HomeMy WebLinkAbout34-Personnel
. .
CIO OF SAN B8RNARDOO - REQUOT FOR COUNCIL ACOON
Date:
3-29-85
DirelMr'lf.tIBv.onne1
. .IH. OFF.
:., APR -I PH 3:"
Subject:
Renewal of Blue Cross A9reement for
Administrative Services and Stop-
Loss Protection
From:
MoJ. Perl ick,
Personne 1
Dept:
Synopsis of Previous Council ection:
In 1975 the City originally entered into an agreement with Blue Cross of Califor-
nia to provide health plan administrative services and stop-loss protection for
the City's self-insured program. This agreement has continued and is periodical-
ly renewed/amended. The existing contract document expired 12-1-84, a revised
document was delivered to the City from Blue Cross on 2-1-85, and has since been
reviewed by the Wyatt Company - the City's new health plan consultant.
Recommended motion:
Approve the resolution to renew the terms of agreement effective until December
I, 1985, with modification as attached.
*NOTE: Agreement is in two (2) parts, requiring signature in two (2) separate
places.
~~--'
Signature
Contact person:
MoJ. Per1ick
Phone:
5161
Supporting data attached: Yes
Ward:
n/a
FUNDING REQUIREMENTS: Amount:
$1,450 per month Source:
($10,150 for FY 84/85)
Finance:
Existing Budgets
/Ja t? ~
Council Notes:
..,..Ln.,,,,.,
J
Aaenda Item Nn 3_~
'cIA OF SAN BERNARDfiaO - REQUQT FOR COUNCIL AC~ON
STAFF REPORT
During 1984. the City's health plan consultant analyzed the administrative
and insurance costs proposed by Blue Cross for the calendar year 1985. and
recommended acceptance of the modification increasing specific stop-loss
insurance and the administrative service charge from $6 to $7 per employee
per month. The total increase in cost is $1.51 per employee/per month
(prior administration/stop loss fee $16.23 - new fee $17074) and was antic-
ipated in the budgeting process. A new consultant has been retained for a
major review of all benefits during 1985. and we expect to contain costs in
these areas. For the present. since these services have been satisfactory
it is recommended that this agreement be continued until such research is
completed.
The new fee is applicable to 960 Blue Cross enrollees. which includes em-
ployees/retirees of the City and the Water Department.
MJ:jr
15.0264
. . Ii
0 I:
!
I i
o
o
o
RESOLUTION NO.
2
RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
IEXECUTION OF AN AGREEMENT WITH BLUE CROSS OF CALIFORNIA FOR GROUP
IINSURANCE, INCREASING THE ADMINISTRATION COST AND RAISING THE STOP
;iLOSS INSURANCE COVERAGE AMOUNT, EFFECTIVE DECEMBER 1, 1984.
i!
,
.'
4
5
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF
,iSAN BERNARDINO AS FOLLOWS:
:;
"
;, SEC'rION 1. The Mayor of the City of San Bernardino is hereby
"
l!authorized and directed to execute on behalf of said City an
I ~
II"
liAgreement with Blue Cross of California for Group Insurance,
[,
II increasing the administration cost and raising the stop loss
!;
iJ
I! insurance coverage amount, effective December 1, 1984, a copy of
Ii
liwhich is attached hereto, marked Exhibit -A" and incorporated
Jl
ilherein by reference as fully as though set forth at length.
!,
! I HEREBY CERTIFY that the foregoing resolution was duly
adopted by the Mayor and Common Council of the City of San
6
7
8
9
10
11
]2
1:
14
15 ,Bernardino at a
I
meeting thereof, held on
16
day of
, 1985, by the following vote,
the
]7 to wit:
]8
AYES:
Council Members
]9
20
NAYS:
21
ABSENT:
22
23
24
City Clerk
The foregoing resolution is hereby approved this
day
25
of
, 1985.
26
Mayor of the City of San Bernardino
27
Approved as to form:
~/A:~
City 'torney
28
'0
o 0
o
roup
enefit
greement
:at:::.:
06~
.
~
V'6<V
BLUE CROSS OF CALIFORNIA
GROUP BENEFIT AGREEMENT 2999
o
for
City of San Bernardino
(the Group)
BLUE CROSS OF CALIFORNIA (Blue Cross) agrees to provide the benefits of this
Agreement for enrolled Members of the Group. These benefits are subject to
all of the terms and conditions of this Agreement. '
SUBSCRIPTION CHARGES
The Group will pay to Blue Cross the following monthly subscription charges:
Subscri ber .............. 0 . . . . . 0 . . . . . . 0 . . . . . 0 . . . . . . . . . . 0 . . . . . . . . .
Subscriber and one Family Member .00.....0......0.........0......
Subscriber and two or more Family Members ................000....
$17.74
17074
17.74
AGREEMENT DATE
This Agreement becomes effective at 12:01 aomo Pacific Standard Time on
December 1, 1984. It remains in effect for the term of one year from that
Agreement dateo It then continues from year to year with the consent of
Blue Cross. Payment of the subscription charges indicates that the Group
accepts this Agreement 0
9808A (12-84)
- 1 -
. .
o
PART ONE:
PART TWO:
PART THREE:
PART FOUR:
PART FIVE:
PART SIX:
PART SEVEN:
PART EIGHT:
PART NINE:
PART TEN:
9808A (12-84)
o
o
o
TABLE OF CONTENTS
DEFINITIONS . 0 0 . . 0
COMPREHENSIVE BENEFITS
A. DEDUCTIBLE
Bo PAYMENT 0 0
Co MAXIMUM BENEFITS
Do COVERED EXPENSE
3
6
6
7
1. Hospital . 0 0 0 0 . 0 0 . . 0 0
20 Skilled Nursing Facility 0 0 0 .
3. Professional Services 0 0 . 0 0 0
40 Additional Services and Supplies
5. Dental Care 0 . 0 0 0 0 . . .
6. Pregnancy and Maternity Care
70 Organ and Tissue Transplants
80 Mental or Nervous Disorders
and Substance Abuse
8
9
9
9
11
11
12
12
12
13
16
19
20
EXTENSION OF BENEFITS . 0 0
EXCLUSIONS AND LIMITATIONS
COORDINATION OF BENEFITS
ARBITRATION . . . 0 . . 0
CONDITIONS OF ENROLLMENT
CANCELLATION OF COVERAGE
CONVERSION 0 . . .
GENERAL PROVISIONS
23
24
25
- 2 -
.
.
o
o
o
o
PART ONE: DEFINITIONS
A. Blue Cross of California, (Blue Cross) is a non-profit hospital
service plan regulated by the California Department of Insuranceo
B.
