12-A Empl Health Ins Res
DRAFT
F:ALICEIRESWORK\CURRENT\Employee Medical Ins Changes
March 10, 2005
RESOLUTION NO.
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PARIS,
PARIS, TEXAS, AUTHORIZING THE CITY MANAGER, FINANCE
DIRECTOR, AND CITY ATTORNEY TO EXECUTE ANY AND ALL
NECESSARY DOCUMENTS ASSOCIATED WITH CHANGES TO THE
CITY EMPLOYEE HEALTH INSURANCE PLAN; MAKING OTHER
FINDINGS AND PROVISIONS RELATED TO THE SUBJECT; AND
PROVIDING AN EFFECTIVE DATE.
WHEREAS, the City Manager and the City Finance Director have identified certain changes
necessary to the City Employee Health Insurance Plan, associated with premiums, co-pay, coverage,
and other issues as such matters effect current and former employees; and,
WHEREAS, the City has received recommendations from representatives of the Texas
Municipal League Health Insurance Pool, which acts as the administrator of the City's health
insurance program, related to the creation of a 454 Flex Plan, enhanced premiums, alternative
insurance plans, and other similar recommendations; and,
WHEREAS, there is a necessity to implement various changes to the City Employee Health
Insurance Plan, both for current and former employees, to meet certain time deadlines associated with
the City's plan year; and,
WHEREAS, the City Council desires to authorize the City Manager, the City Finance
Director, and the City Attorney, where appropriate, to execute any and all necessary documents
associated with appropriate changes to the City Employee Health Insurance Plan, for both current
and former employees; NOW, THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, PARIS,
TEXAS:
Section 1. That the findings set out in the preamble to this resolution are hereby in all things
approved.
Section 2. That the City Manager, City Finance Director, and City Attorney, where
appropriate, shall be, and they are hereby authorized to execute any and all documents necessary and
required associated with implementing changes and amendments to the City's current Employee
Health Insurance Plan, as such changes would apply to both current and former City employees.
Section 3. That this resolution shall be effective from and after its passage.
PASSED AND APPROVED this 14th day of March, 2005.
Curtis Fendley, Mayor
ATTEST:
Janice Ellis, City Clerk
APPROVED AS TO FORM:
Larry W. Schenk, City Attorney
RETIREE/HARTFORD
Active Employee Options Early Retiree Options. SUPPLEMENTAL
Hartford Hartford ATTAINED
Core Dental Vision Core High Std Rx Dental AGE MALE FEMALE
Employee $431.73 $22.38 $7.50 $905.31 $122.00 $43.00 $126.50 $20.00 65-69 $298.97 $280.51
EE + Spouse $602.50 $45.96 nla $1,508.85 $223.00 $78.00 $253.00 $40.00 70-74 $326.41 $298.87
EE + Child(ren) $512.32 $48.32 nla $1 ,257.38 $247.00 $86.00 nla $55.00 75-79 $353.96 $322.74
Family $711.87 $46.34 $15.00 $1,860.92 $343.00 $118.00 nla $75.00 80-84 $368.64 $339.27
85+ $390.68 $353.96
CORE: CORE PLAN Premium #EEs Monthly Annual
70/50 Plan Employee $431.73 114 $49,217 $590,607
$500 Deductible EE + Sp $602.50 21 $12,653 $151,830
$3000 COP EE + Ch $512.32 144 $73,774 $885,289
NoOV Family $711.87 52 $37,017 $444,207
MAC A Core Plan 331 $172,661 $2,071,932
FLEX PLAN 331 EE'sIMo Annualized
$5 Admin Fee $1,655.00 $19,860.00
EARL Y
$4 Admin Fee $1,324.00 $15,888.00 RETIREE Premium #EEs Monthly Annual
Employee $905.31 26 $23,538 $282,457
EE + Sp $1,508.85 11 $16,597 $199,168
*Rates subject to change, TML IEBP EE + Ch $1,257.38 4 $5,030 $60,354
is negotiating w/Hartford currently Family $1,860.92 1 $1,861 $22,331
42 $47,026 $564,310
IITML
~ Int~mentaJ
Empøyee Ben8flts
Pool
SCHEDULE OF MEDICAL EXPENSE BENEFITS - FYO4-05
EARLY RETIREE BENEFITS PLANINON ENTITLED MEDICARE RETIREES
Plan Benefits Effective:
Precertification (800) 847-1213
Claims (800) 282-5385
This schedule represents a summary of benefits. For complete details of benefits and requirements please
refer to the Medical Benefits Booklet.
