HomeMy WebLinkAbout1982-178I RESOLUTION NO. 82-178
2 RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE EXECUTION OF
AN AGREEMENT WITH BLUE CROSS OF SOUTHERN CALIFORNIA RELATING TO A SELF-FUNDED
3 MEDICAL BENEFIT PLAN, EFFECTIVE DECEMBER 1, 1981.
4 BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN
BERNARDINO AS FOLLOWS:
5
SECTION 1. The Mayor of the City of San Bernardino is hereby authorized
6
and directed to execute on behalf of said City an Agreement with Blue Cross
7
of Southern California relating to a self-funded medical benefit plan, effec-
8
tive December 1, 1981, a copy of which is attached hereto, marked Exhibit "A."
9
and incorporated herein by reference as fully as though set forth at length.
10 4
18
19
20 �City Clerk
21 The foregoing resolution is hereby approved this x,70 7"�- day of
22 Anril 1982.
23
24
25 II Approved as to form:
26
27
28 ity Attibrney
I HEREBY CERTIFY that the
foregoing resolution was duly adopted by the
11
Mayor and Common
Council of the
City of San Bernardino at a
12
regular
meeting thereof,
held on the 19th day of April
,
13
1982, by the
following vote, to
wit:
14
AYES:
Council Members
Castnaeda, Reilly, Hernandez,
15
Quiel, Strickler
16
NAYS:
None
17
ABSENT:
Council Member Botts, Hobbs
18
19
20 �City Clerk
21 The foregoing resolution is hereby approved this x,70 7"�- day of
22 Anril 1982.
23
24
25 II Approved as to form:
26
27
28 ity Attibrney
EXHIBIT II
CITY OF SAN BERNARDIN0
Summary of Expected Costs of Blue Cross Medical Plan
Assumptions
1. Number of employees covered remains constant at 964.
2. Monthly per capita charges as follows:
Effective
12/1/81
Administration $ 5.00
Stop -Loss Coverage 6.24
$ 11.24
Effective
12/1/82
$ 5.75 (estimated)
7.50 (estimated)
$ 13.25
3. Foundation standards do not increase effective December 1, 1982.
If standards increase by the same percentage effective in 1980
and 1981 (1270), claims from December, 1982 to July, 1983 would
increase by about $15,000.
Stop -Loss
Month
Paid Claims
Administration
Coverage
Total Cost
07/82
$ 81,750
$ 4,820
$ 6,015
$ 92,585
08/82
82,800
4,820
6,015
93,635
09/82
83,900
4,820
6,015
94,735
10/82
85,000
4,820
6,015
95,835
11/82
86,125
4,820
6,015
96,960
12/82
87,375
5,543
7,230
100,148
01/83
89,000
5,543
7,230
101,773
02/83
90,125
5,543
7,230
102,898
03/83
91,300
5,543
7,230
104,073
04/83
92,500
5,543
7,230
105,273
05/83
93,700
5,543
7,230
106,473
06/83
94,825
5,543
7,230
107,598
$ 1,058,400
$ 621901
$80,685
$1,201,986
Assumptions
1. Number of employees covered remains constant at 964.
2. Monthly per capita charges as follows:
Effective
12/1/81
Administration $ 5.00
Stop -Loss Coverage 6.24
$ 11.24
Effective
12/1/82
$ 5.75 (estimated)
7.50 (estimated)
$ 13.25
3. Foundation standards do not increase effective December 1, 1982.
If standards increase by the same percentage effective in 1980
and 1981 (1270), claims from December, 1982 to July, 1983 would
increase by about $15,000.
n
m
n
3
7
X
O
O
C
00
C
CG O
(D
D
C+ C+
Z w
0
w
O J
C+ J
C
J
(D
o
N
t'
(D - r
a
C
r`
a J
O
o
o a
C') J. w
(-)
n
n to
O
J
O
V
,+
r+n
r+
co
A
W
N
o
m
A
N
a
w e+
N
0
W
w w
J•�c
(n
co
-s r+
a
O
co
CD (D
O
O
N
ID
C
O
• H
n
7
V1
J
00
A
7
C+
D
V
3
A
C
J
V+ J
0
(D
o
N
�
fD
cC +
3
�
a
O
O
t0
N
C)
w
w
O
J
O
V
O f)
r+
co
A
W
N
o
A
N
W
t0
W
W
A
(n
co
f+
O
O
co
O
O
N
O
O
O
N
O
O
O
O
v+
N
r
?
V
�
J
W
(n
N
In
D
Cn
(Il
CT
(n
W
O
lD
Ot
w
W
EH
to
(n
O
J
O
O
O
w
O
O
O
O
ID
N
fA
J
J
C-�
N
O
S
to
A
7
C.11
U'1
V
Z
O
CO
A
J
A
O
N
W
A
m
CD
CD
O
O
O
O
O
O
A
O
I
I
irR
J
J
N
O
N
J
O
A
O
A
_
z
J
A
A
N
O
A
O
O
_
0
0
CD
J
O
O
O
N
O
O
O
U
O
J
J
w
01
N
�c
O1
J
J
V
W
N
W
W
O
N
Cn
co
rn
r
r
N
J
O
O
O
O
0
0
o
rn
a
-i
• H
n
A
7
C+
D
V
C
J
V+ J
J
w
co
N
�
cC +
W
J
O
t0
N
CT
Ot
A
O
V
O
V
O f)
r+
co
A
0
0
o
fn
o (n
w
w
W
C+
C
v f}
f+
0
C
V
fD
W
N
r
?
V
0
W
A
LO
In
D
O
LO
lD
O
a
O
EH
W_
O
CD
ID
N
O
C-�
t0
S
f7
C
7
Z
N
0
O
suS
to
m
CD
Ul
J
Ol
(n
N
N
O
I
I
C
h
O
N
N
O
W
O
A
A
O
_
z
r+
P,
C7
w
w
O
ID
CD
m
X
S
H
W
M
A
V
�
co
cC +
W
J
O
t0
N
CT
Ot
w
O
V
O
V
O
co
A
A
fn
W
C
V
fD
W
N
?
V
W
A
LO
W
D
O
LO
lD
O
a
O
V
V
O
V
O
S
7
suS
7
O
f)
N
O
I
I
W
\
n
1
I
W
7t'
Vi
z
(D
F
_
K
co
O
Z
w
�c
O1
(n
w
cn
W
r
O
N
A
M
O
to t0
A
N
(D
V
Z
N
C
o
a
J
N
N
C
j
Co
J
w
w
io
V
w
O
A
CO
(n
0
0
0
0
r+
P,
C7
w
w
O
ID
CD
m
X
S
H
W
M
GROUP HOSPITAL AND
PROFESSIONAL SERVICE AGREEMENT
ISSUED BY
BLUE CROSS OF SOUTHERN CALIFORNIA
In consideration of payment of charges in the amount and manner herein provided, BLUE
CROSS OF SOUTHERN CALIFORNIA, a nonprofit hospital service plan herein called
"BLUE CROSS", hereby agrees with CITY OF SAN BERNARDINO, herein called "EM-
PLOYER", to furnish benefits to eligible employees and their eligible family members and
provide certain administrative services in connection with the operation of the Employer's
group medical benefit plan according to all terms and conditions of this Agreement.
