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CITY OF SAN BERtODINO - REQUEST lOR COUNCIL ACTION
Dept:
Personnel
REC'O.-AOHIH. tttt:
1333 fES 28 !.;.! 9 14
Resolution to Amend Agreement with
Private Medical-Care. Inc.. to Ext~nd
Term of Agreement an Additional Year
effective January 1. 1989
J12~
From:
Gordon R. Johnson
Date:
January 27. 19a9
Synopsis of Previous Council action:
The City previously entered into an agreement with Private ~edica1-Care Inc.. on
November 1.1981. to make available a Vision Care Plan to City employees.
Recommended motion:
Adopt resolution.
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A-, 4;<. . ~ "'__
. SiVlture
Contact person:
Gordon R. Johnson
Phone:
5161
Supporting data attached:
Ward:
. FUNDING REQUIREMENTS:
Amount: _
Source:
(~ t(),~
Finance:
Council Notes:
75.0262
Agenda Item No ,,1 r:1.,
CITY' OF SAN BE.RN"'DINO - REQUeST lOR COUNCIL ACTION
STAFF REPORT
The PMI Vision Care Plan was first made available for
purchase by employees in 1981 without City contribution. With
the cafeteria type plan now in the unit's MOUs, employees may
now use their cafeteria amounts towards the cost of the
vision plan. There is no change in the current monthly rates
for 1989.
Employee Only
Employee + One
Employee + Family
$ 7.68
10.56
15.36
The attached resolution extends the term of our agreement
with PMI through December 31, 1989.
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1 RESOLUTION NO.
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RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
EXECUTION OF AN AMENDMENT TO AGREEMENT WITH PRIVATE MEDICAL
CARE, INC., EXTENDING THE TERM FOR AN ADDITIONAL YEAR EFFECT-
IVE JANUARY 1, 1989.
BE IT RESOLVED BY THE MAYOR AND COMMON COUNCIL OF THE
CITY OF SAN BERNARDINO AS FOLLOWS:
SECTION 1. The Mayor of the City of San Bernardino is
hereby authorized and directed to execute on behalf of said
City an amendment to agreement with Private Medical Care,
Inc., extending the term for an additional year, effective
January 1, 1989, relating to an Optical Plan for employees
and dependents, a copy of which is attached hereto, marked
Exhibit "A" and incorporated herein 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 for the City of San
Bernardino at a
meeting thereof, held on the
day of
, 1989, by the following vote, to
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AYES:
Council Members
NAYS:
ABSENT:
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City Clerk
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RESOLUTION TO~END AGREEMENT WITH PRIVA~MEDICAL-CARE' INC., Tl
EXTEND TERM OF AGREEMENT AN ADDITIONAL YEAR EFFECTIVE JANUARY 1,
1989
The foregoing resolution is hereby approved this
day of
, 1989.
Mayor of the City of San Bernardino
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6 Approved as to form and legal content:
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II
DENTAL HEALTH PLAN
Affiliated with D~lta Dtntal Plan
OPTOMETRIC HEALTH CARE AGREEMENT
-Prepaid-
THIS AGREEMENT is made and entered into this day of , 198 ,by and
between PRIVATE MEDICAL-CARE, INC., a Californra-torporation (hereinafte~referred
to as "PMI") and CITY OF SAN BERNARDINO, PMI GROUP #9040 (herein called "Group"),
is made with reference to the following facts:
WITNESSETH:
A. PMI is a California corporation, organized to operate a health care service
plan, re9istered under the California Knox-Keene Health Plan Act, to provide
various lndividuals and Groups with health care benefits.
B.
Group represents that it has a bona fide list of enrollees and is authorized
to enter into agreements, for health care services on their behalf.
The parties desire by this Agreement to establish a health care program for
the benefit of the enrollees of the Group, covering the following services:
NOW, THEREFORE, in consideration of the mutual covenants herein contained and for
other good and valuable consideration, it is agreed as follow:
C.
1. Terms
The term of this Agreement shall be from January I, 1989, through
December 31, 1989, and shall automatically be renewed for additional
successive one-year terms, unless either party shall give written notice of
termination to the other party at least ninety (90) days prior to the end of
any such yearly term, in which event this Agreement shall be terminated at
the end of such yearly term.
1.1
PMI shall not increase the monthly fees paid by Group, nor decrease in any
manner the benefits stated in this Contract, except after a period of at
least thirty (30) days from and after a postage-paid mailing to Group, at
Group's address of record with PMI of written notice of such proposed change.
