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CL Y OF SAN BERNARC .10 - REQUE~ ~ FOR COUNCIL AC1.JN
From:
Gordon R. Johnson
Director of Personnel
Personnel
Subject:
Resolution Electing to be Subject
to Public Employees' Medical and
Hospital Care Act only with Respect
to Members of A Specific Employee
Organization
Dept:
Date:
November 16, 1983
Synopsis of Previous Council action:
The conversion from the self insured John Hancock Health Plan to the PERS
Basic Health Plans was recommended by the Council Personnel Committee at
their meeting on November 10, 1938.
Recommended motion:
Adopt resolutions.
.~_ f ilL
Signaturv
Contact person:
Gordon R. Johnson
Phone:
5161
Supporting data attached:
Ward:
FUNDING REQUIREMENTS:
Amount:
Sou rce:
Finance:
Council Notes:
75-0262
Agenda Item No.
s-~
C~ _ Y OF SAN BERNARD 10 - REQUE,- f FOR COUNCIL ACT.,JN
STAFF REPORT
city employees eligible to participate in health insurance
programs choose between two options: Kaiser and a self-
insured fee-for-service plan where John Hancock processes the
claims. The 1988 rates for these two plans are very similar,
however, we are facing an average increase of 46% in the John
Hancock rates for 1989, much higher than the 10% increase
Kaiser has quoted us.
The major reasons for the large increase in the
plan, according to Mike Baker of the Wyatt
insurance consultant, include:
self-insured
Company, our
o Claims and expenses for 1988 projected to exceed
funding by 25%
o Medical utilization increased by 31% over 1987
o Annual medical care inflation increased to over 20%:
a trend rate of 14% was assumed in performing last year's
projection for active medical claims
o 1988 PCS drug claims costs are up 45% over last
year's projection
o The experience of retirees, who make up 1/3 of the
plan enrollees, is 2-3 times worse than for active employees.
Mike Baker recommended several medical and PCS plan design
changes including:
o Increasing medical plan deductible and the annual
out-of-pocket limit
o Changing the PPO medical providers' reimbursement
percentage back to 90% from 100%
o Increasing the PCS deductible from $2 to $5 per
perscription.
In addition, he recommended that the current practice of
active Hancock program participants subsidizing the retiree'
rates by themselves be expanded to include the over 500
active Kaiser enrollees. This plan would have led to rate
increases of around 30-35% for everyone, both Kaiser and
Hancock enrollees.
These suggestions and many more were discussed at several
meetings of the Insurance Committee, composed of representa-
tives of the various employee bargaining units and interested
management employees. After lengthy discussion and analysis,
the majority of the Committee recommended going to the PERS
health plans and dropping the self-insured indemnity plan for
health insurance.
75-0264
The PERS health plans a.e administered by the same Board of
Administration which manages the PERS retirement system. The
Public Employees' Medical and Hospital Care Act was enacted
in 1962 to provide medical insurance for active and retired
employees of the state of California. In 1967, the act was
amended to permit cities and other public agencies to parti-
cipate as well. As of July 1, 1986, all contracting agencies
may elect to contract for participation of all the agency's
members, or to contract for the members of one or more
individual employee organizations.
The types of health plans offered include a statewide indem-
nity plan, numberous HMOs (ie: Kaiser, Health Net, Cigna, and
Partners), and two Preferred Provider organizations (PPOs).
Participating cities include Loma Linda, Rialto, Pomona,
Garden Grove, Burbank, Torrance, Carson, Barstow, Pasadena,
and Upland, as well as Cal state San Bernardino. There are
currently 276,000 households representing active and retired
public agency employees who participate in a PERS health
plan.
The City is required by law to contribute at least $16 a
month for each program participant, be they active or re-
tired. The City currently contributes $17.74 per month for
each of the 1030 participants in the Hancock plan, including
343 retirees. In addition, the City had to subsidize this
self-insured plan by $200,000 during the past year.
The City is required to contribute an administrative fee
which by statute cannot exceed 2% of the total monthly
premium to PERS to cover the cost of providing the program to
the City. The rate for the current contract year 0.5%.
If we were to transfer to the PERS plans, there would be no
need for the City to maintain the risk it now has being self
insured for health insurance since PERS would assume all the
risk and fund all their costs from the premiums assessed. The
PERS plan rates are lower than those we can obtain by
ourselves.
This change would not eliminate the self-insured dental and
vision plans the City now offers its employees. PERS does
not offer dental or vision plans to contracting cities.
Don Harrington, manager of the San Bernardino PERS office,
has met with me and my staff and with the Insurance Committee
to discuss implementation of their plans. since the in-
creases for the self-insured and Kaiser plans are scheduled
to take effect January 1, 1989, it is in the City's best
interest to proceed to change to the PERS plans as rapidly as
possible. We propose the following timetable for implement-
ation:
January 1 - POlice, Fire and Management since we are current-
ly in negotiations with all three groups.
February 1 AFSCME and Mid-Management since they have
existing MOUs which will require amending.
The Water Department ) interested in ,itching over effec-
tive February 1 as well. Attachment A is a memo from Bernard
Kersey of the Water Department stating the Board of Water
Commissioners' desire to adopt the PERS medical plan for
their employees and retirees. The Redevelopment Agency's
employees currently are only eligible to participate in the
Hancock plan. The Community Development Commission would
need to consider adopting a resolution permitting their
employees' participation in the PERS plans as well or make
some other arrangements for them to have medical insurance
coverage. Their staff is currently studying other options of
providing medical insurance to Redevelopment empoloyees.
Attached are fact sheets which describe the health plans in
the San Bernardino/Riverside service areas (attachment B). A
summary of the 1989 monthly rates for those plans in the San
Bernardino/Riverside service areas and the proposed 1989
rates for the City's current self insured John Hancock Plan
and Kaiser HMO are provided for comparison in attachment C.
In summary, staff recommends this action because it will:
o Provide employees and retirees with a lower cost
medical indemnity insurance plan
o Eliminate the City's need to subsidize the self-
funded plan as it has in recent years
o Provide employees with more health insurance plans to
choose from
o Place the City in a pool of nearly 300,000 households
now in PERS medical plans, reducing the impact of catastro-
phic events on our ability to obtain and provide an indemnity
insurance plan
o Simplify administration of the health insurance
program.
FIRST FARWEST'S Cu FO HEALTH PLAN
WHATYOUPAYt
Member Non-Member
Providers Providene
No c~rae 30,.,
Nochilrae 30,.,
Nochilrae 30,.,
COVERED CHARGES
TYPE Of SERVICE
Room .nd boIrd up to semi.priv.~ rilte
Intensive, coronilry.nd intermedi.~ care room ch.rges
Hospiul extrn, includinslab.nd x-rilY, oper.1inS room,
rildiolosist.nd ~tholosist fees.nd sener.1 nursins cilre
Sursial room fee
Rildiiltion .nd ChemocherilPY lreiltment
Kidney di.lysis
SuraerY or hospitiJl visits
Office or Home Visits, including:
- Well B.by Care in first year of life
- Vision.nd He.ring Testing
- AIlef8)' Testing and Injections (Serum is paid.s. prescription drug)
- Immuniz.tions and lnocul.tions
- Periodic Health Exams (once each year) provided only for:
- EXilm wilh PilP sme.r & breast eXilm
- Exam with proctoscopy or proctosigmoidoscopy
Outpi!tienl diilgnostic lab and x-ray services
Excludes drugs in connection with weight control, birth control,
menul disorders and drug addiction. Allergy serum, insulin
and diabetic suppl ies are covered as any other prescription drus
- ~i1 Order Pharmacy
- All Other Philrmacies
When mediCillly lleCesQry and prescribed by a physician
PrqniIncy and childbirth
Routine nursery are
N.turill childbirth c1.sses
VoIuntiIry steriliziltion (reversill is nat covered)
Infertility studies ilnd lreiltment (excludins in vitro fertiliziltion)
Contraceptive drugs ilnd devices
In or out of .reil, medicillly lleCesQry tr.nsportiltion to and from
. hospitill
In or out of ilreil, .ErnerwencY" meilns injury treated within 48
haws iInd illness with iI sudden unexpected onset for which
treiltment annat Qfely be deli1yed
I~tient hospiul c~rges ilnd physiCian visits
Outpatient treiltment
Crisis inlervention
I~tient hospital and physician treiltment
Outpatient treiltment
DetoxnlCiltion.'Crisis intervention
Upon physiciiln'sorder, skilled services of R.N. or l. V.N.
