HomeMy WebLinkAboutCity Council Meeting - Council - Agenda - 07/15/2003 iv City of Kent
City Council Meeting
Agenda
July 15, 2003
Mayor Jim White
Councilmembers
Judy Woods, Council President
Tim Clark Julie Peterson
Connie Epperly Bruce White
Leona Orr Rico Yingling
KE 0 T
WAS HING TON
City Clerk's Office
SUMMARY AGENDA
KENT CITY COUNCIL MEETING
KEN T July 15,2003
W.s H I M G T G N Council Chambers
7:00 p.m.
MAYOR: Jim White COUNCILMEMBERS: Judy Woods, President
Tim Clark Connie Epperly Leona Orr
Julie Peterson Bruce White Rico Yingling
1. CALL TO ORDER/FLAG SALUTE
2. ROLL CALL
3. CHANGES TO AGENDA
A. FROM COUNCIL, ADMINISTRATION, OR STAFF
B. FROM THE PUBLIC
4. PUBLIC COMMUNICATIONS
A. Legislative Recognition
B. Proclamation—National Night Out
a t'c
5. PUBLIC HEARINGS -i
A. Kent Downtown Public Market Development Authority, Transfer of Property and
Dissolution—Adopt Ordinance -j 6 4-qt ---
B. Formation of LID 355, SE 216th& 104th Place SE Sanitary Sewers
6. CONSENT CALENDAR
A. Minutes—Approve
B. Bills—Approve
n C. Amendment to Washington City and County Pipeline Safety Consortium
Agreement—Authorize
D. Kent City Code Amendment, Capital Facilities Element Yearly Update Process,
Ordinance—Adopt 3 (V 5 O
E. Purchase of One Replacement Fire Engine—Authorize
FlexPass Contract 2003-2004—Authorize
G. Group Health Cooperative Contract Renewal—Authorize
H. Alexander Sewer Extension Bill of Sale—Accept
I. Torklift Parking Lot Street Improvement Bill of Sale—Accept
J. Kent Valley Ice Arena Utility Improvement Bill of Sale—Accept
K. Proposed LID 356, 11 lth Avenue Sanitary Sewers, Set Public Hearing Date,
Resolution—Adopt ((o�
L. Change of City Council Meeting Time—Ordinance—Adopt 3&S�
M. Tahoma Vista Rezone Ordinance—Adopt 3 fo5.2
N. U.S. Dept. of Education Grant—Authorize
0. (4UMd.P A66—'-f0, ytr1q(vnO — F*CU58J — !��Yatfer�
7. OTHER BUSINESS
A. Kent Station Preliminary Plat, Closed Record Appeal
(continued next page)
SUMMARY AGENDA CONTINUED
8. BIDS
A. Reith Road Water Main Improvements,42nd Avenue South to Pump Station#4
B. Garrison Well&East Hill Well Replacement Wells
9. REPORTS FROM STANDING COMMITTEES AND STAFF
10. REPORTS FROM SPECIAL COMMITTEES
11 CONTINUED COMMUNICATIONS
12. EXECUTIVE SESSION
A. Property Acquisition
13. ACTION AFTER EXECUTIVE SESSION
14. ADJOURNMENT
NOTE: A copy of the full agenda packet is available for perusal in the City Clerk's Office and the
Kent Library. The Agenda Summary page is on the City of Kent web site at
www.ci.kent.wa.us.
An explanation of the agenda format is given on the back of this page.
Any person requiring a disability accommodation should contact the City Clerk's Office in advance at
(253) 856-5725. For TDD relay service call the Washington Telecommunications Relay Service at
1-800-833-6388.
i^
'S }
CHANGES TO THE AGENDA
C to address the Council will, at this time, make known the subject of
inters*-,so all may be property heard.
A) FROM COUNCIL, ADMINISTRATION, OR STAFF
B) FROM THE PUBLIC
PUBLIC COMMUNICATIONS
e
A) LEGISLATI ;.WNITION
B) PROCLAMATION-NATIONAL NIGHT OUT
'ku ry
R'
Kent City Council Meeting
Date July 15, 0003
Category Public Hearings
1. SUBJECT: KENT DOWNTOWN PUBLIC MARKET DEVELOPMENT
AUTHORITY, TRANSFER OF PROPERTY AND DISSOLUTION—
ADOPT ORDINANCE
2. SUMMARY STATEMENT: On June 25, 2003, the Kent Downtown Public Market
Development Authority ("PDA") authorized the transfer of its assets and liabilities to the City
of Kent. The City Council, at its July 1, 2003, meeting, authorized the Mayor to accept all
property transferred to the City by the PDA, and scheduled a public hearing on the proposed
dissolution of the PDA for July 15, 2003
If adopted,the proposed ordinance dissolves the Kent Downtown Public Market Development
Authority, indemnifies the PDA board members as it indemnifies city board and commission
members in accordance with KCC 2.96.020, and authorizes the Mayor to take any action or
sign any documents which may be deemed necessary in order to dissolve the PDA
3. EXHIBITS: Ordinance
f4 RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
A Councilmember W& moves, Councilmember Qlvv seconds
to close the public hearing. M 0--
B. Councilmember _moves, Councilmember 10—seconds
adoption of Ordinance No.3� dissolving the Kent Downtown Public Market Development
Authority, indemnifying the PDA board members, and authorizing the Mayor to take any
action or sign any documents necessary to dissolve the PDA.
DISCUSSION:
ACTION. rn C
Council Agenda
Item No. SA
ORDINANCE NO.
AN ORDINANCE of the city council of the city of
Kent, Washington, dissolving the Kent Downtown Public
Market Development Authority ("PDA"), ordering the city
clerk to cancel the charter of the PDA, and providing notice
of the PDA's dissolution in accordance with state law.
WHEREAS, on March 3, 1998, the Kent city council enacted Ordinance
No. 3396 that created the Kent Downtown Public Market Development Authority
("PDA") to acquire, renovate, operate, and manage the Lumberman Barn property,
located at 206 Railroad Avenue North in the city of Kent, as the home of the Kent
Downtown Public Market, and
WHEREAS, in order to accomplish the redevelopment of the
Lumberman Barn property, the city, on May 17, 1999, recorded a Quit Claim Deed,
which transferred the city's ownership interest in the Lumberman Barn property to the
PDA, along with the remaining budgeted funds dedicated for that project, and
WHEREAS, after renovation of the Lumberman Barn property, the PDA
leased the property to the Kent Downtown Partnership for it to sublease space to
various vendors, and subsequently also leased a portion of the Lumberman Barn
property to the city of Kent, and
1 Kent Downtown Public Market
Development Authority-Dissolution
WHEREAS, the Kent Downtown Partnership advised the PDA on
December 18, 2002, that it would not seek renewal of its lease with the PDA due to the
difficulties of keeping the public market open, thereby allowing the PDA's lease with
the Kent Downtown Partnership to expire by its own terms on December 31, 2002, and
WHEREAS, the sole purpose of creating the PDA was for the PDA to
maintain and manage the Lumberman Barn property in order to house a year-round,
indoor public market, and since the efforts to save the indoor market at that location
have failed, the need for the PDA longer exists; and
WHEREAS, the PDA's charter, dated June 18, 1998, adopted in
I accordance with the city Ordinance No. 3396, provides that in the event of the PDA's
dissolution, title to all property or assets of the PDA shall vest in the city of Kent for its
4 use for public purposes, and
I
WHEREAS, in addition to the real property assets, the PDA also owned
personal property assets in the amount of $25,168 61 as of June 25, 2003, which
consisted of cash in the estimated amount of $1,285 00, investments in the estimated
amount of$23,430 00, and prepaid insurance in the amount of$453 61, and
WHEREAS, on or about June 25, 2003, the PDA transferred to the city
of Kent all title and interest it had in the Lumberman Barn real property and all other
real and personal property assets of the PDA, and
I
WHEREAS, on July 1, 2003, the city council authorized the mayor to
accept all property, real and personal, that the PDA offered to transfer to the city and
authorized the mayor to execute all necessary documents in order to effect the property
transfer, and
WHEREAS, all real and personal property of the PDA has now been
transferred to the city and, as such, it is now appropriate for the city to dissolve the
PDA, and
2 Kent Downtown Public Market
Development Authority -Dissolution
WHEREAS, on July 1, 2003, the city council scheduled a public hearing
on the proposed dissolution of the PDA, and the city clerk provided appropriate public
notice of the public hearing, which public hearing was held at a regular city council
meeting on July 15, 2003, and
WHEREAS, after the public hearing on July 15, 2003, the city council
has determined that dissolution of the PDA is warranted, NOW THEREFORE,
THE CITY COUNCIL OF THE CITY OF KENT, WASHINGTON,
DOES HEREBY ORDAIN AS FOLLOWS
SECTION 1. — Findings The recitals set forth above are hereby
adopted and incorporated by reference In addition, the city council further finds that
1 All real and personal property of the PDA has been transferred
to, and accepted by, the city of Kent
2 Notice of the July 15, 2003, public hearing before the city
council regarding the dissolution of the PDA was properly given, and the PDA was
afforded an opportunity to present testimony regarding the dissolution
3 The PDA is no longer needed as the indoor public market has
ceased to exist, therefore, dissolution of the PDA is warranted
SECTION 2. — Dissolution The Kent Downtown Public Market
Development Authority is hereby dissolved. The city clerk is authorized and directed
to inscribe "charter canceled" on the original charter of the PDA and any duplicate
originals of the charter which may exist The city clerk is further authorized and
directed to provide notice of the dissolution in accordance with RCW 35 22 288 and to
any other entity that has requested special notice
i
3 Kent Downtown Public Market
Development Authority-Dissolution
SECTION 3. — Indemnification As it does with city board and
commission members, the city shall provide competent legal counsel of its choosing, to
defend any current or former PDA board member or officer who is a party, or is
threatened to be made a party, to any threatened, pending, or contemplated action, suit,
or proceeding, whether civil, criminal, administrative, or investigative, arising from or
connected with that person's actions as a PDA board member or officer The city shall
pay or indemnify such PDA board member or officer against all expenses, fees,
judgments, fines, and amounts paid in settlement actually and reasonably incurred by
him or her in connection with such action, suit, or proceeding, except as otherwise
provided for city board and commission members under Kent City Code section
2 96 020. This indemnification provision shall survive the dissolution of the PDA.
