HomeMy WebLinkAboutBPW-10-03-12 PaperlessBoard of Public Works and Safety Meeting
AGENDA
Wednesday, October 3, 2012 – 10:00 a.m.
Council Chambers City Hall One Civic Square
MEETING CALLED TO ORDER
1. MINUTES
a. Minutes from the August 2, 2012 Special Meeting
b. Minutes from the September 19, 2012 Regular Meeting
2. PERFORMANCE RELEASES
a. Resolution No. BPW-10-03-12-01; Roberts Camera-Old Meridian; Stormwater
Post Construction; Steve Shaver, Buckingham Company
b. Resolution No. BPW-10-03-12-03; Village of West Clay, Block E-Regent Building-
Erosion Control; Keith Lash, Brenwick
c. Resolution No. BPW-10-03-12-05; Village of West Clay; Copeland Building;
CVS/Moultrie Street; Erosion Control; Keith Lash, Brenwick
d. Resolution No. BPW-10-03-12-06; Legacy Master Infrastructure Phase 2; Erosion
Control; Stormwater Construction; Tim Walter, Platinum Properties
e. Resolution No. BPW-10-03-12-07; Legacy Master Infrastructure Phase 2;
Stormwater Post Construction; Tim Walter, Platinum Properties
3. CONTRACTS
a. Indiana Department of Transportation; Report of Contract Final Inspection and
Recommendation for Acceptance; Hazel Dell Parkway Resurfacing; Mike
McBride, City Engineer
b. Request for Purchase of Goods and Services; Additional Service #40; Crossroad
Engineers; ($35,000.00); On Call Consulting; Mike McBride, City Engineer
c. Request for Purchase of Goods and Services; Additional Service #41; Crossroad
Engineers; ($12,500.00); 136th Street Culvert West of Ditch- Survey and Design;
Mike McBride, City Engineer
d. Request for Purchase of Goods and Services; Bartlett Tree Service; ($23,000.00);
Tree Removal and Maintenance; Mike Hollibaugh, Director of the Department of
Community Services
e. Request for Purchase of Goods and Services; Additional Service #1; EA Outdoor
Services; ($10,450.00); Roundabout Maintenance; Dave Huffman, Street
Commissioner
f. Request for Purchase of Goods and Services; JEM Blasting; ($32,904.00); Four
Clarifiers Sandblast; John Duffy, Director of the Department of Utilities
g. Request for Purchase of Goods and Services; E&B Paving; ($770,720.00); Street
Paving; Dave Huffman, Street Commissioner
h. Request for Purchase of Goods and Services; Municipal Emergency Services;
($590,534.48); Chief Keith Smith, Carmel Fire Department
4. USE OF CITY FACILITIES/STREET
a. Request to Gazebo and Common Areas; Gazebo Concerts; Wednesday; Various
dates; Carmel Fountain Square Committee
b. Request to Use City Streets; Artomobilia; Saturday, August 24, 2013; 6:00 pm to
9:00 pm; Carmel Redevelopment Commission
c. Request to Use City Streets; Oktoberfest; Friday, October 26, 2012; 6:00 pm to
11:30 pm; Carmel City Center
d. Request to Use City Streets; Run; October 27, 2012; 9:00 am to 10:00 am; Carmel
Education Foundation
e. Request to Use City Streets; Run; Saturday, October 13, 2012; 8:00 am to 10:00
am; Carmel Lions Club
f. Request to Use City Streets; Run/Walk; Sunday, October 14, 2012; Hamilton
County Crop Hunger Walk
5. OTHER
a. TABLED: Request for Dedication of Streets; Traditions on the Monon; Robert
Potokar, HOA Traditions on the Monon
b. Continued: Appeal hearing Dr. Thomas and Mrs. JoAnn Trancik – 14300
Oakbrook Court
c. Request for Stormwater Technical Standards Variance; 10240 Ditch Road; Mark
Thorpe, Schneider Corporation
d. Request for Variance; Improvements of Right of way; Trails at Avian Glen; Cindy
Armour
e. Request for Dedication of Right of Way; 116th and Rangeline; Rick Radabuagh, Kite
Realty Group
f. Request for Secondary Plat Approval; Bennett Technology Park Block “A”;
Ashton Fritz, Beam, Longest and Neff
g. Resolution BPW-10-03-12-02; A Resolution of the City of Carmel Board of Public
Works and Safety Setting the 2013 City and Participant Contribution Rates for the
Employee Health Benefit Plan; Barbara Lamb, Human Resource Director
h. Resolution BPW-10-03-12-04; A Resolution of the City of Carmel Board of Public
Works and Safety Authorizing Wellness Expense to be Paid from Medical Escrow
Fund; Barbara Lamb, Human Resource Director
i. Request for Approval of the 12th Amendment of the Employee Health Benefit
Plan; Barbara Lamb, Human Resource Director
6. ADJOURNMENT
BOARD OF PUBLIC WORKS & SAFETY MEETING
MINUTES
WEDNESDAY, SEPTEMBER 19, 2012 –10:00 A.M.
COUNCIL CHAMBERS / CITY HALL / ONE CIVIC SQUARE
MEETING CALLED TO ORDER
Board Member Burke called the meeting to order at 10:05 a.m.
MEMBERS PRESENT
Board Member; Mary Ann Burke and Lori Watson, Deputy Clerk; Sandy Johnson
MINUTES
Minutes for the September 5, 2012 Regular Meeting were approved 2-0.
BID/QUOTES OPENINGS AND AWARDS
Bid Opening for the Main Street Patio Seating Modification: Board Member Burke opened and read
the bids aloud;
Company Amount
Yardberry Landscape $29,229.30
Rieth-Riley $31,500.00
Calumet $44,785.00
Gibraltar $19,252.00
The bids were given to Mike McBride, City Engineer for review and recommendation.
Bid Opening for the Hunter Creek Lighting Project: Board Member Burke opened and read the bids
aloud;
Company Amount
Martell Electric $222,800
R&m Electric $190,000.00
Morphey Construction $289,000.00
The bids were given to Mike McBride, City Engineer for review and recommendation.
Bid Opening for the 106th Street Pump Station Improvements: Board Member Burke opened and read
the bids aloud;
Company Amount
M.K. Betts $1,077,000.00
Martell $1,437,000.00
James Babcock $1,302,000.00
Thieneman Construction $1,127,000.00
The bids were given to John Duffy, Director of the Department of Utilities for review and
recommendation.
PERFORMANCE RELEASES
Resolution No. BPW-09-19-12-01; Guilford Condos; Water Line Installation and Sanitary Sewer Main
Install; Board Member Burke moved to approve. Board Member Watson seconded. Request approved
2-0.
CONTRACTS
Request for Purchase of Goods and Services; Gridlock Traffic Systems; ($39,804.34); Street Striping;
Board Member Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request for Purchase of Goods and Services; Additional Service #6; United Consulting; ($89,400.00);
Illinois Street Environmental Mitigation Design; Board Member Burke moved to approve. Board
Member Watson seconded. Request approved 2-0.
Request for Purchase of Goods and Services; Additional Service #39; Crossroad Engineers;
($86,600.00); Illinois Street Right of Way Services; Board Member Burke moved to approve. Board
Member Watson seconded. Request approved 2-0.
Request for Acceptance of Contract Final Inspection and Recommendation; Street Lighting and
Signage Improvements; Board Member Burke moved to approve. Board Member Watson seconded.
Request approved 2-0.
USE OF CITY FACILITIES/STREETS
Request to City Streets; Live Broadcast; Thursday, October 4, 2012; 10:30 a.m. to 7:30 p.m.; Board
Member Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request to Use Council Chambers; Meeting; Thursday, October 18, 2012; 6:00 p.m. to 9:30 p.m.;
Board Member Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request to Use Council Chambers; Meeting; Various Dates; Board Member Burke moved to approve.
Board Member Watson seconded. Request approved 2-0.