Custod~1 are not provided
Semi-privil~ room ilnd other cNrges up to 31 dilys per
diSilbilily. Custodiill are not provided
~tioMI Speech~ is covered upon iI physiciiln's order to correct
n-.r iI speech impediment caused by illness or injury-lunctional
nerYOUSdisorders are not cCMred. Physiul & occ~tionill
~ iscCMred upon iI physiciiln'sorder
limitlecllO 20 visits per alendolr yeilr
limited to 20 visits per calendctr year. Biofeedback is available
upon A!ferral of a Foundiltion member physician
Unreplaced blood ilnd its ildministration No cNrae
HeilIth Eduation Prosrilms; Hospice ure Not CCMred
Ufn.-Muimum Benefit All illnesses ilnd injuries $ 1,000,000
· Benefits ilre pilyable iltIer $200 per pet'SOf\ deductible per calendctr year. F.mily limit on deductibles is three per family. Once $10,000 in
cO\len!d c~rges ~ve been incurred by . covered penon in . calendctr year, the Plan pilYS 100,., of illI additioNl covered charges for that
penon for the rest of the ulend.v ye.. If the mandiltory Hospital Utilintion Review Prosrilm is not complied with, you will be responsible
for.. additiOMI $200 deductible.
.. MerUl Health inpatient hospital .nd physiciiln (30 days maximum per yeilr) and outpiltient physiciiln benefits (20 visits and $ 1,000 payment
rnuimums per ye.r) are limited to . lifetime maximum pilyment of $25,000. Akohol ilnd Orus Abuse benefits ilre limited to a maximum
payment of $ 175 per dily for i~tient tre.tment and a maximum payment of $ 1,000 per cillendctr yeilr for outpatient treatment The maximum
combilled payment for inpiltienl ilOO outpatient treatment is $5,000 per cillendar ye.... Speech TherilPY is limited to . lifetime maximum
~yment 01 $ 1,000.
t If the mandiltory Hospital Utilization Review Prosram is not complied with, you will be responsible for a $200 deductible.
HospibI Sertices
....npiltielll
No c~rae
Noc~...
NoC~rae
Nocharae
$S c~yment
30,.,
30,.,
30,.,
30,.,
30,.,
~
"',... Ure
No charge
~Lab&X.RilY
Prescription OnIp
30,.,
$2 cOpilyment
30,.,
30,.,
30,.,
30,.,
Not Covered
30,.,
30,.,
Not Covered
30,.,
$2 c~yment
20,.,
No c~rae
$5 c~yment
NocNrae
Not Covered
Noctwae
$5 c~yment
Not Covered
No c~rae
Our'" MecrICilI Equipment
Milternily
filmly .......
AInbuL1Ke-Air II Ground
$25 c~yment
30,.,
[me, JMC'J Ure II Services
so,.,..
SO,.,..
Not Covered
$20c~yment..
$20c~ymenr.
$20c~yment..
$10c~yment
50,., ..
50,., ..
Not Covered
30"'..
30,., ..
30"'..
MenUI Health
AIcohoI_ DrusAbuse
Home Health Services
30,.,
NocNrae
SIdled NIInina facility
30,.,
$5 c~ymenr.
30,., ..
30,.,
30,.,
30'"
$S copayment
~~
AcupundureJliofftdbold
~
Not Covered
Ott.
IIT~f/ \\6
29
PERS CARE
YOU PAY
NON OUT Of
. COVERAGE PElS-CARE SERVICES Pro Pf'O ARIA
~
Inpatient . Semi-private room/board and all medically necessary services 1 O'llo" 40"4" 10'\"
Outpatient . Surgical room fee 1 O'llo 40"4 10'\
. Ibdiation, chemotherapy and renal dialysis 1 O'llo 40"4 10'\
Phy;cWl Cue . Office visits; hospital and home visits; surgery 1 O'llo 40"4 10'\
. Well baby care 1 O'llo" 40"4" 10'\"
. Periodic health exams/to Age 40-~ 2 years/age 40 and over-each year
($200 Maximuml 1 O'llo" 40"4" 10'\"
. Immunizations and inoculations 1 O'llo" 40"4" 10'\"
. Allergy testing and allergy injections 1 O'llo 40"4 10'\
. Vision and hearing screening Not Covered
[)ia&nostic IX.ray I Ub . Outpatient diagnostic, X-ray/lab services 1 O'llo 40"4 10'\
Precription Drup . Generic drugs including Insulin (card or mail order plan) $4.00 54.00 5400
. Non-generic drugs including Insulin and diabetic supplies (card or mail order plan) $6.00 $6.00 $6.00
. Birth control pills Not Covered
Dur~ Medic.. Equipment . Rental or purchase of physician prescribed equipment which has a
solely therapeutic value 2 O'llo 20'\ 20'\
~terni1y . Nursery care; newborn exam and circumcision 1 O'llo" 40'\" 10'\"
. Pre and post natal care and complications of pregnancy 1 O'llo 40"4 10'\
. Alternate birth center 1 O'llo" 40"4" 10'\"
Famiy Pl.nninl . Voluntary sterilization 1 O'llo 40'\ 10'\
. Elective abortions 1 O'llo 40'\ 10'\
. Infertility services; contraceptive devices Not Covered
AmIIubna . Air/ground medically necessary transportation 20'll0 20'\ 20'\
Eme. JelleY Cue . Diagnosis and treatment of medical emergencies (in area and out of area) 1 O'llo 10'\ 10'\
Senices NOn: Emergency care shall mean services required for the alleviation of severe pain
or unforeseen illness or injury which if not treated within 48 hours of the onset of
symptoms could lead to further signifICant disability or doth
MeIIUI He..... . $50,000 lifetime maximum for all benefits
Inpatient . Hospital/physician services with approved treatment plan, 30 days/calendar year 1 O'llo" 40"4" 10'\"
Outpatient . Up to $80 maximum charge130 visits per calendar year
First 10 visits 1 O'llo 10'\ 10'\
Next 20 visits 40'll0 40"4 40"4
AIcahoI/OruI Abuse . $ 12,000 lifetime maximum for all benefits
Inpatient . Hospital/physician services with approved treatment plan, 15 days/calendar year 1 O'llo" 40"4" 10'\"
Outpatient . Up to S80 maximum charge/30 visits per calendar year
First 10 visits 1 O'llo 10'\ 10'\
Next 20 visits 40'll0 40"4 40"4
tta.e He..... Senices . A maximum of 100 visits per calendar year with approved treatment plan
(not provided for custodial care) 1 O'llo 10'\ 10'\
sa.ed Nunins fdties . A maximum of 180 days per calendar year
First 10 days 1 O'llo 10.. 10'\
Next 170 days only with approved treatment p1an(not provided for custodial carel 20'll0 20'\ 20'\
Speech 11IeriPY . $5.000 lifetime maximum 20'll0 20'\ 20'\
Cowred when referred by a physician and upon approved treatment plan
Ph,IiaI/~ . Cowred when referred by a physician 1 O'llo 4O'lI. 10'\
n.npy
Aalpunclure/Qirapractic . 20 visits per calendar year for services from an acupuncturist or chiropractor 20'll0 20'\ 20'\
IiaRecIbIdc . Paid under physician benefit 1 O'llo 4O'lI. 10'\
Other . Unreplaced blood and blood products 10% 40.. 10'\
. Hospice-$7,500 lifetime maximum
Two visits bereavement counseling 1 O'llo 10.. 10'\
Five days respite with approved treatment plan 1 O'llo" 10.." 10'\"
. Second opinion when directed by UR 0 0 0
. Christian Science treatment 20'll0 20'\ 20'\
. Heahh education programs Not Covered
-DEDUCTIBLE WAIVID
Ann.... Deductible: S200 Single/S400 Family
Muimum Ann.... Copayment Preferred Provider and Out of Area-Sl,OOO SinglelS2,OOO Family
Non-Preferred Provider-S3,OOO Single/S6,OOO Family.
Payments for Mental Health, Alcohol/DruB, Prescription Drugs, Non-Compliance UR Penalties and Deductibles will not apply to
copayment maximum.