Any such change shall become effect i ve on the anni versary date of thi s
contract next succeeding the expiration of said notice period, unless a
different effective date is agreed to by the parties.
1.2
If this Contract is renewed as provided above, the coverage of each eligible
person is automatically renewed; if the Contract is not renewed, coverage of
all el igible enrollees ceases on the date the Contract terminates. The
5122 Kalella Avenue, Suitt 206, Los A1amilOs, CA 90720 (213) -493-6661, (714) 978-662i
So. Calilormal-800-32S-4S29 No. California 1-800-422-'1234 Nationwide 1-800-821-2058
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primary enrollee may reinstate coverage in the PMI program after having
previously allowed eligibility to lapse so long as this Contract remains in
effect for the Group" A primary enrollee must pay all unpaid monthly fees
from the time elig1bility lapsed up to and including the current payment
before he/she may be reinstated.
1.3
PMI shall not cancel or decl i ne to renew or rei nstate the Contract, nor
modify its terms, nor shall the benefits or coverage be subject to any
limitations, exceptions, exclusions, reductions, copayments, co-insurance,
deductibles, reservations, or fees, price or charge differential, because of
race, color, national origin, ancestry, religion, sex, marital status, sexual
orientation or age of any employee or member of Group or any person
reasonably expected to benefit from this Contract as an enrollee or
otherwise.
2. Entitlement of Eligible Person
Group shall provide a list of eligible enrollees each month commencing,
January I, 1989. PMI promises to Group, to provide, during the term of this
Agreement, to each primary enrollee whose name appears on the eligible list,
and each other elig1ble person in his family as defined in paragraph 3 below,
all commencing on the first day of the first month as to which the primary
enrollee's name so appears, and continuing so long as the primary enrollee's
name continues to appear on such eligible list (but in no event beyond the
term of this Agreement), and so long as the fees are paid with respect to
such primary enrollee as provided in paragraph 4, page 5, the services
described in Schedule A attached, subject to the limitation~ and exclusions
described in Schedule B attached. PMI may require eligible persons to
present, prior to receiving any such services, reasonable proof of
el igibil ity in accordance with uniform procedures to be established by PMI
from time to time. Group shall also provide a monthly list of all persons
electing continued coverage pursuant to Appendix A, showing their Social
Security numbers, their dates of election, the number of months of continued
coverage, and, if applicable, the names of the primary enrollees who
previously entitled them to coverage as eligible dependents.
2.1
All benefits and services described in Schedule A shall cease as to a given
primary enrollee, and other eli~ible persons in his family, at the end of the
last period for which payment 1S made by Group as provided in paragraph 4,
page 5, with respect to such primary enrollee, except as provided in
para~raph 2.2. Notwithstandi ng the foregoi ng, a primary enrollee or other
eli~lble persons may elect to continue coverage under the Continued Coverage
Opt10n Rider (attached hereto as Appendix A). Eligibility for such continued
coverage shall continue for the period required by Appendix A.
2.2
In the event the Group ceases to exist or this Contract is terminated, or a
primary enrollee leaves the Group, or otherwise ceases to be eligible for
coverage, the primary enrollee nonetheless may continue his eligibility in
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the plan if he/she or a family member is then in the process of recel Vl ng
vision services pursuant to this Contract, until such services are completed,
provided that:
a. During such period the primary enrollee must maintain current payments
of feesj and
b. No new or additional work may be started during this temporary period.
2.3
If an eligible person is entitled under a group insurance policy or any other
group health benefits program (including another PMI program) to receive or
be reimbursed for the cost of vision services which are also Benefits under
this program, and if the other 1l01icy or program is "primary" under the rules
described in Paragraph 2.3 (a) below, then the cost of vision services
rendered by non-Primary Optometrists under this program shall be reimbursed
only to the extent that the vision services are Benefits and are not fully
paid for or provided under the terms of the other policy or pr09ram. If this
program is "primary" under those rules, Benefits shall be provlded as if the
other policy or program did not exist and any payment received by an
Optometrist from other coverage shall be applied to any copayments due from
an eligible person.
a. If the other pol icy or program principally covers services or expenses
other than vision care, this program shall be "primar~." Otherwise, the
determination of which pol icy or program is "primary' shall be governed
by the following rules:
1) The policy or program covering the patient as other than a
dependent shall be primary over the policy or program covering the
patient as a dependent.