The Subscriber is the person
stated on the frent page
Agreement" which is attached
enrolled according to
of the "Application
to this Agreemento
the eligibility
for Group Service
C. The Spouse is the Subscriber's spouse under a legally valid
marriage between persons of the opposite sex.
D. A Child is the Subscriber's child, stepchild or legally adopted
chi~
Eo A Family Member is the Subscriber's enrolled Spouse and each
enrolled eligible Child.
F. A Member is the Subscriber or Family Member.
G. The Agreement Date is the date this Agreement between Blue Cross
and the Group comes into effecto
Ho The Effective Date is the date the Member's coverage under this
Agreement begins.
I. Medically Necessary services or supplies are those Blue Cross
determines to be:
1. Appropriate and necessary for the symptoms, diagnosis or
treatment of the medical condition, and
2. Provided for the diagnosis or direct care and treatment of the
medical condition, and
3, Within standards of good medical practice within the organized
medical community, and
4. Not primarily for the convenience of the Member, the Member's
Physician or another provider, and
5. The most appropriate supply or level of service which can
safely be provided. For hospital stays, this means that acute
care as an inpatient is necessary due to the kind of services
the Member is receiving or the severity of thE! Member's
condition, and that safe and adequate care cannot be, received
as an outpatient or in a less intensified medical setting.
9808A (12-84)
- 3 -
. ,
o
o
o
o
Jo A Hospital is a facility which provides diagnosis, treatment and
care of persons who need acute inpatient hospital care under the
supervision of Physicianso It must be licensed as a general acute
care hospital according to state and local lawso It must also be
registered as a general hospital by the American Hospital
Association and meet accreditation standards of the Joint
Commission on Accreditation of Hospitals.
K.
A Contracting Hospital is a Hospital which
Blue Cross to provide care to Members 0
Hospitals will be sent on requesto
has a contract with
A list of Contracting
Lo An Outpatient Surgical Center is a facility, other than a medical
or dental office, whose main function is performing surgical
procedures on an outpatient basiso It must be licensed as an
outpatient clinic according to state and local laws and must meet
all requirements of an ?utpatient clinic providing surgical
services.
Mo A Skilled Nursing Facility is an institution that provides
continuous skilled nursing services. It must be licensed according
to state and local laws and be recognized as a Skilled Nursing
Facility under Medicare. A Skilled Nursing Facility in California
south of Monterey, Fresno or Mono Counties must also have an
agreement with Blue Cross to furnish care to Members 0 A list of
those Skilled Nursing Facilities having such an agreement will be
sent on request.
N. A Day Care Center is an outpatient psychiatric facility which is
part of or affiliated with a Contracting Hospitalo It must be
licensed according to state and local laws to provide outpatient
care and treatment of mental and nervous disorders or substance
abuse under the supervision of psychiatristso
0, A Physician means:
1, A doctor of medicine (M.O,) or a doctor of osteopathy (D.O.)
who is licensed to practice medicine or osteopathy where the
care is provided, or
2. One of the following providers, but only when the provider is
licensed to practice where the care is provided, is rendering
a service wIthin the scope of that license, is providing a
service for which benefits are specified in this Agreement,
and when benefits would be payable if the services were
provided by a Physician as defined in 1. above:
ao A dentist (O.OoSo)
bo An optometrist (0.0.)
c. A dispensing optician
9808A (12-84)
- 4 -
. .
o
o
o
o
d. A podiatrist or chiropodist (D.P.M., D.S.P. or D.S.C.)
e. A psychologist
f. A chiropractor (D.C.)
g. A clinical social worker (C.S.W. or L.C.S.W.)*
h. A marriage, family and child counselor (M.F.C.C.)*
i. A physical therapist (P.T. or R.P.T.)*
j. A speech patho10gist*
k. An audio10gist*
1. An occupational therapist (O.T.R.)*
NOTE: The providers indicated by asterisks (*) are covered only
by referral of a Physician as defined in 1. above.
P.
A Customary and Reasonable charge, as determined annually by Blue
Cross, is a charge which falls within the common range of fees
billed by a majority of Physicians for a procedure in a given
geographic region, or which is justified based on the complexity or
the severity of treatment for a specific case.
Q.
A Year is a twelve-month period starting each January 1 at 12:01
a.m~cific Standard Time.
R.
Custodial Care is care provided primarily to meet the personal
needs of the Member. This includes help in walking, bathing or
dressing. It also includes preparing food or special diets,
feeding, administration of medicine which is usually
self-administered or any other care which does not require
continuing services of medical personnel.
S. Special Care Units are special areas of a Hospital which have
highly skilled personnel and special equipment for acute conditions
that require constant treatment and observation.
T. Experimental procedures are those that are mainly limited to
laboratory and/or animal research.
U. Investigative procedures are those t~at have progressed to limited
use on humans, but which are not widely accepted as proven and
effective procedures within the organized medical community.
V. Mental or Nervous Disorders are those conditions, including drug or
alcohol dependence, which are listed in the International
Classification of Diseases as diagnostic codes 290-319. One or
more of these conditions may be specifically excluded in this
Agreement.
W. Accidental Injury is physical harm or disability which is the
result of a specific unexpected incident caused by an outside
force. The physical harm or disability must have occurred at an
identifiable time and place. Accidental Injury does not include
illness or infection, except infection of a cut or wound.
9808A (12-84)
- 5 -
.'
o
o
o
o
X. A Totally Disabled Subscriber is one who, because of illness or
injury, is unable to work for income in any job for which he or she
is qualified or for which he or she becomes qualified by training
or experience, and who is in fact unemployed. A Totally Disabled
Family Member is one who is unable to perform all activities usual
for a person of that age.
Y. A Pre-existing Condition is an illness, injury or condition which
existed within 180 days before the Member's Effective Date, A
condition is considered to have existed when the Member:
1. Sought or received professional advice for that condition, or
2, Received medical care or treatment for that condition, or
3, Received medical supplies, drugs or medicines for that
condit ion.
z.
The Inter-Plan Bank is an arrangement with other Blue Cross
by which a Member receives hospital services and benefits
other Blue Cross Plan if hospitalized in that Plan's area.
Plans
of the
PART TWO: COMPREHENSIVE BENEFITS
The benefits described below are provided for Covered Expense incurred
for treatment of a covered illness, injury or condition. Expense is
incurred on the date the Member receives the service or supply for which
the charge is made. These benefits are subject to all provisions of
this Agreement, which may limit benefits or result in benefits not being
payable.
A. DEDUCT! BLE
1. Each Member must meet a deductible amount of $50.00 for
Covered Expense incurred during any Year. Any amount
exceeding a Customary and Reasonable charge is not applied
toward the deductible. If two Members of an enrolled familY
each meet their separate deductibles during any Year. no
further deductible is required for the rest of that Year.
