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HomeMy WebLinkAboutC09-132 EC Government Benefit PlanTERM SHEET 1) Requested hearing date: (April 21, 2009) (April 28, 2009) - 2) For County Manager signature: 3) Requesting department: Human Resources 4) Title: Adoption of 2009 Eagle County Government Benefit Plan 5) Check one: Consent: On the Record: 6) Staff submitting: Diana Kafka 7) Purpose: To renew selections and sign and date a new Participation Agreement so the governing Participation Agreement corresponds with the restated Plan document. 8) Schedule: 9) Financial considerations: N/A 9) Other: x{28 I o�i� -�G N IC__. RE C E IV E D EAGLEC-0,rJUIc tt�r ^. o APPROV"A* TO FORM By:-- le county Attorney's Office 891it 88wltf em1rhissi one rs' Office Boa -��9% EAGLE COUNTY For Employees of EAGLE COUNTY GOVERNMENT January 1, 2009 Este folleto co tiene un resumen en ingles de los derechos y benencios ofrecidos en el plan rye benefcios medi+cales y dentales de Eagle County Government. Si tiene cualquier pregunta, favor de ponerse en centacto con la senorita Diana Kafka en su of�cina que se encuentra en 800 Broadway, Eagle, CO 61631 entre las horas de 8 :00am y 6:00pm, lungs a v ernes, Tambien es posible Tamar a la oficina de administracion del plan a 1 -800- 426 -7453 Para ayuda. YOUR HEALTHCARE BENEFITS PROGRAM ..................................................................... ..............................1 USINGYOUR BENEFITS WISELY .......................................................................................... ..............................2 CAFETERIACHOICES .................................................................................................................. ............................... 3 CHANGING YOUR CAFETERIA PLAN CHOICES .............................................................................. ............................... 3 COSTVALUE OPTIONS ................................................................................................................ ............................... 3 PRE -TAX PREMIUMS ................................................................................................................... ............................... 3 Background........................................................................................................................... ............................... 3 Operation.............................................................................................................................. ............................... 4 MEDICALCARE BENEFITS ..................................................................................................... ..............................5 IN- NETWORK AND OUT -OF- NETWORK PROVIDERS ..................................................................... ............................... 5 Exc ,ptions ....................................................................................................................... ............................... .....5 MEDICALBENEFIT SUMMARY ............................................................................................................ ............................... 7 ELIGIBILITY AND ENROLLMENT ................................................................................................ ............................... 1 1 Eligibility.............................................................................................................................. .............................11 Eligibility Waiting Period and Effective Date of Coverage .................................................. .............................11 DependentCoverage ............................................................................................................. .............................11 LateEnrollment .................................................................................................................... .............................11 SpecialEnrollment ................................................................................................................ .............................11 Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) ................... .............................13 Dropping Coverage for You or Your Dependent's Mid -Year .............................................. .............................13 OpeaEnrollment ................................................................................................................... .............................14 MEDICALPLAN DETAIL ............................................................................................................ ............................... 14 CalendarYear Deductible ..................................................................................................... .............................14 Out -of- Pocket Maximums ..................................................................................................... .............................14 Copayments(Copays) ........................................................................................................... .............................14 LifetimeMaximum Benefit ................................................................................................... .............................15 Mental Health and Substance Abuse Benefits ...................................................................... .............................15 HRACovered Expenses: ........................................................ * ................................................... o .... — ................ 15 HRABenefits and Limitations .............................................................................................. .............................15 Medical Plan / Health Reimbursement Account (HRA) / Flexible Spending Account (FSA) Coordination .....16 CoveredMedical Expenses ................................................................................................... .............................16 Limitations and Exclusions.. *­* .......................................................................................... ............................... 21 Pre - Existing Condition Limitations .................................................................................... ............................... 26 VoluntaryPre - Notification ................................................................................................. ............................... 28 Disease Management Program ............................................................................................ ............................... 30 HospitalBill Audit Incentive .............................................................................................. ............................... 30 Complementary Medical Treatment ................................................................................... ............................... 31 PRESCRIIPTIONBENEFIT ............................................................................................................ ............................... 32 GenericSubstitution ........................................................................................................... ............................... 32 WhoCan Prescribe ....................................................................:........................................ ............................... 33 Choiceof Pharmacies ......................................................................................................... ............................... 33 CoveredDrugs ................................................................................................... ............................... .............. 33 Prescription Benefit Exclusions and Limitations ................................................................ ............................... 34 Retail Prescription Card Benefit with your Traditional PPO and HRA PPO Plans ............ ............................... 35 Retail Prescription Card Benefit with your Gold HSA PPO Plan ....................................... ............................... 35 Retail90 .............................................................................................................................. ............................... 36 Eagle County Government i Table of Contents • 1/1/09 MailOrder Pharmacy Benefit ............................................................................................. ............................... 36 Prohibited Use of the Prescription Card ............................................................................. ............................... 37 Termination of Prescription Card Coverage ....................................................................... ............................... 37 GENERAL MEDICAL PLAN INFORMATION .................................................................................. ............................... 37 ClaimsProcedure ................................................................................................................ ............................... 37 Coordinationof Benefits ....................................................................................................... .............................41 Third Party Liability Exclusion ........................................................................................... ............................... 45 Assignmentof Benefits ....................................................................................................... ............................... 48 Recovery of Excess Payments ............................................................................................ ............................... 48 Right to Receive and Release Necessary Information ........................................................ ............................... 48 AlternatePayee Provision ..................................................................................................... .............................48 57 WhenCoverage Ends .......................................................................................................... ............................... 48 FamilyMedical Leave .......................................................................................................... .............................49 57 Prescription Drug Creditability Status Related to Medicare Part D ...................................... .............................50 Qualified Medical Child Support Order ( QMCSO) ............................................................ ............................... 50 DENTALCARE BENEFITS .................................................................................................... ............................... 52 DENTAL PLAN BENEFIT SUMMARY ........................................................................................... ............................... 52 DENTALPLAN DETAIL .............................................................................................................. ............................... 53 Dental Plan Eligibility and Effective Date .......................................................................... ............................... 53 Late Enrollee Benefit Restriction ............................................................ ............................... ............................ COVERED DENTAL EXPENSES ................................................................................................... ............................... 53 PreventiveCare ..................................................................................................................... .............................53 BasicServices ....................................................................................................................... .............................54 MajorServices .................................................................................................................... ............................... 54 Orthodontics....................................................................................................................... ............................... 54 Dental Plan Limitations and Exclusions ............................................................................. ............................... 54 GENERAL DENTAL PLAN INFORMATION ................................................................................... ............................... 57 Choiceof Dentists ............................................................................................................... ............................... 57 Pre - Treatment Review ........................................................................................................ ............................... 57 Claims Procedure .............................. ............................... Coordination of Benefits ............................... WhenCoverage Ends .......................................................................................................... ............................... 57 Continuation of Dental Benefits ......................................................................................... ............................... 57 VISIONCARE BENEFITS ......................................................................................................... .............................58 Vision Eligibility and Effective Date .................................................................................... .............................58 Covered Services, Copays and Maximums ......................................................................... ............................... 58 Howto File a Vision Claim ........................................................................................ ............................... Limitations and Exclusions ............... ............................... ........................................................ ............................... WhenCoverage Ends .......................................................................................................... ............................... 59 Continuation of Vision Benefits ......................................................................................... ............................... 59 CONTINUATION OF COVERAGE .......................................................................................... .............................60 COBRA................................................................................................................................... ............................... 60 Introduction........................................................................................................................ ............................... 60 Plan's COBRA Notification Contact (PCNC) .................................................................... ............................... 60 QualifyingEvents ............................................................................................................... ............................... 61 Noticeof Unavailability ...................................................................................................... ............................... 62 Your Notice Obligations While You are a Plan Participant ................................................ ............................... 62 WrittenNotice Guidelines .................................................................................................. ............................... 63 ElectionProcedures ............................................................................................................ ............................... 64 Typeof Coverage ............................................................................................................... ............................... 65 Monthly COBRA Premiums That You Must Pa ......................... ............................... Eagle County Government H Table of Contents • 1/1/09 Maximum Periods of Coverage .......... ............................................................................. ............................... 67 Children Born to or Placed for Adoption With the Qualified Beneficiary During the COBRA Period ............. 69 Special Enrollment Rights Due To Health Insurance Portability and Accountability Act (HIPAA) ................. 69 ClaimsRecovery ................................................................................................................. ............................... 69 Alternate Recipients Under QMCSOs ................................................................................ ............................... 69 Termination of COBRA Coverage Before the End of the Maximum Coverage Period ...... ............................... 69 Notification of Address Changes, Marital Status Changes, Dependent Status Changes and Disability Status Cha'ges ................................................................................................................................ .............................70 Health Reimbursement Accounts -COBRA ....................................................................... ............................... 71 Continuation Coverage for Same -Sex Domestic Partners ..................................................... .............................71 USERRA........................... ............................... ...... ......................... .......... ... ............... ...... ...... ............................... 71 YourRights Under USERRA .............................................................................................. ............................... 72 BasicRequirements ............................................................................................................ ............................... 72 EmployeeRestoration Rights .............................................................................................. ............................... 73 Electing USERRA Continuation Coverage... ...... o_ .... o ........................................ oo .... o-o-o-o-oo-o ...... o ... o ............... 73 PaymentDue Date .............................................................................................................. ............................... 74 Cancellation of USERRA Election Rights... ... o_ .... o o o o .... . o ..... ....... o ......................... o ... o ... o .............................. _ 74 Termination of USERRA Continuation Coverage.. .. o.. o o ............. o ................. oo-oo .......... — ...... __o ................... _ 74 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) ......................76 DEFINITIONS........................................................................................................................... ............................... 80 DISABILITYBENEFITS ............................................................................................................ .............................89 SHORTTERM DISABILITY ......................................................................................................... ............................... 89 Eligibility............................................................................................................................ ............................... 89 ActivelyWorking Requirement .......................................................................................... ............................... 89 Definitionof Disability ....................................................................................................... ............................... 90 Waiting Period and Duration of Disability Benefits ........................................................... ............................... 90 DISABILITYBENEFIT AMOUNT .................................................................................................. ............................... 90 Conditionsand Limitations ................................................................................................. ............................... 91 WhenCoverage Ends .......................................................................................................... ............................... 91 ClaimsProcedure ................................................................................................................ ............................... 91 FILINGA CLAIM ........................................................................................................................ ............................... 91 CLAIMSAPPEAL PROCEDURES .................................................................................................. ............................... 93 SUMMARY PLAN DESCRIPTION 95 ADOPTION................................................................................................................................ ............................... 97 Eagle County Government iii Table of Contents • 1/1/09 K PLAN SPONSOR Eagle County Government 500 Broadway P.O. Box 850 Eagle, CO 81631 Human Resources Dept: (970) 328 -8790 • (970) 328 -8799 fax Toll Free 1 -800- 255 -6136 www.ea lecounty.us CLAIMS ADMINISTRATION CNIC Health Solutions (CNIC) PO Box 3559 Englewood, CO 80155 -3559 (303) 770 -5710 • (303) 770 -5928 fax Toll Free: 1- 800 - 426 -7453 www.cnichs.com PROVIDER/HOSPITAL NETWORK Cofinity, formerly Sloans Lake Preferred Health Network PO Box 2720 Farmington Hills, MI 48333 Toll Free: (800) 831 -1166 www.cofinitv.net CASE MANAGER, DISEASE MANAGEMENT and VOLUNTARY PRE - NOTIFICATION CNIC Health Solutions (CNIC) PO Box 3559 Englewood, CO 80155 (303) 770 -5710 • (303) 770 -0091 fax Toll Free: 1- 800 - 426 -7453 www.cnichs.com Eagle County Government v Important Contact Information • 1/1/09 I PHARMACY BENEFIT MANAGEMENT Retail: Mail Order: Total Script 10901 W. 120th Ave Suite 175 Broomfield, CO 80021 Toll Free Phone: 1- 800 -752 -2211 Toll Free Fax: 303 - 438 -9922 www.totalscript.com c/o BioScrip Pharmacy Toll Free Phone: 1- 800 - 677 -4323 www.bioscrip.com HEALTH SAVINGS ACCOUNT (HSA) BANKING The BanCorp Bank Attn: Customer Service Center 405 Silverside Road, Suite 105 Wilmington, DE 198093 Toll Free: 1- 800 -555 -9316 Email: bancorphsa @TheBancorp.com www.thenbancorousa.com Eagle County Government vi Important Contact Information • 1/1/09 YOUR HEALTHCARE BENEFITS PROGRAM 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 ➢ 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, if unique definitions apply to the Group Medical, Dental, or Vision 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, 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 contracts, the contracts shall govern. Please contact Human Resources to request a copy of the contract(s) for full details. 