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HomeMy WebLinkAboutC16-389 Vision Service PlanC16-389 November 18, 2015 Vision Care for Life RE: EAGLE COUNTY GOVERNMENT, GROUP #30060824 JANUARY 1, 2016 DOCUMENTS Attention Brie Murray: Enclosed are the JANUARY 1, 2016 documents for the above -referenced Client. Please retain a copy of the documents for your records and forward the additional copy directly to the group. This new document supersedes any existing document your client has with VSP. If you have any questions, or need additional information, please do not hesitate to contact us at 800-216-6248, and a VSP representative will assist you. Enclosures These documents are intended only for the client to whom they are addressed and may contain confidential information. If you are not the intended recipient (or the person responsible for delivering it to the intended recipient) and have received these documents in error, please notify the sender immediately by telephone, and destroy or delete these documents. BRIE MURRAY BSWIFT 1125 17TH ST STE 400 DENVER, CO 80202-2005 Vision Care for Life VISION SERVICE PLAN INSURANCE COMPANY 3333 QUALITY DRIVE RANCHO CORDOVA, CALIFORNIA 95670 GROUP VISION CARE PLAN ADMINISTRATIVE SERVICES PROGRAM Group Name EAGLE COUNTY GOVERNMENT Plan Number 30060824 State of Delivery COLORADO Effective Date JANUARY 1, 2016 Plan Term FORTY-EIGHT (48) MONTHS Premium Due Date FIRST DAY OF MONTH In consideration of the statements and agreements contained in the Group Application and in consideration of payment by Group of the administrative fees and other amounts due as herein provided, VISION SERVICE PLAN INSURANCE COMPANY ("VSP") agrees to provide certain individuals under this Group Vision Care Plan (“Plan”) the benefits provided herein, subject to the exceptions, limitations and exclusions hereinafter set forth. This Plan is delivered in and governed by the laws of the State of Delivery and is subject to the terms and conditions recited on the subsequent pages hereof, which are a part of this Plan. ____________________________________________ Kate Renwick-Espinosa, President VSP-GVCP-ASP-5/07 11/18/15 Tsc TABLE OF CONTENTS I. DEFINITIONS.............................................................................................................. 1 II. TERM, TERMINATION, AND RENEWAL................................................................... 3 III. OBLIGATIONS OF VSP.............................................................................................. 4 IV. OBLIGATIONS OF THE GROUP................................................................................ 6 V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN............................. 8 VI. ELIGIBILITY FOR COVERAGE................................................................................... 11 VII. CONTINUATION OF COVERAGE.............................................................................. 14 VIII. ARBITRATION OF DISPUTES.................................................................................... 15 IX. NOTICES..................................................................................................................... 16 X. MISCELLANEOUS...................................................................................................... 17 EXHIBIT A SCHEDULE OF BENEFITS........................................................................... 19 EXHIBIT B SCHEDULE OF PREMIUMS......................................................................... 27 ADDENDUM ADDITIONAL BENEFIT - PRIMARY EYECARE PLAN................................. 28 I. DEFINITIONS Key terms used in this Plan are defined and shall have the meaning set forth as follows, unless the context of a term’s usage clearly requires otherwise. 1.01 ADMINISTRATIVE FEE: The payments made to VSP by or on behalf of Group in consideration of administrative services rendered. 1.02. ADMINISTRATIVE SERVICES PROGRAM: A group vision care plan whereby Group pays VSP for the Plan Benefits in addition to a monthly Administrative Fee. 1.03. ADVANCE PAYMENT: The amount paid in advance to VSP by or on behalf of Group to cover the estimated benefit costs of Group for one (1) month. 1.04. BENEFIT AUTHORIZATION: Authorization issued by VSP identifying the individual named as a Covered Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled. 1.05. CLAIMS AMOUNT: Total charges for benefits delivered, including the cost of professional services and ophthalmic materials, charges for VSP services related to materials purchased, and taxes. 1.06. CONFIDENTIAL MATTER: All confidential or personal information concerning the medical, personal, financial or business affairs of Covered Persons acquired in the course of providing Plan Benefits here under. 1.07. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully covered. 1.08. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and who is covered under this Plan. 1.09. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and approved by VSP in Article VI of this Plan under which such Enrollee is covered. 1.10. EMERGENCY CONDITION: A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non -medical action. 1.11. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under VI. ELIGIBILITY FOR COVERAGE. 1 1.12. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or accepted by the vision care profession, as determined by VSP. 1.13. GROUP: An employer or other entity which contracts with VSP for coverage under this Plan in order to provide vision care coverage to its Enrollees and their Eligible Dependents. 