Eligibility - You are eligible if you are a retired employee under age 65 and not entitled to Medicare A & B. The early retiree must be an early
retiree from a political subdivision of Texas and is performing the normal duties of a person of like age and gender, residing in the U.S. and not
in fu1t-time military service.
Are my dependents eligible? - Yes, if you are enro1ted in the plan, your spouse (not lega1ty separated or divorced) and/or child(ren), including
stepchildren and adopted children, who are unmanied, dependent on you for support and under age 19 (25 if a fu1t-time student) are eligible.
Dependents must be actively performing the normal duties of persons who are the same age and gender. Newborns are covered ftom birth
provided we are notified of the birth and the appropriate premium is paid within 31 days of birth. Otherwise, the newborn is considered a late
enro1tee and may not be enro1ted and may not be enro1ted until the next open enro1tment period.
Disclaimer: Retiree Continuum of Care Benefits are not comprehensive major medical insurance. It is, however, a valuable benefit plan for
Texas Political subdivisions wanting to provide an alternative lower cost coverage for early retirees.
PPO - Passive Requested Provider Network care can be accessed.
Calendar Year Maximums for High Plan
Doctor's Office Visits (One visit may be used for wellness care)
Diagnostic Testing and X-ray (One visit may be used for wellness care)
Emergency Room
Inpatient Surgery
Outpatient Surgery
Calendar Year Maximums for Standard Plan
Doctor's Office Visits (No wellness visit included)
Diagnostic Testing and X-ray (No wellness visit included)
Emergency Room
Inpatient Surgery
Outpatient Surgery
Physician
Office Visit Fees (per visit)
For treatment of injury or sickness per covered person per calendar year
Chiropractic visits are included in these visits.
Diagnostic Testing or X-ray (per visit)
Medically necessary diagnostic tests and x-rays performed in a doctor's office
or outpatient facility; one visit may be used for wellness care.
Emergency Room (per visit)
Applicable for emergency room visits when patient is not confined to the hospital. One
visit each for injury or sickness per calendar year.
Surgery
Inpatient (per procedure)
Outpatient - limited to one (1) inpatient and one (1) outpatient surgery
(peñonned in a hospital or outpatient surgery center) per calendar year.
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5 visits
3 visits
3 visit for injury/1 visit for sickness
1 surgery
1 surgery
4 visits
2 visits
3 visit for injury/1 visit for sickness
1 surgery
1 surgery
BENEFIT PAYABLE
High Standard
$65
$30
$65
$30
$300
$75
$2,000
$800
$500
$200
Hospitalization (per day)
Regular Inpatient Stay - a maximwn of 100 days per confmement
ICU/CCU - a maximwn of 30 days per confinement
Mental Illness - a maximwn of 30 days per confmement
Alcohol and Substance Abuse - a maximwn of 30 days per confmement
Convalescent Facility - confinement must begin within three (3) days of a
hospitalization stay of at least three (3) days. A maximwn of sixty (60) days
per confinement.
Limitation/Exclusion Specific to Hospitalization and Surgery Benefits of the Plan
Benefits not provided for injury or sickness of a covered person, which results directly or indirectly, wholly or partly,
ftom pre-existing conditions until covered under the plan for 6 continuous months. Refer to the definition of "pre-
existing condition" in the Administration section.
Emergency Ambulance Services! Not currently offered
Maximum payable for Ground Ambulance: $750 per occurrence.
Maximum payable for Air Ambulance: $5,000 per occurrence.