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 • 1/1/09 The Medical Plan is self - funded by Eagle County. Everyone loses if claims under the Plan are higher than they: really need to be. The County would be spending money that might otherwise be used to provide more or better benefits. Here are some ways you can help to keep costs down: 1. Ask questions - Is the procedure or treatment your doctor suggests really likely to help? It has been estimated that each year millions of people have unnecessary operations or take unnecessary medication. 2. Consult your doctor - Avoiding needed medical treatment is foolish. But seeing your doctor for every minor problem wastes time as well as money. 3. Use the phone - Consider your doctor's schedule and available time. Some doctors prefer to give routine medical advice and prescription renewals over the phone and may do so without charge. 4. Be selective - Some doctors and hospitals simply charge more than others. Higher charges do not necessarily mean better care. 5. Avoid duplication - If you move to a new area or change doctors, ask your former doctor to transfer your medical records. Those may include x -ray or diagnostic tests that could save you both money and inconvenience. 6. Watch timing - If you have the choice, try not to enter the hospital on a Friday or on a weekend. Some hospital services close down on the weekends. You may find yourself spending a day or two in a $750 a day room waiting for the lab to open on Monday. 7. Consider home care - Recuperating at home rather than in the hospital or in an extended care facility makes sense if your condition is not very serious or complicated. Ask your doctor. 8. Remember the outpatient department or doctor's office - Minor surgery, an illness, or an uncomplicated injury need not involve a hospital stay. Many such conditions can be handled safely and comfortably in the hospital's outpatient department or the doctor's office. 9. Review your medical bills for accuracy -Did you actually receive all itemized services? Were you charged twice for the same item? If in doubt, ask your doctor or the place where services were performed. 10. Ask your doctor about your diagnostic testing —More tests may not necessarily indicate better care. What are the tests designed to reveal? What do the results indicate? Why are certain tests repeated? Eagle County Government 2 Using Your Benefits Wisely • 1/1/09 GENERAL 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, "Employees" may change the Medical Plan option in which they are enrolled. The deadline for submitting changes will be designated annually by the County, but in no event later than December 31 st. The change will be effective on the following January 1. If you experience a qualified change in status as permitted under Treasury Regulations § 1.125 -4 and the regulations there under and as described in the Special Enrollment section, you may be eligible to make a mid - "Plan Year" change and elect different benefit options only if _you elect those options in wrttin within thirty (30) days of the change in status event. COST VALUE 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- taxable benefit Plan choices. By maintaining a Cafeteria Plan, Employers are allowed to establish and offer a Pre -Tax Premium Plan that serves as a "Salary Reduction" funding vehicle. The Pre -Tax Premium Plan gives employees the following tax advantages: Eagle County Government � 3 General information • 1/1/09 1. Employees' benefit plan contributions are automatically deducted from their salaries before Federal, State, Social Security and Medicare taxes are taken out, i.e. Pre -Tax. 2. Taxable income is reduced by the amount contributed, so employees pay less in taxes and have more take -home pay. Eagle County Government hereby establishes such a Plan to operate as follows: Operation Eagle County Government may require that employees make contributions as a condition of participation in the County's Benefit Plans. Amounts of such contributions are established and changed by the County from time to time. The Plan will allow employees the following choices with regard to the Medical, Dental and Vision Benefit Plans, as well as other County- sponsored benefit Plans that are permitted by the Internal Revenue,' Code to be part of a Pre -tax Premium Plan: Option A. Pre -tax option as described above via "Salary Reduction "; Option B. Employees may choose the option of funding required contribution for the Benefit Plan via payroll deduction from after -tax compensation. All employees will be deemed to have chosen Option "A" unless a written request is submitted to the Payroll Office, requesting Option "B" (after -tax pay deductions). Under Option A, Social Security, Workers' Compensation, Unemployment Insurance, etc. contributions will be based upon the lower pay level and could, over time, result in lower benefit payments. Life Insurance, Long Term Disability, 457 Deferred Compensation and Pension benefits will be based on pay prior to any pay reduction. Eagle County Government 4 General Information • 1/1/09 IN- NETWORK AND OUT -OF- NETWORK PROVIDERS Eagle County Government provides benefits that vary according to your selection of providers. "In- Network" providers are contracted with the Plan's PPO Provider Network (refer to the Important Contact Information 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 In- Network facilities, expenses that the Plan pays and expenses that the Plan requires you to pay will be reduced. When you use In- Network healthcare 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 "In- Network" 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 In- Network professionals, you are free to choose other providers of medical services. "In- Network" benefits are only available when you receive services provided by the Plan's In- Network 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 (refer to the Important Contact Information section for details). "Out -of- Network" means "Physicians," "Hospitals" and other healthcare providers that are not contracted with the Plan's PPO Network or that the Plan designates as being Out -of- Network. Using "Out -of- Network" providers allows you total choice of Physicians and Hospitals, but at a higher cost to you. You may use either "In- Network" or "Out -of- Network" providers at any time. Exceptions Occasionally, the choice of using an "In- Network" or "Out -of- Network" providers is difficult for the patient to control. The "Plan" recognizes this difficulty and allows the following exceptions: 1. An Out -of- Network Physician who sees patients at a In- Network clinic is a In- Network provider. 2. An Out -of- Network emergency room Physician will be covered as In- Network when the treating medical facility is a "In- Network" facility. 3. Out -of- Network Pathology and Anesthesiology services will be covered as In- Network when the treating medical facility is an In- Network facility. Eagle County Government 5 Medical Care Benefits • 1/1/09 4. Out -of- Network laboratory or radiology services (including interpretation of tests by a pathologist or radiologist) will be covered as In- Network when the referring Physician or medical facility are In- Network providers. S. Out -of- Network medical care (both emergency and non - emergency) received by Dependent "Children" covered by this Plan who reside outside Colorado will be covered as In- Network. 6. "Covered Persons" who experience a medical "Emergency" while traveling shall receive In- Network benefits. Proper documentation of the Emergency must be submitted and acceptable to the Plan to receive In- Network benefits. "Non- Emergency" care shall be paid at Out -of- Network levels. 7. An Out -of- Network assistant surgeon will be covered as In- Network when the primary or treating "Physician" or surgeon is a In- Network provider. Eagle County Government 6 Medical Care Benefits • 1/1/09 MEDICAL BENEFIT SUMMARY / ^ N ,,., ! / :` ., � 'n r '�r: G% n ^., .., r .,:. .w.: r. . , .. , ,' , �, .r r ! K, a d' r. b �+. ,. .. / ...r. ,r/r .. r. y .. � r .. r .,, ,r,.,w%..:.., .N. .6 .:..r, F.. %. w,F .r ..f ,✓rb: ,v I 1 F �� �/ ./ / ,. /„ rfF �l/F N'a,! , /.r � ;. /.1 a r, ,� r ., r .l. %., rr %. /rr,J, /r. / ,,., .r. % +,., w., ... ,w ..,., ,.,. ,.a .. / ,. .,:. ry ��. ,/ 1//. .. / ✓.. .r. n,. � r ,. /,� /5 !. f.. r . .w,. ,,.., /,r r,4 /r, / //; ,. /r .. /% .r/ r :. r, /, r, /r ,•%�. ... h; v.�r :,/ % r 1� ,. r / N „ ✓inml a /r /•..:.,r, 4n ,err .. //.,u w,.K.� n. /. ./, ... %. ,; % ,, ///%. r .r ,..�:% .. ... ,. '/ / . :. .. / . ^1 / A r ,?. r rr /, rn /i N.. 'i'.,rb r .''//.,, r. // ri , „ %^' ✓ r� ..� / n //. ,, r r.. r , ....r, r.. .L;, � a r r ;. rs/ w /, :. /✓n// T.w : �I/ .4. % N, ..,, .,., W . ,... %..,. Kr ^.r.,. , ,. w .., , / n ..; .. 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General Medical 1. Physician Office Visit 5, 6 Subject to deductible No Yes No Yes Yes Yes Patient Copay per visit $15 copay 30% $25 copay for 30% 20% 30% for the first 8 the first 8 visits, visits, $35 copay $45 copay for for remaining remaining visits per visits per calendar calendar year. year. Plan Coverage 100% 70% 100% 70% 80% 70% Contact Human Resources for "In- Network” Provider lists and website information. "Out -of- Network" providers may bill amounts that are greater than the Plan allows. Patients are fully responsible for those bills. Use "In- Network" providers when at all possible. 2- Traditional PPO & HRA PPO Only: Copays do not apply to deductible. "In- Network” and "Out -of- Network” deductibles cross - accumulate. All family members can contribute to meeting the family deductible, with no one (1) family member's deductible to exceed the stated individual deductible. 3 In- Network and Out -of- Network deductibles cross accumulate. Copays do not apply to deductible. 4 Gold HSA PPO is a qualified "High Deductible Health Plan" (HDHP). Each individual family member's deductible is limited to that shown under First Individual Family Member, with all family members in aggregate not to exceed the Family Maximum. 5 Traditional PPO & HRA PPO 0&: Office or home setting. Includes office visits for "Injury" and "Illness." Copay applies to professional fees per provider visit. Includes, but is not limited to: physician, physical therapy, behavioral health, etc. Office visit copay is waived for allergy shots (administration thereof and serum) and immunizations if no professional fee is charged. For all other Non- 'Wellcare" services other than professional services provided during an office visit (such as lab, x -ray, tests, injections, etc.), see section III -C (Other Covered Expenses). 6 Traditional PPO & HRA PPO 00&: Maximum of 3 "Modalities" per copay for physical medicine. (Note: A Modality is a service) Eagle County Government 7 Medical Care Benefits • 1/1/09 r 2. `°Wellcare" Phygician Office Visit 7 . Subject to Deductible No No Coverage No No Coverage No No Coverage Patient Copay per visit $15 $25 $25 Plan Coveralge 100% 100% 100% 3. Chiropractic Office Visit 8 Subject to Deductible No Yes No Yes Yes Yes Patient Copay per visit $35 30% $45 30% 20% 30% Plan Coverage 100% 70% 100% 70% 80% 70% B. Prescriptions Subject to Deductible No N/A No N/A Yes N/A 1. Retail Prescriptions No Coverage No Coverage No Coverage Max. 30 -day supply Generic Copay $10 0% 0% Brand Copay $30 30% 30% 2. Mail Order Prescriptions No Coverage No Coverage No Coverage Max 90 -day supply Generic Copay $20 0% 0% Brand Copay $60 30% 30% C. Other Covered Expenses Subject to Deductible Yes Yes Yes Yes Yes Yes Patient Copay 20% after ded 30% after ded 20% after ded. 30% after ded 20% after ded. 30% after ded. Plan Coverage 80% after ded 70% after ded 80% after ded. 70% after ded 80% after ded. 70% after ded. 7 Office visit copay applies to "Wellcare" professional fees and associated preventive care lab /x- ray /test expenses ordered by the "Physician." For example, includes but not limited to, preventive mammograms, pap smears, PSA tests, preventive blood tests, and colonoscopy to name a few. To determine coverage of Wellness benefits, the "Plan" uses nationally- recognized and standardized preventive criteria and guidelines, and the IRS Ruling 2004 -23 (Safe Harbor for HDHP Preventive Care Benefits). All diagnostic (the presence of "Illness" or "Injury" symptoms for which a diagnosis is sought) labs, x -rays, and tests are covered as shown in Section III -C 8 Maximum of 3 modalities per copay. (Note: A "Modality" is a service). Maximum of 12 visits per calendar year per Covered Person. Eagle County Government 8 Medical Care Benefits • 1/1/09 Traditional PPO and HRA PPO: If an If an individual's If an individual's exceeds $3,250 individual's Medical Expense Medical family) in a Medical copays exceed Expense copays Includes* Sections: III -A (General Expense $32000 ($6,000 for a exceed $2,500 Medical), III -C (Other Covered copays exceed family) in a calendar ($5,000 for a Expenses); $1,500 ($31000 year, remaining family) in a Yes for a family) in eligible Medical calendar year, Excludes Sections: I (Deductible) and a calendar Expenses will be remaining III -B (Prescriptions). year, paid at 100% by the eligible Medical remaining Plan. Expenses will be eligible paid at 100% by Medical the Plan. Expenses will be paid at 100% by the Plan. * *Includes Sections: III -A (General Medical), III -B (Prescriptions) and III -C (Other Covered Expenses) Excludes: Section II (Gold HSA Deductible) A. Per Lifetime B. Hearing Aid Benefit 9,10 A. Voluntary Notification of Hospital If an individual's Medical Expense copays exceed $29500 ($59000 for a family) in a calendar year, remaining eligible Medical Expenses will be paid at 100% by the Plan. If an individual's I If an individual's Medical Medical Expense Expense exceeds $3,250 exceeds $7,500 ($6,500 for a ($15,000 for a family) in a family) in a calendar year, calendar year, remaining remaining eligible Medical eligible Medical Expenses will Expenses will be paid at be paid at 100% 100% by the by the Plan. Plan. Yes $2,0001000 $1,000 per Covered Person per Lifetime Admission Yes Yes Yes Yes Yes Yes B. Primary Care Physician Selection No No No No No No C. Case Management Yes Yes Yes Yes Yes Yes D. Hospital Audit Incentive Yes Yes Yes Yes Yes Yes E. Disease Management Yes Yes Yes Yes Yes Yes 9 Benefits shall be covered under section III(c). 10 Lifetime limit not applicable to Cochlear implant due to Illness and /or Injury. Eagle County Government ■ 9 Medical Care Benefits • 1/1/09 11 Unused amounts in a calendar year will be carried forward (roll -over) to the next calendar year. 12 Amount shown will be depositing into employee HRA account upon plan enrollment. For partial year participation, amount shall be pro- rated. 13 Lump sum'amount shown will be deposited into employee HSA account upon opening of HSA account. Matching contributions shall be deposited on a per pay period matching basis, up to the Plan maximum. For partial year participation, both lump sum and matching contribution amounts shall be pro- rated. 14 Consult your tax advisor or refer to IRS Publication 969 & Form 8889 with Instructions for details as to maximum HSA allowable contributions per calendar year. Employee contribution maximum shown is based on the inclusion of the full $1,000 employer contribution. For further details related to allowable calendar year contribution maximums and applicable tax rules, you're strongly encouraged to consult your tax advisor and /or visit http: / /www.Ustreas.gov /offices /public- affairs /hsa/.. NOTE: County Contribution shall be pro -rated for partial year participation. 15 As allowed for Medical - Dental- Vision care under IRS Code Section 213(4) as outlined in IRS Notice 2004 -02 Eagle County Government 10 Medical Care Benefits • 1/1/09 ELIGIBILITY AND ENROLLMENT Elifibility "Regular Full- Time "' employees are eligible to participate in any of the three medical plan options as well as the Dental and Vision plans as described elsewhere in this document. "Regular Part- Time" employees are eligible to participate in the Traditional PPO Medical Plan option only as well as the Dental and Vision plans as described elsewhere in this document. Eligibility Waiting Period and Effective Date of Coverage For "Regular Full - Time" employees, coverage will be effective on the first day of the month coincident with or following the date of employment. For "Regular Part- Time" employees, coverage will be effective on the first day of the month coincident with or following 90 days 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. Dependent Coverage If an employee is enrolled, his/her eligible "Dependents" may also be enrolled at the same time. Common law marriages must be attested to by a signed, notarized affidavit. Dependents do not include "Children" of a dependent son or daughter. 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 his or her eligible working spouse, if elected. The transfer of coverage is not automatic. Employees must request the transfer of coverage, in writing, within thirty (30) days of the date of their spouse's termination. 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, (not including COBRA), you or your dependents may enroll in this Plan after your other coverage ends. Coverage will be effective on the date that the written request is received by the Human Resources, provided enrollment is requested within thirty (30) days of when the other coverage ends. Otherwise, Late Enrollment provisions apply. Other coverage must be ending (but in no event because of your failure to pay required premium) due to: Eagle County Government 11 Medical Care Benefits • 1/1/09 1. loss of eligibility, including legal separation, divorce, death, termination of employment, reduction in hours of employment, or 2. termination of employer contributions and/or the employer no longer offers plan benefits to a class of similarly situated individuals; or 3. teaching the plan's lifetime limit on all benefits, or 4. in the case of coverage under an HMO, no longer residing /living /working in the HMOs service area and there is no other continuation coverage available, Where the other coverage is COBRA continuation coverage, enrollment can be requested only after the COBRA continuation period is exhausted. This includes reaching the maximum allowed coverage duration, the failure of the former employer or other entity to remit payment timely, no longer residing /living /working in the HMO's service area if applicable and there is no other continuation coverage available, or reaching the group health plan's lifetime limit for all benefits, but may not be for failure to make required premium payments. 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 enrollment, in writing, within thirty (30) days after the marriage, birth, adoption or placement for adoption. Such coverage will be effective: 1. on the date that the written request is received by the Human Resources department when as a result of marriage, or 2. retroactively to the Dependent's date of birth or when an adopted newborn, if the child's date of placement is within thirty (30) days after the birth; or 3. For any other adoptive child, from the date of placement. For all other Special Enrollees, coverage will be effective on the date that enrollment paperwork is completed and received by the Human Resources department, as long as enrollment is requested within thirty (30) days of special enrollment event. For more information regarding your special enrollment rights, contact Human Resources (refer to the Important Contact Information section). Please see Preexisting Condition Limitations described elsewhere in this Plan that applies to all Plan participants. If as a result of a qualified special enrollment event, if the request changes which medical plan option You are enrolled, all calendar year plan accumulators such as deductibles and out -of- pocket maximums (but does not include lifetime maximums) will restart upon the date the plan option change becomes effective, i.e. no credit is given from prior plan option for which the "Covered Person(s)" was enrolled. Eagle County Government 12 Medical Care Benefits • 1/1/09 Children's Health Insurance Program Reauthorization Act of 2009 WHIPRA) "Employees" and their "Dependents" who are eligible for the "Plan" but who are not enrolled can enroll in the Plan provided that they request enrollment in writing within sixty (60) days from the date of the following loss of coverage or gain in eligibility: 1. Lose Medicaid or Children's Health Insurance Program (CHIP) coverage; or 2. Become eligible to participate in a Medicaid or CHIP premium assistance program Dropping Coverage -for You or Your Dependent's Mid- Year Once enrolled in the Plan, the enrollment selection made for you and your covered "Dependent(s)" stays in effect for the entire "Plan Year." Terminating your or your Dependent's coverage may only occur mid -year if the change is allowed under IRS rules and is on account of and consistent with a change in status as defined by the IRS. A qualified change in status includes: 1. A change in marital status (marriage, death of spouse, legal separation, or annulment); 2. A change in the number of dependents (as the result of birth, death, adoption, or placement for adoption); 3. A change in employment status (commencement or termination of employment, strike or lockout, commencement of or return from an approved leave of absence, change in worksite, or change in eligibility status for the plan); 4. Dependent ceasing to satisfy eligibility requirements; 5. Conforming to a judgment, decree, or order resulting from a divorce, legal separation, annulment, or change in legal custody for a dependent child or foster child; 6. Entitlement of the participant or the participant's spouse or dependent child to coverage under Medicaid or Medicare, or loss of such coverage; 7. Any other change in status permitted under Treasury Regulations § 1.125 -4 and the regulations there under. To terminate a "Dependent" from your coverage, you must complete and submit an Enrollment Change Form to the Human Resources department. The County must receive this form within thirty (30) days of the qualified change in status. If the Employee fails to timely terminate an ineligible Dependent from the Plan, the County reserves the right to recoup any benefit payments made on behalf of such Dependent back to the date such Dependent should have been terminated from the Plan. It is the covered Employee's responsibility to advise the County in writing of any change in Dependent status within thirty (30) days of the change, including marriage, divorce, legal separation, the addition of newborns or adopted children, and any desire to change beneficiaries. Eagle County. Government 13 Medical Care Benefits • 1/1/09 Open Enrollment Except as stated above under Special Enrollment, enrollment in this plan is only allowed during the open enrollment period designated by the County each December, with coverage effective on the first day of the following January. Please s le Preexisting Condition Limitations described elsewhere in this Plan that applies to all Plan � g pp participants. MEDICAL PLAN DETAIL Calendar Year Deductible The deductible is the amount of out -of- pocket expenses you must pay before covered expenses are paid by the Plan. The deductible amount that applies depends upon the Plan in which you are enrolled and upon the providers that you choose. Please refer to the Medical Benefit Summary for details. The individual deductible must be met by each person during a calendar year. All family members can contribute to meeting the maximum deductible for the family. Deductible Carryover Traditional PPO and HRA PPO Only: If you continue participation in the same Medical Plan option 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 Maximums 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. Copayments (Copays) Copays listed in the Medical Benefit Summary maybe applicable to some benefits and represent the cost each patient must pay each time a medical service is received. Copays are not credited to any deductible. Eagle County Government 14 Medical Care Benefits • 1/1/09 Lifetime Maximum Benefit For participating employees and their participating dependents, the maximum benefit payable (Traditional PPO, HRA PPO and Gold HSA PPO combined) 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. HRA Covered Expenses: 1. Are limited to expenses covered under the HRA PPO Plan are those as stated under the Medical, Dental and Vision sections entitled Covered Expenses within this "Plan." Retail and mail order prescription copays are not eligible expenses. The maximum HRA amount available for reimbursement per "Plan Year" per Employee is as stated in the Medical Benefit Summary. HRA Benefits and Limitations 1. The HRA benefit is solely funded by Eagle County Government, the Plan Sponsor. It is subject to COBRA continuation coverage requirements. 