City of Carmel Health Benefit Plan Amendment Health Plan Amendment
NINTH 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 a First,
Second, Third, Fourth, Fifth, Sixth, Seventh and Eighth 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, 2011, the Plan is amended as follows.
I. In accordance with the Patient Protection and Affordable Care Act, the $2 million Lifetime
Maximum Benefit for Treatment of ALL Medical Conditions Combined is deleted under the
SCHEDULE OF MEDICAL BENEFITS (PLAN B) and SCHEDULE OF MEDICAL
BENEFITS (PLAN C).
II. In accordance with the Patient Protection and Affordable Care Act, Colonoscopy is deleted
from the SCHEDULE OF MEDICAL BENEFITS (PLAN B) and SCHEDULE OF MEDICAL
BENEFITS (PLAN C). Colonoscopies will be included under Wellness benefits.
III. In accordance with the Patient Protection and Affordable Care Act, the calendar year
maximum benefit for Chiropractic Care is changed from $600 to 40 visits under the
SCHEDULE OF MEDICAL BENEFITS (PLAN B) and SCHEDULE OF MEDICAL
BENEFITS (PLAN C).
IV. In accordance with the Patient Protection and Affordable Care Act, the Wellness benefit
under the SCHEDULE OF MEDICAL BENEFITS (PLAN B) and SCHEDULE OF MEDICAL
BENEFITS (PLAN C) is amended to read as follows:
*Deductible will apply only if annual wellness benefit subject to deductible exceeds $500
Wellness benefits include, but are not limited to:
Routine Pap Smear one (1) per calendar year
Routine Mammogram:
one (1) baseline mammogram for females ages 35 through 39
one (1) mammogram per calendar year for females ages 40 and over
Routine Colorectal Screening (fecal occult blood testing, sigmoidoscopy, or colonoscopy)
for males and females ages 50 through 75
Childhood and Adult Immunizations, as recommended by the Centers for Disease
Control (CDC)
Physicals and Well Baby Care
V. In accordance with the Patient Protection and Affordable Care Act, the paragraph
regarding newborns and adopted children under age 18 is deleted from the SCHEDULE
OF MEDICAL BENEFITS (PLAN B) and SCHEDULE OF MEDICAL BENEFITS (PLAN C)
under the Preexisting Condition Limitation sections and from PREEXISTING CONDITION
LIMITATION under the Preexisting Conditions section. The following statement is added
to each of the same sections:
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Health Plan Amendment
The preexisting condition limitation does not apply to a covered employee Tess than
nineteen (19) years of age or a covered dependent less than nineteen (19) years of
age.
VI. In accordance with the Patient Protection and Affordable Care Act, the Wellness section
under DESCRIPTION OF MEDICAL BENEFITS is amended to read as follows:
WELLNESS
Charges for routine health care that includes immunizations screenings, check -ups and
counseling to prevent illness, disease or other health problems, as stated in the Schedule
of Medical Benefits.
Charges will be paid under this benefit only when there is no diagnosis of illness or injury
indicated.
VII. In accordance with the Patient Protection and Affordable Care Act, the Eligible
Dependents section under ELIGIBILITY PROVISIONS is amended to read as follows:
ELIGIBLE DEPENDENTS
Eligible dependents are:
1. The employee's legal spouse or registered domestic partner, if the spouse or domestic
partner is not covered under this Plan as an employee;
2. The employee's child under age twenty -six (26); and
3. The employee's disabled dependent child age twenty -six (26) or over, who meets the
criteria listed below.
A newborn child of an employee or an employee's registered domestic partner 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, copies of birth certificates, marriage
certificates and divorce decrees, verification of domestic partner status, copies of federal
income tax returns, and adoption, guardianship or placement orders 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 parent.
If both parents are covered employees under this Plan, and the spouse carrying
dependent coverage terminates coverage under the Plan, dependent coverage can be
transferred to the spouse who remains covered by the Plan, provided that individual
continues to be an eligible employee. A spouse who terminates coverage may also be
covered as a dependent under the remaining spouse's coverage.
VIII. In accordance with the Patient Protection and Affordable Care Act, the Adopted
Children /Legal Guardianships section under ELIGIBILITY PROVISIONS is amended to
read as follows:
An adopted child of an employee 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
who is related to the employee by blood or marriage and for whom the employee has
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Health Plan Amendment
assumed legal guardianship 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
IX. In accordance with the Patient Protection and Affordable Care Act, the section Full -Time
Students on Medically Necessary Leaves of Absence under ELIGIBILITY PROVISIONS is
deleted in its entirety.
X. In accordance with the Patient Protection and Affordable Care Act, the Disabled
Dependent Children section under ELIGIBILITY PROVISIONS is amended to read as
follows:
Disabled Dependent Child
Coverage for an unmarried disabled dependent child may be continued after age twenty -six
(26), provided the child was disabled prior to his twenty -sixth (26 birthday, and provided
satisfactory medical proof of incapacity is submitted to the Plan Administrator within thirty
(30) days after his twenty -sixth (26th) birthday.
The documentation must show that the dependent:
1. is mentally or physically incapable of self- support;
2. is expected to be incapacitated for a period of twelve (12) months or longer; and
3. depends on the covered employee for his support.
The Plan Administrator may require periodic proof of a continuing disability, but not more
than one time per 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 twenty -six (26) will not be eligible to re- enroll for
coverage as a disabled dependent child under the Plan.