13
1-:'1 '
...J. - (
_EACE
C<MRED SERVICES
Type of 5enlct ~ of 5ervicts
OFFICERS RESE&,CH ASSOCIATION OF CALIFORNIA
(pORAe)
NOTE: Percentages shown below ft bised on c~ expenses incurred
~"hy
~ PftMdIr our of Ala PrcMder Nark~ fItoIMder
HolpCII 5elvas
o~
o~
~Ulf
~AJb
~ Ones
lMm1isaeled 17( PCSl
o ~ ~ MId ill mediafty ~ IeMce. MId
~ rminI QIf
o SlqialIOOIl1 ft. radWIion MId chemotoe.~ lUrnenl MId I!NI
~
o 08ia. home MId hospGl _ llq!IY
o AlIe!IY l!5linI. AlIerf !enIlI ~ MId mtdiaIion
o E)t NIl when ~18l dur III flf llq!IY
o W!IkiIiId QIf, incIudin& III'IU1iaIia15 MId inoolIaons
-51SO~
o Periodic IluIIh _ b llbcriber MId spcu5e. inckdn& 1llIl-
nl bIusl_ - 52SO~.
o Heanng I!Sl1ng
o ~d~ ~ nl ~ ltMC!S
ol'lecripia1 ~ ~ 17( a ~, inck.dirc insulin nl (jabeIic:
!I4lIlIie. BiI1h conboI pills IllX COMd
No eMIr 20\ m
(No deOIt1ilIel
No eMIr 20\ m
(No deduclIbIel
No eMIr 20\ m
No eMIr 20\ m
No eMIr 20\ m
A/llculls eaDrc SMyt AIlIcul& eaedinc 51~ A/llculls ecmirc ~
A/llculls ecee:q SMyr. AIlIcul& eaedna ~ A/llculls eaedit1 ~
(No deduclIbIel (No dlduc1ibIel (No~
Nell COoe!d Nell ClMI8I Nell COoe!d
No eMIr 20\ lO'I.
5~bJmelic 5llX1/peaiplion b J!lll!ric 5~b(leMlC
dnC55~ dnC55~ drup5~
b 101 .-;c ~ b 101 JmeIic dnC5 b 101.-;c ~
20\ 20'\ 20\
No eMIr 20\ lO'I.
Nell COoe!d Nell CQMj Nell cOIeled
No eMIr No~ No~
No~ 20\ m
No~ 20'\ m
Nell COoe!d Nell ClMltd Net cOIeled
Nell COoe!d Nell CQMj ... cOIeled
No~ 20\ m
Nell COoe!d Nell CQMj Nell cOIeled
20'\ 20'\ 2O'fo
No~ No~ I0Io_
50". 50\ 50\
No~ 20\ m
25\- 25\- 50\-
No~ 20'\ lO'I.
No~ 20\ m
~ Medical Equipmenl
nl ~ies
20'\ 2O'fo m
20'\ 20'\ 2O'7t
No ciIarJe 20'10' 30\'
25\ 25\ 5O'fo
No~ m m
2O'fo 20\ m
No~ No~ No_
Nell COoMd Nell CQMj Nell cOIeled
No~in~ No~in~ No_in~
hospic! IIlllpi(! hospic!
No~ No~ No~
No~bCllllllMon No~b~ No~b~
l pnMded 17( l pnMded 17( propn l pnMded 17( plQpII
CIlIllUImI pIllfiJII ~ ~
o Special OIly NlIW1B CR 2O'fo 20'\ 2O'7t
"'hI1Iir rdq l tlr ~ c. pll7o'ider is nol el_ III COI1lIaCl as a ~ Bule ~ ~ ~ 17( a ~ PIl\'5iCWl win be piid aI 75\ 10 a IlWlinun Ii 5SO per _
nallO eaed 50 visa -5eMces mIen!d 17( a ~ PIl\'5iCWl will be piid aI 50\ nollll eaed SO visils a ,.
~I\y
~. PIM1n~
AIIbUn
~CR
5eMce
M!rGI Heal1h
!S5OOOl1ifelime
IlIiUlUlII
AlcdIoI nl One
AIue
Home HYth SeMas
5IliI!d NiMl5eMc!5
Spe!dl1llelavt
PIlf5iaI1lleIavt
~~
Oiqraclic
~
IIiciedlaclt
~
o M\J!l be certified 17( a ~ MId ~ b ~ C3lf Ii ., illness
or InJUIY. ~ apl!Il!e b IelIal CDlOl eaed ~ U5UlII plIdIast
price
o NII5eI'f ~ aka ~ CftMtI~ CRI
o NaIIIaI chilcbl1h cIasse
o NIIW midwi6!
o ~ BiI1h Cenler
o ~ ll!riIWlion
o Sl!riIWlion IMI5aIs
o~dMce
o ramiit'( studies MId lUnlenl
o IMibo fI!r1iIiziIial MId MIificiiI imeminaIion
o GIanI MId lir ~ in MId <u Ii fti
o In MId <u Ii iI& b ~ inilUI1IMInenI ri a sudden MId _
ihss or accidercaI" Inck.des hospGl, pIdessianaI nl !I4lIlIie
o ~ use ~ IOOIl1
Nol!: A Medial ~ is fle inilUIlIfaImenl d a sudden
nl _ ihss or accidercaI injuy.
o ~ CR Cenler-lO ~taIencI.)U'
o ~ ~ seMce b l4J III 5so. SO visils mch aIenda')U'
olnpilienl ~s seMce
olM Ii Olernd ~ IleNbilililion Faolr( ((])Rf)
o One CIllIW ri 1I!iIITIenl Mil )U' Ii nails NIl II ~ Rl nol
I1lOI! INn 30 ~ A IlIiUlUll ri lVIO ClIlR5 d IIfaImenl in a
peI5Ol1's lilelime
o ~~ ~ visits, see MenIal HeiIlh ibM
o OJ visils cbq a 12 IIIllIllh period slri1 wilh ~ finis
CR IIlU5l be pnMded 17( a home IUdI ~ or Yisiq nIIW
BllCiaIiat IncUl!s QC[l4llIlicNI teavf Ilb!s not incblrcusDial c.l
o OJ cRts Mil taIencI. ysldoe naI indudr CUSIlIliaI c.-l
o InplDen or ~ IIIlaImenI when ilDowi1llq!1Y, injIIy or
b~ClIplic__
.~
'1'llMd!d ... Home HeaIfI 5ervic:!5 l ~ MId ~ ..
IkIe CIOS5 ippIUlII!lI
· ServicIs whidI -" be PDided 17( a PIr,9ciM
· Chiqnaic seMce . 40 vfJiIJJyr. INl.
o RaIment 17( liansed ~
· Plotided ... MenlaI HeiIlh
· ~ b . CllIldiIicI\S
· ~ 8Iood
· 8Iood ..allin_allan
· HeiIdI &Wlion Plopns
· Hospicr QIf l4J III a IIlDiml.m liIelime ~ ri 55,00)
ldeductibIr does IllX wyl
· ~ 1Ievitw. l nol oblained. benefits I8b:ed 25\
· Second SuP Opinion, if naI obained. benefils ItlWd 25\
No~
20'\
m
No~
No~
No~
m
20'10
!l\
m
m'
mo
m
mo
m
71
L! --r., !.
MAXI - CARE
maxicare (Lj).
COVERED SERVICES
MEMBER PAYS
HOSPtTAL SERVICES Semi1l"ivllIe room and board unlimited number 01 days, all medically I'leC2Ssary service'.! NO CHARCl
.INPAnENT -SurJicaI room; Radiation and c:hemoIherapy lreaIment
.oUTPATIENT -Renal dialysis NO CHARCl
PHYSICIAN CARE .off'1Ce visits, hospital visits and home visits NO CHARCl
-Services 01 surgeons, assistant surgeons, and anesthetisu
-Vision (refractions) and hearing testing aI Maxiate facilities
-Well baby care
-Periodic physical examinations - Including Lab, X-tay, Pap tellS, breast exam
-Immunizations and Inoculations - Otildren and Adults
-Allergy seNm, injections, medicalion and all allergy testi"l.