2) The policy or program covering a child as a dependent of a parent
whose birthday occurs earlier in a calendar year shall be primary
over the pol icy or program covering a chi ld as a dependent of a
parent whose birthday occurs later in a calendar year (except for a
dependent child whose parents are separated or divorced as
described in 3) below).
3) In the case of a dependent child whose parents are legally
separated or divorced:
a) If the parent with custody has not remarried, the pol icy or
program covering the child as a dependent of the parent with
custody shall be primary over the pol icy or program covering
the child as a dependent of the parent wlthout custody.
b) If the parent with custody has remarri ed, the pol icy or
program covering the chi ld as a dependent of the parent with
custody shall be primary over the policy or program covering
the child as a dependent of the step-parent, and the policy or
program covering the child as a dependent of the step-parent
shall be primary over the policy or program covering the child
as a dependent of the parent without custody.
c) If there is a court decree that establishes financial
responsibility for vision services which are Benefits under
this program, then notwithstanding 3) a) and 3) b), the policy
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or program covering the child as a dependent of the parent
with such financial responsibility shall be primary over any
other policy or program covering the child.
4) If the primary policy or program cannot be determined by the rules
described in I), 2) or 3), the policy or program which has covered
the eligible ferson for the longer period of time shall be primary,
with the fo I owi ng except i on: A po Ii cy or program coveri ng the
eligible person as a laid-off or retired employee or the dependent
of a laid-off or retired employee shall not be primary under this
rule 4) over a policy or program covering the eligible person as an
employee or the dependent of an employee. However, if the
provisions of the other policy or program do not include this
except i on, whi ch results in neither program bei ng primary, then
this exception shall not apply.
b. An eligible person shall provide to PMI and PMI may release to or obtain
from any insurance company or other organization, any information about
the e Ii gi b I e person that is needed to admi ni ster thi s Paragraph 2.3.
PMI shall, in its sole discretion, determine whether any reimbursement
to an insurance company or other organization is warranted under this
Paragraph 2.3, and any such reimbursement paid shall be deemed to be
Benefits under this Agreement. PMI shall have the right to recover from
an optometrist, eligible person, insurance company or other
or~anization, as PMI chooses, the amount of any Benefits paid by PMI
whlch exceed its obligations under the terms of this Paragraph 2.3.
3. Definition of Eligible Persons
Eligible persons shall include all employees or members of Group, and the
spouses (unless legally separated or divorced) and unmarried dependent
children under nineteen (19) years of age, of such employees or members.
Unmarried children who are 191ears of age or older, but less than 23 years
of age, will also be considere as eligible persons if they are enrolled on a
full-time basis (at least 12 units per quarter or semester) as a student in
an accredited school or college and are wholly dependent upon the employee ,or
member for mai ntenance and support. Provided, however, that a dependent
child shall remain eligible despite attaining such limiting age whlle the
child is and continues to be both (a) incapable of self-sustaining employment
by reason of mental retardation or physical handicap, and (b) chiefly
dependent upon the employee or member for support and maintenance, provided
proof of such incapacity and dependency is furnished to PMI by the employee
or member within thirty-one (31) days of the child's attainment of the
limiting age and subsequently as may be required by PMI but not more
frequently than annually after the two-year period following the chi ld' s
attainment of the limiting age. The word "child" includes a lawfully adopted
child, and any stepchild or foster child who depends on the employee or
member for maintenance and support and has the same permanent residence as
the employee or member. Dependents in military service are not eligible.
Eligible persons shall also include persons ceaslng to meet the conditions of
eligibility outlined above who elect continued coverage as provided in Appen-
dix A (Continued Coverage Option Rider), and for whom the appropriate monthly
payment specified in Paragraph 4 is received by PMI.
9040-1. VAG
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4. Fees
The monthly fees payable to PMI hereunder per primary enrollee and eligible
dependents, commencing with the month in which this AQreement becOMes
effective as provided in paragraph 1 above, or the pay perlod in which the
primary enrollee becOMes eligible, whichever later occurs shall be $7.68 per
primary enrollee, $10.56 per primary enrollee plus one dependent and $15.36
per primary enrollee plus two or more dependents. Such fees shall be mailed
to PMI at 5122 Katella Ave., Suite 206, Los Alamitos, California 90720. In
addition to these fees, primary enrollees and eligible dependents are
required to pay any copayments listed in this Agreement directly to the
participating optometrist. Fees for each person who elects continued
coverage as provided in Appendix A for himself or herself only shall be the
same as for a single primary enrollee. Fees for a person who also elects
continued coverage for his or her dependents shall be the same as for a
primary enrollee with the same number of dependents.