Request to Use Council Chambers; Meeting; Wednesday, November 7, 2012; 6:30 p.m.; Board
Member Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request to Use Caucus Room; Meeting; Various Dates; Board Member Burke moved to approve.
Board Member Watson seconded. Request approved 2-0.
Request to Use Council Chambers; Meeting; Tuesday, December 4, 2012; 6:00 p.m. to 8:30 p.m.;
Board Member Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
OTHER
REMAINS TABLED: Request for Dedication of Streets; Traditions on the Monon
CONTINUED: Appeal hearing Dr. Thomas and Mrs. JoAnn Trancik – 14300 Oakbrook Court; The
hearing started at 10:28 a.m.; Testimony began. A Court Reporter was present to record proceedings.
Appeal Hearing ended at 11:15 a.m. – No conclusion was reached. To be continued at a later date
Request for Stormwater Technical Standards Variance; Olive Garden Restaurant; 10206 Michigan
Road; Justin Muller, Board Member Burke moved to approve. Board Member Watson seconded.
Request approved 2-0.
Request for Stormwater Technical Standards Variance; The Centre Retail at 116th; Board Member
Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request for Stormwater Technical Standards Variance; Village of West Clay, Section 10010-C; Board
Member Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request for Variance; Fence in Easement; 2377 Finchley Road; Village of West Clay; Board Member
Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request for Curb Cut; 1839 Hourglass Drive; Village of West Clay Section 12002-B; Board Member
Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request for Easement; Waterline; Board Member Burke moved to approve. Board Member Watson
seconded. Request approved 2-0.
Request for Easement; Waterline; 2008030541; West Carmel Marketplace Owners Association; Board
Member Burke moved to approve. Board Member Watson seconded. Request approved 2-0.
Request for Easement; Waterline; 2008030540; West Carmel Marketplace LLC; Board Member Burke
moved to approve. Board Member Watson seconded. Request approved 2-0.
Request for Easement; Waterline; Fifth Third Bank; Board Member Burke moved to approve. Board
Member Watson seconded. Request approved 2-0.
ADJOURNMENT
Board Member Burke adjourned the meeting at 10:22 a.m.
_____________________________________
Diana L. Cordray, IAMC
Clerk-Treasurer
Approved
____________________________________
Mayor James Brainard
ATTEST:
___________________________________
Diana L. Cordray, IAMC
Clerk-Treasurer
RESOLUTION BPW-10-03-12-02
A RESOLUTION SETTING 2013 CITY AND PARTICIPANT CONTRIBUTION RATES
FOR THE CITY OF CARMEL EMPLOYEE HEALTH BENEFIT PLAN
WHEREAS, the City of Carmel operates the City of Carmel Employee Health
Benefit Plan (the “Plan”) to provide medical and dental benefits for its employees and
retirees; and
WHEREAS, the Board of Public Works and Safety, as Plan Administrator, is
responsible for ensuring adequate current and reserve funding for the Plan; and
WHEREAS, the primary source of revenue for the Plan consists of bi-weekly
employer and participant contributions; and
WHEREAS, it is imperative for Plan revenues to correspond with anticipated
expenses; and
WHEREAS, the City wishes to reward participation in sponsored activities that
promote individual and group wellness, encourage employees to consider a consumer-driven
health plan option and incent employee’s spouses to elect coverage through their own
employers.
NOW, THEREFORE, BE IT RESOLVED by the Carmel Board of Public Works and
Safety as follows:
Effective January 1, 2013, health insurance contribution rates for the City and for its Active
Employees will be as stated on Attachment A, for Common Council Members as stated on
Attachment B, for Retirees as stated on Attachment C and for COBRA participants as stated
on Attachment D, all incorporated herein by this reference.
BE IT FURTHER RESOLVED that the rates stated on Attachment A and Attachment
B shall be adjusted for participants of the City’s wellness program, as outlined below:
1. The City has established a wellness program to complement its insurance plan. The
program is open to all full-time Active Employees and Common Council Members.
2. Participation in the wellness program is voluntary; there is no penalty for opting out.
3. Effective January 1, 2013, any Active Employee or Common Council Member who met
wellness participation goals for every quarter in 2011 and every quarter in 2012 will be
eligible for a $20 reduction to the standard 2013 bi-weekly rates, as listed on Attachment
A or Attachment B, as applicable. This rate reduction will be in place as long as the
participant continues to meet quarterly goals.
4. Effective January 1, 2013, any Active Employee or Common Council Member who met
wellness participation goals for every quarter in 2012, but not in 2011, will be eligible for
a $15 reduction to the standard 2013 bi-weekly rates, as listed on Attachment A or
Attachment B, as applicable. This rate reduction will be in place as long as the
participant continues to meet quarterly goals.
5. Should a participant who is eligible for the incentive described under #3 or #4 above fail
to meet the established goal in any given quarter in 2013, he or she will not be eligible for
a reduction until such time as he or she once again satisfies quarterly plan requirements.
At that time the employee will be eligible for the rate reduction described in #6 below.
6. Except as described in #3 and #4 above, any Active Employee or Common Council
Member who participates in the 2013 wellness program shall be eligible for a $10
reduction to the standard 2013 bi-weekly rates, as listed on Attachment A or Attachment
B, as applicable, as long as the participant continues to meet quarterly goals.
7. Active Employees and Common Council Members who do not participate in the wellness
program, or who do not continue to meet quarterly goals, will not be eligible for a rate
reduction. They will pay the standard rates listed on Attachment A or Attachment B, as
applicable.
BE IT FURTHER RESOLVED that participants who meet the stated requirements will
be eligible for the incentives described below:
1. The City will make a bi-weekly contribution into the Health Savings Account (HSA) of
an Active Employee or Common Council Member who elects to enroll in Plan A, in the
following amounts:
a. $15.39 for employee only coverage
b. $23.08 for employee/spouse or employee child(ren) coverage
c. $30.77 for family coverage
A Retiree who elects to enroll in Plan A shall receive an equivalent amount by check,
half in February and half in July.
The HSA contribution amount will change if and when the participant’s level of coverage
changes, and contributions will cease if coverage is cancelled or, in the case of an Active
Employee or a Common Council Member, if the employment relationship is terminated.
2. The City will make a contribution into the Health Savings Account (HSA) or give a
premium credit, as described below, for each Active Employee or Common Council
Member whose: (a) spouse is enrolled in a City plan in 2012; (b) spouse is eligible for
employer coverage through his or her own job; and (c) spouse elects his or her employer
coverage rather than City of Carmel coverage in 2013. The employee must provide
documentation of the other coverage and verify that he or she is not legally separated and
has not filed for divorce from the spouse to be eligible for this incentive.
a. For a participant enrolled in Plan A, a bi-weekly contribution into the Health Savings
Account (HSA) in the amount of $70.75 if the spouse opts out of both the City’s
medical and dental plan, or $65.00 if the spouse opts out of the City’s medical plan
but enrolls in the City’s dental plan. There will be no contribution if the spouse opts
out of the City’s dental plan only.
b. For a participant enrolled in Plan B, a bi-weekly premium credit in the amount of
$65.00 for medical insurance plus $5.75 for dental insurance if the spouse opts out of
both. If the spouse opts out of the City’s medical plan, but enrolls in the City’s dental
plan, the credit will be $65.00. There will be no premium credit if the spouse opts out
of the City’s dental plan only.
The HSA contribution or premium credit will cease if the spouse re-enrolls in the City
plan, if the Active Employee or Common Council Member cancels his or her coverage or
if the employment relationship is terminated.