DIAGNOSTIC/X-RA Y /LAI CoYers all outpatient diagnostic, X-ray and laboratory services. NO CHAtCl
PRESCRIPTION DRUGS Prescription drugs obtained at Maxicare pharmacies and prescribed by a Maxicare $2.00 PER
physician. Includes insulin, syringes, needles. PRESCRIPTION
.Birth control pills NO CHARCl
DURABLE MEDICAL When approved by Maxicare plan, provided for treatment cl sickness or accidental NO CHARCl
EQUIPMENT bodily injury which has solely therapeutic value and no other use whatsoever and is
appropriate for in-home ute.
Correctiw Appliances/Milidal Aids: includes artmciallimbs, pacemaker, corrective, NO CHARCl
shoes, braces, contacllenses after c:atatact ..pry and hearing aids.
MATERNITY full physidan and hospital services lor any conditions arising lrem pregnancy or birth NO CHARCl
full post-nalal nursery care when newborn added to plan.
-Nal\nl chikl>>irth classes available CO-PA YMENT
MAY APPlY
fAMILY PlANNING IUD, diaphraam, vuectomy, tuballigalion and fertility counseling and testing. NO CHARCl
AMIULANCE When medically necessary, 10 and from hospital in or OW cl area when authorized by NO CHARCl
Muic=-'e physician. Includes air-ambulance if medically necessary.
EMERGENCY CAlf! Worldwide c:overase lor all medically needed care whidl is required for alleviation 01 $25.00 Charp
SBlVICES sewn pain or immediate cfiaanosis and treatment of unbeseen medical conditions . HOSI'lTAlIZED
which, il not treated, would jeopardize or impair the health cl the member. ~AYMENT WAIVED
MENTAL HEALTH In Patient - up to 45 days per disability (includes Physician services). NO CHARCl
OuIpalient - 20 YJsits per contract year with PsydIiatri. or Psychologi..
ALCOHOl AND Diaanosis and medical trealment including OETOX, either inpatient or outpatient, 50"'-
DRUG ABUSE whicheYer is determined 10 be medically appropriate. CO-PAYMENT
HOME HEALTH SBlVICES -Part-time or inlermediate nuRing care and home health aides. NO CHARCl
-Medical social services; Home health services; Physicall~1 therapy
No benefit is p'ovided solely lor custodial care.
SKILLED NURSING Unlimited lemi.private room and board and all other medically necessary tervices. NO CHARGE
fAClLmES No benefit is provided solely lor CUSlodial ca'e.
SPEECH/PHYSICAL When prelCribed by Maxic=-'e physician and when significant irnprcMmel1t is NO CHARGE
OCCUPA T10NAl THERAPY IiIceIy 10 N5U1t wilhin 60 days 01 disablillty.
CHIROPRACTIC/ACU. When medically approprialIe and referred by Maxicare physician. II General Melt NO CHARCl
PUNCTURE! chosen, chiropractors are available at mo. General Meet sites without referral by
II0000BACIC primary care physidan.
OTHEI ..lJInpIKed blood Ind blood plasma NO CHARCl
-Hospice Oimited services povided . part of sldlled nursing " home health benefits) NOT COVERED
-Health Education classes . Maxicare facilities NO CHARCl
The information on these paces pertaini"l to the Maxicare plah is only a I&Immary of some of the benefits and provisions of
this plan. For detailed information reprdi"l the benefits, provisions, exclusions, and limitations of this plan, refer to the
pian's BooIdet-CertiflCate (Evidence of Coverale) which is available throup yow Health Benefits Officer or from the plan
at the address listed on Address and Phone Nwnber pales (see Table of Contents). BinG.,. Arbitration: Enrollment in this
plan constitutes an agreement to have any issue 01 medical malpractice decided by neutral arbitration and waiver of any
right to . jury or court trial.
ss
~)i:": t
TilE HEAL n-: PLAN OF Ar-1ER I CA
PLEASE lEAD THE FOLLOWING INFOIW 1N SO YOU WILL kNOW FIlOA '10M Oil WHAT GIlOUP OF PROVIDE ItS HEALTH CltAy
IE OITAINED.
THE HEALTH PLAN OF AMERICA
SUMMARY OF COVERED BENEFITS & COPAYMENTS
Benefit
HospiUlServkes
-lnPitient
-OUtPitient
....~n Cue
[Npostk/X-by/LAb
Pl'ftCription Drup
Services
. Unlimited semiprivAte room And boArd And All medicilly neceswry services
. Includes outpitient surgery. ridiition And chemotheripy. renil diil}'5iS ind diignostic services
. Well b.lby Cire. immunizitions ind inoculations for children ind idults (except is required for
work or trive!)
· Hospitil visits
. Routine office exams, services for diignosis ind treitment of illness or injury, including surgery,
injections ind mediations, diignostic testing. periodic heAlth exams for children, vision ind
heiring testing for children through ige 17 And PAP smeirs ind breiS! exams.
· Pl!riodic ph}'5ical exams for adults
. House calls by your Plan Ph}'5ician
. Allergy testing/treatment/illergens
. Outpatient diagnostic, x-ray and laboratory services by Primary ure Ph}'5ician (PCP)
Enrollee Pays
No chirge
No charge
No charge
No chirge
$S/visit
S2O/visit
S20/visit
No charge
No charge
· Upto 34-day supply of insulin and insulin syringes and outpatient mediCition. except birth control $3.00/
pills when prescribed by a Plan Ph}'5ician prescription
Du~ Medial Equipment. Includes, when preauthorized. rental or purchase of such items as crutches. braces and walkers.
In addition. prosthetic appliances and artificial limbs
M.ternity
fAmily PLanninB
AmbuLance
Emerpncy ure/Servkes
Within and Outside
SeMce Area
Menul Huhh
-lnPitient
-Outpatient
AkohoI And DruB Abuse
Home Huhh 5ervk:es
SIdled Nuning fKl1ities
~TheraPf
· Includes prenatal. delivery, and postpartum services. hospitalization and nursery care for the
ne'Nborn during mother's hospitalization
. Natural childbirth classes
No charge up
to $2000/yr.
maximum
No charge
Not covered
. Natural family planning services, pregnancy testing and services for the diagnosis and treatment No charge
of infertility as prescribed or authorized by a Primiry ure Ph}'5ician
. Artificial birth control devices, in-vitro fertilization, artificial insemination, ind steriliZition NO! covered
· Land or air ambulince when ordered by PCP or required for transport in the case. of in acute
emergency
Any medical service required for the immediate treitment of An injury or ACute illness where A deLay
in treatment may seriously jeopardize your heAlth. ContKt your PCP first for instructions. In life.
threatening emergency situations, go to the nearest hospital emergency room. Your PrimAry CAre
Ph}'5ician should be contacted within 24 hours. Continuing or folJciw.up are is covered only when
provided by a PCP or if your medical condition prevents your return to your service Area for
treatment. (Service Area is defined AS a JO.mile radius of the hospitAl you selected)
. Ph}'5iciin services And hospital services up to 30 dA}'5 per alendAr year when Authorized by
your PCP
. Up to 20 visits per calendar year for short-term evaluation OJ crisis intervention when authorized
by your PCP
. Diignosis of and detoxification from alcoholind/or drug addiction on either in outpatient or
inpatient b.lsis
· Rehabilitation services for alcohol and/or drug abuse
No charge
$ IS/emergency
room visit (waived if
hospitalized).
20"4 of ph}'5ician
services only
SO"4 of charges
No charge
Not covered
· Care in your home by ph}'5ician-supervised health professiol\.Jlls from ilicensed home health No charge
igency. Service must be prior-authorized by i PCP and does not include custodial or homemiker
services
. When prior-iuthorized by your PCp. up to 100 da}'5 per calendar yeir for semipriwte room and No charge
boird And ill medically neceswry services. No benefit is provided solely for custodi.JIl Cire.
. Includes up to 60 da}'5 of ph}'5ician-ordered therapy when signifiant im~ment an be
expected
ChirapracticI Acupuncture!