2. Unused funds from one "Plan Year" will be carried forward to the next Plan Year. You must remain enrolled in the HRA PPO for the account balance to roll over. 3. HRA benefits are limited to eligible employees enrolled in the HRA PPO Plan and their enrolled dependents. 4. The HRA benefit amount available to Employees enrolled in the HRA PPO is the same, regardless of family status. 5. HRA benefits for partial year participation will be calculated pro -rata based on complete months of participation in a Plan Year. 6. Only care for medical services as listed above under section HRA Covered Expenses shall be covered. Contact the Human Resources office for more detailed information. Reimbursement is limited to "Usual, Reasonable and Customary Charge" as defined in the Definitions section of this Plan. 7. Only expenses incurred while you are covered under the Plan and submitted as a claim by the dates required by the Plan are eligible for reimbursement. Expenses reimbursable under any other health plan or insurance policy are not eligible. Eagle County Government 15 Medical Care Benefits • 1/1/09 8. Claims for expenses incurred during the Plan Year must be filed by no later than as stated in the Claim Filing Deadline section. All claims for reimbursement filed after such time will be denied. 9. If you are also enrolled in the Healthcare Flexible Spending Account (FSA) Plan and expenses are eligible for reimbursement under both plans, HRA claims must be reimbursed first (until exhaustion) before an Employee seeks reimbursement from their FSA. 10. Retail and mail order prescription copays are not eligible expenses. Medical Plan /Health Reimbursement Account (HRA) /Flexible Spending Account (FSA) Coordination All submitted medical expenses will be processed first under the Medical Plan and then automatically under the Health Reimbursement Account (HRA), by the claims administrator (refer to section Important Contact Information for details). If non - reimbursed expenses remain, they will be processed under your healthcare FSA plan, if enrolled, until exhaustion. Note: HRA eligible expenses will be paid to the "Employee," not the provider. It is your responsibility to pay your providers when applicable. Covered Medical Expenses A "Covered Person" shall be entitled to the Covered Medical Expenses as specified below and in accordance with the all other terms and conditions set forth in this Plan. Unless specifically stated otherwise, in order for medical "Expenses Incurred" to be covered, it must be: 1. "Medically Necessary "; 2. Due to an "Injury," "Illness" and/or "Wellcare "; 3. Incurred while the "Covered Person" meets requirements of the Eligibility and Enrollment provisions under this Plan; 4. A service that is not in connection with a Pre - existing Condition during a Pre - existing Condition Limitation Period; 5. Not in excess of the maximum "Usual, Reasonable and Customary Charge "; 6. Within the stated benefit maximums as described in this Plan; 7. A service not listed under the Limitations and Exclusions section of this Plan; 8. Not reimbursable under any other benefit plan. Eagle County Government 16 Medical Care Benefits • 1/1/09 9. Services made by a "Physician" and other licensed health care professionals who are under the direct supervision of a "Physician." 10. Provided at or by facilities meeting all applicable state and federal licensing requirements. The following are examples of the types of medical expenses that have been determined by the Plan Sponsor to meet the above criteria. However the list is not, nor should it be interpreted as, an all - inclusive or exhaustive list, but rather as a useful guide. 1. Allergy testing, treatment, and injections. RAST (radioallergosorbent test) allergy testing allowed only when "Medically Necessary" as the only alternative to traditional allergy testing. 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. Cochlear implantation. 8. 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. Additionally, as required by the Women's Health and Cancer Rights Act of 1998, the Plan provides benefits for mastectomy - related services including all stages of 1 Eagle County Government 17 Medical Care Benefits • 1/1/09 reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema. 9. 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). 10.' 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. Items such as air conditioners, purifiers, vibrating chairs, whirlpools and dehumidifiers are not covered items. 11. Expenses otherwise ineligible under this Plan may be considered eligible expenses if they are determined to represent a more cost - effective form of medical treatment than another covered expense. 12. Prescription eye glasses, frames or contact lenses will be covered only when their function will be to replace the human lens lost through intraocular surgery or ocular injury or when caused by a medically ascertainable problem. The benefit is limited to one (1) pair of prescription glasses or contact lenses unless, due to a change in the patient's condition, the attending "Physician" certifies that a change in prescription is "Medically Necessary." For routine eye exam or eyewear coverage, refer to the Vision Plan section for details. 13. Hearing diagnostic examinations, when "Medically Necessary" and approved by a physician. 14. Expenses for the treatment of kidney disorder by hemodialysis or peritoneal dialysis as an inpatient in a hospital, or other facility, or for expenses in an "Outpatient" facility or in your home, including the training of one (1) attendant to perform kidney dialysis at home. The attendant may be a family member. 15. Expenses for home infusion therapy services and supplies when provided by an accredited home infusion therapy agency, which is not a licensed Home Health Agency. These services must be "Medically Necessary" and are required for the administration of a home infusion therapy regimen when ordered by and are part of a formal written plan prescribed by a Physician. The benefit will include all Medically Necessary services and supplies including the nursing services associated with patient and/or alternative care giver training, visits to monitor intravenous therapy regimen, emergency care, prescription drugs, administration of therapy and the collection, analysis and reporting of the results of laboratory testing services required to monitor a response to therapy. 16. "Hospice" and Home Health care. Eagle County Government 18 Medical Care Benefits • 1/1/09 17. Care by a "Hospital" for "Room and Board" (not to exceed the cost of a semi - private room unless "Medically Necessary ") and other inpatient and "Outpatient" hospital services. Such care shall include routine nursery charges for a newborn infant, which are covered as though incurred by the birth mother. 18. Laboratory and pathology services. 19. Medical supplies and dressings. 20. Expenses for mental health treatment furnished on an inpatient basis by a "Hospital" or on an "Outpatient" basis by a "Physician" or licensed therapist for psychotherapy under direct supervision of a Physician. When direct supervision is not required by the state, that licensed therapist will be a recognized provider. 21. Licensed or certified midwife. 22. Monofocal Implanted Lenses for cataract surgical procedures. Includes routine eye glass frame allowance of no greater than $200 (per lifetime) following the procedure. Expenses for multi -focal refractive Implant Optical Lenses (i.e. ReZoom) are not covered under this Plan. 23. Oxygen and other gases and the equipment necessary for the administration thereof, when prescribed by a "Physician." 24. Physical Therapy (inclusive of Occupational Therapy and/or Speech Therapy) when ordered by a "Physician" and meets medical necessity guidelines. 25. 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. 26. 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 90 days as allowed by the Retail 90 program), 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 Case Manager(s) of the Plan Administrator that there is over - utilization of drugs or evidence of drug abuse, regardless of the medical necessity that exists. Eagle County Government 19 Medical Care Benefits • 1/1/09 27. 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. 28. 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. 29. Accredited facilities, clinics or centers involved in sleep testing and treatment for a covered "Illness" or "Injury." 30. Voluntary sterilization, tubal legations or vasectomies for employees and dependent spouses. Reversals of sterilizations are not covered. 31. Transplant (organ) expenses when "Medically Necessary" for the care and treatment due to an organ or tissue transplant that is not considered "Experimental" or investigational, subject to the following criteria: a. The transplant must be performed to replace an organ or tissue. b. Organ procurement limits. Charges for obtaining donor organs or tissues are covered charges under the Plan only when the recipient is a Plan participant. When the donor has medical coverage, his or her Plan will pay first. The donor benefits under this Plan will be reduced by those payable under the donor's Plan. Donor charges include those for: i. Evaluation and testing of the organ or tissue; ii. Removing the organ or tissue from the donor; and iii. Transportation of the organ or tissue from within the United States or Canada to the facility where the transplant is to be performed. 32. Wigs and artificial hairpieces when there is a physician's prescription and hair loss is due to a serious medical condition such as chemotherapy, radiation therapy, alopecia or trichotillomania. Hair loss due to normal balding is not considered a serious medical Eagle County Government 20 Medical Care Benefits • 1/1/09 condition. Plan coverage is limited to one (1) wig or hairpiece per "Covered Person" per lifetime. 33. X -ray and radiology services. Limitations and Exclusions Your Medical Plan will = pay for charges resulting from any of the following: 1. Acupuncture unless provided by a "Physician" as defined by this Plan. Refer to the Definitions section for details. 2. Bio- feedback. 3. Expenses for birthing classes. 4. Expenses for breast pumps except in the case when the baby is ill and hospital confined after the mother is discharged. 5. Expenses incurred prior to the "Covered Person's" effective date of coverage and expenses after the date the Covered Person ceases to be covered under the Plan. 6. Claims filed after the claims filing deadline. All claims must be filed with the Plan within six (6) months after the end of the Plan year in which the expense was incurred. 7. Any expenses for cosmetic surgery complications that result and/or the revision of a previous procedure performed for cosmetic purposes, including, but not limited to, breast augmentation unless due to symmetrical reconstruction as provided under the reconstructive surgery benefit. Benefits for cosmetic surgery and related expenses are allowed only when such surgery is required as the result of a 1) congenital anomaly; 2) disease process; or 3) an accidental "Injury" that occurred while covered by this plan. 8. Domiciliary care and inpatient hospitalization for the purposes of custodial care. 9. Expenses for deluxe or luxury items. An example is motorized equipment when manually operated equipment can be used. The Plan will cover deluxe equipment only when additional features are required for effective medical treatment, or to allow the covered person to operate the equipment without assistance. 10. Expenses for dental services or dental supplies. Such as, but not limited to the care of or treatment to the teeth, gums or supporting structures such as, periodontal treatment, endodontic services, extractions, implants, or any treatment to improve the ability to chew or speak, unless otherwise covered under this Medical Plan. Eagle County Government 21 Medical Care Benefits • 1/1/09 11. Expenses incurred for services provided outside the United States unless due to an "Emergency." 12. Expenses for examination for employment, licensing, insurance, or adoption purposes. 13.' Expenses deemed "Experimental." 14.1 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. 15. 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. This exclusion does not apply if the injury resulted from an act of domestic violence or a medical (including both physical and mental health) condition. a. 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 of legal jurisdiction finds 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. Charges for services, supplies, care or treatment to a Plan Participant for an "Injury" or "Illness" which occurred as a result of that Plan Participant operating a motor vehicle while under the influence of alcohol or drugs or a combination thereof or operating a motor vehicle with a blood or breath alcohol content (BAC) above the legal limit. The arresting officer's determination of inebriation will be sufficient for this exclusion. It is not necessary for this exclusion to apply that criminal charges be filed, or if filed, that a conviction result. Expenses will be covered for injured Plan Participants other than the person operating the vehicle while under the influence or a BAC above the legal limit, and expenses may be covered for chemical dependency treatment as specified in this Plan. This exclusion does not apply if the injury resulted from an act of domestic violence or a medical (physical and/or mental health) condition. 16. Treatment, services or follow up care provided as a result of or in conjunction with a treatment or service not covered by the "Plan," including but not limited to expenses for Eagle County Government 22 Medical Care Benefits • 1/1/09 the revision of a previously excluded treatment or procedure, regardless of Medical Necessity. 17. 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, are covered when "Medically Necessary" in the treatment of a metabolic or peripheral vascular disease. 18. Gene manipulation therapy. 19. Genetic counseling 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. 20. Expenses for health club membership. 21. 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. 22. Expenses related to hypnosis. 23. Treatment for infertility (absence of the ability to conceive a child) and/or artificial insemination, including drugs for treatment of infertility, in vitro fertilization, or reversal of vasectomies or reversal of tubal legations 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 confirmed, no expenses for the treatment of infertility will be covered unless the diagnosis constitutes a medical condition which is a threat to the covered person's health, and such additional treatment is medically necessary for that condition. 24. Services for which there is no legal obligation to pay, or charges which would not be made, but for existence of the Benefit Plan. 25. Maternity expenses or abortions for "Children," unless the life of the mother is endangered by the continued pregnancy or the pregnancy is the result of rape or incest. 26. Expense for preparing medical reports or itemized bills. 27. Benefits provided under Title XVIII of the Social Security Act (Medicare), as amended, to the extent that charges for the same services are also allowed under Medicare, except as may be required by law. 28. Expenses not "Medically Necessary" for diagnosis or treatment, except as specifically indicated as a covered medical expense. Eagle County Government 23 Medical Care Benefits • 1/1/09 29. Expenses for missed appointments and/or charges incurred when scheduled services are canceled by the covered person. 30. Expenses for multi -focal refractive Implant Optical Lenses (i.e. ReZoom). 31.' Accidents, when "No- Fault" auto /motor vehicle coverage exists or should have existed had there been compliance with applicable no -fault insurance regulations. Covered expenses in excess of No Fault medical reimbursement limits may be covered by the Plan. 32. Nonmedical expenses such as training, educational instruction, educational materials or studies, modifications to home, vehicle or work place to accommodate medical conditions, even if prescribed by a physician. However, this exclusion does not apply to patient, family member or other designated assistant, for education, training or supplies at the onset of a medical condition that is necessary to the proper care of that condition, or to further training caused by a change in the medical condition or the development of new treatment methods. 33. Care in an institution not licensed as a "Hospital" such as a nursing home or a home for the aged. Care in a convalescent facility following a period of hospitalization is a covered expense. 34. Expense in connection with services or supplies provided for treatment of obesity and weight reduction (except "Morbid Obesity "). 35. Personal comfort items while hospital confined, such as telephone, television, guest meals, etc. 36. Non - Physician referred Physical Therapy (inclusive of Occupational Therapy and/or Speech Therapy). 37. 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. 38. Any treatment or service furnished by a "Physician" who is a resident of a participant's household or member of the immediate family. 39. Services related to post - mortem testing. 40. Expenses subject to the pre- existing condition exclusion provision. 41. 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. Eagle County Government 24 Medical Care Benefits • 1/1/09 42. 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. 43. Expense for rental or purchase of equipment such as air conditioners, dehumidifiers, purifiers, whirlpools, heating pads and hot water bottles. 44. Expenses for sex change, transsexualism, gender dysphoria, including drugs, medication, hormone therapy, surgery, medical or psychiatric care and/or treatment. - 45. Any treatment or service provided for the purpose of smoking cessation, except as described under the Prescription benefit. 46. Special duty nursing services when requested by, or for the convenience of, the patient or the patient's family or when rendered by a private duty nurse who is related by blood, marriage, adoption, or a member of the household of the "Covered Person," such as a spouse, parent, child, brother or sister. 47. 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. 48. Surrogate expenses. 49. Treatment or surgical expense related to craniofacial muscle disorders and Temporomandibular disorders. The following services are not covered: electromyography, sonography, thermography, study models, dietary and related biochemical analysis, dental kinesiology, grinding the surface of the teeth, appliances, orthodontic treatment, or change of vertical dimension, including crowns. 50. Claims for any otherwise covered services during coverage suspension periods caused by non - compliance with the Plan's Third Party Liability Exclusion provision. 51. Transplant:services that are not human -to -human organ or tissue transplant procedures. 52. Travel expense by a "Covered Person" whether or not recommended by a physician, or travel expense incurred by a physician attending a "Covered Person." 53. Expenses exceeding the "Usual, Reasonable and Customary Charge" in the geographic area in which services are rendered. Eagle County Government 25 Medical Care Benefits • 1/1/09 54. Vitamins, minerals, nutritional supplements, appetite suppressants, dietary supplements, and formulas whether or not prescribed by a physician, except as specifically indicated as a covered expense. 55. Services provided to a "Covered Person" who sustains bodily "Injury" while participating in war, or "Illness" as the result of participating in war, whether declared or undeclared, insurrection, rebellion or revolution, or to any act or condition incident to any of the foregoing, unless as the result of a random act. 56. Expense for care not the result of an "Injury," "Illness" or "Sickness" except for "Wellcare" such as physical exams and appropriate tests performed by In- Network Providers and routine hospital nursery services for newborns which are covered as the mother's expenses. 