Group may charge persons electing continued coverage pursuant to Appendix A
such amounts as are permitted by Title X of P.L. 99-272.
5. Participating Optometrists
The services provided for by this Agreement shall be rendered by partici-
pating optometrists only, and PMI shall have no obligation or liabllity to
eligible i persons with respect to serviices rendered to them by non-
participating optometrists.
A list of participating optometrists shall be furnished to all primary
enrollees and notices of revisions of such list will be mailed to primary
enrollees periodically, or furnished to them on request. All services will
be rendered at the office of the participating optometrist. It is understood
that any participating optometrist may provide services to eligible persons
either personally, or through associated optometrists, or other technicians,
personnel or employees as may lawfully perform the particular service
required. PMI agrees to provide participatlng optometrists during the term
of this Agreement at convenient locations mutually acceptable to Group.
5.1
The primary enrollee may select any participating optometrist whose name is
contained' in said list at the time his eligibility begins, and MaY I1Iake a
change to any other such participating optometrist during the thirty (30) day
period before the renewal date of this Agreement. Any other change requested
by a primary enrollee will be made upon thirty (30) days written notice given
by the I'rimary enrollee to PMI, and a showing by him of a confl ict between
himself/herself and the optometrist previously selected.
5.2
PMI shall provide written
termination or breach of
participating optometrists
thereby.
notice within a reasonable time to Group of any
Contract by, or inabil ity to perform of, any
if Group may be materially and adversely affected
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5.3
In the event PMI fails to pay a participating optometrist, the eligible
person shall not be liable to the participating optometrist for any sums owed
by PMI.
In the event PMI fails to pay a non-participating optometrist, the eligible
person may be 1 iable to the non-participatlng optometrist for the cost of
servi ces.
5.4
Upon termination of.a contract between PMI and a participating optometrist,
PMI shall be 1 i ab 1 e for covered serv ices rendered by such optomet ri st (other
than for copayments as set forth in the Schedule of Benefits) to a primary
enrollee or dependent enrollee who retained eligibility under this Contract
or by operation of law under the c~re of such optometrist at the time of such
termination until the services being rendered to the primary enrollee or
dependent enrollee by such optometrist are completed, unless PMI makes
reasonable and medically appropriate provisions for the assumption 9f such
services by another participating optometrist.
6. Disputes
Any dispute or controversy arising out of or relating to this Agreement,
shall be resolved by arbitration as follows: Either party to the dispute (if
one of the parties is an eligible person, Group, at its option, may act on
behalf 9f such person; if one of the parties is a participating optometrist,
PMI, at its option, may act on behalf of such optometrist) may c~ence the
arbitration proceeding at any time within six (6) months after the dispute
arises by written notice to the 9ther party selecting and naming an
arbitrator. Within thirty (30) days after receipt of such notice, the other
party shall select and name an arbitrator and so advise the initiating party
in writ i ng. The two persons so selected shall proceed to name a thi rd
neutral arbitrat9r withln sixty (60) days after notice of appointment of the
second arbitrator.
The Board of Arbitration shall proceed with all possible dispatch to hear and
determine the dispute. It shall require the affirmative vote of two of the
three members of the Board to decide the issue and the decision in all cases
shall be binding up9n the parties hereto. The decisi9n shall be in writing
and signed by all members 9f Board but shall be legal and binding when signed
by a maj9rity thereof. Each party shall bear the fees and expenses of the
arbitrat9r selected by him, but fees and expenses 9f the neutral arbitrat9r,
wh9 shall be Chairman 9f the Board, and sten9graphic expenses shall be b9rne
equally by the parties t9 the dispute. The Board 9f Arbitrati9n shall have
n9 p9wer t9 add t9, subtract fr9m, m9dify, 9r make any changes as t9 the
terms 9f this Agreement. In the event the tW9 arbitrat9rs fail t9 select a
third neutral arbitrat9r within the sixty (60) day period prescribed ab9ve,
9r if the part ies t9 the di spute S9 agree, the matter shall instead be
submitted t9 arbitration before the American Arbitrati9n Ass9ciation in
accordance with its then prevailing rules, in which case the decision of the
arbitrat9r shall be. binding 9n the parties. In the event that suit is
instituted to enforce any of the provisions of. this Agreement, or. the
Arbitrati9n award, the prevailing party shall be entitled to reC9ver, in
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addition to any other relief which may be awarded, its reasonable attorney's
fees in connection therewith.
