HomeMy WebLinkAboutAnthem Blue Cross Blue Shield/14th Amendment to Employee Health Benefit PlanHealth Plan Amendment
FOURTEENTH AMENDMENT
TO THE CITY OF CARMEL
EMPLOYEE HEALTH BENEFIT PLAN
WHEREAS, the City of Carmel ( "Plan Sponsor "), by action of its governing body, adopted the City of
Carmel Employee Health Benefit Plan (the "Plan ") effective February 1, 1992, and subsequently modified
the Plan by a full restatement effective January 1, 2004, and thirteen amendments to the restated Plan;
and
WHEREAS, Plan Sponsor wishes to amend the restated Plan; and
WHEREAS, authority to amend the Plan is granted therein.
NOW, THEREFORE, effective January 1, 2015, the Plan is amended as follows.
1. On Page 1, the group number is changed to 004007834.
2. On page 2, the name, address and telephone number for the third party administrator is changed as
follows:
Anthem Blue Cross and Blue Shield
220 Virginia Avenue
Indianapolis, IN 46204
800 - 331 -1476
3. The following is added to SCHEDULE OF MEDICAL BENEFITS (Plan A)
AUTISM SPECTRUM DISORDER
APPLIED BEHAVIORAL ANALYSIS 100%
Deductible Applies Yes
Weekly Maximum
100%
Yes
20 hours
4. The following is added to SCHEDULE OF MEDICAL BENEFITS (Plan 8)
AUTISM SPECTRUM DISORDER
APPLIED BEHAVIORAL ANALYSIS 80% 60%
Copay Applies No No
Deductible Applies Yes Yes
Weekly Maximum 20 hours
5. Under DESCRIPTION OF MEDICAL BENEFITS, Pervasive Development Disorders is amended to
read as follows:
Charges for the treatment of pervasive developmental disorders, limited to treatment prescribed by
the treating physician in accordance with a treatment plan. Pervasive developmental disorder means
a neurological condition, including neurodevelopment disorders, within the autism spectrum. The
treatment of pervasive developmental disorders includes applied behavioral analysis, which will be
paid as shown in the Schedule of Benefits. This benefit is subject to precertification rules.
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Health Plan Amendment
6. In the SCHEDULE OF DENTAL BENEFITS, the Maximum Calendar Year Benefit per Participant
(Non - orthodontia) and the Maximum Lifetime Benefit per Participant for Orthodontia are both
increased to $2,000.
7. Under SCHEDULE OF DENTAL BENEFITS, the Deductible Carryover section is deleted in its
entirety.
8. Under DEFINITIONS, the definition of Physician is amended to read as follows:
A legally qualified medical professional who is practicing within the scope of his license and holding a
degree of Doctor of Medicine (M.D.), Doctor of Psychology (Ph.D.), Doctor of Podiatric Medicine
(D.P.M.), Doctor of Osteopathic Medicine (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of
Optometry (O.D.), or Doctor of Chiropractic (D.C.). The term "physician" shall also be extended to
include Physician's Assistant (P.A.), Nurse Practitioner (N.P.), Nurse - Midwife, Clinical Nurse
Specialist (C.N.S.), Licensed Clinical Social Worker (L.C.S.W.), Orthoptic Technician, Registered
Occupational Therapist, Registered Physical Therapist, Licensed Speech Therapist or Licensed
Behavioral Analyst, provided they are licensed in the political jurisdiction where practicing, and
practicing within the scope of their license.
In all other respects the Plan remains unchanged.
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
(DT
James srainard,yresidinA Offic
Mary Ann urke, Board - Member
i
Lori Wats*7Bo rd Member
ATTEST:
a a Cordray, IAM erk- Treasurer
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