1.14. GROUP APPLICATION: The form signed by an authorized representative of the Group to signify the Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP. 1.15. GROUP VISION CARE PLAN (also, "THE PLAN"): The Plan provided by VSP in favor of a Group, under which its Enrollees, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan Benefits in accordance with the terms of such Plan. 1.16. MEMBER DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care materials on behalf of Covered Persons of VSP. 1.17. NON-MEMBER PROVIDER: Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP. 1.18. PLAN BENEFITS: The vision care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under this Plan, as defined in the Schedule of Benefits attached hereto as Exhibit A. 1.19. RENEWAL DATE: The date on which the Plan shall renew, or terminate if proper notice is given. 1.20. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A, which lists the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of this Plan. 1.21. SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE: The document, attached hereto as Exhibit B, which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him to Plan Benefits. 2 II. TERM, TERMINATION, AND RENEWAL 2.01. Plan Term: This Plan shall become effective on the Effective Date and shall remain in effect for the Plan Term. At the end of the Plan Term, it will renew on a month to month basis unless either party notifies the other in writing , at least sixty (60) days before the end of the Plan Term, that the party is unwilling to renew the Plan. If such notice is given, the Plan will terminate at 12:00 midnight on the last day of the Plan Term, unless the parties reach mutual agreement on its renewal. If the Plan continues on a month to month basis after the Plan Term, either Party may thereafter terminate the Plan upon thirty (30) days advance written notice to the other party. If VSP issues written renewal materials to Group at least sixty (60) days before the end of the Pla n Term and Group fails to accept the new terms and/or rates in writing prior to the end of the Plan Term, this Plan shall terminate at 12:00 midnight on the last day of the Plan Term as noted above. 2.02. Termination: Either party may terminate the agreement upon a sixty (60) day advance written notice. Group agrees to pay all Claims Amount and Administrative Fees for Plan Benefits provided pursuant to Benefit Authorizations issued prior to the Plan termination date, provided claims for such Plan Benefits a re filed with VSP within six (6) months after termination of this Plan. 3 III. OBLIGATIONS OF VSP 3.01. Coverage of Covered Persons: VSP will enroll each eligible Enrollee and his Eligible Dependents, if dependent coverage is provided, all of whom shall be referred to as "Covered Persons." To institute coverage, Group may be required to complete and sign a Group Application and forward such application to VSP, along with information regarding Enrollees and Eligible Dependents, and applicable amounts due. (Refer to VI. ELIGIBILITY FOR COVERAGE for further details.) Following enrollment, VSP will provide Group with Member Benefit Summaries for Covered Persons. Such Member Benefit Summaries will summarize the terms and conditions of this Plan. 3.02. Provision of Plan Benefits: Through its Member Doctors (or through other licensed vision care providers in cases where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non-Member Provider) VSP shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, subject to any limitations, exclusions, or Copayments therein stated. Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a Member Doctor. When a Covered Person desires to receive Plan Benefits from a Member Doctor, the Covered Person must schedule an appointment and identify himself as a VSP Covered Person in order for the Member Doctor to obtain Benefit Authorization from VSP. VSP shall provide Benefit Authorization to the Member Doctor to authorize the provision of Plan Benefits to the Covered Person. Each Benefit Authorization will contain an expiration date, allowing a specific period of time for the Covered Person to obtain Plan Benefits. Benefit Authorization shall be issued by VSP in accordance with the latest eligibility information furnished by Group and the Covered Person’s past service utilization, if any. Any Benefit Authorization so issued by VSP shall constitute a certification to the Member Doctor that payment will be made. VSP shall not be held liable to Grou p for any Benefit Authorization issued in error in reliance on the latest eligibility information available to VSP as provided by the Group. VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, within a reasonable time but not more than thirty (30) calendar da ys after VSP has received a completed claim, unless special circumstances require additional time. In such cases, VSP may obtain an extension of fifteen (15) calendar days of this time limit by providing notice to the claimant of the reasons for the extension. 3.03. Provision of Information to Covered Persons: Upon request, VSP will make available to Covered Persons necessary information describing Plan Benefits and procedures. A copy of this Plan will be placed with Group. The Plan will also be available at the offices of VSP for copying or inspection by Covered Persons. VSP shall provide 4 Group with an updated list twice annually of Member Doctors' names, addresses, and telephone numbers for distribution to Covered Persons. Covered Persons may also obtain a copy of the latest Member Doctor list by contacting VSP’s Customer Service Department in writing or via the toll-free Customer Service telephone line, or by visiting VSP's Web site at www.vsp.com. 3.04. Preservation of Confidentiality: VSP will hold in strict confidence all Confidential Matters. VSP will also exercise its best efforts to prevent any of its employees, Member Doctors, or agents, from disclosing any Confidential Matter . An exception would be if disclosure is necessary to enable any of the above to perform their obligations under this Plan, including but not limited to sharing information with medical information bureaus, or as may otherwise be required by law. Covered Persons and/or Groups that want more information on VSP’s Confidentiality Policy Provisions may obtain