7. Definitions
As used in this Agreement, the following terms shall have the following
meanings:
a. "Primary enrollee," "Dependent enrollee," "Enro11ee(s)," or "E1 igib1e
person" means a person who is enrolled in the PMI program, and who is a
recipient of services from the PMI program.
b. "Copayment" means an additional fee charged to an eligible person which
is approved by the Commissioner of Corporations, provided for in this
Contract, and disclosed in the Evidence of Coverage.
c. "Evidence of Coverage" means any certificate, agreement, contract,
brochure, or letter of entitlement issued to a primary enrollee or
eligible person setting forth the coverage to which the eligible person
is entitled.
d. A factor is "material" with respect to a matter if it is one to which a
reasonable person would attach importance in determining the action to
be taken on the matter.
e. "Act" means the Knox-Keene Health Care Service Plan Act of 1975, or any
successor thereto under which PMI is regulated.
f. "Participating Optometrist" means an optometrist with whom PMI has an
agreement to provide services to eligible persons hereunder.
g. "Benefits" and "Coverage" mean the health care services available under
this Contract.
8. Cancellation
Enrollment of a primary or dependent enrollee or eligible person under this
Agreement may be canceled, or renewal refused, by PMI only in the following
events (cancellation of enrollment of a primary or dependent enrollee shall
automatically cancel the enrollment of all other eligible persons in his
family as defined in paragraph 3 above):
a. Upon expiration or termination of this Group Contract, if it is not
renewed.
b. Upon the person's ceasing to come within the definition of "Eligible
Person" as set forth in paragraph 3 above.
c. If the fees are not paid by or for the eligible person within fifteen
(15) days. .
d. On thirty (30) days written notice, such cancellation to be effective at
the end of the notice period:
1) If the primary. enrollee is dropped by the Group from the eligible
list, or ceases to be a employee or member of Group.
2) If the primary enrollee fails to make payments of copayments or
other charges required of him or an eligible dependent enrollee of
his family hereunder; provided, however, that the primary enrollee
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may be reinstated during the term of this Agreement upon payment of
sai d delinquent charges or copayments and any unpaid monthly fees.
3) If the primary or dependent enrollee or eligible person is guilty
of habitual intemperance or misconduct while in the office of a
participating optometrist.
4) If in the professional judgment of the optometrist who is to render
service, that service cannot properly be rendered to the primary or
dependent enrollee.
5) If the primary or dependent enrollee of his family knowingly
perpetrates or permits another person to perpetrate, fraud, or
deception in the use of the services or facility of or provided by
PM I.
e. A primary or dependent enrollee or eligible person who alleges that his
enrollment has been canceled or not renewed because of the enrollee's
health status or requirements for health care services may request a
review by the Commissioner of Corporations. If the Commissioner
determines that a proper complaint exists under the provisions of 1365
of the Health and Safety Code, the Commissioner shall notify PMI.
Within fifteen (15) days after receipt of such notice, PMI shall either
request a hearing or reinstate the primary or dependent enrollee. If,
after hearing, the Commissioner determines that the cancellation or
failure to renew is contrary to subdivision (a) of Section ~1365, the
Commi ss i oner sha 11 order PMI to rei nstate the primary or dependent
enrollee. A reinstatement pursuant to subdivision (b) of Section 1365
shall be retroactive to the time of cancellation or failure to renew and
PMI shall be liable for the expenses incurred by the primary or
dependent enrollee for covered health care services from the date of
cancellation or non-renewal to and including the date of reinstatement.
f. In the event of cancellation by PMI (except in the case of fraud or
deception in the use of services or facilities of PMI or knowingly
permitting such fraud or deception by another) or by Group, PMI shall
within thirty (30) days return to Group the pro rata portion of the
money paid to PMI which corresponds to any unexpired period for which
payment had been received, together with amounts due on claims, if any,
less any amounts due to PMI.
g. Acceptance by PMI of the proper monthly fees, after termination of the
Contract and without requiring a new application, shall reinstate the
Contract as though it had never terminated, unless PMI shall within .five
(5) business days of receipt of such payment, either (1) refuse the
payments s6 made, or (2) issue to Group a new Contract accompanied by
written notice stating clearly those respects in which the new Contract
differs from the terminated Contract in benefits, coverage, or
otherwi se.