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
_________________________________ ________________________
James Brainard, Presiding Officer Date
_________________________________ ________________________
Mary Ann Burke, Board Member Date
_________________________________ ________________________
Lori Watson, Board Member Date
ATTEST:
_________________________________ ________________________
Diana Cordray, IAMC, Clerk-Treasurer Date
Attachment A
ACTIVE EMPLOYEES
2013 BI-WEEKLY HEALTH INSURANCE RATES
SURCHARGES AND DISCOUNTS MAY BE APPLIED TO THE RATES BELOW
Plan A (HDHP)
Total Premium
City Portion
City %
Employee Portion
Employee %
Employee Only $278.00
$236.00
85%
$42.00
15%
Employee/Spouse $642.00
$546.00
85%
$96.00
15%
Employee/Child(ren) $590.00
$502.00
85%
$88.00
15%
Employee/Family $964.00
$819.00
85%
$145.00
15%
Plan B (PPO)
Total Premium
City Portion
City %
Employee Portion
Employee %
Employee Only $327.00
$262.00
80%
$65.00
20%
Employee/Spouse $755.00
$607.00
80%
$148.00
20%
Employee/Child(ren) $694.00
$558.00
80%
$136.00
20%
Employee/Family $1,134.00
$912.00
80%
$222.00
20%
Dental
Total Premium
City Portion
City %
Employee Portion
Employee %
Employee Only $23.00
$17.25
75%
$5.75
25%
Employee/Spouse $43.00
$32.25
75%
$10.75
25%
Employee/Child(ren) $40.00
$30.00
75%
$10.00
25%
Employee/Family $60.00
$45.00
75%
$15.00
25%
Attachment B
COMMON COUNCIL MEMBERS
2013 BI-WEEKLY HEALTH INSURANCE RATES
SURCHARGES AND DISCOUNTS MAY BE APPLIED TO THE RATES BELOW
Plan A (HDHP)
Total Premium
City Portion
City %
Employee Portion
Employee %
Employee Only $278.00
$208.50
75%
$69.50
25%
Employee/Spouse $642.00
$481.50
75%
$160.50
25%
Employee/Child(ren) $590.00
$442.50
75%
$147.50
25%
Employee/Family $964.00
$723.00
75%
$241.00
25%
Plan B (PPO) Plan B
Total Premium
City Portion
City %
Employee Portion
Employee %
Employee Only $327.00
$245.25
75%
$81.75
25%
Employee/Spouse $755.00
$566.25
75%
$188.75
25%
Employee/Child(ren) $694.00
$520.50
75%
$173.50
25%
Employee/Family $1,134.00
$850.50
75%
$283.50
25%
Dental Dental
Total Premium
City Portion
City %
Employee Portion
Employee %
Employee Only $23.00
$17.25
75%
$5.75
25%
Employee/Spouse $43.00
$32.25
75%
$10.75
25%
Employee/Child(ren) $40.00
$30.00
75%
$10.00
25%
Employee/Family $60.00
$45.00
75%
$15.00
25%
Attachment C
RETIREES
2013 MONTHLY HEALTH INSURANCE RATES
SURCHARGES AND DISCOUNTS MAY BE APPLIED TO THE RATES BELOW
Plan A (HDHP)
Total Premium
City Portion
City %
Employee Portion
Employee %
Retiree Only $603.00
$0.00
0%
$603.00
100%
Retiree/Spouse $1,391.00
$0.00
0%
$1,391.00
100%
Retiree/Child(ren) $1,279.00
$0.00
0%
$1,279.00
100%
Retiree/Family $2,089.00
$0.00
0%
$2,089.00
100%
Plan B (PPO)
Total Premium
City Portion
City %
Employee Portion
Employee %
Retiree Only $709.00
$0.00
0%
$709.00
100%
Retiree/Spouse $1,636.00
$0.00
0%
$1,636.00
100%
Retiree/Child(ren) $1,504.00
$0.00
0%
$1,504.00
100%
Retiree/Family $2,457.00
$0.00
0%
$2,457.00
100%
Dental
Total Premium
City Portion
City %
Employee Portion
Employee %
Retiree Only $50.00
$0.00
0%
$50.00
100%
Retiree/Spouse $94.00
$0.00
0%
$94.00
100%
Retiree/Child(ren) $87.00
$0.00
0%
$87.00
100%
Retiree/Family $130.00
$0.00
0%
$130.00
100%
Attachment D
COBRA
2013 MONTHLY HEALTH INSURANCE RATES
SURCHARGES AND DISCOUNTS MAY BE APPLIED TO THE RATES BELOW
Plan A (HDHP)
Total Premium
City Portion
City %
Employee Portion
Employee %
Retiree Only $616.00
$0.00
0%
$616.00
100%
Retiree/Spouse $1,419.00
$0.00
0%
$1,419.00
100%
Retiree/Child(ren) $1,305.00
$0.00
0%
$1,305.00
100%
Retiree/Family $2,131.00
$0.00
0%
$2,131.00
100%
Plan B (PPO)
Total Premium
City Portion
City %
Employee Portion
Employee %
Retiree Only $724.00
$0.00
0%
$724.00
100%
Retiree/Spouse $1,669.00
$0.00
0%
$1,669.00
100%
Retiree/Child(ren) $1,535.00
$0.00
0%
$1,535.00
100%
Retiree/Family $2,507.00
$0.00
0%
$2,507.00
100%
Dental
Total Premium
City Portion
City %
Employee Portion
Employee %
Retiree Only $51.00
$0.00
0%
$51.00
100%
Retiree/Spouse $96.00
$0.00
0%
$96.00
100%
Retiree/Child(ren) $89.00
$0.00
0%
$89.00
100%
Retiree/Family $133.00
$0.00
0%
$133.00
100%
RESOLUTION BPW-10-03-12-04
A RESOLUTION AUTHORIZING WELLNESS EXPENSES
TO BE PAID FROM THE MEDICAL ESCROW FUND
WHEREAS, Ordinance D-1048, passed by the Common Council of the City of Carmel,
Indiana, on February 21, 1994, established the City of Carmel Medical Escrow Fund, to be used
to accumulate employee and employer insurance premium payments for qualified City employees
and Parks Department employees, and to pay benefits and administrative costs related to the City
of Carmel Employee Health Benefit Plan; and
WHEREAS, D-1048 authorizes excess funds in the Medical Escrow Fund to be utilized
to provide additional benefits for full-time City employees, by resolution of the Board of Public
Works and Safety; and
WHEREAS, the success of the City’s Wellness Program is closely associated with the
viability of the medical insurance plan, and is expected to have a significant positive impact on
employee quality of life and on the Medical Escrow Fund; and
WHEREAS, the costs of the Wellness Program can be paid from the Medical Escrow
Fund without affecting employer or employee insurance rates.
NOW, THEREFORE, BE IT RESOLVED that the Clerk-Treasurer is authorized and
directed to pay all properly documented wellness expenses submitted to the Medical Escrow
Fund, up to a maximum of $45,000.00 in 2013 and in each year thereafter, unless and until that
limit is amended by the Board of Public Works and Safety.
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
_________________________________ ________________________
James Brainard, Presiding Officer Date
_________________________________ ________________________
Mary Ann Burke, Board Member Date
_________________________________ ________________________
Lori Watson, Board Member Date
ATTEST:
_________________________________ ________________________
Diana Cordray, IAMC, Clerk-Treasurer Date
Health Plan Amendment XII
1
TWELFTH 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 eleven
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, 2013, the Plan is amended as follows.
I. The section entitled SCHEDULE OF MEDICAL BENEFITS (PLAN A) is added to read as
follows:
SCHEDULE OF MEDICAL BENEFITS (PLAN A)
(see Description of Medical Benefits for detailed explanation of the following provisions)
LIFETIME MAXIMUM BENEFITS:
Inpatient/Outpatient Hospice Care (combined) 365 days/365 visits
Treatment of Temporomandibular Joint Disorder $1,000
Laser Eye Surgery $250 per eye
BENEFIT PERIOD: Calendar Year (unless otherwise stated)
CALENDAR YEAR DEDUCTIBLES:
Preferred Non-Preferred
Individual Deductible $2,000 $4,000
Family Deductible $4,000 $8,000
The following items do not apply toward satisfaction of the calendar year deductible:
charges in excess of reasonable and customary, except as otherwise stated herein;
penalties incurred for failing to obtain precertification/utilization review; and
expenses for services and supplies not eligible under this Plan.
When the participant utilizes BOTH preferred and non-preferred providers during the calendar
year, the maximum year deductible will not exceed the non-preferred provider deductible.