57. Expense resulting from a work related "Accident" or "Illness" whether or not covered under workers' compensation or occupational disease laws. The term "work" as used herein includes not only employment with the Plan Sponsor, but employment by other employers or self - employment which are legally obligated to carry workers' compensation in an activity which requires that any income generated be reported to the Internal Revenue Service. For example, work does not include hobbies for personal pleasure, such as gardening or mechanical repairs on one's own automobiles, but does include self - employment in farming or automobile repair. Expenses otherwise ineligible under this Pan may be considered eligible expenses if they are determined to represent a more cost - effective form of medical treatment than another covered expense. The eligibility of such expenses is subject to prior written approval of the Plan. Pre- Existinz Condition Limitations The Plan will not cover treatment of a "Pre- Existing Condition" until you or your covered "Dependents" have been covered under the Plan for twelve (12) consecutive months. This provision does not apply to participating newborn infants, adopted "Children" or pregnancy related care if such participants are enrolled when first eligible. Also, genetic information may not be treated as a preexisting condition in the absence of a diagnosis. The twelve (12) 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 "HIPAA 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 ") or health coverage that is maintained by state, U.S. Government, foreign country, or any political subdivision and a state Children's Health Eagle County Government 26 Medical Care Benefits • 1/1/09 Insurance Program (S -CHIP) that provided coverage generally similar to that provided by this Plan. This Plan will follow the Standard Method 16 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. As allowed under HIPAA, 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 C. Auto liability insurance d. Workers' compensation e. Automobile medical payments insurance f. Credit -only insurance g. On -site medical clinic coverage h. Limited group dental or vision benefits i. Long -term care insurance j. "Convalescent Nursing Home" care k. Home health care 1. Community -based care m. Fixed income coverage n. Specific disease policies o. Medigap coverage p. Other plans for which HIPAA credit is not required by law 3. Documentation confirming participation in prior plans or other evidence of prior coverage, satisfactory to this Plan, must be provided to receive credit for prior coverage. 16 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 27 Medical Care Benefits • 1/1/09 This Plan will follow legal requirements for administering these provisions as may exist pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as amended, which apply to this Plan. Voluntary Pre - Notification You and your eligible "Dependents" are strongly encouraged to voluntarily notify the Claims Administrator, before the following: 1. All "Inpatient" hospitalizations. (Refer to item #4 below, for maternity.) 2. All surgical procedures not performed in the doctor's office. Notification is also suggested in the following circumstances: 1. Emergency "Hospital" admissions or surgeries should be phoned in within forty -eight (48) hours of the confinement or surgery, or the next business day if a weekend or holiday. 2. "Inpatient' hospitalizations for maternity that exceed forty -eight (48) hours for a normal delivery or ninety -six (96) hours for a cesarean delivery (c- section). It is highly recommended you notify the Claims Administrator within two (2) or three (3) days of a diagnosed pregnancy. This will allow the Claims Administrator to coordinate your treatment program throughout the entire pregnancy. 3. If a newborn infant must be hospitalized beyond the mother's discharge date. 4. Cancer treatment programs, administered on an inpatient or out - patient basis. The Claims Administrator will review the proposed hospitalization or surgery and may recommend that a second surgical opinion be obtained at the Plan's expense, or that the procedure be performed in an "Outpatient" setting. All Claims are subject to the terms and conditions, limitations and exclusions of the Plan at the time charges are incurred. How to voluntarily Pre - Notify the Claims Administrator When you or the "Physician's" office call the Claims Administrator to voluntarily notify, some detailed questions concerning the services to be performed will be asked, such as: a. Employee and Patient Name b. Hospital Name, Address and Phone Number C. Admitting "Physician" Name, Address and Phone Number Eagle County Government 28 Medical Care Benefits • 1/1/09 d. Medical Diagnosis e. Expected Admission and Discharge Time of Day and Dates f. Planned Course of Diagnosis or Treatment The phone number of the caller will be taken so that after the notification process is completed, a notification confirmation number can be given by return phone call. Phone -in notifications are completed within twenty -four (24) hours in most circumstances. Written verification to the employee will follow. For Voluntary Notification, Eligibility and/or Benefits, call or write to the Plan's Claims Administrator (refer to the Important Contact Information section for details): NOTE: Obtaining a notification confirmation number means the proposed treatment is appropriate for the condition, but it does not guarantee you are eligible for benefits or that the services are eligible medical expenses under the Plan. Coverage is contingent upon eligibility and all Plan provisions and limitations at the time the service is rendered and must be verified by the Claims Administrator. If requirements under the Plan for voluntary notification should differ from the guidelines and procedures set forth under the utilization review contract, as may be amended from time to time, it is the intent of the Plan that the provisions of the Plan's most current utilization review contract shall prevail. Case Management Program You may be contacted or can voluntarily contact the Plan's Medical Consultant as shown in the Important Contact Information section. 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 29 Medical Care Benefits • 1/1/09 Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate, however you're strongly encouraged to participate. Each treatment plan is individually tailored to a specific patient and should not be seen as appropriate or recommended for another patient, even one with the same diagnosis. Telephone Consultation Nurses are available by a toll -free line during the Case Manager's normal working hours to answer a Covered Person's health- related questions (Refer to Section Important Contact Information). Assistance ranges from providing a better understanding of specific medical procedures, to plain - English translations of medical terminology and help in locating community support services. Disease Management Program The plan contains, and strongly encourages use of, the Disease Management Program (DMP) provided by the Plan's Case Manger(s). The Program is voluntary and the purpose is to provide "Covered Person's" diagnosed with chronic medical condition(s) with education, monitoring and lifestyle coaching in order to help you better manage your health condition. Once you have been identified as a candidate for the DMP, a Case Manger will contact you and offer to help better understand your risk factors and utilize the most appropriate resources in the most appropriate settings. The DMP is intended to supplement the advice and care provided by your "Physician," not to replace it. The DMP nurses may contact your Physician to discuss your treatment, coordinate care plans or intervention when appropriate. For more information, contact the DMP team at the number listed in section Important Contact Information. Hospital Bill Audit Incentive It is not unusual that, given the complex nature of providing medical care and the immediacy of solving medical problems, patients are billed incorrectly for services. Patients are in the best position to know what services (doctor visits, tests, hospital care, x -rays, etc.) they received and have an obligation to be sure they are billed properly. To encourage careful scrutiny of bills, the Plan provides a cash audit incentive when errors are caught and corrected by employees for eligible services incurred covered under the Medical Plan. The payment is 50% of the amount of the corrected error to a maximum of $1,000 per calendar year. Carefully examine the bills you receive to be sure services were provided and billed correctly. For complex! services, it may be useful to maintain a diary of services rendered to use in auditing the bills and question attending doctors and nurses as services are provided. If errors are found, immediately contact the hospital and have the error corrected. For audit incentive payment, then send both the original and corrected bill to the Plan's Claims Administrator — refer to Eagle County Government 30 Medical Care Benefits • 1/1/09 the Important Contact Information section for contact information details. They will process your audit incentive claim, verify eligibility and correction and make incentive payments directly to you. This Benefit is not designed to reimburse for gross typographical clerical errors (i.e. a $3,000 entry which should have been $30.00). The claims processing system is designed to catch large clerical errors. You can help by verifying there are no duplicate charges or charges for services that were never performed and the like. The Audit Incentive is one additional common sense approach to helping us all control healthcare costs and we encourage your active involvement. All decisions on eligibility for incentive payments will be made by the Claims Administrator. Complementary Medical Treatment Modern medicine offers many new innovative and effective techniques for diagnosing and treating medical problems, and it offers the potential of better and more cost effective health care. Our Plan is designed not to merely cover traditional medical practices, but to cover services that are sensibly oriented to help the patient recover as quickly as possible and only use medical services that are necessary to the recovery. Thus Complementary Medical Treatment (CMT) provision allows the Plan latitude to adapt to complex medical situations creatively and cover many expenses that might normally be excluded such as: • Convalescent Care • Home Health Care Recuperation . • Home Health Aides • Social Workers 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? Eagle County Government 31 Medical Care Benefits + 1/1/09 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 an wers 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, 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 Contact Information section for contact information details. The PBM contracts with select pharmacies on the Plan's behalf. In this way, the Plan receives In- Network pricing for pharmaceuticals. An option is also available to obtain prescriptions by mail order, which is a convenient, and for the HRA PPO and Gold HSA PPO may be at a lower cost way to purchase maintenance medications that are needed on a regular basis. Generic, Substitution The Plan strongly encourages the use of generic prescription drugs. By law, generic and brand name drugs must meet the same standards of safety, purity, strength and effectiveness. At the same time, brand names are much more expensive than generic drugs. Use of generic drugs with this benefit will save you money and we encourage you to ask your "Physician" to prescribe them whenever possible. Unless your "Physician" indicates on your prescription that the brand name drug is "Medically Necessary" for you, the pharmacy will substitute the generic equivalent when available and permissible by law. Eagle County Government 32 Medical Care Benefits • 1/1/09 Who Can Prescribe "Physicians" as defined by this "Plan" and as allowed by law. Prescriptions written by other providers are not covered. Choice of Pharmacies In conjunction with the PBM, the Plan has developed a network of In- Network pharmacies with convenient locations to cover your needs. Your ID card will provide data to pharmacists necessary to fill your prescription. In- Network pharmacies contracted with the Plan's PBM will automatically file the prescription claim for you. Below is a list of a few of the pharmacies contracted with our Plan's PBM. However, for a complete list of PBM pharmacies, contact the Human Resources department or visit the PBM's website. 1. Wal -Mart 2. Eagle Pharmacy 3. King Soopers / City Market 4. Rite Aid — (Glenwood Springs) 5. Costco Also, on the PBM website, you can log -on to their Web Member Services which allows you to: 1. Locate In- Network Pharmacies, by city and state; 2. Access Mail Order pharmacy information 3. Research formulary drugs Covered Druzs Covered prescription drugs include but are not limited to (see Excluded Drugs for limitations): 1. "Legend" drugs; 2. Compounded drugs containing at least one "Legend" drug; 3. Insulin syringes and other diabetic supplies (glucometers limited to one (1) per calendar year) as prescribed by a "Physician;" 4. Bee sting kits, Imitrex (limited to two (2) injections per script), Depo - Provera, Lovenox, and Insulin; 5. Oral contraceptives, devices and other forms of birth control that require a prescription by a Physician; Eagle County Government 33 Medical Care Benefits • 1/1/09 6. Smoking cessation drugs, limited to one period of a maximum of six (6) consecutive months during a covered "Adult" person's lifetime. 7. The following Over the Counter (OTC) drugs: Prilosec OTC, Alavert, Claritin, and Zyrtec (their OTC generic equivalents). Prescri Lion 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 mav 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, Depo Provera, Lovenox 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, and over - the - counter drugs. 5. Rogaine, or similar hair loss medications. 6. Drugs used to promote or enhance fertility or ovulation. 7. Refilling of a prescription in excess of the number of units specified by the "Physician" or dentist, or any refill dispenses after one year from the order of a physician or dentist. 8. Therapeutic devices or appliances, such as Spinhaler, Inspirease, Aerochamber, etc. 9. Any medication, "Legend" or not, which is consumed or administered at the place where it is dispensed. 10. Any charge for the administration of prescription Legend drugs or injectable insulin. 11. Medication which is to be taken by or administered to the patient, in whole or in part, while he or she is a patient in a hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution which operates on its premises, or allows to be operated on premises, a facility for dispensing pharmaceuticals. 12. Immunization agents, injectable immunosuppressants, biological sera and blood plasma. Eagle County Government 34 Medical Care Benefits • 1/1/09 13. Newly approved drugs may not automatically be covered. They must be reviewed by the Plan on a case -by -case basis. 14. Prescription drugs that are provided by local, state or federal programs, including Workers' Compensation. 15. Tretinoin (e.g. Retin A, Accutane) except to treat anon- cosmetic condition, for persons over age 35. Retail Prescription Card Benefit with your Traditional PPO and HRA PPO Plans USING YOUR RETAIL PRESCRIPTION CARD Pharmaceuticals covered by this Plan, other than those dispensed while you are hospitalized, must be purchased at one of the pharmacies that have contracted with our Plan. These arrangements allow the Plan to provide both enhanced benefits and help moderate the rapidly increasing cost of pharmaceuticals. Present your prescription card at the time you present your prescription to the Pharmacist every time you have a prescription filled. RETAIL PRESCRIPTION (Rx) COPAYMENTS 1. For Traditional PPO and HRA PPO Only, the "Employee" or "Dependent" will be responsible to pay the copay. Please refer to the Medical Benefit Summary section 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 of the plan deductibles or out -of- pocket limits. Retail Prescription Card Benefit with your Gold HSA PPO Plan USING YOUR RETAIL PRESCRIPTION CARD Pharmaceuticals covered by this Plan, other than those dispensed while you are hospitalized, must be purchased at one of the pharmacies that have contracted with our Plan or through the mail order program. These arrangements allow the Plan to provide both enhanced benefits and help moderate the rapidly increasing cost of pharmaceuticals. Present your medical /prescription card at the time you present your prescription to the Pharmacist every time you have a prescription filled to ensure that you received the discounted drug price. Eagle County Government 35 Medical Care Benefits • 1/1/09 RETAIL RX DISPENSING LIMITATIONS Up to a 30 -day supply Retail 9 A convenient option to mail order is the Retail 90 program which allows you the option of filling a 90 -day supply at participating pharmacies for your regular mail order copay. Please see the Human Resources office for a list of participating pharmacies. Mail Order Pharmacy Benefit A valuable option in the Medical Plan is the Mail Order Prescription Drug service, managed by our Plan's PBM (see Important Contact Information 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 Mail Order Pharmacy's website (refer to the Important Contact Information section for details). 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 Mail Order Pharmacy and mail it in on or after the refill date printed on the reorder form, or (b) you may call the Mail Order Pharmacy's toll -free number, 1- 800 - 677 -4323 or the 24 Hour Refill Line at 1- 800 - 926 -2455. 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 should 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 Mail Order Pharmacy. 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 ordering Eagle County Government 36 Medical Care Benefits • 1/1/09 from mail service and ask your physician to write the prescription for a 90 -day supply with the appropriate number of refills. 8. Be sure to discuss with your physician the possibility of prescribing generic medication. Utilizing generic medications will reduce your health care cost. MAIL ORDER RX DISPENSING LIMITATIONS Up to a 90 -day supply. Prohibited Use of the Prescription Card The Prescription Card cannot be used if you are no longer eligible for benefits. Also, you cannot obtain drugs prescribed for the treatment of a work - related "Injury" or "Illness." Termination of Prescription Card Coverage Your right to use the Prescription Card Benefit ends when your coverage under this Plan terminates. GENERAL MEDICAL PLAN INFORMATION Claims Procedure Defined Terms A Claim means a request for a Plan benefit, made by a Covered Person or by an authorized representative of a Covered Person that complies with the Plan's reasonable procedures for filing benefit Claims. A Claim for benefits is not a Claim that has been previously submitted, denied, appealed, and redenied upon appeal. A Claim is a Post - Service Claim under the terms of the Plan. A Post - Service Claim means a Claim for covered medical or dental services that have already been received by the Plan Participant. All questions regarding Claims should be directed to the Claims Administrator. All claims will be considered for payment according to the Plan's terms and conditions, limitations and exclusions, and industry standard guidelines in effect at the time charges were incurred. The Plan may, when appropriate or when required by law, consult with relevant health care professionals and access professional industry resources in making decisions about claims involving specialized medical knowledge or judgment. The Plan Administrator shall have full responsibility to adjudicate all claims and to provide a full and fair review of the initial claim determination in accordance with the following Claims review procedure. Eagle County Government 37 Medical Care Benefits • 1/1/09 For the purposes of this Claims Procedure section, You and Your means the Plan Participant or the Plan Participant's authorized representative. You and your does not include a healthcare provider simply by virtue of an assignment of benefits. You may appoint an authorized representative to act upon his or her behalf with respect to the Claim. Cjontact the Claims Administrator for information on the Plan's procedures for authorized representatives. A Claim Denial shall mean all or part of a claim is denied, a reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit. An inquiry regarding eligibility or benefits without a Claim for benefits is not a Claim and, therefore, cannot be appealed. In- Network Providers Hospital and facility claims will be filed by In- Network providers by way of the Plan's Provider Network. Patients are responsible for dollar copays, as applicable, at the time of service. Out -of- Network Providers As you and/or your family members accumulate "Out -of- Network" expenses, you should submit them to the Plan's Claims Administrator. You are encouraged to "batch" your claims together whenever possible to help the Plan to control processing costs. Specific data regarding all claims is necessary for prompt payment. How TO FILE A CLAIM FOR A OUT -OF- NETWORK PROVIDER SERVICE The appropriate claim forms and identification cards may be obtained directly from the Claims Administrator or Eagle County Human Resources office. The following general steps should be followed in order to file a claim: 1. Complete the employee portion of the claim form in full. Answer all questions, even if the answer is "none" or "N /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; Eagle Coynty Government 38 Medical Care Benefits • 1/1/09 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 Contact Information section for contact information details. Note: A Claim will not be deemed submitted until it is 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. Should an extension be necessary, you will be notified of the following: (a) the reasons for the extension; (b) when your claim is expected to be decided; and (c) any additional information needed to decide the claim. If additional information is needed, you will have forty -five (45) days to provide the information. If you do not provide the information within forty -five (45) days, the Claims Administrator may decide your claim based on the information received. If your claim is denied in whole or in part, you will receive a written notice of denial containing: 1. The specific reason(s) for the denial, referencing the plan provision(s) which the decision is based, as well as references to any internal rule(s) or guideline(s) relied upon in making the decision. 