9. California Health & Safety Code
PMI is subject to the requirements of Chapter 2.2 of Division 2 of the
Ca I iforni a Health & Safety Code (the "Act:) and of Subchapter 5.5 of
Chapter 3 of Title 10 of the California Administrative Code (the
"Regulations"), and any provision required to be in this Contract by either
of the above shall bind PMI whether or not provided in this Contract.
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10. Group shall designate in writing a representative for purposes of receIvIng
notices from PMI under this Contract. Group may change its representative at
any time on thirty (30) days written notice to PMI." Any notice required from
PMI to either Group or any eligible person may be given by PMI to the group
representative, who shall disseminate such notice to prImary enrollee and
enrollees from Group by the next regular communicatIon to such primary
enrollee and enrollees but in no event, later than thirty (30) days after the
receipt thereof. The initial group representative for purposes of this
Contract shall be
IN WITNESS WHEREOF, the parties have executed this Agreement and have affixed
their signatures on the day of , 19___
CITY OF SAN BERNARDINO
PMI GROUP #9040
By:
SIgnature and TItle
P.O. Box 1318
Address
San Bernardino CA
CIty State
714/384-5002
Telephone Number
92402
ZIp
Date
Approved as to form and
legal content:
JAMES F. PENMAN
City Attorney
B~
9040-1. VAG
PMI
BY.~~~
. 1 na ur an . 1. .
ATTEST:
City Clerk
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SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS
PROGRAM Al
The following optometric services are available from a panel optometrist
subject to the exclusions and governing administrative policies of the
program:
ENROLLEE
PAYS
DEDUCTIBLE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . None
COMPLETE EYE EXAMINATION
every 12 months............................................ No Cost
If examination reveals the need of glasses and the
patient wishes to take the prescription elsewhere
the patient pays........................................... No Cost
LENSES (Glass or Plastic) if needed, every.......................12 mos.
No Cost
Single Vision (Sph. & Cyl. to 4 Oio.)...................... No Cost
Single Vision (Over 4 Oio.) additional per Oio............. No Cost
Single Vision, Lenticular.......................... ..Cost + $ 5.00
Flat Top 25 Bifocal (Sph. & Cyl. to 4 Oio.)................ No Cost
Flat Top 25 Bifocal (over 4 Oio.) additional per Oio....... No Cost
Executive Bifocal (Sph. & Cyl. to 4 Oio.).................. No Cost
Executive Bifocal (over 4 Oio.) additional per Oio......... No Cost
Blended or no line......................................... $ 60.00
Lenticular.... ..... ..... ........... .... ..... .... .... .Cos.t + $ . 5.00
Trifocal (Sph. & Cyl. to 4 Oio.)........................... No Cost
Trifocal (over 4 Oio.) additional per Oio.................. No Cost
Executive Trifocal................................. ..Cost + $ 5.00
Progressive.. ..................... ........... .'...... .Cost + $ 5.00
Double 0 Trifocal................................... .Cost + $ 5.00
Glass Tinted Lens, Single Vision
(Pink, Grey3, Green3).................................... No Cost
Glass Tinted Lens, Bifocal or Trifocals
(Pink, Grey3, Green3).................................... No Cost
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Coated Lenses
Solid color (glass or plastic)........................
Grad~ent (~lass or plastic)...:.......................
Multl-gradlent (~laSS or plaStlC).....................
Anti Reflection glass)...............................
Anti Reflection plastic).............................
UV 400 (ultraviolet coating)..........................
Scratch Coat..........................................
Photogray Extra, Single Vision........................
Photogray Extra, Bifocal..............................
Photol ite (plastic photogray).........................
$ 10.00
$ 15.00
$ 25.00
20.00
35.00
25.00
25.00
15.00
25.00
60.00
Oversize Lenses, Single Vision (frame size 55 and over).... $ 10.00
Oversize Lenses, Bifocal (frame size 55 and over)....~..... $ 12.00
Pri sm per every two degrees................................ $ 4.00
Flat Top 28 Segs, additionaL.............................. $ 3.00
Flat Top 35 Segs, additionaL.............................. $ 10.00
FRAMES (up to $40.00 retail value) if needed, every..............12 mos.
No Cost
Designer................... ..................... ...UCR less $ 30.00
CONTACT LENSES
Hard...................................................... .
Medically necessary*....................................... No COst
Annua 1 Serv i ce Pol icy. .. . . .. . . . .. . . . . .. . . .. . . . .. . . .. ..