SECTION 4. — Authorization The city council specifically authorizes
the mayor to take any action and to execute any documents necessary to dissolve the
PDA
SECTION 5. — Severabih If any one or more section, subsections, or
sentences of this ordinance are held to be unconstitutional or invalid, such decision
shall not affect the validity of the remaining portion of this ordinance and the same
shall remain in full force and effect
SECTION 6. — Effective Date This ordinance shall take effect and be
in force thirty(30) days from and after its passage as provided by law
i
JIM WHITE, MAYOR
ATTEST
BRENDA JACOBER, CITY CLERK
4 Kent Downtown Public Market •
Development Authority-Dissolution
APPROVED AS TO FORM:
TOM BRUBAKER, CITY ATTORNEY
PASSED day of 2003
APPROVED day of 2003
PUBLISHED day of 2003
I hereby certify that this is a true copy of Ordinance No
passed by the city council of the city of Kent, Washington, and approved by the mayor
of the city of Kent as hereon indicated
(SEAL)
BRENDA JACOBER, CITY CLERK
5 Kent Downtown Public Market
Development Authority-Dissolution
Kent City Council Meeting
Date July 15, 2003
Category Public Hearings
1. SUBJECT: FORMATION OF LID 355, SE 216TH & 104TH PLACE SE
SANITARY SEWERS
2. SUMMARY STATEMENT: Per Council authorization, this date has been set for
the public hearing on the formation of LID 355. The Public Works Department will be
making a presentation.
3. EXHIBITS: Public Works Director memorandum
4. RECOMMENDED BY: Council 6/17/03
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES_
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
A. Councilmember Wd o moves, Councilmember &-a seconds
to close the public hearing. -niC
B. Councilmember moves, Councilmember Pa&_seconds
to approve the formation of LID 355, for the construction of SE 216th and 104th Place
SE Sanitary Sewers project, including related improvements, and to direct the City
Attorney to prepare the necessary ordinance.
DISCUSSION.
ACTION: C
Council Agenda
Item No. 5B
PUBLIC WORKS DEPARTMENT
Don E Wickstroin, RE Public Works Director
00 Phone 253-856-5500
K E N T Fax 253-856-6500
W.5 MIw GTO.
Address 220 Fourth Avenue S
Kent,1VA 98032-5895
Date: June 17,2003
To. Mayor and City Co ncd
From: Don Wickstrom 04
RE LID 355 SE 216'b Street& 104`b Place SE Sanitary Sewers
Formation Public Hearing
July 15, 2003 has been scheduled for the formation hearing for the above referenced LID project
BACKGROUND
The City received a petition with 23 signatures for the installation of sanitary sewers in the vicinity of SE
216'b Street and 104'b Place SE including the residential plats of Mount View Park as shown on the
attached maps Subsequently, all property owners within the project area were contacted and there
appears to be adequate support to proceed with the LID formation The project area is outside of the City
limits, however, it is within the City's potential annexation area and franchised sewer service area The
project location is shown in the City's Sewer Comprehensive Plan to be sewered by Kent
The City developed a proposal, mailed information to all property owners involved and held an
informational meeting November 20, 2002 Property owners then completed a questionnaire indicating
their interest of disinterest in the proposal Those responding to proceed represented 43% This is
enough interest to form an LID, however, a higher support level is desirable The LID boundary was
revised to delete various non-supportive properties The support level indicated by the questionnaires for
the revised boundary is shown below Those responding to proceed with the LID are identified on the
attached map.
Proceed with LID 60 20%
Do not proceed with LID 19 90%
Did not respond 19 90%
The proposal was reviewed by the Public Works Committee on June 2, 2003 and the Resolution of intent
was passed by City Council on June 17, 2003 setting the hearing date for July 15, 2003
PROPOSED SANITARY SENVER IMPROVEMENTS
The proposed project is the construction of an 8" sanitary sewer system with 6" side sewer stubs to the
right-of-way line or easement line for each of the 39 properties included in the LiD boundary
P iASPT%MemINL1 D 555 FGmvoon Public Hearing Mena doc
The construction will include 8"sewer at the following locations
ON FROM TO •
105"' Place SE SE 218'b Street Approximately 400 feet north
SE 21 Sib Street 105"Place SE 105'b Avenue SE
105"b Avenue SE SE 2181b Street SE 220"Street approximately 75' West
of East plat boundary
SE 219" Street 105'b Avenue SE East and West to cul-de-sac
Easement SE 219'b Street at end of Approximately 240 feet northwesterly
cul-de-sac West of 105`b from center of cul-de-sac
Avenue SE
Easement End of above easement Intersection of 103'd Place SE and
SE 2161b Street at existing manhole
NEED FOR SEWERS
The project area consists of two older residential plats (1961 and 1964) developed with septic systems A
larger residential property (assessments 1 and 2 on the map) is owned by a developer who has indicated
his interest in developing. it is not known how many existing septic systems are technically in a state of
failure, however,we understand from the residences that there are septic problems in the area Usually it
is difficult to repair septic problems, especially on small lots such as these with limited space Sanitary
sewers are usually the most feasible, economical and long term method for addressing these problems,
especially when numerous property owners in a neighborhood support sewer installation as is the case
with this proposal
The Department of Public Health has told us the life expectancy of a septic system is 20 to 30 years
depending on use and maintenance and they are a short term disposal method until public seders become
available The project area has greatly exceeded this time frame and the reports of failures substantiate
these systems are at or are near the end of their useful life They also say that the cost of septic repairs
may be as high as converting to public sewers The latest State Codes make septic repairs more difficult
and expensive
The soil type within the project area is poorly rated for septic system use According to the Soil
Conservation Service (US Dept of Agriculture) Soil Survey for King County, the sod type as mapped is
rated severe limitation for septic dram fields The soil series is designated as AmC (arents, Alderwood
material 6-15% slope) This soil exhibits very slow permeability below a depth of 24-40 inches and a
seasonal high water table. Effluent and drainage move laterally over the lower impetuous layers
Effluent may come to the surface in the neighbors yards and in roadside ditches
In addition to the need for sewers in this area to replace the failing septic systems, there are environmental
concerns. The project area is located adjacent to the north bank of the middle fork of Garrison Creek
Septic seepage and runoff can cause bank erosion and degrade water quality in the stream
PROPERTY OWNER COMMENTS
Various input from property owners has been received One owner wants the sewer because she has to
measure the water table in her back yard to evaluate if her family can shower or run the dishwasher. They
frequently shower at the gym She also complained about failing systems around her home and the
resulting odor problem
P USPT%MemMLID 355 Fomwwn Public Heannk Memo doc
One non-supporter who claimed she doesn't need sewers recently called to change her position due to a
septic failure which has occurred since the informational property owner meeting
. One supporter can't get a building permit from King County for an addition to his house due to the septic
situation.
Other owners say their septic systems are failing or have failed in the past and they support the sewer
project
Another response summed it up as follows.
"This project is long overdue These septic systems were installed in the 60's and intended to be only
temporary Many of these systems have been replaced in the last 20 years. My system has failed twice,
and with surface water management issues complicating an already marginal situation, this must be
permanently resolved by sewers as soon as possible."
Those that are non-supportive mentioned that their septic systems are currently working and they don't
want the expense One man said he is retired and would have to sell his home of many years due to the
additional expense of the LID assessment and sewer bill Another owner is concerned about the
annexation covenant requirement.
PROJECT FUNDING
LLD $758,965 62
CITY 60,404 80
TOTAL $819,271 42
The total LID assessment is estimated at $758,865 62 Single family lots are estimated at $15,101 20
Several larger subdividable properties are assessed higher due to development potential beyond a single
residence
There are no City owned properties within the proposed project However, the proposal is for the City to
contribute $60,404 80 sewer utility funds There are four parcels on 104th Place SE that \\ere deleted
from the LID when the proposal was revised and the sewer on 104`b Place SE was deleted These
properties will have the potential to connect to the sewer to the rear Therefore, the City will pick up the
costs for these parcels as if they were assessed and establish a charge in lieu of assessment
METHOD OF ASSESSMENT
Each parcel's proportionate share of the total project cost is determined by the following method The
assessments are based upon square footages using a zone and termini method within the assessment
boundary. The assessment rate decreases with 150-foot zones back from the sanitary sewer to the rear of
the properties seniced In this case there are three zones The zone rate for the first 150-foot strip of
each parcel abutting the sanitary sewer is three times the zone rate for the 150-foot strip which begins
300-feet from the sanitary sewer, and so on
There are a number of single-family residential lots within the LLD. These parcels can't subdmde and are
limited to one residence. In this case, a variation in square footage doesn't affect benefit Each of these
parcels will receive one residential side sewer connection, therefore the benefit is equal The total
assessment for all of these parcels determined by the square footage calculation as described above is
averaged based on the total number of single family lots thereby creating equal assessments
Those portions of properties that contained steep ravines were not included in the square footage
calculation assessment. The lots or portions thereof that are too low for a gravity side sewer require a
pumped system and were calculated at 0 5 factor
P\ASPT\WmH\LID 355 Fommun Pobhc Hnnng Mcnw dm
PAYMENT OF ASSESSMENT
Upon Council passing the Ordinance confirming the Final Assessment Roll, there is a 30-day period in
which any portion or all of the assessment can be paid without interest charges After the 30-day period,
the balance is paid over a ten-year period wherein each year's payment is one-tenth of the principal plus
interest on the unpaid balance The market determines the interest rate at the time the L I D bonds are
sold to the public
SUPPORT FOR LID 355
To defeat an LID proposal, there must be protest from property owners representing 60% or more of the
proposed LID assessments The total project cost for calculating protest percentage is $758,865 62 The
60%protest amount would be$455,319 37
As indicated previously, there appears to be substantial property owner support for the project ii ith 60 2%
expressing interest through the questionnaire process. Should this level of support continue through the
public hearing process, it will then be a City Council decision whether or not to proceed with the LiD
formation process and approve the LID formation ordinance
ANNEXATION TO CITY
The proposed LID is located outside of the Kent City limits but within our sewer franchise boundary and
proposed annexation area
These properties will not be required to annex to the City prior to the LID formation Houever, each
person applying for a sewer permit will be required to execute an Annexation No Protest Covenant This
means that in the case of an annexation attempt, they will be counted as a "yes" vote and once enough
covenants have been signed, an annexation could proceed
MANDATORY SEWER CONNECTION
The City Code states that all residences, whether within or outside the City limits, located within 200 feet
of a City of Kent sanitary sewer shall be required to connect to the sewer and shall be bitted for the
service. The Code provides that compliance with this provision be within 90 days after the date of
official notice In the case of a public health or safety hazard, compliance shall be within 20 days of
official notification.
Following construction of the project should the LID be formed, the City will send each property owner
an official notice that the sanitary sewer service is available to the parcel and is within 200 feet of the
house Following the compliance period, all properties which have not yet applied for aside sewer permit
will automatically be added to the sewer billing list
EASEMENT AND RIGHT-OF-WAY ACQUISITION
The construction of the project will require property acquisition in some locations to provide easements
for the sanitary sewers. Each property involved will be appraised followed by negotiation between the
City and owner Final settlement can be a direct payment or can be a credit toward the assessment
thereby reducing the amount of the yearly payments
A King County Right-of-Way Construction Permit must also be obtained.