NOTHING CONTAINED IN THIS AGREEMENT SHALL IN ANY MANNER RESTRICT
OR INTERFERE WITH THE RIGHT OF ANY INDIVIDUAL ENTITLED TO SERVICE
AND CARE TO SELECT THE CONTRACTING HOSPITAL, CONTRACTING SKILLED
NURSING FACILITY OR TO MAKE A FREE CHOICE OF HIS ATTENDING PHYSI-
CIAN OR SURGEON WHO SHALL BE THE HOLDER OF A VALID AND UNREVOKED
PHYSICIAN'S OR SURGEON'S CERTIFICATE AND WHO IS A MEMBER OF, OR
ACCEPTABLE TO, THE ATTENDING STAFF AND BOARD OF DIRECTORS OF THE
FACILITY IN WHICH SERVICES ARE TO BE PROVIDED AND RENDERED. PAYMENT
OF BENEFITS HEREIN SHALL NOT BE CONSTRUED AS REGULATING THE FEE
WHICH A PHYSICIAN OR SURGEON MAY CHARGE FOR HIS SERVICES OR AS
ATTEMPTING TO EVALUATE HIS SERVICES.
A-2999 12181 PAGE 1
ARTICLE I. Definitions
A. A "SUBSCRIBER" shall be the eligible employee of the EMPLOYER who must be
concurrently enrolled under this Agreement and the Base Program.
B. A "FAMILY MEMBER" is the eligible dependent of a Subscriber who must be con-
currently enrolled under this Agreement and the Base Program.
C. 'BASE PROGRAM" shall mean the self-insured health care plan as set forth in
Appendix A of this Agreement which EMPLOYER agrees to provide to his employees
and their dependents at all times during which this Agreement remains in effect.
D. "SPECIFIC STOP -LOSS POINT" shall mean that point at which $25,000 of claim
payments have been made under the Base Program for expenses incurred between
December 1, 1981 and December 1, 1982, and paid by December 1, 1982, for any one
individual Subscriber or Family Member.
E. "CONTRACT YEAR" is the annual term which begins on the effective date of this
Agreement.
ARTICLE II. Term of Agreement
A. This Agreement will become effective on December 1, 1981 at 12:01 a.m. standard time
of Los Angeles, California, and will remain in effect for an initial term of twelve (12)
consecutive months, subject to the payment of all subscription charges set forth under
Article VI herein.
B. It is agreed between the parties hereto that this Agreement, unless terminated by either
party as provided in Article 11, C (below), shall automatically renew on an annual basis
thereafter on the same terms and conditions, subject to the renegotiation of Subscrip-
tion Charges and Stop -Loss Points and Agreement between the involved parties prior
to the commencement of the renewal term.
C. This Agreement may be terminated by either party at the end of any annual term by
giving the other party thirty (30) days prior notice, in writing, of its intent to terminate.
ARTICLE III. Eligibility
A. Eligibility for Subscribers and their eligible dependents under this Agreement shall be
as set forth in the Base Program of the EMPLOYER and contained in Appendix A and
incorporated herein as if set forth in full. To be eligible for benefits under this Agree-
ment, a Subscriber or Family Member must be enrolled under the Base Program.
EMPLOYER agrees to provide BLUE CROSS with adequate and complete eligibility
information necessary to carry out performance of this Agreement.
A-2999 12/81
PAGE 2
ARTICLE IV. Consideration to be Provided by Blue Cross
A. During the continuance of this Agreement, BLUE CROSS shall make benefit payments
and perform other services for EMPLOYER as set forth in Appendix B of this Agree-
ment.
B. EMPLOYER authorizes BLUE CROSS to withdraw daily such funds as are necessary to
satisfy the above charges directly from EMPLOYER'S bank account established in
accordance with Article VII herein.
ARTICLE V. Stop -Loss Arrangement
A. EMPLOYER agrees to assume full liability for all claims paid under this Agreement by
BLUE CROSS in good faith after the effective date of this Agreement. However, BLUE
CROSS shall provide Stop -Loss protection whereby EMPLOYER'S liability for all
claim payments made during the current contract year of this Agreement shall not
exceed the Specific Stop -Loss Point as defined herein.
B. EMPLOYER shall be solely liable, irrespective of any Stop -Loss point referred to
above, for any monetary recoveries awarded a claimant by any court of law or adminis-
trative body arising out of the payment or non-payment of a claim under the plan. In
no event shall any such recovery, in excess of benefit amounts due under the plan, be
included in part or in whole as part of paid claims figures for purposes of Stop -Loss
protection calculations referred to above.
ARTICLE VI. Subscription Charges
A. EMPLOYER shall pay to BLUE CROSS, in advance, a monthly subscription charge of
$11.24 for each Subscriber covered hereunder. Such charges shall be due and payable
on the first day of each month and shall be based upon eligibility information for the
previous month given to BLUE CROSS by EMPLOYER. Subsequent adjustments in
charges will be made in the event there have been any changes in enrollment for the then
current month. A grace period of thirty-one (31) days shall be allowed for the payment
of subscription charges during which time this Agreement shall remain in effect. In the
event this Agreement terminates for any reason, the EMPLOYER shall be liable for all
subscription charges due and owing including any charges for any time this Agreement
is in force during a grace period. Additionally, should the EMPLOYER fail to pay any
installment of subscription charges after a grace period, this Agreement shall terminate
without the necessity of notice to the EMPLOYER or Subscriber.
A-2999 12/81
PAGE 3
ARTICLE VII. Banking Arrangements
A. During the term of this Agreement, EMPLOYER agrees to establish and maintain a
bank account to provide funds for benefits paid under the terms of this Agreement.
BLUE CROSS shall make benefit payments for hospital and professional chargesdirectly
from its own general funds and shall thereafter be periodically reimbursed directly
from EMPLOYER'S bank account.
B. EMPLOYER agrees to assure that sufficient funds are available at all times in the plan
bank account to fully cover all benefit payments made by BLUE CROSS on behalf of
the plan. BLUE CROSS shall have the authority and power to make direct demands
upon such account on a weekly basis for purposes of reimbursement.
C. Responsibilities between the parties hereto with respect to EMPLOYER'S bank account
shall be as set forth in Article VIII of this Agreement.
ARTICLE VIII. Relationship and Responsibilities of EMPLOYER and BLUE CROSS
A. Except as specifically provided to the contrary herein, EMPLOYER retains all final
authority and responsibility for the plan and its operation, and BLUE CROSS is em-
powered to act on behalf of EMPLOYER in connection with the plan only as expressly
stated in this Agreement.
B. BLUE CROSS shall, to the extent reasonably possible, advise EMPLOYER as to matters
which come to its attention involving potential legal actions involving the plan and shall
promptly advise EMPLOYER of legal actions commenced against EMPLOYER which
come to its attention. The defense of any legal action involving a claim for benefits
under the plan, including but not limited to any actions arising from or in connection
with the Employee Retirement Income Security Act of 1974, shall not be the obligation
of BLUE CROSS but it is understood and agreed that BLUE CROSS shall fully co-
operate with EMPLOYER in the defense of any action arising out of matters related to
services rendered under this Agreement.