2.
Covered expense incurred during the last quarter
applied toward the deductible for that Year is
toward the deductible for the next Year.
of a Year and
also applied
B. PAYMENT
Payment is provided as follows for covered expense incurred in
excess of the deductible. Any amount exceeding a Customary and
Reasonable charge is not covered expense. All payments are subject
to any maximum amounts stated below.
9808A (12-84)
- 6 -
.
o
o
o
o
1, First Level Payment
a, Payment is provided at 100 percent of the covered expense
incurred by a Member for services of a surgeon, an
assistant surgeon, anesthetist and for physician's
hospital visits, Then,
b. Until Blue Cross pays $2,000.00* in benefits for a Member
in a Year:
1)
Payment is provided for
expense incurred by
professional services
Disorders and Substance
50 percent of the covered
that Member for outpatient
under Mental or Nervous
Abuse, and
2) Payment is provided for 80 percent of the covered
expense incurred by that Member for all other
services other than those under Mental or Nervous
Disorders and Substance Abuse and for services of a
surgeon, assistant surgeon, anesthetist and
physician's hospital visits.
2, Second Level Payment
After
Year:
Blue Cross pays $2,000.00* in benefits for a Member in a
a.
Payment continues to be provided for 50 percent of the
covered expense incurred by that Member for outpatient
professional services under Mental or Nervous Disorders
and Substance Abuse, and
b.
Payment is provided for 100 percent of the covered
expense incurred by that Member for the rest of that Year
for services other than those under Mental or Nervous
Disorders and Substance Abuse and for services of a
surgeon, assistant surgeon, anesthetist and physician's
hospital visits.
*Note;
Any benefits paid by
would have been paid to a
included in this amount.
Medicare
Member
(up to the amount that
without Medicare) are
C. MAXIMUM BENEFITS
1, Benefits paid for outpatient Physician's services under Mental
or Nervous Disorders and Substance Abuse are limited to a
$15,00 maximum payment for each visit.
9808A (12-84)
- 7 -
.
o
o
o
o
2. All Comprehensive Benefits are limited to a maximum amount of
$1,000,000.00 during each Member's lifetime. Any benefits
paid by Medicare (up to the amount that would have been paid
to a Member without Medicare) are included in this amount,
3. Up to $1,000,00 in Comprehensive Benefits received are
automatically restored each January 1. Also, Comprehensive
Benefits received in excess of $1,000.00 may be restored by
the sending of proof of good health satisfactory to Blue Cross.
Any additional limits on the number of visits or days covered are
stated under the specific benefit.
D. COVERED EXPENSE
1. Hospital
a. Covered Services
(1) Inpatient services and supplies, including Special
Care Units, except private room charges over the
prevailing two-bed room rate of the Hospital.
(2) Outpatient services and supplies, including those in
connection with surgery performed at an Outpatient
Surgical Center.
b. Conditions of Service
(1) Services must be those which are regularly provided
and billed by a Hospital,
(2) Benefits are provided only for the number of days
required to treat the Member's illness, injury or
condition.
(3) If a Member is hospitalized for illness in
California south of Monterey, Fresno or Mono
Counties, payment as stated above is provided only
if care is received in a Contracting Hospital. If
such care is received in a non-contracting Hospital,
benefits are provided at 75 percent of the payment
stated above. A list of Contracting Hospitals is
available on request.
(4)
If a hospital stay is
Contracting Hospital
provided,
needed outside California, the
benefits of this Agreement are
9808A (12-84)
- 8 -
.
. .
Q
o
o
o
2, Skilled Nursing Facility
a. Covered Services
Inpatient services and supplies, except private room
charges over the prevailing two-bed room rate of the
Skilled Nursing Facility.
b. Conditions of Service
(1)
(2)
The Member must be referred to the Skilled Nursing
Facility by a Physician.
Services must be those which are regularly provided
and billed by a Skilled Nursing Facility.
(3)
The services must be consistent with the illness,
injury, degree' of disability and medical needs of
the Member, Benefits are provided only for the
number of days required to treat the Member's
illness or injury.
(4)
The Member must remain under the active medical
supervision of a Physician treating the illness or
injury for which the member is confined in the
Skilled Nursing Facility.
(5)
If a Member is confined in a Skilled Nursing
Facility in California south of Monterey, Fresno or
Mono Counties that does not have an agreement with
Blue Cross to furnish care to Members, no benefits
are provided. A list of Skilled Nursing Facilities
having such an agreement is available on request.
(6) Benefits are provided if a Skilled Nursing Facility
stay is needed outside California.
3. Professional Services
a. Services of a Physician,
b. Services of an anesthetist.
c. Services of a registered nurse.
4. Additional Services and Supplies
a. Outpatient diagnostic radiology and laboratory services.
b. Base charge, mileage and non-reusable supplies of a
licensed ambulance company for ground service to and from
a Hospital.
9808A (12-84)
- 9 -
.
o
9808A (12-84)
o
o
o
c. Base charge, mileage and non-reusable supplies of an air
ambulance from the area where the Member is first
disabled to the nearest Hospital where appropriate
treatment is provided.
d,
Monitoring, electrocardiograms
defibrillation, cardiopulmonary
administration of oxygen and
in connection with ambulance
must be rendered by a certified
(EKG's or ECG's), cardiac
resuscitation (CPR) and
intravenous (IV) solutions
service. These services
paramedic.
e,
Radiation therapy,
treatment.
hemodialysis
chemotherapy
and
f. Surgical implants.
g. Artificial limbs or eyes,
h. The first pair of contact lenses and the first pair of
eyeglasses when required as a result of eye surgery.
i. Rental or purchase of dialysis equipment. Dialysis
supplies. Rental or purchase of other medical equipment
and supplies which are:
(1) Ordered by a Physician, and
(2) Of no further use when medical need ends, and
(3) Usable only by the patient, and
(4) Not primarily for the Member's comfort or hygiene,
and
(5) Not for env i ronmenta 1 cont ro 1, and
(6) Not for exercise, and'
(7) Manufactured specifically for medical use.
Rental charges that exceed the reasonable purchase price
of the equipment are not covered. Blue Cross determines
whether the item meets the above conditions.
j, Blood transfusions, including blood processing and" the
cost of unrep1aced blood and blood products.
k. Drugs and medicines approved for general use by the Food
and Drug Administration that are available only if
prescribed by a Physician. The drug or medicine must be
- 10 -
.
o
o
o
o
dispensed by a Physician or a licensed pharmacist. Drugs
prescribed for Mental or Nervous Disorders and Substance
Abuse are included.
i. Injectable insulin prescribed by a Physician.