a copy of the Notice of Privacy Practices by contacting VSP’s Customer Service Department or by visiting VSP's Web site at www.vsp.com and clicking on the HIPPA link. 3.05. Emergency Vision Care: When vision care is necessary for Emergency Conditions, Covered Persons may obtain Plan Benefits by contacting a Member Doctor or Out -of-Network Provider. No prior approval from VSP is required for Covered Person to obtain vision care for Emergency Condition s of a medical nature. However, services for medical conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and should contact a physician under Covered Persons' medical insurance plans for care. For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service Department for assistance. Reimbursement and eligibility are subject to the terms of this Plan. 5 IV. OBLIGATIONS OF THE GROUP 4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage under this Plan, if he satisfies the enrollment criteria specified in Paragraph 6.01(a) and/or as mutually agreed to by VSP and Group. Group shall provide monthly eligibility information to VSP in a mutually agreed upon format and medium to identify all Enrollees who are eligible for coverage under this Plan. Group will supply to VSP, on or before the last day of each month, eligibility information suffici ent to identify all Enrollees to be added to or deleted from VSP 's coverage rosters for the coming month. The eligibility information shall include designation of family status for each such Enrollee, if dependent coverage is provided. Group shall, when requested, make available for inspection by VSP records having a bearing on the coverage of Covered Persons under this Plan. 4.02. Claims Amounts and Advance of Payment: Group shall provide all funds necessary to pay the Claims Amount associated with Covered Persons pursuant to this Plan. In order to assure timely and adequate payment, Group agrees to make an Advance Payment as outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. This Advance Payment is an estimate of the Claims Amount for one (1) month. Group agrees to pay the actu al Claims Amounts on a monthly basis within ten (10) days after receipt of VSP's statement. The Advance Payment amount may be adjusted each Plan Term if the average of monthly Claims Amount increases or decreases. The parties agree that such Advance Payment is reimbursable to the Group upon termination of this Plan, after the Group's indebtedness to VSP and/or its benefit providers has been satisfied. However, amounts paid to VSP as Advance Payment shall not be considered assets of the Group, and need not be held in trust by VSP. 4.03. Administrative Fee: Additionally, on or before the first day of each month, Group shall remit to VSP an Administrative Fee as outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. Change will not be made to the Administrative Fee during any Plan Term unless there is a change in the Schedule of Benefits or a material change in any other terms and conditions of the Plan, provided any such change is mutually agreed upon in writing between VSP and Group. Notwithstanding the above, VSP reserves the right to increase amounts due hereunder during a Plan Term by the amount of any tax or assessment not now in effect which is subsequently levied by any taxing authority, which is attributable to the amount due VSP from Group. 4.04. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the due date for making any payment of amounts due under this Plan. During the grace period, this Plan will remain in full force and eff ect for all Covered Persons. Late payments will be considered by VSP at the time of Plan renewal and may impact Group's 6 Advance Payment and Administrative Fees in future Plan Terms. If Group fails to make any payment of amounts due by the end of any grace period, VSP may notify Group that the payment of amounts due has not been made, that coverage is canceled and that the Group is responsible for payment for the Claims Amount associated with Plan Benefits provided to Covered Persons af ter the last period for which amounts due were fully paid, including the grace period and through the effective date of the termination. Group shall also remain responsibl e for payment, in accordance with Paragraph 2.02, of any Claims Amount associated with Benefit Authorizations outstanding at the time of termination, and for any legal and/or collection fees incurred by VSP in collecting amounts due under this Plan. 4.05. Distribution of Required Documents: Group agrees to distribute to Enrollees any disclosure forms, plan summaries or other materials that may be required to be given to plan subscribers by any regulatory authority. Such material s shall be distributed by Group no later than thirty (30) days after receipt or as otherwise required under sta te law. 7 V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN 5.01. General: By this Plan, Group makes coverage available to its Enrollees and their Eligible Dependents, if dependent coverage is provided. This Plan may be amended or terminated by agreement between VSP and Group as otherwise indicated herein. Consent or concurrence of Covered Persons for any such amendment or termination is not necessary. This Plan, and all Exhibits, attachments and amendments, constitute VSP's sole and entire undertaking to Covered Persons under this Plan. All Covered Persons under this Plan shall have the following obligations as a condition of their coverage. 5.02. Copayments for Services Received: Where, as indicated on the Schedule of Benefits, Exhibit A hereto, Copayments are required for certain Plan Benefits, these Copayments shall be the personal responsibility of the Covered Person receiving the care and must be paid to the Member Doctor (or N on-Member Doctor if Non-Member Provider benefits are indicated on the attached Schedule of Benefits at Exhibit A) on the date the services are rendered. 