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L.I.D. 355
L.I.D. VICINITY MAP
CITT OP KENT ENGINEERING DEPARTMENT BOG W. COWS ST KENT. WA. 99033
S.E. 216TH STREET AND 104TH PLACE S.E.
g .... NT PROPOSED SANITARY SEWER LID MAP
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WATER AND
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EXISTING s —KSE-NT SEWER
SANITARY SERVICE AREA
BOUNDARY
SEWER 1
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LID
BOUNDARY
1
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LEGEND
O O ASSESSMENT
*O 74 NUMBER
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PROPOSED
SANITARY
f SEWER
18 ' 77 i6 NA NOT ASSESSE
OUESTIONNAIRE
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BOUNDARY 37
25
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L.I.D. 355
Q L.I.D. BOUNDARY MAP
p CITY Or KENT ENGINEERING DEPARTMENT 400 W OOWE ST KENT. WA. 9/033
S.E. 216TH STREET AND 104TH PLACE S.E.
PROPOSED SANITARY SEWER LID MAP
v
CONSENT CALENDAR
6. City Council Action:
Councilmember w 0WZQIO moves, Councilmember Q/v✓
seconds to approve Consent Calendar Items A through➢eO
Discussion
Action G
6A. Approval of Minutes.
Approval of the minutes of the regular Council meeting of July 1, 2003.
6B Approval of Bills.
Approval of payment of the bills received through June 30 and paid on June 30 after
auditing by the Operations Committee on July 1, 2003.
• Approval of checks issued for vouchers:
Date Check Numbers Amount
6/30/03 Wire Transfers 1450-1460 $1,019,243.89
6/30/03 Prepays & 550074 401,194.41
6/30/03 Regular 550073 1,647,741.42
$3,068,179.72
Approval of checks issued for payroll for June 1 through June 15 and paid on June 20,
2003:
Date Check Numbers Amount
6/6/03 Interim Checks 270836-270837 $ 2,81725
$ 2,817.25
6/20/03 Checks 270838-271142 $ 240,036 08
6/20/03 Advices 149348-150030 1,194,43163
$1,434,467.71
Council Agenda
Item No 6 A-B
•
KENT Kent City Council Meeting
""s^'°°'°" July 1, 2003
The regular meeting of the Kent City Council was called to order at 7 00 p m by Mayor White
Councilmembers present Clark, Epperly, Orr, Peterson, White, and Yingling Councilmember
Woods was excused from the meeting Approximately 30 people were at the meeting (CFN-198)
CHANGES TO AGENDA
A From Council (CFN-198) Consent Calendar Item N was added by Council member Orr
Martin added three additional items of land acquisition and one item of potential litigation to the
Executive Session
B From the Public. (CFN-198) Continued Communications Items A, Hazardous Sites List and
B, 2003 Citizen Survey Report were added by members of the audience
PUBLIC COMMUNICATIONS
A Emplovee of the Month. (CFN-147) Mayor White announced that Paula Thayer of Fire
PreN ention, has been selected as the July 2003 Employee of the Month
B Proclamation —Group Workcamp Week. (CFN-155) Mayor White read a proclamation
declaring the week of July 6 -13, 2003 as Group Workcamp Week, and presented it to Dim Duclos
of the Multi Service Center, who explained the project
C Proclamation — Pause to Remember Our Korean War Veterans. (CFN-155) Mayor
White read a proclamation proclaiming 2003 as Pause to Remember Our Korean War Veterans
year The proclamation x+as accepted by Korean War Veteran Bill Swmford
D Recreation and Parks Month. (CFN-155) Mayor White read a proclamation declaring the
month of July 2003 as Recreation and Parks Month and presented it to Parks Director Hodgson
E Presentation of Century 21 Donation. (CFN-198) Representatives of Century 21 Allstate in
Kent presented a check in the amount of$1,000 to the mayor to be used to improve a youth
baseball field
F Diversity Champion Award. (CFN-155) Mayor White then noted receipt of the AWC
Diversity Champion Award for Excellence and presented it to Jed Aldridge of Employee Services
PUBLIC HEARINGS
A S. 259th Place Street Vacation. (CFN-102) Resolution No 1639 established this date for the
public hearing on the application by Ms Phyllis M Dettler to vacate a portion of South 259th
Place Because Ms Dettler rescinded her application on June 9, 2003, there was no public heating
or further action by Council on this item
B Sale of Surplus Utilitv Equipment. (CFN-239) Mayor White noted that the City owns
certain public utility equipment which the Public Works Director has determined is no longer
needed as part of the City's water system He then opened the public hearing There were no
comments from the audience and ORR MOVED to close the public hearing Clark seconded and
the motion carried CLARK MOVED to adopt Resolution No 1647 which declares certain public
1
Kent City Council Minutes July 1, 2003
utility equipment surplus and authorizes its sale to the highest bidder at public bid, or, if the
equipment is not sold at auction, to be sold for scrap metal Peterson seconded and the motion
carried
CONSENT CALENDAR
ORR MOVED to approve Consent Calendar Items A through N Clark seconded and the motion
carried
A Approval of Minutes. (CFN-198) The minutes of the regular meeting of June 17, 2003, were
approved
B Approval of Bills. (CFN-104) Payment of the bills received through June 15 and paid on
June 17 after auditing by the Operations Committee on June 17, 2003, was approved as follows
Approval of checks issued for vouchers-
Date Check Numbers Amount
6/17/03 Wire Transfers 1440-1449 $1,139,995 38
6/17/03 Prepays & 549411 259,334 30
6/17/03 Regular 550073 1,220,508 43
$2,619,838 11
Approval of checks issued for payroll for May 16 through May 31 and paid on June 5, 2003
Date Check Numbers Amount
5/28/03 Interim Check 270527 $ 14698
6/5/03 Checks 270528-270835 245,788 21
6/5/03 Advices 148665-149347 1,186,85642
$1,432,791 61
C Data Center Power Supply Unit Project. (CFN-1155) The Mayor was authorized to sign
purchase orders for the purchase and installation of additional power supply units for the data
center using contingency funds from Technology Plan 2002
D Re-Appointment of Lodging Advisory Board Members. (CFN-1170) As recommended by
the Operations Committee, the re-appointment of Kathy Madison and Andy Wangstad for
additional three (3) year terms on the Lodging Tax Advisory Board was approved
E Kent Lodgin¢ Association Budget. (CFN-1170) An amendment of the Kent Lodging
Association budget, which extends the contract through the end of 2003 was approved, as
recommended by the Operations Committee
F Kent Downtown Public Market Development Authoritv, Transfer of Propertv, Set
Hearing Date. (CFN-462) The Mayor was authorized to accept all property, real and personal,
that the PDA offers to transfer to the City of Kent, to execute any and all necessary documents in
order to effect the property transfer, and to set a public hearing on the proposed dissolution of the
PDA before the City Council at its July 15, 2003, meeting
2
Kent City Council Minutes July 1, 2003
G. Declare Listed Equipment and Materials as Surplus. (CFN-239) As recommended by the
Public Works Committee, equipment and materials no longer needed by the City were declared
surplus and the sale thereof at the Cornucopia Days Public Auction was authorized.
H Restrictive Covenant Kent Highlands Landfill. (CFN-311) As recommended by the Public
Works Committee, the Mayor was authorized to sign the Restrictive Covenant Kent Highlands
Landfill document and to direct staff to record the Covenant and the Declarative Statement and
Cleanup Action Plan on the City's Kent Highlands property
T Partial Termination and Relinquishment of Wetland Easement and Reservation.
(CFN-239) As recommended by the Public Works Committee, the Mayor was authorized to sign
the Partial Termination and Relinquishment of Wetland Protection Easement and Resenation
document with respect to Wetland Areas G, H, M, and SW of Boeing Company Pacific Gateway
Business Park
J Zoning Code Amendment, Auto Repair as Home Occupation, Extension of Amortization
Period, Ordinance. (CFN-131) Ordinance No 3646, extending the amortization period for auto
repair as a home occupation to October 18, 2004, three (3) years from the effective date of the
initial code amendment that prohibited this type of use, was adopted
K Zoning Code Amendment, Auto Repair and Washing Services in M-3 Zoning District,
Ordinance. (CFN-131) Ordinance No 3647, amending sections 15 04 090 and 15 04 100 of the
Kent City Code to permit auto repair and washing services in the M3, General Industrial, zoning
district when the property is used for heavy equipment repair and/or truck repair, and the property
abuts or is split-zoned with Gateway Commercial (GWC)property, was adopted
L Zoning Code Amendment, Neighborhood Convenience Commercial District, Ordinance.
(CFN-131) Ordinance No 3648, amending sections 15 04 070, 15 04 080, 15 04 090, 15 04 100,
15 04 190, 15 04 195, 15 06 050, and 15 07 060 of the Kent City Code to permit accessory din e-
through facilities, require design techniques to enhance compatibility betty een neighborhood com-
mercial development and surrounding residential uses, and to modify the signage and landscaping
requirements for Neighborhood Convenience Commercial ("NCC") properties, was adopted
M Bill of Sale, Gagliardi Sewer Extension. (CFN-484) As recommended by the Public Works
Director, the Bill of Sale for the Gagliardi Sewer Extension for continuous operation and
maintenance of 1,342 feet of sewers was accepted
N Councilmember Absence. (CFN-198) An excused absence for Councilmember Woods from
tonight's meeting was approved
OTHER BUSINESS
A Tahoma Vista Rezone #RZ-2002-5. (CFN-121) Mayor White noted that this request by
Donald L Gill-More is to rezone approximately 4 84 acres of property from SR-4 5, Single
Family Residential, to SR-6, Single Family Residential Sharon Clamp of Planning Services
explained the rezone and said staff and the Kent Hearing Examiner recommend approval ORR
MOVED to accept the Findings, Conclusions, and Recommendation of the Hearing Examiner on
the Tahoma Vista Rezone, and to direct the City Attorney to prepare the necessary ordinance
Clark seconded and the motion carried
3
Kent City Council Minutes July 1, 2003
B Boeing Resolution. (CFN-198) Mayor White noted that the proposed resolution expresses
Kent's commitment to the state-wide effort to recruit the final assembly of the Boeing Company's
7E7 next generation commercial Jetliner in Washington State, to keep the Boeing Company's
manufacturing facilities in Puget Sound, and to sustain the Boeing Company's rank as the top
commercial airplane maker in the world YINGLING MOVED to adopt Resolution No 1648,
which expresses Kent's commitment to the state-wide effort to recruit the final assembly of the
Boeing Company's 7E7 next generation commercial Jetliner in Washington State Epperly
seconded and the motion carried.
REPORTS
A Council President. (CFN-198) Clark reminded Councilmembers that Kent is the host of the
next Suburban Cities Association meeting
B Operations Committee. (CFN-198) Orr noted that all items at today's meeting were
approved Yingling concurred that the items can go on the Consent Calendar
C Public Safety Committee. (CFN-198) Epperly noted that the next meeting will be at
5 00 p m on July 8th
D. Public Works Committee. (CFN-198) Clark reminded the public that Highway 167 will be
closed from July 18-21
E Plannin2 Committee. (CFN-198) Orr noted that the next meeting will be July 15th at
300pm
G Administrative Reports. (CFN-198) Martin noted that there will bean executive session of
approximately 40 minutes to discuss five items, and that no action is anticipated
CONTINUED COMMUNICATIONS
A. Hazardous Sites List. (CFN-198) Bob O'Brien 1131 Seattle Street, displayed a hazardous
sites list put out by the State Department of Ecology and spoke about the ranking of the Borden
Chemical site
B 2003 Citizen Survey Report. (CFN-198) Ted Ko-is�ta, 25227 Rerth Road, opined that the
2003 Citizen Survey Report should be revisited
EXECUTIVE SESSION
The meeting recessed to Executive at 7 35 p m , and reconvened at 8 28 p in (CFN-198)
ADJOURNMENT
At 8 28 p m , PETERSON MOVED to adjourn Orr seconded and the motion carried (CFN-198)
Brenda Jacober, CMC
City Clerk
4
Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: AMENDMENT TO WASHINGTON CITY AND COUNTY
PIPELINE SAFETY CONSORTIUM AGREEMENT—AUTHORIZE
2. SUMMARY STATEMENT: Authorization is requested for the Mayor to sign
Amendment 2 to Interlocal Agreement establishing the Washington City and County
Pipeline Safety Consortium.
