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HomeMy WebLinkAboutC05-126 Eagle County Employee Benefit Plan C05 -1210 - 45 \ EMPLOYEE BENEFIT PLAN EAGLE COUNTY For Employees of EAGLE COUNTY GOVERNMENT January 1, 2005 VOLUNTARY NOTIFICATION OF HOSPITAL ADMISSION Sloans Lake Preferred Health Network PO Box 241322 Denver, CO 80224-9322 (303) 504-5615 Denver Metro Area (800) 850-2249 Toll Free www.sloanslake.com PHARMACY BENEFIT MANAGEMENT Retail: RxAmerica 221 N. Charles Lindbergh Drive Salt Lake City, UT 84116 Toll Free Phone: 1-800-770-8014 Toll Free Fax: 1-800-961-6039 www.rxamenca.com Mail Order: c/o PrecisionRx P.O. Box 961025 Fort Worth, TX 76161-9863 Toll Free Phone: 1-888-879-9432 Covered l\1edical Expenses... ...... ...... ....... ..... ..... ....... ...................... .... ....... ........ ................. ... ... ... .......... ....... .... .14 Limitations and Exclusions.. ....... ............. ..... ...... ....... ...... ...... ...... ............. ............. ....... ........... ... .... ................ ...18 Pre- Existing Condition Limitations................................................................................................................... . 22 V oluntary Notification of Hospital Admission. .... ....... ...... ........... ...... ..... ......... ....... ..... ........... ......... ......... .........24 Case Management Program... ...... ..... ................... ........... ....... ...... ................ ................. ................. ...... ...............25 Hospital Bill Audit Incentive ........ .............................. ...... ..... .............. ............ ............... ...................................26 Complementary Medical Treatment. ...... ...... ............. ........... ............. ....... ...... .... ... .... ......... .... .... .... .............. ... ... 26 PRESCRIPTION BENEFIT............................................................................................................................. ..............27 Generic Substitution.................................................................................................................... .......................28 Who Can Prescribe........................................................................................................................... ..................28 Covered Drugs............................................................................................................................ .......................29 Prescription Benefit Exclusions and Limitations ...............................................................................................29 Retail Prescription Card Benefit.......................... ......................... ............ ...................... .... ...... ......................... .30 Mail Order Pharmacy Benefit................. ........... ............. .... ............... ................................. ................ ...............31 Prohibited Use of the Prescription Card.................... ........ ........ ......... ....... ............. ............. ......................... ......32 Termination of Prescription Card Coverage..................... ...... ..... ................... ............. ........... .................... ...... ..32 GENERAL MEDICAL PLAN INFORMATION.. ........... ... ...... ... ........ .......... .... ........ .... ........ ....... ..... ............ ..... .......... .... ..32 Claims Procedure.......................................................................................................................... .....................32 Coordination of Benefits. ......... .......................... ...... ........... .................... ................. .......... .... ............ .......... ......36 Third Party Liability Exclusion... ..... .................. ............ ..... ..................... ............ .............. ............... ........... ...... 36 Assignment of Benefits ...... ........ ...... ...... ...... ......... ...................... ............ .......... ........... .......... ...... ................ ...... 3 7 Recovery of Excess Payments... ........ ........................ .............. ................. ............................. ......... ....................37 Right to Receive and Release Necessary Information........................................................................................38 Alternate Payee Provision... ....... .... ............... .............. ..................... ...................................... ........... ................. 38 When Coverage Ends......................... .................... ................... ........................................... ..............................38 Family Medical Leave.............. .............. ...... ......... .... ........ ..... ..... ...... .............. .... ........ ........ ... ........ ... ........ ..... ....39 Qualified Medical Child Support Order (QMCSO) ...........................................................................................39 Eagle County Government ii Table of Contents . 1/1/05 Eligibility for Eagle Plus Choices ......................................................................................................................51 Making and Changing Your Eagle Plus Elections .............................................................................................51 Eagle Plus - Maximum Plan Benefit ..................................................................................................................51 Unused Benefits.. ...... ......................... ................ ....... ....................................... ....... ........................................... 52 PLAN OPTION D ET AILS...... ........... ............. ..... ............. ......... ............... ................................. ..... ...................... ...... ..52 Non-Taxable Options........ ........... ........ ................ .............. ...... .... ................ ............... .... .............. ........... ..........52 Taxable Options............................................................................................................................. ....................54 Provisions for AU Taxable Benefits ...................................................................................................................54 EAGLE PLUS CLAIMS PROCEDURES .........................................................................................................................54 Claims Filing Deadline. ..... ........... ....... ... '" ............. ... ... ............... ... ............. ... ...... ........ ............. .... ... ......... .........55 General Information....................................................................................................................... ....................55 CO NTINU A TI 0 N OF CO V ERAG E .......................................................................................................................56 COBRA. .... ........... ...... ............ ..... ................ ...... .... ............ ............... ....... ....... ... ... ........,...... '.. ........ ........ ............,....56 Introduction................................................................................................................... .....................................56 Plan's COBRA Notification Contact (PCNC)....................................................................................................56 Quali tying Events......................................................................................................................... ......................57 Notice of Unavailability .... ......... ............. ......... ..... .................... ........ ......... .......... ................ ........ ............. .........58 Your Notice Obligations While You are a Plan Participant ...............................................................................58 Written Notice Guidelines........................................................................................................................... .......59 Election Procedures............................................................................................................................... .............60 Type of Coverage..................... .............. .......... .... ................................ ............................... .......... ........ ........ .....61 Monthly COBRA Premiums That You Must Pay ..............................................................................................61 Maximum Periods of Coverage.... ........................ ............. ............................................. .............. ............ .......... 62 Children Born to or Placed for Adoption With the Qualified Beneficiary During the COBRA Period .............64 Special Enrollment Rights Due To Health Insurance Portability and Accountability Act (HIPAA)..................64 Claims Recovery........................................................................................................................... .....................65 Alternate Recipients Under QMCSOs ...............................................................................................................65 Eagle County Government iv Table of Contents . 1/1/05 Legal Action......................................................................................................................... ..............................87 GROUP ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE ............................................................87 Eligibility ...................................................................................................................................... .....................87 Coverage........................................................................................................................ ....................................88 Exclusions......................................................................................................................... .................................88 Filing an AD&D Insurance Claim......................................................................................................................89 Beneficiary Designation ................... .......... ................ ..... ........ .., ....... ..... ......... ............. ................. ....... ...... ........ 89 Legal Action................................................................................................................................ .......................89 V OLUNT ARY LIFE INSURANCE .......... ...................... ........... ......... ........... ......... ....................... .......... ....... ............ .....90 Eligibility ................................................................................................................................... ........................90 Effective Date of Voluntary Life Insurance .......................................................................................................90 Coverage...................................................................................................................... ......................................91 When Voluntary Life Coverage Ends ................................................................................................................92 Conversion Privilege.................. .................... ...............,............. ................... .............. ........ ........... ............ ....... 92 VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE ................................................... 93 Eligibi lity ....................................................................................................................................... ....................93 Effective Date of Voluntary AD&D Coverage ..................................................................................................93 Coverage........................................................................................................................... .................................94 Exclusions.......................................................................................................................... ................................94 When Voluntary AD&D Coverage Ends ...........................................................................................................95 Conversion Privilege...... ............................. ........... ........... .................. .................... ............. ..............................95 GENERAL INFORMATION ABOUT YOUR SURVIVOR BENEFIT PLANS ........................................................................ 96 Naming a Beneficiary........... .......... ......... .......... ......... ............... .................. ..................... ............. ..................... 96 Payment of Benefits...... ....................................... .......... ............. ................ ............ ........................... ................96 Filing a Claim............. .............. ......................... ......... .... ..................... ......................... ..... ........ ......... ....... .........96 D I SA B I LIT Y BEN E FITS ............... ...... .......... .......... ......................... ........ ...... ................. ........ ................ ........ ........ 97 SHORT TERJvl DISABILITY.. ............................... ................................................... ........... ........ ................. ................ 97 Eagle County Government vi Table of Contents · 1/1/05 YOt.JB..HBAI.,'fHIJ1\.IIB..BBNE.nTS.PBOGKAM While your salary or wages are the most apparent part of your compensation, fringe benefits are a substantial additional value that you receive for your services. Benefits are very important to your financial security and physical well being. The County's goal is to provide you with a comprehensive program of benefits. Benefits are meaningful only if you clearly understand and take advantage of the plans available to you. In addition to benefits described here, please refer to other written materials provided by the Eagle County Government Human Resources Office for additional Benefits information. ~ Self-funded Medical Plan ~ Self-funded Dental Plan ~ Self-funded Vision Plan ~ Self-funded Eagle Plus ~ Fully-insured Survivor Benefits . Travel Accident . Group Life/Accidental Death and Dismemberment . Voluntary Life/Accidental Death and Dismemberment ~ Disability Benefits . Self-funded Short Term Disability . Fully-Insured Long Term Disability This document describes the important details of your benefits program in a clear and concise manner. Words and phrases are normally described in context; however, ifunique definitions apply to the Group Medical, Dental, Vision or Eagle Plus Plans, the words are in quotation marks (i.e. "Hospital") and can be found in the Definitions section of this "Plan Document." Eagle County Government is the Plan Administrator and herein referred to as the County, Eagle County, Plan Sponsor or Employer. If additional clarification is needed, please contact the Eagle County Human Resources office. This is the "Plan Document" and Summary Plan Description of the self-funded Medical, Dental, Vision, Eagle Plus and Short-term Disability Plans. It outlines all rules on Plan operations including participation, reimbursement and operational procedures. This booklet also contains a brief description of the fully-insured benefits listed above. Should the summary provided herein differ from the actual insurance contract, the contract shall govern. Please contact Human Resources to obtain additional information about these Plans. Eagle County Government reserves the right to amend or terminate all Plans at its sole discretion and to make administrative and interpretive decisions necessary to Plan operation. Eagle County Government 1 Your Healthcare Benefits Program · 1/1/05 GENE~.INFORMATION CAFETERIA CHOICES Employees are eligible to select from a variety of medical and other benefit options and change those choices each year during the annual open enrollment period as described below, Changing Your Cafeteria Plan Choices. Please carefully consider which options will work best for you and your family and understand the rules so that you will get the most value from your chosen plans. CHANGING YOUR CAFETERIA PLAN CHOICES During the month of December, "Covered Persons" may change the Medical Plan option in which they are enrolled. The deadline for submitting changes will be designated annually by the County. The change will be effective on the following January 1. Written election for such changes must be on file with the Human Resources Department prior to each January 1. Mid- "Plan Year" changes are allowed only as described under Special Enrollment. If you experience a qualified change in status as permitted under Treasury Regulations ~ 1.125-4 and the regulations thereunder and as described in the Special Enrollment section, you may be eligible to elect different benefit options only if you elect those options in writing within thirty (30) days of the change in status event. COST V ALUE OPTIONS Eagle County pays a substantial amount towards the cost of your benefits. Periodically, the County will reset the respective costs of each option, normally based on expected future costs. Such changes will normally be effective on January 1. A supplement to this "Plan" is available to you and will be updated as necessary. Contact Human Resources for a copy. PRE-TAX PREMIUMS Background Section 125 of the Internal Revenue Code provides that an employer may create and offer to its employees a Cafeteria Plan, which is defined as a Plan that allows an employee the opportunity to elect between two or more benefits consisting of taxable (including cash compensation) and non- Eagle County Government 3 Generallnformation . 