6. Dental Care
a. Admissions for Dental Care
(1) Covered Services
Inpatient hospital services stated above when a
hospital stay for dental treatment is required due
to an unrelated medical condition of the Member, and
has been ordered by a Physician (M.D.) and a Dentist
(D.D.S.).
(2) Conditions of Service
(a) Blue Cross makes the final determination as to
whether the dental treatment could have been
safely rendered in another setting due to the
nature of the procedure or the Member's medical
condition.
(b) Hospital stays for the purpose of administering
general anesthesia are not considered necessary,
Dental Injury
Services of a Physician (M.D.) or Dentist (D,D.S.) treating an
Accidental Injury to natural teeth which occurs while the
Member is covered under this Agreement. Services must be
received during the six months following the date of injury.
Damage to natural teeth due to chewing or biting is not
Accidenta 1 Injury.
7. Pregnancy and Maternity Care
a. All Comprehensive Benefits when provided for pregnancy,
maternity care and abortion for the Subscriber or
enrolled Spouse,
b.
Comprehensive hospital
of a newborn Child,
Subscriber or enrolled
benefits for routine nursery care
if the'Chi1d's natural mother is a
Spouse.
c,
Comprehensive
Member are
complications
$100.00.
Benefits for the dependent daughter of a
provided for normal delivery and
of pregnancy. un to a maximum oayment of
9808A (12-84)
- 11 -
. .
o
o
o
o
8. Organ and Tissue Transplants
Services in connection with a non-Investigative organ or
tissue transplant for:
a. An enrolled Member who receives the organ or tissue, and
b. An enrolled Member who donates the organ or tissue, and
c. An organ or tissue donor who is not an enrolled Member,
if the organ or tissue recipient is an enrolled Member,
Benefits are reduced by any amounts paid or payable by
that donor's own coverage.
9. Mental or Nervous Disorders and Substance Abuse
a, Covered Services
(1) Inpatient services stated above.
(2) The following services of a Physician, limited to
one visit a day:
(a) Visits during a covered inpatient stay.
(b) Outpatient psychotherapy or psychological
testing, limited to 50 visits a Year.
(c) Outpatient visits to a Day Care Center.
b. Conditions of Service
(1) Services must be for treatment of Substance Abuse
(such as drug or alcohol dependence) or a Mental or
Nervous Disorder which can be improved by standard
medical practice.
(2) The Member must be under the direct care and
treatment of a Physician for the condition being
treated.
PART THREE: EXTENSION OF BENEFITS
A. If aMemberi s Totally Disab1 ed when coverage ends and is under . the
treatment of a Physician, the benefits of this Agreement may
continue to be provided for services treating the totally disabling
illness or injury, No benefits are provided for services treating
any other illness, injury or condition, Application for these
total disability benefits must include written certification by the
Physician that the Member is Totally Disabled, Blue Cross must
9808A (12-84)
- 12 -
. .
o
o
o
o
receive this certification within 90 days of the date coverage ends
under this Agreement. At least once every 90 days while benefits
are extended, Blue Cross must receive proof that the Member's total
disability is continuing. Benefits are provided until whichever of
the following occurs first:
1. The Member is no longer Totally Disabled, or
2. The maximum benefits of this Agreement are paid, or
3.
The Member becomes covered under
that provides coverage without
illness or injury, or
another group health plan
limitation on the disabling
4. A period of 12 consecutive months has passed since the date
coverage ended.
PART FOUR: EXCLUSIONS AND LIMITATIONS
Benefits of this Agreement are not provided for or in connection with
the fo 11 owi ng ,
A. Services or supplies that are not Medically Necessary as defined
Experimental or Investigative procedures,
B. Services received before the Member's Effective Date or during an
inpatient stay that began before the Member's Effective Date.
Services received after the Member's coverage ends, except as
specifically stated under Extension of Benefits,
C. Any amounts in excess of Customary and Reasonable charges.
D. Services not specifically listed in this Agreement as covered
services.
E. Services for which the Member is not legally obligated to pay.
Services for which no charge is made to the Member. Services for
which no charge is made to the Member in the absence of insurance
coverage, except services received at a non-governmental charitable
research Hospital. Such a Hospital must meet the following
guidelines:
1. It must be internationally known as being devoted mainly to
medical research, and,
2. At least ten percent of its yearly budget must be spent on
research not directly related to patient care, and
3.
At least one-third of
donations or grants other
care, and
its gross income must
than gifts or payments
come from
for patient
9808A (12-84)
- 13 -
.
o
o
o
o
4. It must accept patients who are unable to pay, and
5. Two-thirds of its patients must have conditions directly
related to the Hospital's research.
F. Work-related conditions if benefits are recovered or can be
recovered, either by adjudication, settlement or otherwise, under
any workers' compensation, employer's liability law or occupational
disease law, even if the Member does not claim those benefits.
G. Conditions caused by an act of war. Conditions caused by release
of nuclear energy, whether or not the result of war.
H. Any services provided by a local, state or federal government
agency,
I. Any services to the extent that the Member is entitled to receive
Medicare benefits for those services, whether or not Medicare
benefits are actually paid. Any services for which payment may be
obtained from any other local, state or federal government agency
(except Medi-Ca1).
J. Professional services received from a person who lives in the
Member's home or who is related to the Member by blood or marriage.
K. Inpatient room and board charges in connection with a hospital stay
primarily for environmental change, physical therapy or treatment
of chronic pain. Custodial Care or rest cures. Services provided
by a rest home, a home for the aged, a nursing home or any similar
facility. Services provided by a Skilled Nursing Facility, except
as specifically stated under Comprehensive Benefits,
L.
Inpatient room and board charges in connection with
primarily for diagnostic tests which could have
safely on an outpatient basis.
a hospital stay
been performed
M. Hyperkinetic syndromes, learning disabilities, behavioral problems,
mental retardation or autistic disease of childhood. Mental or
Nervous Disorders and substance abuse, except as specifically
stated under Comprehensive Benefits.
N. Braces, other orthodontic appliances or orthodontic services.
O. Dental Care: Dental plates, bridges, crowns, caps or other dental
prostheses, dental services, extraction of teeth or treatment to
the teeth or gums, except as specifically stated in this Agreement.
P. Hearing aids and routine hearing tests.
9808A (12-84)
- 14 -
. \
C
o
o
o
Q.
Optometric services, eye exercises including
eyeglasses, contact lenses, routine eye exams and
refractions, except as specifically stated under
Benefits.
orthoptics,
routine eye
Comprehensive
R. Outpatient occupational therapy.
S. Outpatient speech therapy, except following surgery, injury or
non-congenital organic disease.