Iiofftdbldl . Chiropractic services ire covered when iuthorized by i PCP
· Acupuncture and biofeedb.lck
. tfotPce: ure ind treatment in iliospice facility when iuthorized by your PCP
.1Iood: Blood ind blood products. (AdministrAtion of blood covered it no chirgel
No chArge
55.oo/visit
Not covered
No charge
NO! covered
unless repl.Jlced
The infonMtlon on these rNJft pergi~ to The Hohh PLan of America is only A sumlMry of some of the benefits And 'provisions of this pLan. For
cIeWIed information reprol" the its, provisions, exkusions And limitAtions of this plan, refer to the plan's Iooldet-CertificAte (Evidence of
Cowrqe) which is AVaiLable through your Health IeMflts OffICer or from the pLan At the Address listed on Address And Phone Number pige (see
Table of Contents).
MONTHLY lATES AIlE LISTED ON THE PlAN lATE PAGES (SEE TAILE Of CONTENTS).
IINDI NG ARIITlATION: Enrollment in this pIAn constitutes in Agrftment to ~ Any issue of medkAl malpractice decided by neulralirbitration
and wai~ of any riaht to A jury or court triaL
Other
43
1r~ . ,
L1 ,_ i..
/- - I
r I ~- ~
TAKE CARE BENEFITS AND SERVICES
TUeC.ve Benefits ~nd Services
COVERED SERVICES MEMBER PAYS
,__ ,.._. . .. .~_;~.~~., ___., _......_..;.'~-,=-r.'.~..~_."'-"'I fI.:"..8.:..__-=..
......- .... \.t'-~ ~ . ' .,"
~~'~.. ~~.... fttvIIt f...tcallrn<<1 ~. Noc:twwe
~~"IIIlIM"""',~~ ".. 'r"~'.i""'\. r... ...... fl4oc:twwe
Office ind hospital visilS; surpry; well baby ~ lhroush II! 2; vision nl hearina tesdna lhroush No cha,.e
. 17; physical exams _ specified inlerVals including Pip ~ and pelvic nl br9st elWnS;
immunizations and inoculations; allertY testina. sen.Jm and injections.
Home visilS if medially necessary.
, OulpIdeii~'i4y"iilil)(i;,~J:~.;-"'~ -~~~';--
BENERT
tt()5IIIW.
........
<>........
PHYSICIAN CUE
DlAGHOSTICIX-lAYI
LAB
PRESCRIPTION
DRUGS
I>UIAaU MEDICAl.
EQlJWIMENT
MATBNITY
fMUl Y PlANNING
AMBtJI.ANCE
In area
Out~.....
EMB<iENCY CMf1
SDY1C!5
MEIIlW HEALTH
SEIV1C1S
InpIIieN
0uIpidenI
ALCOHOl/DIUC
AlUSI
InpIIieII
0......
HOMf HEALTH
SEIV1CES
SlaUfD NURSING
FAC1UT1E5
SP&OtIPHYSICAll
OCCUPATJONAL
THRAPY
o-.w:nCI
A.CDUNC'RJIE/
..0. -..JIMX
OTtB
UtnpIaced ....
HuIIh EGKation
Ho5Pa
."W:-~-.~
Prescription drugs, including lNil order lNintenance drugs; diabetic urine gJUC05e testing strips,
insulin, needles and syringes; birth control pills and ocher contraceptive devices needing a
prescription. Experimental! investiptional drugs excluded.
ItentaVpuIChMe wNn wart" III Auifiortzed Home..... ......menc PIIn.
"':-~-:.!..'~.. - ...-._~.._...~ -. ~ -, .......-. ..
Physician and hospital services for mocher and child, for any condition resulting from pregancy Of'
childbirth and any complications.
Natural childbirth classes: fee set by provider; not a benefit of TakeCare.
Voluntary SllriIiDllalL '.'~.<,
Infer1ilily studies and ...........
In vitro ~........ fI'tI'OIunIary.nlDlian. .
Emergency ground transpOrt.1tion.
Emergency ground transpOrt.1tion; air ambulance if pre-authorized and medically necessary.
Indudes ~.....iC)- Cane ~wd1ee In the counlry and ~
Definition<< ~.' ...... - u..., -'ous and une~ illness Of' injury ~ immecIIaR
medic:aI....~...... 72 hours reqund. .
30 hospital days per calendar year.
30 ptlysiNn visilS per calendar year, not to exeed one per day.
20 visilS per calendar year for short-term evaluation/crisis intervention.
._....~~.
."- +-
Dtt .-1k~1I...... OIly. RI!hIbi1ItaIion not CXMftld.
~_~~...1he~oI,~~~benefiI~
Provided for illnesses Of' injuries requirina skilled services including nursina nl physical,
occupationalOf'speech therapy; does not include rest cures Of custodial are. Services limited to 3
visilS per day 2 hours per visit for all types of services.c60 days eKfl caIendar,..- for~ room and all 0Iher medically necessary.mces.
CUSlDdUl care is not CIDWI'Id.
Shon-term speech, physical, occupational and ocher rehabilitative services in any selling: 60
consecutive days for each illness Of' injury startina from first day of treatment.
Servic811lU11 be ...m...... be mdally IPPftlP'IIIe and mdcaIIy.-y far ~
COlIdltion and be IUIhorized '" MnlryCare A1ysidan and ~ MelIcaI Goup.
Instruction in personal health care measures and education in use of appropriate health services.
Some services fOf' tenninally ill are provided under Skilled NUBing Facilities and Home Heallh
Services. No stand-alone coverase.
S 1 O/visit
Noctwwe
S4/prescription
Of' refi II
No cbarwe
No charge
Not covered
Nochqe
50"10 copayment
Not cowred
No charge
No charge
S 1 Ot'episode
No charge
S2O/visit
S20lvisit
No cNrwe
S20Msit
No cha,.e
No cNrwe
Nocha,.e
No cNrwe
Not covered
No charge
Not covered
The inIDnnation on these pips pen.inina
to TabCare HeaIIh Plan is only ~ IUIIlIIWY
of some of the benefils and proWions of
this plan. For tIet.1Ied Information reprcIina
the benefits, provisiol., exclusions and
IimitaIions 01.. plan, refer 10 the plan'.
BooIdd-<:et1iliale (&idence 01 CcMrap).
which is MIabIe throuIh )'OW' Health
IIenefiII Officer or from the plan _ the
addresIlllted on AddresI and Phone Number
pap (lee TlIbIe of ConIenII).
Monthly ratel.-e listed on the Plan late
.... (see TIbIe of ContenlJ)'
..... Arbitration
Enrollment in this plan constitutes an
apeement to have any issue of medical
INIpractice decided by neutral arbitration
nl waiver of any right to a jury Of' court tNt.
63
/ J.". , :"."
