HomeMy WebLinkAboutFifteenth Amendment to Health PlanHealth Plan Amendment
FIFTEENTH 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 fourteen 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. The PLAN SPECIFICATIONS are amended as follows to include reference to both Anthem (medical
and prescription drug plans) and BAS (dental plan and COBRA administration):
MEDICAL GROUP NUMBER (AS ASSIGNED BY ANTHEM):
004007834
DENTAL GROUP NUMBER (AS ASSIGNED BY BAS)
113310
NAME, ADDRESS AND TELEPHONE NUMBER OF THE THIRD PARTY ADMINISTRATOR:
Medical
Anthem Blue Cross and Blue Shield
220 Virginia Avenue
Indianapolis, IN 46204
844 - 453 -4508
Dental
Benefit Administrative Systems
17475 Jovanna Drive, Suite 1B
Homewood, IL 60430
800 - 523 -0582
2. Under SCHEDULE OF BENEFITS (PLAN A), the Deductible section is amended to read as follows:
CALENDAR YEAR DEDUCTIBLES:
Individual Plan Deductible
Family Plan Deductible
Preferred Non - Preferred
$2,000 $4,000
$4,000 $8,000
The following items do not apply toward satisfaction of the calendar year deductible:
• penalties incurred for noncompliance;
• charges for services and supplies not eligible under this Plan;
• charges that exceed the amount allowed by the Plan; and
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• charges for services deemed not medically necessary.
When the 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.
3. Under SCHEDULE OF BENEFITS (PLAN B), the deductible section in the is amended to read as
follows:
CALENDAR YEAR DEDUCTIBLES:
Individual Deductible
Family Deductible
Preferred Non - Preferred
$750 $1,500
$1,500 $3,000
The following items do not apply toward satisfaction of the calendar year deductible:
• copays;
• penalties incurred for noncompliance;
• charges for services and supplies not eligible under this Plan;
• charges that exceed the amount allowed by the Plan; and
• charges for services deemed not medically necessary.
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,
4. Under SCHEDULE OF MEDICAL BENEFITS (PLAN A) the Out -of- Pocket Maximum section is
amended to read as follows:
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:
• penalties incurred for noncompliance;
• charges for services and supplies not eligible under this Plan;
• charges that exceed the amount allowed by the Plan; and
• charges for services deemed not medically necessary.
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.
5. Under SCHEDULE OF MEDICAL BENEFITS (PLAN B), the Out -of- Pocket Maximum section is
amended to read as follows:
OUT -OF- POCKET MAXIMUMS:
Preferred Non - Preferred
Individual $1,500 $3,000
Family $3,000 $6,000
The out -of- pocket maximum includes deductibles, copays and coinsurance. The following items do not
apply toward the calendar year out -of- pocket expense maximum:
• penalties incurred for noncompliance;
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• charges for services and supplies not eligible under this Plan;
• charges that exceed the amount allowed by the Plan; and
• charges for services deemed not medically necessary.
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.
6. Under DESCRIPTION OF MEDICAL BENEFITS (PLAN A) and DESCRIPTION OF MEDICAL
BENEFITS (PLAN B), the limit on hearing aids is amended to read as follows:
Maximum per 60 -Month Period one hearing aid per ear
7. Under DESCRIPTION OF MEDICAL BENEFITS (PLAN A), the Organ and Tissue Transplant benefit is
added to read as follows:
PREFERRED BENEFIT NON - PREFERRED BENEFIT
ORGAN/TISSUE 100% NA
TRANSPLANT
Deductible Applies: Yes NA
8. Under DESCRIPTION OF MEDICAL BENEFITS (PLAN 6), the Organ and Tissue Transplant benefit is
added to read as follows:
PREFERRED BENEFIT NON - PREFERRED BENEFIT
ORGAN/TISSUE 80% NA
TRANSPLANT
Copay Applies: No NA
Deductible Applies: Yes NA
Blue Distinction Centers for Transplants... not subject to deductible or coinsurance
9. Under DESCRIPTION OF MEDICAL BENEFITS (PLAN A) and DESCRIPTION OF MEDICAL
BENEFITS (PLAN B), the Therapy section is amended to include vision therapy.
10. Under DESCRIPTION OF MEDICAL BENEFITS (PLAN A) and DESCRIPTION OF MEDICAL
BENEFITS (PLAN B), the Penalty for Failure to Precertify section is amended to read as follows:
Some of the services and procedures covered under the Plan require precertification. In- network
providers are responsible for obtaining precertification on the participant's behalf. If the participant goes
out of network, he is responsible to ensure that the precertification requirements, as detailed under Cost
Containment Procedures, are satisfied. Participants can call the customer service number listed on the
medical identification card to determine whether precertification is required.