T. Cosmetic surgery or other services for beautification. Services
primarily for weight reduction or treatment of obesity, or any care
which involves weight reduction as the main method of treatment.
U. Procedures or treatments to change characteristics of the body to
those of the opposite sex.
v.
Sterilization reversal.
fertilization.
Artificial insemination and in vitro
W. Orthopedic shoes (except when joined to braces) or shoe inserts,
air purifiers, air conditioners, humidifiers, exercise equipment
and supplies for comfort, hygiene or beautification. Educational
services, nutritional counseling or food supplements. Telephone
consultations.
X. Routine physical exams or tests which do not directly treat an
actual illness, lnJury or condition, including those required by
employment or government authority,
Y. Any illness, lnJury, disease or other condition for which a third
party may be liable or legally responsible by reason of negligence,
an intentional act or breach of any legal obligation on the part of
such third party. Nevertheless, Blue Cross will advance the
benefits of this Agreement to the Member subject to the following:
1. Blue Cross will automatically have a lien, to the extent of
benefits advanced, upon any recovery, whether by settlement,
judgment or otherwise, that the Member receives from the third
party, the third party's insurer, or the third party's
guarantor. The lien will be in the amount of benefits paid by
Blue Cross under this Agreement for the treatment of the
illness, disease, injury or condition for which the third
party is liable.
2. The Member agrees to advise Blue Cross, in writing; within
60 days of his or her claim against the third party and to
take such action, furnish such information and assistance, and
execute such papers as Blue Cross may require to facilitate
enforcement of its rights. The Member also agrees to take no
action which may prejudice the rights or interests of
9808A (12-84)
- 15 -
.
o
o
o
o
Blue Cross under this Agreement. Failure of the Member to
give such notice to Blue Cross or cooperate with Blue Cross,
or actions of the Member that prejudice the rights or
interests of Blue Cross, will be a material breach of this
Agreement and will result in the Member being personally
responsible for reimbursing Blue Cross.
z.
The following services
Member's Effective Date
Condition:
received on, or within 12 months after, the
if they are related to a Pre-existing
1, Surgical services of a surgeon and assistant surgeon.
2. Services of an anesthetist.
3. Hospital services during an inpatient hospital stay.
4. Professional services during an inpatient hospital stay.
This exclusion does not apply to a Member who was covered under
another plan which was sponsored by the Group and replaced within
60 days by this Agreement.
PART FIVE: COORDINATION OF BENEFITS
All of the benefits
following provisions
of this Agreement.
provided by this Agreement are subject to the
and limitations regardless of any other provisions
A. DEFINITIONS
1. Other Plan means any of the following plans which provide full
or partial benefits or services for hospital, surgical,
medical, vision or dental care or treatment: (a) group,
blanket or franchise insurance coverage; (b) group service
plan contract, group practice, group individual practice and
other group prepayment coverages; and (c) any group coverage
under labor-management trusteed plans, union welfare plans,
employer organization plans, employee benefit organization
plans or self-insured employee benefit plans. The term Other
Plan refers separately to each agreement, policy, contract or
other arrangement for services and benefits, and only to that
portion of any such agreement, policy, contract or other
arrangement which reserves the right to take the services ,and
benefits of Other Plans into consideration in determining its
benefits.
2. This Agreement means the portion of this Agreement providing
the benefits that are subject to this provision.
9808A (12-84)
- 16 -
.
o
o
o
o
3. Allowable Expenses means any necessary, reasonable and
customary item of covered expense which is at least partially
covered under at least one of the Other Plans covering the
person for whom claim is made.
4. Claim Determination Period means a Year.
5. Covered Individual means a person covered for hospitalization,
surgical, medical, vision or dental services and benefits
under both This Agreement and the Other Plan.
B. ORDER OF BENEFITS DETERMINATION
1. This provision applies in determining the benefits of a
Covered Individual under This Agreement for any Claim
Determination Period if, for the Allowable Expenses incurred
by that Covered Individual during that period, the sum of
(a) the benefits that would be provided under This Agreement
without this provision, and (b) the benefits that would be
provided under all Other Plans without provisions similar to
this provision would exceed those Allowable Expenses.
2. Except as provided in 3. and 4, below, the benefits payable
under This Agreement for Allowable Expenses incurred by a
Covered Individual will be reduced to the extent that the sum
of those reduced benefits and all of the benefits provided for
those Allowable Expenses under all Other Plans will not exceed
the total of those Allowable Expenses. Benefits provided
under any Other Plan include the benefits that would have been
provided had claim been made for those benefits.
3, If an Other Plan contains a provlslon coordinating its
benefits with those' of This Agreement and its rules require
the benefits of This Agreement to be determined first, the
stated benefits of This Agreement will be provided without
reduction.
4. The following rules are used to determine the order in which
benefits are payable by the plans;
a. A plan which has no coordination of benefits provision
pays before a plan which has a coordination of benefits
provision.
b. A plan on which the Covered Individual is a Subscriber
pays before a plan on which the Covered Individual is a
dependent.
9808A (12-84)
- 17 -
.
o
o
o
o
c. A plan on which the Covered Individual is the Child of a
male Subscriber pays before a plan on which the Covered
Individual is the Child of a female Subscriber, except
that:
(1) When the parents are separated or divorced and the
parent with custody of the Child has not remarried,
the plan which covers the Child as a dependent of
the parent with custody pays first;
(2) When the parents are divorced and the parent with
custody of the Child has remarried, a plan which
covers the Child as a dependent of the parent with
custody pays before a plan which covers the Child as
a dependent of the stepparent, and a plan which
covers the Child as a dependent of the stepparent
pays before a plan which covers the Child as a
dependent of the parent without custody;
(3) Regardless of (1) and (2) above, if there is a court
decree which establishes a parent's financial
responsibility for the Child's health care expenses,
a plan which covers the Child as a dependent of that
parent pays first.
d, When the above rules do not establish the order of
payment, the plan on which the Covered Individual has
been enrolled for the longest period of time pays first.
In no event will the Covered Individual be entitled to
benefits from Blue Cross in excess of those which the Covered
Individual would have received if no Other Plan benefits were
available.
C. RESPONSIBILITY FOR TIMELY NOTICE
Blue Cross is not responsible for coordination of benefits unless
timely information has been provided by the complaining party
regarding the application of this provision.
D. REASONABLE CASH VALUE
When an Other Plan provides benefits in the form of services rather
than cash payment, the reasonable cash value of services provided
will be considered to be a benefit paid. The reasonable cash value
..of any service provided to the Covered Individual by any service
organization will be considered expense incurred' by that
individual, and the liability of Blue Cross will be reduced
accordingly.
