Morris & Assoc Sec Amend Pln/Hr SECOND AMENDMENT
TO THE CITY OF CARMEL
EMPLOYEE HEALTH BENEFIT PLAN
FX3330
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 a First
Amendment 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, 2005, the Plan is amended as specified below.
tl.
The following line is added to the section entitled LIFETIME MAXIMUM BENEFITS (Plans
A, B and C):
Laser Eye Surgery
$250 pereye
The following is added to the section entitled SCHEDULE OF MEDICAL BENEFITS (Plans
A, B and C):
PREFERRED BENEFIT
NON-PREFERRED BENEFIT
LASER EYE SURGERY 100% 100%
Copay Applies: No No
Deductible Applies: No No
Lifetime Maximum .................................................................................. $250 per eye
III. The following is added under the section entitled DESCRIPTION OF MEDICAL BENEFITS:
IV.
LASER EYE SURGERY
Charges for laser correction of myopia, hyperopia, presbyopia, astigmatism and other
imperfect refractive powers of the eye, as stated in the Schedule of Medical Benefits.
Paragraph 2 under the section entitled MEDICAL EXCLUSIONS is amended to read as
follows:
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, except as stated and
limited in the Schedule of Medical Benefits.
In the section entitled SCHEDULE OF MEDICAL BENEFITS (PLAN A), SUB-SECTION
PRESCRIPTION DRUGS, the copay for drugs purchased through the major medical plan
(Plan A) is amended as follows:
PREFERRED BENEFIT
NON-PREFERRED BENEFIT
PRESCRIPTION DRUGS:
Copay Applies:
Deductible Applies:
100% 80%
Yes ($25) No
No Yes
One copay will apply to each 30 day supply (or portion thereof);
maximum 90-day supply per prescription
VI.
In the sections entitled SCHEDULE OF MEDICAL BENEFITS (PLAN B) AND SCHEDULE
OF MEDICAL BENEFITS (PLAN C), SUB-SECTION PRESCRIPTION DRUGS, the copay
for drugs purchased through the major medical plan (Plans B and C) is amended as
follows:
PREFERRED BENEFIT
NON-PREFERRED BENEFIT
PRESCRIPTION DRUGS: 100%
Copay Applies: Yes ($30)
Deductible Applies: No
80%
No
Yes
One copay will apply to each 30 day supply (or portion thereof);
maximum 90-day supply per prescription
VII. The section entitled PHARMACY COPAY (PLAN A) is amended to read as follows:
PHARMACY COPAY:
(each prescription fill, see dispensing limitations)
Generic Drugs/Single Source Brand Name Drugs
$10 per 30 day supply
(or portion thereof)
Brand Name Drugs
$25 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.
VIII. The section entitled PHARMACY COPAY (PLANS B AND C) is amended to read as
follows:
PHARMACY COPAY:
(each prescription fill, see dispensing limitations)
Generic Formulary Drugs
Brand Name Formulary Drugs
Non-Formulary Drugs
$10 per 30 day supply
(or portion thereof)
$20 per 30 day supply
(or portion thereof)
$30 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.
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IX.
Under SCHEDULE OF DENTAL BENEFITS, the Section entitled MAXIMUM BENEFITS is
amended to read:
Maximum Calendar Year Benefit per Participant (Non-Orthodontia) ............................ $1,500
Maximum Lifetime Benefit per Participant for Orthodontia ........................................... $1,500
X. The section entitled ELIGIBLE DEPENDENTS is amended to read as follows:
Eligible dependents are:
1. The employee's spouse, if the spouse is not covered under this Plan as an employee.
2. The employee's natural child, stepchild or legally adopted child who meets all of the
following conditions:
a) is unmarried;
b) qualifies as a dependent exemption on the employee's federal income tax return;
and
c) is under the age of nineteen (19), or age twenty-three (23) if a full-time student,
as defined herein, at an accredited institution of higher education, unless the
dependent is a disabled dependent child.
A child who has been placed under the legal custody or guardianship of the employee
who meets all of the following conditions:
a) is unmarried;
b) qualifies as a dependent exemption on the employee's federal income tax return;
c) is under the age of nineteen (19), or age twenty-three (23) if a full-time student,
as defined herein, at an accredited institution of higher education, unless the
dependent is a disabled dependent child; and
d) if under age eighteen (18), resides in the employee's home.
A newborn child of an employee will automatically be covered for the first thirty (30) days of
life.
The Plan Administrator reserves the right to require full documentation of any claim for
dependent qualification including, but not limited to, verification of full-time student status,
copies of marriage licenses and divorce decrees, adoption, guardianship or placement
orders or similar documentation giving the employee legal responsibility for a dependent
child.
No participant is eligible for coverage both as an employee and as a dependent. If both
parents of a child are covered employees under this Plan, the child may be covered as the
dependent of only one (1) parent.
Adopted ChildrenlLe,qal Guardianships
An adopted child of a participant will be eligible for coverage as of the date of legal placement
for adoption, or the date of actual adoption, whichever occurs first. A child under the legal
guardianship of a participant will be eligible for coverage on the date the guardianship
becomes effective.
Coverage under the Plan for an adopted child or a child under legal guardianship will be the
same coverage that is available to all other dependent children under the Plan, except that all
XI.