C. BLUE CROSS agrees to use its best efforts and due diligence in the performance of its
duties; EMPLOYER agrees to indemnify and hold harmless BLUE CROSS against any
settlement, judgment, and all related expenses which may arise in connection with
any function of BLUE CROSS under this Agreement, unless it is determined that the
liability thereof was the direct consequence of dishonest, fraudulent, or criminal con-
duct on the part of BLUE CROSS in which case BLUE CROSS agrees to indemnify and
hold EMPLOYER harmless.
D. If it is determined that any payment has been madeunderthis Agreementtoan ineligible
employee or dependent, or if it is determined that more or less than the correct amount
has been paid by BLUE CROSS, BLUE CROSS will, at the request of the EMPLOYER,
make a reasonable effort to recover any overpayment made or adjust the payment,
but BLUE CROSS will not be required to initiate court proceeding for any such re-
covery.
A-2999 12/91
PAGE
E. In regard to responsibilities under the Employee Retirement Income Security Act of
1974 (ERISA), EMPLOYER shall for all purposes be the "administrator" of the plan
and shall assume fiduciary responsibilities for all operations of the plan. BLUE CROSS'
sole responsibility under the plan shall be the providing of a full and fair review of claim
denials as required by Section 503 of ERISA.
F. BLUE CROSS reserves the right to utilize the services of a third party to assist in the
performance of any administrative activities to be provided under this Agreement.
ARTICLE IX. Accounting and Audit Procedures
A. BLUE CROSS shall prepare an annual accounting report summary of benefits paid
during each annual term which shall be forwarded to Employer within 120 days after
the end of the Contract Year.
B. For all purposes, each twelve (12) month term of this Agreement shall be deemed
separate and distinct and shall not become cumulative.
C. BLUE CROSS shall conduct its own internal auditing of the plan in connection with a
review of payments made. An audit report shall be prepared by BLUE CROSS within
120 days following the end of each twelve (12) month term and shall be forwarded to
Employer for review.
D. EMPLOYER shall have one hundred eighty (180) days following receipt of the audit
report to bring to the attention of BLUE CROSS any discrepancies. If no written notice
of discrepancy is received by BLUE CROSS within the one hundred eighty (180)
day period, it shall be conclusively presumed that EMPLOYER has fully accepted
BLUE CROSS' performance under this Agreement as acceptable and consistent with all
provisions herein.
BLUE CROSS shall have the right under this Agreement, at reasonable times and upon
reasonable notice, to inspect any of EMPLOYER'S records relevant to any aspect of
this Agreement.
ARTICLE X. Conversion Privilege
A. When the Subscriber or Family Member ceases to be eligible for coverage hereunder,
coverage shall terminate automatically without notice; however, such Subscriber or
Family Member shall be entitled, upon written notice to BLUE CROSS within 15 days
from the date that eligibility ceases, to make application for a Group Conversion Agree-
ment on the basis and at such subscription charges as are then in effect for such program.
B. No conversion coverage shall be offered if the date of termination of coverage and of
this Agreement is the same.
ARTICLE XI. Applicable Law
This Agreement shall be governed by the laws of the State of California.
A-2999 12/81 PAGE 5
ARTICLE XII. General Provisions
A. This Agreement, the application of the EMPLOYER and the individual applications of
the employees, if any, shall constitute the entire Agreement between the parties and all
statements made by the EMPLOYER or by any individual Subscriber shall, in the
absence of fraud, be deemed representations and not warranties, and no such statement
shall be used in defense to a claim under this Agreement unless it is contained in a
written application.
B. If this Agreement is terminated by the EMPLOYER or BLUE CROSS, all individual
Certificates issued to Subscribers hereunder shall be terminated, and no Subscriber shall
be entitled to continue his individual certificate in force or make application for a
Group Conversion Agreement under the Conversion Privilege.
C. This Agreement is not in lieu of and does not affect any requirement for, or coverage
by Workers' Compensation Insurance.
D. Subject otherwise to the conditions and limitations set forth herein, services performed
by the following providers of care who are acting within the scope of their licenses will
be treated as though performed by a Physician for purposes of determining eligible
benefits under this Agreement: 1) a licensed chiropractor, 2) a licensed dentist, 3) a
licensed optometrist, 4) a licensed podiatrist, and 5) a licensed psychologist.
In addition, services performed by the following providers will be eligible for benefits
if the Member has first obtained a written referral from a Physician: 6) a licensed audio-
logist, 7) a licensed clinical social worker, 8) a licensed marriage, family and child
counselor, 9) a certified occupational therapist, 10) a licensed physical therapist, or
11) a licensed speech pathologist.
E. BLUE CROSS shall not have the right to cancel or terminate any individual Certificate
issued to any Subscriber hereunder while this Agreement remains in force and effect
and while said Subscriber remains in the eligible class of employees of the EMPLOYER
and his subscription charges are paid in accordance with the terms hereof.
F. None of the terms or provisions of the charter, constitution or by-laws of BLUE CROSS
shall form a part of this Agreement or be used in the defense of any suit hereunder un-
less the same is set forth in full herein.
G. This Agreement shall terminate if at any time the number of Subscribers covered hereby
shall not meet the enrollment regulations of BLUE CROSS.
H. The EMPLOYER shall not be responsible for the furnishing of hospital care nor for the
quality thereof.
1. No person other than the Subscriber or Family Member is entitled to receive hospital
care or other benefits to be furnished by BLUE CROSS under this Agreement. Such
right to hospital care or other benefits is not transferable.
A-2999 12/81 PAGE 6
J. No agent of BLUE CROSS is authorized to change the form or content of this Agree-
ment except to make necessary and proper insertions in blank spaces, other than by
endorsement issued to form a part hereof and over the signature of an officer of BLUE
CROSS.
K. The hospitals (or skilled nursing facilities if such benefits are included in this Agree-
ment) furnishing care or other benefits to the Subscriber or Family Member do so as
independent contractors with BLUE CROSS, and BLUE CROSS shall not be liable
for any claim or demand on account of damages arising out of or in any manner connected
with any injuries suffered by the Subscriber or Family Member while receiving care
in any hospital or skilled nursing facility.
L. BLUE CROSS reserves the right to utilize the services of a third party to assist in the
performance of any administrative activities to be provided under this Agreement.
M. EMPLOYER hereby agrees that the Base Program is, and shall remain during all times
this Agreement is in effect, in compliance with, and not violative of, any and all applic-
able laws including all statutory requirements applicable to the issuance of an Agree-
ment by BLUE CROSS OF SOUTHERN CALIFORNIA irrespective of the fact that the
Base Program itself may or may not be subject to such requirements.