9808A (12-84)
- 18 -
,
o
o
o
o
E, FACILITY OF PAYMENT
Whenever payments which should have been made under This Agreement
have been made under any Other Plan, Blue Cross will have the right
to pay to that Other Plan any amount Blue Cross determines to be
warranted to satisfy the intent of this provision, Any amount so
paid will be considered to be benefits paid under This Agreement,
and with that payment Blue Cross will fully satisfy its liability
under this provision.
F. RIGHT OF RECOVERY
Whenever pay~ents for covered benefits have been made by Blue Cross
and those payments are more than the maximum payment necessary to
satisfy the intent of this provision, regardless of who was paid,
Blue Cross has the right to recover the excess amount from any
persons to or for whom those payments were made, or from any
insurance company, service 'p1an or any other organizations or
persons.
PART SIX: BINDING ARBITRATION
A, Any dispute between the Member and Blue Cross regarding the
decision of Blue Cross'must be submitted to binding arbitration if
the amount in dispute exceeds the jurisdictional limits of the
small claims court. This arbitration is begun by the Member making
written demand on Blue Cross.
B, This arbitration will be held before a designated neutral
arbitrator appointed by the county medical association of the
county in which the services were provided, If the county medical
association declines or is unable to appoint an arbitrator, the
arbitration will be conducted according to the rules of the
American Arbitration Association.
C. Any dispute regarding a claim for damages within the jurisdictional
limits of the small claims court will be resolved in such court.
D. THE ARBITRATION FINDINGS WILL BE FINAL AND BINDING.
9808A (12-84)
- 19 -
,
o
o
o
o
PART SEVEN: CONDITIONS OF ENROLLMENT
A. ELIGIBILITY
1. The persons eligible to enroll as Subscribers are all
full-time permanent employees working 30 hours a week.
2. Family Member's Eligibility
The following persons are eligible for coverage as Family
Members of the Subscriber:
a. The Subscriber's Spouse.
b, Unmarried Children to the 19th birthday.
c. Unmarried Children from the 19th to the 23rd birthday who
are going to school and who qualify as dependents for
federal income tax purposes. Blue Cross must receive
this information in writing.
d. Unmarried Children enrolled before age 23 who, after
reaching age 23, depend on the Subscriber for support and
are unable to work due to mental retardation or physical
handicap. A Physician must certify this disability in
writing. This certification must be received by Blue
Cross within 31 days of the Child's 23rd birthday. After
the Child's 25th birthday, Blue Cross may request proof
of continuing dependency and disability, but not more
often than yearly.
B, APPLICATION FOR ENROLLMENT
1. Fi1ihg of Applications
a. Every person eligible to enroll as a Subscriber must file
an application with the Group within a time period ending
31 days after becoming eligible for coverage. This
application must include any eligible Family Members for
whom application is being filed.
b. The Subscriber must file an application with the Group to
enroll a new Spouse within a time period ending 31 days
after marriage.
c. The Subscriber must file an application with the ~roup to
enroll a newly-acquired Child within a time period ending
31 days after the birth or the acquiring of the Child.
9808A (12-84)
- 20 -
.
o
o
o
o
2. If this Agreement replaces a prior Blue Cross Agreement issued
to the same Group, applications are not required for any
Members enrolled under the prior Agreement immediately before
its termination.
3.
Any application not filed within the time limits stated
must be submitted to Blue Cross with a health statement,
application and the health statement require Blue
underwriting approval.
above
The
Cross
4. The Group is responsible for forwarding all enrollment
applications to Blue Cross.
5. All of the persons eligible to be Subscribers who are not
enrolled under another Group-sponsored plan must be enrolled
as Subscribers. If the number of Subscribers enrolled falls
below 100 percent of the persons eligible to enroll as
Subscribers, Blue Cross may cancel this Agreement,
C. EFFECTIVE DATES
If subscription charges are paid for an eligible person within the
time period stated in Subscription' Charges below, the Effective
Date of coverage for that person is as follows:
1. Subscriber's Effective Date
a. For a person enrolled as a Subscriber on the Agreement
Date, coverage begins on the Agreement Date.
b, For a person who files an application to enroll as a
Subscriber within the time limit stated above under
Filing of Applications, coverage begins on the first day
of the month after completion of the Probationary Period
shown on the "Application for Group Service Agreement".
c.
For a person who does not file an application
as a Subscriber within the time limit stated
Filing of Applications, coverage begins on the
of the month following Blue Cross underwriting
to enroll
above under
first day
approval.
2, Family Member's Effective Date
a, If the application of a person enrolling as a Subscriber
includes application for an eligible Spouse. or Child,
coverage for that Spouse' or Child begins on the
Subscriber's Effective Date.
b, For a new Spouse of a Subscriber who is already enrolled
under this Agreement, coverage begins on the first day of
9808A (12-84)
- 21 -
. ,
o
o
o
o
the month following marriage, but only if an application
to enroll the Spouse has been filed within 31 days of
marriage.
c. For a newly-acquired Child (except a newborn) of a
Subscriber who is already enrolled under this Agreement,
coverage begins on the first day of the month after
acquiring the Child, but only if an application to enroll
the Child has been filed within 31 days of acquiring the
Ch il d,
d. For a Child born to a Subscriber or Spouse who is already
enrolled under this Agreement, coverage begins at birth.
This coverage ends on the day following the 31st day of
life if Blue Cross does not receive an application to
enroll the child and any additional subscription charges
due.
e. For a Spouse or Child for whom the Subscriber does not
file an application within the time limits stated above
under Filing of Applications, coverage begins on the
first day of the month following Blue Cross underwriting
approval.
D, INDIVIDUAL CERTIFICATES
Blue Cross delivers a certificate to the Group for each
Subscriber. The certificate describes the benefits to which that
Subscriber and enrolled Family Members are entitled, An
identification card showing the Subscriber's Effective Date is
attached to the certificate.
E. SUBSCRIPTION CHARGES
1. The Group will pay Blue Cross the subscription charges listed
on the front page of this Agreement. The first payment is due
on the Agreement Date. Succeeding subscription charges are
due on the subscription charge due date of each following
month.
2. After the first payment, there is a 31-day grace period in
which to pay subsequent subscription charges. This Agreement
remains in force during the grace period. The Group is liable
for payment of subscription charges covering any period of
time that this Agree~nt remains in force, Blue Cross
reserves the right to cancel this Agreement if subscription
charges are not paid by the end of the grace period.
3. The amounts of the subscription charges may be changed by
Blue Cross as of any subscription charge due date. Blue Cross
9808A (12-84)
- 22 -
,
o
o
o
o
must send written notice of any change in subscription charges
at least 30 days before the date when the change goes into
effect.