Rep 1 acement per 1 ens wi th Serv i ce Po li cy** .. . .. .. . .. ..
Replacement per lens without Service Policy**.........
Soft, Dai ly Wear...........................................
Annua 1 Serv i ce Pol icy.. . . . .. . . . .. .. . .. . . . . .. . . . . .. . . ; .
Replacement per lens with Service Policy**............
Replacement per lens without Service Policy**.........
Soft, Torie.......................... ~.....................
Annua 1 Servi ce Pol icy. . . . .. . . . . . .. . .. . .. . . .. .. . . . . . . . .
Replacement per lens with Service Policy**............
Replacement per lens without Service Policy**.........
Extended Wear..............................................
Annua 1 Serv i ce Pol icy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Replacement per lens with Service Policy**............
Replacement per lens without Service Policy**.........
Opaque Colored.............................................
Annua 1 Serv i ce Pol icy.. . . . . .. . . . .. . . . . .. . . . .. . . . . .. . . .
Replacement per lens with Service Policy**............
Replacement per lens without Service Policy**.........
9040-1. VAG
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I 50.00
15.00
15.00
25.00
1100.00
35.00
35.00
50.00
$250.00
$ 65.00
$.65.00
$125.00
$150.00
$ 65.00
$ 65.00
$ 75.00
1200.00
65.00
65.00
$100.00
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Gas Penneable..............................................
Annual Service Pol icy.................................
Replacement per lens with Service Policy**............
Replacement per lens without Service Policy**.........
f125'00
35.00
35.00
$ 60.00
Follow-up Visits, first 90 days............................ No Cost
Follow-up Visits, after 90 days,
per vi s it with Service Pol icy.. .. .. .. .. .. .. . .. .... .. .. ... No Cost
Follow-up Visits, after 90 days
per visit without Service Policy......................... No Cost
Failure to cancel appointment
(24 hour prior notification)............................... $ 10.00
* Medically necessary contact lenses or subnormal vision aids are covered
only when the visual acuity of the patient is not correctable to 20/70 in
the better eye by use of conventional type lenses, but can be improved to
20/70 or better by the use of contact lenses or other subnormal vision
aids.
** Applies only if original contacts were made by the assigned panel
optometrist.
Services not listed above (other than contact lenses) are available at the
doctor's actual lab cost plus $5.00. Contact lenses not listed are
available at a cost of 30% less than the doctor's usual, customary and
reasonable fees.
REFUND POLICY
All glasses are guaranteed for 90 days if factory defective or if there is
a change in the prescription.
If the patient cannot successfully wear contact lenses during the first 90
days, they may be exchanged (no cash refunds) for one pair of eyeglasses.
After the 90 day period, no exchanges will be made.
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SCHEDULE B
EXCLUSION OF BENEFITS
The following services are not Benefits under this program:
1.
2.
3.
4.
5.
6.
Orthoptics or vision training;
Subnormal vision aids;
Aniseikonic lenses;
Medical consultations;
Medical or surgical treatment of the eyes;
Any condition for which benefits are receivable under any Worker's
Compensation or occupational disease law, to the extent of such benefit;
Eye examinations requires (1) by a,n employee as a condition of employment,
which the employer 1S required to provide by virtue of labor agreement, or
(2) a government body;
Replacement of lenses or frames which were furnished under this program and
which have been lost, stolen or broken.
Two pair of lenses in lieu of bifocals.
7.
8.
9.
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SCHEDULE C
GOVERNING ADMINISTRATIVE POLICIES
The following administrative guidelines are an integral part of this program and
are consistent with the principles of accepted optometric practices:
1. Visual Analysis
The visual analysis shall be available at no cost once during any 12 month
period and shall include a complete case history; an external and internal
eye examination for pathology or anomalies; a complete refraction; binocular
coordination measurement and tests; a visual field charting, if indicated;
near point visual functions analysis; a diagnosis of visual problems; a
prescription of proper lenses, if indicated; a tonometry examination for all
patients over the age of 18 and for younQer patients based on family medical
history of if indicated, and an occupatlonal vision analysis with specific
attention to the job being performed.
If medical services regarding the visual health of the Enrollee are
indicated, the panel optometrist shall refer the Enrollee to the medical
practitioner of the Enrollee's choice. This referral is not a covered
Benefit under this program and if required is at the Enrollee's expense.