COINSURANCE PERCENTAGES:
Preferred Non-Preferred
Individual Coinsurance
Percentage
100% 60%
Family Coinsurance Percentage 100% 60%
Health Plan Amendment XII
2
OUT-OF-POCKET MAXIMUMS:
Preferred Non-Preferred
Individual $2,000 $4,000
Family $4,000 $8,000
The following items do not apply toward the calendar year out-of-pocket expense maximum:
charges in excess of reasonable and customary, except as otherwise stated herein;
penalties incurred for failing to obtain precertification/utilization review;
expenses for services and supplies not eligible under this Plan; and
charges that exceed Plan limits in dollar amounts or visits, as stated herein.
When the participant utilizes BOTH preferred and non-preferred providers during the calendar
year, the maximum out-of-pocket expense will not exceed the non-preferred provider maximum.
BENEFIT LIMITS FOR ELIGIBLE EXPENSES:
Preferred Provider benefits will not be subject to “reasonable and customary”.
PREFERRED BENEFIT NON-PREFERRED BENEFIT
PHYSICIAN’S CHARGES
FOR OFFICE VISIT
100% 60%
Deductible Applies: Yes Yes
PHYSICIAN’S CHARGES
FOR SERVICES
RENDERED AT TIME OF
OFFICE VISIT
100% 60%
Deductible Applies:
Yes Yes
PHYSICIAN’S CHARGES
FOR SERVICES
RENDERED IN ABSENCE
OF OFFICE VISIT
100% 60%
Deductible Applies:
Yes Yes
ALLERGY SHOTS 100% 60%
Deductible Applies:
Yes Yes
PHYSICIAN HOSPITAL
VISITS
100% 60%
Deductible Applies:
Yes Yes
RETAIL HEALTH CLINIC
VISIT
100% 60%
Deductible Applies: Yes Yes
EMPLOYEE HEALTH
CLINIC VISIT
Deductible Applies:
100%
No
N/A
N/A
Health Plan Amendment XII
3
PREFERRED BENEFIT NON-PREFERRED BENEFIT
SURGEON OR
ANESTHESIOLOGIST
CHARGES
100%
60%
Deductible Applies: Yes Yes
AMBULANCE CHARGES 100% 60%
Deductible Applies:
Yes Yes
DURABLE MEDICAL
EQUIPMENT
100% 60%
Deductible Applies: Yes Yes
EMERGENCY ROOM
FACILITY
100% 100%
Deductible Applies:
Yes Yes (preferred deductible)
EMERGENCY ROOM
PHYSICIAN
100% 100%
Deductible Applies: Yes Yes (preferred deductible)
HEARING EXAM
(See Preventive Services)
HEARING AIDS 100% 60%
Deductible Applies: Yes Yes
Maximum per 60-Month Period .............................................................................. $2,000
HOME HEALTH CARE 100% 60%
Deductible Applies: Yes Yes
Calendar Year Maximum .................................................................................... 100 visits
INPATIENT HOSPICE
CARE
100% 60%
Deductible Applies: Yes Yes
Lifetime Maximum ......................................................................... 365 days or 365 visits
OUTPATIENT HOSPICE
CARE
100% 60%
Deductible Applies: Yes Yes
Lifetime Maximum ......................................................................... 365 visits or 365 days
BEREAVEMENT
COUNSELING
100% 60%
Deductible Applies: Yes Yes
Per Death Maximum ............................... 5 visits within six months from date of death
INPATIENT & INTENSIVE
CARE FACILITY CHARGES
100% 60%
Deductible Applies: Yes Yes
Health Plan Amendment XII
4
PREFERRED BENEFIT NON-PREFERRED BENEFIT
LASER EYE SURGERY 100% 60%
Deductible Applies: Yes Yes
Lifetime Maximum ........................................................................................ $250 per eye
CHIROPRACTIC CARE 100% 60%
Deductible Applies: Yes Yes
Calendar Year Maximum ...................................................................................... 40 visits
ORTHOTIC DEVICES 100% 60%
Deductible Applies:
Yes Yes
OUTPATIENT SURGICAL
FACILITY
100% 60%
Deductible Applies:
Yes Yes
PATHOLOGY AND/OR
LABORATORY TESTS
100% 60%
Deductible Applies:
Yes Yes
PRESCRIPTION DRUGS: 100% 60%
Deductible Applies: Yes Yes
Maximum 90-day supply per prescription.
RADIOLOGY TESTS
100%
60%
Deductible Applies: Yes Yes
PREVENTIVE SERVICES 100% 60%
Deductible Applies: No Yes
Preventive Care Services as required under the Patient Protection and Affordable Care Act
(PPACA). See PREVENTIVE SERVICES under DESCRIPTION OF MEDICAL SERVICES
for more detailed information.
These services include routine or periodic exams (including school enrollment exams, but
excluding sports exams), immunizations, pelvic exam s, pap tests, labs or x-rays, annual
dilated eye examinations for diabetic retinopath y, routine vision screenings for disease or
abnormality, routing hearing screenings, routine mammograms, routine PSA tests, bone
density tests, routine colorectal cancer examination s and related lab tests and routine
colonoscopies.
Also included under preventive services are costs for physician-supervised tobacco-cessation
and hospital-sponsored non-surgical weight loss programs, under the condition that approval
of the program is given by the Plan Administrator prior to the date the participant starts the
program. Participants are responsible for the up-front cost of such a program, and will be
reimbursed 100% of that cost upon confirmation of successful completion.
PREVENTIVE SERVICES FOR WOMEN 100% 60%
Deductible Applies: No Yes
Preventive Services for Women as required under the Patient Protection and Affordable Care
Act (PPACA). See PREVENTIVE SERVICES under DESCRIPTION OF MEDICAL
SERVICES for more detailed information.
Health Plan Amendment XII
5
PREFERRED BENEFIT NON-PREFERRED BENEFIT
WELLNESS SCREENING* 100% N/A
Deductible Applies: No N/A
*This benefit applies to screening provided through the City’s Wellness program.
SKILLED NURSING
FACILITY
100% 60%
Deductible Applies: Yes Yes
Calendar Year Maximum ....................................................................................... 90 days
THERAPY (PHYSICAL,
OCCUPATIONAL, SPEECH
AND OTHER)
100% 60%
Deductible Applies:
Yes Yes
TREATMENT OF
TEMPOROMANDIBULAR
JOINT DISORDER (TMJ)
100% 60%
Deductible Applies: Yes Yes
Lifetime Maximum ................................................................................................... $1,000
WEIGHT LOSS
TREATMENT (SURGICAL)
100% 60%
Deductible Applies: Yes Yes
Surgical treatment for morbid obesity, as defined under Description of Medical Benefits, must
be non-experimental. Participant must have been involved in a physician-supervised, non-
surgical weight loss program for at least eighteen (18) consecutive months within thirty (30)
months immediately preceding the surgery, or must participate in an intensive non-surgical
weight loss program approved by the Plan Administrator.
WEIGHT LOSS TREATMENT (NON-SURGICAL)
(See Preventive Services)
TOBACCO-CESSATION TREATMENT
(See Preventive Services)
INPATIENT PSYCHIATRIC &
SUBSTANCE ABUSE CARE
100% 60%
Deductible Applies: Yes Yes
OUTPATIENT
PSYCHIATRIC &
SUBSTANCE ABUSE
CARE
100% 60%
Deductible Applies: Yes Yes
II. The section entitled SCHEDULE OF MEDICAL BENEFITS (PLAN B) is amended to read as
follows:
Health Plan Amendment XII
6
SCHEDULE OF MEDICAL BENEFITS (PLAN B)
(see Description of Medical Benefits for detailed explanation of the following provisions)
LIFETIME MAXIMUM BENEFITS:
Inpatient/Outpatient Hospice Care (combined) 365 days/365 visits
Treatment of Temporomandibular Joint Disorder $1,000
Laser Eye Surgery $250 per eye
BENEFIT PERIOD: Calendar Year (unless otherwise stated)
OFFICE VISIT COPAYS:
Preferred Non-Preferred
Physician Office Visit Copay $25 Deductible and Coinsurance
CALENDAR YEAR DEDUCTIBLES:
Preferred Non-Preferred
Individual Deductible $500 $1,000
Family Deductible $1,000 $2,000
The following items do not apply toward satisfaction of the calendar year deductible:
copays;
charges in excess of reasonable and customary, except as otherwise stated herein;
penalties incurred for failing to obtain precertification/utilization review; and
expenses for services and supplies not eligible under this Plan.