N. Benefits hereunder will be provided only if notice of claim is made within ninety (90)
days from the date on which covered expenses were first incurred, unless it shall be
shown not to have been reasonably possible to give notice within such time limit and
that such notice was furnished as soon as was reasonably possible, but in no event shall
benefits be allowed if notice of claim is made beyond one year from the date on which
expenses were incurred. Such notice should be provided to the following address:
Blue Cross of Southern California
P.O. Box 70000
Van Nuys, California 91470
0. Any notice required of BLUE CROSS shall be deemed to be sufficient if mailed to the
EMPLOYER at the address appearing on the records of BLUE CROSS; and, if required
of the EMPLOYER, if mailed to the principal office of BLUE CROSS in Woodland
Hills, California.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement at Los Angeles,
California on
(Datel
BLUE CBQSS OF SOUTHERN CALIFORNIA
by
Tit
by
Title
by
Title secMary Title
A-2999 12-01 PAGE 7
APPENDIX A
HEALTH BENEFIT PLAN
PART I. DEFINITIONS
A. BLUE CROSS OF SOUTHERN CALIFORNIA, called in this DOCUMENT, BLUE
CROSS, is a non-profit hospital service plan which is regulated by the California Depart-
ment of Insurance.
B. The SUBSCRIBER is the eligible employee of the Employer whose Enrollment Form
has been accepted in accordance with the enrollment regulations of this Document and
in whose name the Blue Cross Identification Card is issued.
C. FAMILY MEMBERS are members of the Subscriber's family who meet the eligibility
requirements for coverage under this Document.
D. The term "MEMBER" shall mean both the Subscriber and the Family Member.
E. A LEGALLY OPERATED HOSPITAL is an institution licensed by the State in which it
is situated, operated in accordance with that State's laws, and which is primarily engaged
in providing diagnostic and therapeutic facilities for care and treatment of injured and
sick persons by and under the supervision of a staff of licensed physicians, and with
service by registered graduate nurses twenty-four hours a day.
A CONTRACTING HOSPITAL is a Legally Operated Hospital which, at the time the
Member is admitted, has a direct reimbursement contract with Blue Cross to furnish
care to eligible Members.
G. An eligible SKILLED NURSING FACILITY is an institution which is licensed by the
State in which it is situated to provide skilled nursing services. At the time of the
Member's admission, the facility must be approved as a participating skilled nursing
facility under the Medicare program and have in effect an agreement with Blue Cross to
furnish care to its Members.
H. A PHYSICIAN is a person who is duly licensed to prescribe and administer drugs and to
perform surgery within the scope of his license, and who holds the degree of Doctor of
Medicine or Doctor of Osteopathy.
TREATMENT means medical and surgical services generally recognized and accepted
by the medical profession as appropriate for the illness or injury requiring care.
J. CUSTODIAL CARE is care primarily provided to assist a patient in meeting the activi-
ties of daily living — such as help in walking, getting in and out of bed, bathing, dressing,
feeding and preparation of special diets, and supervision of medications which are
ordinarily self-administered, but not care that requires skilled nursing services on a
continuing basis.
A-2999 12/81
50-1007 10-80
ASO -A PAGE 1
PART I. DEFINITIONS
-CONTINUED -
K. RELATIVE VALUE STUDIES (RVS) is a listing of medical and surgical procedures
published by the California Medical Association with "Units" assigned to each
procedure in accordance with various medical criteria. Benefits will be valued by
assigning a monetary value to the RVS Unit for covered procedures.
L. USUAL, CUSTOMARY AND REASONABLE is the amount charged or the amount
Blue Cross determines to be the prevailing charge within the general area in which the
service was provided, whichever is the lesser.
M. ACCIDENT means a sudden, unexpected and unplanned event occurring by chance
which is caused by an independent, external force and which results in definite physical
trauma.
N. MEDICALLY NECESSARY SERVICES and/or supplies are services or supplies which
medical advisors determine to be reasonably necessary and which are provided in
accordance with local community standards for care and treatment of the illness or
injury involved. Benefits will be provided only for those services and supplies which are
determined to have been Medically Necessary at the time the claim is processed.
0. MEDICARE is the name commonly used to describe Health Insurance Benefits for the
Aged and Disabled provided under Public Law 89.97 as amended to date or as later
amended.
P. The "EFFECTIVE DATE" for each Subscriber will appear on the Subscriber's Identifi-
cation card.
Q. A CALENDAR YEAR is the twelve-month period commencing January 1 of each year
at 12:01 a.m. standard time of Los Angeles, California.
R. SERVICE AREA consists of the 13 southernmost counties in the State of California.
A-2999 12/81 ASO - A PAGE 2
PART 11. ELIGIBILITY AND RECORDS
A. Application for Coverage
Each eligible employee in active employment during the initial enrollment period
shall be entitled to apply for coverage for himself or herself and eligible Family
Members.
2. Each new employee entering employment after the initial enrollment shall be
permitted, when eligible, to apply for coverage for himself or herself and eligible
Family Members, subject to the enrollment regulations in effect with the Employer.
3. Employees and dependents who do not apply when first eligible may be required to
submit satisfactory proof of good health before being accepted for coverage under
this Document. Medical review of those applications could result in denial of
coverage.
B. Who is Eligible for Coverage
1. Eligible employees shall be all full-time, permanent employees.
2. Eligible Family Members, who are listed on the Enrollment Form completed by the
Subscriber, shall be:
a. The Subscriber's lawful Spouse of the opposite sex; and
b. Any unmarried child of either or both who is under age 19; and
c. Any such unmarried child who is between 19 and 23 years, provided the child is
dependent upon his or her parents for at least half of his or her support; and
d. Any such unmarried child who is and continues to be both (1) incapable of self-
sustaining employment by reason of mental or physical handicap, and (2) chiefly
dependent upon the Subscriber for economic support and maintenance,
provided proof of such incapacity and dependency is furnished to Blue Cross by
the Subscriber within 31 days of the child's attainment of the limiting age and
subsequently as may be required, but not more frequently than annually after
the two-year period following the child's attainment of the limiting age. The
determination of eligibility shall be conclusive.
e. Newborns for the first 31 days of life if illness or injury occurs, provided the
Subscriber is covered by this Document, under a two-party or family member-
ship. Coverage after 31 days is contingent upon the Subscriber enrolling the
Newborn as a Family Member within 60 days following birth.
A•2999 12/81 ASO -A PAGES
PART II. ELIGIBILITY AND RECORDS
-CONTINUED -
C. Delivery of Documents
The Employer shall deliver to each Subscriber an individual Certificate, setting forth a
statement of benefits to which the Members are entitled, and an Identification Card
showing the Effective Date of coverage.
D. When the Member Becomes Ineligible
A Member becomes ineligible for coverage under this Document under these conditions:
1. The Subscriber:
a. Upon termination of the Group Agreement;
b. When eligibility requirements as established by the Employer are not met;
2. A Spouse:
a. On the date the Subscriber becomes ineligible;
b. Upon 'entry of final decree of divorce, annulment, or dissolution of marriage.
3. A Child:
a. On the date the Subscriber becomes ineligible;
b. Upon attainment of the age limitations described in this Document, to be
effective on the first of the month following the month in which the birthday
occurs;
c. When the child between 19 and 23 years ceases to be dependent upon his or her
parents for at least half of his or her economic support;
d. Upon marriage.
E. Notice of Ineligibility
It shall be the Subscriber's responsibility to provide notification of any changes which
will affect his or her eligibility or that of Family Members for benefits under this
Document.