5.03. Obtaining Services from Member Doctors: Benefit Authorization must be obtained prior to receiving Plan Benefits from a Member Doctor. When a Covered Person desires to receive Plan Benefits from a Member Doctor, the Covered Person must select a Member Doctor, schedule an appointment, and identify himself as a Covered Person in order for the Member Doctor to obtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a Member Doctor without such Benefit Authorization, then for the purposes of those Plan Benefits provided to the Covered Person, the provider will be considered a Non-Member Provider and the benefits available will be limited to those for a Non-Member Provider, if any. 5.04. Submission of Non-Member Provider Claims: All claims for services received from Non-Member Providers (if Non-Member Provider coverage is indicated on the attached Schedule of Benefits at Exhibit A) shall be submitted by Covered Persons to VSP within three hundred sixty-five (365) days of the date of service. VSP reserves the right to reject such claims which are filed more than three hundred sixty-five (365) days after the date of service. Failure to submit a claim within three hundred sixty-five (365) days, however, shall not invalidate or reduce the claim if it was not reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as was reasonably possible and in no event, except in absence of legal capacity, later than one year from the required date. 5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or grievances to VSP at the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care, treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may 8 submit written comments or supporting documentation concerning his/her complaint or grievance to assist in VSP's review. VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances req uire an extension of time. In that case, resolution shall be achieved as soon as possible, but not later than one hundred twenty (12 0) days after VSP's receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thi rty (30) days, VSP will notify the Covered Person of the expected resolution date. Upon final resolution, VSP will notify the Covered Person of the outcome in writing. 5.06. Claim Denial Appeals: If, under the terms of this Plan, a claim is denied in whole or in part, a request may be submitted to VSP by Covered Person or Covered Person's authorized representative for a full review of the denial. Covered Person may designate any person, including his/her provider, as his/her authorized representative. Re ferences in this section to "Covered Person" include Covered Person's authorized representative, where applicable. a) Initial Appeal: The request must be made within one hundred eighty (180) days following denial of a claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the VSP Enrollee's name, the VSP Enrollee's Membe r Identification Number, the Covered Person's name and date of birth, the provider of services and the claim number. The Covered Person may review, during normal working hours, any documents held by VSP pertinent to the denial. The Covered Person may als o submit written comments or supporting documentation concerning the claim to assist in VSP's review. VSP's response to the initial appeal, including specific reasons for the decision, shall be provided and communicated to the Covered Person as follows: Denied Claims for Services Rendered: within thirty (30) calendar days after receipt of a request for an appeal from the Covered Person. b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the claim, the Covered Person has a right to a second level appeal. Within sixty (60) calendar days after receipt of VSP's response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable state and federal laws and regulations and shall include the specific reasons for the determination. 9 c) Other Remedies: When Covered Person has completed the appeals process stated herein, additional voluntary alternative dispute resolution options may be available, including mediation, or Group should advise Covered Person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally, under the provisions of ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(l)(B)], Covered Person has the right to bring a civil action when all available levels of review of denied claims, including the appeals process, have been completed, the claims were not approved in whole or in part, and Covered Person disagrees with the outcome. 5.07. Time of Action: No action in law or in equity shall be brought to recover on the Plan prior to the Covered Person exhausting his grievance rights as described in Paragraphs 5.05 and 5.06 above and/or prior to the expiration of sixty (60) days after the claim and any applicable invoices have been filed with VSP. No such action shall be brought after the expiration of six (6) years from the last date that the claim and any applicable invoices may be submitted to VSP, in accordance with the terms of this Plan. 10 VI. ELIGIBILITY FOR COVERAGE 6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all the applicable requirements set forth below. (a) Enrollees: To be eligible for coverage, a person must: (1) currently be an employee or member of the Group, and (2) meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP. (b) Eligible Dependents: If dependent coverage is provided, the persons eligible for dependent coverage are: (1) the legal spouse of any Enrollee, and (2) any child of an Enrollee, including any natural child from the moment of birth, legally adopted child from the moment of placement for adoption with the Enrollee, or other child for whom a court holds the Enrollee responsible; Such dependent shall be eligible until the end of the month in which they attain the age of 26 years. (3) as further defined by Group. If a dependent unmarried child, prior to attainment of the prescribed age for termination of eligibility, becomes and continues to be, incapable of self-sustaining employment because of mental or physical disability, that Eligible Dependent's coverage shall not terminate. Coverage will continue as long as he remains chiefly dependent on the Enrollee for support and the Enrollee's coverage remains in force; PROVIDED satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty-one (31) days of the date the Eligible Dependent's coverage would have otherwise terminated, and at such other times as VSP may request proof, but not more frequently than annually. 