employee Retirement System(IPERS), the Municipal Fire Police
Retirement System of Iowa(MFPRSI) or a Social Security Disability benefit;
C. The date of death; or
d. The date the Retired Employee becomes eligible for Medicare.
RESPONSIBILITIES FOR PLAN ADMINISTRATION
PLAN ADMINISTRATOR. City of Dubuque, Iowa, Point of Service Plan is the benefit Plan of City of Dubuque,the
Plan Administrator, also called the Plan Sponsor. An individual may be appointed by City of Dubuque to be Plan
Administrator and serve at the convenience of the Employer. If the Plan Administrator resigns, dies or is otherwise
removed from the position, City of Dubuque shall appoint a new Plan Administrator as soon as reasonably possible.
The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies, interpretations,
practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have maximum legal
discretionary authority to construe and interpret the terms and provisions of the Plan,to make determinations regarding
issues which relate to eligibility for benefits,to decide disputes which may arise relative to a Plan Participant's rights, and
to decide questions of Plan interpretation and those of fact relating to the Plan. The decisions of the Plan Administrator
will be final and binding on all interested parties.
DUTIES OF THE PLAN ADMINISTRATOR.
1. To administer the Plan in accordance with its terms.
2. To interpret the Plan, including the right to remedy possible ambiguities, inconsistencies or omissions.
3. To decide disputes which may arise relative to a Plan Participant's rights.
4. To prescribe procedures for filing a claim for benefits and to review claim denials.
5. To keep and maintain the Plan documents and all other records pertaining to the Plan.
6. To appoint a Claims Administrator to pay claims.
7. To delegate to any person or entity such powers, duties and responsibilities as it deems appropriate.
PLAN ADMINISTRATOR COMPENSATION. The Plan Administrator serves without compensation; however, all
expenses for plan administration, including compensation for hired services, will be paid by the Plan.
CLAIMS ADMINISTRATOR IS NOT A FIDUCIARY. A Claims Administrator is not a fiduciary under the Plan by
virtue of paying claims in accordance with the Plan's rules as established by the Plan Administrator.
NONDISCRIMINATION.This Plan is intended to be nondiscriminatory and to meet the requirements under applicable
sections of the Code. If the Plan Administrator determines before or during any Plan Year, that the Plan may fail to
satisfy any nondiscrimination requirement imposed by the Code or any limitation on benefits provided to Highly
Compensated Individuals, the Plan Administrator shall take such action as the Plan Administrator deems appropriate,
under rules uniformly applicable to similarly situated Participants,to assure compliance with such requirements or
limitation including,but not limited to,providing coverage on an after-tax basis or re-characterizing benefits under the
Plan as taxable income.
- 48 -
FUNDING THE PLAN AND PAYMENT OF BENEFITS
The cost of the Plan is funded as follows:
For Employee and Dependent Coverage: Funding is derived from contributions from both the Employee and Employer.
Benefits are paid directly from the Plan through the Claims Administrator.
PLAN IS NOT AN EMPLOYMENT CONTRACT
The Plan is not to be construed as a contract for or of employment.
CLERICAL ERROR
Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records or a delay
in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly terminated. An
equitable adjustment of contributions will be made when the error or delay is discovered.
If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount,the Plan retains a contractual right to
the overpayment. The person or institution receiving the overpayment will be required to return the incorrect amount of
money. In the case of a Plan Participant, if it is requested, the amount of overpayment will be deducted from future
benefits payable.
STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
City of Dubuque,Iowa("Employer") sponsors a group health plan known as City of Dubuque, Iowa Point of Service Plan
(the"Plan") for the benefit of its Eligible Employees and their Dependents.
Certain members of the Employer's workforce perform services in connection with administration of the Plan. In order to
perform these services, it is necessary for these employees from time to time to have access to Protected Health
Information(as defined below).