When a participant utilizes BOTH preferred and non-preferred providers during the calendar
year, the maximum calendar year deductible will not exceed the non-preferred provider
deductible.
DEDUCTIBLE CARRYOVER:
Eligible expenses incurred during the last three (3) months of a calendar year that are used to
satisfy all or part of the deductible for that year will also count towards that participant’s individual
or family deductible for the next calendar year.
COINSURANCE PERCENTAGES:
Preferred Non-Preferred
Individual Coinsurance
Percentage
80% 60%
Family Coinsurance Percentage 80% 60%
OUT-OF-POCKET MAXIMUMS:
Preferred Non-Preferred
Individual $1,000 $2,000
Family $2,000 $4,000
The out-of-pocket maximum includes deductibles and coinsurance. The following items do not
apply toward the calendar year out-of-pocket expense maximum:
Health Plan Amendment XII
7
copays;
charges in excess of reasonable and customary, except as otherwise stated herein;
penalties incurred for failing to obtain precertification/utilization review;
expenses for services and supplies not eligible under this Plan; and
charges that exceed Plan limits in dollar amounts or visits, as stated herein.
When the participant utilizes BOTH preferred and non-preferred providers during the calendar
year, the maximum out-of-pocket expense will not exceed the non-preferred provider maximum.
BENEFIT LIMITS FOR ELIGIBLE EXPENSES:
Preferred Provider benefits will not be subject to “reasonable and customary”.
PREFERRED BENEFIT NON-PREFERRED BENEFIT
PHYSICIAN’S CHARGES
FOR OFFICE VISIT
100% 60%
Copay Applies: Yes ($25 per visit) No
Deductible Applies: No Yes
PHYSICIAN’S CHARGES
FOR SERVICES
RENDERED AT TIME OF
OFFICE VISIT
80% 60%
Copay Applies: No No
Deductible Applies:
Yes Yes
PHYSICIAN’S CHARGES
FOR SERVICES
RENDERED IN ABSENCE
OF OFFICE VISIT
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
ALLERGY SHOTS
100%
60%
Copay Applies: Yes ($10 per injection) No
Deductible Applies:
No Yes
PHYSICIAN HOSPITAL
VISITS
80% 60%
Copay Applies: No No
Deductible Applies:
Yes Yes
RETAIL HEALTH CLINIC
VISIT
100% 60%
Copay Applies: Yes ($15 per visit) No
Deductible Applies: No Yes
EMPLOYEE HEALTH
CLINIC VISIT
Copay Applies:
Deductible Applies:
100%
No
No
N/A
N/A
N/A
Health Plan Amendment XII
8
PREFERRED BENEFIT NON-PREFERRED BENEFIT
SURGEON OR
ANESTHESIOLOGIST
CHARGES
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
AMBULANCE CHARGES 80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
DURABLE MEDICAL
EQUIPMENT
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
EMERGENCY ROOM
FACILITY
100% 100%
Copay Applies: Yes ($100 per visit) Yes ($100 per visit)
Deductible Applies:
No No
EMERGENCY ROOM
PHYSICIAN
Copay Applies:
Deductible Applies:
100%
Yes ($50 per visit)
No
100%
Yes ($50 per visit)
No
HEARING EXAM
(See Preventive Services)
HEARING AIDS 80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
Maximum per 60-Month Period ............................................................................. $2,000
HOME HEALTH CARE 80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
Calendar Year Maximum .................................................................................. 100 visits
INPATIENT HOSPICE
CARE
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
Lifetime Maximum ........................................................................ 365 days or 365 visits
OUTPATIENT HOSPICE
CARE
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
Lifetime Maximum ........................................................................ 365 visits or 365 days
Health Plan Amendment XII
9
PREFERRED BENEFIT NON-PREFERRED BENEFIT
BEREAVEMENT
COUNSELING
80%
60%
Copay Applies: No No
Deductible Applies: Yes Yes
Per Death Maximum ................................ 5 visits within six months from date of death
INPATIENT & INTENSIVE
CARE FACILITY CHARGES
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
LASER EYE SURGERY 80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
Lifetime Maximum ........................................................................................ $250 per eye
CHIROPRACTIC CARE
100%
60%
Copay Applies: Yes ($25 per visit) No
Deductible Applies: No Yes
Calendar Year Maximum ....................................................................................... 40 visits
ORTHOTIC DEVICES 80% 60%
Copay Applies: No No
Deductible Applies:
Yes Yes
OUTPATIENT SURGICAL
FACILITY
80% 60%
Copay Applies: No No
Deductible Applies:
Yes Yes
PATHOLOGY AND/OR
LABORATORY TESTS
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
PRESCRIPTION DRUGS: 100% 60%
Copay Applies: Yes ($10, $30 or $50 per
30-day supply,
or portion thereof)
No
Deductible Applies: No Yes
Maximum 90-day supply per prescription.
RADIOLOGY TESTS 80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
PREVENTIVE SERVICES 100% 60%
Copay Applies: No No
Deductible Applies: No Yes
Preventive Care Services as required under the Patient Protection and Affordable Care Act
(PPACA). See PREVENTIVE SERVICES under DESCRIPTION OF MEDICAL SERVICES for
more detailed information.
Health Plan Amendment XII
10
These services include routine or periodic exams (including school enrollment exams, but
excluding sports exams), immunizations, pelvic exams, pap tests, labs or x-rays, annual
dilated eye examinations for diabetic retinopathy, routine vision screenings for disease or
abnormality, routing hearing screenings, routine mammograms, routine PSA tests, bone
density tests, routine colorectal cancer examinations and related lab tests and routine
colonoscopies.
Also included under preventive services are costs for physician-supervised tobacco-
cessation and hospital-sponsored non-surgical weight loss programs, under the condition
that approval of the program is given by the Plan Administrator prior to the date the
participant starts the program. Participants are responsible for the up-front cost of such a
program, and will be reimbursed 100% of that cost upon confirmation of successful
completion.
PREFERRED BENEFIT NON-PREFERRED BENEFIT
PREVENTIVE SERVICES FOR WOMEN 100% 60%
Copay Applies: No No
Deductible Applies: No Yes
Preventive Services for Women as required under the Patient Protection and Affordable
Care Act (PPACA). See PREVENTIVE SERVICES under DESCRIPTION OF MEDICAL
SERVICES for more detailed information.
WELLNESS SCREENING* 100% 100%
Copay Applies: No N/A
Deductible Applies: No N/A
*This benefit applies only to screening provided through the City’s Wellness program.
SKILLED NURSING
FACILITY
80%
60%
Copay Applies: No No
Deductible Applies: Yes Yes
Calendar Year Maximum .............................................................................. 90 days
THERAPY (PHYSICAL,
OCCUPATIONAL,
SPEECH AND OTHER)
80% 60%
Copay Applies: No No
Deductible Applies:
Yes Yes
TREATMENT OF
TEMPOROMANDIBULAR
JOINT DISORDER (TMJ)
80%
60%
Copay Applies: No No
Deductible Applies: Yes Yes
Lifetime Maximum .................................................................................................. $1,000
WEIGHT LOSS
TREATMENT (SURGICAL)
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
Health Plan Amendment XII
11
Surgical treatment for morbid obesity, as defined under Description of Medical Benefits, must
be non-experimental. Participant must have been involved in a physician-supervised, non-
surgical weight loss program for at least eighteen (18) consecutive months within thirty (30)
months immediately preceding the surgery, or must participate in an intensive non -surgical
weight loss program approved by the Plan Administrator.