6.02. Documentation of Eligibility: Persons satisfying the requirements for coverage under either of the above classes shall be eligible if: (a) in the case of an Enrollee, the individual's name and Social Security Number have be en reported by the Group to VSP in the manner provided hereunder, and (b) in the case of changes to an Eligible Dependent's status, the change has been reported by the Group to VSP in the manner provided herein. As indicated in Paragraph 4.01 above, VSP may elect to inspect the Group's records in order to verify eligibility of Enrollees and dependents. Plan Benefits will be available only to persons on whose behalf applicable amounts due have been paid for the current period, or Grace Periods outlined ab ove in Paragraph 4.04. If a clerical error is made, it will not affect the coverage to which the Covered Person is entitled under the Plan. 11 6.03. Retroactive Eligibility Changes: Retroactive eligibility changes are limited to sixty (60) days prior to the date notice of any such requested change is received by VSP. If coverage is retroactively terminated for an individual, Grou p shall remain responsible for the Claims Amount associated with any Plan Benefits provided to th at individual pursuant to the Benefit Authorization issued by VSP in reliance on the latest eligibility information available to VSP at the time of such Be nefit Authorization. 6.04. Change of Participation Requirements, Contribution of Fees, and Eligibility Rules: Composition of the Group, percentage of Enrollees covered under the Plan, and Group’s contribution and Group's eligibility requirements are all material to VSP's obligations under this Plan. During the term of this Plan, Group must provide VSP w ith written notice of changes to its composition, percentage of Enrollees covered, contribution or eligibility requirements. Any such change which materially affects VSP's obligations hereunder must be mutually agreed upon in writing between VSP and Group and may constitute a material change to the terms and conditions of this Plan for purposes of Paragraph 4.03. Nothing in this section shall limit Group's ability to add Enrollees and/or Eligible Dependents in accordance with the terms of this Plan. 6.05. Change in Family Status: In the event Group is notified of any change in a Covered Person's family status (by marriage, the addition (e.g., newborn or adopted child) or deletion of dependent children, etc.) Group shall provide noti ce of such change to VSP via the next eligibility listing required under Paragraph 4.01. If such notice is given, the change in the Covered Person's status will be effective on the first day of the month following the request for change, or at a requested l ater date. Notwithstanding any other provision in this section, a newborn child will be covered for thirty -one (31) days after birth and an adopted child will be covered for thirty-one (31) days after the date the Enrollee or Enrollee's spouse acquires the right to control the health care of the child. To continue coverage for a newborn or adopted child beyond the initial thirty -one (31) day period, the Group must be properly notified of the Enrollee's change in family status and applicable amounts due must be paid to VSP on behalf of the child. 12 6.06. Family and Medical Leave Act: The federal Family and Medical Leave Act of 1993 (FMLA), requires that under certain circumstances health plan benefits available to an eligible Enrollee and his or her Eligible De pendents be made available during certain periods of leave. Benefits will be available at the level and under the conditions coverage would h ave been provided if the eligible Enrollee had not gone on leave. If, and only to the extent, FMLA applies to the parties to this Plan, VSP shall make the statutorily-required continuation coverage available based on the eligibility information provided by the Group. 13 VII. CONTINUATION OF COVERAGE 7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available for purchase by said persons upon the occurrence of a COBRA-qualifying event. If, and only to the extent, COBRA applies, VSP shall make the statutorily-required continuation coverage available for purchase in accordance with COBRA. 14 VIII. ARBITRATION OF DISPUTES 8.01. Dispute Resolution: Any dispute or question arising between VSP and Group or any Covered Person involving the application, interpretation, or performance under this Plan shall be settled, if possible, by amicable and info rmal negotiations. This will allow such opportunity as may be appropriate under the circumstances for fact-finding and mediation. If any issue cannot be resolved in this fashion, it shall be submitted to arbitration. 8.02. Procedure: The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association in effect at the time of the dispute. 