HomeMy WebLinkAboutBenefit Admin/HR/13th Amendment to Health Plan Health Plan Amendment
THIRTEENTH 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 twelve 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 October 1, 2013, the Plan is amended as follows.
1. The definition of Preferred provider Organization (PPO) is amended to read as follows:
The contracting organization responsible for negotiating reduced rates for services rendered by
providers in the organization. Benefits for PPO services are paid as stated in the Schedule of Medical
Benefits.
Effective January 1, 2014, the Plan is amended as follows.
1. The following will no longer be covered expenses under the Plan; reference to these benefits is
deleted from the SCHEDULE OF MEDICAL BENEFITS (Plan A and Plan B) and from the
DESCRIPTION OF MEDICAL BENEFITS.
• Surgical Weight Loss Treatment
• Bereavement Counseling
• Laser Eye Surgery
• Prescription Drugs under the medical plan; prescription drugs will be eligible expenses only
through the prescription drug plan
• Treatment of Temporomandibular Joint Disorder(TMJ)
2. Under SCHEDULE OF MEDICAL BENEFITS (Plan B) the Calendar Year Deductibles are amended
to:
Preferred Non-Preferred
Individual Deductible $750 $1,500
Family Deductible $1,500 $3,000
3. Under SCHEDULE OF MEDICAL BENEFITS (Plan B) the Deductible Carryover is deleted.
4. Under SCHEDULE OF MEDICAL BENEFITS (Plan B) Out-Of-Pocket Maximums are amended to:
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:
• charges in excess of reasonable and customary, except as otherwise stated herein;
• penalties incurred for failing to obtain precertification/utilization review;
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• 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.
5. Under SCHEDULE OF MEDICAL BENEFITS (Plan B) copays are amended as follows:
Physician Charges for Office Visit $50
Outpatient Psychiatric and Substance Abuse Care $50
Chiropractic Care $50
Retail Health Clinic Visit $25
Allergy Shots $20 per injection
Ambulance Charges $100 per trip
Emergency Room Facility $250 in-network and out-of-network
6. Under SCHEDULE OF MEDICAL BENEFITS (Plan B) the Emergency Room Physician benefit is
amended as follows:
EMERGENCY ROOM 80% 80%
PHYSICIAN
Copay Applies: No No
Deductible Applies: Yes Yes
7. Under SCHEDULE OF MEDICAL BENEFITS (Plan A and Plan B) Penalty for Failure to Precertify is
amended to read as follows:
Failure to precertify a planned surgery or hospital admission (or to retroactively certify an emergency
surgery or admission), as detailed under Cost Containment Procedures, will cause eligible expenses
to be reduced by a penalty of$500 per occurrence.
The penalty will not count towards the satisfaction of the participant's out-of-pocket maximum.
8. Under COST CONTAINMENT PROCEDURES the introductory paragraph, Precertification
Requirements and Notification Procedure for Precertification are amended to read as follows:
PRECERTIFICATION
Plan cost containment procedures include a precertification requirement when any participant is
anticipating or planning an inpatient hospital admission or an inpatient or outpatient surgery.
Time requirements for precertification are:
1. If the hospital admission or surgery is scheduled in advance, the provider must initiate
precertification at least five (5) business days prior to the date of the admission or surgery.
2. In the case of an emergency hospital admission or surgery, the provider must initiate retroactive
certification no later than two(2) business days after the surgery or admission date.
The provider—not the participant—must call for precertification, using the number listed on the
participant's insurance card. It is the participant's responsibility to ensure that the provider
follows required precertification procedures.
The amount of the penalty, which is shown in the Schedule of Medical Benefits, will apply to each non-
compliance occurrence. The precertification requirement shall be waived for all hospital admissions and
surgeries outside of the United States.
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This Plan conforms to the procedures, protocols and methodologies of the contracted pre-certification
vendor.