2. Information concerning your right to receive an explanation of the scientific or clinical judgment relied upon to exclude healthcare expenses for services or supplies that are experimental or investigational or are not necessary or accepted according to generally accepted standards of medical or optical practice. Eagle County Government 39 Medical Care Benefits • 1/1/09 3. Request and describe any additional information necessary to support your claim. 4. Information concerning your right to appeal the claims decision with applicable time frames you must follow. Concurrent Care Decisions i When the Plan has approved an ongoing course of treatment to be provided over a period of time or number of treatments, any decision to reduce or terminate the course of treatment (other than by Plan amendment or Plan termination) before the end of the period of number of treatments shall be treated as a benefit denial. Notification of such a concurrent care decision must be given to the affected Plan participant or beneficiary in sufficient time to allow an appeal and determination on review before the treatment is terminated or reduce. Timely Filing of Claims Except in the absence of legal capacity, in no event will an expense be considered if the claim is filed more than six (6) months after the end of the calendar year in which the expense was incurred. Claims Appeal Procedures If all or part of a claim for benefits is denied, you may request an appeal of the claims denial. You must request an appeal in writing within 180 days after receiving notice of the denial. When appealing a benefit decision, you should: 1. State the reason you feel the claim is valid; 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 member identification, the name of the patient and the Group Identification Number, if any. 4. Send written appeals to the Claims Administrator —refer to the Important Contact Information section for contact information details. Note: A ! Claim will not be deemed submitted until it is received by the 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. Eagle County Government 40 Medical Care Benefits • 1/1/09 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. If upon review of a denial of a claims appeal, the "Covered Person" does not agree with the final determination, the Covered Person has the option to bring an action for benefits. The Covered Person must exhaust appeals process as described in this section before taking any legal action to obtain benefits. Furthermore, such action must be commenced within one (1) year of the date of the notice of the Plan Administrator's final appeal decision. Coordination of Benefits The Plan's Coordination of Benefits provision sets forth rules for the order of payment of Covered Charges when two or more plans — including Medicare — are paying. The Plan has adopted the order of benefits as set forth in the National Insurance Commissioners Association (NAIL) Model COB Regulations, as amended. When a Covered Person is covered by this Plan and another plan, or the Covered Person's Spouse is covered by this Plan and by another plan, or the couple's Covered children are covered under two or more plans, the plans will coordinate benefits when a claim is received. The plan that pays first according to the rules will pay as if there were no other plan involved. The secondary and subsequent plans will pay the balance due up to 100% of the total Allowable Charges. Eagle County Government 41 Medical Care Benefits • 1/1/09 Benefit plan This provision will coordinate the medical and dental benefits of a benefit plan. The term benefit plan means this Plan or any one of the following plans: 1. Group or group -type plans, including franchise or blanket benefit plans. 2. Blue Cross and Blue Shield group plans. 3. Group practice and other group prepayment plans. 4. Federal government plans or programs. This includes Medicare. 5. Other plans required or provided by law. This does not include Medicaid or any benefit plan like it that, by its terms, does not allow coordination. 6. Any automobile insurance, including but not limited to, No Fault Auto Insurance, by whatever name it is called, when not prohibited by law. 7. Any third -party liability insurance, including but not limited to, homeowners liability insurance, umbrella insurance and premises liability insurance, whether individual or commercial, or on an insured, uninsured, under - insured or self- insured basis. If the Covered Person, or someone on behalf of the Covered Person, has received any compensation and/or benefits from any third -party source, this compensation and/or benefits shall be primary and shall be coordinated with the benefits that they may be eligible to receive through this Plan before they may receive any benefits from this Plan. Allowable Charge(s) For a charge to be allowable it must be a Usual, Customary, and Reasonable Charge and at least part of it must be covered under this Plan. In the case of HMO (Health Maintenance Organization) or other in- network only plans: This Plan will not consider any charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an HMO or network plan is primary and the Covered Person does not use an HMO or network provider, this Plan will not consider as an Allowable Charge any charge that would have been covered by the HMO or network plan had the Covered Person used the services of an HMO or network provider. In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the Allowable Charge. Automobile limitations When any payments are available under vehicle insurance, the Plan shall pay excess benefits only, without reimbursement for vehicle plan deductibles. This Plan shall always be considered the secondary carrier regardless of the individual's election under PIP (personal Injury protection) coverage with the auto carrier. Eagle County Government 42 Medical Care Benefits • 1/1/09 Benefit plan payment order When two or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules. 1. Plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision will be considered after those without one. 2. Plans with a coordination provision will pay their benefits up to the Allowable Charge. The first rule that describes which plan is primary is the rule that applies: a. The benefits of the plan which covers the person directly (that is, as a Member/Employee, Retiree, or subscriber) ( "Plan A ") are determined before those of the plan which covers the person as a Dependent ( "Plan B "). For Qualified Beneficiaries, coordination is determined based on the person's status prior to the Qualifying Event. Special rule. If: 1. The person covered directly is a Medicare beneficiary, 2. Medicare is secondary to Plan B, and 3. Medicare is primary to Plan A (for example, if the person is retired), THEN Plan B will pay first. 4. Unless there is a court decree stating otherwise, when a child is covered as a Dependent by more than one plan the order of benefits is determined as follows: a. When a child is covered as a Dependent and the parents are married or living together, these rules will apply: (1) The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined before those of the benefit plan of the parent whose birthday falls later in that year; (2) If both parents have the same birthday, the benefits of the benefit plan which has covered the parent for the longer time are determined before those of the benefit plan which covers the other parent. When a child's parents are divorced, legally separated or not living together, whether or not they have ever been married, these rules will apply: (i) A court decree may state which parent is financially responsible for medical and dental benefits of the child. In this case, the benefit plan of that parent will be considered before other plans that cover the child as a Eagle County Government 43 Medical Care Benefits • 1/1/09 Dependent. This rule applies beginning the first of the month after the plan is given notice of the court decree. (ii) A court decree may state both parents will be responsible for the Dependent child's health care expenses. In this case, the plans covering the child shall follow order of benefit determination rules outlined above when the parents are married or living together (as detailed above); (iii) If the specific terms of the court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined above when a child is covered as a Dependent and the parents are married or living together. If there is no court decree allocating responsibility for the Dependent child's health care expenses, the order of benefits are as follows: 1 st The plan covering the custodial parent, 2nd The plan covering the spouse of the custodial parent, 3rd The plan covering the non - custodial parent, and 4th The plan covering the spouse. of the non- custodial parent. (3) The benefits of a benefit plan which covers a person as a Member/Employee who is neither laid off nor retired are determined before those of a benefit plan which covers that person as a laid -off or Retired Member/Employee. The benefits of a benefit plan which covers a person as a Dependent of a Member/Employee who is neither laid off nor retired are determined before those of a benefit plan which covers a person as a Dependent of a laid off or Retired Member/Employee. If the other benefit plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule does not apply. (4) The benefits of a benefit plan which covers a person as a Member/Employee who is neither laid off nor retired or aDependent of a Member /Employee who is neither laid off nor retired are determined before those of a plan which covers the person as a COBRA beneficiary. This rule does not apply if rule #1 can be used to determine the order of benefits. (5) If there is still a conflict after these rules have been applied, the benefit plan which has covered the patient for the longer time will be considered first. When there is a conflict in coordination of benefit rules, the Plan will never pay more than 50% of Allowable Charges when paying secondary. (i) Medicare will pay primary, secondary or last to the extent stated in federal law. When Medicare is to be the primary payer, this Plan will base its payment upon benefits that would have been paid by Medicare under Parts A and B, regardless of whether or not the person was enrolled under both of these parts. Eagle County Government 44 Medical Care Benefits • 1/1/09 (ii) If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will pay first and this Plan will pay second. Claims determination period Benefits will be coordinated on a Calendar Year basis. This is called the claims determination period. Right to receive or release necessary information To make this provision work, this Plan may give or obtain needed information from another insurer or any other organization or person. This information may be given or obtained without the consent of or notice to any other person. A Covered Person will give this Plan the information it asks for about other plans and their payment of Allowable Charges. Facility of payment This Plan may repay other plans for benefits paid that the Plan Administrator determines it should have paid. That repayment will count as a valid�payment under this Plan. Right of recovery This Plan may pay benefits that should be paid by another benefit plan. In this case this Plan may recover the amount paid from the other benefit plan or the Covered Person. That repayment will count as a valid payment under the other benefit plan. Further, this Plan may pay benefits that are later found to be greater than the Allowable Charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid. Exception to Medicaid In accordance with ERISA, the Plan shall not take into consideration the fact that an individual is eligible for or is provided medical assistance through Medicaid when enrolling an individual in the Plan or making a determination about the payments for benefits received by a Covered Person under the Plan. Third Party Liability Exclusion Defined Terms "Covered Person" means anyone covered under the Plan, including but not limited to minor dependents and deceased Covered Persons. Covered Person, shall include the parents, trustee, guardian, heir, personal representative or other representative of a Covered Person, regardless of applicable law and whether or not such representative has access or control of the Recovery. Eagle County Government 45 Medical Care Benefits • 1/1/09 "Recover," "Recovered," "Recovery" means all monies recovered by way of judgment, settlement, reimbursement, or otherwise to compensate for any loss related to any Injury, Sickness, condition, and/or accident where a Third Party is or may be responsible. "Recovery" includes, but is not limited to, recoveries for medical or dental expenses, attorneys' fees, costs and expenses, pain and suffering, loss of c ' nsortium, wrongful death, wages and/or any other recovery of any form of damages or compensation whatsoever. "Third Party" means any third party including but not limited to another person, any business entity, insurance policy or any other policy or plan, including but not limited to uninsured or underinsured coverage, self - insured coverage, no -fault coverage, automobile coverage, premises liability (homeowners or business), umbrella policy. Right to Reimbursement This provision applies when the Covered Person incurs medical or dental expenses due to an Injury, Sickness, condition, and/or accident which may be caused by the act or omission of a Third Party or a Third Party may be responsible for payment. In such circumstances, the Covered Person may have a claim against a Third Party for payment of such expenses. To the extent that the Plan paid benefits on the Covered Person's behalf, the Covered Person agrees that the Plan has a lien on any Recovery whether or not such Recovery(s) is designated as payment for such expenses. This lien shall remain in effect until the Plan is repaid in full. The Covered Person, and/or anyone on his or her behalf, agrees to hold in trust for the benefit of the Plan, that portion of any Recovery received or that may be received from a Third Party in an amount equal to the benefits paid by the Plan or that the Plan has agreed pay on the Covered Person's behalf. The Covered Person shall promptly reimburse the Plan out of such Recovery, in first priority for the full amount of the Plan's lien. The Covered Person will reimburse the Plan first, even if the Covered Person has not been fully compensated or "made whole" and/or the Recovery is called something other than a Recovery for healthcare, medical and/or dental expenses The Plan will only be responsible for those attorney fees and/or costs of recovery associated with a Covered Person pursuing a claim against a Third Party to the extent that the Plan agrees in writing, or subject to the terms of a court order. Right to' Subrogation This provision applies when the Covered Person incurs medical or dental expenses due to an Injury, Sickness, condition, and /or accident which may be caused by the act or omission of a Third Party or a Third Party may be responsible for payment. In such circumstances, the Covered Person may have a claim against a Third Party for payment of such expenses. The Covered Person agrees that the Plan is subrogated to any and all claims, causes of action or rights that the Covered Person may have now or in the future against a Third Party who has or may have caused, contributed aggravated, and or be responsible for the Covered Person's Injury, Sickness, condition, and/or accident to the extent the Plan has paid benefits or has agreed to pay Eagle County Government 46 Medical Care Benefits • 1/1/09 benefits. The Covered Person further agrees that the Plan is subrogated to any and all claims or rights that the Covered Person may have against any Recovery, including the Covered Person's rights under the Plan to bring an action to clarify his rights under the Plan. The Plan may assert this Right of Subrogation independently of the Covered Person. The Plan is not obligated to pursue this right independently or on behalf of the Covered Person, but may choose to exercise this right, in its sole discretion. Provisions Applicable to Both the Right to Reimbursement and Right to Subrogation The Covered Person automatically assigns to the Plan any and all rights he or she has or may have against any Third Party to the full extent of the Plan's equitable lien. The Covered Person agrees to: 1. Cooperate fully with the Plan and its agents, regarding the Plan's rights under this section; 2. Advise the Plan of any right or potential right to reimbursement and/or subrogation on the Plan's behalf; 3. Provide to the Plan in a timely manner any and all facts, documents, papers, information or other data reasonably related to the Covered Person's Injury, Sickness, condition, and/or accident, including any efforts by another individual to Recover on the Covered Person's behalf; 4. Execute all instruments and papers that the Plan or its agents may reasonably request to protect the Plan's rights under this section; Hold in trust that portion of any Recovery received by the Covered Person or on the Covered Person's behalf equal to the Plan's lien 5. Agree not to impair, impede or prejudice in any way, the rights of the Plan under this section; and 6. Do whatever else the Plan deems reasonably necessary to secure the Plan's rights under this section. The Plan may take one or more of the following actions to enforce its rights under this section: 1. The Plan may require the Covered Person as a condition of paying benefits for the Covered Person's Injury, Sickness, condition, or accident, to execute documentation acknowledging the Plan's rights under this section; 2. The Plan may, to the extent of any benefits paid by the Plan, exercise its Right of Reimbursement against any Recovery received, or that will be received, by or on behalf of Covered Person; 3. The Plan may, to the extent of any benefits paid by the Plan, exercise its Right of Subrogation directly against a Third Party who is or may be responsible; or 4. If full re- payment is not made to the Plan within 60 days after benefits are received from a third party or a third party's insurer, Plan participation will 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. In addition to this suspension of benefits, the Plan may bring legal action to recover these benefits in any court with jurisdiction over the individual who received these benefits. Eagle County Government 47 Medical Care Benefits • 1/1/09 Plan Administrator is vested with full discretionary authority to interpret and apply the provisions of this section. In addition, the Plan Administrator is vested with the discretionary authority to waive or compromise any of the Plan's rights under this section. Any decision of the Plan Administrator made in good faith will be final and binding. The Plan Administrator is authorized to adopt such procedures as deemed necessary and appropriate to administrate the Plan's rights under this section. Assi n ent of Bene its 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 determined 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 w have caused the error. Recovery of Excess Payments 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. Right N Recei ve and Release Necessary Information The Plan may, without the consent of or notice to any person, release to or obtain from any organization or person, information needed to implement plan provisions. When you request benefits, you must furnish all the information required to implement Plan provisions. Alternate Payee Provision Under normal conditions, benefits are payable to you and can only be paid directly to another party upon signed authorization from you. If conditions exist under which a valid release or assignment cannot be obtained, the Plan may make payment to any individual or organization that has assumed the care or principal support for you if they are entitled to payment. The Plan may also honor benefit assignments made prior to your death in relation to remaining benefits',payable by the Plan. Any payment made by the Plan in accordance with this provision will fully release the Plan of its liability to you and your heirs. When Coverag e Ends Coverage for "Employees" will end at midnight the earliest of the following: 1. The last day of the month during which employment terminates; Eagle County Government 48 Medical Care Benefits • 1/1/09 2. The last day of the month during which the "Employee" is no longer eligible; 3. The date the Plan ends; 4. The last day of the month in which the Employee stops required contributions, if any. 5. Upon reaching the Plan's Lifetime Maximum benefit (refer to Medical Benefit Summary section for details). "Dependent(s)" coverage will end at midnight on the earliest of the following: 1. The date that "Employee" coverage stops except when as a result of the Employee reaching the Plan's Lifetime Maximum benefit; 2. The last day of the month during which the "Dependent" no longer qualifies for Plan coverage; 3. The last day of the Calendar Year in which a "Dependent" reaches 24 -years of age if a full - time student. Refer to the Definitions section for further details; 4. The last day of the month in which the "Employee" stops required contributions for "Dependent" coverage. 5. Upon reaching the Plan's Lifetime Maximum benefit (refer to Medical Benefit Summary section for details). Continuation of Coverage During an Illness or Approved Leave of Absence Coverage may be continued after the date coverage would have otherwise stopped if approved by the County, for up to six (6) months. 