8.03. Choice of Law: Question(s) and dispute(s) hereunder are to be resolved by arbitration. However, if there are any matters arising in connection with this Plan which do become the subject of legal process, the applicable law shall be that of the State of delivery of this Plan. 15 IX. NOTICES 9.01. Required Notices: Any notices to be given under this Plan to either the Group or VSP shall be in writing and delivered by United States First Class Mail. Notices sent to the Group will be mailed to the address shown on the Group Application. Notices sent to VSP shall be sent to the address shown on this Plan. Any notices m ay be hand-delivered by either party to an appropriate representative of the party, with the burden being on the party effecting such hand -delivery, to prove, if questioned, that such delivery was made. 16 X. MISCELLANEOUS 10.01. Entire Plan: This Plan, the Group Application, and all Exhibits and attachments, and any amendments hereto, constitute the entire understanding between the parties and supersedes any prior understandings and agreements between them, either written or oral. Any change or amendment to the Plan must be approved by an officer of VSP and attached to be valid. No agent has the authority to change this Plan or waive any of its provisions. Communication material s prepared by Group for distribution to Enrollees do not constitute a part of this Plan. 10.02. Indemnity: VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its officers, agen ts or employees, to perform any of the activities, duties or responsibilities specified herein. Group agrees t o indemnify, defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees) of any nature whatsoever arising or resulting from the failure of Group, its officers or employees to perform any of the duties or responsibilities specified herein. 10.03. Liability: VSP arranges for the provision of vision care services and materials through agreements with Member Doctors, who are independent contractors responsible for exercising independent judgment. VSP does not itself directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization performing services or supplying materials in connection with this Plan. 10.04. Assignment: Neither this Plan nor any of the rights or obligations of either of the parties may be assigned or transferred, except as noted herein, without the prior written consent of both parties. 10.05. Severability: Should any provision of this Plan be declared invalid, the remaining provisions shall remain in full force and effect. 10.06. Governing Law: This Plan shall be governed by and construed in accordance with applicable federal and state law. Any provision that is in conflict with, or not in compliance with, applicable federal or state statutes or regulations is hereby amended to conform with the requirements of such statutes or regulations, now or hereafter existing. 10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or plural, as the identity(ies) of the person(s) may require. 17 10.08. Communication Materials: All Communication materials created by Group which relate to this vision care Plan must adhere to VSP's Member Communication Guidelines, distributed to Group by VSP. Such communication materials may be sent to VSP for review and approval in advance of mailing to Enrollees. VSP’s review of such materials shall be limited to approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group’s materials meet any applicable legal or regulatory requirements, including, but not limited to, ERISA requirements. 18 EXHIBIT A VISION SERVICE PLAN INSURANCE COMPANY SCHEDULE OF BENEFITS VSP Choice Plan GENERAL This Schedule lists the vision care services and vision care materials to which Covered Persons of VISION SERVICE PLAN INSURANCE COMPANY ("VSP") are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non-Member Provider services, as indicated by the reimbursement provisions below, vision care services and vision care materials may be received from any licensed optometrist, opht halmologist, or dispensing optician, whether Member Doctors or Non-Member Providers. This Schedule forms a part of the Plan or Certificate to which it is attached. Member Doctors are those doctors who have agreed to participate in VSP’s Choice Network. When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to any Copayments as stated below. When Plan Benefits are available and received from Non -Member Providers, the Covered Person is reimbursed for such benefits according to the schedule in the second column below less any applicable Copayments. COPAYMENT The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Copayments are required for Plan Benefits received from Member Doctors and Non -Member Providers. Covered Persons must also follow the proper procedures for obtaining Benefit Authorization. There shall be a Copayment of $10.00 for the examination payable by the Covered Person to the Member Doctor at the time services are rendered. If materials (lenses and frames) are provided, there shall be a n additional $25.00 Copayment payable at the time the materials are ordered. However, the Copayment for materials shall not apply to elective contact lenses. PLAN BENEFITS MEMBER DOCTOR BENEFIT NON-MEMBER PROVIDER BENEFIT VISION CARE SERVICES Eye Examination Covered in Full* Up to $ 45.00* Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated. Subsequent regular eye examinations once every plan year beginning on January 1st. *Less any applicable Copayment. 19 VISION CARE MATERIALS MEMBER DOCTOR NON-MEMBER BENEFIT PROVIDER BENEFIT Lenses Single Vision Covered in full* Up to $ 30.00* Bifocal Covered in full* Up to $ 50.00* Trifocal Covered in full* Up to $ 65.00* Lenticular Covered in full* Up to $ 100.00* Available once every plan year beginning on January 1st. Frames Covered up to Plan Allowance* Up to $ 70.00* Available once every plan year beginning on January 1st. *Less any applicable Copayment. Lenses and frames include such professional services as are necessary, which shall include: • Prescribing and ordering proper lenses; • Assisting in the selection of frames; • Verifying the accuracy of the finished lenses; • Proper fitting and adjustment of frames; • Subsequent adjustments to frames to maintain comfort and efficiency; • Progress or follow-up work as necessary. 