WEIGHT LOSS TREATMENT (NON-SURGICAL)
(See Preventive Services)
TOBACCO-CESSATION TREATMENT
(See Preventive Services)
PREFERRED BENEFIT NON-PREFERRED BENEFIT
INPATIENT PSYCHIATRIC
& SUBSTANCE ABUSE
CARE
80% 60%
Copay Applies: No No
Deductible Applies: Yes Yes
OUTPATIENT
PSYCHIATRIC &
SUBSTANCE ABUSE
CARE
100% 60%
Copay Applies: Yes ($25 per visit) No
Deductible Applies: No Yes
III. The section entitled SCHEDULE OF MEDICAL BENEFITS (PLAN C) is deleted in its
entirety.
IV. Under DESCRIPTION OF MEDICAL BENEFITS, the section entitled WELLNESS is
changed to PREVENTIVE SERVICES and amended to read as follows:
PREVENTIVE SERVICES
Charges for preventive services as follows:
Preventive Care Services as required under the Patient Protection and Affordable Care Act
(PPACA) include the following:
1. Evidence-based items or services with an A or B rating recommended by the United
States Preventive Services Task Force;
2. Immunizations for routine use in children, adolescents or adults recommended by the
Advisory Committee on Immunization Practices of the Centers for Disease Control and
Prevention;
3. Evidence-informed preventive care and screenings provided for in comprehensive
guidelines supported by HRSA for women.
4. The complete list of recommendations and guidelines can be found at:
http://www.healthcare.gov/center/regulations/prevention/recommendations.html.
Services as shown above include routine or periodic exams (including school enrollment
exams, but excluding sports exams), immunizations, pelvic exams, pap tests, labs or x -rays,
annual dilated eye examinations for diabetic retinopathy, routine vision screenings for
disease or abnormality, routing hearing screenings, routine mammograms, rou tine PSA tests,
bone density tests, routine colorectal cancer examinations and related lab tests and routine
colonoscopies.
Health Plan Amendment XII
12
Also included under preventive services are costs for physician-supervised tobacco-cessation
and hospital-sponsored non-surgical weight loss programs, under the condition that approval
of the program is given by the Plan Administrator prior to the date the participant starts the
program. Participants are responsible for the up-front cost of such a program, and will be
reimbursed 100% of that cost upon confirmation of successful completion.
Charges for preventive services for women as follows:
1. Annual well-woman preventive care visit for adult women to obtain recommended age
and developmentally-appropriate services, including preconception and prenatal care
(additional visits are covered, if necessary, to obtain all recommended preventive
services based on risk factors and health status);
2. Gestational diabetes screening for women 24-28 weeks pregnant, and those at high risk
of developing gestational diabetes;
3. Human papillomavirus (HPV) DNA testing for women age 30 and older every three years,
regardless of pap smear results;
4. Annual counseling on sexually transmitted infections for sexually-active women;
5. Annual screening and counseling on human immunodeficiency virus (HIV) infections for
sexually-active women;
6. All FDA-approved contraceptive methods, sterilization procedures, patient education and
counseling, excluding abortifacient drugs. FDA-approved oral contraceptives will be
covered with no cost sharing when a generic (if available) is dispensed. If a participant
requests brand when generic is available, the participant will be responsible for the
applicable deductible (Plan A) or copay (Plan B).
7. Comprehensive lactation support and counseling from trained providers, as well as rental
fees for breastfeeding equipment for pregnant and postpartum women;
8. Screening and counseling for interpersonal and domestic violence.
V. Under MEDICARE the section entitled ACTIVE EMPLOYEES AND THEIR SPOUSES AGED
65 AND OLDER is amended to read as follows:
ACTIVE EMPLOYEES AND THEIR SPOUSES AGED 65 AND OVER
All health benefits to which a covered employee and covered spouse are entitled under the
Plan will be paid before and without regard to any payments that would be available under
Medicare, unless and until the employee or spouse declines in writing coverage for health
benefits under the Plan.
If the active employee or his spouse is enrolled in any part of Medicare, they cannot be enrolled
in Plan A.
If the active employee or his spouse retains Plan B as primary coverage, then Medicare will
supplement payments of this Plan.
If the active employee declines coverage under the Plan for health benefits, he and all of his
dependents will not be eligible for any health benefits under this Plan. If his dependent spouse
rejects coverage under the Plan for health benefits, the spouse will not be eligible for any health
benefits under this Plan.
VI. The section entitled SCHEDULE OF PRESCRIPTION DRUG BENEFITS is amended to read
as follows:
Health Plan Amendment XII
13
SCHEDULE OF PRESCRIPTION DRUG BENEFITS
(see Description of Prescription Drug Benefits for detailed explanation of the following
provisions)
PLAN A:
Participant pays 100% of all prescription charges until deductible is met; Plan pays 100% of all
eligible prescription expenses thereafter.
NOTE: There is no charge to participants for any prescribed generic FDA-approved oral
contraceptive.
PLAN B:
Pharmacy Copay:
(each prescription fill, see dispensing limitations)
Generic Formulary Drugs $10 per 30-day supply
(or portion thereof)
Brand Name Formulary Drugs $30 per 30-day supply
(or portion thereof)
Non-Formulary Drugs $50 per 30-day supply
(or portion thereof)
Covered Percentage after Copay 100%
Dispensing Provision: Up to a maximum of a 90-day supply
Prescription Drug Card copays are not eligible expenses under the medical Plan.
NOTE: There is no charge to participants for any prescribed generic FDA-approved oral
contraceptive.
Mail Order Copay:
(each prescription fill, see dispensing limitations)
Generic Formulary Drugs $20
Brand Name Formulary Drugs $60
Non-Formulary Drugs $100
Covered Percentage after Copay 100%
Dispensing Provision: Up to a maximum of a 90-day supply
Mail Order Program copays are not eligible expenses under the medical Plan.
VII. The section entitled PRESCRIPTION DRUG CARD PROGRAM is amended to read as
follows:
Health Plan Amendment XII
14
PRESCRIPTION DRUG CARD PROGRAM
Upon presentation of a valid identification card for this Plan, a participant may obtain medications
that are prescribed by a licensed physician from participating pharmacies. Alternatively,
maintenance medications may be obtained through a mail order program for convenience and
cost savings. For each prescription order and each refill, the program requires that the
participant pay the full cost before the deductible is met or no cost after the deductible is met
(Plan A), or the copayment (Plan B) for each generic or brand name drug shown in the
Schedule of Prescription Drug Benefits. There is no charge for any prescribed, FDA-approved
oral contraceptive or contraceptive device under Plan A or Plan B.
Participating pharmacies and the mail order pharmacy will dispense prescriptions in a quantity
not to exceed the amount stated in the Schedule of Prescription Drug Benefits.
Charges for federal legend drugs, prescription drugs and compound medications containing at
least one federal legend drug are eligible expenses, with the conditions and exceptions listed
below.
VIII. The section entitled ELIGIBLE PRESCRIPTION DRUG EXPENSES is amended to read as
follows:
ELIGIBLE PRESCRIPTION DRUG EXPENSES
1. Charges for federal legend drugs (those requiring the label, “Caution: Federal law prohibits
dispensing without a prescription”) and drugs that may only be dispensed by written
prescription under State law.
2. Charges for compound medications containing at least one federal legend drug.
3. Charges for insulin, disposable syringes, needles, lancets and test strips when prescribed
with insulin—one copayment is applicable when dispensed at the same time. The
quantity of the supplies must correspond to the amount of insulin dispensed.
4. Charges for oral contraceptives available by prescription only.
5. Charges for immunosuppressants.
6. Charges for interferons.
7. Charges for behavioral syndrome drugs.
8. Charges for legend and non-legend tobacco cessation products, including prescription
medications, patches, gum, nasal spray and inhalers.