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. Family Medical Leave If you qualify for an approved Family or Medical Leave of Absence as defined 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 Eagle County Government 49 Medical Care Benefits • 1/1/09 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. Prescri Lion Drug Creditability Status Related to Medicare Part D "Covered Persons" entitled to Medicare should read this section carefully. The County's Traditional PPO and HRA PPO Plan options provide Creditable Coverage, meaning it is, on average, for all plan participants, expected to provide coverage as good or better coverage than the standard Medicare prescription drug coverage will pay. Prescription drug coverage under the Gold HSA PPO Plan option is Non - Creditable Coverage. Because such coverage is on average for all Gold HSA PPO plan participants, NOT expected to pay out as much as the standard Medicare prescription drug coverage will pay, you might want to consider enrolling in a Medicare prescription drug plan. You may join between November 15th and December 31St of each calendar year. This is important, because if you do not get Medicare prescription drug coverage (or equivalent coverage) when you are first eligible, you may have to pay a higher premium if you join later. You will pay that higher premium as long as you have Medicare prescription drug coverage. You are strongly encouraged to contact Medicare at www.medicare.gov or 1- 800 - MEDICARE (1- 800 - 633 -4227) for personalized help. For more information or to request a copy of the Plan's Medicare Part D Notice of Creditable Coverage, contact the Human Resources office at the number listed within the Important Contact Information section herein. QuaE��d Medical Child Support Order (OWCSO) 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. The court order may not require a plan to provide any type or form of benefit, or any option, not otherwise provided under the Plan. Eagle County Government 50 Medical Care Benefits • 1/1/09 The term "Alternate Recipient" means any child of a participant who is recognized under a medical child support order as having a right to enrollment under a health plan. When the Plan receives a medical child support order, the following steps will be taken: 1. Notify both the participant and each Alternate Recipient of the receipt of the order; 2. Furnish an explanation of the Plan's procedures for determining whether the court order is a QMCSO; 3. Determine if it is qualified; and 4. Notify the participant and each Alternate Recipient of the determination, and if qualified, when coverage becomes effective. The Plan Administrator is responsible for deciding if the court order satisfies the conditions of a QMCSO. If it does, the child is an Alternate Recipient and is considered a beneficiary under the Plan for purposes of ERISA, if applicable. This child is also considered a participant under the Plan for reporting and disclosure purposes of ERISA, if applicable. The Plan will also recognize a properly executed National Medical Support Notice. Eagle County Government 51 Medical Care Benefits • 1/1/09 DENTALICARE'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, cleaning, fluoride None treatment and sealants "Children" BASIC X -rays, fillings, $50 per person per 80% 20% SERVICES extractions, surgery, calendar year for Basic periodontics, denture and Major services repair, anesthesia combined ($150 family maximum per year) MAJOR Crowns, bridgework, $50 per person per 80% 20% SERVICES dentures, inlays, calendar year for Basic gold restorations and Major services 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 52 Dental Care Benefits • 1/1/09 DENTAL PLAN DETAIL Dental Plan Eliaibility and Effective Date Eligibility for "Employees" and "Dependents" for the Dental Plan is identical to that for Medical. For more information, please refer to the Medical Plan Eligibility and Enrollment section. Late Enrollee Benefit Restriction Eligible Employees and Dependents that do not elect to enroll in the dental Plan when initially eligible or as maybe permitted via Special Enrollment will be required to be continuously enrolled in the dental Plan for a consecutive twelve (12) month period prior to becoming eligible for Basic, Major, or Orthodontic benefits under the Plan. Likewise, any Employee or Dependent that enrolls in the Plan when first eligible, but then subsequently drops coverage (while the employee is still employed) will be required to be re- enrolled in the dental plan for a consecutive twelve (12) month period prior again becoming eligible for Basic, Major, or Orthodontic benefits under the Plan. COVERED DENTAL EXPENSES Preventive Care The Plan covers 100% of the following services: 1. Routine examinations and teeth cleaning services -- twice in any 12 consecutive months ' 2. Diagnostic x -rays once per 12- consecutive month period 3. Space maintainers 4. One panoramic x -ray in any consecutive 36- calendar month period. 5. Fluoride treatment for dependent children age 19 and under j- once per calendar year 6. Sealants for the posterior teeth of "Children" age 14 and under are limited to one application per 3 -year period 7. "Emergency" treatment to relieve pain When "Medically Necessary," a "Covered Person" may be eligible for two (2) additional cleanings in any 12- consecutive month period. You must utilize the Pre - Treatment Review process in advance of such care or your claim may be denied. Refer to the Pre - Treatment Review section for details. Eagle County Government 53 Dental Care Benefits • 1/1/09 Basic Services The Plan covers 80% of the following services: 1. Fillings (amalgam, acrylic, plastic or composite) 2. Oral surgery, including extractions 3. General anesthesia when "Medically Necessary" and administered in connection with oral or dental surgery 4. General anesthesia for "Children" when "Medically Necessary" 5. Periodontics (treatment of gum disease) and endodontics (treatment of dental pulp) including root canal therapy 6. Repair of dentures or bridgework 7. Injectable antibiotics Major 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. Orthodop tics 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 flan 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. Eagle County Government 54 Dental Care Benefits • 1/1/09 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 periodontically 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. The term "work" as used herein includes not only employment with the Plan Sponsor, but employment by other employers or self - employment which are legally obligated to carry workers' compensation in an activity which requires that any income generated be reported to the Internal Revenue Service. For example, work does not include hobbies for personal pleasure, such as gardening or mechanical repairs on one's own automobiles, but does include self- employment in farming or automobile repair. 7. Expenses to the extent they may be reimbursed through any public program including "Medicare" (anyone eligible for both Part A and Part B of Medicare will be considered covered under those programs). 8. 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, except as required by law. 9. Charges which you or your family members are not legally required to pay, or charges which would not be made, but for the existence of this Benefit Plan. 10. Dental care that is not "Medically Necessary" 11. Charges in excess of what is the "Usual, Reasonable and Customary" charge for your locality. 12. Charges for hospitalization due to dental treatment unless "Medically Necessary." , 13. Accidents, when "No- Fault" auto /motor vehicle coverage exists or should have existed had there been compliance with applicable no -fault insurance regulations. Covered expenses in excess of No Fault medical reimbursement limits may be covered by the Plan. Eagle County Government 55 Dental Care Benefits • 1/1/09 14. Services provided by or under the direct supervision of parties other than a properly licensed "Dentist." 15. Charges for services commencing prior to start of coverage. 16. Expenses for dental implants to replace missing teeth that were missing prior to enrollment in this Plan. 17.' Charges for services rendered after coverage terminates. 18. Charges for completion of forms or missed appointments. 19. Services provided a "Covered Person" who sustains bodily "Injury" while participating in war, whether declared or undeclared, insurrection, rebellion or revolution, or to any act or condition incident to any of the foregoing unless as the result of a random act. 20. Expenses for any "Injury" incurred or "Illness" 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 of legal jurisdiction finds 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. 21. Procedures not commonly recognized by the Dental profession or American Dental Association. 22. Expenses covered under the County's Medical Plan. 23. Orthodontic services incurred prior to Plan participation. 24.' Claims filed after any claim filing deadlines. 25.', Occlusal and/or night guards for Bruxism or harmful habits. 26. Charges for education or training, such as, but not limited to, oral hygiene instructions or dietary planning for control of dental decay. Eagle County Government 56 Dental Care Benefits • 1/1/09 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, or when your "Dentist" has recommended when "Medically Necessary" up to two additional teeth cleanings beyond the Plan's limitation (two per 12- consecutive month period), you must have your "Dentist" complete a pre- treatment claim form in advance of this additional procedure or your claim may be denied. 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. The Pre - treatment Review is not mandatory but if the process is not followed, payment will be determined by the Plan taking into account medical necessity, alternate procedures or services, based on acceptable standards of dental practices. Claims Procedure Please refer to the Claims Procedure section in the Medical portion of this Plan for instructions on how to file claims under "Out -of- Network" Providers. Coordination of Benefits Please refer to section Coordination of Benefits in the Medical portion of this Plan for rules that apply when a person is covered by two or more Plans. When Coverage Ends Please refer to section When Coverage Ends in the Medical portion of this Plan for details about when coverage ends. Continuation of Dental Benefits Please refer to Continuation of Coverage section for further details. Eagle County Government 57 Dental Care Benefits • 1/1/09 VISION CARE BENEFITS A vision benefit is available to Employees examinations, lenses, frames and contact lenses. Vision �Ltkibility and Effective Date and their "Dependent(s)" to help pay for eye 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, Copays and Maximums Maximum Benefit The Plan will pay up to $400 per calendar year per "Covered Person" for the following services and supplies gombined: 1. Eye Exams — Limited to one (1) exam per calendar year. 2. Prescription Lenses, Frames and Contact Lenses 3. Corrective eye surgery such as LASIK and PRK. Vision Providers Covered participants may select either an "In- Network" or "Out -of- Network" licensed optometrist, ophthalmologist or eyewear retailer. How to File a Vision Claim Please refer to the Claims Procedure section in the Medical portion of this Plan for instructions on how to file claims under "Out -of- Network" Providers. Please contact Human Resources for the appropriate claim form. Limitations and Exclusions The Vision Plan covers "Usual, Reasonable and Customary Charges" for services and supplies that are "Medically Necessary." Eagle County Government 58 Vision Care Benefits * 1/1/09 Vision benefits are not provided for: 1. Care that is not "Medically Necessary" or is considered "Experimental." 2. Services provided while you are not a "Covered Person" 3. Expenses covered under the County's Medical Plan. 4. Expense resulting from a work related "Accident" or "Illness" whether or not covered under workers' compensation or occupational disease laws. When Coveraze Ends Please refer to the When Coverage Ends section in the Medical portion of this Plan for further details. Continuation of Vision Benefits Please refer to Continuation of Coverage section for further details. Eagle County Government 59 Vision Care Benefits • 1/1/09 Introdu ti'on This section contains important information about your right to COBRA continuation coverage (COBRA), which is a temporary extension of group health coverage under this Plan. The right to COBRA was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 as amended (COBRA). COBRA may become available to you, your spouse and dependent children who are covered under the Plan (know as "Qualified Beneficiaries ") when you or they would otherwise lose group health coverage under this Plan (the result of which is known as a qualifying event). This section explains when COBRA may become available to Qualified Beneficiaries (QBs) and what you need to do to protect your right to receive it. QBs who fail to elect COBRA coverage may cause a gap in their health coverage. Gaps in health coverage of more than sixty -three (63) days may subject you to a preexisting condition exclusion under the next group health plan you become eligible to enroll in. Both 'you (the employee) and your spouse should read this section carefully. Plan's COBRA Notification Contact (PCNC) Eagle County Government has assigned the Plan's COBRA Notification Contact (PCNC). All initial 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 500 Broadway / P.O. Box 850 Eagle, CO 81631 (970) 328 -8790 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. Eagle County Government 60 Continuation of Coverage • 1/1/09 All provisions shall hereby be automatically amended to be in minimal compliance, or as otherwise elected by the Plan, with the American Recovery and Reinvestment Act of 2009 (ARRA) as it pertains to the COBRA subsidy provisions. Qualifying 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. Same sex domestic partners and Children of a covered Employee's domestic partner, who otherwise satisfy the eligibility requirements set forth in this Plan's Eligibility section and are covered under this Plan, will also be offered the opportunity to make an independent election to receive COBRA Continuation Coverage. All references to spouse will also be applicable to a same sex domestic partner, unless otherwise indicated. 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 S. You become divorced or legally separated from your spouse. Your "Dependent" Children) 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; Eagle County Government 61 Continuation of Coverage • 1/1/09 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." Notice of Unavailability If the Plan's COBRA Notification Contact (PCNC) determines that a qualified beneficiary who furnished the plan with a notice of qualifying event, second qualifying event, or disability determination is not entitled to COBRA 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. Your Notice Obligations While You are a Plan Participant If your spouse or dependent child loses coverage under the Plan because of divorce, legal separation or the child's losing dependent status under the Plan, then you (the employee), your spouse or dependent must notify the Plan's COBRA Notification Contact (PCNC) in writing, of such an event. The written notice to the PCNC must be received no later than sixty (60) days after the later of: 1. The date of the Qualifying Event; or 2. The date on which the Qualified Beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the Qualifying Event. Your written Qualifying Event (QE) notice must contain the information as described later in this section under Written Notice Guidelines. Incomplete QE notices may not be accepted by the Plan and may result in the loss of COBRA coverage. Failure to provide the written QE notice to the PCNC during this 60 -day notice period may have the following consequences: 1. Any spouse or dependent child who loses coverage will NOT be offered the option to elect !COBRA; 2. 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. If the PCNC is timely provided with written notice of a divorce, legal separation, or a child's losing dependent status that has caused a loss of coverage, it is the PCNC's responsibility to notify the Eagle County Government 62 Continuation of Coverage • 1/1/09 affected Qualified Beneficiaries of the right to elect COBRA coverage (but only to the extent that the PCNC has been notified in writing of the QBs current mailing address —see the Notification of Address Changes, Marital Status Changes, Dependent Status Changes and Disability Status Changes sub - section below). The PCNC will also notify you (the employee), your spouse and dependent children of the right to elect continuation coverage after it receives written notice of the following events that result in a loss of coverage: the employee's termination of employment (other than for gross misconduct), reduction in hours, death, or the employee's becoming entitled to Medicare (Part Aand/or Part B). 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). 2. The date of the Qualifying Event. 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 Eagle County Government 63 Continuation of Coverage • 1/1/09 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 Maximum 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; 4. The date the second qualifying event 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); Entitlement to "Medicare" or Another Group Health Plan: 1. The initial Qualifying Event for which you became eligible for COBRA coverage; 2. That date you became entitled to (enrolled in) "Medicare" Incomplete or Untimely Notices to the PCNC If the written notice you, your spouse or dependent children) provide to the PCNC does not contain all of the information and documentation required as stated above in the Written Notice Guidelines sub - section, such a 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. Election Procedures When the Plan's COBRA Notification Contact (PCNC) receives written notice that a Qualifying Event has occurred, COBRA maybe offered to each of the Qualified Beneficiaries. Election must be Eagle County Government 64 Continuation of Coverage • 1/1/09 submitted within sixty (60) days from the later of: (1) the date that coverage terminated, or (2) the date the qualified beneficiary receives notice. Failure to elect within the 60 -day period will result in no coverage and no further rights to elect COBRA. You (the employee) and/or your spouse and dependent children may elect continuation coverage for all qualifying family members or you each have an independent right to elect continuation coverage. Thus, a spouse or dependent child may elect continuation coverage even if the covered employee does not elect it. You (the employee) and/or your spouse and dependent children may elect continuation coverage even if covered under another employer - sponsored group health plan or are currently entitled (enrolled in) to Medicare. 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 COBRA 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. Type of Coverage 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 or 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. Eagle County Government . 65 Continuation of Coverage • 1/1/09 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. Monthly COBRA Premiums That You Must Pav [Note: "Yremium(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 yon, 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. Monthly COBRA premiums will include a 2°Io 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 through 29). The amount of your COBRA premiums may change from time to time during your period of COBRA coverage (will most likely increase). You will be notified of COBRA premium changes at the same time as actively working employees are notified. The Plan may not bill you for monthly premium payments. It is the responsibility of the COBRA participant to send in the monthly COBRA premiums by the due date following the procedures outlined by the PCNC. All COBRA premiums must be paid by check or money order and must be mailed or hand - delivered to the PCNC. If mailed, your payment is considered to have been made on the date that it is postmarked. If hand - delivered, your payment is considered to have been made when it is received by the PCNC. You will not be considered to have made any payment by mailing or hand delivering a check if your check is returned due to insufficient funds or otherwise. Initial Premium The premium payments for the "initial premium months" must be paid for you (the employee) and for any spouse or dependent children) by the 45th day after electing continuation coverage. Your initial premium months are the months that end on or before the 45th day after the date of the COBRA election (i.e., not including the month in which the 45th day falls). For example: Jane's employment terminates in September. She loses coverage on September 30. Jane elects COBRA on November 15. Her initial premium payment equals the premiums for October and November and is due on or before December 30, the 45th day after the date of her COBRA election. All subsequent premium payments are due by the I St of the month. Eagle County Government 66 Continuation of Coverage • 1/1/09 No claims under continuation coverage will be paid until the initial premium for coverage is paid in full. If no initial premium payment is made within the 45 -day period, then coverage for the affected qualified beneficiary(ies) remains canceled and no COBRA coverage will be provided. Payment of Premiums After the Initial Premium Once continuation coverage is elected, the right to continue coverage is subject to timely payment of the required COBRA premiums. All premiums are due on the first (1St) of the, month for which the premium is paid, subject to a 30- day grace period. A premium payment that is mailed is considered to be made on the date that it is postmarked. If you don't make the premium payment by the due date or within the 30 -day grace period, then COBRA coverage will be canceled retroactively to the 1St of the month. Maximum Periods of Coverage The maximum duration for COBRA coverage is described below. COBRA coverage terminates before the maximum coverage period in certain situations described later under the heading Termination of COBRA Coverage Before the End of the Maximum Coverage Period. 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 additional 11 months of COBRA continuation coverage, for a total maximum of 29 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. Eagle County Government 67 Continuation of Coverage • 1/1/09 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. 2. 