Xll.
preexisting condition exclusions or waiting periods will be waived for such a child, provided
the child is enrolled within the time period specified under the section entitled Special
Enrollment Period Provision Due to Dependent Acquisition.
The section entitled EFFECTIVE DATE FOR NORMAL ENROLLMENT is amended to
read:
The employee must file a written application with the Employer for himself and his eligible
dependents within sixty (60) days of his full-time hire date. The employee must enroll for
employee benefits in order to also enroll for dependent benefits. The employee is
responsible for timely forwarding to the Employer the application for enrollment. If the
employee fails to enroll for coverage for himself or any eligible dependents within sixty (60)
days, he will be able to enroll only during an Open Enrollment period unless he qualifies for
enrollment under the Special Enrollment provisions below.
The effective date of coverage under this Plan as the result of normal enrollment will be the
first day following the satisfaction of the waiting period if coverage is requested prior to the
end of the thirty (30) day waiting period. If coverage is not elected during the thirty (30) day
waiting period, but is elected during the thirty (30) days immediately following the
completion of the waiting period, then coverage will be effective as of the date of the
election. The date of election will be the date the written application is submitted to the
Employer.
The section entitled SPECIAL ENROLLMENT PERIOD PROVISION DUE TO OTHER
COVERAGE is amended to read:
An employee and/or dependent who did not enroll for coverage under this Plan because he
had other coverage when he initially became eligible for coverage under this Plan may
request a special enrollment period under this provision if he is no longer eligible for the
other coverage. The employee must provide the Employer with written proof of the loss of
coverage and the reason for loss. A special enrollment period will be granted if the
employee and/or dependent loses eligibility due to one (1) or more of the following:
1. divorce or legal separation;
2. termination of other employment;
3. reduction in the number of hours of employment;
4. cessation of the employer contributions (by any current or former employer) for the
other coverage;
5. exhaustion of COBRA benefits; or
6. death of the employee.
The end of any extended benefits period that has been provided due to any of the above
items one (1) through six (6) will also be considered a loss of eligibility.
Loss of eligibility will also include the decision to discontinue coverage provided by another
employer during the other employer's designated open enrollment period that does not
coincide with the Plan's open enrollment period.
Loss of eligibility does not include failure of the individual to pay premiums or contributions
on a timely basis or termination of other coverage for cause (such as making a fraudulent
4
claim or an intentional misrepresentation of a material fact in connection with the other
coverage).
The employee and/or dependent must apply for coverage under the Plan within thirty (30)
days of losing his other coverage. The effective date of coverage under this Plan as the
result of special enrollment will be the date of the loss of eligibility if coverage is requested
within thirty (30) days. If the employee fails to enroll for coverage for himself or any eligible
dependents within thirty (30) days, he will be able to enroll only during an Open Enrollment
period.
An employee and/or dependent who enrolls during a Special Enrollment period is not
treated as a late enrollee.
XIll. The section entitled SPECIAL ENROLLMENT PERIOD PRQVISION DUE TO DEPENDENT
ACQUISITION is amended to read:
An eligible employee who previously declined coverage, but then acquires a new
dependent, may request a special enrollment period for himself and his eligible
dependents. A special enrollment period will be granted for one (1) or more of the following
events:
1. a marriage (the new spouse may be added, and/or the spouse's children who qualify as
eligible dependents);
2. the birth, adoption, placement for adoption of a new child, or commencement of legal
guardianship (the child and/or the spouse may be added).
In the case of birth, adoption, placement or legal guardianship, the spouse must be given a
special enrollment period (if otherwise eligible) even if coverage under the Plan was
previously declined.
The employee must make written application for employee and/or dependent coverage
under the Plan within thirty (30) days of the acquisition of the dependent. The effective
date of coverage as the result of a special enrollment period will be the date of the event
(marriage birth, adoption, placement or guardianship) if coverage is requested within thirty
(30) days of the event. If the employee fails to enroll for coverage for himself or any eligible
dependents within thirty (30) days, he will be able to enroll only during an Open Enrollment
period.
An employee and/or dependent who enrolls during a special enrollment period is not
treated as a late enrollee.
XIV. The section entitled OPEN ENROLLMENT is amended to read:
Open enrollment is the period designated by the Employer each year during which the
employee makes coverage elections for the following calendar year.
Absent a Special Enrollment period, the open enrollment period allows an employee the
opportunity to enroll for coverage, terminate coverage, add or delete dependent coverage or
select another plan option. An employee must make written application for coverage during
the open enrollment period. Coverage for any employee or dependent who is enrolling
during an open enrollment period shall become effective January 1 of the succeeding
calendar year.
An employee or dependent who enrolls during the open enrollment period will be treated as a
late enrollee, and will be subject to a pre-existing condition limitation of up to eighteen (18)
months.
XV. The section entitled LATE ENROLLEE PROVISION is deleted in its entirety.
XVI. The following definition is added under the section entitled DEFINITIONS:
Late Enrollee
An employee and/or his dependents who make written application for coverage under the
Open Enrollment provisions of the Plan. A late enrollee will be subject to a pre-existing
condition limitation of up to eighteen (18) months.
In all other respects the Plan remains unchanged.
CITY OF CARMEL~ INDIANA
By and through its Board of Public Works and Safety
~inard~P~ d~ i'~ng ~
../~iana Cordray, IAMC Clerk,:'Creasurer
~,- ~dr~ M. Johnso~
~epu~ Clerk for
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