PRECERTIFICATION DOES NOT GUARANTEE PAYMENT OR ELIGIBILITY
9. Under PREFERRED AND NON-PREFERRED PROVIDERS, Exceptions to Non-Preferred Level of
Benefits is amended to read as follows:
EXCEPTIONS TO NON-PREFERRED LEVEL OF BENEFITS
Under the following circumstances only, services and supplies rendered by a non-preferred provider
shall be payable at the preferred provider level of benefits:
1. If a participant requires emergency transport by ambulance and/or emergency medical treatment.
Charges for the ambulance, emergency room or immediate care facility, physicians and related
services, including radiology, anesthesiology and pathology, will be covered as preferred provider
charges. If the participant is admitted to a hospital after emergency treatment, eligible hospital
charges will be covered as preferred provider charges.
2. If a participant uses a preferred facility or practice, but the provider who performs the services and
bills for the services is not a member of the preferred provider organization. Or, if a participant uses
a physician in the preferred provider organization, but the facility or practice that bills for the service
is not a member of the preferred provider organization.
3. If a participant uses a preferred provider to perform radiology and pathology (laboratory) tests, but
the tests are interpreted by a service provider outside the preferred provider organization.
4. If a participant uses an operating surgeon and surgical facility (if applicable) that are preferred
providers, but the assistant surgeon and/or anesthesiologist is a not a member of the preferred
provider organization.
10. In compliance with the Affordable Care Act, all language pertain to preexisting health conditions is
deleted, including SCHEDULE OF MEDICAL BENEFITS (Plan A and Plan B, Pre-existing Condition
Limitation), PREEXISTING CONDITION LIMITATION, DESCRIPTION OF MEDICAL BENEFITS
(introductory paragraph), DESCRIPTION OF PRESCRIPTION DRUG BENEFITS (first line),
ELIGIBILITY PROVISIONS (Open Enrollment, Termination of Employee Coverage, Termination of
Dependent Coverage), CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)
CONTINUATION OF COVERAGE (Election of Coverage, End of Continuation Coverage, Termination
of Coverage), COORDINATION OF BENEFITS (Order of Benefit Determination), CLAIMS
INFORMATION (Pending a Claim) and DEFINITIONS (Late Enrollee, Preexisting Condition)
11. In compliance with the Affordable Care Act, the following section is added to DESCRIPTION OF
MEDICAL BENEFITS:
CLINICAL TRIALS
Charges made for routine patient services associated with clinical trials approved and sponsored by
the federal government for life-threatening conditions or diseases, as mandated by the Affordable
Care Act (ACA). The following criteria must be met, which list is intended to comply with the
requirements of the ACA and may be updated in accordance with amendments to the Act or its
regulatory provisions:
1. the clinical trial is listed on the National Institutes of Health website www.clinicaltrials.gov as being
sponsored by the federal government;
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2. the trial investigates a treatment for a life-threatening condition or disease and: (1) the person has
failed standard therapies for the disease; (2) cannot tolerate standard therapies for the disease;
or (3) no effective non-experimental treatment for the disease exists;
3. the person meets all inclusion criteria for the clinical trial and is not treated "off-protocol";
4. the trial is approved by the institutional review board of the institution administering the treatment;
and
5. coverage will not be extended to clinical trials conducted at non-participating facilities if a person
is eligible to participate in a covered clinical trial from a participating provider.
12. In compliance with the Affordable Care Act, under DESCRIPTION OF MEDICAL BENEFITS the last
sentence of the Contraceptives section is deleted. Emergency contraceptives will be an eligible
expense.
13. Under DESCRIPTION OF MEDICAL BENEFITS, Weight Loss Treatment is amended to read as
follows:
Charges for non-surgical weight loss treatment, but only for participants with a body mass index (BMI)
of thirty (30) kilograms per meter squared or higher. Eligible weight loss expenses shall include only
those expenses that are medically necessary, including office visits, laboratory tests and prescription
drugs. (Prescription drugs for weight loss will be covered under the prescription drug benefit.) Bariatric
surgery will NOT be considered an eligible expense. Other ineligible expenses include, but are not
limited to, food, food replacements, dietary supplements, weight loss group membership fees, exercise
or fitness classes, gym membership fees and other costs related to diet and exercise.