A•2999 12181 ASO -A PAGE 4
PART III. COORDINATION OF BENEFITS
A. Explanation: All benefits provided under this Document are subject to coordination
with benefits payable to the Member for eligible expense by any other group coverage
including any hospital, surgical, or medical benefit policy, service plan contract, group
prepayment plan, coverage through any governmental program, or that provided by any
state or federal statute.
B. Purpose: "Coordination of Benefits" determines responsibility for payment of eligible
expenses among insurers providing group coverage to the Member, so that the total of
all reasonable expense for covered services and supplies will be paid up to the stated
limits of all such coverages, but not to exceed total expense incurred for those services
and supplies.
C. Administration: If the Member is known to have group coverage through any other
health plan or insurer, responsibility for payment of benefits is determined by following
the Rules Establishing the Order of Benefits Determination, formulated by the
Insurance Commissioner of the State of California and incorporated in this Document.
Such Rules determine the order of payment responsibilities between this Health Benefit
Plan and any other applicable group health plan or group insurer, by establishing which
is Prime Carrier and which is Secondary Carrier.
The Susbcriber: This Health Benefit Plan is the prime carrier with responsibility for
first payment, except when (a) the Subscriber is covered by another group health
plan as the Employee and that plan has covered him or her longer than this Health
Benefit Plan, or (b) the other plan does not contain a Coordination of Benefits
provision similar to this one.
2. The Spouse: This Health Benefit Plan is the prime carrier with responsibility for
first payment, except when (a) the spouse is covered under another group health
plan as the Employee, or (b) the other plan does not contain a Coordination of
Benefits provision similar to this one.
3. The Child: This Health Benefit Plan is the prime carrier with responsibility for first
payment, unless:
(a) this Document covers the child as a dependent of a female Subscriber, and the
other plan covers the child as a dependent of a male Employee; or
(b) the order of benefit determination is affected because of a divorce and assign-
ment of legal custody of the child. If the mother has legal custody, her plan pays
first; the stepfather's (if any) plan pays second; and the natural father's third.
If the father has legal custody, his plan pays first; the stepmother's (if any)
plan pays second, and the natural mother's third.
A-2999 12/81 ASO - A PAGE 5
PART IV. GENERAL LIMITATIONS
Benefits shall NOT be provided for:
A. Diagnostic Admissions: Admissions primarily for diagnostic study when inpatient bed
care is not Medically Necessary, unless otherwise provided for in this Document.
B. Care and treatment not provided in accordance with accepted professional standards.
C. Routine Examinations or Screening Tests: Medical examinations or tests not connected
with care and treatment of an actual illness or injury, unless otherwise provided for in
this Document.
D. That portion of charges in excess of Usual, Customary and Reasonable Charges as
determined by Blue Cross.
E. Care and treatment of obesity or weight reduction.
The following Surgeries Irrespective of Whether they are Performed for Cosmetic,
Therapeutic, or any other Purpose: Surgical excision or reformation of any sagging
skin of or on any part of the body including but not limited to the eyelids, face, neck,
abdomen, arms, legs or buttocks; any services performed in connection with the enlarge-
ment, reduction, or change in appearance of a portion of the body including but not
limited to the breasts, lips, jaw, chin, nose, ears, or genitals; hair transplantation;
chemical face peels or abrasion of the skin; or electrolysis epilation. This exclusion shall
not be applicable when the surgery or other services are performed to correct or repair
the physical functioning of a body part as a result of a medical complication resulting
from surgery or an accidental injury occurring while the Member is covered under this
Agreement and for which the Subscriber submits to Blue Cross documented evidence
showing medical treatment of such accident at the time of injury.
G. Any procedure or treatment designed to alter physical characteristics of the Member
to those of- the opposite sex, and any other treatment or studies related to sex
transformations.
H. Reconstruction of prior surgical sterilization procedures.
I. Experimental: Experimental or investigative therapy, including any type of therapy not
generally recognized as of value by the medical community and its societies, is not
covered; all other charges, as for office visits or laboratory procedures, incurred in
conjunction with noncovered therapy will be considered noncovered.
J. Dental Care: Treatment on or to the teeth and gums or any tooth extraction except
when it is required because of an accident occurring while the Member is covered under
this Document. Treatment of dental abscess, granuloma, gingival tissues or dental
examinations. Also, medical or surgical care for or prevention of temporo -mandibular
joint syndrome or disease.
K. Custodial or domiciliary care, regardless of the type of facility.
A-2999 12/81 ASO -A PAGE 7
PART IV. GENERAL LIMITATIONS
- CONTINUED -
L. Noneligible Institutions: Any services or supplies furnished by an institution which is
other than a Legally Operated Hospital or Medicare -approved skilled nursing facility, or
which is primarily a place of rest, a place for the aged, a nursing home, or any similar
institution, regardless of how denominated.
M. Workers' Compensation: No benefits under this Document will be paid for any injury
sustained by a Member if benefits therefor are in whole or in part either payable or
required to be provided under any Workers' Compensation or Occupational Disease Law,
regardless of whether application has been made or benefits paid under such laws.
N. Government: Care or treatment obtained from or for which payment may be obtained
by any United States Federal or foreign government agency, regardless of whether
application is made.
0. War, Invasion, Atomic Explosion: Conditions caused by or arising out of an act of war,
armed invasion or aggression, or any illness or injury occurring after the effective date of
this Document and caused by atomic explosion or other release of nuclear energy,
whether or not the result of war.
P. Duplicate Health Benefit Plan: If the Member is covered by more than one Health
Benefit group plan, benefits will be determined by applying provisions of the Coordina-
tion of Benefits section.
Q. Medicare: On the first of the month in which the Member becomes age 65, or on the
date the Member can first apply and become eligible for any type of Medicare coverage
(whether or not such application is made), benefits under this Document will be
modified and reduced so as to supplement Medicare coverage. Benefits will not be
furnished for any services or supplies payable by Medicare, whether or not claim for
such Medicare benefits is made.
R. Noncovered Services and Supplies: ANY SERVICES OR SUPPLIES NOT
SPECIFICALLY LISTED IN THIS DOCUMENT AS COVERED SERVICES OR
SUPPLIES, SUCH AS BUT NOT LIMITED TO HEARING AIDS, EYEGLASSES AND
EXAMINATIONS INCIDENTAL TO THESE.
A-2999 12181 ASO - A PAGES
PART V. GENERAL CONDITIONS UNDER WHICH BENEFITS WILL BE PROVIDED
FOR CARE IN A LEGALLY OPERATED HOSPITAL OR A
MEDICARE -APPROVED SKILLED NURSING FACILITY
When all the following conditions are met, benefits will be provided:
A. A physician must authorize admission to the Legally Operated Hospital or Medicare -
approved Skilled Nursing Facility.
B. Admission must occur on or after the Member's Effective Date under this Document.
C. The Subscriber's Identification Card must be presented at time of admission or during
confinement.
D. Services for inpatient bed care must be Medically Necessary and not capable of being
performed on an outpatient basis.
E. Services and supplies furnished and billed by the Legally Operated Hospital or Medicare -
approved Skilled Nursing Facility must be Medically Necessary for treatment of the
illness or accident requiring institutional care.