Failure to precertify out -of- network services and procedures will cause eligible expenses to be reduced
by a penalty of $500 per occurrence.
11. COST CONTAINMENT PROCEDURES is amended to read as follows:
COST CONTAINMENT PROCEDURES
The Plan includes the processes of precertification, concurrent review and post - service clinical review
to determine when services should be covered by the Plan. Their purpose is to promote the delivery
of cost - effective medical care by reviewing medical necessity, the use of specific procedures and,
where appropriate, the setting or place where they are performed.
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PRECERTIFICATION
Precertification is a required review of a service, treatment or admission for a benefit coverage
determination, which must be obtained prior to the service, treatment or admission date. In an
emergency situation, precertification must be obtained within two (2) business days after the service,
treatment or admission commences.
Precertification will be based on multiple criteria, including medical policy, clinical guidelines,
pharmacy and therapeutics guidelines and other relevant industry guidelines. Inpatient admissions
and many outpatient surgeries, procedures, treatments, therapies, tests, devices and equipment may
be subject to precertification requirements. For childbirth admissions, precertification is not required
unless there is a complication and /or the mother and baby are not discharged at the same time.
The Plan requires that covered services be medically necessary for benefits to be provided. The
Third Party Administrator may determine that a service that was initially prescribed or requested is not
medically necessary if the member has not previously tried alternative treatments which are more
cost effective. In addition, when setting or place of service is part of the review, services that can be
safely provided to you in a lower cost setting will not be medically necessary if they are performed in
a higher cost setting.
Responsibility for precertification depends on where the treatment is performed:
1. For all in- network treatment, the provider is responsible for obtaining precertification.
2. For all treatment provided out -of- network, the participant is responsible for obtaining
precertification. If the participant or provider does not obtain the required precertification, the
participant will be subject to a $500 penalty. Participants can call the customer service number
on their insurance identification card to determine whether precertification is required.
A participant is entitled to receive, upon request and free of charge, reasonable access to any
documents relevant to his precertification request by contacting the customer service number on his
identification card.
PRECERTIFICATION DOES NOT GUARANTEE COVERAGE OR PAYMENT
FOR THESERVICE OR PROCEDURE REVIEWED
CONCURRENT REVIEW
It may be necessary for inpatient care to extend beyond the number of days initially certified. Additional
days, beyond those certified at admission, must also be certified.
The Third Party Administrator's utilization management team will monitor the patient's progress
throughout the hospital stay to assure that discharge is not delayed by inadequate planning, and that
each day of confinement is medically necessary and appropriate.
POST - SERVICE CLINICAL REVIEW
A claim may be reviewed retrospectively to determine the medical necessity or experimental/
investigative nature of a service, treatment or admission that did not require precertification.
The Third Party Administrator will utilize its clinical coverage guidelines and other applicable policies
and procedures to assist in making medical necessity decisions. The clinical coverage guidelines
may be reviewed and updated periodically.
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EXCEPTIONS
The Third Part Administrator may, from time to time, waive, enhance, modify or discontinue certain
cost - containment procedures if, in its discretion, such change furthers the provision of cost effective,
value based and /or quality services. Exceptions to any process, provision or claim will be determined
by the specific circumstances that apply in that case, and will not constitute a precedent for future
decisions.
The Third Party Administrator may also identify certain providers to review for potential fraud, waste,
abuse or other inappropriate activity if the claims data suggests there may be inappropriate billing
practices. If a provider is selected under this program, the Third Party Administrator may use one or
more clinical utilization management guidelines in the review of claims submitted by this provider,
even if those guidelines are not used for all providers delivering services to Plan participants.
REQUEST CATEGORIES AND TIME FRAMES
1. Prospective Non - Urgent: A request for precertification that is conducted prior to the service,
treatment or admission.
Decision and notification will be made within 15 calendar days of receipt of request.
2. Prospective Urgent: A request for precertification that in the opinion of the treating provider or
any physician with knowledge of the participant's medical condition, could in the absence of such
care or treatment, seriously jeopardize the life or health of the participant, inhibit the ability of the
participant to regain maximum function or subject the participant to severe pain that cannot be
adequately managed without such care or treatment.
Decision and notification will be made within 72 hours of receipt of request.
3. Concurrent Urgent: A request for precertification that is conducted during the course of
outpatient treatment or during an inpatient admission.
Decision and notification will be made within 24 -72 hours of receipt of request, depending on
whether there has been a previous certification, and the status of the previous certification.