20 CONTACT LENSES Contact lenses are available once every plan year in lieu of all other lens and frame benefits available herein. When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for one plan year. Necessary- Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses. MEMBER DOCTOR NON-MEMBER BENEFIT PROVIDER BENEFIT Professional Fees and Materials Professional Fees and Materials Covered in full* Up to $210.00* Elective - MEMBER DOCTOR NON-MEMBER BENEFIT PROVIDER BENEFIT Elective Contact Lens fitting and evaluation** services are covered in full once every plan year, after a maximum $60.00 Copayment. Materials Professional Fees and Materials Up to $130.00 Up to $105.00 *Subject to Copayment **15% discount applies to Member Doctor’s usual and customary professional fees for contact lens evaluation and fitting. 21 LOW VISION BENEFIT The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular lenses. MEMBER DOCTOR BENEFIT NON-MEMBER PROVIDER BENEFIT Supplementary Testing Covered in Full Up to $125.00 Complete low vision analysis/diagnosis, which includes a comprehensive examination of visual functions, including the prescription of corrective eyewear or vision aids where indicated. Supplemental Care Aids 75% of Cost 75% of Cost Subsequent low vision aids. Copayment for Supplemental Aids: 25% payable by Covered Person. Benefit Maximum The maximum benefit available is $1000.00 (excluding Copayment) every two years. NON-MEMBER PROVIDER BENEFIT Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements as described above for a Member Doctor. The Covered Person should pay the Non -Member Provider his full fee. The Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature. 22 EXCLUSIONS AND LIMITATIONS OF BENEFITS Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by calling VSP’s Customer Care Division at (800) 877-7195. PATIENT OPTIONS This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses or frames, a nd the Covered Person will pay the additional costs for the options. • Optional cosmetic processes. • Anti-reflective coating. • Color coating. • Mirror coating. • Scratch coating. • Blended lenses. • Cosmetic lenses. • Laminated lenses. • Oversize lenses. • Polycarbonate lenses. • Photochromic lenses, tinted lenses except Pink #1 and Pink #2. • Progressive multifocal lenses. • UV (ultraviolet) protected lenses. • Certain limitations on low vision care. • A frame that costs more than the Plan allowance. • Contact lenses (except as noted elsewhere herein). NOT COVERED There is no benefit for professional services or materials connected with: • Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a ± .50 diopter power); or two pair of glasses in lieu of bifocals; • Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services are otherwise available; • Medical or surgical treatment of the eyes; • Corrective vision treatment of an Experimental Nature; • Costs for services and/or materials above Plan Benefit allowances; • Services and/or materials not indicated on this Schedule as covered Plan Benefits. VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON. 23 PLAN BENEFITS AFFILIATE PROVIDERS GENERAL Affiliate Providers are providers of Covered Services and Materials who are not contracted as Member Doctors but who have agreed to bill VSP directly for Plan Benefits provided pursuant to this Schedule. However, some Affiliate Providers may be unable to provide all Plan Benefits included in this Schedule. Covered Person should discuss requested services with their provider or contact VSP Customer Care for details. BENEFIT PERIOD A twelve-month period beginning on January 1st and ending on December 31st. COPAYMENT There shall be a Copayment of $10.00 for the examination payable by the Covered Person at the time services are rendered. If materials (lenses and frames) are provided, there shall be an additional $25.00 Copayment payable at the time the mater ials are ordered. The Copayment for materials shall not apply to Elective Contact Lenses. COVERED SERVICES AND MATERIALS EYE EXAMINATION- Covered in full* once every 12 months** Comprehensive examination of visual functions and prescription of corrective eyewear. LENSES - Covered in full* once every 12 months** Spectacle Lenses (Single, Lined Bifocal, or Lined Trifocal ) FRAMES - Covered up to the Plan allowance* once every 12 months** CONTACT LENSES ELECTIVE Elective Contact Lenses (materials only) are covered up to $130.00 once every 12 months. Elective Contact Lens fitting and evaluation services are covered in full once every 12 months, after a maximum $60.00 Copayment. NECESSARY Necessary Contact Lenses are covered up to $210.00* once every 12 months** Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor. Contact Lenses are provided in place of spectacle lens and frame benefits available herein. *Less any applicable Copayment. **Beginning with the first day of the Benefit Period. 24 LOW VISION Professional services for severe visual problems not correctable with regular lenses, including: Supplemental Testing: Up to $ 125.00† -Includes evaluation, diagnosis and prescription of vision aids where indicated. Supplemental Aids: 75% of Affiliate Provider’s fee up to $1000.00† †Maximum benefit for all Low Vision services and materials is $1000.00 every two (2) years and a maximum of two supplemental tests within a two-year period Low Vision Services are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Doctor. 25 EXCLUSIONS AND LIMITATIONS OF BENEFITS 1. Exclusions and limitations of benefits described above for Member Doctors shall a lso apply to services rendered by Affiliate Providers. 2. Services from an Affiliate Provider are in lieu of services from a Member Doctor or a Non -Member Provider. 3. VSP is unable to require Affiliate Providers to adhere to VSP’s quality standards. 4. Where Affiliate Providers are located in membership retail environments, Covered Persons may be required to purchase a membership in such entities as a condition of obtaining Plan Benefits. 