1/1/05 MEDICALCiU(EBENEFITS PREFERRED AND NON-PREFERRED PROVIDERS Eagle County Government provides benefits that vary according to your selection of providers. "Preferred" providers are contracted with the Plan's PPO Provider Network (refer to the Important Telephone Numbers section for details) and have agreed to accept the Plan's guidelines as to fees for their services. This will ensure that patients will not be charged for fees beyond those allowed by the Plan. In addition, the hospitals and other medical facilities have agreed to accept reduced fees for outpatient and inpatient services that they provide to Plan members. This means that when you and your "Dependents" use Preferred facilities, expenses that the Plan pays and expenses that the Plan requires you to pay will be reduced. When you use Preferred hea1thcare professionals, they will file claims directly with and be paid directly by the Plan. Expenses for services not covered by this Plan and amounts the Plan requires you to pay will be billed to you by your providers. The "Preferred" health professionals agree with the Plan's goal of encouraging the provision of quality healthcare using sound and efficient health treatment practices. While the County strongly hopes you are able to employ the services of these Preferred professionals, you are free to choose other providers of medical services. "Preferred" benefits are only available when you receive services provided by the Plan's Preferred group of healthcare professionals. The listing of participating facilities and providers is updated periodically, and is available from the Human Resources office and on the PPO Provider Network's website. "Non-Preferred" means "Physicians," "Hospitals" and other healthcare providers that are not contracted with the Plan's PPO Network or that the Plan designates as being Non-Preferred. Using "Non-Preferred" providers allows you total choice of Physicians and Hospitals, but at a higher cost to you. You may use either "Preferred" or "Non-Preferred" providers at any time. Exceotions Occasionally, the choice of using an "Preferred" or "Non-Preferred" providers is difficult for the patient to control. The "Plan" recognizes this difficulty and allows the following exceptions: 1. A Non-Preferred anesthesiologist or assistant surgeon will be covered as Preferred when the primary or treating "Physician" or surgeon is a Preferred provider. 2. A Non-Preferred Physician who sees patients at a Preferred clinic is a Preferred provider. 3. A Non-Preferred emergency room Physician will be covered as Preferred when the treating medical facility is a "Preferred" facility. 4. Non-Preferred laboratory or radiology services (including interpretation of tests by a pathologist or radiologist) will be covered as Preferred when the referring Physician or medical facility are Preferred providers. Eagle County Government 5 Medical Benefits · 1/1/05 LOW COPAY MID COPAY Preferred 1 Non.Preferred Preferred 1 Non.Preferred 5. Outpatient Surgery Center 5 Subject to Deductible No Yes Yes Yes Patient Pays/Admit $0 20% $0 40% Plan Coverage 100% 80% 100% 60% 6. Surgeon (Inpatient) Subject to Deductible Yes Yes Yes Yes Patient Pays $0 20% $0 40% Plan Coverage 100% 80% 100% 60% 7. Surgeon (Outpatient) Subject to Deductible No Yes No Yes Patient Pays $0 20% $0 40% Plan Coverage 100% 80% 100% 60% 8. Assistant Surgeon Subject to Deductible No Yes No Yes Patient Pays $0 20% $0 40% Plan Coverage 100% 80% 100% 60% 9. Doctor's Office Visit 6 Subject to Deductible No Yes No Yes Patient Pays Per Visit $10 copayfor 20% $20 copay for 40% the first 8 visits, the first 8 visits, $30 copay for $40 copay for remaining remaining visits/cal. year. visits/cal. year. 100% 80% 100% 60% Plan Coverage 5 Includes radiology, pathology and anesthesia during outpatient surgery. 6 Copay applies per office visit for professional fees only. Copay is waived for allergy shots and immunizations if no professional fee is charged. Includes, but is not limited to office visits for 'Physician,' physical therapy, mental health, ER Physician visits, substance abuse, etc. Includes office visits related to "Illness' or "Injury." Copay is waived for allergy shots and immunizations if no professional fee is charged. Eagle County Government 7 Medical Benefits . 1/1/05 LOW COPAY MID COPAY Preferred 1 Non-Preferred Preferred 1 Non-Preferred 16. Prescription Coverage Subject to Deductible No Yes No Yes a. Retail Prescriptions (up to 30 day supply) Generic copay $10 75% $15 75% Brand copay $20 75% $40 75% Plan Coverage 100% 25% 100% 25% b. Mail Order Prescriptions (up to 9O-day supply) Generic copay $10 $15 Brand copay $20 N/A $40 N/A Plan Coverage 100% 100% B. Treatment for Mental Health and Substance Abuse 1. Outpatient Subject to Deductible No Yes No Yes Patient Pays Per Visit Same as 2(A)(9) 20% Same as 2(A)(9) 40% Coverage 10 Calendar year Calendar year Calendar year Calendar year maximum of maximum of maximum of maximum of 25 visits. 25 visits. 25 visits. 25 visits. 2. Inpatient 11,12 Same as 2-A-(1) Same as 2-A-(1) Same as 2-A-(1) Same as 2-A-(1) & (2) expenses. & (2) expenses. & (2) expenses. & (2) expenses. Max 60 days per Max 60 days per Max 20 days per Max 15 days per Calendar yr. Calendar yr. Calendar yr. Calendar yr. C. Other Covered Expenses Subject to Deductible Yes Yes Yes Yes Copay 20% 20% 20% 40% Coverage 80% 80% 80% 60% 10 Combined for all plans. 11 Maximum days per calendar year for both "Preferred" and "Non-Preferred" combined is sixty (60). 12 Borrow provision may apply. Plan participants may extend in-patient care in anyone calendar year by borrowing up to ten (10) days from the following year. Two (2) partial days may be substituted for one full day. Eagle County Government 9 Medical Benefits · 1/1/05 ELIGIBILITY AND ENROLLMENT Elillibilitv "Regular Full-Time" and "Regular Part-Time" employees are eligible to participate. Elillibilitv Waitinll Period and Effective Date of Cover aile Coverage will be effective on the first day of the month coincident with or following the date of emploYment. For coverage to be effective, a completed and signed enrollment form must be submitted to Human Resources within thirty (30) days of when first eligible. If completed enrollment forms are not submitted within this time period, "Late Enrollment" provisions apply. Deoendent Coveralle If an "Employee" is enrolled, his/her eligible "Dependents" may also be enrolled. Eligible "Dependents" are described in the Definitions section of this "Plan Document." Dependents do not include Children of a dependent son or daughter. If coverage for "Dependents" is elected (requires employee participation), coverage will be effective on the same date as the employee claiming them as dependents. Common law marriages must be attested to by a signed, notarized affidavit. No Dependent can be covered before the date the employee becomes covered. In cases where both husband and wife are employed by the County, an eligible employee cannot be covered as both an Employee and a Dependent by this Plan. If one spouse loses the County coverage for any reason, coverage that had been elected by that spouse can be transferred to hislher eligible working spouse. Late Enrollment "Late Enrollment" is not allowed except as described below under Special Enrollment and Open Enrollment. Special Enrollment If you decline enrollment for yourself or your "Dependents" because you have other health coverage, you may in the future be able to enroll yourself or your Dependents in this Plan, provided that you request enrollment within thirty (30) days after your other coverage ends. Other coverage must be ending due to loss of eligibility, including legal separation, divorce, death, termination of employment, reduction in hours of employment, or termination of employer contributions. In addition, if you have a new Dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your Dependents, provided that you request Eagle County Government 11 Medical Benefits . 1/1/05 The individual deductible must be met by each person during a calendar year. The maximum deductible for a family is three (3) times the individual deductible. All family members can contribute to meeting the maximum deductible for the family. Deductible Carryover If you continue participation in the same Medical Plan for a successive year, expenses incurred in the last three (3) months of the calendar year that are credited to your deductible will also be credited to the deductible applicable to the following calendar year. Out-of-Pocket EXDenses To help protect you and your family against high health care expenses, the Plan includes out-of- pocket maximums. The Plan's calendar year out-of-pocket maximums are shown in the Medical Benefit Summary. CODavments (Covavs) Copays listed in the Medical Benefit Summary may be applicable to some benefits and represent the cost each patient must pay each time a medical service is received. The "Hospital" admission copay does not apply to the baby's hospital stay during which birth occurs. Hospital copays for re- hospitalization within two (2) weeks of discharge for the same medical condition will not apply. Copays are not credited to any deductible. 111aximum Benefit For participating employees and their participating dependents, the maximum benefit payable while covered by the Plan is as stated in the Medical Benefit Summary. Mental Health and Substance Abuse Benefits The Plan covers you and your dependents for "Inpatient" and "Outpatient" charges due to "Mental Health" and "Substance Abuse." Please refer to the Medical Benefit Summary for full details. The copay is applied per professional session. Out-of-Area EmerflenCV Care There are several specific circumstances under which "Preferred" benefits are available for care provided by any health care provider who may not be a member of the Preferred network. They are as follows: Eagle County Government 13 Medical Benefits · 1/1/05 2. Ambulance Services: a. Professional ambulance service, to the nearest hospital or appropriate facility. b. Professional ambulance service from the hospital to the patient's home, if such home is within the locality of the hospital when "Medically Necessary." c. Air Ambulance Service when the aircraft used meets all qualifications of a professional ambulance. Covered expense includes the base rate, mileage, nursing services and necessary supplies from the place the patient is picked up to the nearest hospital or medical facility necessary to supply needed medical services. 3. Anesthesia and its administration by a "Physician," nurse or anesthetist. 4. Attention deficit disorder (ADD) Expenses for diagnostic testing to determine the diagnosis, medication and medical management of the medication. All other expenses for treatment of ADD will be covered under the mental health disorders provision of the Plan. 5. Birth control devices and procedures that are prescribed and provided by a "Physician." 6. Blood transfusions, blood processing costs, blood handling charges, and the cost of blood and blood plasma. Any credit allowable for the replacement of blood plasma by donor or blood insurance will be deducted from the total of eligible covered charges. 7. Expenses for cosmetic, restoration or reconstructive surgery and related expenses are covered when such surgery is required as a result of a congenital anomaly, accidental "Injury," disease process or its treatment. Reconstructive surgery due to a mastectomy will include reconstruction of the remaining breast. 8. Dental services to repair damage to the jaw and sound natural teeth, if the damage is the direct result of an "Injury" (but did not result from chewing) which occurs while the "Covered Person" claiming benefits is covered under the Plan and only when the first service was received within six (6) months after the injury. Subsequent services will be covered up to two (2) years from date of accidental injury provided there has been continuous coverage under this Plan. 9. Rental of "Durable Medical Equipment" when "Medically Necessary" for therapeutic use; except that if in the judgment of the Plan Administrator, purchase of an item of Durable Medical Equipment will be less expensive than the rental thereof, or such equipment is not available for rental. Such items purchased will become the property of the County. Items such as air conditioners, purifiers, vibrating chairs, whirlpools and dehumidifiers are not covered items. Eagle County Government 5 Medical Benefits . 1/1/05 22. Charges made by a "Physician" and other licensed health care professionals who are under the direct supervision of a "Physician," provided such services are not rendered by a person who is related to the "Covered Person" by blood or marriage. 23. Prescription drugs, services and supplies: a. No prescription drug charges or charges for any other service or supply will be allowed in a quantity where normal dosage or usage would extend for more than thirty (30) days if purchased at a retail pharmacy, or ninety (90) days if purchased by mail order. b. Benefits for prescription drugs and medicines will not be provided when a written prescription is not required in order to purchase a certain drug or medicine, even though a prescription number has been assigned. c. No expenses for prescription drugs will be allowed when it has been determined by the medical consultants of the Plan Administrator that there is over-utilization of drugs or evidence of drug abuse, regardless of the medical necessity that exists. 24. Prosthetic Appliances and Orthopedic Appliances: a. Benefits include charges for the fitting, adjusting and repairing of such Prosthetic and Orthopedic Appliances, and charges for the replacement of Prosthetic and Orthopedic Appliances when determined by the attending physician to be "Medically Necessary" because of change in the patient's condition or wear of an appliance. b. Prosthetic bras following a partial or radical mastectomy are covered. Items such as arch supports, orthotic appliances and corrective shoes, (or charges for the casting, molding or fitting thereof), heating pads and hot water bottles are not covered expenses. 25. Expense for second surgical opinion, to substantiate medical necessity of the procedure to be performed. A third opinion will be covered in case of conflict between the first two opinions. 26. Accredited facilities, clinics or centers involved in sleep testing and treatment for a covered "Illness" or "Injury." 27. Voluntary sterilization, tubal ligations or vasectomies for employees and dependent spouses. Reversals of sterilizations are not covered. Eagle County Government 17 Medical Benefits . 1/1/05 13. Expenses for routine eye examinations, routine refractive examinations, eyeglasses, contact lenses, or prescriptions for services and supplies except where specifically indicated as a covered medical expense. Expenses for services and/or supplies in connection with lasik, kerato-refractive or any other procedure designed to correct farsightedness, nearsightedness or astigmatism. 14. Expenses for injuries incurred or illnesses contracted in the course of committing a felony. A felony, as defined in the jurisdiction in which the felony is prosecuted, will be deemed to have occurred on the earlier of the date felony charges are filed by the appropriate legal authority, or on the date the criminal activity occurs if the Plan Administrator could reasonably expect felony charges to be filed. A felony will no longer be deemed to have occurred on the earliest of either the date the filed felony charges are dropped; the date a court oflegaljurisdiction fmds the party not guilty; or, in the event felony charges are not filed, the date on which the Plan Administrator no longer expects charges to be filed. When such an event occurs, claims not filed, pended or denied under this provision may be refiled for reconsideration, but only if this Plan has not been terminated prior to that date, in which event the claims are not eligible for coverage. 15. Expenses for foot care with respect to: corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, or symptomatic complaints of the feet. Expenses for removal of corns, calluses or trimming of toenails, except when necessary in the treatment of a metabolic or peripheral vascular disease. 16. Gene manipulation therapy. 17. Genetic connseling and amniocentesis testing unless recommended by a "Physician" based on the existence of adverse risk factors such as a documented high-risk pregnancy or family history of genetic disorder. Any procedure intended solely for sex determination is not covered. 