ROSS-LaOS MeuICAL GROUP (CIGNA)
Ross loos CIGNA
Ross Laos Medical Group or (IGNA Private Practice Plan MediCil Privite
Group Prictice
HOSPlT Al SERVICES
Inpitienl . Room ind BOird - semi privite accomodations No cNrge No cNrge
· General and speciil duty nuning care No cNrge No cNrge
. Operating room, Intensive care No chirge No CNrge
. Diagnostic, X-ray and laboratory services No chirge No charge
Outpatient . Surgical Room Fee No chirge No charge
. Radiation and Chemotherapy No cNrge No cNrge
· Ren.11 diilysis No chirge No cNrge
PHYSICIAN CARE . Physician office visits, hospital visits, No ch.lrge No cNrge
surgery and consultations
. Physician home visits No chirge S 1 0 per visit
· Vision and hearing tests No charge No charge
· Well baby care No chirge No charge
. Periodic health exams - including pap smean and breast exams No chirge No charge
. Immunizations and inoculations including No cNrge No chirge
allergy serum, injections and medications
· Allergy testing No charge No charge
DIAGNOSTICIX-RA Y /LAB . Outpatient diagnostic. X-ray and laboratory services No chirge No chirge
PRESCRIPTION DRUGS . All prescription drugs to include birth control pills, insulin S2 per S2 per
and diabetic supplies (30 day supply) prescription prescription
DURABLE MEDICAl EQUIPMENT . When prescribed by plan physician No charge No chirge
MATERNITY . Pregnancy and Nunery care No cNrge No chirge
. Natural childbirth classes Not covered Not covered
FAMll Y PlANNING · Voluntary sterilization No chirge SSO cNrge
. Infertility studies and treatment No cNrge No cNrge
· Contraceptive devices Not covered Not covered
AMBULANCE SERVICES . When authorized or approved in-area/out of ilreil No ch.lrge No cNrge
. Air ambulance when medically necessary No chirge No cNrge
EMERGENCY CARElSERVICES Emergency Services include conditions which produce severe
pain, loss of consciousness, excessive bleeding. which are life
threatening or ITliIY result in physical impairment
. In area - must be obtiIined by Healthplan unless medically No chirge S2S per visit if
inappropriate. not hospitalized
. Out of area is limited to emergency services. No chirge S2S per visit if
not hospitalized
MENTAl HEAlTH . Inpatient days and physician services No cNrge No ch.lrge
(up to 60 days per calendar year)
. Up to 20 outpatient visits per calendar year for treatment S4 per visit S 20 per visit
and'or for crisis intervention
AlCOHOl AND DRUG ABUSE . Inpatient days and physician services as c1inic.1l1y indicated No ch.lrge No cNrge
. OutpiItient Oeto)(ificilti~risis intervention $4 per visit No charge
. Unlimited outpatient counseling sessions $4 per visit No charge
HOME HEALTH SERVICES . Available only within the Service Areil limited to visits of a No charge $ 1 0 per visit
frequency, duration and level iluthorized by Healthplan
. Custodial care not a covered benefit Not covered Not covered
SKillED NURSING FACILITY . Unlimited number of prescribed days No cNrge No cNrge
. Custodial care not a covered benefit Not covered Not covered
SPEECH/PHYSlCAI/ . Short-term rehibilitation services and physic.11 therapy up to a No chirge No cNrge
OCCUPATIONAL THERAPV 2 month period
CHIROPRAOIC/ . Services not a covered benefit Not covered , Not covered
ACUPUNOURE/
BIOFEEDBACK
OTHER · Unreplaced Blood Not covered Not covered
. Administration of Blood No chirge No cNrge
· l-tealth Education No cNrge No cNrge
. Hospice Not covered No<< covered
61
/J77} ,.1
.,
.~~
PARTNERS HEALTH PLAN
Benefits
PARTNERS
Health Plan
CA TEGORY
Hospital Servicrs Inpallenl
Outpallent
Physician Care
Diilgnostic/X-rilY ilnd Lilb
Prl!SCription Drugs
Durilble MediCi1lI
Equipment
Miltemity
Filmily PIi1inning
Ambulilnce
Emergency Cilre/Servicrs
Mentill Hulth Inpatient
Outpatient
Akohol _ 0ruI Abuse
Home Heillth Servicrs
Skilled Nursing Fildlity
SpHch/PhysiaV
Occupiltionill TMrilpy
Acupunctul'l!/
Biofeedbild/
ChiroprilCtic
Other Benefits
DESCRIPTION
· All medically necessary Inpatient services ,ncluding semipm'ate room and
board, nursing care services. intensive care, coronary care. cathode ray
scann,n!:. operating room, diagnostic. X-ra\, and laboratorv services,
· Operating room, radiation and chemotherapy, renal dlal\s's and other
outpatient hospital services,
· Physician office visits. office surgery. well-baby care from bIrth to 2 yrs, of age,
· Ph~slCian hospital serv'ces, including surgeon fees.
· Phvslclan house call. if medically necessary.
· Eve or ear examinations for determining the need for vision or hearing
corrections for members under age 18.
· Periodic health exams which may include pap smears and breast exams,
· Pediatric and adult immunizations and Inoculations,
· Allergy testing and treatment; including allergy serum,
· Outpatient diagnostic. X-ray / lab,
· Generic prescriptions or refills including birth control pills and disposable
needles and syringes prescribed with injectable insulin,
· Purchase of prosthetic devices such as artiiiciallimbs. and the purchase or
rental of durable medical equipment such as crutches. wheelchairs etc.
· Pre-natal and post-natal physician services.
· Nursery care for newborn infants during the mother's hospitalization.
· Natural childbirth classes.
· Voluntary sterilization.
· Contraceptive devices prOVided by a physician.
· Infertility services. including hospitalization.
· In and out-of-service area ambulance serviCes (including air ambulance) if
medically necessary.
· Worldwide emergency health coverage for both in and out~f-service area
emergency room visits. ^ medical emergency is defined as an accidental
injury or the sudden and unexpected onset of a condillon requiring immediate
medical or surgical care.
· Short-term evaluation and treatment including physician services for the
purpose of crisis intervention only. Benefits limited to 30 inpatient hospital
days during a calendar year.
· Short-term evaluation and treatment for the purpose of crisis intervention only.
benefits are limited to a calendar year maximum of 20 visits_
· In hospital: medically necessary management of withdrawal symptoms.
· Inpatient or outpatient rehabilitation.
· In physician's office: medical management of withdrawal svmptoms.
· Home health services as prescribed or directed by a participating phvsician
when medically necessary. Custodial care is not a covered benefit.
· Skilled nursing facility services for 60 days per calendar year. Custodial care is
not a covered benefit.
· Benefits are limited to short-term treatmenl of acute conditions that are
expected to result in a significant improvement within 60 calendar days.
· Not covered.
· Blood administration,
· Unreplaced blood and blood derivatives.
· Health ~ducation Programs (i.e.. stop smoking clinics. etc.1.
· Hospice. not a Plan benefit. Referral services available.
· Disposable medical supplies.
57
COPAYMENTS
No charge
No charge
SJ per visil
No charge
55 per visit
53 per visil
53 per visit
53 per visit
53 per visit
No charge
52 per prescription or
refill.
No charge
53 per visit
No charge
Nol covered
No charge
53 per visit
50"'0 of all costs
No charge
51 5 per visit
,Copavmenl is waived if
the ,"'ember is hospital-
izedl.
No charge
520 per visit
No charge
Nol covered
53 per visit
S 5 per visit
No charge
No charge
Not covered
No charge
Not covered
Not covered
Not covered
Not covered
i~ , ~-.1" .I /
/
HEALTH NET
HEAlTH NET
PlEASE lEAD THE FOUOWINC INFORMATION SO \'OU WlU kNOW
FROM WHOM 01 WHAT GROUP OF neMons HEALTH CARE MAY IE OITAlNED.
Schedule of Covered Services and Co-Payments
THE SERVICES OF THIS PlAN AlE neMDED WHEN PERfORMED, rRESClllED, DIRECTED 01
AUTHOIIZED IV THE PAImCIPATINC MEDICAl. GlOUP (PMe) AS DmItMlNED MEDICAI.1.Y NEaSSARY
HOSPITAl. SEIMCES
INPATIENT
legend Drugs including oral contraceptives, injectable insulin, needles and syringes 52.00 charge
State Restricted drugs Which require a prescription for each prescription filled
Must be an essential, standard medical requirement for exdusive use ci patient and prescribed or
authorized by PMG
Pre-natal, normal delNery, Caesarean section, post-natal and newborn care
Cornpliations ci pregnancy .
Earlybird Prenataf CIisses available
Natural Childbirth elutes
Infertility services (exduding in vitro fertilization procedures)
Sterlization for females
Sterlization for males
Contraceptive devices
AMBUlANCE In area, out 01 area ambulance/air ambulance, as determined medically necesYry by PMG
EMERCENCY SERVICES An emerget ICY is defined as a sudden, serious and unexpected illness or injury requiring immediate
medial attention. It is 01 the utmost importance that your PMG be contacted 6eIore emergency
services are sought. The only permissible ~ion is if the member is unable to contact the ~
because 01 unconsciousness or the catastrophic nature ci the illness or accident and immediate
~ ~ea.t.ment is essential.
In-Area/0uI4-Atea If ~ ~ Medial Group it notified within 48 hours 01 emerp"cy services beinC soupt
Emerpncy Care and authoriZes are:
Prolessional services
Hospital outpatient services
HosJIitaI inpatient services
Pa~t foe' continuing or follow-up emergency care will be made only if pnMded or authorized
I?Y Partici ti Medkal Crou .