9. Charges for injectable sumatriptan succinate.
10. Charges for injectable epinephrine.
11. Charges for injectable enoxaparin sodium.
12. Charges for isotretinoin.
13. Charges for tretinoin, for participants under age twenty-six (26) only.
14. Charges for legend vitamins and hematinics.
Health Plan Amendment XII
15
15. Charges for legend dental vitamins, rinses and fluoride agents.
16. Charges for FDA approved male impotency medications, up to a maximum of six (6) pills in
twenty-nine (29) days or eighteen (18) pills per ninety (90) days.
IX. The section entitled PRESCRIPTION DRUG EXCLUSIONS is amended to read as follows:
PRESCRIPTION DRUG EXCLUSIONS
(exclusions in addition to General Plan Exclusions)
1. Charges for drugs provided and/or administered in a physician’s office or hospital, or any
setting other than home use.
2. Charges for more than a ninety (90) day supply of a drug, or any amount in excess of the
quantity prescribed.
3. Charges for refills not authorized by a physician, or refills dispensed after one (1) year from
the date of the original order (six [6] months if a federally controlled drug).
4. Charges for non-legend drugs (other than insulin), or drugs not prescribed by a licensed
physician or not dispensed by a licensed pharmacist.
5. Charges for experimental or investigational drugs, including compound medications for non-
FDA approved use.
6. Charges for DESI Drugs (drugs determined by the Food & Drug Administration as lacking
substantial evidence of effectiveness).
7. Charges for immunization agents, vaccines, allergy extract, biological sera, blood or blood
plasma.
8. Charges for insulin supplies, including, but not limited to, alcohol swabs, blood glucose
monitors, blood monitor kits and blood glucose calibration solutions.
9. Charges for injectables, except as provided under Eligible Expenses above.
10. Charges for anorectics, dietary aids and food supplements.
11. Charges for fertility drugs.
12. Charges for human growth hormones.
13. Charges for hair growth agents.
14. Charges for minerals.
15. Charges for cosmetic drugs.
16. Charges for over-the-counter medications.
17. Charges for the administration of drugs.
18. Charges for therapeutic equipment, devices or appliances, including hypodermic needles
and syringes, except as provided under Eligible Expenses above; charges for other non-
medical substances, even if prescribed by a physician.
Health Plan Amendment XII
16
X. The section entitled SPECIAL ENROLLMENT PERIOD FOR PREVIOUSLY ENROLLED
COVERED EMPLOYEES AND COVERED DEPENDENTS WHO HAVE EXCEEDED THE
LIFETIME MAXIMUM BENEFIT is deleted in its entirety.
XI. The section entitled LEAVES OF ABSENCE is amended to read as follows:
LEAVES OF ABSENCE
This Plan shall comply at all times with the provisions of the Family and Medical Leave Act of
1993 (FMLA).
An employee on leave of absence may continue coverage for himself and his eligible
dependents in accordance with Ordinance D-1490-00 if:
1. the employee is on a duly approved medical leave or personal leave, or has been
suspended for disciplinary reasons or pending resolution of criminal charges; and
2. the employee pays the required bi-weekly contribution to the Employer on or before each
payday.
If the employee does not return to work after commencement of a leave of absence, his
coverage will continue until the date the coverage would otherwise cease as described under
Termination of Employee Coverage above. However, coverage under this Plan will not extend
more than six (6) months beyond commencement of FMLA leave or personal leave if the
employee does not return to work during that period, unless the employee is eligible for
coverage as a retiree or an early retiree.
XII. Under HOW TO SUBMIT A CLAIM, the TIMELY SUBMISSION OF CLAIMS and the
CLAIMS REVIEW PROCEDURE sections have been deleted and replaced with the
following:
TYPES OF CLAIMS
Under the Plan, there are four types of claims: Pre-service (Urgent and Non-urgent),
Concurrent Care and Post-service.
1. Pre-service Claims.
A “Pre-service Claim” is a claim for a benefit under the Plan where the Plan conditions
receipt of the benefit, in whole or in part, on approval of the benefit in advance of
obtaining medical care.
A “Pre-service Urgent Care Claim” is any claim for medical care or treatment with respect
to which the application of the time periods for making non-urgent care determinations
could seriously jeopardize the life or health of the covered person or the covered person’s
ability to regain maximum function, or, in the opinion of a Physician with knowledge of the
Covered Person’s medical condition, would subject the Covered Person to severe pain
that cannot be adequately managed without the care or treatment that is the subject of
the claim.
If the Plan does not require the Covered Person to obtain approval of a specific medical
service prior to getting treatment, then there is no Pre-service Claim. The Covered
Person simply follows the Plan’s procedures with respect to any notice which may be
required after receipt of treatment, and files the claim as a post-service claim.
Health Plan Amendment XII
17
2. Concurrent Claims. A “Concurrent Claim” arises when the Plan has approved an on-
going course of treatment to be provided over a period of time or number of treatments,
and either:
a) The Plan Administrator determines that the course of treatment should be reduced or
terminated; or
b) The Covered Person requests extension of the course of treatment beyond that
which the Plan Administrator has approved.
If the Plan does not require the Covered Person to obtain approval of a medical service
prior to getting treatment, then there is no need to contact the Plan Administrator to
request an extension of a course of treatment. The Covered Person simply follows the
Plan’s procedures with respect to any notice which may be required after receipt of
treatment, and files the claim as a Post-service Claim.
3. Post-service Claims: A “Post-service Claim” is a claim for a benefit under the Plan after
the services have been rendered.
WHEN HEALTH CLAIMS MUST BE FILED
Post-service health claims must be filed with the Claims Administrator within twelve (12)
months of the date charges for the service was incurred. Failure to fi le a claim within this
time limit will not invalidate the claim provided that the Covered Person submits evidence
satisfactory to the Plan Administrator that it was not reasonably possible to file the claim
within the time limit. Benefits are based upon the Plan’s provisions at the time the charges
were incurred. Claims filed later than that date shall be denied.
A Pre-service Claim (including a Concurrent Claim that also is a Pre-service Claim) is
considered to be filed when the request for approval of treatment or services is made and
received by the Claims Administrator in accordance with the Plan’s procedures.
Upon receipt of the required information, the claim will be deemed to be filed with the Plan.
The Claims Administrator will determine if enough information has been submitted to enable
proper consideration of the claim. If not, more information may be requested as provided
herein. This additional information must be received by the Claims Administrator within forty-
five (45) days from receipt by the Covered Person of the request for additional information.
Failure to do so may result in claims being declined or reduced.
TIMING OF CLAIM DECISIONS
The Plan Administrator shall notify the Covered Person, in accordance with the provisions set
forth below, of any Adverse Benefit Determination (and, in the case of Pre -service Claims
and Concurrent Claims, of decisions that a claim is payable in full) within the following
timeframes:
Pre-service Urgent Care Claims:
1. If the Covered Person has provided all of the necessary information, as soon as possible,
taking into account the medical exigencies, but not later than seventy-two (72) hours after
receipt of the claim.
2. If the Covered Person has not provided all of the information needed to process the
claim, then the Covered Person will be notified as to what specific information is needed
as soon as possible, but not later than seventy-two (72) hours after receipt of the claim.
The Covered Person will be notified of a determination of benefits as soon as possible,
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but not later than seventy-two (72) hours, taking into account the medical exigencies,
after the earliest of:
a) The Plan’s receipt of the specified information; or
b) The end of the period afforded the Covered Person to provide the information.
Pre-service Non-urgent Care Claims:
1. If the Covered Person has provided all of the information needed to process the claim, in
a reasonable period of time appropriate to the medical circumstances, but not later than
fifteen (15) days after receipt of the claim, unless an extension has been requested, then
prior to the end of the fifteen (15) day extension period.
2. If the Covered Person has not provided all of the information needed to process the
claim, then the Covered Person will be notified as to what specific information is needed
as soon as possible, but not later than five (5) days after receipt of the claim. The
Covered Person will be notified of a determination of benefits in a reasonable period of
time appropriate to the medical circumstances, either prior to the end of the extension
period (if additional information was requested during the initial processing period), or by
the date agreed to by the Plan Administrator and the Covered Person (if additional
information was requested during the extension period).