18. Expenses for health club membership. 19. Hearing aids, supplies and hearing therapy, except where "Medically Necessary" due to an "Accident" or "Injury," but in no event shall it be covered due to the normal aging process. 20. Expenses related to hypnosis. 21. Treatment for infertility (absence of the ability to conceive a child) including drugs for treatment of infertility, in vitro fertilization, or reversal of vasectomies or reversal of tubal ligations NOTE: Initial fertility testing and related services for diagnosis is covered by the Plan. Once these procedures are completed, and the underlying medical diagnosis is Eagle County Government 19 Medical Benefits · 1/1/05 35. Any treatment or service furnished by a Physician or intern of a medical facility who is reimbursed for his or her services by a medical facility. 36. Any treatment or service furnished by a "Physician" who is a resident of a participant's household or member of the immediate family. 37. Services related to post-mortem testing. 38. Expenses subject to the pre-existing condition exclusion provision. 39. Care in any private institution, or any institution owned or operated by the federal, state or local government, which would be provided to the "Covered Person" under this Plan at no cost, except as required by law. 40. Psychoanalysis or psychotherapy that can be credited towards earning a degree or furtherance of the education or training of a "Covered Person," regardless of diagnosis or symptoms that may be present. 41. Expense for rental or purchase of equipment such as air conditioners, dehumidifiers, purifiers, whirlpools, heating pads and hot water bottles. 42. Expense for self-inflicted injuries, unless the injury results from a medical condition (physical and/or mental health condition) and the expenses would otherwise be covered by the plan. 43. Expenses for sex change, transsexualism, gender dysphoria, including drugs, medication, hormone therapy, surgery, medical or psychiatric care and/or treatment. 44. Any treatment or service provided for the purpose of smoking cessation, except as described under the Prescription benefit. 45. Special duty nursing services which ordinarily would be provided by the hospital: a. when requested by, or for the convenience of, the patient or the patient's family. This could consist of bathing, feeding, exercising, homemaking, moving the patient, giving medication, acting as companion or sitter, or when otherwise deemed not to be "Medically Necessary;" or b. when rendered by a private duty nurse who is an immediate relative by blood, marriage, adoption, or a member of the household of the "Covered Person," such as a spouse, parent, child, brother or sister. 46. Expense for special education, counseling, therapy or care for behavioral disorders or learning deficiencies whether or not associated with manifest mental disorders or other disturbances. Expenses incurred for initial diagnostic testing to determine the diagnosis and expenses for medication and medical management of the medication will be covered. Eagle County Government 21 Medical Benefits · 1/1/05 The twelve-month period during which pre-existing conditions are not covered will be reduced by periods of creditable coverage under this Plan as well as eligible previous plans. For creditable coverage from prior plans to apply, the following conditions must be met: 1. There must not be a break in coverage of more than 63 consecutive days from the date prior coverage ends to your "HIP AA Enrollment Date." Time spent satisfying eligibility waiting periods in prior plans will not be counted towards the 63-day limit. 2. The prior plan must be either an individual or group health plan or policy (including "Medicaid" and "Medicare") that provided coverage generally similar to that provided by this Plan. This Plan will follow the Standard Method 14 for crediting of prior coverage. That is, credit will be provided in this Medical Plan for creditable prior coverage under plans providing similar Medical benefits. No prior credit will be provided for periods of coverage in the following types of plans: a. Accident or disability income b. Liability insurance, including general liability and auto liability insurance c. Workers' compensation d. Automobile medical payments insurance e. Credit-only insurance f. On-site medical clinic coverage g. Limited group dental or vision benefits h. Long-term care insurance 1. "Convalescent Nursing Home" care J. Home health care k. Community-based care 1. Fixed income coverage m. Specific disease policies 14 The Standard Method of counting creditable coverage counts the number of days during which an individual had one or more types of creditable coverage. Eagle County Government 23 Medical Benefits · 1/1/05 f. Planned Course of Diagnosis or Treatment 4. The above information should be phoned, faxed or mailed to the Plan's Medical Consultant. If necessary, they will consult with the admitting "Physician." For emergency care, please call the Plan's Medical Consultant within the 72 hours as stated herein. 5. Voluntary Notification does not mean that a claim has been approved. Your claim is still subject to all Plan approval provisions such as pre-existing conditions, eligibility and other guidelines and limitations in the Plan. All written notifications, questions and phone inquiries should be directed to the Plan's Medical Consultant - refer to section Important Telephone Numbers for detailed contact information. Please remember, by voluntarily notifying the Plan's Medical Consultant of all hospital admissions, the Plan will be best able to serve the interests of all employees and dependents. Case Mana1!ement Pro1!ram The plan contains, and encourages use of, a Medical Case Management Program. Case Management can begin when the Plan becomes aware of any serious health conditions. This program focuses on the medical care, treatments, and procedures performed. The purpose of this program is to work with the patient and his/her attending "Physician" to identify and arrange cost-effective and medically sound alternatives such as home health care services, IV antibiotic therapy, "Hospice" care, outpatient surgery, homebound rehabilitation services, and other outpatient services. The case management program also extends to outpatient therapies, treatments, and procedures. Cost-effective alternatives are implemented when possible. Following are typical services provided by a Registered Nurse Case Manager: 1. A Registered Nurse (RN) case manager may visit and/or telephone the patient to discuss medical needs and treatment. 2. Information will be provided to assist the patient in understanding his/her medical coverage. 3. Information will be provided to the "Physician" and the patient concerning appropriate treatment alternatives that may be considered. 4. The RN case manager will work closely with the patient and the attending "Physician" to arrange home health services, therapies, and rehabilitation services when "Medically Necessary" and appropriate. 5. The RN case manager will also work closely with the attending "Physician" and the patient to identify and arrange cost-effective "Outpatient" alternatives. Eagle County Government 25 Medical Benefits · 1/1/05 . Birthing Centers . Licensed Practical Nurses Each medical situation or problem that could possibly be improved by using this approach will be thoroughly reviewed by the Plan's Medical Consultant who discusses all issues with the attending "Physician," and a specific plan of coverage is designed for each event. The decisions of the medical consultant and Plan Administrator are final. Potential uses for CMT special coverage are best identified by each employee/patient. Think about the services you are receiving or are about to receive and ask questions: 1. Do you need to be in the hospital? 2. Does your therapy seem to be progressing at too slow a pace? 3. Are you receiving tests and services that you do not understand or seem unrelated to your medical problem? 4. Are doctors suggesting inpatient care that you do not think is necessary? 5. Is discharge from the hospital being delayed for minor reasons? 6. Do you feel you would like a second opinion on a suggested diagnosis and course of treatment (not necessarily surgery) and do not know what to do? If the answers are yes to these types of questions, call the Plan's Claims Administrator, explain the situation and they will advise you on how, or if, the CMT special provisions may help solve your problem. Another way the Plan will identify situations in which CMT may help is via the Claims Administrator auditing medical events in progress. If they identify ways in which CMT might help, they will initiate contact with the patient to discuss and suggest options. This form of special CMT help only works if all of us in the Plan make it work. If we do, it can work for all of us by helping those who are seriously ill by personalizing care and coverage and by paying only for necessary medical care. In this way, we can reduce and control Plan costs and that helps everyone in the Plan. PRESCRIPTION BENEFIT Prescription medications are frequently used to treat both simple and complex medical problems and coverage for pharmaceuticals is an important part of this Plan. The County's Prescription Card Benefit is provided through the Plan's Pharmacy Benefit Manager (PBM). Refer to the Important Telephone Numbers section for contact information details. The PBM contracts with select pharmacies on the Plan's behalf. In this way, the Plan receives preferred pricing for pharmaceuticals. Eagle County Government 27 Medical Benefits . 1/1/05 Prescriptions Provided By Non-Preferred Pharmacies You may be away from home, or may choose to purchase your prescription from a retail pharmacy not participating with our Plan. If so, you will need to submit a regular claim form to the Plan's Claims Administrator. These expenses will be subject to the same limitations, exclusions, calendar year deductibles, etc. as set forth in this "Plan Document." Your amount of reimbursement, however, will be reduced to 25% of the purchase price. Covered DruJ!s Covered prescription drugs include (see Excluded Drugs for limitations): 1. "Legend" drugs; 2. Compounded drugs containing at least one "Legend" drug; 3. Insulin syringes and other diabetic supplies as prescribed by a "Physician;" 4. Bee sting kits, Imitrex and Insulin; 5. Oral contraceptives, devices and other forms of birth control that require a prescription by a Physician; 6. Smoking cessation drugs, limited to one period of a maximum of six (6) consecutive months during a covered "Adult" person's lifetime. Prescription Benefit Exclusions and Limitations The following are excluded from your prescription card benefit. Prescriptions for these items may be obtained; however, the patient must pay the full cost of the prescription. Prescription drugs not covered by the Prescription Card or Mail Order Prescription Benefit may be covered by the Medical Plan. Those benefits are subject to all applicable deductibles, coverage terms and limitations and exclusions. 1. All drugs which do not require a prescription under Federal law. 2. Any injectable medication, except for insulin, Imitrex (limit 2 injections per script) and bee sting kits. 3. Drugs labeled "Caution - Limited by Federal Law to Investigational Use," or investigational, "Experimental," or medications not approved by the Food and Drug Administration 4. "Legend" vitamins (except pre-natal), anorexic agents, infertility medications, anabolic steroids (for body building), fluoride products, drugs for which no prescription is required and over-the-counter drugs. Eagle County Government 29 Medical Benefits . 1/1/05 1. The "Employee" or "Dependent" will be responsible to pay the copay. Please refer to the section Medical Benefit Summary for copay details. 2. The "Employee" or "Dependent" will be responsible to pay for the drug if it is not a covered benefit. 3. Rx copays do not accumulate toward any ofthe plan deductibles or out-of-pocket limits. RETAIL Rx DISPENSING LIMITATIONS Up to a 30-day supply. Mail Order Pharmacv Benefit A valuable option in the Medical Plan is the Mail Order Prescription Drug service, managed by our Plan's PBM (see Important Telephone Numbers section for contact information details). It allows each person to save money when purchasing maintenance medications and helps to keep Plan costs down. 1. An initial Mail Service order form is available from Human Resources as well as a brochure describing the program. You will need to complete the patient profile information only for your initial order. The Plan's PBM will include a prepaid reorder envelope as each order is mailed to you. You may also access the Mail Order forms through the PBM's website. 2. You can order up to a 90-day supply. 3. The Plan has the convenience of home delivery. 4. Refills may be ordered in one of two ways: (a) you may complete the reorder form supplied by the Plan's PBM and mail it in on or after the refill date printed on the reorder form, or (b) you may call the PBM's toll-free number, 1-800-770-8014. You can charge your purchase to VISA, MasterCard or Discover Card on phoned in refill orders, or pay by check or money order. 5. You will receive your prescriptions within 14 days after your order is received. 6. If you need to take maintenance medications right away, ask your doctor for two prescriptions, one for a 30-day supply and one for your mail order supply with refills. Fill the 30-day supply at your local network Retail Pharmacy and send the mail order prescription to the Plan's PBM. 7. Your prescription( s) will be filled for the exact quantity prescribed by your physician up to a 90-day supply. For example, if your prescription is written for a 30-day supply with 2 refills, you will receive a 30-day supply. The refills cannot be combined to equal one 90-day supply. With this in mind, please remind your physician that you will be Eagle County Government 31 Medical Benefits . 1/1/05 1. Complete the employee portion of the claim form in full. Answer all questions, even if the answer is "none" or "NI A" (not applicable). 2. Attach all necessary documentation of expenses to the claim form. Documentation must include: a. A description of services or supplies provided, detailing the charge for each service or supply; b. The diagnosis; c. The date(s) of service; d. The patient's name; e. The provider's name, address, phone number and degree; f. The federal tax identification number of the provider. 3. Complete a separate claim form for each person for whom benefits are being requested. 4. If another plan is the primary payor, a copy of the other plan's Explanation of Benefits (EOB) must accompany the claim form sent to this Plan. 5. Mail completed claim forms to the Claims Administrator - refer to the Important Telephone Numbers section for contact information details. Note: The date that a claim is considered "filed" is the date that it is stamped "received" by the Claims Administrator. Information, including employee or dependent's name, medical diagnosis and itemized bills from providers of services must be provided. Additionally, the Plan's Claims Administrator may require additional information necessary to process a "Covered Person's" claim, to include but not limited to, verification of current student status; "Accident" details if applicable; validation of a dependent's last name if different from the employee whose coverage the claim is based; and spousal employment verification. Claims Decision Timeline The Claims Administrator will evaluate your claim for benefits promptly after receiving it. Within thirty (30) days after receipt of your claim, the Claims Administrator will send you: (a) a written decision of your claim; or (b) a notice that the Claims Administrator is extending the period to decide your claim for an additional fifteen (15) days. If the extension is due to your failure to provide information necessary to decide the claim, the extended time period for deciding your claim will not begin until you provide the information or otherwise respond. Eagle County Government 33 Medical Benefits · 1/1/05 2. Submit any written comments, documents, or other information you wish to be considered to support your claim; 3. Include the name of the Employee, his or her Social Security number, the name of the patient and the Group Identification Number, if any. 4. Send written appeals to the Claims Administrator refer to the Important Telephone Numbers section for contact information details. Note: The date that an appeal is considered "filed" is the date that it is stamped "received" by the Plan's Claims Administrator. Your Rights When Requesting an Appeal of a Claims Denial 1. You may review all "Relevant Information" to the benefit claim and copies shall be provided free of charge, upon request. 2. You may review the Plan's internal rules, guidelines, and scientific or statistical research relevant to the benefit claim, upon request. 3. You may review the Plan's schedule of usual and customary fees for those health benefit claims involving a reduction in "Physician" fees, upon request. 4. The Plan must disclose the name of any medical professionals who were consulted during the claim review process, upon request. 