Hospice Care (Inpatient and Outpatient); Maximum of $25,000 payable per lifetimeINot currently offered
MentaI/NervouslNot currently offered
Inpatient and Residential limited to 7 days per calendar year.
Day treatment limited to 14 days per calendar year.
Outpatient limited to 26 individual or group visits per calendar year.
Intensive Outpatient accumulates to the 26 outpatient visit limit per
calendar year.
Medication checks are not included in the 26 outpatient visit limit per
calendar year
Vision Care Benefit
Discounts on frames, lenses, contact lenses and eye examinations are available
ftom national providers such as Pearle Vision, Sears Optical, JCPenney Optical
and Target Optical. To find a participating provider, go to Vision One's website
at www.colemanagedvision.com, plan number: 46907 or call (800) 804-4384.
Survivor Benefit
Dependent coverage continues - premium ftee - following an
insured employee's death for up to 18 months.
Health Insurance Portability and Accountability Act of 1996 (HIP AA)
HIP AA provides individuals certain rights and protection relating to healthcare coverage. Federal law gives the plan sponsor of
non-Federal governmental plans the right to exempt the plan in whole or in part ftom requirements of Title I except for the
creditable coverage certificate requirements. TML IEBP has opted out of HIP AA and is exempt trom the Title I HIP AA
requirements.
Title I:
BENEFIT PAYABLE
High Standard
$500
$1,000
$250
$250
$250
$200
$400
$100
$100
$100
Refers to creditable coverage, restrictions on pre-existing conditions, special enrollments, non-discrimination based on
Health Status Factors, Newborns' and Mothers' Health Protection Act, Mental Health Protection Act, Mental Health
Parity Act and Women's Health and Cancer Rights Act;
Has an exemption option for self-funded, non-federal, governmental plans.
.
.
Title II:
Effective April 14, 2003, Administrative Simplification guidelines have been mandated. The administrative
simplification process includes standards for electronic transactions and code sets, national identifiers (for employers,
health plan and providers), Security and Electronic Signature Standards (final rule was published February 20,2003)
and Standards for Privacy of Individually Identifiable Health Information (Privacy Rule);
. A self-funded, non-federal, governmental health plan cannot exempt itself ftom the Title II requirement.
Privacy of Your Health Information
TML Intergovernmental Employee Benefits Pool will provide information regarding Privacy and Confidentiality guidelines.
Each Covered Individual will receive a letter upon annual enrollment, regarding the Privacy and Confidentiality procedure
guidelines. TML Intergovernmental Employee Benefits Pool maintains procedures to protect the privacy and confidentiality of
personal health information. If personal health information is requested, the Covered Individual will be required to sign a
.
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Consent Form. The reason for the request of personal health information will be stated on the Consent Form. At any point in
time, the Covered Individual may revoke consent. If the consent is revoked, the Covered Individual may request how the
personal health information has been used and the outcome of the use of the information. TML Intergovernmental Employee
Benefits Pool will maintain documentation of consent requestors, responses and revocations.
A Federal regulation, called the "Privacy Rule," requires TML Intergovernmental Employee Benefits Pool to protect the privacy
of each Covered Individual's identifiable health information. Under the Privacy Rule, TML Intergovernmental Employee
Benefits Pool may use and disclose a Covered Individual's identifiable health infonnation only for certain permitted purposes,
such as the payment of claims under the health plan. If TML Intergovernmental Employee Benefits Pool needs to use or disclose
a Covered Individual's health information for a purpose not pennitted under the Privacy Rule, TML Intergovernmental
Employee Benefits Pool must first obtain a written authorization signed by the Covered Individual.
In addition to restrictions on how TML Intergovernmental Employee Benefits Pool may use and disclose a Covered Individual's
identifiable health information, the Privacy Rule gives each Covered Individual certain rights. These include the right of a
Covered Individual to access his or her health information, to amend his or her health information, and to receive an accounting
of certain disclosures of his or her health information.