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 of 36 months from the date of the initial termination or reduction in hours, if notice of the 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 if the 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 1) the date of the second qualifying event; or 2) the date on which the qualified beneficiary would lose coverage under the terms of the Plan. . Refer to the Written. Notice Guidelines sub - section for further details about notice requirements to the PCNC. 3. Medicare Entitlement. If the qualifying event occurs within 18 months after the employee becomes entitled to Medicare, then the maximum coverage period (for the spouse and dependent child) ends three years from the date the employee became entitled to Medicare. This 36 -mo. COBRA coverage period is available only if the covered employee become entitled to Medicare within 18 months BEFORE the his/her termination of employment or reduction of hours. For example: If a covered employee becomes entitled to Medicare eight (8) 'months before the date on which his employment terminates, COBRA coverage for his spouse and children) who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, i.e. 28- months after the date of the qualifying event. Refer to the Written Notice Guidelines sub - section for further details about notice requirements to the PCNC. Eagle County Government 68 Continuation of Coverage • 1/1/09 Children Born to or Placed-for Adoption With the Qualified Benericiary During the COBRA Period A child born to, adopted by or placed for adoption with a QB during a period of continuation coverage is considered to be a qualified beneficiary provided that, if the covered person is a qualified beneficiary, the covered person has elected continuation coverage for himself or herself. The child's COBRA coverage begins when the child is enrolled in the Plan, and lasts for as long as COBRA coverage lasts for other family members of the former employee. To be enrolled in the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age). Special Enrollment Rights Due To Health Insurance Portability and Accountability Act (HIPAA) HIPAA's special enrollment rights will apply to those who have elected COBRA. HIPAA, a federal law, gives a person already on COBRA certain rights to add coverage for dependents if such person acquires a new dependent (through marriage, birth, adoption or placement for adoption), or if an eligible dependent declines coverage because of other coverage and later loses such coverage due to certain qualifying reasons. Except for certain children described above under Children Born to or Placed for Adoption With the Covered Employee During COBRA Period, dependents who are enrolled in a special enrollment period do not become qualified beneficiaries their coverage will end at the same time that coverage ends for the person who elected COBRA and later added them as dependents. Claims Recovery 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 Recipients Under QALCSOs 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 Coverage Before the End of the Maximum Coverage Period Continuation coverage of the employee, spouse and/or dependent child will automatically terminate (before the end of the maximum coverage period) when any one of the following six (6) events occurs: 1. Eagle County Government no longer provides group health coverage to any of its employees; Eagle County Government 69 Continuation of Coverage • 1/1/09 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 HIPAA, 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 Aand/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). 6. Occurrence of any event (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 14 days of becoming informed of any of the above listed events. Notification of Address Changes, Marital Status Chanzes, Dependent Status Changes and Disgbility Status Chanzes 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 (such notification is necessary to protect COBRA rights for your spouse and dependent children). In addition, you must notify the PCNC if a disabled employee or family member is determined by the Social Security Administration to be no longer disabled. You should also always keep a copy, for your records, of any notices you send to the PCNC. Eagle County Government 70 Continuation of Coverage • 1/1/09 Health Reimbursement Accounts - COBRA Persons electing COBRA continuation coverage will have HRA benefits administered in the following manner: 1. HRA and Medical Plan coverages are combined and are not available separately; 2. HRA benefit amounts for COBRA- qualified beneficiaries who were Employees will be the same as though you were an active Employee for the remainder of the Plan Year. For example, if your employment terminates on May 1' and you had $275 unclaimed in HRA benefits and you elected COBRA, you would have $2 75 for the remainder of the plan year. For subsequent Plan Years, HRA benefits will be the same as those available to eligible active employees, had the qualifying event not occurred. 3. HRA benefit amounts for COBRA - qualified beneficiaries, separately electing COBRA, who were not Employees will be the same as though you were an active Employee for the remainder of the Plan Year. For example, if your spouse's coverage terminates due to a divorce on May I` and you (Employee) had $275 unclaimed in HRA benefits prior to the divorce and your ex- spouse elected COBRA, the ex- spouse would have $275 HRA for the remainder of the Plan Year. For subsequent Plan Years, HRA benefits will be the same as those available to eligible active Employees, had the qualifying event not occurred. NOTE: Because a delay can exist between the time an HRA expense is incurred and when it is paid, HRA benefits available to a COBRA - qualified beneficiary will be estimated as the amount shown to be available in the HRA claims administrator's records. Should the estimate be wrong and result in overpayment of HRA claims, the overpayment will be deducted from future claim payments made under the Plan to the COBRA - qualified beneficiary or shall be recovered by other means, up to and including collections. Continuation Coverage- r Same -Sex Domestic Partners Pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), asame -sex domestic partner may not be a qualified beneficiary (spouse or COBRA dependent child). However, the Plan Sponsor has chosen to offer the same coverage rules and continuation options outlined in the COBRA section above to covered same -sex domestic partners who lose eligibility. USERRA The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) governed by the U.S. Department of Labor's Veteran's Employment and Training Service, provides that if a covered employee is absent from work due to voluntary or involuntary Uniform service, health Eagle County Government 71 Continuation of Coverage • 1/1/09 coverage may be continued for the employee and any "Dependents" 1 for up to twenty -four (24) months. Uniform service includes active duty, active duty for training, inactive duty for training (such as drills), full -time National Guard duty (also service in the commissioned corps of the Public Health Services), and funeral honors duty performed by National Guard and reserve members, as a disaster - response appointee, persons designated by the President in time of war or national emergency, as well as the period for which a person is absent from a position of employment for the purpose of an examination to determine fitness to perform any such duty. USERRA also covers a cadet or midshipman attending a service academy and members of the Reserve Officers Training Corps, Commissioned Corps of the National Oceanic and Atmospheric Administration, Civil Air Patrol and Coast Guard Auxiliary. USERRA covers nearly all employees (if eligible under the terms of the "Plan ") including temporary, part -time, seasonal and probationary employees and applies to virtually all U.S. employers, regardless of size. USERRA also covers employees on strike, layoff or leave of absence. An individual may serve up to five years in the uniform services, in a single period of service or in cumulative periods totaling five years and retain the right to reemployment by his or her pre- service employer. If an employee is absent for uniform service and has rights under both COBRA and USERRA, the employee is entitled to protection under the law that provides the more favorable benefit. Your Rights 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, if any, 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 REguirements 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, (unless unable due to military necessity, impossibility, or Where the service member is a Dependent of the covered "Employee" or is a retiree, USERRA's continuation coverage and reinstatement provisions do not apply because the coverage is not in connection with his /her position of employment. However, such persons may be entitled to reinstatement of coverage following periods of certain types of military service under the provisions the Service members Civil Relief Act (SCRA). Eagle County Government 72 Continuation of Coverage • 1/1/09 unreasonableness), 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. Employee Restoration Rights The time limits for returning to work are as follows: 1. One to 31 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. 32 to 180 days: The employee must apply for reemployment no later than 14 days after completion of military service. 3. 181 days or more: The employee must apply for reemployment no later than 90 days after completion of military service. 4. Service - connected "Injury" or "Illness" - reporting or application deadlines are extended for up to two (2) years for persons who are hospitalized or convalescing. 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. Electinz USERRA Continuation Coverage When the Plan Administrator receives notice an employee will be leaving for active military duty, USERRA Continuation Coverage may be offered to the Employee and Dependent (if enrolled). The Employee may elect coverage in writing if submitted within sixty (60) days from the later of: (1) the date the employee notified the Plan, or (2) the date the Employee's Dependent(s) receive notice of USERRA rights from the Plan. Failure to elect continuation coverage within the 60 -day period will result in no coverage and no further rights to elect USERRA continuation coverage (if you initially decline USERRA continuation coverage, you may change your mind as long as you submit your election in writing to the Plan Administrator before the expiration of the sixty (60) day election period). If the Employee was excused from giving advance notice of service because of military necessity, impossibility or unreasonableness, then coverage may be retroactively reinstated if the Employee elects continuation coverage by notifying the Plan Administrator in writing and at the same time, submits payment in full for all premium due back to the date coverage was terminated. Eagle County Government 73 Continuation of Coverage • 1/1/09 NOTE: Qral USERRA continuation covera e elections will not be acce ted and will not reserve g p p your USERRA rights. Maximul m Period of Coverage The maximum duration for USERRA continuation coverage is 24 months. Coverage may terminate before t e maximum coverage period in certain situations as described in section Termination of USERRA Coverage. Payment Due Date The payment for the "initial premium months" must be paid by the 45th day after electing USERRA continuation coverage. Your initial premium months are the months that end on or before the 45th day fter the date of the USERRA election (i.e., not including the month in which the 45th day falls). y g y ) Thereafter, the right to continue coverage is subject to timely payment of required premiums. All premiums are due on the first (1St) of the month for which the premium is paid, subject to a 30 -day grace period. A premium payment that is mailed is considered to be made on the date that it is postmarked. If hand - delivered, your payment is considered to have been made when it is received by the Plan Administrator. You will not be considered to have made any payment by mailing or hand delivering a check if your check is returned due to insufficient funds or otherwise. If you don't make the premium payment by the due date or within the 30 -day grace period, then USERRA coverage will be canceled retroactively to the 1St of the month. The Plan will not bill you for monthly premium payments. It is the Employee's responsibility to send in the monthly USERRA continuation coverage premiums by the due date as described herein. No claims under USERRA continuation coverage will be paid until the initial premium for coverage is paid in full. If no initial premium payment is made within the 45 -day period, then coverage will be permanently canceled. Cancellation of USERRA Election Rights USERRA continuation coverage will be canceled if: 1. The departing employee fails to give advance notice of service due to military necessity, impossibility, or unreasonableness and fails to elect continuation coverage. 2. The employee leaves for a period of service exceeding 30 days and gives advance notice of service but fails to elect continuation coverage within the 60 -day election period. Termination of USERRA Continuation Coverage Coverage will terminate on the earlier of: Eagle County Government 74 Continuation of Coverage • 1/1/09 1. 2. 3. Failure to pay required premiums within thirty (30) days of the due date; On the day after the date you fail to apply for or return to work following release from military service as outlined above under the Employee Restoration Rights section. At the end of twenty -four (24) months. Eagle County Government 75 Continuation of Coverage • 1/1/09 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 HIPAA 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 HIPAA. 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 - HIPAA Privacy - Title II Notwithstanding any other Plan provision, effective as of the 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 defined 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 HIPAA Privacy sets forth rules which govern and limit the use and disclosure of PHI. The objectives of the rues 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 HIPAA: 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; Eagle County Government 76 HIPAA • 1/1/09 4. For judicial and administrative proceedings, in response to lawfully executed process, such as a court order or subpoena; 5. For public health and health oversight activities, and other governmental activities accompanied by lawfully executed process; 6. To obtain premium bids; to amend, modify, or terminate the Plan; and to obtain enrollment and waiver information, claims processing, auditing, and monitoring the Plan; or 7. As otherwise may be required or permitted by law. Disclosure of PHI to Obtain Stop -loss or Excess Loss Coverage The Plan Sponsor hereby authorizes and directs the Plan, through the Plan Administrator or the Claims Administrator, to disclose PHI to stop -loss carriers, excess loss carriers or managing general underwriters (MGUs) for underwriting and other purposes in order to obtain and maintain stop -loss or excess loss coverage related to benefit claims under the Plan. Such disclosures shall be made in accordance with the Privacy Standards and any applicable Business Associate Agreement(s). Plan Sponsor Certification to Group Health Plan The Plan Sponsor has certified to the Plan that it shall fully comply with the laws and regulations set forth under HIPAA. The Plan will disclose PHI to the Plan Sponsor only for purposes of general Plan administration, including but not limited to, enrollment and eligibility functions, reporting functions, auditing functions, financial and billing functions, to assist in the administration of a Participant dispute or inquiry, to obtain and maintain stop -loss coverage related to benefit claims under the Plan, and any other authorized insurance or benefit function. The Plan may disclose PHI to the Plan Sponsor only after the Plan Sponsor hereby: 1. Amends the Eagle County Government Employee Benefit Plan as required; 2. Authorizes the Privacy Official and HIPAA Privacy Compliance Team to be given access to PHI (no other persons shall have access to PHI). These specified employees shall receive proper training and only have access to and use PHI to the extent necessary to perform plan administrative functions that the Plan Sponsor performs for the Plan. In the event an authorized employee fails to comply with the provisions within this Section, he /she may be subject to disciplinary action, including termination of employment. The Plan Administrator, or its delegate, also shall document the facts of the violation, actions that have been taken to discipline the offending party and the steps taken to prevent future violations. Further, Plan Sponsor will take the following actions by the required compliance date stated herein: Eagle County Government 77 HIPAA • 1/1/09 SECURITY STANDARDS Where `Electronic Protected Health Information" 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 p rotect 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. PRIVACY 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 HIPAA. 6. Make available the information required to provide an accounting of disclosures in accordance with HIPAA; 7. Make PHI available to Plan Participants for the purposes of the rights of access and inspection in accordance with HIPAA; 8. Make PHI for amendment, and incorporate any amendments to PHI in accordance with HIPAA; 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 Eagle County Government 78 HIPAA • 1/1/09 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 79 HI PAA • 1/1/09 As used in this Plan, the following words shall have the meaning indicated in this section: "Accident" shall mean an unforeseen and unplanned event or circumstance resulting in bodily injury. "Adult" shall mean a Covered Person who is age 19 or older. , "Children" shall mean the employee's unmarried: 1. Natural children; 2. Lawfully adopted children, children placed with a covered Employee or same sex domestic partner in anticipation of adoption; a. The phrase children placed with a covered Employee or same sex Domestic Partner in anticipation of adoption refers to a child whom the covered Employee or same sex Domestic Partner intends to adopt, whether or not the adoption has become final, who has not attained the age of 18 as of the date of such placement for adoption. The term "placed" means the., assumption and retention by such covered Employee or same sex Domestic Partner of a legal obligation for total or partial support of the child in anticipation of adoption of the child. The child must be available for adoption and the legal process must have commenced. 3. Stepchildren who reside in the covered Employee's household may also be included as long as a natural parent remains married to the covered Employee and also resides in the covered Employee's household; 4. Children for whom the employee has been appointed legal guardian, legal ward, a ward by court decree. 5. Children, meeting one of the four criteria listed above, of a same sex domestic partner. In all cases, to qualify as an eligible Child under the Plan, the child must be dependent upon the covered Employee for over one -half of his or her support during the Calendar Year. A special rule applies in the case of a child of divorced parents, legally separated parents or parents who lived apart at all times of the year or during the last six months of the calendar year. The child will be considered dependent upon the Employee for over one -half of his or her support if the child is in the custody of the Employee and/or the other parent for more than one -half of the year and the child is dependent upon one and/or both parents for more than one -half of his or her support for the year. The Plan Administrator may require documentation proving dependency, including birth certificates, tax records or initiation of legal proceedings severing parental ties. Eagle County Government 80 Definitions • 1/1/09 "Convalescent Nursing Home" shall mean an institution other than a hospital, which meets all of the following requirements: 1. Maintains permanent and full -time facilities for bed care of ten (10) or more resident patients; 2. Has available, at all times, the services of a Physician; 3. Has a registered nurse (R.N.) or Physician on full -time duty in charge of patient care, and one or more registered nurses (R.N.) or licensed practical nurses (L.P.N.) on duty at all times; 4. Maintains a daily medical record for each patient; 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. A same -sex Domestic Partner; Same sex domestic partnerships must be attested to by submission of a signed affidavit to Eagle County Government. 3. The employee's or their same sex domestic partner's Children from birth to the end of the calendar year during which age 19 is reached. 4. The employee's or their same sex domestic partner'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 Eagle County Government 81 Definitions • 1/1/09 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 of the Calendar Year in which the 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, maybe 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. 5. 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. 7. These persons are excluded as Dependents: other individuals living in the covered Employee's home, but who are not eligible as defined herein; the legally separated or divorced former Spouse of the Employee; any person who is on active duty in any military service of any country; any former same sex Domestic Partner of the Employee; or any person who is covered under the Plan as an Employee. 8. If a person covered under this Plan changes status from Employee to Dependent or Dependent to Employee, and the person is covered continuously under this Plan before, during and after the change in status (for medical plan purposes, this means the same medical plan option), credit will be given for deductibles and all amounts applied to maximums. "Disability" means the inability, due to injury, illness, or maternity /childbirth, to do your job or other jobs the County may make available. "Durable Medical Equipment" shall mean any equipment which: 1. Can withstand repeated use; 2. Is primarily and customarily used to serve a medical purpose; and 3. Is generally not useful to a person in the absence of Illness or Injury. "Electronic Protected Health Information" (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. "Emergency" shall mean a serious medical condition resulting from Illness or Injury which arises suddenly' and requires immediate care and treatment to avoid jeopardy to life or health. In such Eagle County Government 82 Definitions • 1/1/09 emergency, medical care is covered as if provided under the In- Network benefits provided that full documentation of the emergency is submitted that is acceptable to the Plan. "Employee" shall mean a person employed by the employer on a Regular Full -Time basis or Regular Part -Time basis who is included in a class or group of employees to which the Plan extends. "Expenses Incurred" shall mean, for the purposes of this Plan, that an expense shall be considered to be incurred at the time the service for that expense incurred is rendered or at the time the supply for which such expense incurred is furnished. Specifically as it relates to a dental charge, it is incurred on the date the service or supply for which it is made is performed or furnished. However, there are times when one overall charge is made for all or part of a course of treatment. In this case, the Claims Administrator will apportion that overall charge to each of the separate visits or treatments. The pro -rata charge will be considered to be incurred as each visit or treatment is completed. "Experimental" shall mean: 1. As to drugs and medicines, those that are not commercially available for purchase, or are not approved by the Food and Drug Administration for broad public use for the condition being treated; and 2. As to other treatment, services or supplies, those that are not approved or generally accepted by the medical profession within the United States as essential to the treatment of the symptoms or diagnosed condition in question. 