14. Under SCHEDULE OF PRESCRIPTION DRUG BENEFITS (Plan A) the first paragraph is amended
to read as follows:
Participant pays 100% of all prescription charges until deductible is met; Plan pays 100% of all eligible
prescription expenses thereafter. Plan will pay only for generic drugs (after participant meets
deductible) unless there is no generic equivalent or a brand drug is required by participant's provider. If
a generic is available, a Participant who elects to use a brand drug as a matter of preference will be
responsible for the difference in cost between the brand and the generic prescription.
15. Under SCHEDULE OF PRESCRIPTION DRUG BENEFITS (Plan B) the following paragraph is
added:
Plan will pay only for generic drugs under the copay arrangement detailed below, unless there is no
generic equivalent or a brand drug is required by participant's provider. If a generic is available, a
Participant who elects to use a brand drug as a matter of preference will be responsible for the brand
copayment plus the difference in cost between the brand and the generic prescription.
16. Under SCHEDULE OF PRESCRIPTION DRUG BENEFITS (Plan B) the copays are amended as
follows:
Pharmacy Copay:
(each prescription fill, see dispensing limitations)
Generic Formulary Drugs $10 per 30-day supply
(or portion thereof)
Brand Name Formulary Drugs $60 per 30-day supply
(or portion thereof)
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Non-Formulary Drugs $100 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 per 90-day supply
(or portion thereof)
Brand Name Formulary Drugs $120 per 90-day supply
(or portion thereof)
Non-Formulary Drugs $200 per 90-day supply
(or portion thereof)
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.
17. Under PRESCRIPTION DRUG EXCLUSIONS, #5 is amended to read as follows:
5. Charges for experimental or investigational drugs, including compound medications for non-FDA
approved use, unless such drugs are covered under the Clinical Trial provisions of the Description of
Medical Benefits.
18. Under DENTAL EXCLUSIONS, #7 is amended to read as follows:
7. Charges for the diagnosis and treatment of temporomandibular joint disorder.
19. Under ELIGIBILITY PROVISIONS (Termination of Employee Coverage), #5 is amended to read as
follows:
5. the date the employee becomes eligible for Medicare due to having attained the age of 65, if covered
as a retiree or an early retiree, or as the spouse of an employee who dies in the line of duty; or
20. Under ELIGIBILITY PROVISIONS (Termination of Employee Coverage), the final paragraph is
amended to read as follows:
Proof of loss of coverage shall be provided as necessary.
21. Under ELIGIBILITY PROVISIONS (Termination of Dependent Coverage), #8 is amended to read as
follows:
8. the date the dependent becomes eligible for Medicare due to having attained the age of 65, if the
employee is covered as a retiree or an early retiree;
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22. Under ELIGIBILITY PROVISIONS (Termination of Dependent Coverage), the second to last
paragraph is amended to read as follows:
Proof of loss of coverage shall be provided as necessary
23. ELIGIBILITY PROVISIONS (Dependent Spouse of a Retiree) is amended to read as follows:
The spouse of an employee who qualifies as a retiree or an early retiree (hereinafter jointly referred to
as "retiree") may continue to be enrolled in the Plan after the retiree becomes eligible for Medicare due
to having attained the age of 65 or dies. Coverage may be continued until the date the spouse
becomes eligible for Medicare due to having attained the age of 65, provided that the spouse makes
timely payment of the required contributions. Other dependents already in the Plan at the time of the
retiree's Medicare eligibility or death may remain in the Plan, but no new dependents may be added.
24. Under GENERAL PLAN EXCLUSIONS, #13 is amended to read as follows:
13. Charges for services and supplies that are either experimental or investigational, unless such
services and supplies are covered under the Clinical Trials provision of the Description of Medical
Benefits.
25. Under CLAIMS INFORMATION (Pending a Claim)#3 is amended to read as follows:
3. when the claim is being subrogated.
26. The following DEFINITIONS are deleted in their entirety: Late Enrollee, Preexisting Condition and
Temporomandibular Joint Disorder.
In all other respects the Plan remains unchanged.
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
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Diana Cordray, 1AMS{Clerk-Treasurer Date
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