5. No prior approval is needed to appeal benefit claims and no fees may be charged to appeal benefit claims. 6. An authorized representative may advocate or act on your behalf in pursuing or appealing a benefit claim. A written authorization, which is signed by the Plan participant or beneficiary, must be completed on a form provided by the Plan that serves to designate the authorized representative of the Plan participant or beneficiary. You may request an Authorized Representative form from the Claims Administrator. The person(s) conducting the appeal will be the Named Plan Fiduciary (NPF) and is someone other than the person who denied the claim originally. The NPF will not give deference to the initial denial decision. If the denial was based on the judgment of a "Physician," the NPF will consult with a qualified "Physician." This "Physician" will be someone other than the "Physician" who made the original judgment and will not be subordinate to that person. All written comments or other items you submit will be taken into consideration to support your claim. Upon receipt of the requested appeal, the claim shall be decided upon within a reasonable period but not later than sixty (60) calendar days, with no extensions allowed. A written determination of your claim will be sent to you. Eagle County Government 35 Medical Benefits · 1/1/05 2. In spite of the individual not being made whole by such payment. The repayment obligation will be binding upon the Covered Person (or legal representative of a minor or incompetent) whether or not: 1. The payment received from the third party, or its insurer, is the result of: a. A legal judgment; or b. An arbitration award; or c. A compromise settlement; or d. Any other arrangement; or 2. The third party, or its insurer, has admitted liability for the payment; or 3. The medical expenses or loss of earnings are itemized in the third party payment. If full repayment is not made to the Plan within sixty (60) days of settlement with a third party or their insurer, Plan participation may be suspended until such time full repayment is received. No Plan coverage will exist during such suspension other than may be available and elected under the Plan's Continuation of Health Benefits provision. The Plan's first lien rights will not be reduced due to the individual's (or legal representative of a minor or incompetent) own negligence or due to the individual's (or legal representative of a minor or incompetent) attorney fees and costs. AssiJmment of Benefits All benefits for "Expenses Incurred" will be paid to the employee unless the Claim Administrator is in receipt of an appropriately executed assignment of benefits or unless benefits are payable to a provider contracting with the Plan. The Plan shall have the right to recover from the Participant any payments or portions of payments detennined by the Plan to have been made in error or under false pretenses regardless of which party (Participant, Plan Administrator, Claims Administrator, or facility or person furnishing services) is found to have caused the error. Recoverv of Excess Pavments Whenever payments have been made in excess of the amount necessary to satisfY the provisions of this Plan, the Plan has the right to recover these excess payments from any individual, insurance company or other organization to whom the excess payments were made. Further, whenever payments have been made based on fraudulent information provided by claimants, the Plan has the right to withhold payment on future benefits for the claimant and/or any covered family members until the overpayment is recovered. Eagle County Government 37 Medical Benefits · 1/1/05 During such approved leave of absence, the employee is required to pay the applicable cost of these benefits in the amounts and at the times required by the County. For additional continuation options, please refer to the Continuation of Coverage section. Familv Medical Leave If you qualify for an approved Family or Medical Leave of Absence as defmed in the Family Medical Leave Act of 1993 (FMLA), as amended, your health benefits may continue for the duration of the leave if you pay any required contributions toward the cost of coverage. Eagle County has the responsibility to provide you with prior written notice of the terms and conditions under which payment can be made. Failure to make a payment within thirty (30) days of the due date established by Eagle County may result in the termination of your coverage. Subject to certain exceptions, if you fail to return to work after the Leave of Absence, Eagle County has the right to recover from you any contributions toward the cost of coverage made on your behalf during the leave, as outlined in the FMLA. If your coverage is terminated for failure to make payments while you are on an approved family or medical Leave of Absence (as defined in the Family Medical Leave Act of 1993), coverage for you and your eligible dependents will be automatically reinstated, without evidence of good health, on the date you return to active employment if you and your dependents are otherwise eligible under the Plan. The pre-existing condition limitation and any waiting periods will apply with credit applied for the periods of coverage immediately preceding the leave. All previously accumulated annual and "Lifetime Maximums" will apply. Qualified Medical Child Support Order rQMCSO) A QMCSO is a type of court order, usually issued as part of a settlement agreement or divorce decree, that provides for child support or health care coverage for the child of a Plan participant. The Plan will honor this QMCSO if it meets the following requirements. The court order must: 1. Create, or recognize the existence of, the child's right: a. To receive benefits for which the Plan participant is eligible under the Plan, OR b. To assign those rights; 2. Clearly specify the Plan participant's name and last known mailing address and the name and mailing address of each child covered by the court order; 3. Specify a reasonable description of the type of coverage to be provided by the Plan to each child or the manner in which the type of coverage is to be determined; and 4. Specify each Plan to which the court order applies and the period to which it applies. Eagle County Government 39 Medical Benefits . 1/1/05 DENTAL CARE BENEFITS DENTAL PLAN BENEFIT SUMMARY The Dental Care program can help you and your family pay for the regular care necessary for good Dental health. The key to the plan is the preventive care feature, which could help you to avoid costly repairs later. SERVICE TYPE ExAMPLES OF DEDUCTIBLE PLAN PATIENT COVERED SERVICES PAYS PAYS PREVENTIVE Oral exams, 100% 0% CARE diagnostic x-rays, None cleaning, fluoride treatment and sealants "Children" BASIC X-rays, fillings, $50 per person per 80% 20% SERVICES I extractions, surgery, calendar year for Basic I periodontics, and Major services denture repair, combined , anesthesia ($150 family maximum per year) MAJOR Crowns, $50 per person per 80% 20% SERVICES bridgework, calendar year for Basic dentures, inlays, and Major services gold restorations combined ($150 family maximum per year) Maximum Plan payment for Preventive, Basic and Major services combined is $1,500 per "Covered Person" per calendar year. ORTHODONTIC Orthodontic services None 50% 50% SERVICES and supplies Maximum Plan payment for Orthodontic Services is limited to $1,000 per covered "Child" or "Adult" per lifetime. Eagle County Government 41 Dental Benefits · 1/1/05 Maior Services The Plan covers 80% of the following services: 1. Gold fillings, inlays, crowns, pontics 2. Fixed bridgework 3. Full or partial dentures, and precision attachments 4. Temporomandibular joint syndrome NOTE: Gold fillings, crown restorations or implants will be considered covered expenses only when the tooth cannot be saved through other adequate forms of restoration. Orthodontics Orthodontic care is available when required for sound Dental health. Coverage is as stated in the Dental Plan Benefit Summary. Claim payments will be prorated over the course of treatment. Dental Plan Limitations and Exclusions The following services and supplies are not covered by the Dental Plan: 1. Services performed solely for cosmetic reasons. 2. Replacement of lost or stolen dental appliances. 3. Replacement of a bridge or denture within five (5) years following the date of its original installation unless: a. The replacement is needed to place an original opposing full denture or to extract natural teeth, b. The bridge or denture, while in the mouth, is damaged beyond repair as a result of "Injury" received while you are a "Covered Person" 4. Replacement at any time of a bridge or denture which is or can be made to be functional. 5. Dental appliances or restorations, other than full dentures, whose primary purpose is to alter vertical dimension, stabilize periodontic ally involved teeth, or restore occlusion. 6. Expense resulting from a work related "Accident" or "Illness" whether or not covered under workers' compensation or occupational disease laws. Eagle County Government 43 Dental Benefits . 1/1/05 only if this Plan has not been terminated prior to that date, in which event the claims are not eligible for coverage. 20. Procedures not commonly recognized by the Dental profession or American Dental Association. 21. Expenses covered under the County's Medical Plan. 22. Orthodontic services started prior to Plan participation. 23. Claims filed after any claim filing deadlines. 24. Occlusal and/or night guards for Bruxism or harmful habits. 25. Expense for self-inflicted injuries, unless the injury results from a medical condition (physical and/or mental health condition) and the expenses would otherwise be covered by the Plan. 26. Charges for education or training, such as, but not limited to, oral hygiene instructions or dietary planning for control of dental decay. GENERAL DENTAL PLAN INFORMATION Choice of Dentists The Dental Plan will cover eligible "Expenses Incurred" from any "Dentist." Pre- Treatment Review When charges for a proposed dental service, or series of dental services, for you or your family members are expected to be more than $200, you are strongly encouraged to take a pre-treatment claim form with you to the "Dentist." After you fill out the employee section of the form, your Dentist should itemize all the proposed dental services and fees. Then he or she submits the treatment plan to the Plan's Claims Administrator, before beginning the actual services. The Claims Administrator will determine the extent of benefit for each dental service, according to the terms of the Plan and will return the form to the Dentist with the covered benefit amounts listed. You and your Dentist can then discuss the proposed treatment and the costs involved. When treatment is complete, the Dentist will re-submit the claim form and payment will be as specified This procedure will help you by advising you and your Dentist, before treatment begins, of the estimated benefits which will be paid by the Plan, and what costs, if any, you will have to pay. Eagle County Government 45 Dental Benefits . 1/1/05 VISION CARE BENEFITS A vision benefit is available to Employees and their "Dependent(s)" to help pay for eye examinations, lenses, frames and contact lenses. Vision Elil!ibilitv and Effective Date Eligibility for Vision is identical as for Medical. For more information, please refer to the Eligibility and Enrollment section. Enrollment in the Medical Plan is not required to participate in the Vision Plan. Covered Services. Cooavs and Maximums Maximum Benefit The Plan will pay up to $300 per calendar year per "Covered Person" for the following services and supplies combined: 1. Eye Exams - Limited to one (1) exam per calendar year. 2. Lenses, Frames and Contact Lenses Vision Providers Covered participants may select any licensed optometrist, ophthalmologist or eyewear retailer. How to File a Vision Claim Please refer to the Claims Procedure section in the Medical portion ofthis Plan for instructions on how to file claims under "Non-Preferred" Providers. Please contact Human Resources for the appropriate claim form. LimuauonsandExdu~ons The Vision Plan covers "Usual, Reasonable and Customary Charges" for services and supplies that are "Medically Necessary." Eagle County Government 47 Vision Benefits . 1/1/05 EAGLE..PLIJS.BENEFITS In the ongoing process of creating the County's Employee Benefits Program, many complex issues are taken into consideration. Benefits must be designed to meet the individual personal needs of employees and be affordable for both employees and the County. One of the unique ways the County has chosen to meet these objectives is to create an Eagle Plus benefit that allows you the flexibility to choose from among a variety of benefits to best meet your particular needs. You may find the process of making these benefit choices new and different and we urge you to carefully review the terms of each option and be sure to select a choice that will work best for you. Please refer any questions that you might have to the Eagle County Human Resources Department. Your Eagle Plus benefit choices are described in this booklet using the following structure: 1. Benefit Summary - Summarizes the principal elements of each option. 2. Eagle Plus General Information - Outlines rules and procedures unique to the Eagle Plus Benefit. 3. Plan Option Details - Particular rules that apply to each part of the Eagle Plus Benefit. 4. Claims Procedures The Eagle Plus Benefits are part of the self-funded Medicai Cafeteria Plan and it is important to all employees that the Plan be used properly. All Plan participants can help control current and future Health Plan costs. To ensure that quality health care is provided, discuss your needs candidly with your health care specialists. Remind them that you expect quality and cost effective services. Eagle County Government 49 Eagle Plus . 1/1/05 EAGLE PLUS PLAN GENERAL INFORMATION Eliflibilitv for Ea1l1e Plus Choices The following "Employees" are eligible to participate in the Eagle Plus benefit: 1. Employees who participate in Eagle County's Mid Copay Medical Plan; or 2. Employees eligible to participate in any Eagle County Medical Plan who decline medical coverage. The chosen options will apply to each employee and where applicable, to the employee's participating "Dependents." If both an employee and spouse work for the County and are both eligible for benefits, Eagle Plus benefits will follow the "Employee" that elects Medical Plan coverage. If both Employees elect separate medical coverage, Eagle Plus benefits follow those elections. Makinll and Chanllinf! Your Eaf!le Plus Elections Voluntary changes in your existing Eagle Plus elections may be made as of each successive January 1st. Written election to change must be on file with Human Resources prior to each January 1st. Unless a change request is received, the existing Health Plan election will be continued for the following year. If you do not make an election, enrollment will be made in the following order to the extent benefits are available: 1. Premium Reimbursement 2. Unreimbursed Health Benefits EaJ!le Plus - J/aximum Plan Benefit Eagle County determines the contribution to Eagle Plus on a year-to-year basis. Contact Human Resources to obtain the amount of the current maximum benefit per calendar year for each employee and his or her eligible "Dependents," if any. An additional amount per calendar year is provided when Medical Plan coverage is declined. This additional amount is available only during periods of active employment at Eagle County Government. Persons with an employment date after January 1st are eligible for a prorated maximum benefit, based on date of employment. For example, if a person is eligible on July 1st, his/her maximum Eagle Plus benefit for that year is 6/12, or one-half of the annual Plan benefit. The available benefit is determined at the beginning of each calendar year based on Plan elections at that time and is not affected by subsequent allowed Plan changes later in that year. Eagle County Government 51 Eagle Plus . 1/1/05 e. Care is not for the purpose of allowing the parent to work full-time or go to school full-time. f. The dependent "Child" is over age 12. 