A-2999 12/81 ASO - A PAGE 9
PART VI. BASIC BENEFITS
A. BENEFITS FOR SERVICES AND SUPPLIES IN CONTRACTING HOSPITALS AND
ELIGIBLE SKILLED NURSING FACILITIES
1. Days of Inpatient Care
a. Covered inpatient services in a Contracting Hospital or Skilled Nursing Facility
will be paid up to an aggregate of 365 days during each Period of Disability.
b. A Period of Disability is a continuous inpatient stay or a series of stays where
dates of discharge and readmission are separated by less than 28 days. However,
if inpatient care is required because of an accident within the 28 -day period, a
new Period of Disability begins.
2. Room Accommodations in a Contracting Hospital
a. 100% of charges will be provided for a room of two or more beds to a maximum
of $175 per day.
b. 100% of charges will be provided for care in special treatment units licensed by
the State, such as intensive care and coronary care units, to a maximum of
$412 per day.
c. If a private room is used, benefits will be equivalent to 100% of the Contracting
Hospital's most prevalent charge for a two -bed room to a maximum of $175
per day.
3. Room Accommodations in a Skilled Nursing Facility
a. 100% of charges will be provided for a room of two or more beds to a maximum
of $110 per day.
b. If a private room is used, benefits will be equivalent to 100% of the Skilled
Nursing Facility's most prevalent charge for a two -bed room to a maximum of
$110 per day.
4. Other Inpatient Services
When furnished and billed by the Contracting Hospital, or Skilled Nursing
Facility, all services and supplies Medically Necessary for treatment of the illness
or injury requiring the covered confinement will be provided at 80% of the
first $2,500 of hospital charges, and at 100% thereafter for each period of
disability, EXCEPT THE ACQUISITION COSTS OF BLOOD AND BLOOD
PLASMA AND THE CHARGES FOR EXPERIMENTAL OR INVESTIGATIVE
PROCEDURES AND SERVICES.
ASO -A PAGE 30
A-2999 12/81
PART VI. BASIC BENEFITS
- CONTINUED -
5. Skilled Nursing Facility
a. Prior care in a Contracting Hospital is not required before being eligible for care
in a Skilled Nursing Facility.
b. ADMISSIONS OR CONTINUED STAYS FOR CUSTODIAL OR DOMICILIARY
CARE ARE NOT COVERED.
6. Outpatient Hospital Benefits
Benefits will be provided for 100% of the Contracting Hospital's charges for services
and supplies in connection with:
a. Surgery requiring use of operating facilities, but not the physician's charges for
the surgical procedure.
b. Treatment of an accidental injury within 72 hours of the accident, including
necessary X-rays and laboratory tests, but not the physician's charges for
professional services.
B. BENEFITS FOR SERVICES AND SUPPLIES IN NON -CONTRACTING HOSPITALS
AND INELIGIBLE SKILLED NURSING FACILITIES
1. Within the Service Area, if care is required in a non -contracting Legally Operated
Hospital or in an ineligible skilled nursing facility not participating in the Medicare
Program, benefits shall be as follows:
a. Hospital Admissions for Illness: Seventy-five percent (75%) of benefits provided
in this Document for confinement in Contracting Hospitals.
b. Hospital Admissions for accidents requiring emergency confinement: Benefits
will be the same as in Contracting Hospitals.
c. Hospital Outpatient Services: NO BENEFITS ARE PROVIDED.
d. Ineligible Skilled Nursing Facilities: NO BENEFITS ARE PROVIDED.
A-2999 12/91 ASO - A PAGE 11
PART VI. BASIC BENEFITS
-CONTINUED -
2. Outside the Service Area
a. Hospitals Contracting with Other Blue Cross Plans: If inpatient care is required
outside the service area in a hospital contracting with another Blue Cross Plan,
benefits will be provided under the terms of the Blue Cross Inter -Plan Benefit
Bank — a reciprocal arrangement among the nation's Blue Cross Plans where the
hospital may bill and be paid by the local Plan.
b. Non -contracting Facilities: Reimbursement will be made toward charges of a
Legally Operated Hospital or Medicare -approved Skilled Nursing Facility on the
same basis as in Contracting Hospitals and Skilled Nursing Facilities. The
Member must arrange for such bills to be submitted for reimbursement of
eligible charges.
C. TOTAL DAYS OF CARE
Days of care provided in any facility either within or outside the service area shall be
counted against total days of care available under this Document.
D. BASIC PROFESSIONAL BENEFITS
Basic Professional Benefits are provided when they are Medically Necessary. These
benefits are limited to Usual, Customary and Reasonable charges for the covered services
as defined in this Document.
Claims adjudication is the responsibility of Blue Cross of Southern California, but
actual determination of benefits and processing of claims are performed by the Founda-
tion for Medical Care of San Bernardino County.
Physician members of the Foundation for Medical Care agree to accept these benefits
as payment in full for any covered service, and will not charge the Member additional
fees. Non-member physicians will be paid the same amounts as member physicians,
but are not obligated to accept the benefits as payment in full.
1. Benefits for Surgical Services
a. Surgical Services are defined as Medically Necessary operative and cutting pro-
cedures for treatment of diseases and injuries, and for reduction of fractures
and dislocations.
b. Primary Surgeon: Benefits cover the services of a primary surgeon.
A2999 12/81 ASO - A PAGE 12
PART VI. BASIC BENEFITS
-CONTINUED -
c. Assistant Surgeon: If a benefit is paid to the Primary Surgeon and the scope of
surgery customarily requires an Assistant Surgeon, benefits will be provided
for one Assistant Surgeon who is not a hospital intern, resident or house officer.
The benefit payable is limited to 20% of the amount payable to the Primary
Surgeon.
d. Benefits for Surgical Services are subject to these conditions and limitations:
(1) The service must be performed by a licensed physician.
(2) The service must be performed on or after the Member's Effective Date of
coverage under this Document. However, if the Member is already hospitali-
zed prior to the Effective Date, benefits for surgical services will not be
provided until after the Member is discharged from that hospital.
(3) If more than one surgical service is performed during one operative session
in the same operative area, payment will be made only for the major pro-
cedure.
(4) If more than one surgical service is performed during the same operative
session in different operative areas, maximum payment is made for the major
procedure, plus one-half the allowance for the minor procedure which pro-
vides the next greatest allowance, but not to exceed Usual, Customary, and
Reasonable charges.
2. Professional Anesthetist Benefit
When the Member is entitled to care in Contracting Hospitals and Benefits for
Surgical Services, benefits shall be provided up to the Usual, Customary, and Rea-
sonable charge for services of a professional anesthetist, or the billed amount, which-
ever is the lesser charge. Benefits will be based on both the services performed and
the actual time spent administering the anesthesia.
3. Physician Visits in the Hospital
When a Member receives covered care in a hospital or Skilled Nursing Facility as
a result of illness or injury and no surgery is performed, benefits shall be provided
up to the Usual, Customary, and Reasonable charge, or the billed amount, which-
ever is the lesser for one visit a day by the attending physician during each eligible
confinement.