4, The Group is responsible for supplying up-to-date eligibility
information. Blue Cross may rely upon the latest information
received as correct without verification. Benefits provided
to an ineligible Member because of inaccurate information
supplied by the Group are charged against the Group's
experience. Subscription charges paid for an ineligible
Member are not returned to the Group, whether or not benefits
are actually provided to that Member.
5.
If a state or any other taxing authority imposes a tax
Blue Cross which is based on subscription charges,
subscription charges stated in this Agreement will
increased by an amount sufficient to cover that tax.
increase will begin on the date the tax goes into effect.
on
the
be
This
PART EIGHT: CANCELLATION OF COVERAGE
A. Either Blue Cross or the Group may cancel coverage under this
Agreement by glvlng at least 30 days' prior written notice to the
other party. Cancellation is effective on the next subscription
charge due date. If' no written" notice is given, the Agreement
renews on the same terms and conditions.
B.
No written
cancelled.
conditions:
notice is sent to
A Member's coverage is
the Member when coverage is
cancelled under the following
1. Subscriber
a. On the date this Agreement between the Group and
Blue Cross is cancelled, or
b. On the next subscription charge due date after t~e
Subscriber no longer meets the eligibility requirements
established by the Group and Blue Cross (coverage may
continue up to two months during a leave of absence if
subscription charges are paid), or
c.
At the end of the grace period when the
subscription charges are not paid, or
required
d.
On the next subscription charge due
receives written notice of the
cancellation of coverage.
date after Blue Cross
Subscriber's voluntary
9808A (12-84)
- 23 -
. ,
o
o
o
o
2. Spouse
a. On the date the Subscriber's coverage is cancelled, or
b. On the next subscription charge due date after final
decree of divorce, annulment or dissolution of marriage.
3, Child
a. On the date the Subscriber's coverage is cancelled, or
b. On the next subscription charge due date after the Child
reaches age 19, or
c, On the next subscription charge due date after the Child
age 19 or over no longer qualifies as a dependent for
federal income tax purposes or reaches age 23, or
d. On the next subscription charge due date after marriage.
PART NINE: CONVERSION
When a Member's coverage under this Agreement is cancelled, that Member
may apply to Blue Cross within 31 days for a conversion Benefit
Agreement, THE TERMS, BENEFITS AND SUBSCRIPTION CHARGES OF THE
CONVERSION PLAN ARE DIFFERENT THAN THOSE OF THIS AGREEMENT, Application
for conversion membership does not require a health statement,
Conversion membership is not available if:
A. The Member's coverage ends because this Agreement between the Group
and Blue Cross terminates, or
B. The Member's coverage under this Agreement ends because the
Subscriber fails to pay subscription charges, or
C. The Member is eligible for group' health coverage when coverage
under this Agreement ends, or
D. The Member is eligible for Medicare coverage when coverage under
this Agreement ends, whether or not the Member has actually
enrolled in Medicare, or
E. The Member is covered under any individual health plan when
coverage under this Agreement ends,
9808A (12-84)
- 24 -
. .
o
o
o
o
PART TEN: GENERAL PROVISIONS
A. FORM OR CONTENT OF AGREEMENT
1, The entire agreement between the parties consists of:
a. This Agreement, and
b. The application of the Group, and
c. The individual applications of eligible persons.
2. Non-fraudulent statements of the Group or of any eligible
person that are not in written applications will not be used
to deny a claim under this Agreement.
3. Terms or provisions of the charter, constitution or by-laws of
Blue Cross will not be used in defense of a claim under this
Agreement.
4. No agent of Blue Cross may change this Agreement or waive any
of its contents. No change in this Agreement is valid unless
the change is by endorsement signed by the officers of
Blue Cross.
B. WORKERS' COMPENSATION INSURANCE
This Agreement does not
Workers' Compensation
insurance.
affect any
insurance.
requirement for coverage by
It also does not replace that
C, PROTECTION OF COVERAGE
Blue Cross does not have the right to cancel the coverage of any
Member under this Agreement while:
1. This Agreement is still in effect, and
2. The Member is still eligible, and
3. The Member's subscription charges are paid according to the
terms of this Agreement.
D. MAILING ADDRESSES
Any notice required of Blue Cross in this Agreement will be mailed
to the address of the Group as shown on Blue Cross records. Any
notice required of the Group in this Agreement must be mailed to
Blue Cross at 1950 Franklin Street, Oakland, California 94659 or
Blue Cross at P,O. Box 70000, Van Nuys, California 91470.
9808A (12-84)
- 25 -
.
o
o
o
o
E, CLERICAL ERRORS
Clerical errors of the Group do not deprive any Member of his or
her coverage under this Agreement. Also, these errors do not
create or continue coverage which would not otherwise be effective.
F. GROUP RECORDS
This Group
Agreement.
records.
is responsible
Blue Cross
for keeping records relating to this
has the right to inspect and audit those
G. PROVIDING OF CARE
Blue Cross is not responsible for providing any type of hospital,
medical or similar care, Also, Blue Cross is not responsible for
the quality of any type of hospital, medical or similar care
received.
H. NON-REGULATION OF PROVIDERS
Benefits provided under this Agreement do not regulate the amounts
charged by providers of medical care.
I. BENEFITS NOT TRANSFERABLE
Only eligible Members are entitled to receive benefits under this
Agreement. The right to benefits cannot be transferred.
J. INDEPENDENT CONTRACTORS
All providers are
liable for any claim
injury resulting from
independent contractors.
or demand for damages
any treatment.
Blue Cross is
connected with
not
any
K. AVAILABILITY OF CARE
Benefits are provided to the Member only when providers and
facilities are available. If there is an epidemic or public
disaster and the Member cannot obtain care, Blue Cross refunds the
unearned part of the subscription charge paid for that Member. A
written request for that refund and satisfactory proof of the need
for care must be sent to Blue Cross within 31 days. This payment
fulfills the obligation of Blue Cross under this Agreement.
L. MEDICAL NECESSITY
The benefits of this Agreement are provided only for services that
are Medically Necessary as determined by Blue Cross. The services
must be ordered by the attending Physician for the direct care and
980SA (12-84)
- 26 -
. .
o
o
o
o
treatment of a covered illness, lnJury or condition, except for
routine care, dental care and vision care as specifically stated.
They must be standard medical practice where received for the
illness, injury or condition being treated and must be legal in the
United States. When an inpatient stay is necessary, services are
limited to those which could not have been performed before
admission.