If the ~~ Medical er:. it NOT notified and are is NOT authorized
MENTAL HEALTH SEIMCES Hospitalization, physician services for mental conditions, up to 30 days per calendar year in a
semiprivate room with ancillary services
Oucpadent mental health consultation
(determined medically necessary by PMG- 5O-Yisit limit per calendar year)
Medical social services
Crisis inteM!ntion
Inpatient & Outpatient drug/alc0hoi abuse, ~ute care/detoxification only
Rehabilitation
(Referrals to community agencies available through PMG)
Skilled Nursing and services determined medically necessary by PMG, excluding custodial care
Unlimited days ci care in a semiprivate room with ancillary services, exduding custodial care
HOME HEALTH CAllE
SlalLED MJISINC
FACIlITIES
SPEECH/PtmICAlJ Short-term therapy
OCCUPATIONAl. THERAPY
CHIIOI'IACTIC/
ACUPUNCTUIW
IIOREDIACK
OTHER
OUTPATIENT
PHYSICIAN CAllE
DIAGNOSTIC X.IAY
AND lAIOIATOIY
PRESCRIPTION DRUGS
DURAJlLE MEDICAl.
EQUIPMENT
MATElNm CAllE
FAMilY PlANNING
ALCOHOl AND
DIUG AIUSE
Unlimited days 01 are in a semiprivate room with ancil~ry services
Intensi\le care
X-ray and laboratory procedures, hemodialysis, chemotherapy, nuclear medicine, surgery
VISit to physician in Participating Medical Group (PMG)
Specified fmmunizations and Inoculations
Allergy Testing and treatment (including serum and medication)
InjectlOn5 and injected substances
Periodic health evaluations (including pap smears and breast exams if determined to be
medically necessary)
VISion and hearing examinations
Specialist consultations
Physician visit to hospital or skilled nursing facility (exduding neM>US and mental care)
Physician mental health visit to hospital or skilled nursins facility (30 day limit per calendar year)
Physician visit to member's home (at discretion 01 Physician)
Surgery in hospital or PMG
Wen Baby Care
Outpatient diagnostic, X-ray and laboratory services
'"Short-term- shall ~ construed 10 ~ a p<<iod IlO( exaeding 60
conseculM d.1ys following the dale caridilion is first ~alecf
When determined medically necessary by PMC
HEALTH EDUCAT1ON-Aim for Wellness ~ams through PMG
HOSPICE CARE-Elected by member (certiflCltion required)
Unreplaced blood, blood derivatives and blood factors
"For some special (optional) programs, a nominal charge may apply
41
lOUR
CO-PAYMENT
No charwe
No charwe
Noc:twje
No charge
Nocharwe
No charge
No charge
No charge
No charge
No charge
No charge
No charge
S 10 charge
No charge
No charge
No charge
No charge
No charge
No charge
No cha~
Not CXM!rid
50% charge
51 SO charge
5 50 cha~
Not~
No charge
No charge
No charge
No charge
No charge
No charge
No charge
Not~
No charwe
S20 eN Wit
~charJ!
NocNrBe
No chirp
Not CXM!rid
No charge
No charge
No charge
No charge
No charge "
No charge
No charge
,
.......,--;
CALIFORNIA Flk~(IGHTERS
COVERED CHARGES
WHATYOUPAvt
Member Non-Member
Providers Providers-
No CM,..e 30'"
Noch~~ 30'"
No ch~~ 30'"
TYPE Of SERVICE
Room ~nd board up to semi-priv~te r~te
Intensive, coron~ry ~nd intennedi~te Cire room CMrges
Hospiul extr~S, including I~b ~nd x-ray, operating room,
ridiologist ~nd ~tholoaist fees ~nd gener~1 nursing c~re
Surgic~1 room fee
Ridi~tion ~nd chemother~py treatment
Kidney di~lysis
Surgery or hospiul visits
OffICe or Home Visits, including:
_ Well B~by ure in first ye~r of life
_ Vision ~nd Hearing Testing
_ Allergy Testing and Injections (5enJm is ~id as a prescription dru81
_ Immunizations and Inoculations
_ Periodic Health bams (once each ye~r) provided only for:
_ Exam with Pap sme~r & bre~ exam
_ Ex~m with proctoscOPY or proctosigmoidoscopy
Ou~tient di~gnostic I~b and x-ray services
Excludes drugs in connection with weight control, birth control,
menul disoniers and drug addiction. Allergy serum, insulin
and diabetic supplies are covered as any other prescription drug
_ Mail Order Pharmacy
_ All Other Pharmacies
When medically necessary and prescribed by a physician
Pregnancy ~nd childbirth
Routine nursery c~re
Natur~1 childbirth classes
Volunury sterilization (reversal is not covered)
Infertility studies ~nd tre~tment (excluding in vitro fertilization)
ContrKeptive drugs ~nd devices
In or out of ~re~, medic~lIy necessary ~nsportation to ~nd from
a hospiul
In or out of ~re~, "Emergency" me~ns injury tre~ted within 48
hours ~nd illness with ~ sudden unexpected onset for which
treatment unnot safely be delayed
In~tient hospital charges and physician visits
Outpatient treatment
Crisis inteM!f\tion
In~tient hospiul and physician treatment
Outpatient treatment
DetoxifiutionlCrisis inteNerltion
Upon physici~n' s order, skilled seMces of R. N. or L. V. N.
Custodi~1 Ute not provided
Semi-priv_ room and other CMrges up to 31 days per
disability. Custodi~I c~re not provided
~ Speech therapy is covered upon a physician'sordertoconeCl
11Ierapr ~ speech impediment c~used by illness or inju~nctiOMI
nerwus disorders are not ccwered. Physical & occupatioMl
therapy is covered upon a physician's order
limited to 20 visits per ulendar year
limited to 20 visits per calendar year. BioIeedbKk is av~i1able
upon referral of ~ Foundation member physician
Unreplaced blood and its idministration No CM~
Health Education Proar~rns; Hospice ure Not covered
LjfetimeMulrnumIenefil All illnesses and injuries $2,000,000
. Benefits ~re ~yable ~fter $200 per person deductible per calendar ~r. F~i1y limit on deductibles is three per f~mily. Once $10,000 i
covered ctwJes Mve been incurred by ~ covered person in ~ Cilendar year, the Plan ~ys 100'Jl. of all idditional covered CMrwes for tho
person tor the rest 01 the calendar year. If the mandatory Hospiul Utilization Review Progr~m is not complied with, you will be responsibl
for ~ additional $200 deductible.
.. MerUI Health inpatient hospital and physici~n (30 d~ys maximum per year) ~nd ~tient physician benefits (20 visits and $1,000 pa-(me.
lNXimumS per yeN) are limited to ~ lifetime maximum ~yment of $25,000. Alcohol and Drug Abuse benefits ~re limited to a maximul
~yment 01 $ 175 per day for in~tient tre~tment and ~ lNXimum ~yment of $ 1 ,000 per calendar ye~r for ~tient tre~tment. The maximu
combined ~yment for in~tient ~nd ~tient tre~tment is $5,000 per calend~r yeil'. Speech Therapy is limited to a lifetime maximu
~yment 01 $1,000.
t If the mandatory Hospi~1 Utilization Review Progr~m is not complied with, you will be responsible for ~ $200 deductible.
HcJIpit.II Services
~npl"'"
30...
30'"
30'"
30'"
30...
No CM,..e
NOCM~
NOcM~
No cha,..e
$5 c.yment
-OutpIIient
"'yticiIft Care
30...
NoCM~
DYpostic Lab. X-by
PrescriIJtion [)nip
$2 c.yment
30'"
30'"
30'"
30'"
Not Covered
30'"
30'"
Not Covered
30'Jl.
S2 c.yment
20'"
NocMrge
$5 c.yment
No charge
Not Ccwered
No charge
$5 c.yment
Not Covered
No charge
Durable Medical Equipment
~temity
FamIy PIanninI
AInbuIance-Air. Ground
30'"
$25 c.yment
En.... .ncv Care. Services
so... ..
50'" ..
Not Covered
30'" ..
30... ..
30'" ..
so.....
SO'" ..
Not Ccwered
$20 c.ymen".
$20 c.yment..
$20 c.yment..
$ 1 Oc.yment
MeIUI HeaMh
AIcohoI- OnIIAbuse
30...
Home HsIth Services
30'"
NoCM~
SIdled NursinI facility
30'" ..
$5C.ymen".
30'Jl.
3O'Jl.
30"
$5 c.yment
aa~-*
~
30...
Not covered
Other
73
r/1!"J./
KAISER SOUIII
Your Benefits
hrvIc..