6. That part of any expense paid by other insurance or reimbursement plan, 7. Expenses not allowed under Internal Revenue Service regulations or guidelines including, but not limited to, Code Sections 105(b), 105(h) and 129, 8. Claims filed after the claim filing deadline, 9. Expenses incurred while you were not a "Covered Person" under the terms of this Plan. Health Plan Premium Reimbursement Eagle County's Medical, Dental and Vision Plans may require contributions from employees who wish to enroll themselves and/or their "Dependents" in those Plans. If you desire, Eagle Plus Benefits may be used to pay those required contributions. For example, if your Plan payroll deductions are $300/year, you could elect to have all or part of the $300 paid from your Eagle Plus Plan. This will be administered over the calendar year. For example, if your normal annual contributions are $300 and you commit $150 of Eagle Plus towards the $300, your regular pay deduction will be 50% of the normal amount each pay day. Once the election is made, it cannot be changed until the next Eagle Plus Plan election effective for the following year. Also, if employment terminates or you drop coverage, no refund is available. Deferred Compensation Plan Subject to current Deferred Compensation Plan rules and IRS rules, you may designate that some, or all, of your Eagle Plus Plan Benefit be directed to Eagle County's Deferred Compensation Plan. This election has the effect of both saving for the future and deferring Federal and State income taxes on both the contributions and any Plan earnings. This election will be implemented over the calendar year. For example, if you elect to contribute $400 per year, 1/26th or $15.38 will be deposited to your chosen Deferred Compensation investment at the end of each of 26 payroll periods during the year. Should your employment and/or eligibility for this Benefit stop during the year, contributions will cease as of the end of your last payroll period. Contributions will be 100% of your elected amount; however, deductions for employee Social Security will be made and the remainder will be credited to your Deferred Compensation Plan. Current IRS deferred compensation contribution limits are 25% of payor $8,000, whichever is less. It is your responsibility to be sure that all applicable IRS rules are met. Eagle County Government 53 Eagle Plus · 1/1/05 Claims Filinf! Deadline All Eagle Plus claims must be filed within three (3) months of the close of the Calendar Year in which services were provided. Claims filed after that date will not be paid. General Information Should employment and/or eligibility for these options stop before you have received the full benefit, you may submit expenses for eligible services only if they were provided during your participation. Eagle County Government 55 Eagle Plus . 1/1/05 OualitVinll Events COBRA must be offered to each person who is a "Qualified Beneficiary" (QB). A QB is someone who will lose coverage under the Plan as a result of a qualifying event (QE). Depending on the type of QE, employees, spouses of employees, and dependent children of employees enrolled in the Plan may be QBs. The Plan coverage offered under COBRA must be the same as that offered to other active (non-COBRA) participants under the Plan who are not receiving COBRA coverage. Furthermore, each QB who elects COBRA will have the same rights under the Plan as active participants. If you are an Employee, you may become a Qualified Beneficiary if you lose your coverage under the Plan because either one of the following Qualifying Events occur: 1. Your hours of employment are reduced below that of a benefit-eligible class, or 2. Your employment ends for any reason other than your "Gross Misconduct." If you are the spouse of an employee, you may become a Qualified Beneficiary if you would lose your coverage under the Plan because any of the following Qualifying Events occur: 1. Your spouse dies; 2. Your spouse's hours of employment are reduced below that of a benefit-eligible class; 3. Your spouse's employment ends for any reason other than his or her "Gross Misconduct;" 4. Your spouse becomes entitled to (enrolled in) "Medicare"; or 5. You become divorced or legally separated from your spouse. Your "Dependent" Child(ren) may become Qualified Beneficiaries if they lose coverage under the Plan because any of the following Qualifying Events happens: 1. The parent-employee dies; 2. The parent-employee' s hours of employment are reduced below that of a benefit-eligible class; 3. The parent-employee's employment ends for any reason other than his or her "Gross Misconduct; " 4. The parent-employee becomes entitled to (enrolled in) "Medicare"; 5. The parents become divorced or legally separated; or 6. The child stops being eligible for coverage under this Plan as a "Dependent Child." Eagle County Government 57 Continuation of Coverage . 1/1/05 Written Notice Guidelines All written notices you are required to submit to the Plan's COBRA Notification Contact must contain the following information: 1. The name of the Plan for which you are (were) enrolled; 2. The name and address of the employee or former employee who is or was covered under the Plan; 3. The name( s) and address( es) of all qualified beneficiary( ies) who lost coverage due to the qualifying event/disability/second qualifying event; 4. The signature of the individual sending the notice. In addition to the above, the following information must be included (depending on which type of notification you are submitting): Qualifying Event Notice: 1. A description of the Qualifying Event that has occurred (Notices due to divorce or legal separation require a copy of the page from the court documents reflecting the effective date, court officials signature and seal). '"' The date of the Qualifying Event. L.. Disability Extension Notice (or cessations of Disability status): 1. A description of the Qualifying Event for which you initially became eligible for COBRA coverage; 2. The date the covered employee's termination of employment or reduction of hours occurred; 3. The name and address of the disabled Qualified Beneficiary; 4. The date the Qualified Beneficiary became disabled (according to the Social Security Administration's determination); 5. A copy of the Social Security Administration's determination of disability; and 6. A statement as to whether or not the Social Security Administration has subsequently determined that the qualified beneficiary is no longer disabled. Second Qualifying Event Notice (Please see ;l1aximum Periods of Coverage section): 1. A description of the Qualifying Event for which you initially became eligible for COBRA coverage; 2. The date the covered employee's termination of employment or reduction of hours occurred; 3. A description of what is the second Qualifying Event; Eagle County Government 59 Continuation of Coverage . 1/1/05 To elect COBRA coverage, the Election Form you receive from the PCNC must be completed and submitted (mailed or hand-delivered) to the PCNC within the sixty (60) day period. Oral communications regarding CO BRA coverage (including in-person or telephone statements about an individual's COBRA coverage) will not be accepted as electing COBRA and will not preserve your COBRA rights. NOTE: If you decline COBRA before the due date to elect, you may change your mind as long as you furnish a completed Election form to the PCNC before the expiration of the sixty (60) day period. When on an approved FMLA Leave of Absence If an Employee is out on an approved FMLA leave of absence and does not return to work at the end of such leave, the employee (and the employee's spouse and dependent children, if enrolled in the Plan) may be entitled to elect COBRA if 1) he/she was covered under the plan on the day before the FMLA leave began and 2) he/she will lose Plan coverage within 18 months because of the employee's failure to return to work at the end of an FMLA leave (even if they were not covered under the Plan during the leave of absence). COBRA coverage elected in these circumstances will begin on the last day of the FMLA leave, with the same 18-month maximum coverage period generally applicable to the COBRA qualifying events of termination of employment and reduction of hours. Tvpe of Coveraf!e Ordinarily the continuation coverage that is offered will be the same coverage that you, your spouse or dependent children had on the day before the qualifying event. Therefore, an employee, spouse of' dependent child who is not covered under the Plan on the day before the qualifying event generally is not entitled to COBRA coverage except, for example, when there is no coverage because it was eliminated in anticipation of a qualifying event such as divorce. If the health coverage is modified (copay or deductible changes, for example) for similarly-situated (actively working) employees or their spouses or dependent children, then COBRA health coverage will be modified in the same way. Monthlv COBRA Premiums That You Must Pav [Note: "Premium(s)" shall mean an amount calculated to determine contributions necessary to fund the Plan. It does not mean that benefits are provided by an insurance company.] Once you, your spouse or dependent children elect COBRA continuation coverage, each has the right to continue the coverage subject to timely payment of the required premiums. Unless the full premium for continuation coverage is paid on a timely basis, you, your covered spouse and dependent children will lose your rights under COBRA. MontWy COBRA premiums will include a 2% add-on to cover administrative expenses. In the case of a disability extension, there may be a 50% add-on for the disability extension period (months 19 Eagle County Government 61 Continuation of Coverage · 1/1/05 36 Months. If you (the spouse or dependent child) lose group health coverage because of the employee's death, divorce, legal separation, or the employee's becoming entitled to Medicare, or because you lose your status as a dependent child under the Plan, then the maximum coverage period (for the spouse and dependent child) is three years (thirty-six months) from the date of the qualifying event. 18 Months. If you (the employee, spouse or dependent child) lose group health coverage because of the employee's termination of employment (other than for gross misconduct) or reduction in hours, than the maximum continuation coverage period (for the employee, spouse and dependent child) is eighteen (18) months from the date of termination or reduction in hours. There are three exceptions: 1. Disability. If an employee or spouse/dependent child who is covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan's COBRA Notification Contact in a timely fashion, you and your entire family may be entitled to receive up to an additiona111 months of COBRA continuation coverage, for a total maximum of29 months (from the date of termination or reduction in hours). The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. For the 29-month continuation coverage period to apply, written notice must be provided to the PCNC within sixty (60) days of the Social Security determination of disability and prior to the end of your 18-month period of COBRA coverage. Refer to the Written Notice Guidelines sub-section described in this section for details and notification due dates. If a disabled qualified beneficiary is determined by the Social Security Administration to no longer be disabled, you must notify the PCNC of that fact within thirty (30) days after the Social Security Administration's determination. ') Second Qualifying Event. If an employee's spouse or dependent child(ren) experience .... another Qualifying Event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children may get up to 18 additional months of COBRA continuation coverage (or 29-month coverage period), for a maximum of36 months from the date of the initial termination or reduction in hours, ifnotice ofthe second qualifying event is properly and timely provided to the PCNC. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only ifthe event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. For the 36-month maximum coverage period to apply, written notice of the second qualifying event must be provided to the PCNC within 60 days after the later of I) Eagle County Government 63 Continuation of Coverage . 1/1/05 Claims Recoverv If, for whatever reason, any qualified beneficiary receives any medical benefits under the Plan during a month for which the premium was not timely paid, you and any qualified beneficiary will be required to reimburse the Plan for the benefits received. Alternate Recioients Under OMCSOs A child of yours (the employee's) who is receiving benefits under the Plan pursuant to a Qualified Medical Child Support Order (QMCSO) received by the PCNC during your (the employee's) period of employment is entitled to the same rights to elect COBRA as a dependent child of yours, regardless of whether that child would otherwise be considered your dependent. Termination of COBRA Covera1!e Before the End of the Maximum Covera1!e Period Continuation coverage of the employee, spouse and/or dependent child will automatically terminate (before the end of the maximum coverage period) when anyone of the following six (6) events occurs: 1. Eagle County Government no longer provides group health coverage to any of its employees; 2. The premium for the qualified beneficiary's COBRA coverage is not timely paid; 3. After electing COBRA, you (the employee, spouse or dependent child) become covered under another group health plan (as an employee or otherwise) that has no exclusion or limitation with respect to any preexisting condition that you have. If the other plan has applicable exclusions or limitations, then your COBRA coverage will terminate after the exclusion or limitation no longer applies (for example, after a 12-month preexisting condition waiting period expires). This rule applies only to the qualified beneficiary who becomes covered by another group health plan. (Note that under HIP AA, an exclusion or limitation of the other group health plan might not apply to the qualified beneficiary, depending on the length of his or her creditable health plan coverage prior to enrolling in the other group health plan). 4. After electing COBRA coverage, you (the employee, spouse or dependent child) become entitled to Medicare benefits (Part A and/or Part B). This applies only to the person who becomes entitled to Medicare. 5. You (the employee, spouse or dependent child) became entitled to a 29-month maximum coverage period due to disability of a qualified beneficiary, but then there is a final determination under Title II or XVI of the Social Security Act that the qualified beneficiary is no longer disabled (however, continuation coverage will not end until the month that begins more than 30 days after the determination). Eagle County Government 65 Continuation of Coverage · 1/1/05 An employer is not required to reemploy a returning service member if the employer's circumstances have so changed as to make such reemployment impossible or unreasonable or if the reemployment would impose an undue hardship on the employer. Your Rif!hts Under USERRA The "Covered Person" must pay for USERRA coverage. For periods of up to 30 days of training or service, the employer can require the person to pay only the normal employee share, ifany, of the cost of such coverage for the employee or for dependents. For longer periods of service, the employer is permitted to charge 102% of the entire premium. Upon re-employment, the Plan may not impose a waiting period or any exclusion that would not have been applied had the employee not left employment for military service. However, the Plan may still have exclusions for service-related "Injuries" or "Illness." Basic Requirements The pre-service employer must reemploy service employees returning from a period of active duty if the "Employee" meets the following five criteria: 1. The "Employee" must have held a civilian job; 2. The "Employee" must have given adequate oral or written notice in advance of the employee's departure if possible, to the employer that he or she was leaving the job for service in the uniformed services. 3. The single or cumulative period of uniform service must not have exceeded five years; 4. The "Employee" must not have been released from service under dishonorable or other punitive conditions; and 5. The "Employee" must have reported back to the civilian job in a timely manner or have submitted a timely application for reemployment. Emolovee Restoration Rif!hts The time limits for returning to work are as follows: 1. One to 30 days: The person must report to his or her employer by the beginning of the first regularly scheduled work day taking into account reasonable travel time and an eight-hour rest period. 2. 31 to 180 days: The employee must apply for reemployment no later than 14 days after completion of military service. Eagle County Government 67 Continuation of Coverage · 1/1/05 HEALTH INSURANCE. PORTABILITY AND 4CCOUNrABILITY4~IO:Fl99'...