2. Lenses and Frames
When the visual analysis indicates the need for a correction to ensure proper
visual health and welfare, lenses and frames are covered in conjunction with
necessary professional services based on the Schedule of Benefits and
Copayments. Included as Benefits are facial measurements; assistance in the
selection of frames; procuring of proper lenses and frame; verifyin~ the
accuracy of fabricated materials (finlshed glasses); a progress viSlt or
follow-up of both a professional or mechanical nature, as required;
subsequent adjustments of frames to maintain comfort and efficiency; lens
tests, case-hardened and drop ball tested lenses.
Should a problem arise, consultation and advice are available at any time.
New prescription lenses and frames are available only once during the covered
period whenever the visual analysis so indicates. Prescription sunglasses
are available in lieu of clear prescription glasses.
9040-1. VAG
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APPENDIX A
CONTINUED COVERAGE OPTION RIDER
In consideration of the payments specified in Paragraph 4 of the Vision Health
Care Agreement, and subject to all of the terms and conditions of the. AgreE!lllent,
PMI agrees to provide Benefits to persons who elect continued coverage pursuant to
this Rider.
I. For the purposes of thi s Rider, each of the following shall constitute a
"Qualifying Event:"
a. Termination of a primary enrollee's employment with Group (other than
for gross misconduct), or a reduction in the number of hours worked by
the primary enrollee to less than any minimum number of hours required
under Paragraph 3 of the amended Agreement.
b. Death of a primary enrollee.
c. Divorce or legal separation from a primary enrollee.
d. A primary enrollee's becoming entitled to Medicare benefits.
e. A dependent child's ceasing to meet the description of dependent child
contained in Paragraph 3 of the amended Agreement.
2. Primary enrollees whose coverage under this program is terminated by reason
of a Qualifying Event described in ParaQraph la of this Rider may elect to
continue coverage for themselves and thelr eligible dependents for 18 months
following the month in which the Qualifying Event occurs.
3. Eligible dependents whose coverage under this program is terminated by reason.
of any of the QualifyinQ Events described in Paragraph Ib throuQh Ie of this
Rider may elect to contlnue their coverage for 36 months followlng the month
in which the Qualifying Event occurred. However, persons who elect to
continue their coverage based on a Qualifying Event described in Paragraph Ia
of this Rider, and who become entitled wlthin the next 18 months to elect to
cont i nue coverage by reason of a Qua 1 i fyi ng Event descri bed in Paragraph Ib
through Ie of this Rider, may elect to continue their coverage fora maximum
of 36 months following the month in which the first Qualifying. Event
occurred.
4. Continued coverage can be elected only by notice to the Group, which must be
given no later than 60 days after a termination of coverage by reason of a
Qualifying Event, or within 60 days after the Eligible Person receives from
the Group a notice about his or her rights to continued coverage because of
the particular Qualifying Event, whichever is later. PerSons for whom a
Qualifying Event described in Paragraph lc or Ie occurs must report it to the
Group within 60 days, or lose their right to elect continued coverage.
5. Continued coverage elected by a person under this Rider shall be effective as
of the first day of the month following the applicable Qualifying Event
described in Paragraph 1 of the Rider. However, Benefits shall not be
available to a person electing continued coverage before Group furnishes PMI
wi th the data about such person requi red in Parilgraph 2 of the Agreement,
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along with all fees then currently payable for su.ch person as stated in
Paragraph 4 of the Agreement. PMI shall not, in any event, make Benefits
available under this Rider with respect to any person for whom such
information and fees are not received by PMI withln 60 days after the date
such person is required by law to notify Group of his or her election.
6. Cont i nued covera~e for persons under thi s Ri der shall be the same as the
coverage for slmi1ar1y situated eligible persons under the attached
Agreement, and if coverage and/or Fees specified in Paragraph 4 are modified
for such eligible persons, they shall also be modified in the same manner for
persons having continued coverage under this Rider. .
7. A person's continued coverage elected under Paragraphs 2 or 3 of this Rider
sha 11 termi nate on the 1 as t day of the month in wh i ch any of the fo 11 owi ng
events first occurs:
a.
The period of continued coverage specified in Paragraph 2 or 3 expires.
This Agreement terminates.
Group fails to pay Fees for the person as specified in amended Paragraph
4 of this Agreement.
The person with continued coverage becomes eligible for vision benefits
under another group health plan (as an employee or otherwise).
The person becomes eligible for Medicare benefits.
b.
c.
d.
e.
8. Once continued coverage under this Rider is terminated, it cannot be
reinstated.
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