3A. Consultations
Benefits shall be provided up to the Usual, Customary, and Reasonable charge, or
the billed amount, whichever is the lesser for the services of a consulting physician
(EXCEPT STAFF CONSULTATIONS REQUIRED BY HOSPITAL REGULA-
TIONS), if the condition requires special skill or knowledge for diagnosis and
treatment.
A-2999 12/81 ASO -A PAGE 23
PART VI. BASIC BENEFITS
-CONTINUED-
3B.
CONTINUED -
3B. Diagnostic X-ray and Laboratory Benefit
a. In non -hospitalized cases, benefits shall be provided up to the Usual, Customary
and Reasonable charge for diagnostic X-rays and laboratory tests when ordered
by a physician for treatment of an illness or injury.
b. The maximum benefit allowed during a Calendar Year is $300.
c. No benefit shall be provided for eye examinations and treatments or for routine
physical examinations.
d. Eligibility
(1) This benefit is payable for:
[ ] The Subscriber Only.
[ X I The Subscriber and Family Members.
4. Ambulance Benefit
a. Benefits shall be provided for expense incurred by the Member for necessary
use of local surface ambulance service for transportation to or from the Legally
Operated Hospital (or Skilled Nursing Facility if that benefit is included in
this Document) up to $50 for each covered inpatient admission or conditions
for which outpatient services are payable.
E. CARE FOR CONDITIONS OF PREGNANCY
1. Normal Delivery
a. Basic Benefits will be provided only for the Subscriber and spouse.
b. Hospital charges for routine nursery care of the Newborn will be covered when
the mother is the Subscriber or spouse.
c. A Basic Hospital Benefit for Normal Delivery of $100 will be provided for
Dependents.
2. Cesarean Section and Other Complications of Pregnancy
a. Basic Benefits will be provided for all Members.
b. Hospital charges for routine nursery care of the Newborn will be covered, if the
mother is the Subscriber or spouse.
A-2999 12/81 ASO - A PAGE 14
PART VI. BASIC BENEFITS
-CONTINUED-
F.
CONTINUED -
F. SUPPLEMENTAL ACCIDENT BENEFIT
If the Member is injured accidentally while covered under this Document, supple-
mental benefits up to $500 will be provided for any one accident to pay Usual,
Customary and Reasonable Charges for the following services INCURRED WITHIN
90 DAYS OF THE ACCIDENT, when these services are not covered in full by other
Basic Benefits.
a. Professional medical or surgical treatment by a licensed physician.
b. Necessary services furnished and billed by a Legally Operated Hospital, except
for blood and blood plasma and personal expenses.
c. Services of a Registered Nurse not related to the Member by blood or marriage.
d. X-rays and laboratory examinations.
LIMITATIONS OF SUPPLEMENTAL ACCIDENT BENEFIT
THIS BENEFIT WILL NOT BE PROVIDED FOR ANY INJURIES ARISING OUT OF OR
IN THE COURSE OF EMPLOYMENT; PTOMAINE POISONING; DISEASE OR INFEC-
TION (EXCEPT INFECTION OCCURRING FROM AN ACCIDENTAL CUT OR WOUND);
EYE REFRACTIONS OR FITTING OF EYE GLASSES; OR AN INTENTIONALLY SELF-
INFLICTED INJURY.
A-2999 12/81 ASO -A PAGE 15
PART VII. MAJOR MEDICAL BENEFITS
Major Medical Benefits supplement certain Basic Benefits and/or provide payment for
services and supplies which are not covered under Basic Benefits.
A. Conditions of Coverage
Treatment of an illness or injury must be provided or authorized by a licensed
physician, and must be generally recognized by the medical profession as medically
appropriate, reasonable and necessary. Benefits shall be provided only as long as
such authorization is given.
2. Deductible: The Deductible Amount each Calendar Year for care of accident or
illness is $50.
a. During a Calendar Year, each Member shall be responsible for expense incurred
for Covered Services and Supplies as subsequently described, up to the
Deductible Amount. However, no family shall be required to satisfy more than
three separate deductibles during any one Calendar Year.
b. If the Deductible Amount is not met during the first three quarters of a Calendar
Year, any expense incurred for Covered Services and Supplies during the last,
quarter of that year, and applied toward the Deductible Amount for that year
shall be carried forward and applied against the Deductible Amount for the
following year.
c. If more than one Member is injured in the same accident, only one deductible
shall be applied for the year in which the accident occurs against all expense in
connection with that accident.
3. Benefits
a. When expense incurred by the Member for Covered Services and Supplies,
exceeds the Deductible Amount, benefits will be provided at 80% of Usual,
Customary and Reasonable Charges for those Covered Services and Supplies
which exceed the Deductible Amount until total paid Major Medical benefits
during the Calendar Year reach $1,600. For the remainder of the Calendar
Year, benefits will be provided at 100% of Usual, Customary and Reasonable
Charges for covered Services and Supplies.
b. For outpatient psychiatric care by a physician or a licensed psychologist, the
benefit will be 50% of charges up to $15.00 visit, with a maximum of 50 visits
during a Calendar Year.
A-2999 12181 ASO - A PAGE 16
PART VII. MAJOR MEDICAL BENEFITS
-CONTINUED -
4. Lifetime Maximum
a. Major Medical Benefits provided under this Document shall not exceed an
aggregate amount of $1,000,000.00 per Member.
b. A Member who receives more than $1,000 in benefits under this Plan may apply
for reinstatement of the Lifetime Maximum by furnishing evidence of good
health. However, on the last day of a Calendar Year, $1,000 shall be restored
automatically to the Member's Lifetime Maximum if at least $1,000 has been
provided for Covered Services and Supplies for that Member. These provisions
do not apply if the Member is receiving benefits under the Terminal Benefits
Section of this Document.
B. Covered Services and Supplies
1. Medically appropriate and necessary professional services by a licensed physician.
2. Professional services rendered by a physician or by a doctor of dental surgery for
treatment of a fractured jaw or other accidental injury to natural teeth, provided
that injury occurs while the Member is covered under this Document. Such dental
services will be covered only during the six-month period immediately following the
date of injury.
3. Professional nursing services of a Registered Nurse, other than one who ordinarily
resides in the Member's home or who is related to the Member by blood or marriage.
4. Administration of anesthetics by a professional anesthetist.
5. X-ray, radium and radioactive isotope therapy.
6. Services of a registered physical therapist in connection with treatment authorized
by a physician, other than a therapist who ordinarily resides in the Member's home
or who is related to the Member by blood or marriage.
7. Diagnostic X-ray and laboratory tests necessary for treatment or diagnosis of an
illness or injury. Multiple nonemergency laboratory tests will be paid as automated
panel testing, regardless of how or where performed.
8. Services of a licensed ambulance company for local surface ambulance services to or
from a Legally Operated Hospital or Skilled Nursing Facility.
9. Drugs and medicines requiring a written prescription and dispensed by a physician
or a licensed pharmacist and generally recognized by the medical profession as
appropriate for treatment of the illness or injury being treated. Benefits will be paid
at Usual, Customary and Reasonable Charges for such drugs and medicines, but not
to exceed expenses incurred.