HospiUl Services
Physici~n ure
Di~lnostic
X-ray/Ub
Prescription
Drup
Durable Medical
Equipment
~ternity
F~mily PI~nnina
Ambul~nce
Emersency ure!
Services
Menul He~lth
Alcohol
~nd Drul
Dependency
Home He~lth
Services
Skilled Nursina
Facility
Speech/Physic~1I
Occu~tiOMI
TIIer.,-
ChiroprKticl
Acupuncture!
liofeedbKk
Other
Followina is ~ sum~ry of )Our Kaiser Permanente benefits when services are provided,
prescribed, or directed by ~ Plan physici~n.
Inpatient-Semiprivate room and board; all necessary medical services including specialized
care units and prescribed medications
Outpatient-Surgical room, radiation, chemother.apy treitment. and renal dialysis
Medical office and hospital visits, surgery, vision and hearing testing. well<hild care, periodic health
exams including pap smear and breast exam, immuniZAltions and inoculations, allergy testing.
injections, and administered medications; home visits for supervision of patients in a home health care
program
Diagnostic X-ray, and laboratory services
Up to a l{)()..day supply 01 prescription drugs, includinc birth control pills, insulin and diabetic
supplies, obtained at a Plan pharmacy
Durable medical equipment
Orthotics and prosthetics
Prenatal, post-partum, hospitalization, complications d pregnancies, and nursery care during mother's
confinement.
Natural childbirth classes available
Diagnosis and treatment of infertility problems; \IOlun~ sterilization
Contraceptive devices
Within Service Area-When appl'CJYed by a Plan physician
Outside Service Area-When provided as part of the out~-Plan emergency benefit
Air-ambulance with prior approval from Plan
Conditions that if not treated lead to further disability or death
Care received in a Plan facility
Care received in a non-Plan facility:
Outside Service Area
Inside Service Area (ClM!red only if life threateni...,
Services are limited to evaluation, crisis intervention, ~ acute psychiatric conditions
Inpatient-Up to 45 days per calendar year including ptlysicians' services
Outpatient-Up to 20 visits per calendar year
Additional visits
Inpatient-When necessary for medical management d withdmval symptoms
Outpatient-Counseling for dependency, medical ~~nt 01 withdrawal symptoms, crisis
intervention
Care for supervision of patients in an appl'CJYed home care program on a part-time intermittent basis
(Excluding custodial and convalescent care)
Up to 100 days per calendar year (Excluding custodial ~ convalescent care)
Therapy is limited to conditions subject to significant imprlM!ment within a twcHnonth period
Inpatient-SOOrt-term speech, physical, and occupatiorYl therapy
Outpatient-
a) Short-term physical and occupational therapy
b) Short-term speech therapy .
Chiropractic, acupuncture, and biofeedback
Unreplaced blood (No charge, if replaced)
Health education programs
Hospice care-When selected as an alternative to traditional services ClM!red by Plan
...... ~
No Charge
No Charge
No Charge
No Charge
$1 per prescription
No Charge
The first $100 plus
20" 01 charges lM!r
$2,500
No Charge
Reasonable rate
No Charge
Reasonable cNrge
No Charge
No Charge
No Charge
No Charge
No Charge
Up to $SO copay
No Charge
No Charge
$5 each visit
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$5 charge per visit
Not ClM!red
NotclM!red
Reasonable rate
No Charge
The infornYtion on these ~Ies perYinina to IWser South P~n is only a sumnYry of some of the benefits ~ pl'O\'i-
sions of this pI~n. for deYiled infonNtion reprdi.. the benefits, provisions, exclusions, ~nd IimiYtions of this plan,
refer to the ~n's Booldet-certific~te (Evidence of c.c.wrqe) which is ~v~i1~ble throuah your He.lth Benefits Officer or
from the pI.n at the address listed on Address ~nd rtIone Number ~Ie (see Table of Contents).
51
MONTHLY PLAN RATES 1989
CITY'S CURRENT PLANS
PLAN
MONTHLY RATES
EO- $166.00
E1- $318.00
E2- $447.00
PLAN
MONTHLY RATES
John Hancock
Self-insured
(includes
dental/vision
coverage)
Kaiser
EO- $100.46
E1- $200.92
E2- $284.50
-----------------------------------------------------------------------
PROPOSED PERS PLANS
INDEMMITY/PPO
PERS Care
EO- $134.00
E1- $253.00
E2- $338.00
PORAC
EO- $ 96.66
E1- $170.72
E2- $239.76
Fire Fighters
EO- $105.00
E1- $203.00
E2- $268.00
First Far
West
EO- $121.85
E1- $229.42
E2- $308.49
HMO CARRIERS
Partners EO- $ 98.94 Kaiser South EO- $ 99.29
E1- $199.68 E1- $198.59
E2- $287.15 E2- $281.19
Health Plan EO- $100.79 Maxi Care EO- $ 99.07
of America E1- $195.11 E1- $214.07
E2- $260.18 E2- $281. 02
Ross-Loos EO- $104.94 Health Net EO- $ 93.58
E1- $205.31 E1- $189.49
E2- $275.58 E2- $277.77
Take Care EO- $ 98.53
E1- $197.32
E2- $266.78
A-l-
1
2
RESOLUTION NO:
3 RESOLUTION ELECTING TO BE SUBJECT TO PUBLIC EMPLOYEES'
MEDICAL AND HOSPITAL CARE ACT ONLY WITH RESPECT TO MEMBERS OF
4 THE MANAGEMENT/CONFIDENTIAL UNIT.
5 WHEREAS, Government Code Section 22850.3 provides that a
6 contracting agency may elect upon proper application to par-
7
8
9
10
ticipate under the Public Employees' Medical and Hospital
Icare Act with respect to a recognized employee group only~
I and
WHEREAS, CITY OF SAN BERNARDINO , hereinafter
11 referred to as Public Agency is a local agency contracting
12 with the Public Employees' Retirement System~ and
13 WHEREAS, the Public Agency desires to obtain for the
14 members of MANAGEMENT/CONFIDENTIAL UNIT , who are employees
15 and annuitants of the agency, the benefit of the Act and to
16 accept the liabilities and obligations of an employer under
17 the Act and Regulations~ now, therefore, be it
18
RESOLVED, that the Public Agency elect, and it does
19 hereby elect, to be subject to the provisions of the Act~ and
20 be it further
21
RESOLVED, that the employer's contribution for each
22 employee who is a member of, and each annuitant who retired
23 from employment which would be covered by the above identi-
24 fied Employee Group enrolled in PERS health benefits plan
25 shall be as follows:
26
"Sixteen dollars towards the enrollment of each
27 employee and annuitant including family members."
28 (Continued)
Page 1
17 Nov 1988
s-t,
1
2 And that the contribution shall be in addition to those
3 amounts contributed by the Public Agency for administrative
4 fees and to the Contingency Reserve Fund, and be it further
5
6
7
8
9
10
11
12
RESOLVED, that the executive body appoint and direct,
and it does hereby appoint and direct, DIRECTOR OF PERSONNEL
to file with the Board of Administration of the Public
I Employees' Retirement System a verified copy of this Resolu-
/tion, and to perform on behalf of said Public Agency all
. functions required of it under the Act and Regulations of the
Board of Administration; and be it further
RESOLVED, that coverage under the Act be effective on
13
14
January 1. 1989 .
I HEREBY CERTIFY that the foregoing resolution was duly
15 adopted by the Mayor and Common Council of the City of San
16
17
Bernardino at a
meeting therof, held on the
18 vote to wit:
day of
, 1988, by the following
19
20
21
22
23
24
25
26
AYES:
Council Member
NAYS:
ABSENT:
27
28 (Continued)
Page 2
17 Nav 1988
City Clerk
1
2
RESOLUTION ELECTING TO BE SUBJECT TO PUBLIC EMPLOYEE'S
3 MEDICAL AND HOSPITAL CARE ACT ONLY WITH RESPECT TO MEMBERS OF
THE MANAGEMENT/CONFIDENTIAL UNIT.
4
5
6 The foregoing resolution is hereby approved this
7
8
9
day of
I
I
10
11
12
13
14
, 1988.
Evlyn Wilcox, Mayor
City of San Bernardino
Approved as to legal
form and content:
15
16
17
18
19
t.~
Attorney
20
21
22
23
24
25
26
27
28
Page 3
17 Nov 1988