Under the Standards for Privacy of Individually Identifiable Health Information(45 CFR Part 164,the"Privacy
Standards"),these employees are permitted to have such access only if the Plan is amended in accordance with the
Privacy Standards.
General. The Plan shall not disclose Protected Health Information to any member of Employer's workforce unless each
of the conditions set out in this Amendment are met. "Protected Health Information" shall have the same definition as set
out in the Privacy Standards but generally shall mean individually identifiable information about the past,present or
future physical or mental health or condition of an individual, including Genetic Information and information about
treatment or payment for treatment.
Permitted Uses and Disclosures. Protected Health Information disclosed to members of Employer's workforce shall be
used or disclosed by them only for purposes of Plan administrative functions. The Plan's administrative functions shall
include all Plan payment functions and health care operations. The terms"payment"and"health care operations" shall
have the same definitions as set out in the Privacy Standards,but the term"payment" generally shall mean activities taken
with respect to payment of premiums or contributions, or to determine or fulfill Plan responsibilities with respect to
coverage,provisions of benefits, or reimbursement for health care. "Health care operations" generally shall mean
activities on behalf of the Plan that are related to quality assessment; evaluation,training or accreditation of health care
providers; underwriting, premium rating and other functions related to obtaining or renewing an insurance contract,
including stop loss insurance; medical review; legal services or auditing functions; or business planning,management and
general administrative activities. However,Protected Health infonnation that consists of Genetic Information will not be
used for underwriting purposes.
Authorized Employees. The Plan shall disclose Protected Health Information only to members of the Employer's
workforce who are designated as listed below hereto and are authorized to receive such Protected Health Information, and
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only to the extent and in the minimum amount necessary for that person to perform his or her duties with respect to the
Plan. For purposes of this Amendment, "members of the Employer's workforce" shall refer to all employees and other
persons under the control of the Employer.
a. Updates Required. The Employer shall amend the list of designated employees promptly with respect to any
changes in the members of its workforce who are authorized to receive Protected Health Information.
b. Use and Disclosure Restricted. An authorized member of the Employer's workforce who receives Protected
Health Information shall use or disclose the Protected Health Information only to the extent necessary to perform
his or her duties with respect to the Plan.
C. Resolution of Issues of Non-compliance. In the event that any member of the Employer's workforce uses or
discloses Protected Health Information other than as permitted by this Amendment and the Privacy Standards,the
incident shall be reported to the Plan's privacy officer. The privacy officer shall take appropriate action,
including:
i. Investigation of the incident to determine whether the breach occurred inadvertently, through negligence or
deliberately; whether there is a pattern of breaches; and the degree of harm caused by the breach;
ii. Appropriate sanctions against the persons causing the breach which, depending upon the nature of the breach,
may include oral or written reprimand, additional training, or termination of employment;
iii. Mitigation of any harm caused by the breach, to the extent practicable; and
iv. Documentation of the incident and all actions taken to resolve the issue and mitigate any damages.
Certification of Employer. The Employer must provide certification to the Plan that it agrees to:
a. Not use or further disclose the information other than as permitted or required by the Plan documents or as
required by law;
b. Ensure that any agent or subcontractor, to whom it provides Protected Health Information received from the
Plans, agrees to the same restrictions and conditions that apply to the Employer with respect to such information;
C. Not use or disclose Protected Health Information for employment-related actions and decisions or in connection
with any other benefit or employee benefit Plan of the Employer;
d. Report to the Plan any use or disclosure of the Protected Health Information of which it becomes aware that is
inconsistent with the uses or disclosures permitted by this Amendment, or required by law;
e. Make available Protected Health Information to individual Plan members in accordance with §164.528 of the
Privacy Standards;
f. Make available Protected Health Information for amendment by individual Plan members and incorporate any
amendments to Protected Health Information in accordance with §164.526 of the Privacy Standards;
g. Make available the Protected Health Information required to provide an accounting of disclosures to individual
Plan members in accordance with§164.528 of the Privacy Standards;
h. Make its internal practices,books and records relating to the use and disclosure of Protected Health Information
received from the Plan available to the Department of Health and Human Services for purposed of determining
compliance by the Plan with the Privacy Standards;
i. If feasible,return or destroy all Protected Health Information received from the Plan that the Employer still
maintains in any form, and retain no copies of such information when no longer needed for the purpose for which
disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to
those purposes that make the return or destruction of the information infeasible; and
j. Ensure the adequate separation between the Plan and members of the Employer's workforce, as required by
§164.504 (f)(2)(1ii) of the Privacy Standards and set out in Section 1.3 hereof.