Important Disclaimer
The information presented in this Schedule of Benefits IS NOT a guarantee of payment.
The benefits described are subject to all plan limitations, preexisting information, filing deadlines, exclusions and eligibility
requirements. All benefits are based on the plan document language.
If a Covered Individual is on continuation of coverage (COC), coverage could tenninate retroactively if the individual's
contribution is not made within the COC payment timeframe.
Requests for reimbursement for a covered benefit should be sent to the Group Benefits Administrator within ninety (90) days of
the date of service but not later than twelve (12) months.
All inpatient and outpatient facilities are required to be JCAHO/Medicare accredited for the bill to be considered for payment.
Precertification is the determination only on the medical necessity of a proposed treatment based on the information provided at
the time the precertification is issued. Precertification does not verify or certify:
I. eligibility of any individual for coverage;
2. benefit coverage for services rendered pursuant to the precertification; or
3. network status of the provider(s).
Exclusions and Limitations applicable to aU Benefits
Benefits are not provided for injury or sickness of a covered person which results directly or indirectly, wholly or partly, fi'om:
I. Insurrection, rebellion, participation in a riot, commission of or attempting to connnit an assault, battery, felony, or act
of aggression;
War or any act of war, whether declared or undeclared, or sickness contracted or accidental bodily injury occurring
while on full-time active duty in the Armed Forces of any country or combination of countries; .
Occupational injury or sickness or any injury or sickness otherwise covered by any Workers' Compensation Act,
Occupational Disease Law or similar law;
Operating a motor vehicle under the influence of alcohol as evidenced by a blood alcohol level in excess of the state
legal intoxication limit;
Care or treatment related to intentionally self-inflicted injury or self-induced sickness;
Charges for which there is no legal obligation to pay, or no charge is made, or in the absence of coverage no charge
would be made;
Charges incurred after tennination of coverage;
Charges for care or services furnished by any agency or program funded by federal, state or local government except
Medicaid;
Charges which are not medically necessary for treatment of sickness or injury;
Unless specifically provided for in the plan, charges for routine physicals or exams or routine immunizations when no
injury or sickness is present; ,
Charges for medical care, services or supplies which are not furnished or prescribed by a doctor; .
Charges for experimental or investigational treatment, procedures for research purposes or practices when not generally
recognized as accepted medical practices; .
Charges for care, treatment, services or supplies that are not approved or accepted as essential to the treatment of an
injury of sickness by any of the following:
a. The American Medical Association,
b. The U.S. Surgeon General,
2.
3.
4.
s.
6.
7.
8.
9.
10.
II.
12.
13.
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29.
30.
31.
32.
33.
34.
14.
c. The U.S. Department of Public Health,
d. The National Institute of Health;
Charges related to cosmetic surgery except:
a. To repair disfigurement because of an accidental bodily injury which occurs while covered under the plan, or
b. For reconstructive surgery because of mastectomy which is perfonned within 12 months of the mastectomy
because of malignancy and while covered under the plan, or
c. For treatment of a congenital anomaly in a child born to the insured while covered under the Plan;
Unless specifically provided for in the plan, dental care or oral surgery except for closed or open reduction of ftactures
or dislocation of the jaw;
Unless specifically provided in the Plan, charges for treatment of Mental Illness;
Unless specifically provided in the Plan, charges for treatment of Alcohol or Drug Abuse;
Unless specifically provided in the Plan, charges for refractions, eyeglasses or their fitting;
Hearing aids or their fitting;
Charges in connection with obesity, weight reduction, or dietetic control except for morbid obesity or disease etiology;