The Washington City and County Pipeline Safety Consortium was established by
Interlocal Agreement in the year 2000 in response to the devastating explosion of the
Olympic Pipeline in Bellingham. The current Consortium membership includes-
Auburn, Bellevue, Bellingham, Bothell, Kent, Redmond, Renton, SeaTac, Seattle,
Tumwater, Woodinville, Clark County and Thurston County The amendment would
extend this agreement for an additional one year period as outlined in the current
agreement.
3. EXHIBITS: Amendment & interlocal agreement
4 RECOMMENDED BY:Fire Chief and Public Safety Committee (3-1)
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: S
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION.
Council Agenda
Item No. 6C
Amendment 2 to Interlocal Agreement Establishing the Washington City and County
Pipeline Safety Consortium
The undersigned parties to the Interlocal Agreement Establishing the Washington City and County
Pipeline Consortium(the "Agreement") agree as follows:
1 In accordance with section 3.G of the Agreement, the duration of the Agreement is extended
until December 31, 2004
2. The Consortium will be funded through December,2004, with a grant from the Washington
Utilities and Transportation Commission and will require no additional individual jurisdiction
contribution with this Amendment 2
3. No other provision of the Agreement is affected by the Amendment.
IN WITNESS WHEREOF, this Amendment No. 2 has been executed and affirms and ratifies
• participation in past consortium activities and for the next year by each party on the date set forth
below.
CITY OF KENT Approved as to form
Date: Date
i
Amendment 2 to Interlocal Agreement Establishing the Washington City and County
Pipeline Safety Consortium
The undersigned parties to the Interlocal Agreement Establishing the Washington City and County
Pipeline Consortium (the "Agreement") agree as follows•
1. In accordance with section 3.G of the Agreement, the duration of the Agreement is extended
until December 31, 2004
2. The Consortium will be funded through December, 2004, with a grant from the Washington
Utilities and Transportation Commission and will require no additional individual jurisdiction
contribution with this Amendment 2.
3 No other provision of the Agreement is affected by the Amendment.
IN WITNESS WHEREOF, this Amendment No. 2 has been executed and affirms and ratifies
participation in past consortium activities and for the next year by each party on the date set forth
below.
CITY OF KENT Approved as to form
Date: Date-
t•
INTERLOCAL AGREEMENT ESTABLISHING THE
WASHINGTON CITY AND COUNTY PIPELINE SAFETY CONSORTIUM
THIS AGREEMENT is entered into by and between the undersigned cities and
counties. This Agreement is made pursuant to the Intedocal Cooperation Act, Chapter
39.34 RCW, and has been authorized by the legislative body of each jurisdiction.
WHEREAS, concern about pipeline safety has been expressed by the member
cities and counties; and
WHEREAS, Cities and Counties along the Olympic Pipeline corridor have a
common goal of ensuring the safety of their communities; and
WHEREAS, Cities and Counties seek independent, expert third party
assessments of the condition of the Olympic Pipeline and its potential hazards; and
WHEREAS, Cities and Counties desire legal analysis of the pending pipeline
safety legislation at the state and federal level and assistance in developing a model
franchise;
WHEREAS, Cities and Counties desire expert third party analysis of the
procedures required to maximize the safety of the pipeline; and
WHEREAS, Cities and Counties desire a unified voice relating to pipeline safety
issues where Olympic Pipeline Facilities are located; now,therefore,
The City and County signatories agree as follows.
Establishment of the Washington City and County Pipeline Safety Consortium There is
hereby created a city and county consortium hereinafter called the Washington City and
County Pipeline Safety Consortium(the Consortium). The parties hereto each hereby
task the Consortium with the responsibility for achieving the following goals:
1. Provide a coordinated response for member Cities and Counties on certain
issues related to fuel pipeline safety in general and the activities of Olympic Pipe
Line Company in particular,
2. Obtain expert independent analysis and monitoring of the Olympic Pipeline
Corridor Safety Action Plan so as to ensure it provides the degree of safeguards
and security that our communities demand and deserve;
3. Identify deficiencies in Olympic Pipeline's Pipeline Corridor Safety Action Plan;
4. Identify steps Olympic Pipeline should take before re-starting the flow of product
through its pipeline;
. 5. Provide advocacy and public relations services on behalf of cities and counties;
1
6. Monitor franchisee compliance in jurisdictions along pipeline corridors;
7. Coordinate signage and activity within pipeline corridor right of ways;
8. • Analyze and provide comment on federal and state legislative efforts with regard
to pipeline safety;
9. Work cooperatively with other groups and governments mutually interested in
pipeline safety;
10. Work directly with the State of Washington and any state task force established
to examine pipeline safety;
11. Work to meet other goals as defined by the membership.
1. Definitions,
A. Principal. A Principal is a City or County which has accepted the terms of,
and is a party to, this Interiocal Agreement and has paid its share of the costs of the
Consortium. The initial Principals to this Agreement are the undersigned cities and
counties. Principals will receive services as offered by the Consortium according to
such terms and conditions as may be established.
B. General Membership. The General Membership shall consist of all the
voting representatives of the Principals.
C. Voting Representatives. Each Principal will designate one representative,
and one alternate representative to vote on issues before the General Membership.
D. Alternate Representatives. Each Principal shall be entitled to designate
one alternate representative who shall serve on behalf of the voting representative
during his or her absence or inability to serve.
E. Administrator. The City of Bellevue shall be designated as the
Consortium's Administrator. Principals shall pay to the City of Bellevue the agreed upon
Financial Contribution.
F. Financial Contribution. Each Principal shall make an initial$5,DD0
Annual Financial Contribution. Additional Financial Contributions shall be provided in
the future on a basis and in an amount agreed by the General Membership. A Principal
shall be obligated as to any future Financial Contributions only upon ratification by its
respective legislative body. A Principal shall be allowed to withdraw from the
Consortium and not incur any additional financial obligation N its legislative body
decides against a future Financial Contribution.
2
G. Executive Board. The Executive Board shall be composed of seven
representatives of 7 different Consortium members,appointed by their jurisdictions.
The initial slate of Executive Board Members shall include a member from each of the
following jurisdictions: The cities of Bellevue, SeaTac, Renton, Redmond, Bellingham,
Tumwater,and the county of Thurston. The initial Board shall serve for a period of one
year from the effective date of this Agreement Subsequent Boards shall consist of
seven members elected by the General Membership from among the representatives
appointed by their respective jurisdictions.
2. Roles
A. GGr4pral Membership. The General Membership shall approve the budget
and have final decision-making authority to approve the final budget and the work plan
of the Consortium. The General Membership shall approve the members of the
Executive Board.
B. Executive Board.
1.) Chair. The Chair of the Executive Board shall be elected by the
members of the Board from the Board membership. The Chair of the Executive Board
shall process issues, organize meetings and preside over meetings of the Board,and
shall have no other powers than those enumerated here.
2.) Powers of the Executive Board. The Executive Board shall meet
as often as it deems necessary and shall have the following powers:
(a.) To recommend periodic budgets and work plans for the
Consortium for approval by the General Membership;
(b.) To establish policies to carry out the work plan approved by
the General Membership;
(c.) To establish policies for expenditures of budgeted items for
the Consortium;
(d.) To hold regular meetings on such dates and at such places
as the Board may designate and call for meetings of the General Membership;
(a.) To authorize the Administrator to enter into agreements with
other federal, state and local agencies, and private entities to receive grants and funds,
and other agreements for services.
C. Administrator. City of Bellevue, as Administrator, shall contract for
services as necessary to accomplish the purposes of the Consortium under this
Agreement subject to the approval of the Executive Board; establish a special fund or
funds as authorized by RCW 39.34.030;collect from the Principals Financial
Contributions due to Bellevue as Administrator for the Principals; and reimburse its
Principals. In addition, the Administrator will provide for secretarial and other
administrative support for the Board as the Board deems necessary. The Administrator
shall not be reimbursed for expenditures made prior to the effective date of this
Agreement
3
T
3. Offer Pertinent Matters
A. Proportionality of Represerdtt},ionNot ng Each Principal shall be entitled
to one vote on all actions required to be approved by the General Membership and
each Principal which has a representative on the Executive Board shall be entitled to
one vote on all actions required to be approved by the Executive Board.
B. Voting Percentage Reggirements. All actions required to be approved by
the General Membership or the Executive Board shall require approval of 70% of the
vote of those present. Dissenting comments shall be recorded.
C. Quorum. A quorum at any meeting of the General Membership or the
Executive Board shag consist of the voting members or Board members (or agemates)
who represent a simple majority of the General Membership or Executive Board
membership.
D. Additional Principals. The Executive Board may, by vote,accept new
Principals who become parties to this Agreement and who have paid the agreed-upon
amount as the new Principars share. The Executive Board may, by vote, accept new
Principals to the consortium by approving the proposed new Principal's signed
agreement.
E. Finance and Budget.
1.) Acceptance of Funds. The Administrator is hereby authorized to
accept all Financial Contributions of the Principals allocated to the Consortium and any
federal, state or private grants in order to accomplish the purposes of this Agreement
and Chapter 39.34 RCW.
2.) Budget The Executive Board shall draft a proposed initial budget
for the remainder of the current calendar year and present it to the General
Membership. Thereafter,the Executive Board shag draft proposed period budgets as
it deems appropriate. The General Membership shall review and recommend revisions
to the draft budgets as it deems appropriate. The Executive Board shag revise the draft
budgets and shall present them for a vote of the General Membership.The budgets are
adopted when approved by the General Membership.
3.) Delinquencies. A Principal who is six months delinquent in
payment shall be considered to have withdrawn from the Consortium. Withdrawal does
not extinguish the obligation to pay for services rendered.
4.) Use Guidelines. The Consortium may use any available funds for
any purpose authorized by this Agreement, and included In the work plan adopted by
the Consortium. Additional projects and expansion of the scope of worts are
authorized, for purposes of this Agreement, when approved and funded by all the then
current Principals or through any grants provided the Consortium. Consortium funds
will not be used to pay for any City or County staff time.
4
F. InteMovernmental Cooperation. The Consortium shall cooperate in all
practical and available ways with local, state and federal government agencies so as to
maximize utilization of grant funds and to enhance the effectiveness of operations and
to minimize costs.