XI. In accordance with the Patient Protection and Affordable Care Act, the following sections
are added under ELIGIBILITY PROVISIONS:
SPECIAL ENROLLMENT PERIOD DUE TO EXTENSION OF DEPENDENT AGE TO
TWENTY -SIX (26)
A dependent child who ceased to be eligible for participation in the Plan prior to the
passage of the Patient Protection and Affordable Care Act shall be provided with a one-
time thirty (30) day special enrollment period. All dependent children whose coverage
under this Plan had previously ended, or who were denied coverage (or were not eligible
for coverage) because the availability of dependent coverage of children ended before age
twenty -six (26), are eligible to enroll, or re- enroll, in the Plan under this special enrollment
period. The special enrollment period will begin November 15, 2010. Coverage for
dependents that enroll during this special enrollment period will become effective January
1, 2011.
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Health Plan Amendment
SPECIAL ENROLLMENT PERIOD FOR PREVIOUSLY ENROLLED COVERED
EMPLOYEES AND COVERED DEPENDENTS WHO HAVE EXCEEDED THE LIFETIME
MAXIMUM BENEFIT
A covered employee or a covered dependent who was previously enrolled, but was
terminated from the Plan due to exhaustion of the lifetime maximum benefit shall be
provided with a one -time thirty (30) day special enrollment period. All covered persons
whose coverage under this Plan had previously ended, or who were denied coverage (or
were not eligible for coverage) because the prior lifetime maximum benefit had been
exhausted, are eligible to enroll, or re- enroll, in the Plan under this special enrollment
period. The special enrollment period will begin November 15, 2010. Coverage for
dependents that enroll during this special enrollment period will become effective January
1, 2011.
XII. In accordance with the Patient Protection and Affordable Care Act, the Termination of
Dependent Coverage section under ELIGIBILITY PROVISIONS is amended to read as
follows:
TERMINATION OF DEPENDENT COVERAGE
Dependent coverage will end on the earliest of the following dates:
1. the date the employee's coverage ends;
2. the date the dependent ceases to qualify as an eligible dependent under the Plan (a
spouse will not cease to be an eligible dependent until the participant provides written
proof of divorce or legal separation);
3. December 31 of the year the participant requests that dependent coverage end as part
of the annual open enrollment process;
4. the end of the period for which the employee made any required contributions, if the
employee fails to make any further required contributions;
5. the date the Plan is changed to end coverage for a class to which the dependent
belongs;
6. the date the dependent becomes covered as an employee;
7. the date the dependent enters the armed forces of any country on a full -time active -duty
basis;
8. the dependent's Medicare eligibility date, if the employee is covered as a retiree or an
early retiree;
9. the date the Plan is terminated; or
10. the date the eligible dependent dies.
In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
a Certificate of Coverage shall be issued when dependent coverage ends, indicating the
period of time the dependent was covered under this Plan. The certificate may help reduce
the preexisting exclusion period of any plan that provides coverage subsequent to this
Plan.
A dependent who ceases to be eligible for coverage under the Plan may be eligible for
COBRA coverage.
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Health Plan Amendment
XIII. In accordance with the Patient Protection and Affordable Care Act, #2 under GENERAL
PLAN EXCLUSIONS is amended to read as follows:
2. Charges for services and supplies that exceed the annual and /or lifetime maximum
benefits stated in the Schedule of Benefits.
XIV. Under CLAIMS INFORMATION, the Pending a Claim section is amended to read as
follows:
PENDING A CLAIM
A claim that has been filed with the Third Party Administrator may be pended under
circumstances that include, but are not limited to:
1. when there is not enough information to process the claim;
2. when coordination of benefits information is needed; or
3. when preexisting conditions are being determined.
Once a claim has been pended, the claimant and provider (if applicable) shall receive a
letter from the Third Party Administrator requesting the information needed to process the
claim. If necessary, three (3) additional letters will be sent, one every thirty (30) days, for a
total of ninety (90) days. If the required information is not provided within that time period,
the claim will be denied. The claimant has the right to appeal any denial within 180 days of
the date of the denial.
XV. In accordance with the Patient Protection and Affordable Care Act, the DEFINITIONS for
Full -Time Student, Institution of Higher Education and Totally Disabled are eliminated in
their entirety. The following DEFINITIONS are added or amended:
Child
A participant's child under twenty -six (26) years of age. 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.
Dependent
An eligible participant's spouse, domestic partner, child under the age of twenty -six (26)
and /or an eligible disabled dependent child age twenty -six (26) or over.
Disabled Dependent Child
A child who is physically or mentally incapable of self- support upon attaining age twenty -six
(26). The covered employee is required to provide periodic medical proof of the child's
incapacity.
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 age nineteen (19) or over will be
subject to a pre- existing condition limitation of up to eighteen (18) months.
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Health Plan Amendment
Maximum Benefit
The highest calendar year and /or lifetime benefit payable under this Plan as, described in the
Schedule of Benefits.
Wherever the word "lifetime" appears in this Plan in reference to benefit maximums and
limitations, it is understood to include both this Plan and any previous plans of the Employer.
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
PI 1,2
lams Brain.., Presiding icer Date
t4■
M: ry An oa, Member Date
ilk 0
Lori Watsd Be :1 Member Date
ATTES
Di. a Cordray, IA, Clerk- Treasurer Date
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