(BIPAA.) Certificate of Creditable Coverage - Title I If coverage terminates under this plan, a certificate of creditable coverage will be provided containing information as specified in the model HIP AA certificate. Do not lose this certificate. It can be used to document your period of coverage in this Plan for future enrollment in plans that are subject to HIP AA. In addition, a certificate of creditable coverage may be requested from the Plan Administrator any time within two (2) years after coverage ends. Protected Health Information - HIP AA Privacy - Title II Notwithstanding any other Plan provision, effective as ofthe effective date of the regulations, to the extent the Plan is a group health plan subject to the privacy regulations, the Plan will operate in accordance with the requirements of the Health Insurance Portability and Accountability Act of 1996 and its medical privacy regulations at 45 C.F.R., Parts 160-164, with respect to "Protected Health Information" (PHI), as defmed therein. The Plan Administrator, or its delegate, retains full discretion in interpreting these rules and applying them to specific situations. All such decisions shall be given full deference unless the decision is determined to be arbitrary and capricious HIP AA Privacy sets forth rules which govern and limit the use and disclosure of PHI. The objectives of the rules are to: 1. Give patients the right to access their medical records; 2. Restricts most disclosure of PHI to the minimum necessary for the intended purpose; and 3. Establish safeguards and restrictions regarding disclosure of records for certain public responsibilities, such as public health, research and law enforcement. PERMITTED USES AND DISCLOSURES FROM THE PLAN To THE PLAN SPONSOR: The Plan is permitted to use and disclose PHI for the following purposes, to the extent they are not inconsistent with HIP AA: 1. For Plan administrative functions related to treatment, payment, or health care operations without participant authorization; 2. Pursuant to a valid authorization signed by the individual (or authorized representative) to whom the PHI pertains; 3. Directly to the individual to whom the PHI pertains; 4. For judicial and administrative proceedings, in response to lawfully executed process, such as a court order or subpoena; Eagle County Government 69 HIPAA · 1/1/05 PRIV ACY RULE The Plan Sponsor agrees that with respect to any PHI disclosed to it by the Plan, Plan Sponsor shall: 1. Not use or further disclose PHI other than as permitted or required by the Plan or by law; 2. Ensure that any agent, including a subcontractor, to whom it provides PHI received from the Plan agrees to the same restrictions and conditions that apply to the Plan Sponsor with respect to PHI; 3. Not use of disclose the PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the Plan Sponsor; 4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for, of which it becomes aware; 5. Ensure that the adequate separation between Plan and Plan Sponsor required in accordance with HIP AA. 6. Make available the information required to provide an accounting of disclosures in accordance with HIP AA; 7. Make PHI available to Plan Participants for the purposes of the rights of access and inspection in accordance with HIP AA; 8. Make PHI for amendment, and incorporate any amendments to PHI in accordance with HIP AA; 9. Make internal practices, books, and records relating to the use and disclosure of PHI available to the Secretary of the U.S. Department of Health and Human Services (HHS) upon request and 10. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and will retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible. Eagle County Government 71 HIPAA · 1/1/05 5. Is primarily engaged in providing continuous skilled nursing care for sick or injured persons during the convalescent stage of their illness or injuries and is not, other than incidentally a rest home or a home for custodial care or for the aged, and; 6. Is operating lawfully as a nursing home in the jurisdiction where it is located; in no event, however, in the care and treatment of drug addicts or alcoholism. "Covered Person" shall mean an employee, Medicare recipient, or a dependent who has met the eligibility requirements and to whom benefits are payable under this Plan. "Dentist" shall mean a person duly licensed to practice dentistry by the governmental authority having jurisdiction over the licensing and practice of dentistry in the locality where the service is rendered. "Dependent" shall mean: 1. The employee's lawful spouse. Common law marriages must be attested to by submission of a signed, notarized affidavit to Eagle County Government. 2. The employee's Children from birth to the end of the calendar year during which age 19 is reached. 3. The employee's unmarried dependent children to the end of the calendar year during which age 24 is reached if they attend an accredited or licensed educational institution as a full-time student (as defined by the institution) and depends upon the covered person for support and maintenance. Proof of full-time student status must be provided to the Claims Administrator as requested. a. Vacation breaks scheduled by the school do not jeopardize a dependent child's full-time student status. However, if a dependent child is not attending as a full- time student during the semester following the break, that dependent child will no longer be considered a dependent under the Plan. Coverage will terminate at the end ofthe Calendar Year in which dependent attended an accredited or licensed educational institution as a full-time student. b. A previously ineligible dependent child who becomes an attending full-time student at an educational institution at a later date, may be enrolled under the Plan as a new dependent within thirty (30) days of the date the semester begins. Proof of attendance as a full-time student from the registrar of the educational institution must be provided to the Plan within the thirty (30) day period for coverage to become effective on the first day of the month in which classes start. 4. Any person who is covered as an employee shall not be considered a dependent, and no person shall be considered as a dependent of more than one employee. Eagle County Government 73 Definitions · 1/1/05 d. Response to therapy is usually of short duration. e. It is unclear whether the overall survival is improved or shortened. f. There is significant risk involved as compared to standard therapy. g. Procedures are performed in selected hospitals under Experimental research protocols. The Plan Administrator in its sole discretion shall determine if a drug, medicine, treatment, procedure, service, device or supply is Experimental. The Plan Administrator may employ the services of such medical peer review service organizations as the Medical Review Institute or UMAC and utilize data obtained from such national assessment organizations as HCF A, the Office of Health Technology Assessment and Institutes of the Department of Health and Human Services to aid in its determination. "Gross Misconduct" shall mean conduct characterized by: 1. Willful or wanton disregard of Eagle County's interests; 2. Deliberate violations or disregard of standards of behavior that Eagle County has the right to expect of an employee; 3. Carelessness or negligence of such degree or recurrence as to indicate evil design or wrongful intent on the part of the employee. "IDP AA Enrollment Date" shall mean the date you first begin your waiting period, if any, required by this Plan. "Hospice" shall mean a facility which provides short periods of stay for a terminally ill person in a home-like setting, or visits terminally ill individuals in their homes, for either direct care or respite. The facility may be either free-standing, or affiliated with a hospital and must operate as an integral part of the Hospice Care Program. "Hospital" shall mean an instituti<;m which is engaged primarily in providing medical care and treatment of sick and injured persons on an in-patient basis at the patient's expense and which fully meets all of the tests set forth in a, b or c below: 1. It is a hospital accredited by the Joint Commission on Accreditation of Hospitals. 2. It is a hospital, a psychiatric hospital, or a tuberculosis hospital, as those terms are defined in Medicare, which is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare. 3. It is an institution which fully meets all of the tests: Eagle County Government 75 Definitions . 1/1/05 "Medicare" shall mean Federal Insurance or assistance such as provided by the Health Insurance for the aged Act (42 D.S.C. Section 1395-1395pp), or as such Act may be amended. "Mental Health" shall mean neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder. "Morbid Obesity" shall mean a condition in which all of the following are present: 1. the presence of excess weight causes physical trauma; 2. pulmonary and circulatory insufficiencies are present; 3. complications related to the treatment of conditions such as arteriosclerosis, diabetes, coronary disease, etc., exist; and 4. the person is fifty percent (50%) or one hundred (100) pounds overweight. "No-Fault Benefits" means the minimum level of personal injury benefits which state law requires to be offered under automobile insurance policies and which would be paid, regardless of fault, if claim had been made for such benefits. "Non-Preferred" providers shall mean physicians, hospitals and other medical care providers who are not contracted with the Plan's Preferred Provider Network and/or as determined by the Plan to be Non-Preferred providers. "Outpatient" shall mean a Covered Person who is treated in a hospital but is not confmed for the Room and Board charge. "Physician" shall mean a person acting within the scope of his license and holding the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (D.O.), Doctor of Chiropractic (D.C.), or a Psychologist (Ph.D.). In addition, Physician shall include licensed behavioral health therapists who practice within the scope of their license, as allowed by law, and as such are permitted to provide services without the direct supervision of a Doctor of Medicine (M.D.) "Plan" shall mean the plan of benefits detailed in the Plan Document. "Plan Administrator" shall mean the employer sponsoring and administrating benefit plan. "Plan Document" shall mean the Plan Document detailing the plan of benefits. "Plan Sponsor" shall mean Employer/Plan Administrator. "Pre-Existing Condition" shall mean any injury or sickness for which, in the three (3) month period immediately preceding your "HIP AA Enrollment Date," medical advice, diagnosis, care or Eagle County Government 77 Definitions . 1/1/05 "Room and Board" shall mean room, board, general duty nursing and any other services regularly furnished by the hospital as a condition of occupancy of the class of accommodations occupied, but not including professional services of a Physician nor intensive care by whatever name called. "Salary Reduction" shall mean an employer-sponsored arrangement in which employees may elect to have some portion of their salaries be contributed to a tax-qualified plan on their behalf. "Security Incident" shall mean the attempt or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with systems operations in an information system as set forth in 45 C.F.R section 164.304, as amended from time to time. "Sickness" shall mean an Illness or a disease. Sickness will include congenital defects or birth abnormalities. "Substance Abuse" shall mean the use of a potentially impairing substance to the point that it adversely affects performance or safety, either directly through intoxication or hangover, or indirectly through social or health problems. Substance abuse is considered to occur when a drug is taken without medical reasons, or if a substance impairs or jeopardizes the health or safety of oneself or others. Abuse can occur by using a substance too much, too often, for the wrong reasons, at the wrong time, or at the wrong place. The range of substances that are abused is wide and can include alcohol, cocaine (including crack), marijuana, other illicit drugs, solvents, and misuse of prescription drugs or over-the-counter medications. "Surgery" shall mean any operative (cutting) procedures and the treatment of diseases or injuries including the necessary treatment of fractures and dislocations, severe sprains, and casting thereof, but not including simple sprains or bruises. "Usual, Reasonable and Customary Charge" shall mean the usual charge for a Like Service or Like Supply (if a plan of benefits were not involved), which is not more than what is generally charged in a given geographic service Area for like service or supply by most physicians or providers of service with similar training and experience. 1. A Like Service is the same nature and duration, requires the same skill and is performed by a provider of similar training and experience. 2. A Like Supply is one that is identical or substantially equivalent. 3. Area means the municipality in which the service or supply is actually provided, or it may be as great an area as is necessary to obtain a representative cross section of charges for a like service or supply. "Wellcare" shall mean physical exams and related tests for preventive health care and wellchecks for children, including normal immunizations. Eagle County Government 79 Definitions . 1/1/05 Air travel coverage is limited. It only applies while you are riding as a passenger, and not as a pilot or crew member on a military air transport aircraft or on any civil aircraft. Injuries resulting from an accident which occurs while the Covered Person is on, boarding or alighting from and aircraft engaged in an Extra-Hazardous Aviation Activity or an aircraft owned or operated by either you or by Eagle County. Commuting travel is not covered. The terms Injury, Business Trip and Trip are defined by the insured policy as: Iniurv means, and an Insured Person is covered for, bodily injury resulting directly and independently of all other causes from accident which occurs: 1. while he or she is covered under; 2. and in the manner specified in; 3. a Hazard applicable to his or her class. Business Trip means a bond fide trip: 1. while on assignment or at the direction of the Policyholder for the purpose of furthering the business of the Policyholder; 2. which begins when a person leaves his or her residence or place of regular employment, whichever last occurs, for the purpose of beginning the trip; 3. which ends when he or she returns to his or her residence or place of regular employment, whichever first occurs; and 4. excluding any travel to and from work; bona fide leave of absence and vacations. Trip means a trip which: 1. begins when a person leaves his or her residence or place of regular employment, whichever first occurs, for the purpose of beginning the trip; and 2. ends when he or she returns to his or her residence or place of regular employment, whichever first occurs. Elif!ibilitv You are eligible if you are an active, full-time employee or commissioner working your regular scheduled workweek of at least 30 hours per and are regularly employed by the Policyholder in the course of their business. Coverage will be effective on the first (1 st) of the month coincident with or next following your date of employment. Eagle County Government 81 Survivor Benefits · 1/1/05 The amount for each person will be proportionately reduced so that the total will equal the Aggregate Amount. Benefit Reductions The Travel Accident Death and Dismemberment (AD&D) benefit will reduce as shown in the following Table: Attainment of Age: AD&D Benefit reduced to: 70-74 65% of the benefit 75-79 45% of the benefit 80-84 30% of the benefit 85 or over 15% of the benefit The reductions take place on the date of the Insured Person's attainment of ages 70, 75, 80, and 85. You may not increase coverage after age 70. Claim Filinf! and Proof of Loss The person who has the right to claim benefits (the employee or beneficiary, or his/her representative) must file a written notice of a claim within thirty (30) days after a covered loss begins. If notice cannot be given within that time, it must be given as soon as reasonably possible. Proof of loss must be submitted in writing to the insurance carrier (refer to the Summary Plan Description section for details) within ninety (90) days after: 1. the end of a period of our liability for periodic payment claims; or 2. the state of the loss for all other claims. The notice should include the Insured Person's name and the policy number. For more information on filing a claim, contact Human Resources. Exclusions This Policy does not cover any loss resulting from: 1. intentionally self inflicted injury, suicide or attempted suicide, while sane; 2. war or act of war, whether declared or undeclared; 3. Injury sustained while in the armed forces of any country or international authority; 4. Injury sustained while on any aircraft, unless, and only to the extent, a Hazard specifically describes such coverage; Eagle County Government 83 Survivor Benefits . 1/1/05 BASIC GROUP LIFE INSURANCE NOTE: The following information is onlv a summary of a Contract through which these benefits are provided. You may request a Certificate of Coverage free of charge for additional information. Should the wording of this summary and the Contract disagree, the Contract wording will govern. Your family's current standard of living could be greatly altered if you were to die prematurely without any life insurance. In the event of your untimely death, the Basic Life Insurance Plan provides your survivors with some fmancial security. EliJdbilitv Regular Full-Time employees working at least 30 hours a week and elected officials are eligible for coverage. Coverage will be effective on the fIrst of the month coincident with or next following your date of employment. Coveralle Life Insurance benefIts for those eligible is $50,000 and Accidental Death and Dismemberment (AD&D) benefits is $50,000. Your coverage will be reduced at age 65 by 35%, age 70 by 55%, age 75 by 70% of the pre-65 coverage amount. The reduction will be made on the day you attain the specifIed age. The coverage will terminate at retirement. If You Are Disabled If you become totally and permanently disabled as a result of sickness or injury before age 60, your Life Insurance may continue. The disability application period is the nine consecutive months of total disability beginning on the date you first become totally disabled. After receiving written notifIcation of your disability, an Initial Proof of Disability form will be sent to you for your physician to complete. You must return this form to the insurance company within ninety (90) days after receipt. When approved, premium payments will be waived for at least one year as long as you continue to be disabled. Re-approval must be obtained for each subsequent year, but in no event will exceed age 65. When Coveralle Ends Your life insurance will end at midnight at the main office of the Policyholder on the earliest of: 1. The date this insurance policy ends; 2. The day any premium contribution for Your insurance is due and unpaid; Eagle County Government 85 Survivor Benefits . 