4. Retrospective: A request for precertification that is conducted after the service, treatment or
admission has occurred.
Decision and notification will be made within 30 calendar days of receipt of request.
If additional information is needed to make a decision, the Third Party Administrator will notify the
requesting provider and send written notification to the participant of the specific information
necessary to complete the review. If the Third Party Administrator does not receive the specific
information requested or if the information is not complete by the timeframe identified in the written
notification, a decision will be made based upon the information in its possession.
Notification may be given verbally (via telephone) or in writing (via USPS, email or fax).
LARGE CASE MANAGEMENT /ALTERNATE TREATMENT
When a participant's condition warrants (e.g., chronic illness or catastrophic injury), Utilization Review
will contact the participant's attending physician to ensure that all available resources are being
considered to maximize treatment and recovery. Rehabilitation, public assistance and alternate forms
of treatment are subject to consideration.
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Normal provisions of the Plan may be waived as part of the large case management process when it is
reasonable to expect a cost effective result from an alternative treatment without sacrifice to the quality
of patient care. If a proposed alternate treatment is approved by the medical community and shown to
be cost effective, the Plan may allow expenses that would not otherwise be covered.
Consideration for alternate treatment will be determined by the merits of each individual case, and any
care or treatment provided will not be considered as setting any precedent or creating any future liability
with respect to that participant or any other participant.
The use of large case management or alternate treatment is a voluntary program, which the participant
may choose to accept or decline.
12. The following statement is added to the introduction of the DESCRIPTION OF MEDICAL BENEFITS:
The City of Carmel will comply with all requirements of the Affordable Care Act (ACA), the Mental
Health Parity Act (MHPA) and all other applicable federal and state regulations.
13. The following sentence is added to the Organ and /or Tissue Transplant section of the DESCRIPTION
OF MEDICAL BENEFITS:
The Plan does not cover organ and /or tissue transplants performed at non - network facilities.
14. The MEDICAL EXCLUSIONS are amended as follows:
2. Charges for services and supplies related to correcting refractive defects of the eye, including, but
not limited to, radial keratotomy by whatever name called, or other eye surgery to correct near
sightedness, far sightedness or astigmatism.
13. Charges for wigs, artificial hair pieces, hair transplants, prescription drugs or any other treatment
to conceal or eliminate hair loss, except when hair loss is the result of burns, chemotherapy,
radiation therapy or surgery; then the purchase of a wig or artificial hairpiece is limited to one
every two years.
16. Charges for counseling services, including religious, marital, and sex counseling, unless provided
in connection with a condition, illness or injury that is covered under this Plan.
20. Charges for services and supplies for the purpose of controlling harmful habits or promoting self -
help, except as stated in the Schedule of Benefits under Preventive Services.
29. Charges for non - medical expenses such as training, educational instruction or educational
materials, even if they are performed or prescribed by a physician, except services for education
and nutrition counseling that are incurred in connection with a diagnosed diabetic condition or
eating disorder.
30. Charges for anesthesia by hypnosis or anesthesia for non - eligible services.
The exclusions for biofeedback therapy, acupuncture and B -12 injections are deleted.
An exclusion for bariatric surgery is added.
15. Under MEDICARE, the second sentence in the section Active Employees and Their Spouses Aged
65 And Older is amended to read as follows;
If an active employee is enrolled in any part of Medicare, he cannot be enrolled in Plan A.
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16. Under DESCRIPTION OF PRESCRIPTION DRUG BENEFITS, the following items are deleted from the
section on Eligible Prescription Drug Expenses in their entirety:
Charges for injectable sumatriptan succinate
Charges for injectible epinephrine
Charges for injectable enoxaparin sodium
Charges for injectable drugs is added to the list of eligible drugs.
17. Under DESCRIPTION OF PRESCRIPTION DRUG BENEFITS, the section on Prescription Drug
Exclusions is amended as follows:
13. Charges for vitamins, minerals and food supplements not medically necessary for the treatment of a
specific illness or condition.
The exclusion for injectable drugs is deleted.
18. Under ELIGIBILITY PROVISIONS, the reference to newborn children in the section on Eligible
Dependents is amended to read as follows:
A newborn child of an employee or an employee's registered domestic partner must be enrolled
within thirty (30) days of birth in order to have coverage from birth.
19. Under ELIGIBILITY PROVISIONS, the section Disabled Dependent Children is amended to read as
follows:
Coverage for an unmarried disabled dependent child may be continued after age 26, provided the child
was disabled prior to his 26`h birthday.