G. Duration. This Agreement shall continue in effect for at least two years
from creation of the Consortium. Additional one year renewals shall be approved by
agreement of the Principals. Any Principal may withdraw from this Agreement by giving
60 days written notice to the Executive Board of its intention to terminate. A Principal
shall not be entitled to reimbursement for its financial contributions to the Consortium.
A Principal who withdraws shall hold the remaining Principals harmless against any
resultant increased costs allocated to them,for a project or contract approved by the
General Membership before its withdrawal.
This Agreement shall be effective until terminated as provided herein.
This Agreement may be terminated at any time by agreement of Principals holding at
least 70%of the vote of all the Principals hereto. Upon termination of this Agreement,
any assets acquired during the Iffe of the Agreement or any financial contributions
remaining shall be disposed of in the following manner.
1.) All property contributed without charge by each Principal shall
revert to the contributor,
2.) All property purchased after the effective date of this Agreement
shall be distributed based on the percentage of the total annual charges assessed by
the Executive Board during the period of this Agreement and paid by each Principal;
3.) All unexpended or reserved funds shall be distributed to the
Principals based on their financial contribution on a pro rata basis.
H. Hold Harmless. Except for acts or omissions which are dishonest,
fraudulent, criminal or malicious, any loss or liability resulting from the acts or omissions
of the Executive Board, or Administrator while acting within their scope of authonty
under this Agreement shall be bome by the Consortium. If a claim, demand,or cause
of action arises from any other negligent act or failure to act,or intentional wrongful act
of one of the Principals or its agents or employees, that Principal shall hold the
Consortium and other Principals harmless except to the extent that the harm
complained of arises from the negligence or other fault of another Principal; provided,
that 'Fault" as herein used shall have the same meaning as set forth in RCW 4.22.015.
1. Insurance. The Consortium may obtain and provide insurance for the
Executive Board and the Administrator for coverage consistent with the terms of this
Agreement.
J. Amendments. This Agreement may be amended by written agreement of
the legislative bodies of all the Principals hereto.
5
K. Severability. The invalidity of any clause, sentence, paragraph,
subdivision, section or portion of this Agreement shall not affect the validity of the
remainder of the Agreement.
L. Effective Date. The effective date of this Agreement shall be the date of
filing with the appropriate County Auditors, the Secretary of State, and the Clerk of each
Principal.
IN WITNESS WHEREOF, this Agreement has been executed by each party on the
date set forth below.
CITY OF BELLEVUE Approved as to Form:
Chuck Mosher Lori Riordan
Mayor C i ty of 13-awue Assistant City Attorney
Date: [. Date: G I2 3 IUD
COUNTY OF Approved as to Form:
Donald D. Rode Wavn . Tanaka
City Manager City Attorney
Date: ia, FOOD Date: j4,L lad a ODO
CITY OF Woodinville Approved as to Form:
CaT CQi+►k4ejlt&
Date: Date:
CITY OF Approved as to Form:
6
Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: KENT CITY CODE AMENDMENT, CAPITAL FACILITIES
ELEMENT YEARLY UPDATE PROCESS, ORDINANCE—ADOPT
2 SUMMARY STATEMENT: Adoption of Ordinance No. amending
Chapter 12.02 of the Kent City Code, to add provisions for considering city initiated
amendments to the comprehensive plan more than once per year and providing for a
public hearing before the City Council rather than the Land Use and Planning Board for
certain amendments to the Capital Facilities Element
3. EXHIBITS: Ordinance; Staff report; Land Use & Planning Board minutes of
5/27/03; and staff memo dated 7/8/03
4. RECOMMENDED BY: Planning Committee
is (Committee, Staff, Examiner, Commission, etc.)
5 UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6 EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION-
Council Agenda
Item No. 6D
COMMUNITY DEVELOPMENT
Fred N Satterstrom, AICP, Director
PLANNING SERVICES
. K EN T Charlene Anderson,AICP, Manager
W/�SMINGTON
Phone 253-856-5454
Fax 253-856-6454
Address 220 Fourth Avenue S
Kent, WA 98032-5895
DATE: JULY 8, 2003
TO: MAYOR JIM WHITE, COUNCIL PRESIDENT JUDY WOODS AND CITY
COUNCIL MEMBERS
FROM: CHARLENE ANDERSON, AICP, PLANNING MANAGER
THROUGH: PLANNING COMMITTEE, LAND USE & PLANNING BOARD
SUBJECT: KENT CITY CODE AMENDMENT #CPA-2003-1
CAPITAL FACILITIES ELEMENT YEARLY UPDATE PROCESS
SUMMARY: At their June 171h meeting, the Planning Committee recommended approval of the Land
Use & Planning Board's recommendation to amend Kent City Code Sections 12 02 010 and 060 and to
delete Section 12 02 035 as proposed by staff The amendments provide for consideration of city-
initiated amendments to the comprehensive plan more frequently than once per year and provide for a
public hearing before the City Council rather than the Land Use & Planning Board for certain
amendments to the Capital Facilities Element
BUDGET IMPACT None
MOTION: Adoption of Ordinance No amending Chapter 12 02 of the Kent City Code, to
add provisions for considering city initiated amendments to the comprehensive plan more than
once per year and providing for a public hearing before the city council rather than the land use
and planning board for certain amendments to the Capital Facilities Element
BACKGROUND: RCW Section 36 70A 130 states that amendments to the comprehensive plan can be
considered by the goveming body no more frequently than once every year except under a limited number
of circumstances, which include an amendment of the capital facilities element that occurs concurrently
with the adoption or amendment of the city budget The capital facilities plans of the Kent and Federal
Way School Districts are part of the Capital Facilities Element of the Kent Comprehensive Plan, as is the
City's Capital Facilities Plan For the past several years both the school districts and the Kent Finance
Department have submitted updated plans as part of the annual comprehensive plan amendment process
The updated plans have been considered by the Land Use & Planning Board and have been forwarded to
the City Council along with applications from the private sector
As provided for in RCW 36 70A 130 and Kent City Code 12 13 070, the proposed amendments to Kent
City Code allow the City Council to hear and consider the City's 6-year financing plan and the capital
facilities plans for the school districts concurrently with the annual budget The code amendment details
of the proposal are provided in the ordinance
The proposed procedural amendments are categorically exempt under the provisions of SEPA Rules per
WAC 197-11-800(20)
CA\pm S�Pemit�Plan20NECODEAMEND\2003\2031290-2003-Icc doc
Eric Ordinance Minutes of 5/27/03 LU&PB hearing 5+19/03 Staff Report to Board
COMMUNITY DEVELOPMENT
Fred N Satterstrom, C D Director
PLANNING SERVICES
Charlene Anderson,AICP, Manager
KENT Phone 253-856-5454
Fax. 253-856-6454
Address 220 Fourth Avenue S
Kent,WA 98032-5895
LAND USE & PLANNING BOARD MINUTES
PUBLIC HEARING
MAY 27, 2003
The meeting of the Kent Land Use and Planning Board was called to order by Chair Ron
Harmon at 7 00 p.m on Monday, April 28, 2003 in Chambers West of Kent City Hall
LUPB MEMBERS PRESENT: STAFF MEMBERS PRESENT:
Ron Harmon, Chair Charlene Anderson, AICP, Planning Manager
Nicole Fincher, Vice Chair Gloria Gould-Wessen, Planner, GIS Coordinator
Steve Dowell William Osborne, Planner
Deborah Ranniger Kim Adams-Pratt, Asst City Attorney
Pamela Mottram, Administrative Secretary
LUPB MEMBERS ABSENT:
Jon Johnson, Excused
David Malik, Excused
Greg Worthing, Excused
• APPROVAL OF MINUTES
Nicole Fincher MOVED and Deborah Ranniger SECONDED to approve the Minutes of April
28, 2003 Motion CARRIED
ADDED ITEMS:
None
COMMUNICATIONS
Planning Manager Anderson stated that the Planning Committee considered zoning code
amendments #ZCA-2003-1 Auto Repair as Home Occupations, #ZCA-2003-3 Auto Repair and
Washing Services in M-3 Zoning District, and #ZCA-2002-2 NCC, Neighborhood Convenience
Commercial District at their May 20, 2003 meeting unanimously recommending approval to the
City Council
Ms Anderson stated that these amendments will be placed on the Consent Calendar for the July
1, 2003 City Council meeting
NOTICE OF UPCOMING MEETINGS
Ms. Anderson stated that a joint meeting will be held with the City of Sea Tac and the Land
Use and Planning Board at Sea Tac City Hall on June 16 at 6 00 pm.
#CPA-2002-1 COMPREHENSIVE PLAN UPDATE CH 5 COMMUNITY DESIGN
Planner, William Osborne stated that the Community Design Element has been in the process
of revision for over a year A number of changes have been made with consideration to
recommendations made by staff, citizens, and the Board. All changes made to the onginal
Comprehensive Plan document have been tracked, and are indicated with strikethroughs for
deletions and underlines for insertions. Each succeeding revision to an element of the
Comprehensive Plan has indicated the most recent changes, including removal of previously
suggested additions or deletions.
Mr. Osborne stated that the Community Design Element is the policy guide for the physical
manifestation of several comprehensive plan elements including the Land Use, Capital
Facilities and Transportation Elements.
Mr. Osborne articulated the changes made since the Board's March 240'workshop. He stated
that the term pedestrian oriented" was replaced with "pedestrian friendly" in the first
paragraph of the Introduction as suggested by Board member Johnson.
Mr. Osborne stated that throughout the element, reference to the Parks Element has been
changed to"Parks and Open Space Element", to reflect the new title for that element
Mr. Osborne stated that attention has been brought to the topical sections in the introduction of
this element with the addition of text stating "As noted in each of the topical sections below,..."
Mr. Osborne stated that most of these issues were raised ongmally in 1992 In the Community
Forum on Growth Management and Visioning
Mr Osborne stated that the reference to automobiles has been generally changed to motor
vehicle, to incorporate other forms of motor vehicles such as trucks, motorcycles or mopeds, if
one wanted to consider these as a motor vehicle rather than a bicycle.
Mr. Osborne stated that there are language changes to Policy CD-2 3 referring to streets He
stated that the language "in consideration of existing budding features" was added to Policy
CD-2.4 as suggested by former Board member Thomas.
Mr. Osborne stated that staff has added language "appropriate opportunities"to Policy CD-2 6.
Mr. Osborne stated that the term motor vehicle"replaces automobile"In Goal CD-3
Mr. Osborne stated that the term "landscaping" has been removed from CD-3 2 to
acknowledge other permeable barriers
Mr. Osborne stated that one of the concerns of the Board was the coordination of amenities for
transportation mode connections. Mr. Osborne said that staff changed language to say that
the City would encourage the location of transit type facilities, rather than to coordinate the
location of those facilities, as there may be a responsible agency such as Sound Transit or
King County Metro to provide those facilities.
Mr. Osborne stated that although Board member Dowell voiced concern with reference to
Policy CD-5 1, staff has not made any changes He stated that staff feels that the existing
policy language addresses the avoidance of blank walls.