1/1/05 Beneficiarv Desilmation If you die while insured under this provision, we will pay the Amount of Life Insurance shown in the Schedule. Benefits will be paid to the beneficiary you name. If you do not name a beneficiary or if no beneficiary survives you, benefits will be paid: 1. to your surviving spouse; if none, then 2. to your surviving natural and/or adopted children; if none, then 3. to your surviving parent(s); ifnone, then 4. to your estate. Benefits will be paid equally among surviving children or surviving parents. To request a Beneficiary form, contact Human Resources. Le1!al Action No action can be brought until at least sixty (60) days after the insurance company has been given written proof ofloss. No legal action can be brought more than three (3) years after the date written proof of loss is required. GROUP ACCIDENTAL DEATH AND DISMEMBERl\tlENT (AD&D) INSURANCE NOTE: The following information is onlv a summary of a Contract through which these benefits are provided. You may request a Certificate of Coverage free of charge for additional information. Should the wording of this summary and the Contract disagree, the Contract wording will govern. If as the direct result of an accident within 365 of an accident, your survivors may receive a single sum payment under the provisions ofthe AD&D Plan. If you are seriously injured in an accident, the Plan also may provide a single sum benefit payment. Accident is defmed for these purposes to mean a sudden, unexpected and unintended event, independent of sickness and all other causes. Accident does not include sickness, disease, bodily or mental infirmity or medical or surgical treatment thereof, bacterial or viral infection, regardless of how contracted. Accident does include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. Eli1!ihilitv Coverage starts at the same time your Basic Life Insurance coverage begins. Eagle County Government 87 Survivor Benefits . 1/1/05 6. caused by You and as a result of injuries Yon receive, while under the influence of any controlled drug, unless administered on the advice of a physician; 7. is caused by Yon, and is a result of injuries You receive, while Intoxicated. 8. results from injuries You receive in any aircraft other than while riding as a passenger in a commercial aircraft on a regularly scheduled flight; or while: a. operating; b. riding as a passenger in; or c. boarding or leaving: an aircraft while You are Traveling on Business of the Policyholder, provided the aircraft: a. has a current and valid FAA (Federal Aviation Administration of the United States) standard air worthiness certificate; and b. is operated by a person holding a current and valid FAA pilot's certificate of rating authorizing him or her to operate the aircraft; 9. is excluded under the General Exclusions and Limitations section outlined in the insurance policy, which include: a. any loss which results, whether the insured person is sane or insane, from and intentionally self-inflicted injury or sickness, or suicide or attempted suicide; b. any loss which resulting from the insured person's participation in a riot or in the commission of a felony; c. any loss which results from an act of declared or undeclared war or armed aggreSSIOn; or d. any loss which is incurred while the insured person is on active duty or training in the Armed Forces, National Guard or Reserves of any state or country; and for which any governmental body or its agencies are liable. Filinl! an AD&D Insurance Claim Please refer to the Basic Group Life Insurance section for details. Beneficiarv DesiI!nation Please refer to the Basic Group Life Insurance section for details. LeI!al Action Please refer to the Basic Group Life Insurance section for details Eagle County Government 89 Survivor Benefits · 1/1/05 first eligible. Additional amounts of coverage over the maximum guarantee issue amount of$30,000 may be available if the application for coverage, which is medically underwritten, is approved by the insurance carrier. Please refer to the Coverage section below for further details regarding additional coverage options. For eligible dependent children, a guarantee issue amount of$lO,OOO is available. CoveraJ!e You and your spouse may elect from $10,000 to $300,000 of life insurance, available in $10,000 increments, not to exceed five (5) times your basic annual salary. Your spouse may apply for an amount higher or lower than your elected amount and may apply even if you do not. If you elect insurance for your dependent children, each will be insured for the same amount of insurance for the same price, regardless of how many children you have. Benefit Reduction If you are under age 70 on the effective date of your insurance, your amount of insurance will be reduced by 50% at age 70. Life insurance for your spouse will end at age 70. Monthly Premium for Employees and Spouses Premiums depend on your age. As you or your spouse enter a higher age bracket, the premium is adjusted accordingly. Please contact Eagle County Human Resources for the most current information on your cost for voluntary life insurance. Accelerated Death Benefits An accelerated death benefit allows the certificate holder who is an employee or spouse under the age of 70 to use the death benefit while still alive if that individual has a terminal illness. The insured person must provide proof of a terminal illness which is defined as "a medical condition expected to result in the insured person's death within six months and from which the insured person is not expected to recover." There is a l80-consecutive-day waiting period beginning on the date a person's insurance takes effect. The accelerated benefit amount will be discounted to reflect the cost of providing the benefit. The minimum accelerated death benefit will be $10,000, less the discount. The maximum accelerated death benefit will be 50% of the insured's life insurance amount, less the discount or $250,000 less the discount, whichever is less. An accelerated benefit will be paid only once and in one lump sum. After an accelerated benefit has been paid, the insured person's amount of life insurance will be reduced by the amount of the accelerated benefit, plus the discount. Eagle County Government 91 Survivor Benefits . 1/1/05 applying for insurance. You will be notified of the approval of your application for insurance and receive a certificate describing the coverage in detail. VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE NOTE: The following information is onlv a summary of a Contract through which these benefits are provided. You may request a Certificate of Coverage free of charge for additional information Should the wording of this summary and the Contract disagree, the Contract wording will govern. If you should die or suffer the loss of sight, hand or foot as a result of an injury caused by an accident, due to proof of such loss must be sent to United States Life. The accident must happen while you are insured and the loss must occur within 90 days after the date of that accident. When the proof is received, United States Life will pay the benefit amounts described below. Eligible employees, spouses and elected officials may enroll in the Voluntary AD&D plan without enrolling in the Voluntary Life plan. Elif!ihilitv Yau are eligible if you are an active employee working your regular scheduled workweek of at least 30 hours per week or are an elected official. Elected officials are eligible without regard to hours worked. Your spouse is eligible if he or she is under age 70. You may apply for coverage to be effective no earlier than the first day of the month coincident with or next following your date of employment. Your dependent "Children" are eligible if they are over 14 days of age and under 21 years of age. Children who are full-time students, wholly dependent upon you for support, are eligible up to age 25. Effective Date of V oluntarv AD&D Coveraf!e You must request coverage for yourself and your spouse in writing by completing an enrollment form. Upon written approval from the policy carrier, you will be insured on the first day of the month in which payroll deductions are made for the premiums. Guaranteed Issue The guarantee issue amount for this coverage, if applied for when first eligible, is from $10,000 to $300,000, available in $10,000 increments, but not to exceed five (5) times your basic annual salary. Eagle County Government 93 Survivor Benefits . 1/1/05 6. a bacterial infection, unless the infection occurs in an accidental cut or wound; 7. intentionally self-inflicted injury; 8. active military duty in the service of any country; 9. committing a crime, or an attempt to do so; 10. being intoxicated or under the influence of any drug, unless taken as prescribed by a physician; 11. flight in any type of aircraft, unless you travel as a fare paying passenger, or on a pass and if: . the aircraft is licensed to carry passengers . the carrier is licensed to fly such aircraft . the aircraft is flown by a licensed pilot, and . the flight is regularly scheduled between established airports. When Voluntarv AD&D Coverafle Ends A person's insurance will end at the earliest of: 1. the date the group policy ends; 2. the date insurance ends for the person's class; 3. for a spouse, the date her marriage ends by divorce or annulment and/or the date a spouse attains age 70; 4. the end of the period for which the last premium has been paid for the person; or 5. the date the employee's employer ceases to be a Participating Employer. Conversion PrivileIle If coverage ends, you should contact the insurance carrier within 45 days for conversion rights information. Eagle County Government 95 Survivor Benefits · 1/1/05 DISABILITY BENEFITS SHORT TERM DISABILITY If you are unable to work due to a non-occupational accident or sickness, you may receive payment from the Short Term Disability (STD) Plan. The STn Plan is self-funded by Eagle County Government. EliJlibilitv If you are a full-time employee working over 30 hours a week, you are eligible for coverage as of the first day of the month coincident with or next following 90 days of employment. If you are not at work due to a medical condition on the day your coverage would begin coverage is delayed until you complete one day of work on a full-time basis. CoveraJle Benefits start with the 31 sf day of a disability caused by an accident, maternity or by an illness and are payable for up to the 26th week of a disability. Benefits are based upon base pay weeldy pay and are 60% of pay up to a maximum benefit of $1 ,OOO/week. LimuauonsandExdumons The Short Term Disability Plan has the following limitations and exclusions: 1. Coverage stops at age 70; 2. Pay means compensation defined as your actual base wage at time of claim; 3. Disability is the inability to do your job or other jobs the County may make available; 4. A relapse will be considered a continuation of an existing disability unless you have been back to work for two (2) consecutive weeks or more; 5. You must be under the care of a medical doctor; 6. The County can require an independent review by a physician of the County's choice, which will be paid for by the County; 7. Any leave taken under this plan will constitute leave under the County's Family and Medical Leave Policy. Eagle County Government 97 Disability Benefits . 1/1/05 performance of all main duties of such employee's occupation at the employer's usual place of business or any other business location to which the employer requires the employee to travel. Total Disabilitv The Plan pays benefits when you are totally disabled. For the first three (3) years of Long Term Disability (L TD) payments, your disability must prevent you from performing each of the main duties of your regular occupation. After the first three-year period of total disability, then total disability means you are unable to work in any gainful occupation for which you are reasonably qualified by your education, experience or training. The loss of a professional license, an occupational license or certification, or a driver's license for any reason does not, by itself, constitute Total Disability. Please refer to your Certificate of Coverage for specific details regarding this section. Partial Disabilitv The Plan pays benefits when you are partial disabled and unable to perform one or more of the main duties of your regular occupation, or are unable to perform such duties full-time. You will receive partial disability benefits if you are disabled; engaged in partial disability employment; are earning at least 20% of your predisability income when partial employment begins; under the regular care of a Physician, and continually submit proof of your continued partial disability. The partial disability monthly benefit will replace your lost income; provided that it does not exceed the total disability monthly benefit. Recurrent Disabilitv If you return to your regular job for less than six months after receiving Plan benefits and then again become disabled from the same or related causes, the second disability is counted as a continuation of your first. You do not have to wait six months before you begin receiving benefits for your second disability. If you return to your regular job for more than six months after receiving Plan Benefits and then you become disabled from the same or related causes, a new elimination period must be met before further monthly benefits are payable. If your second disability results from unrelated causes regardless of the time since the previous disability, the second disability period will be considered a new disability. Benefit Amount After a waiting period of six (6) months of total disability, the LTD Plan provides benefits of60% of your basic monthly earnings at the time of disability. It also includes commissions averaged over the 12 months just prior to the determination dates or over the actual period of employment. Your monthly earnings excludes bonuses, overtime pay, and extra compensation. The maximum L TD benefit you may receive is $5,000 a month. The minimum is $50 per month. Eagle County Government 99 Disability Benefits . 1/1/05 Additional Benefits Within your L TD policy are additional benefits such as the Reasonable Accommodation Benefit and the Family Income Benefit. Please refer to your Certificate of Coverage for specific details. Exclusions and Limitations Your Plan covers most types of disabilities. The Plan, however, does not cover disability resulting from: 1. War or act of war, declared or undeclared 2. An attempt to commit an assault, battery or felony 3. During which the Insured Employee is incarcerated for the commission of a felony 4. Active participation in a riot 5. During which the Insured Employee is not under the regular care of a Physician. 6. Due to intentionally self-inflicted injuries, attempted suicide When CoveraI!e Ends Your Plan coverage will end on the earliest of the following dates: 1. The date the L TD Policy terminates; 2. The date your employment terminates; 3. The date on which you cease to meet eligibility requirements; 4. The date on which you cease to be a member of an eligible class; 5. The date on which your lay-off or leave of absence exceeds two (2) weeks. 6. The end of the period for which the last required premium has been paid. Continuation as a Covered Person Status as a covered person and coverage under the L TD policy will continue: 1. While you are disabled; 2. \-Vbile you are on a leave of absence under the terms of any state or federally mandated family or medical leave act or law; or Eagle County Government 101 Disability Benefits · 1/1/05 SUMMARY PLAN DESCRIPTION 1. Name and address of employer whose employees are covered by the Plan: Eagle County Government 500 Broadway P.O. Box 850 Eagle, CO 81631 2. The County and its employees (via pre tax cafeteria elections) contribute towards the cost of this benefit program. 3. Plan FundinglInsurance Carriers: A. Medical Benefits are self-funded by Eagle County Government. The County purchases Stop Loss insurance for medical claims over certain amounts. Health Promotion Benefits (Eagle Plus) are included as part of the Medical Plan. B. Dental Benefits are self-funded by Eagle County Government. C. Vision Benefits are self-funded by Eagle County Government. D. Business Travel Accident Insurance is provided under an insurance contract with Hartford Life and Accident Insurance Company, policy #ETB-112552. E. Basic Life and AD&D Insurance is provided under an insurance contract with Mutual of Omaha Insurance Company, policy #GOO0930A. F. Voluntary Life and AD&D Insurance is provided under an insurance contract with American General Financial Group, policy #V-180907. G. Long Term Disability Benefits are provided under an insurance contract with Jefferson Pilot Financial, policy #000010063325. H. Short Term Disability Benefits are self-funded by Eagle County Government. 