Charges for treatment or services for Temporomandibular Joint (TMJ) Syndrome, orofacial, or myofacial syndrome
whether medical or dental in scope;
Charges for reversal procedures in connection with previous male or female sterilization;
Charges for services related to educational or vocational testing or training;
Any charges for abortions which are not medically necessary;
Any charges for outpatient food, food supplements or vitamins;
Any charges for prescription drugs or durable medical equipment;
Surgery to correct vision problems which are not caused by sickness or injury;
Charges for treatment of male or female infertility; in vitro and in vivo fertilization of an ovum, or artificial
insemination including but not limited to:
a. Drugs and medicine;
b. Diagnostic and surgical procedures including but not limited to:
. Aspiration of ovarian cysts;
. Harvesting or obtaining eggs;
. Other surgical treatment of infertility;
. Diagnostic laboratory and pathology procedures; and
. Diagnostic radiology, nuclear medicine and ultra sound procedures;
Charges made by a surgeon, nurse, dentist or doctor who:
a. Normally lives with the covered person;
b. Is a member of the covered person's family; or
c. Is the covered person's employer or another employee of the employer; or
d. Is contracted for or by a union, employee benefit association, trustee or similar organization or the employee
of a clinic contracted for or by any such organization;
Charges for custodial care;
Charges for care, treatment, services, supplies or confinements primarily for the convenience of the covered person, his
doctor, his family or other providers;
Charges related to smoking cessation;
Treatment received outside of the United States except for emergency treatment while traveling;
The processing of nuclear fission or fusion, or the processing, use, handling or transporting of radioactive material,
including but not limited to nuclear reactors or any weapon of war or explosive device employing nuclear fission or
fusion.
IS.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
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-
OPTIONAL BENEFITS
RA TES
MANDATORY
OPTION I - PRESCRIPTION BENEFITS (PHARMACARE FORMULARY)
A. Prescription Drugs
Retail (30 days) .... $300 Deductible; $5,000 Calendar Maximum
Retiree Only
Retiree & Spouse
$126.50
$253.00
Preferred Brand Drugs
$35 or 50% copay, whichever is greater
(generic substitution is required)
$15 Copay
100% copay with Member discount
Generic Drugs
Retail Non-Preferred Brand
Mail Order (90 days)
Generic
Preferred Brand
Non-Preferred Brand
$45 Copay
$105 or 50% copay, whichever is greater
100% copay with Member discount
B.
Prescription Drugs (Catalyst Generic Only Formulary)
$100 Deductible; $5,000 Calendar Year Maximum
Generic (Formulary) Drugs
Generic (Non-Formulary) Drugs
Brand Drugs
No Mail Order
Retiree Only $31.20
Retiree + Child(ren) $49.53
$10 copay Retiree + Spouse $56.28
100% copay with Member discount Family $81.50
100% copay with Member discount
C.
Generic (Formulary) Drugs
Generic (Non-Formulary) Drugs
Brand (Open Formulary) Drugs
Retiree Only $59.95
Retiree + Child(ren) $95.30
Retiree + Spouse $109.20
$10 copay Family $156.50
100% copay with Member discount
$35 or 50% copay whichever is greater
Prescription Drugs (Catalyst GenericlBrand with Open Formulary)
$100 Deductible; $5,000 Calendar Year Maximum; $400 Calendar Year Maximum on Brand
Drugs
D.
Retiree Only $88.89
Retiree + Child(ren) $143.78
Retiree + Spouse $168.89
Family $215.68
Prescription Drugs (SavRx Minimal Formulary)
$100 Deductible; $5,000 Calendar Year Maximum
Generic (Formulary) Drugs
Generic (Non-Formulary) Drugs
Brand (Formulary) Drugs
$14 Copay
100% copay with Member discount
$30 Copay
(generic substitution required)
100% copay with Member discount
Brand (Non-Formulary) Drugs
Mail Order (30 day dispensement)
Generic (Formulary)
Brand (Formulary)
Brand (Non-Formulary)
$9 Copay
$25 Copay
100% copay with Member discount
E.
BeneScript Prescription Drug Discount Card
Discounts of up to 25% off of average wholesale drug prices are provided through a network
of 45,000 national, regional and local participating pharmacies (including Walgreen's,
Walmart, CVS and Target). To find a phannacy near you, go to: www.benescriotcom.
Optional
Retiree $4.00
Family $8.00
If employer not going with other
Rx option
.