Concurrent Claims:
1. Plan Notice of Reduction or Termination. If the Plan Administrator is notifying the
Covered Person of a reduction or termination of a course of treatment (other than by Plan
amendment or termination), before the end of such period of time or number of
treatments. The Covered Person will be notified sufficiently in advance of the reduction
or termination to allow the Covered Person to appeal and obtain a determination on
review of that Adverse Benefit Determ ination before the benefit is reduced or terminated.
2. Request by Covered Person Involving Urgent Care. If the Plan Administrator receives a
request from a Covered Person to extend the course of treatment beyond the period of
time or number of treatments that is a claim involving urgent care, as soon as possible,
taking into account the medical exigencies, but not later than seventy-two (72) hours after
receipt of the claim, as long as the Covered Person makes the request at least seventy -
two (72) hours prior to the expiration of the prescribed period of time or number of
treatments. If the Covered Person submits the request with less than seventy-two (72)
hours prior to the expiration of the prescribed period of time or number of treatments, the
request will be treated as a claim involving urgent care and decided within the urgent
care timeframe.
3. Request by Covered Person Involving Non-urgent Care. If the Plan Administrator
receives a request from the Covered Person to extend the course of treatment beyond
the period of time or number of treatments that is a claim not involving urgent care, the
request will be treated as a new benefit claim and decided within the timeframe
appropriate to the type of claim (either as a Pre-service non-urgent Claim or a Post-
service Claim).
Post-service Claims:
1. If the Covered Person has provided all of the information needed to process the claim, in
a reasonable period of time, but not later than thirty (30) days after receipt of the claim,
unless an extension has been requested, then prior to the end of the fifteen (15) day
extension period.
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2. If the Covered Person has not provided all of the information needed to process the claim
and additional information is requested during the initial processing period, then the
Covered Person will be notified of a determination of benefits prior to the end of the
extension period, unless additional information is requested during the extension period,
then the Covered Person will be notified of the determination by a date agreed to by th e
Plan Administrator and the Covered Person.
Extensions – Pre-service Urgent Care Claims. No extensions are available in connection
with Pre-service Urgent Care Claims.
Extensions – Pre-service Non-urgent Care Claims. This period may be extended by the Plan
for up to fifteen (15) days, provided that the Plan Administrator both determines that such an
extension is necessary due to matters beyond the control of the Plan and notifies the
Covered Person, prior to the expiration of the initial fifteen (15) day processing period, of the
circumstances requiring the extension of time and the date by which the Plan expects to
render a decision.
Extensions – Post-service Claims. This period may be extended by the Plan for up to fifteen
(15) days, provided that the Plan Administrator both determines that such an extension is
necessary due to matters beyond the control of the Plan and notifies the Covered Person ,
prior to the expiration of the initial thirty (30) day processing period, of the circumstances
requiring the extension of time and the date by which the Plan expects to render a decision.
Calculating Time Periods. The period of time within which a benefit determination is required
to be made shall begin at the time a claim is deemed to be filed in accordance with the
procedures of the Plan.
NOTIFICATION OF AN ADVERSE BENEFIT DETERMINATION
The Plan Administrator shall provide a Covered Person with a notice, either in writing or
electronically (or, in the case of Pre-service Urgent Care Claims, by telephone, facsimile or
similar method, with written or electronic notice), containing the following information:
1. A reference to the specific portion(s) of the Plan Document and Summary Plan
Description upon which a denial is based;
2. Specific reason(s) for a denial;
3. A description of any additional information necessary for the Covered Person to perfect
the claim and an explanation of why such information is necessary;
4. A description of the Plan’s review procedures and the time limits applicable to the
procedures, including a statement of the Covered Person’s right to bring a civil action
under section 502(a) of ERISA (if applicable) following an Adverse Benefit Determination
on final review;
5. A statement that the Covered Person 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 Covered Person’s claim for benefits;
6. The identity of any medical or vocational experts consulted in connection with a claim,
even if the Plan did not rely upon their advice (or a statement that the identity of the
expert will be provided, upon request);
7. Any rule, guideline, protocol or similar criterion that was relied upon in making the
determination (or a statement that it was relied upon and that a copy will be provided to
the Covered Person, free of charge, upon request);
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8. In the case of denials based upon a medical judgment (such as whether the treatment is
Medically Necessary or Experimental), either an explanation of the scientific or clinical
judgment for the determination, applying the terms of the Plan to the Covered Person’s
medical circumstances, or a statement that such explanation will be provided to the
Covered Person, free of charge, upon request; and
9. In a claim involving urgent care, a description of the Plan’s expedited review process.
APPEALS OF ADVERSE BENEFIT DETERMINATIONS
Full and Fair Review of All Claims: In cases where a claim for benefits is denied, in whole or
in part, and the Covered Person believes the claim has been denied wrongly, the Covered
Person may appeal the denial and review pertinent documents. The claims procedures of
this Plan provide a Covered Person with a reasonable opportunity for a full and fair review of
a claim and Adverse Benefit Determination. More specifically, the Plan provides:
1. Covered Persons at least one hundred eighty (180) days following receipt of a notification
of an initial Adverse Benefit Determination within which to appeal the determination and
one hundred eighty (180) days to appeal a second Adverse Benefit Determination;
2. Covered Persons the opportunity to submit written comments, documents, records, and
other information relating to the claim for benefits;
3. For a review that does not afford deference to the previous Adverse Benefit
Determination and that is conducted by an appropriate named fiduciary of the Plan, who
shall be neither the individual who made the Adverse Benefit Determination that is the
subject of the appeal, nor the subordinate of such individual;
4. For a review that takes into account all comments, documents, records, and other
information submitted by the Covered Person relating to the claim, without regard to
whether such information was submitted or considered in any prior benefit determinat ion;
5. That, in deciding an appeal of any Adverse Benefit Determination that is based in whole
or in part upon a medical judgment, the Plan fiduciary shall consult with a health care
professional who has appropriate training and experience in the field of medicine involved
in the medical judgment, who is neither an individual who was consulted in connection
with the Adverse Benefit Determination that is the subject of the appeal, nor the
subordinate of any such individual;
6. For the identification of medical or vocational experts whose advice was obtained on
behalf of the Plan in connection with a claim, even if the Plan did not rely upon their
advice;
7. That a Covered Person will be provided, upon request and free of charge, reasonable
access to, and copies of, all documents, records, and other information relevant to the
Covered Person’s claim for benefits in possession of the Plan Administrator or the Claims
Administrator; information regarding any voluntary appeals procedures offered by the
Plan; any internal rule, guideline, protocol or other similar criterion relied upon in making
the adverse determination; and an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to the Covered Person’s medical
circumstances; and
8. In an Urgent Care claim, for an expedited review process pursuant to which:
a) A request for an expedited appeal of an Adverse Benefit Determination may be
submitted orally or in writing by the Covered Person; and
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21
b) All necessary information, including the Plan’s benefit determination on review, shall
be transmitted between the Plan and the Covered Person by telephone, facsimile or
other available similarly expeditious method.
XIII. The section entitled DEFINITIONS is amended to read as follows; provisions not specifically
amended below remain unchanged:
Employee Health Clinic
Primary healthcare facility owned and operated by the City for the exclusive benefit of Plan
participants.
Physician
A legally qualified medical or dental doctor 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 or Licensed Speech Therapist, provided they are licensed in the political
jurisdiction where practicing, and practicing within the scope of their license.
Preventive (formerly Wellness)
Services provided for preventive purposes, when there is no diagnosis of illness or injury.
In all other respects the Plan remains unchanged.
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
_________________________________ ________________________
James Brainard, Presiding Officer Date
_________________________________ ________________________
Mary Ann Burke, Board Member Date
_________________________________ ________________________
Lori Watson, Board Member Date
ATTEST:
_________________________________ ________________________
Diana Cordray, IAMC, Clerk-Treasurer Date