Mr. Osborne stated that the term activity centers"has been replaced with "activity areas". He
stated that Transit Agencies are encouraged to provide attractive and distinctive shelters that
are tied to the identity of the city.
Mr. Osborne stated that CD-6 4 addresses Mr. Dowell's concerns regarding street walls He
stated that this policy has been added to the Community Design Element and reads
"Encourage ground floor budding fagade treatments and activities that generate pedestrian
interest and comfort. Large windows, canopies, arcades, plazas and outdoor seating are
examples of such amenities " Mr. Osborne stated that language was changed in Policy CD-
11.2 with some of this language replicated In CD-6 4 He stated that CD-11.4 is changed,
incorporated and copied into CD-6 4.
Mr. Osborne stated that the term"mixed use" as been removed from Policy CD-8.5
Mr. Osborne stated that the phrase "by encouraging structured parking" has been removed
from CD-11.8 because the city has regulations encouraging structured parking. He stated that
Land Use and Planning Board Minutes
staff desires to reduce the visual impact of off-street parking in the downtown area without
discouraging parking for downtown businesses
Mr. Osborne stated that a reference to the Kent Downtown Design Guidelines has been added
to Goal CD-12.
Mr. Osborne stated that in the Residential Development section, the term "and fencing" has
been added to acknowledge that many problems with the larger apartment complexes was
that they were basically isolated with undesirable design features
Mr Osborne stated that in the Residential Development section, it acknowledges that
multifamily complexes "comprise a large amount of Kent's housing stock" At this time single
family housing is outpacing the development of multifamily housing in Kent.
Mr. Osborne stated that Goal CD-14 is redefined to reflect the City's desire to lay out
neighborhoods oriented to the pedestrian and fostering a sense of community The changes
to the Policies under CD-14 address these issues and the concerns of the Board members
about the block length issue. Mr Osborne stated that there are regulations limiting block
lengths to 500 feet with flexibility in the design review and application review process Mr
Osborne stated that the revisions to Policy CD-14 2 reflect a connection with community
Mr Osborne stated that Policy CD-14 3 has been moved to CD-15.5, where it is more
representative of that goal referring to setbacks.
Mr. Osborne stated that Goal CD-15 refers to residential site design and architecture and
addresses setbacks. He pointed out changes to CD-15 2 which includes limiting the repetitive
character of new development.
Mr Osborne stated that terminology "Establish flexible standards for small lot design " has
been removed from Policy CD-15 3 Mr Osborne stated that the intent of this policy is to
address garages, where to site them, and how to organize them to maximize the efficiency
and use of the overall site area.
Mr Osborne stated that Policy CD-15 5 has been moved from Goal CD-14 He stated that
parking"has been included in Policy CD-15 6 as one of the amenities that could be commonly
owned within clustered, cottage or attached single family residential housing types
Mr. Osborne stated that in Policy CD-15 7 the term "pleasing addition " was changed to
"complimentary to neighborhoods...",
Mr. Osborne stated that in regards to Board member Malik's concern over Planned Unit
Developments, no change was made to Policy CD-15 11 as the language is general and
states that the city would "utilize the PUD process where appropriate to realize the benefits of
desirable community design"which would be addressed through development regulations.
Mr. Osborne stated that "public spaces' was rephrased to "public open spaces" in CD-18 to
acknowledge that the city is referring to spaces that can be used for passive or active
recreation.
Mr. Osborne stated language has been both added and deleted to the "Environmentally
Sensitive Design and Construction" section, explanatory of the Built Green Program which is
the Master Builder's Association of King and Snohomish County, a voluntary incentive based
certification program, the Leadership in Energy and Environmental Design (LEED) sponsored
by the US Green Building Council, a voluntary consensus based program that sets national
standards for passive energy use; and Low Impact Development is an approach to minimizing
the impacts on land.
Land Use and Planning Board Minutes
Mr. Osborne referenced the following goals and policies added to the "Environmentally
Sensitive Design & Construction section of the Community Design Element: Goal CD-21,
Policy CD-21.1, Policy CD-21 2, Policy CD-21.3, Goal CD-22, Policy CD-22 1, Policy CD-22 2
and Policy CD-22.3.
Mr. Osborne defined a "rain garden" per Deborah Ranniger's request
Ms Fincher spoke about her concerns with vehicular movement as it is stated in Policy 14.1.
Mr. Osborne stated that the intent of this policy is to support safe pedestrian, bicyclist and
vehicular movement.
Chair Harmon questioned the intent of Policy 15.1 and 15.6 & 7. Mr. Osborne stated that this
policy encourages the development of cluster, cottage, attached single-family and multifamily
housing within a neighborhood context The intent of the language is to establish design
standards so that when this type of housing is developed, it will fit into the existing
neighborhood context.
Chair Harmon declared the Public Hearing open Seeing no speakers, Steve Dowell MOVED
and Nicole Fincher SECONDED to close the Public Hearing Motton CARRIED.
Steve Dowell MOVED and Deborah Ranniger SECONDED to accept CPA-2002-1,
Comprehensive Plan Update, Chapter 5 Community Design Element, as recommended by
staff. Motion CARRIED
#CPA-2003-1 CAPITAL FACILITIES ELEMENT YEARLY UPDATES PROCESS
Planning Manager, Charlene Anderson stated that this proposal comes before the Board as a
result of issues in the past with the annual comprehensive plan amendments. She stated that
the City receives private requests for amending the comprehensive plan and zoning, as well
as capital facilities updates from the Kent and Federal Way School District, and the City itself
as required annually
Ms Anderson stated that the capital facilities updates include suggestions regarding school
impact fees that are implemented as code
Ms. Anderson stated that the State requirements in GMA allow these capital facilities updates
to occur with the annual budget Ms. Anderson stated that this proposal is a request to allow
the City Council to hold a public hearing at the time they consider the annual budget to
address the City's Six Year Capital Improvement Program as well as consider the School
Districts Capital Facilities Plans which include impact fees.
Chair Harrison declared the Public Hearing open. Seeing no speakers, Steve Dowell MOVED
and Nicole Fincher SECONDED to close the Public Hearing.
Steve Dowell MOVED and Nicole Fincher SECONDED to approve #CPA-2003-1 Capital
Facilities Element, Yearly Update Process, as recommended by staff, sending this on to City
Council. Motion CARRIED
Ms Anderson stated that this item will be considered by the Planning Committee on June 17th
and will possibly be considered at the July 15'" City Council meeting. The sixty day State
notification prevents this item from being moved to Council sooner
ADJOURNMENT
Chair Harmon adjourned the meeting at 7 50 p m
Respectfully Submitted,
Charlene Anderson, AICP, Planning Manager
Secretary, Land Use and Planning Board
S 1PennR�PIanXLUP0\2003V.4mutes%052703mm doe
Land Use and Mannino Board Minutes
COMMUNITY DEVELOPMENT
Fred N Satterstrom,AICP, Director
PLANNING SERVICES
K E N T Charlene Anderson,AICP,Manager
W"s"'""TD" Phone 253-856-5454
Fax 253-856-5454
Address 220 Fourth Avenue S
Kent, WA 98032-5895
DATE: MAY 19, 2003
TO: CHAIR RON HARMON AND MEMBERS OF THE LAND USE AND PLANNING
BOARD
FROM: CHARLENE ANDERSON,AICP,PLANNING MANAGER
SUBJECT: CAPITAL FACILITIES PLANS—UPDATES TO COMPREHENSIVE PLAN
LUPB Public Hearing May 27, 2003
INTRODUCTION: At their March 18, 2003 meeting, the City Council Planning Committee directed
staff to move forward with a proposal to explore options for updating the Capital Facilities Element of the
Kent Comprehensive Plan concurrent with the annual budgeting process Staff introduced at the May 12th
Land Use & Planning Board workshop proposed amendments to Kent City Code to allow updates of the
Capital Facilities Element of the Comprehensive Plan to include updates of the School District Capital
Facilities Plans and the City's Capital Facilities Plans concurrent with adoption of the city's budget
BACKGROUND- RCW Section 36 70A 130 states that amendments to the comprehensive plan can be
considered by the governing body no more frequently than once every year except under a limited number
of circumstances, which include an amendment of the capital facilities element that occurs concurrently
with the adoption or amendment of the city budget. Kent City Code (KCC) Section 12 02 010 states the
City Council shall consider amendments to the Kent comprehensive plan no more than once each
calendar year, except if an emergency exists Kent City Code currently does not provide for an exception
for the annual budget or other exceptions allowed by the Growth Management Act
In March 1996,Ordinance#3281 adopted the school districts' capital facilities plans as part of the Capital
Facilities Element of the Kent Comprehensive Plan and established an impact fee schedule KCC
12 13 060 requires school distracts on an annual basis to submit their updated capital facilities plan, and
KCC 12.13 070 requires Council review of the updates in conjunction with any update of the Capital
Facilities Element of the Kent Comprehensive Plan.
RCW Section 36.70A 070 requires Capital Facilities Elements to contain an inventory of existing public
facilities, a forecast of future needs, the location and capacity of proposed facilities, and a six-year
financing plan with projected funding capacities, and to coordinate the land use element, capital facilities
element, and financing plan. The City Council reviews the 6-year financing plan annually during the
budget cycle. The school districts capital facilities plans also address 6-year financing. Staff believes
both the City's 6-year financing plan and the capital facilities plans for the school distncts may be
considered by the City Council concurrently with the annual budget.
LUPB Public Hearing 5/27/03
Capital Facilities Plans—Updates to Comprehensive Plan
Staff Report
Page 2
RECOMMENDATION:
Following are the specific amendments for which staff is recommending Board approval.
Code Amendment Details•
1) Amend KCC 12 02.010 as follows. "The city council shall consider amendments to the
comprehensive plan no more than once a year except as pi:Ewlded .n KGG „ 02 rn c under
the following_circumstances, which may be processed separately and in addition to the
standard annual update:
a) If an emergency exists, (An emergency is defined as an issue of community-wide
silznificance that promotes the public health, safety,and general welfare)
b) To resolve an appeal of a comprehensive plan filed with a growth management
hearings board or with the court.
c) The adoption or amendment of a shoreline master program under the procedures set
forth in chapter 90 58 RCW:
d) The initial adoption of subarea plan,and
e) The amendment of the capital facilities element of the comprehensive plan that
occurs concurrently with the adoption or amendment of the city budget
2) Amend KCC 12.02.060, Hearing procedures — Notice requirements, to read, "The planning
depaHnient services office shall prepare a report and recommendation on proposed plan
amendments which shall be presented to the planning eemmissiefiland use and planning
board at a public hearing For amendment of the capital facilities element of the
comprehensive plan that occurs concurrently with the adoption or amendment of the city
budget, the city council will hold the public hearing instead of the land use and planning
board
3) Delete KCC 12 02 035.
Staff will be available at the May 27'h hearing to present the proposal.