A•2999 12/81 ASO - A PAGE 17
PART VII. MAJOR MEDICAL BENEFITS
-CONTINUED -
10. Prostheses, and durable medical equipment including but not limited to splints,
braces, crutches, wheelchairs, respirators and hospital -type beds. This equipment
must be that which generally requires both a physician's order and is Medically
Necessary for treatment of illness or injury occurring while the Member is covered
under this Document. Convenience or comfort items are not covered. Rental or
purchase of such equipment, whichever is more economically prudent, is covered,
but shall not exceed the purchase price. Where multiple choices are available,
benefits will be based on the least expensive, professionally adequate choice.
11. Blood transfusions, including cost of blood and blood plasma
C. Care for Conditions of Pregnancy
1. Normal Delivery
a. Benefits will be provided only for the Subscriber and spouse.
2. Cesarean Section and Other Complications of Pregnancy
a. Benefits will be provided for all Members.
D. Major Medical Limitations
In addition to GENERAL LIMITATIONS which apply both to Major Medical Benefits
and Basic Plan Benefits, unless otherwise specified, the following limitations shall apply
ONLY TO THE MAJOR MEDICAL PORTION OF THIS DOCUMENT.
Major Medical Benefits will not be provided for any injury or illness, including any
condition of pregnancy, for which treatment or expense for Covered Services and
Supplies was incurred during the three-month period preceding the Member's
Effective Date of coverage under this Document.
This limitation shall not apply when, during a period of three consecutive months
after enrollment, no expense for Covered Services or Supplies is incurred for such
injury or illness, including any condition of pregnancy. The limitation ceases to
apply to any Member who has been covered under this Document for six
consecutive months. It shall not apply to any Member whose coverage under this
Document became effective on the initial Effective Date of the current Group
Agreement between the Employer and Blue Cross.
2. No benefits are provided for services or supplies furnished or billed by a hospital or
Skilled Nursing Facility for inpatient bed care.
A-2999 12/81 ASO -A PAGE 18
PART VIII. TERMINAL BENEFITS
A. Should a Member be totally disabled at the date of termination of coverage and be
under treatment of a physician, the services and benefits set forth in this Document
shall be furnished to the extent such services and benefits relate directly to the
condition causing such total disability and for no other condition, illness, disease or
injury. Terminal Benefits shall be provided only when written certification of the total
disability and the cause thereof has been furnished by the attending physician within 90
days from the date coverage is terminated under this Document. Proof of continuation
of total disability shall be furnished not less frequently than 90 -day intervals during the
period that terminal benefits are available.
B. Terminal benefits for total disability shall be provided:
1. Up to a maximum period of 12 consecutive months, or
2. Until the maximum amount of benefits has been paid, or
3. Until the total disability ends, whichever occurs first.
C. For the purposes of this benefit, the Subscriber shall be considered totally disabled
when, as a result of bodily injury or disease, such Subscriber is unable to engage in any
employment or occupation for which he or she is or becomes qualified by reason of
education, training or experience and is not, in fact, engaged in any employment or
occupation for wage or profit. A Family Member shall be considered totally disabled
when such Member is prevented from performing all regular and customary activities
usual for a person of that age and family status.
D. Terminal Benefits for total disability shall not be provided if the Subscriber is required
to pay the whole or any part of the subscription charges required under the terms of this
Document and such Subscriber ceases to pay such subscription charges while this Docu-
ment is in effect.
A-2999 12/81 ASO - A PAGE 19
APPENDIX 'B"
BLUE CROSS shall provide the following administrative services to the EMPLOYER:
I. Benefit Eligibility Determination
BLUE CROSS shall determine benefit eligibility in connection with any claim
submitted for processing. Such determination shall be based upon most current
eligibility information provided BLUE CROSS by the EMPLOYER. The EM-
PLOYER agrees to notify BLUE CROSS of any changes in persons eligible under
the EMPLOYER plan.
11. ID Cards
BLUE CROSS shall not provide standard identification card issuance operations
in connection with this plan.
111. Customer Service Function
BLUE CROSS shall not provide its standard customer service operations in con-
nection with this plan.
IV. Plan Claim Reports
BLUE CROSS shall provide the EMPLOYER with claim listings indicating pay-
ments made by BLUE CROSS on behalf of the EMPLOYER. BLUE CROSS shall
not be responsible for furnishing any additional claim listings or reports except such
financial data reports required to be provided to the EMPLOYER annually in
accordance with the Employee Retirement Income Security Act of 1974.
V. Claims Payment
A. BLUE CROSS shall process all Plan claims incurred during the term of the
Agreement in accordance with plan benefits as set forth in Appendix A and
administrative policies and practices currently in force and utilized by BLUE
CROSS.
B. With respect to any person who makes a request for plan benefits which is
denied, BLUE CROSS will notify said person of the denial and of his right of
review of the denial in accordance with the requirements of the Employee
Retirement Income Security Act of 1974.
C. BLUE CROSS shall provide inter -plan claims processing.
D. BLUE CROSS shall make all claims overpayment decisions in accordance with
plan benefits as set forth in Appendix A and administrative policies and practices
currently in force and utilized by BLUE CROSS. BLUE CROSS shall only be
required_ to pursue reasonable recovery attempts and such attempts shall not
include commencement of any legal action.
A•2999 12/8
50-1007 10-80
ASO PAGE 1
V I. Certificates and Literature
BLUE CROSS shall prepare and issue to the EMPLOYER for delivery individual
certificates setting forth the benefits of the plan.
VII. Representative Services
BLUE CROSS shall provide the service of a Blue Cross Marketing Representative.
VII I.Other Claims Services
A. Occupational Injury Review
BLUE CROSS shall make all Workers' Compensation decision in accordance
with plan benefits as set forth in Appendix A and policies and practices
currently in force and utilized by BLUE CROSS.
B. Medical Review Program
BLUE CROSS shall make all medical review decisions in accordance with plan
benefits as set forth in Appendix A and policies and practices currently in
force and utilized by BLUE CROSS. BLUE CROSS shall provide the EM-
PLOYER the opportunity to review medical review activities.
C. Coordination of Benefits
BLUE CROSS shall make all "coordination of benefits" decisions in accord-
ance with plan benefits as set forth in Appendix A and policies and practices
currently in force and utilized by BLUE CROSS.
IX. Membership Services
A. BLUE CROSS shall provide for the establishment, and ongoing retention of
membership information for the EMPLOYER. This service will include the
handling of ongoing additions, deletions, and changes which will be accom-
plished in accordance with notification by the EMPLOYER.
A-2999 12/81
ASO PAGE 2
B. BLUE CROSS shall provide for retroactive additions, deletions, and changes
to the EMPLOYER Membership; BLUE CROSS shall provide standard Health
Statement administration in accordance with administrative policies and prac-
tices currently in force and utilized by BLUE CROSS; BLUE CROSS shall
provide administration and control of an employees' exclusion clause in ac-
cordance with provisions set forth in Appendix A.
X. Actuarial/Underwriting Services
BLUE CROSS shall provide to the EMPLOYER those actuarial and underwriting
services consistent with policies and practices currently in force and utilized by
BLUE CROSS.
X1. Payment Vouchers
BLUE CROSS shall be responsible for the development of payment vouchers.
A-2999 12/81
ASO PAGE 3