An initial certification form must be submitted at least 30 days prior to the dependent's 26th birthday.
The certification requires evidence that the dependent:
1. is permanently disabled due to a mental or physical incapacity; and
2. relies on the covered employee for financial support.
The Plan Administrator may require periodic proof of a continuing disability, but not more frequently than
every other year. Such proof may include a medical examination at the Plan's expense. Failure to
provide satisfactory proof upon request may result in termination of the dependent's coverage.
A child who becomes disabled after age 26 will not be eligible to re- enroll for coverage as a disabled
dependent child under the Plan.
20. GENERAL PLAN EXCLUSIONS is amended as follows:
9. Charges for treatment and services provided by a non - licensed provider or those that do not
require a license to provide, and charges for treatment and services that exceed the scope of the
provider's license.
21. Under COORDINATION OF BENEFITS, the Order of Benefit Determination is amended to include
the following, with subsequent sections re- numbered.
7. Continuation of Coverage
A plan covering a participant as an employee, a retiree or a dependent pays before a plan offered
under a continuation of coverage provision in accordance with state or federal law.
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22. Under CLAIMS INFORMATION, the Notification of An Adverse Benefit Determination and Appeals of
an Adverse Benefit Determination sections are amended as follows:
NOTIFICATION OF AN ADVERSE BENEFIT DETERMINATION
When a claim is denied, in whole or in part, the Third Party Administrator shall provide a participant
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. Information sufficient to identify the denial in question;
2. A reference to the specific portion(s) of the Plan Document or other criteria upon which the denial
is based;
3. Specific reason(s) for the denial;
4. A description of any additional information necessary for the participant to appeal the denial and
an explanation of why such information is necessary;
5. A description of the Plan's review procedures and the time limits applicable to the procedures.
6. A statement that the participant 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
denial;
7. The identity of any medical or vocational experts consulted in connection with the denial, even if
the Plan did not rely upon their advice (or a statement that the identity of the expert will be
provided, upon request);
8. 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 participant, free of
charge, upon request);
9. 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 participants medical circumstances, or
a statement that such explanation will be provided to the participant, free of charge, upon request;
10. The availability of, and contact information for, any applicable office of health insurance consumer
assistance or ombudsman who may offer assistance ; and
11. In a denial involving urgent care, a description of the Plan's expedited review process.
APPEALS OF ADVERSE BENEFIT DETERMINATIONS
The Plan requires that the participant be provided a reasonable opportunity for a full and fair review of
a claim and adverse benefit determination. A participant who believes his claim has been wrongly
denied, in whole or in part, should first call customer service at the number listed on his identification
card. A customer service representative will try to resolve the complaint informally.
If the participant is not satisfied with the resolution of his complaint, he has the right to file an internal
appeal. This right applies to either a pre - service claim (precertification) or post- service claim (denial,
in part or in whole, of payment for services already provided), pursuant to the following guidelines:
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1. The participant has one hundred eighty (180) days following notice of an initial adverse benefit
determination within which to appeal the determination.
2. The participant or his representative has the opportunity to submit written comments, documents,
records and other information relating to the claim for benefits.
3. Written appeals should be sent to:
Anthem Blue Cross and Blue Shield
ATTN: Appeals, P.O. Box 105568
Atlanta, Georgia 30348
The participant's Member Identification Number must be included with an appeal.
4. For appeals involving urgent or concurrent care, the Plan provides an expedited appeal process.
The participant or his representative may request an expedited appeal orally or in writing by
contacting customer service at the number on the participant's insurance identification card. If the
expedited appeal is approved, all necessary information, including the Plan's benefit
determination on review, shall be transmitted between the Plan and the participant or his
representative by telephone, facsimile or other available similarly expeditious method.
5. The appeal will be conducted by an appropriate reviewer who will not rely on the initial benefits
determination, who did not make the initial determination and who does not work for the person
who made the initial determination.
6. Upon request and free of charge, the participant will be provided reasonable access to, and
copies of, all documents, records and other information relevant to the participant's claim for
benefits in possession of the Plan Administrator or the Third Party Administrator, including
documents records and other information that:
a) were submitted, considered or produced in the course of making the benefit determination;
b) were relied on in making the benefit determination;
c) state a policy, rule, guideline, protocol or other similar criterion relied upon in making the
benefit determination; and /or
d) demonstrate compliance with processes and safeguards, to ensure the terms of the plan are
applied consistently for similarly- situated claimants.
The participant will also be given a rationale for the decision, including an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan to the
participant's medical circumstances.