The Plan shall disclose Protected Health Information only to members of the Employer's workforce who are designated
below:
City Manager Personnel Assistant
Personnel Manager Personnel Secretary
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COMPLIANCE WITH HIPAA ELECTRONIC SECURITY STANDARDS
Under the Security Standards for the Protection of Electronic Protected Health Information(45 CFR Part 164.300 et.
seq.,the"Security Standards"), the Plan documents must be amended to reflect certain obligations required of the
Employer.
1. The Employer agrees to implement reasonable and appropriate administrative,physical and technical
safeguards to protect the confidentiality, integrity and availability of Electronic Protected Health Information
that the Employer creates,maintains or transmits on behalf of the Plan. 'Electronic Protected Health
Information" shall have the same definition as set out in the Security Standards,but generally shall mean
Protected Health Information that is transmitted by or maintained in electronic media.
2. The Employer shall ensure that any agent or subcontractor to whom it provides Electronic Protected Health
Information shall agree,in writing, to implement reasonable and appropriate security measures to protect the
Electronic Protected Health Information.
3. The Employer shall ensure that reasonable and appropriate security measures are implemented to comply
with the conditions and requirements set forth in Compliance With HIPAA Privacy Standards provisions
Authorized Employees and Certification of Employers.
GENERAL PLAN INFORMATION
TYPE OF ADMINISTRATION
The Plan is a self-funded group health Plan and the administration is provided through a Third Party Claims
Administrator. The funding for the benefits is derived from the funds of the Employer. The Plan is not insured.
PLAN NAME
City of Dubuque, Iowa Point of Service Plan
PLAN NUMBER: 502
TAX ID NUMBER: 42-6004596
PLAN EFFECTIVE DATE: May 1, 2004; Restated July 1, 2015
PLAN YEAR ENDS: June 30
EMPLOYER INFORMATION
City of Dubuque, Iowa
50 West 13th Street
Dubuque, Iowa 52001
563-589-4125
PLAN ADMINISTRATOR
City of Dubuque, Iowa
50 West 13th Street
Dubuque, Iowa 52001
563-589-4125
CLAIMS ADMINISTRATOR
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Health Choices
1605 Associates Drive, Suite 101
Dubuque, Iowa 52002
800-747-8900 or 563-556-8070
This group health plan believes this Plan is a"grandfathered health plan"under the Patient Protection and Affordable
Care Act(the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve
certain basic health coverage that was already in effect when that law was enacted.Being a grandfathered health plan
means that your Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans,
for example, the requirement for the provision of preventive health services without any cost sharing. However, a
grandfathered health plan must comply with certain other consumer protections in the Affordable Care Act, for example,
the elimination of Lifetime limits on benefits.
Questions regarding which protection apply and which protections do not apply to a grandfathered health plan and what
might cause a plan to change from grandfathered health plan status can be directed to the Plan Administrator at the City of
Dubuque. You may also contact the Employee Benefits Security Administration,U.S. Department of Labor at 1-866-444-
3272 or www.dol.,vov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to
grandfathered health plans.
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BY THIS AGREEMENT, City of Dubuque, Iowa Point of Service Plan is hereby adopted as stated herein.
IN WITNESS WHEREOF, this instrument is executed for City of Dubuque on or as of the day and year first below
written.
By:
Michael C. Van Milligen, City Manager
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Date:
Af/d