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HomeMy WebLinkAboutTwelfth Amendment to Employee Health Benefit Plan •z Health Plan Amendment XII 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 100% 60% Percentage Family Coinsurance Percentage 100% 60% 1 Health Plan Amendment XII 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 100% 60% FOR OFFICE VISIT Deductible Applies: Yes Yes PHYSICIAN'S CHARGES 100% 60% FOR SERVICES RENDERED AT TIME OF OFFICE VISIT Deductible Applies: Yes Yes PHYSICIAN'S CHARGES 100% 60% FOR SERVICES RENDERED IN ABSENCE OF OFFICE VISIT Deductible Applies: Yes Yes ALLERGY SHOTS 100% 60% Deductible Applies: Yes Yes PHYSICIAN HOSPITAL 100% 60% VISITS Deductible Applies: Yes Yes RETAIL HEALTH CLINIC 100% 60% VISIT Deductible Applies: Yes Yes EMPLOYEE HEALTH 100% N/A CLINIC VISIT Deductible Applies: No N/A 2 Health Plan Amendment XII PREFERRED BENEFIT NON-PREFERRED BENEFIT SURGEON OR 100% 60% ANESTHESIOLOGIST CHARGES Deductible Applies: Yes Yes AMBULANCE CHARGES 100% 60% Deductible Applies: Yes Yes DURABLE MEDICAL 100% 60% EQUIPMENT Deductible Applies: Yes Yes EMERGENCY ROOM 100% 100% FACILITY Deductible Applies: Yes Yes (preferred deductible) EMERGENCY ROOM 100% 100% PHYSICIAN 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 100% 60% CARE Deductible Applies: Yes Yes Lifetime Maximum 365 days or 365 visits OUTPATIENT HOSPICE 100% 60% CARE Deductible Applies: Yes Yes Lifetime Maximum 365 visits or 365 days BEREAVEMENT 100% 60% COUNSELING Deductible Applies: Yes Yes Per Death Maximum 5 visits within six months from date of death INPATIENT& INTENSIVE 100% 60% CARE FACILITY CHARGES Deductible Applies: Yes Yes 3 Health Plan Amendment XII 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 100% 60% FACILITY Deductible Applies: Yes Yes PATHOLOGY AND/OR 100% 60% LABORATORY TESTS 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 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. 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. 4 Health Plan Amendment XII 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 100% 60% FACILITY Deductible Applies: Yes Yes Calendar Year Maximum 90 days THERAPY(PHYSICAL, 100% 60% OCCUPATIONAL, SPEECH AND OTHER) Deductible Applies: Yes Yes TREATMENT OF 100% 60% TEMPOROMANDIBULAR JOINT DISORDER(TMJ) Deductible Applies: Yes Yes Lifetime Maximum $1,000 WEIGHT LOSS 100% 60% TREATMENT(SURGICAL) 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 & 100% 60% SUBSTANCE ABUSE CARE Deductible Applies: Yes Yes OUTPATIENT 100% 60% PSYCHIATRIC & SUBSTANCE ABUSE CARE Deductible Applies: Yes Yes II. The section entitled SCHEDULE OF MEDICAL BENEFITS (PLAN B) is amended to read as follows: 5 Health Plan Amendment XII 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 80% 60% Percentage 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: 6 Health Plan Amendment XII • 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 100% 60% FOR OFFICE VISIT Copay Applies: Yes($25 per visit) No Deductible Applies: No Yes PHYSICIAN'S CHARGES 80% 60% FOR SERVICES RENDERED AT TIME OF OFFICE VISIT Copay Applies: No No Deductible Applies: Yes Yes PHYSICIAN'S CHARGES 80% 60% FOR SERVICES RENDERED IN ABSENCE OF OFFICE VISIT 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 80% 60% VISITS Copay Applies: No No Deductible Applies: Yes Yes RETAIL HEALTH CLINIC 100% 60% VISIT Copay Applies: Yes($15 per visit) No Deductible Applies: No Yes EMPLOYEE HEALTH 100% N/A CLINIC VISIT Copay Applies: No N/A Deductible Applies: No N/A 7 Health Plan Amendment XII PREFERRED BENEFIT NON-PREFERRED BENEFIT SURGEON OR 80% 60% ANESTHESIOLOGIST CHARGES Copay Applies: No No Deductible Applies: Yes Yes AMBULANCE CHARGES 80% 60% Copay Applies: No No Deductible Applies: Yes Yes DURABLE MEDICAL 80% 60% EQUIPMENT Copay Applies: No No Deductible Applies: Yes Yes EMERGENCY ROOM 100% 100% FACILITY Copay Applies: Yes($100 per visit) Yes($100 per visit) Deductible Applies: No No EMERGENCY ROOM 100% 100% PHYSICIAN Copay Applies: Yes($50 per visit) Yes($50 per visit) Deductible Applies: No 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 80% 60% CARE Copay Applies: No No Deductible Applies: Yes Yes Lifetime Maximum 365 days or 365 visits OUTPATIENT HOSPICE 80% 60% CARE Copay Applies: No No Deductible Applies: Yes Yes Lifetime Maximum 365 visits or 365 days 8 Health Plan Amendment XII 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 80% 60% CARE FACILITY CHARGES 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 80% 60% FACILITY Copay Applies: No No Deductible Applies: Yes Yes PATHOLOGY AND/OR 80% 60% LABORATORY TESTS Copay Applies: No No Deductible Applies: Yes Yes PRESCRIPTION DRUGS: 100% 60% Copay Applies: Yes($10, $30 or$50 per No 30-day supply, or portion thereof) 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. 9 Health Plan Amendment XII These services include routine or periodic exams (including school enrollment exams, but P ( 9 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, 80% 60% OCCUPATIONAL, SPEECH AND OTHER) Copay Applies: No No Deductible Applies: Yes Yes TREATMENT OF TEMPOROMANDIBULAR 80% 60% JOINT DISORDER(TMJ) Copay Applies: No No Deductible Applies: Yes Yes Lifetime Maximum $1,000 WEIGHT LOSS 80% 60% TREATMENT(SURGICAL) Copay Applies: No No Deductible Applies: Yes Yes 10 Health Plan Amendment XII 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 80% 60% & SUBSTANCE ABUSE CARE Copay Applies: No No Deductible Applies: Yes Yes OUTPATIENT 100% 60% PSYCHIATRIC & SUBSTANCE ABUSE CARE 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.Qov/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, routine PSA tests, bone density tests, routine colorectal cancer examinations and related lab tests and routine colonoscopies. 11 Health Plan Amendment XII 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: 12 Health Plan Amendment XII 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: 13 Health Plan Amendment XII 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. 14 Health Plan Amendment XII 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. 15 Health Plan Amendment XII 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. 16 Health Plan Amendment XII 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 file 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, 17 Health Plan Amendment XII 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 Determination 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. 18 Health Plan Amendment XII 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 the 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); 19 Health Plan Amendment XII 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 determination; 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 20 Health Plan Amendment XII 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 / . /0 r3-/ 2. /- es1rainard 'residing •.icer l Date 44/ /ii• , Mary Ann urke, Bo.,r. Member Date /Lf /0/ f/ Lori W.tso., =oard Member Date ATTEST: � / 1 ,� J O )-- diana Cordray, IA C Clerk-Treasurer Date 21 1