CAVni S.1Penmt%Plan\ZONECODEAMEND12003icapfacihueslupbpb dm
cc Fred N Sanerstrom,AICP,CD Director
Charlene Anderson,AICP,Planning Manager
Project File
ORDINANCE NO.
AN ORDINANCE of the city council of the
city of Kent, Washington, amending Chapter 12 02 of
the Kent City Code, to add provisions for considering
city initiated amendments to the comprehensive plan
more than once per year and providing for a public
hearing before the city council rather than the land
use and planning board for certain amendments to the
Capital Facilities Element.
WHEREAS, in accord with RCW 36.70A 130, the city council
desires to amend chapter 12 02 of the Kent City Code, to add provisions for
considering city initiated amendments to the comprehensive plan more than once per
i
year and providing for a public hearing before the city council rather than the land
use and planning board for certain amendments to the Capital Facilities Element, and
WHEREAS, after providing appropriate public notice, the city held a
public hearing on this modification proposal at the regular land use and planning
board meeting held on May 27, 2003, and
WHEREAS, the planning committee considered this matter at the
regularly scheduled meeting on June 17, 2003, and
1 Captial Facilities Plans—
Comprehensive Plan Update
WHEREAS, on May 5, 2003, the city provided notification to the
State of Washington under RCW 36 70A.106 of the city's proposed amendment to
add provisions for considering city initiated amendments to the comprehensive plan
more than once per year and providing for a public hearing before the city council
rather than the land use and planning board for certain amendments to the Capital
Facilities Element, and
WHEREAS, the sixty (60) day notice period under RCW 36 70A 106
has elapsed, NOW THEREFORE,
THE CITY COUNCIL OF THE CITY OF KENT, WASHINGTON,
DOES HEREBY ORDAIN AS FOLLOWS
SECTION I. — Amendment Chapter 12 02 of the Kent City Code is
amended as follows.
CHAPTER 12 02
PROCEDURES FOR AMENDMENTS
TO COMPREHENSIVE PLAN
Sec. 12.02.010. Amendments. The city council shall consider amendments
to the Kent comprehensive plan no more than once each calendar year, except as
pre..,aed in KCG 12 02 035.under the following circumstances, which may be
processed separately and in addition to the standard annual update•
a If an emergency exists which is defined as an issue of
community wide significance that promotes the public health safety, and general
welfare,•
b To resolve an appeal of a comprehensive plan filed with a
growth management hearings board or with the court,
c To adopt or amend a shoreline master program
under the procedures set forth in chapter 90 58 RCW:
2 Captial Facilities Plans—
Comprehensive Plan Update
d The initial adoption of a subarea plan, and
e The amendment of the capital facilities element of the
comprehensive plan that occurs concurrently with the adoption or amendment of the
city budget
Sec. 12.02.020. Concurrent review. In considering annual amendments to
the comprehensive plan, city staff, the planning eammissilanland use and planning
board, and the city council shall consider all proposed amendments concurrently so
as to assess their cumulative impact.
I
Sec. 12.02.030. Time of filing. Annual amendments to the comprehensive
plan shall be submitted to the Kent planning services office depaftment-by September
1 of each calendar year Requests for amendments shall be submitted on forms
prescribed by the planning services officedepartmeet Incomplete amendment
applications will not be accepted for filing. Requests received each year after
• September I shall be considered in the following year's comprehensive plan
amendment process
I
I
See 12.02.035. Emergeney amendments. The city e eel m sidef
i
i
u d adopt RF r@VjSj8HS tO the eOffiffelieRsive pia fnere than eflee a yea
i
if anemergeney eg fists An emergeney is-defiAcd as an—issue-of eemmunity wide
signifieanee that p metes the ,.ublie health, t..,saf and g r-al wel faFe Enief:geney
eompFeliensive plan a end..,ents ni be p sed s tel. and in „dd.tiOR t.. thstandard annual update
See. 12.02.040. SEPA review. After September I of each calendar year, the
city's responsible official shall review the cumulative anticipated environmental
impact of the proposed comprehensive plan amendments, pursuant to the
Washington State Environmental Policy Act (SEPA) If the responsible official
determines that a draft final or supplemental environmental impact statement (EIS)
3 Captial Facilities Plans-
Comprehensive Plan Update
or other appropriate environmental review is warranted, applicants may be
responsible for a full or proportionate share of the costs of preparing the EIS as
11 determined by the responsible official
I'
See. 12.02.050. Standard of review. The planning services
officedepaAme»t may recommend and the city council may approve, approve with
modifications or deny amendments to the comprehensive plan text or map
designations based upon the following criteria
Ij
1 The amendment will not result in development that will adversely
I
affect the public health, safety and general welfare, and
2. The amendment is based upon new information that was not available
at the time of adoption of the comprehensive plan, or that circumstances have
changed since the adoption of the plan that warrant an amendment to the plan, and
3 The amendment is consistent with other goals and policies of the
comprehensive plan, and that the amendment will maintain concurrency between the
land use, transportation, and capital facilities elements of the plan
See. 12.02.060. Hearing procedures— Notice requirements The planning
depafErrlent-services office shall prepare a report and recommendation on proposed
plan amendments which shall be presented to the planning ,,,... miss.,.., land use and
planning board at a public hearing For an amendment of the capital facilities
element of the comprehensive plan that occurs concurrently with the adoption or
amendment of the citLQet, the city council will hold the public hearing instead of
the land use and planning board For proposed text amendments, notice of public
hearing shall be given in at least one (1) publication in the local newspaper at least
ten (10) days prior to said hearing. For plan map amendments, notice of public
hearing shall be given both by publication in the local newspaper as prescribed
above, and by notification of all property owners within two hundred (200) feet of
the affected property Affected property is defined as the parcels identified by the
applicant, plus any additional parcels contiguous to the applicant's property which
4 Captial Facilities Plans—
Comprehensive Plan Update
. the planning manaeerdiieeteF determines should also be considered The following
criteria should be used in deciding whether to expand the geographic scope of a
proposed amendment
I The effect of the proposed amendment on the surrounding area,
i
I
2. The effect of the proposed amendment on the land use and circulation
pattern of the area, and
3. The effect of the proposed amendment on the future development of
the area.
i
Following a tlpubhc hearing by the land use and plannmg boardpg
eemmissien, the planning services office dePTrecommendation shall be
forwarded to the city council for action
I
Sec. 12.02.070. City council action. Within sixty (60) days after receipt of
the planning services office depaARmit-recommendation, the city council shall either
affirm, deny, or modify or return the application to the planning department for
further consideration In the event the city council modifies the recommendation, it
shall make its own findings and set forth in writing the reasons for the action taken
I
Sec. 12.02.080. Standing.
Comprehensive plan amendments may be initiated by the city planning services
officedepanment or other administrative staff of the city, private citizens, or the city
council
Sec. 12.02.090. Fees. Application fees for comprehensive plan amendments
shall be the same as the fee established for rezones
Sec. 12.02.100. Appeals. Appeals from a decision of the Kent city council
shall be pursuant to Chapter 36.70A RCW.
5 Captial Facilities Plans—
Comprehensive Plan Update
SECTION 2. — Savtnzs The existing chapter 12.02 of the Kent City .
Code, which is amended by this ordinance, shall remain in full force and effect until
the effective date of this ordinance
SECTION 3. —Severability If anyone or more section, subsections, or
sentences of this ordinance are held to be unconstitutional or invalid, such decision
shall not affect the validity of the remaining portion of this ordinance and the same
shall remain in full force and effect
SECTION 4. — Effective Date This ordinance shall take effect and be
in force thirty (30) days from and after passage as provided by law.
JIM WHITE, MAYOR
I
ATTEST:
BRENDA JACOBER, CITY CLERK
i
APPROVED AS TO FORM
TOM BRUBAKER, CITY ATTORNEY
PASSED- day of July, 2003
APPROVED day of July, 2003.
PUBLISHED- day of July, 2003
I
6 Captial Facilities Plans—
Comprehensive Plan Update
I hereby certify that this is a true copy of Ordinance No
passed by the city council of the city of Kent, Washington, and approved by the
mayor of the city of Kent as hereon indicated
(SEAL)
BRENDA JACOBER, CITY CLERK
PIGvd0Mtpe ce 1202-CapwlFuilme$Upda din
I
7 Captial Facilities Plans—
Comprehensive Plan Update
. Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: PURCHASE OF ONE REPLACEMENT FIRE ENGINE—
AUTHORIZE
2. SUMMARY STATEMENT: Authorization for the Mayor to sign the contract
between the City of Kent and Pierce manufacturing for the purchase of one (1)
replacement fire engine.
Staff requests authorization to purchase one (1) fire engine to replace a 1990 Pierce fire
engine (apparatus 732) that has 94,175 miles, from the previous vendor, Pierce
Manufacturing, which is also the manufacturer of the four(4) newer fire engines
purchased in 2001.
Due to safety, maintenance and efficiency issues a request was made, and approved by
the Mayor that the bidding process usually required by Kent City Code, Section
3.70.030 and .040 was not in the best interest of the City and that the Fire Department
be allowed to enter into direct negotiations with Pierce Manufacturing for the purchase
of this replacement fire engine.
3 EXHIBITS: Letter to Mayor
4. RECOMMENDED BY: Fire Chief and Public Safety Committee 7/8/03 (3-0)
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $490,000
SOURCE OF FUNDS: Fire Dept Apparatus Replacement Fund
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6E
•
KENT
WASHINGTON May 21, 2003
FIRE TO: Mayor Jim White
Jim Schneider
Fire Chief FR: Jim Schneider, Fire Chief
Director ofEmerwncyMgmt RE- Purchase of a Fire Engine
220 Fourth Ave S
Kent,WA 98032-5895 Dear Mayor White,
Administration 253-856-4300
Prevention 253-8564400 This is a request to allow the Fire Department to purchase one (1) Pierce
Quantum fire engine using a contract similar to the previous contract for
Pierce Quantums, three (3) of which were purchased by the City and one
(1) that was purchased by King County Fire District#37.
The Kent Fire Department has purchased Pierce fire engines since (at
least) 1978, and the reliability has been excellent Due to a decision by the
sales representative of Pierce Manufacturing, Inc , the company did not
bid in 1995 when we purchased two (2) fire engines Without a bid from
Pierce, the bid was awarded to Boise Mobile Equipment (BME) Our
experience with the two (2) BME engines cost the City a tremendous
amount of money and repair time, resulting in a refection of the fire
engines after having them for two (2) years Of the two (2) years we had
the fire engines, they were out-of-service for one (1) year, and only in-
service for one (1) year That caused a great deal of frustration and lost
maintenance time
In 2000, we were given permission by the Kent City Council to purchase
three (3) fire engines and at the same time, King County Fire District #37
authorized the purchase of one (1) engine. We were able to "piggy-back"
on a bid at that time, from Mesa, Arizona As a result, the Department
purchased four (4) first-rate fire engines that were placed in service in late
2001
It is our request that we be authorized to purchase one (1) fire engine from
Pierce Manufacturing, Inc that is substantially the same as the previous
four (4) engines. The primary reasons for this request deal with safety,
cost savings and efficiency of operation.