26 EXHIBIT B VISION SERVICE PLAN INSURANCE COMPANY SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE VSP Choice Plan VSP shall be entitled to receive amounts due for each month on behalf of each Enrollee and his/her Eligible Dependents, if any in the amounts specified below: ADVANCE PAYMENT: $0.00 ADMINISTRATIVE FEE: $2.70 PER ELIGIBLE ENROLLEE NOTICE: The amount due under this Plan is subject to change upon renewal (after the end of the Plan Term or any subsequent Plan Term) or upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Plan. 27 ADDENDUM VISION SERVICE PLAN INSURANCE COMPANY ADDITIONAL BENEFIT - PRIMARY EYECARE Primary Eyecare is designed for the detection, treatment, and management of ocular conditions and/or systemic conditions which produce ocular or visual symptoms. Under the plan, Member Doctors provide treatment and management of urgent and follow-up services. Primary Eyecare also involves management of conditions which require monitoring to prevent future vision loss. The Member Doctor is responsible for advising and educating patients on matters of general health and prevention of ocular, as well as systemic disease. If consultation, treatment, and/or referral are necessary, it is the responsibility of the Member Doctor as a Primary Eyecare Professional, to manage and coordinate on behalf of the patient to assure appropriateness of follow-up services. SYMPTOMS Examples of symptoms which may result in a patient seeking services on an urgent basis under the Primary Eyecare Plan include, but are not limited to: • ocular discomfort or pain • recent onset of eye muscle dysfunction • transient loss of vision • ocular foreign body sensation • flashes or floaters • pain in or around the eyes • ocular trauma • swollen lids • diplopia • red eyes CONDITIONS Examples of conditions which may require management under the Primary Eyecare Plan, include, but are not limited to: • ocular hypertension • macular degeneration • glaucoma • corneal abrasion • retinal nevus • corneal dystrophy • cataract • blepharitis • pink-eye • sty PROCEDURES FOR OBTAINING PRIMARY EYECARE SERVICES 1. To obtain Primary Eyecare Services, the Covered Person contacts a Member Doctor's office and makes an appointment. If necessary, the Covered Person may call VSP's Customer Service Department first to determine the nearest location of a Member Doctor's office. 2. If urgent care is necessary, the Covered Person may be seen by a Member Doctor immediately. 3. The Covered Person pays the applicable Copayment to the Member Doctor at the time of each Primary Eyecare office visit. 4. When the Member Doctor has completed the services, he will fill out the necessary paperwork and mail it to VSP. VSP will pay the Member Doctor directly according to VSP's agreement with the Docto r. 28 COPAYMENT The benefits described herein are available to each Covered Person from any participating Member Doctor at no cost to the Covered Person except there shall be a Copayment amount of $20.00 payable by the Covered Person to the Member Doctor at the time of each Primary Eyecare office visit. EXCLUSIONS AND LIMITATIONS OF BENEFITS The Primary Eyecare Plan is designed to cover Primary Eyecare services only. There is no coverage provided under the Plan for the following: 1. Costs associated with securing materials such as lenses and frames. 2. Orthoptics or vision training and any associated supplemental testing. 3. Surgical or pathological treatment. 4. Any eye examination, or any corrective eye wear, required by an employer as a condition of employment. 5. Medication. 6. Pre and post-operative services. REFERRALS BY THE MEMBER DOCTOR The Member Doctor will refer the patient to another doctor under the following conditions: 1. If the patient requires additional services which are covered by the Primary Eyecare Plan but are not provided in his office, the Member Doctor will refer the patient to another Member Doctor or to the major medical physician whose offices provide the necessary services. 2. If the patient requires services beyond the scope of the Primary Eyecare Plan, the Member Doctor will refer the patient back to the major medical physician. 3. If the patient requires emergency services beyond the scope of the Primary Eyecare Plan, the Member Doctor will make a "STAT" (emergency) referral by calling either another Member Doctor or the major medical physician. 29 DEFINITIONS Blepharitis - Inflammation of the eyelids. Cataract - A cloudiness of the lens of the eye obstructing vision. Conjunctiva - The mucous membrane that lines the inner surface of the eyelids and is continued over the forepart of the eyeball. Corneal Abrasion - Irritation of the transparent part of the coat of the eyeball. Corneal Dystrophy - A disorder involving nervous and muscular tissue of the transparent part of the coat of the eyeball. Diplopia - The observance by a person of seeing double images of an object. Eye Muscle Dysfunction - A disorder or weakness of the muscles that control eye movement. Glaucoma - A disease of the eye marked by increased pressure within the eyeball which causes damage to the optic disc and gradual loss of vision. Flashes or Floaters - The observance by a person of seeing flashing lights and/or spots. Macula - A small, yellowish area lying slightly lateral to the center of the retina that constitutes the region of maximum visual acuity. Macular Degeneration - Degeneration of the macula. Ocular - Of or relating to the eye or the eyesight. Ocular Hypertension - Unusually high blood pressure within the eye. Ocular Conditions - Any condition, problem, or complaint relating to the eyes or eyesight. Ocular Trauma - A forceful injury to the eye due to a foreign object, e.g., fist, baseball, racquetball, auto accident, etc. Pink-eye - An acute, highly contagious, conjunctivitis (inflammation of the conjunctiva). Retinal Nevus - A pigmented birthmark on the sensory membrane lining the eye which receives the image formed by the lens. Sty - An inflamed swelling of the fatty material at the margin of the eyelid. Systemic Condition - Any condition or problem relating to a person's general health. Transient Loss of Vision - Temporary loss of vision. 30