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RETIREE OPTION
OPTION n
A. Dental Care Benefits
Scheduled amounts are payable up to $2,000 per covered individual per calendar year for preventive
and diagnostic care, restorative treatment, root canals, periodontics ($500 lifetime maximum), oral
surgery and orthodontia ($1,000 maximum per course of treatment, for adults or children). Some
benefits require a 12 month waiting period before benefits are available.
Type I Preventive & Diagnostic - Annual Maximum $2,000
a. Oral exams, including prophylaxis:
b. Bitewings, per film:
c. X-ray, panoramic or cephalometic:
d. Sealants/topical fluoride:
e. Space maintainers:
PLAN PAYS
$48.00
$6.40
$48.00
$13.60
$144.00
Type 2 Major Restorative - Annual Maximum $2,000/12 month waiting
period applies
a. Crowns, bridges and dentures:
b. Pre-fabricated crowns:
c. Crown build-up procedures:
$240.00
$80.00
$64.00
Type 3 Minor Restorative - Annual Maximum $2,000
a. Fillings:
b. Crown, bridge and denture repair:
c. Relining or rebasing dentures:
$56.00
$32.00
- $80.00
Type 4 Endodontics - Annual Maximum $2,000
a. Root canals, apicoectomies:
b. Root amputation:
c. Therapeutic pulpotomy, retrograde, fillings, apexification and
Hemisection:
$256.00
$128.00
$64.00
Type 5 Periodontics - Lifetime Maximum $500/12 month waiting period
applies
a. Tissue grafts or bone surgery:
b. Gingivectomy (per quadrant), periodontal scaling, periodontal splinting
and root planning:
c. Gingival curettage (per quadrant):
d. Gingivectomy (per tooth):
$128.00
$80.00
$48.00
$32.00
Type 6 Oral Surgery - Annual Maximum 52,000/12 month waiting
period applies
a. Surgeries Levell (removal of exostosis):
b. Surgeries Level 2 (removal of impacted tooth):
c. Surgeries Level 3 (simple extraction):
$160.00
$88.00
$48.00
Type 7 Anesthesia - Annual Maximum 52,000/12 month waiting period
applies
a. Intravenous sedation:
b. General anesthesia, first half-hour and each additional quarter-hour:
$96.00
$96.00
Type 8 Orthodontia - Annual Maximum 52,000/12 month waiting period
applies
a. Adult or Child - per course of treatment
$500.00
Types through 7 subject to annual maximum of $1 ,000
Types 2, 5, 6a, 7 and 8 are subject to 12-month waiting period
RATES
Retiree Only 520.00
Retiree & Spouse $40.00
Retiree & Child{ren) $55.00
Family $75.00
Dental Only Option
B.
No Dental
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--
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c.
Aetna Discount Benefits
No waiting period; all ADA codes
Retiree Only
Family
S5.00
S8.00
RATES
OPTION ill
A. Vision Care Benefits (High Plan)
One eye exam per covered person per calendar
year and payment toward a set of frames and
lenses or contact lenses per covered person
once every two calendar years.
Exam: $50
FrameslLenses: $150
Embedded into High Plan
B.
Vision Care Discounts
Discounts on frames, lenses, contact lenses and eye examinations are available fÌ'om national
providers such as Pearle Vision, Sears Optical, JCPenney Optical and Target Optical. To find
a participating provider, go to Vision One's website at www.colemanagedvision.com, plan
number: 46907 or call (800) 804-4384.
Optional
Exclusions Specific to the Vision Care Benefits of the Plan
In addition, benefits are not provided for: any medical or surgical treatment of the eye; sunglasses, plan or prescription; safety
lenses or goggles; orthoptics, vision training or aniseikonia.
Employee's
Attained Age
<50
50-64
65+
Dental and Vision Option
Retiree Retiree Retiree Family
& Spouse & Child(ren)
$25.00 $49.00 $64.00 $88.00
$28.00 $56.00 $67.00 $95.00
$33.00 $65.00 $72.00 $103.00
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