3. Indications of Experimental treatment include, but are not limited to: a. There are a minimal number of treated patients whose cases have been reported. b. A randomized clinical study trial that indicates a benefit over conventional therapy has not been established. C. A threshold for rate of cure or improvement in the quality of life has not been established. 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 Eagle County Government 83 Definitions • 1/1/09 services i,of such medical peer review service organizations as the Medical Review Institute or UMAC and utilize data obtained from such national assessment organizations, by example, as CMS, 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. "Health Savings Account" (HSA) shall mean a tax - favored trust or custodial account as defined in IRS Code § 223 established exclusively for the purpose of paying qualified medical expenses of the account owner (and his/her eligible dependents if any) who, for the months for which contributions are made to an HSA, is covered under a qualified High- Deductible Health Plan (HDHP) and no other health plan that is not an HDHP. Refer to IRS Notice 2004 -2, and other subsequent notices and regulatory guidance issued thereafter. For more details, visit www.treas.gov /offices /public- affairs/hsa. "High Deductible Health Plan" (HDHP) shall mean a qualified medical plan which meets the terms and guidelines as set forth in IRS Notice 2004 -2 and other subsequent notices and regulatory guidance issued thereafter. For more details, visit www.treas.gov /offices /public- affairs/hsa. "HIPAA 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" is an institution that is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense and that fully meets these tests: it is approved by Medicare as a Hospital; it maintains diagnostic and therapeutic facilities on the premises for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of Physicians; it continuously provides on the premises 24 -hour nursing services by or under the supervision of registered nurses (R.N.$); and it is operated continuously with organized facilities for operative surgery on the premises. The definition of "Hospital" shall be expanded to include the following: Eagle County Government 84 Definitions • 1/1/09 1. A facility operating legally as a psychiatric Hospital or residential treatment facility for mental health and licensed as such by the state in which the facility operates. 2. A facility operating primarily for the treatment of Substance Abuse if it has received accreditation from CARF (Commission of Accreditation of Rehabilitation Facilities) or JCAHO (Joint Commission of Accreditation of Hospital Organizations) or if it meets these tests: maintains permanent and full -time facilities for bed care and full -time confinement of at least 15 resident patients; has a Physician in regular attendance; continuously provides 24 -hour nursing service by a registered nurse (R.N.); has a full -time psychiatrist or psychologist on the staff; and is primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Substance Abuse. "Illness" shall mean the same as Sickness. "Injury" shall mean bodily damage other than sickness, including all related conditions and recurrent symptoms. "In- Network" providers shall mean physicians, hospitals and other medical care providers who are contracted with the Plan's In- Network Provider Network and/or as determined by the Plan to be In- Network providers. "Inpatient" shall mean occupation of a hospital bed, crib or bassinet while under observation, care, diagnosis or treatment for at least 24 hours. "Late Enrollment" shall mean enrollment in a benefit plan at any time after expiration of the initial enrollment period. "Legend" drug shall mean any drug for which a prescription is required by applicable federal and/or state laws or regulations. "Lifetime Maximum" shall mean the maximum amount of benefit dollars the Plan will pay for covered Expenses Incurred by an individual for all periods combined during which such individual is covered by the Plan. The maximums are combined for all plans. "Medicaid" shall mean a medical benefits program administered by the States and subsidized by the federal government that pays certain medical expenses for those who meet income and other guidelines. "Medically Necessary" means services or supplies which are: 1. Generally accepted by the national medical professional community as being safe and effective in treating a covered illness or injury; 2. Consistent with the symptoms or diagnosis; Eagle County Government 85 Definitions • 1/1/09 3. Furnished at the most appropriate medical level; and 4. Not primarily for the convenience of the patient, a health care provider or anyone else. Notwithstanding the above, benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than forty -eight (48) hours following a normal vaginal delivery, or less than ninety -six (96) hours following a cesarean section will be deemed "Medically Necessary." "Medicare" shall mean Federal Insurance or assistance such as provided by the Health Insurance for the aged Act (42 U.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. Body Mass Index of 40 +. "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 - Emergency" shall mean any medical care, including a surgical procedure, that is scheduled at the patient's convenience without endangering the patient's life or without causing serious impairment to the patient's normal bodily functions. "Out- of�Network" providers shall mean physicians, hospitals and other medical care providers who are not contracted with the Plan's In- Network Provider Network and/or as determined by the Plan to be Out -of- Network providers. "Outpatient" shall mean a Covered Person who is treated in a hospital but is not confined 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 (O.D.), Doctor of Chiropractic (D.C.), or a Psychologist (Ph.D.) as well as other licensed health care professionals who are under the direct supervision of a Physician. Eagle County Government 86 Definitions • 1/1/09 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 "HIPAA Enrollment Date," medical advice, diagnosis, care or treatment was provided or recommended by a medical professional operating within the scope of practice authority authorized by State law. "Protected Health Information" (PHI) shall mean individually identifiable health information as defined by the Health Insurance Portability and Accountability Act of 1996 and its Privacy regulations at 45 C.F.R § 160.103. "Qualified Beneficiary" shall mean an employee (or former employee), an employee's spouse, or dependents who are covered under the Plan on the day before a qualifying event: "Regular Full - Time" shall mean an employee scheduled to work an average of at least thirty -six (36) hours per week. Duly elected County officials are eligible without regard to scheduled hours. "Regular Part- Time" shall mean an employee who is employed in a position which normally requires more than 30 hours, but less than 36 hours per week, and such person is not classified by the County as temporary, occasional or seasonal or Regular Full Time. "Relevant Information" shall mean any information if it: 1. Was relied upon in making the benefit determination; 2. Was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record or other information was relied upon in the making of the benefit determination; 3. Demonstrates compliance with the plan's administrative processes and consistency safeguards required in making the benefit determination; or 4. Constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit for the Plan participant or beneficiary's diagnosis, without regard to whether such advice or statements were relied upon in making the benefit determination. Eagle County Government 87 Definitions • 1/1/09 "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 tithe, 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 healthcare and wellchecks for children,, including normal immunizations. Eagle County Government 88 Definitions • 1/1/09 DISABILITY BENEFITS SHORT TERM DISABILITY One of your most valuable assets is your ability to provide yourself and your family with a regular income to meet the cost of day -to -day living. Obviously, it is important to keep this security even if a medical problem prevents you from working. If you are unable to work due to "Illness," "Injury," or maternity /childbirth, you may be eligible to receive payment from the Short -Term Disability (STD) Plan. Your employer provides this benefit at no premium cost to you. Elizibility "Employees" who are classified as a "Regular Full- Time" Employee are eligible for Short -Term Disability (STD) on the first day of the month coincident with or next following ninety (90) days of employment. Actively Working Requirement Plan coverage will begin on the first day of the month that coincides with or follows the day the employee becomes eligible, provided the employee is Actively Working on that day. 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. Actively Working or Active Work means performing the normal duties of a regular job for the County at: 1. the employer's usual place of business; 2. an alternative work site at the direction of the County; or 3. any other business location to which the Employer requires the Employee to travel. Unless disabled on the prior workday or on the day of absence, an Employee will be considered Actively Working on any day that is: 1. a Saturday, Sunday or a regular paid holiday which is not a scheduled workday; 2. a paid vacation day or other scheduled or unscheduled non - workday; or 3. an excused or emergency leave of absence (except a medical leave) of 30 days or less. Eagle County Government 89 Disability Benefits • 1/1/09 Definition of Disability Disability means the inability, due to injury, illness, or maternity /childbirth, to do your job or other jobs the County may make available. Waitin z Period and Duration of Disabilit y Benefits After a "Disability" occurs, benefits start on the 14th consecutive day of that disability. In no event shall the maximum period of STD benefits exceed the lesser of the following: 1. The duration (in days /weeks; as measured from the 14th day of disability forward) as stated in the Attending Physician Statement (refer to the STD Claims Procedure section for details) attesting to the "Employee's" Disability.* or 2. Twenty -six (26) weeks or 3. Your return to work for two consecutive weeks with Basic Weekly Earnings greater than 80% 4. Upon the date benefits become payable to the You under the County's Long Term Disability Plan. *The Plan may require additional information from the Employee's Physician. If the County requests an independent examination by a Physician, the cost of which will be paid by the Plan. Should the first and second opinion conflict, a final third opinion will be required (again, the cost of which will be paid by the Plan). DISABILITY BENEFIT AMOUNT Benefits paid are based on an Employee's pre - disability Basic Weekly Earnings, which means your gross income immediately prior to the date in which your disability began. It includes base pay, but does not include bonuses or overtime pay. Approved STD claim benefits are paid at a rate of 60% of your Base Weekly Earnings to a maximum benefit of $1,000 /week. Available sick leave and vacation may be used to cover the 40°Io (or more if a partial disability) of pay not provided by this Plan. Partial disabilities and intermittent disabilities are covered if you lose more than 20% of Basic Weekly earnings due to your Disability. In such case, the benefit amount you shall receive will be calculated based on the amount of your lost pay only. Contact the Human Resources Department to obtain forms to apply for STD coverage. Eagle County Government 90 Disability Benefits • 1/1/09 Conditions and Limitations 1. Work related injuries and illness are excluded, whether or not covered by worker's compensation. 2. You must be under the care of a "Physician," and your inability to work due to the Disability must be attested to in writing by a Physician and approved by the Plan. 3. The County can require an independent review by a Physician of the County's choice, which will be paid for by the County. 4. Periods of Disability for which benefits are paid under this Plan will constitute leave under the County's Family and Medical Leave Policy. 5. A relapse will be considered a continuation of an existing disability unless you have been back to work for two consecutive weeks or more in which case it will be considered a new Disability. The applicable waiting period (refer to the Waiting Period and Duration of Benefits section) will apply to the new disability. When Coveraze Ends Participation in this "Plan" will terminate upon the earlier of the following dates: I. You are no longer an eligible employee; 2. You retire; 3. The date your employment terminates; or 4. The STD Plan is discontinued. Claims Procedure The Claims Administration —refer to Important Contact Information for details. FILING A CLAIM To receive benefits under this "Plan" for which "You "(the "Employee ") are eligible, You must file a claim. Short -Term Disability benefit claims will be processed after written proof of "Disability" is submitted to the Claims Administrator. However, additional written proof of Disability may be required upon request of the Claims Administrator. Contact the Claims Administrator or the County's Human Resources for the proper claim forms or any other information you need. The Claim form consists of the following three (3) sections: Eagle County Government 91 Disability Benefits • 1/1/09 1. Employer Section 2. Employee Section 3. Attending Physician's Statement The "Clajims Administrator" will evaluate your claim promptly after it is filed. (The date the claim is considered filed is the date that it is received by the Claims Administrator.) Within 45 days y 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 3O 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. Should an extension be necessary, you will be notified of the following: (a) the reason(s) for the extension; (b) when your claim is expected to be decided; and (c) any additional information needed to decide the claim. If additional information is needed, you will have 45 days to provide the information. If you do not provide the information within 45 days, the Claims Administrator may decide your claim based on the information received. Note: The Claims Administrator may request a second 30 -day extension for matters beyond their control. In such case, you will be notified of the circumstances requiring the extension and the date as of which the "Plan " expects to render a decision. If your claim is denied in whole or in part, you will receive a written notice of denial containing: 1. The specific reason(s) for the denial, referencing the plan provision(s) which the decision is based, as well as references to any internal rule(s) or guideline(s) relied upon in making the decision. 2. Information concerning your right to receive an explanation of the scientific or clinical judgment relied upon in making the determination. 3. Request and describe any additional information necessary to support your claim. Eagle County Government 92 Disability Benefits • 1/1/09 4. Information concerning your right to appeal the claims decision with applicable time frames you must follow. CLAIMS APPEAL PROCEDURES If all or part of a claim for disability is denied, "You" may request an appeal of the claims denial. You must request an appeal in writing within 180 days after receiving notice of the denial. When appealing a claim You should: 1. State the reason you feel the claim is valid; 2. Submit any written comments, documents, or other information you wish to be considered to support your claim; 3. Include your name, Social Security number, and the Group Identification Number, if any. 4. Send written appeals directly to the "Claims Administrator." Note: A Claim will not be deemed submitted until it is received by the Claims Administrator. Your Rights When Requesting an Appeal of a Claims Denial 1. You may review all "Relevant Information" to the claim and copies shall be provided free of charge, upon request. 2. You may review all of the Plan's internal rules, guidelines, and scientific or statistical research relevant to the claim, upon request. 3. The "Plan" must disclose the name of any "Physician(s)" who were consulted during the claim review process, upon request. 4. No prior approval is needed to appeal claims and no fees will be charged. 5. An authorized representative may advocate or act on your behalf in pursuing or appealing a claim. You must provide written authorization designating the authorized representative to act as such for the "Plan" participant. The individual(s) conducting the appeal will be the Named Plan Fiduciary (NPF) and will not be the same individual(s) 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 another 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. Eagle County Government 93 Disability Benefits • 1/1/09 Those reviewing your claim must make their final determination within forty five (45) days of receiving the appeal. However, should special circumstances exist, they are allowed an extension of an additional forty -five (45) days. The final decision will be sent to you in writing, together with an $xplanation of how the decision was made. Eagle Copnty Government 94 Disability Benefits • 1/1/09 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 Funding/Insurance Carriers: A. Medical Benefits are self - funded by Eagle County Government. The County purchases Stop Loss insurance for medical claims over certain amounts. B. Dental Benefits are self - funded by Eagle County Government. C. Vision Benefits are self - funded by Eagle County Government. D. 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. 5. Plan Administrator *: Human Resources Director Eagle County Government 500 Broadway P.O. Box 850 Eagle, CO 81631 *Also serves as the Named Plan Fiduciary for all Claims Appeals. 6. HIPAA Privacy and Security Official: Human Resources Director Eagle County Government 500 Broadway P.O. Box 850 Eagle, CO 81631 Eagle County Government 95 Summary Plan Description • 1/1/09 7. Agent for service of legal process: The Plan Administrator has authority to control and manage the operation and administration of the Plan and is the agent for service of legal process 8. Plan Termination: The right is reserved for the County to terminate, suspend, withdraw, amend or modify the Plan in whole or in part at any time, for any reason. 9. Employer Identification Number: EIN: #9804908 10. 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 96 Summary Plan Description • 1/1/09 EAGLE COUNTY GOVERNMENT EMPLOYEE BENEFIT PLAN AMENDMENT 01/01/2009 -01 Plan Sponsor: Eagle County Government Plan- Document: Eagle County Government Medical, Dental, Vision and Short -term Disability Benefit Plan dated 1/1/09, as Amended. Plan Amendment: The purpose of this Amendment is to expand the Plan's eligibility definitions of Regular Full -Time and Regular Part -Time employees to include non - exempt employees who experience a temporary reduction in hours. Pursuant to authority as outlined in the Plan under "Your Healthcare Benefits Program," last paragraph, the Plan is amended as follows: CHANGE NUMBER 1: Under section Definitions replace the existing definition of Regular Full -Time and Regular Part - Time with the following: "Regular Full - Time" shall mean an employee scheduled to work an average of at least thirty -six (36) hours per week. Duly elected County officials are eligible without regard to scheduled hours. Also includes Regular Full -Time non - exempt employees enrolled in the Plan as of 5/1/09 whose regular work schedule has been temporarily reduced by not more than 8 hours per week on average and whose regular work schedule is intended to be restored upon economic conditions improving. "Regular Part - Time" shall mean an employee who is employed in a position which normally requires more than 30 hours, but less than 36 hours per week, and such person is not classified by the County as temporary, occasional or seasonal or Regular Full Time. Also includes Regular Part -Time non - exempt employees enrolled in the Plan as of 5/1/09 whose regular work schedule has been temporarily reduced by not more than 8 hours per week on average and whose regular work schedule is intended to be restored upon economic conditions improving. Effective Date: 5/01/09 Adopted: Date: V Signature: Title: ECG Plan Document Amendment 01/01/2009-01 Adoption Date: Signature: Title: [A Eagle County Government 98 Adoption • 1/1/09 L 2. 3. 4. Sponsor: Eagle County Government Plain Document: Self Funded Medical, Dental, Vision, Pre -Tax Premiums, Short Term Disability Summary Plan Description: Self Funded Medical, Dental, Vision, Pre -Tax Premiums, Short Term Disability. Replacement: This Plan replaces the County's Employee Benefit Plan dated 1 / 1 /08, as amended, as of the effective date stated herein. 5. Takeover Provisions: This Plan will cover expenses which are incurred and payable under the 1 / 1 /08 Plan, as amended, which are unpaid as of 12/3 1 /08, pursuant to 1/ 1/08 Plan terms, which are included by reference for this specific purpose only. Continuous hospitalizations beginning prior to 1/1/09 and continuing after 1/1/09 will be covered pursuant to the 1/ 1/08 Plan terms until the "Covered Person" is discharged from the hospital. 6. Legal Compliance: The Plan is intended to comply with all applicable federal or state laws and findings of their regulatory authorities and by this provision is automatically amended to be in minimal compliance as necessary. 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 of the calendar year in which services are provided. S. Effective Date: January 1, 2009 Eagle County Government 97 Adoption • 1/1/09