7. The decision on an appeal will be made within the following time frames:
a) If the appeal involves a claim for urgent/concurrent care, the participant will be notified of the
outcome of the appeal as soon as possible, but not later than 72 hours after receipt of the
appeal.
b) If the appeal involves any other pre- service claim the participant will be notified of the
outcome of the appeal within 30 days after receipt of the appeal.
c) If the appeal involves a post - service claim the participant will be notified of the outcome of
the appeal within 60 days after receipt of the appeal.
If the participant is dissatisfied with the first -level appeal decision, he may request a second -level
appeal, which will follow the procedures above, except for the following:
1. A second -level appeal is voluntary; a participant is not required to submit a second -level appeal
before requesting an independent external review (see below).
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2. The secondary appeal must be submitted in writing within sixty (60) calendar days following
denial of the first -level appeal.
3. The second -level appeal will be conducted by an appropriate reviewer who was not involved with
the adverse benefits determination or the initial appeal and who does not work for those persons.
If either a first level or secondary internal appeal results in another adverse benefit determination, the
participant may request an independent external review, pursuant to the following guidelines:
1. The participant has four (4) months following notice of the final internal adverse benefit
determination within which to request the external review.
2. There is no cost to the participant for an independent external review.
3. A request for an external review should be submitted in writing, to the address listed above for the
internal appeal process.
4. The external review will take into account all comments, documents, records and other
information submitted by the participant relating to the claim, without regard to whether such
information was submitted or considered in any prior benefit determination. The participant is not
required to submit additional information, but may do so.
5. In deciding an appeal of any adverse benefit determination that is based in whole or in part upon
a medical judgment, the Plan shall consult with a health care professional who has appropriate
training and experience in the field of medicine involved in the medical judgment, who was not
consulted in connection with the adverse benefit determination that is the subject of the appeal
and who does not work for any such individual.
6. The Plan will also identify 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.
23. Under GENERAL PROVISIONS, the assignment section is amended to read as follows:
ASSIGNMENT
Preferred providers will bill the Plan directly. If services or supplies have been received from a preferred
provider, benefits are automatically paid to that provider. The participant's portion of the negotiated
rate, after the Plan's payment, will be billed to the participant by the preferred provider.
The Plan will pay benefits for claims from non - preferred providers to the employee.
The Plan will pay benefits for an alternate recipient to the responsible party designated in the Qualified
Medical Child Support Order.
24. Under DEFINITIONs, the following definitions are amended to read as follows:
Child
A participant's child under twenty -six (26) years of age (coverage ends the last day of the month in
which the 26'" birthday occurs). The term "child" shall include a biological child, a legally adopted child,
a step - child, a child of a registered domestic partner, a child related to the employee by blood or
marriage and for whom the employee has assumed legal guardianship, or a child whom the employee
must cover due to a Qualified Medical Child Support Order (QMCSO), subject to the conditions and
limits of the law.
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Health Plan Amendment
Coinsurance
The percentage of eligible expenses the Plan will pay after the participant meets his calendar year
deductible and before he meets his annual out -of- pocket maximum. The coinsurance is stated in the
Schedule of Benefits.
Copay
The amount payable by the participant for certain services and supplies rendered, as stated in the
Schedule of Benefits. The copay must be paid each time the service or supply is rendered, unless
otherwise noted. The copay will not be applied to the calendar year deductible, but will be applied to the
out -of- pocket maximum.
Full -Time Employee
An employee who works an average of 30 hours per week or more, and who is not a seasonal
employee.
Precertification
The process of evaluating in advance whether services, treatment and supplies are medically
necessary, and of giving approval for such services, treatments and supplies to be provided under the
Plan. The purpose of precertification is to ensure medically appropriate and cost - effective care.
Precertification of in- network services, treatment and supplies is the responsibility of the provider. Out -
of- network precertification is the responsibility of the participant.
Step -Down Treatment is deleted in its entirety.
Surgery is deleted in its entirety.
Third Party Administrator (TPA)
Anthem Blue Cross and Blue Shield for medical and prescription drug benefits; Benefit Administrative
Systems for dental benefits and COBRA administration. These organizations have been engaged by
the Plan Administrator to pay benefits on its behalf, in accordance with the terms and conditions of the
Plan, and to perform other administrative services on behalf of the Employer.
In all other respects the Plan remains unchanged.
Remainder of page left intentionally blank.
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Health Plan Amendment
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
Brainar. Presiding • icer
Mary An
Burke, Board Member
Lori Wat�,'Board Member
ATTEST:
na Cordray, IAMC rk-Treasurer
,2_,
Date
/a^-/7— 1 y
Date
4/4
Date
- Date
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