M. EXPENSE IN EXCESS OF BENEFITS
Blue Cross is not liable for any expense the Member incurs in
excess of the benefits of this Agreement,
N. PAYMENT TO PROVIDERS
Blue Cross pays Contracting Hospitals directly for the benefits of
this Agreement. Also, Blue Cross may pay non-contracting Hospitals
and other providers of service directly when the Member assigns
benefits in writing. These payments fulfill the obligation of
Blue Cross to the Member for those services.
O. NOTICE OF CLAIM
Properly completed claim forms itemizing the services received, and
the charges must be sent to Blue Cross by the Member or the
provider of service. These claim forms must be received by
Blue Cross within 24 months of the date services are received.
Blue Cross is not liable for the benefits of this Agreement if
claims are not filed within this time period. Cancelled checks or
receipts are not acceptable instead of claim forms.
p, RIGHT OF RECOVERY
When the amount paid by Blue Cross exceeds the amount for which
Blue Cross is liable under this Agreement, Blue Cross has the right
to recover the excess amount. This amount may be recovered from
the Subscriber, the person to whom payment was made or any other
plan.
Q. FREE CHOICE OF HOSPITAL AND PHYSICIAN
THIS AGREEMENT IN NO WAY INTERFERES WITH THE RIGHT OF ANY PERSON
ENTITLED TO HOSPITAL BENEFITS TO SELECT THE CONTRACTING HOSPITAL,
THAT PERSON MAY CHOOSE ANY PHYSICIAN WHO HOLDS A VALID PHYSICIAN
AND SURGEON'S CERTIFICATE AND WHO IS A MEMBER OF, OR ACCEPTABLE. TO;
THE ATTENDING STAFF AND BOARD OF DIRECTORS OF THE HOSPITAL WHERE
SERVICES 'ARE RECEIVED.
980SA (12-84)
- 27 -
. ,
"0
o
o
o
This Agreement has been approved by officers of Blue Cross as of the
Agreement date.
BLUE CROSS OF CALIFORNIA CITY OF SAN BERNARDINO
By ~.;~L.~
President
, ~~../
By~ i':"- --;.~".,
By
By
9808A (12-84)
- 28 -
. . =0=
F --~~.._---~'--~--_.._---~.~~- --,
. ~. - - . '-' .
I ----~~--~--~ ~---~~-~--~
MEMORANDUM OF MODIFICATION OF AGREEMENT
In consideration of the obligations assumed under Group Benefit
Agreement 2999 (the Agreement) by Blue Cross of California (Blue Cross)
and City of San Bernardino (the Group) the parties agree to the following
provisions:
A. The Agreement Year:
The Agreement Year will be a period of twelve (12) consecutive
months beginning December 1, 1984, and ending December I, 1985.
Each subsequent Agreement Year will be a period of twelve (12)
consecutive months beginning December 1 of any year. However, any
Agreement Year will end when the Agreement terminates.
B. Claims Liability and Reimbursement Method:
1. Retention and Stop-loss Subscription Charges:
a. On the first day of each month of the Agreement Year, the
Group will pay to Blue Cross monthly retention and
stop-loss subscription charges as follows:
Retention Stop-loss
Subscriber . . . . . . . . . . . . . . .
Subscriber and one Family Member . . . .
Subscriber and two or more Family Members
$ 10.74
10.74
10.74
$ 7.00
7.00
7.00
b. Blue Cross may change the amount of retention and stop-loss
charges according to the provisions of the Agreement
relating to adjustment of Subscription Charge, or at any
time if:
i. At the request of the Group, Blue Cross undertakes the
performance of any administrative services with respect
to the Agreement which Blue Cross had not agreed to
perform, or
ii.
Legislation
additional
respect to
regulations impose
on Blue Cross with
or governmental
administrative duties
the Agreement, or
I,
I
I
I:
il
Ii
I
iii. A state of any other taxing authority imposes a tax
upon Blue Cross which is levied upon or is measured by II
the Agreement. As of the effective date of the tax,
Blue Cross may increase the retention charge by an
amount sufficient to cover the tax.
9808A (12-84)
,
o
o
o
o
c. Blue Cross will notify the Group, in writing, thirty (30)
days before the effective date of any change in retention
and stop-loss charges.
d. There will be no retention or stop-loss charges following
termination of the Agreement.
2. Reimbursement:
Weekly Paid Claims means the amount of claims paid by
Blue Cross under the Agreement during the immediately preceding
week.
a. On the first working day of every week Blue Cross will bill
the amount of Weekly Paid Claims to the Group.
b. The Group will immediately reimburse Blue Cross for the
amount of Weekly Paid'C1aims.
C. Stop-loss Protection:
1. Specific Stop-loss
At the end of each month during the Agreement Year, Blue Cross
will determine if .the accumulated total of claims paid under
the Agreement by Blue Cross for anyone Member during the
Agreement Year exceeds $35,000,00. Any excess amount will not
be included in Weekly Paid Claims. The stop-loss limit may be
changed by mutual consent.
2. Aggregate Stop-loss
a. The aggregate stop-loss attachment point for the first
Agreement Year will be $176.37 multiplied by the sum of the
number of Subscribers actually covered during each month of
that Agreement Year, Blue Cross may change the amount of
the attachment point if required by a change in the level
of benefits, and will notify the Group, in writing, thirty
(30) days before the effective date of any change.
b. Aggregate Claims means the total of claims paid by
Blue Cro~s under the Agreement during an Agreement Year
reduced by any specific stop-loss excess amount credited to
the Group for that year.
c,
If, at the end 'of
that Agreement
attachment point,
any Agreement Year, aggregate claims for
Year exceed the' aggregate stop-loss
the excess will be refunded to the Group.
9808A (12-84)
- 30 -
.
o
o
o
o
D, Terminal Provisions:
Upon termination of the Agreement, the Group will continue to
reimburse Blue Cross, according to the provisions of paragraph
B.3., and will assume full liability for all claims payable under
the terms of the Agreement and paid by Blue Cross following the
date of termination. Upon termination of the Agreement, stop-loss
protection will terminate, and the liability of the Group will not
be subject to or limited by the stop-loss provisions of paragraph
B,2. and paragraph C.
E. Blue Cross will not be responsible for the Group's use of any
payment made by Blue Cross under this memorandum.
F. This memorandum becomes effective on December 1, 1984, and is part
of the Agreement, All other provisions of the Agreement which are
not in variance with this memorandum will remain in effect.
Authorized officers of Blue Cross and the Group have approved this
memorandum as of the effective date.
BLUE CROSS OF CALIFORNIA
By
By ~:~~l.~~
pr~/
BY~ ~
Secretary
By
Approved as to form:
~~e~$
9808A (12-84)
- 31 -