4. The Plan year begins each January 1 and ends each December 31; financial records of the Plan are kept on a calendar year basis. Eagle County Government 103 Summary Plan Description . 1/1/05 13. Identification Number: EIN: #9804908 14. Your Rights to Information About the Plan: Eagle County Government feels strongly about all Plan participants having access to complete information about the Plan. You are entitled to: A. Examine, without charge, at the Plan Administrator's office and at other specified locations, such as work sites, all "Plan Documents." B. Obtain copies of all "Plan Documents" and other Plan information upon written request to the Plan Administrator. The Administrator may make a reasonable charge for the copies. C. Receive a summary of the Plan's annual financial report. In addition, the people who operate the Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the particpants' and beneficiaries' best interest. If your claim for a welfare benefit is denied in whole or in part, you will receive a written explanation of the reason for the denial. You have the right to have the Plan Administrator review and reconsider your claim. Eagle County Government 105 Summary Plan Description · 1/1/05 7. Claims Filing Deadline: If due to provider error or administrative delay, claims are not filed by the Plan's claim filing deadline, the Plan Administrator may, at his sole discretion and without setting any precedent, accept and process such claims as covered by the Plan provided such claims are submitted no later than twelve (12) months after the end ofthe calendar year in which services are provided. 8. Eligible Entity: Eagle County Government 9. Effective Date: January 1,2005 Title II of section Health Insurance Portability and Accountability Act of 1996 (HIP AA), subsection Security Standards, shall be effective as of 4/21/05. All other changes become effective upon this Plan's Effective date as stated herein. Adoption ~ Date: Signature: Title: C0tn(~ r:pYO ~ A{--+-d7t : cpt-r 1ttLk .J. B ~ r'V1 0 114- b v1 . 1"0 fl1G- D?Lr). tf eil~ UWU Wli "5~7 0V1 <<::7 , Eagle County Government 107 Adoption . 1/1/05 EAGLE COUNTY GOVERNMENT HEALTHCARE FLEXIBLE SPENDING ACCOUNT PLAN AMENDMENT 01/01/2004-01 Sponsor: Eagle County Government Plan Document: The Eagle County Government Healthcare Flexible Spending Account Plan dated 1/1/04, as Amended Plan Amendment: The purpose of this Amendment is to update the Continuation of Coverage (COBRA) section to comply with the Department of Labor Final Cobra Regulations as described in the Federal Register, 29 CFR Part 2590, as of 5/26/04. Pursuant to authority as outlined in the Plan (Section "Introduction to Flexible Spending Accounts," last paragraph), the Plan is amended as follows: CHANGE NUMBER 1 DELETE the provisions within the CONTINUATION OF COVERAGE OPTIONS section and REPLACE them with the following text. DURING A LEAVE OF ABSENCE A participating Employee on either a Family Medical Leave (as defined in the Family Medical Leave Act of 1993, as amended) or any other Leave of Absence approved by the Employer, is entitled to maintain coverage in the Healthcare FSA. There are two (2) options for continuing contributions during a Leave of Absence: 1. For a paid leave, contributions will continue on a pre-tax "Salary Reduction" basis. 2. For an unpaid leave, contributions must be made monthly by direct payment to the Plan on a post-tax basis. Coverage and claims payment will not be disrupted as long as monthly contributions are received by the Plan by the first day of each month. Reimbursements from the Healthcare FSA will be discontinued if the contribution is not received by the first day of any month. If coverage is not continued during a Leave of Absence and unless Special Enrollment provisions apply, the employee's original Plan election will resume immediately upon return to work. Claims incurred during periods of time for which contributions are not made are not eligible for reimbursement. Eagle County Government HC FSA Amendment 0 1012004-01 1 COBRA This section contains important information about your rights to continuation of coverage, which may become available to "Qualified Beneficiaries" (QBs) as mandated by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, and subsequent related regulations and amendments. As mandated by Federal law, the Plan offers optional continuation coverage to QB's when you or they would otherwise lose coverage under this Plan (the result of which is known as a qualifying event). This section explains when COBRA may become available to QBs and what you need to do to protect your right to receive it. NOTE: Continuation coverage is available only if, on the date of the qualifying event, remaining benefits for the current Plan Year are greater than remaining contribution payments for the Plan Year. Plan's COBRA Notification Contact fPCNC) Eagle County Government has assigned the Plan's COBRA Notification Contact (PCNC). All written notices** and other communications regarding COBRA must be directed to the following individual who is acting on behalf of the Plan Administrator: Human Resources Director Eagle County Government P.O. Box 850 500 Broadway Eagle, CO 81631 Phone: (970) 328-8790 Fax: (970) 328-8799 **COBRA administration may be administered by other parties in the PCNC's behalf. In that event, subsequent correspondence and notices are to be sent to that party. In this description, PCNC is defined to include such other party. The PCNC for the Plan may change from time to time. It is your responsibility to consult the most recent Plan Document or call Eagle County Government to obtain the most current information. Oualifvillfl Events COBRA must be offered to each person who is a "Qualified Beneficiary" (QB). A QB is someone who will lose coverage under the Plan as a result of a qualifying event (QE). Depending on the type of QE, employees, spouses of employees, and dependent children of employees enrolled in the Plan may be QBs. The Plan coverage offered under COBRA must be the same as that offered to other active (non-COBRA) participants under the Plan who are not receiving COBRA coverage. Furthermore, each QB who elects COBRA will have the same rights under the Plan as active participants. Eagle County Government HC FSA Amendment 0 I 0 12004-0 I 2 Continuation Coverage may be available to QBs if one of the following events occur: 1. Your ("Employee") termination of employment for any reason except "Gross Misconduct." Coverage may continue for Qualified Beneficiaries. 2. A reduction in hours worked which results in loss of Plan eligibility. Coverage may continue for Qualified Beneficiaries. 3. The Employee's death. Coverage may continue for eligible "Dependents." 4. Divorce or legal separation from a spouse. Coverage may continue for that spouse and eligible Dependents. 5. Loss of eligibility of a covered Dependent Child due to Plan eligibility requirements. Coverage may continue for that Dependent Child. Continuation Coverage is available only if, on the date of the qualifying event, remaining benefits for the current Plan year are greater than remaining contribution payments for the Plan Year. Notice of Unavailabilitv If the Plan's COBRA Notification Contact (PCNC) determines that a QB who experiences and/or furnishes the Plan with a notice of QE is not entitled to COBRA continuation coverage, they will receive a Notice of Unavailability, which notifies them that they are not entitled to COBRA coverage. This Notice will be provided within 14 days of receiving the QE information. Notification Requirements Qualified Beneficiary Notice Obligations The QB has the responsibility to notify the PCNC of a divorce, legal separation, or a child losing dependent status under the Plan, in writing, within sixty (60) days after the later of the QE or the date on which the QB loses (or would lose) coverage under the terms of the Plan as a result of the QE. Failure to provide this notification within sixty (60) days will result in the loss of continuation coverage rights. All written notices QBs are required to submit to the PCNC must contain the following information: 1. The name ofthe Plan for which you are (were) enrolled; 2. The name and address of the employee or former employee who is or was covered under the Plan; 3. The name(s) and addressees) of all qualified beneficiary(ies) who lost coverage due to the qualifying event/disability/second qualifying event; 4. The signature of the individual sending the notice. Eagle County Government HC FSA Amendment 01012004-01 3 Incomplete or Untimely Notices to the PCNC If the written notice you, your spouse or dependent child(ren) provide to the PCNC does not contain all of the information and documentation required as stated above, such notice will nevertheless be considered complete and timely if all of the following conditions are met: 1. The notice is mailed or hand-delivered to the PCNC; 2. The notice is provided by the deadline described herein; 3. From the written notice provided, the PCNC is able to a. determine that the notice relates to the Plan, b. identify the covered employee and Qualified Beneficiary(ies) and any additional information as stated above; 4. The notice is submitted in writing with the additional information and documentation necessary to meet the Plan's requirements within 15 business days after a written or oral request is made by the PCNC for more information. If any of these conditions are not met, the incomplete and/or untimely notice will be rejected and COBRA will not be extended. The Plan's Obligations The PCNC will also notify you of the right to elect continuation coverage after it becomes aware of or receives written notice of a loss of coverage due to one of the following qualifying events: the employee's termination of employment (other than for gross misconduct), reduction in hours, death or becoming entitled to Medicare. Election Procedures When the PCNC receives written notice that a QE has occurred, COBRA may be offered. QBs must submit their completed COBRA election form within sixty (60) days from the later of the date that coverage terminated or the date the QB receives notice. Failure to elect within the 60- day period will result in no coverage and no further rights to elect COBRA. The following will not be accepted as electing COBRA and will not preserve your COBRA rights: 1) oral communications regarding COBRA coverage (including in-person or telephone statements about an individual's COBRA coverage) and 2) electronic communications, including emails and faxed communications. NOTE: If you decline COBRA before the due date to elect, you may change your mind as long as you furnish a completed Election form to the PCNC before the expiration of the sixty (60) day period. Cost of Continuation Coveralle The Cost of continuation coverage will be equal to one-twelfth (1/12) of your annual contribution election plus a 2% administration fee. The administration fee will not be credited to the participant's account but shall be treated as an administrative charge. Eagle County Government HC FSA Amendment 01012004-01 4 The QB must make the initial payment within forty-five (45) days of notifying the Plan of election of continuation coverage. Future payments must be made in monthly installments by the first of the month, but not later than within thirty (30) days of such due date. The initial payment for continuation coverage is computed from the date coverage would normally end due to the qualifying event. Failure to make the initial payment within forty-five (45) days of notifying the Plan of election of continuation coverage will result in cancellation of continuation coverage and loss of COBRA continuation rights. No claims will be reimbursed for services incurred while a QB is ineligible for coverage either because of a loss of Plan eligibility due to a QE and/or non-payment of premium. NOTE: The Plan may not bill you for monthly contribution payments. It is the COBRA participant's responsibility to send in the monthly contributions by the due date. Maximum Period of Continuation Covera1!e The maximum period of continuation coverage is to the end of the "Plan Year" in which the QE occurs but may terminate sooner if: 1. Contributions are not paid within thirty (30) days of the due date 2. The Employer no longer offers the Healthcare FSA Plan to any of its employees, or 3. Any other occurrence (e.g. submission of fraudulent benefit claims) that permits termination of coverage for cause with respect to covered employees or their spouses or dependent children who have coverage under the Plan for a reason other than the COBRA coverage requirements of federal law A Notice of Termination will be provided to you at your last known address within fourteen (14) days of becoming informed of any of the above listed events. Notification of Address Chan1!es. Marital Status Chan1!es. Dependent Status Chan1!es and Disabilitv Status Chan1!es If your or your spouse's address changes, you must promptly notify the PCNC in writing (the PCNC needs up-to-date addresses in order to mail important COBRA notices and other information to you). Also, if your marital status changes or if a dependent ceases to be a dependent eligible for coverage under the Plan terms, you or your spouse or dependent must promptly notify the PCNC in writing. You should also always keep a copy, for your records, of any notices you send to the peNCe When COBRA Continuation Covera1!e Ends Continuation of coverage ends on the earliest of: 1. The date the maximum continuation period expires; or 2. The last period for which payment was made when coverage is canceled due to non- payment of the required cost. NOTE: If any claims are mistakenly paid for expenses incurred after the date coverage should have ended, then you, your spouse and/or dependent children will be required to reimburse the Plan for such claims mistakenly paid. Eagle County Government HC FSA Amendment 0 I 0 12004-0 I 5 Effective Date: 1/1/05 Adopted: Date: Signature: - Title: Ai' -f'.e7t : '( tttK J. 5; fV1O()-fbV} . CAerk of. f/;t~ IDVMv\ of u,vrtj COVV1W1"V:/:,lVVl.e-f::> / Eagle County Government HC FSA Amendment 01012004-01 6 EAGLE COUNTY GOVERNMENT HEAL THCARE FLEXIBLE SPENDING ACCOUNT PLAN AMENDMENT 01/01/2004-02 Plan Sponsor: Eagle County Government Plan Document: The Eagle County Government Healthcare Flexible Spending Account Plan dated 1/1/04, as Amended Plan Amendment: The purpose of this Amendment is to bring the Health Insurance Portability and Accountability Act of 1996 (HIP AA) section into compliance with the HIPAA Security Standards (45 C.F.R. Parts 160, 162 and 164 issued on Feb. 20, 2003) by establishing Plan Sponsor's obligations with respect to the security of Electronic PHI, effective 4/21/05. Pursuant to authority as outlined in the Plan (Section "Introduction to Flexible Spending Accounts," last paragraph), the Plan is amended as follows: CHANGE NUMBER 1 ADD the following det"med terms to the Definitions section: 1. ELECTRONIC PROTECTED HEALTH INFOIL1\1A TION (EPHI) shall mean protected health information that is transmitted by, or maintained in, electronic media and is set forth in 45 C.F.R. section 160.103 as amended from time to time. Electronic media includes storage media such as hard drives, magnetic tape or disks and digital memory cards, and it includes transmission media such as the internet, extranets, leased lines, dial-up lines, private networks and the physical movement of electronic storage media. 2. SECURITY INCIDENT shall mean the attempt or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with systems operations in an information system as set forth in 45 C.F.R. section 164.304, as amended from time to time. ECG Plan Document Amendment 01/01/2004-02 1 CHANGE NUMBER 2 Under section Health Insurance Portability and Accountability Act of 1996 (HIPAA), DELETE the paragraph in subsection Security Standards, and REPLACE it with the following: Where "EPHI" will be created, received, maintained or transmitted to or by the Plan Sponsor on behalf of the Plan, the Plan Sponsor shall reasonably safeguard the EPHI as follows: 1. Implement, administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the EPHI that Plan Sponsor creates, receives, maintains, or transmits on behalf of the Plan; 2. Ensure that adequate separation as required by the Privacy Rule is supported by reasonable and appropriate security measures; 3. Ensure that any agent, including a subcontractor, to whom it provides EPHI agrees to implement reasonable and appropriate security measures to protect such information; and 4. Report to the Plan any "Security Incident" of which the Plan Sponsor becomes aware. Effective Date: 4/21/05 Adopted: Date: Signature: , Title: A-t:te?f: ~a..J. 'i)ilMPlt1{o1ll . Glul.-fD 1'V1& botu"d 4 0JUM1j 6;M)'Vi~f:>~ .' ECG Plan DocumentAmendment 01/0112004-02 2