Currently our Department has nearly 100 firefighters who are qualified as
fire engine driver/engineers. With that number, it is very difficult to
maintain proficiency because they do not individually get the chance to
drive often enough, which is a definite safety issue We have two(2) basic
styles of engines with their own, unique pump panels and other features
critical to the operating efficiency by a pump operator. As mentioned
above, it is difficult to maintain proficiency when a firefighter does not drive
an apparatus very often, and when he/she does (under emergency
conditions), it is challenging with two (2) different styles and arrangements
of fire engine. We have been able to work around this issue up to this
point However, if we were to add another type of apparatus, built by a
company with their own, unique style, it would definitely complicate the
matter.
Another cost efficiency consideration, is having our mechanics maintain
different apparatus, and the need to stock parts from a different
manufacturer. Currently they deal with one company and stock parts that
are often consistent between engines The purchase of an engine from a
different manufacturer may result in the need to stock different parts from
different manufacturers. In addition, it is much more efficient for city
mechanics to become familiar with, and maintain, engines produced by
the same manufacturer
Although not the least expensive, we believe that Pierce Manufacturing,
Inc., makes the best fire engine for our application, and the benefit of
having consistency with our fire engines, provides a safer and more
efficient operation.
Authorization of this purchase would be advantageous to the interest of
the City and the Fire Department
By this memo, the Fire Department requests that you determine that the
bidding process usually required by Kent City Code Section 3 70 030 and
040 is not in the best interest of the city. The Department requests that
the Mayor authorize the city to enter direct negotiations with Pierce
Manufacturing, Inc for the purchase of one (1) engine. In the event that
the Department successfully negotiates a purchase contract, the contract
will be brought before the Public Safety Committee and the City Council
for approval.
Signed,
`tJiar OSGV.✓�-�.A�w�
Jim Schneider, Fire Chief
I, Mayor Jim White, find that, in lieu of the formal bid or request for
proposal process, negotiating with Pierce Manufacturing for the purchase
of one (1) fire engine would best serve the interests of the city. Therefore,
I hereby authorize the Fire Department to negotiate a contract for the
purchase of one (1) fire engine from Pierce Manufacturing, Inc , that is
substantially similar to the previous four (4) engines purchased in 2001
Ji White, Mayor Date
tity of Kent
Approved by
6 4pa4trik Date
Deputy City Attorney
• Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: FLEXPASS CONTRACT 2003-2004—AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the administrative
contract with King County and Sound Transit effective July 1, 2003 through June 30,
2004, to renew the City of Kent contract with King County and Sound Transit for the
F1exPass Program The F1exPass Program will be available to approximately 442
eligible CTR affected, benefited employees at a cost of$25,858 per year for the twelve
month period (July 1, 2003-June 30,2004).
3. EXHIBITS: Contract
. 4 RECOMMENDED BY: Operations Committee 7/l/03 (3-0)
(Committee, Staff, Examiner, Commission, etc.)
5 UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS: General Fund
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6F
OFFICE OF THE MAYOR
Jim White, Mayor
Phone 253-856-5700
Fax 253-856-6700
KEN T Address 220 Fourth Avenue S
WA5HINGTON
Kent,WA 98032-5895
DATE: July 1, 2003
TO: Kent City Council Operations Committee
FROM: Ellen Bradley-Mak, Employee Transportation Coordinator
THROUGH Sue Viseth, Employee Services Director
SUBJECT: Flexpass Contract 2003-2004
SUMMARY: Renewal of the City of Kent contract with King County and Sound Transit for the
F1exPass Program The F1exPass Program will be available to approximately 442 eligible CTR
affected, benefited employees at a cost of$25,848 per year for the twelve month period(July 1,
2003 —June 30,2004)
BUDGET IMPACT $25, 000 is allocated in the CTR budget
MOTION: I move to recommend that council authorize the Mayor to sign the administrative
contract with King County and Sound Transit effective July 1, 2003 through June 30, 2004
BACKGROUND:
In 1991, the State Legislature passed the Commute Trip Reduction or CTR law, which was
incorporated into the Washington Clean Air Act The goals of the CTR program are reducing
traffic congestion, air pollution, and petroleum consumption through employer-based programs
that decrease the number of commute trips made by people driving alone Counties that are
affected by CTR, and the cities within those counties, are required to provide support to local
employers in implementing CTR programs The Public Works department is responsible for
administering and enforcing the City wide program that is comprised of over 40 employers
within the City limits. Employee Services is responsible for administering our organizational
CTR program
Our City ordinance requires that employers make a good faith effort to comply with CTR goals
The results of our last employee survey, which was conducted in March of this year, indicate that
we have reduced the number of single occupancy vehicle trips from the baseline of 85%to 68%
Our goal is to reduce the number of single occupancy trips to 55% by 2005
FlexPass Costing
2003-20M Contract Year
As of June, 2003
•
For 2002- 2003 Total cost of FlexPass program: $44,300
For 2003 - 2004 King County/Sound Transit proposed cost: $49,811
Less Employee Cost sharing: $25,768
Less VanPool expansion grant: $12,000
Total Net Cost of FlexPass: $13,763
AGREEMENT FOR SALE OF FLEXPASSES BETWEEN KING COUNTY,
SOUND TRANSIT AND CITY OF KENI
This Agreement(hereinafter,"Agreement")is made and entered into by and between King County(hereinafter
individually, "KING COUNTY"),Sound Transit(hereinafter individually,"SOUND TRANSIT"), or collectively
referred to hereinafter as"TRANSPORTATION PARTIES", and City of Kent(hereinafter, "CITY")
RECITALS
A CITY and TRANSPORTATION PARTIES share the desire to provide a comprehensive transportation pass
program that will reduce single occupant vehicle(SOV)commute trips and improve the mobility of CITY
employees
B KING COUNTY and SOUND TRANSIT are authorized to provide public transportation and generally promote
alternatives to SOV commuting in King County,Pierce County and Snohomish County
C CITY has a desire to provide incentives and benefits to its employees,which promote non-SOV commuting to
its worksite
D CITY and TRANSPORTATION PARTIES desire to create a single pass media that can be used to access a
variety of services and benefits,which enable CITY employees to commute,by non-SOV modes
AGREEMENT
NOW,THEREFORE, in consideration of the terms,conditions and covenants herein contained,the sufficiency of
which is hereby acknowledged, the parties hereto agree to the following
I PURPOSE
if Purpose .
This Agreement establishes a cooperative arrangement between TRANSPORTATION PARTIES and CITY for sale
and distribution of FlexPasses to CITY's Eligible Employees at the rate set forth herein.
2 DEFINITIONS
21 Eligible Employees
Eligible Employees shall mean only those employees of the CITY who meet the following criteria
All CTR-affected eMplovees
22 FlexPass Card
A FlexPass Card is a pass of predetermined duration,usually twelve (12)months,that allows each Eligible
Employee,as defined in Paragraph 2 1,to choose from a variety of non-SOV commute options provided by CITY or
TRANSPORTATION PARTIES. Each FlexPass Card shall bear the inscriptions"FlexPass,"CITY's narne,each
TRANSPORTATION PARTIES' logo,or an agreed to regional logo and beginning and expiration dates in a design
and color scheme mutually agreed upon by TRANSPORTATION PARTIES and CITY FlexPass Cards shall also
bear a fare amount on the face of the card,the amount of wluch shall be agreed upon by TRANSPORTATION
PARTIES and CITY prior to the start of this Agreement TRANSPORTATION PARTIES or their designated
contractor shall produce FlexPass Cards FlexPass Card's are non-refundable by TRANSPORTATION PARTIES,
except as set forth in Paragraph 8 2 Eligible Employees may be asked to present a valid CITY identification card
when using a FlexPass,if available
23 Trip Revenue
Trip revenue shall mean the cost of a single bus trip taken by a CITY's employee as set forth in Attachment A In
the event of a generally applicable fare increase adopted by KING COUNTY or SOUND TRANSIT,the amount of
the cost may be increased at such time as a generally applicable fare increase is implemented by KING COUNTY or
SOUND TRANSIT,and CITY shall be required to pay the amount of such adjustment to the appropriate party
FlexPass Agreement Page I of 13
City of Kent
July 2003-June 2004
24 Baseline Trips
Baseline Trips shall mean the estimated number of transit trips taken by CITY's Eligible Employees,as defined in
Paragraph 2 1,in the twelve(12)months preceding execution of the CITY's new FlexPass Agreement Baseline
Trips shall be calculated using the most current transit ridership data available on Eligible Employees,at the time
said Agreement becomes effective Baseline Trips shall be used,in part,to calculate the price of the transit cost set
forth in Attachment A Baseline Trips shall not change during the life of this Agreement,unless agreed toby
TRANSPORTATION PARTIES for reasons such as a significant change in the number of Eligible Employees or a
change in location of CITY's worksrte.
25 Added Trips
Added Trips shall mean those trips taken by CITY's Eligible Employees that have exceeded Baseline Trips,as
defined in Paragraph 2 4,during the period since Baseline Trips was established Added Trips shall be calculated
using an estimate,based on a survey or other agreed upon equivalent data source,of current transit ridership by
Eligible Employees Added Trips shall be used,in part,with Baseline Trips to calculate the price of renewing this
Agreement for another term
3 EMPLOYEE CONTRIBUTIONS AND COMMUTE BENEFITS AND INCENTIVES
3 1 Eligible Employee Contributions
CITY may require Eligible Employees to contribute toward the cost of a FlexPass Card, in the amount specified in
Attachment B
32 CITY-Provided Incentives and Benefits
CITY shall provide at least two(2)additional non-single occupant vehicle commute mode incentives or benefits,
listed in Attachments A or B,as a condition of participating in TRANSPORTATION PARTIES'FlexPass program
4. CITY RESPONSIBILITIES
4.1 Eligible Recipients Of A FlexPass Card
CITY shall ensure that only Eligible Employees,as defined in Paragraph 2 1,receive FlexPass cards
4.2 Ordering FlexPass Cards
CITY shall provide to TRANSPORTATION PARTIES' representative,as listed in Section 16,the number of
FlexPass Cards that CITY shall provide to Eligible Employees The number of FlexPass Cards shall be listed in
Attachment A CITY shall allow TRANSPORTATION PARTIES at least four(4)weeks in advance of the cards'
effectry a date to fulfill the request for FlexPass Cards CITY understands that failure to provide the number of
FlexPass Cards destred at least four(4)weeks in advance, may incur additional and extraordinary costs Such costs
may be related to,but are not linuted to,overtime staffing,additional manufacturing charges and express delivery
charges. These additional and extraordinary charges shall be borne solely by CITY
43 Ordering Additional FlexPass Cards
CITY shall retain the right to purchase additional FlexPass Cards for distribution to Eligible Employees,over and
above the number specified in Attachment A,during the term of this Agreement CITY shall allow
TRANSPORTATION PARTIES at least four(4)weeks to fulfill the request for additional FlexPass Cards
Requests shall be made to the TRANSPORTATION PARTIES'representatne,as listed in Section 16 The cost for
a single additional FlexPass Card shall be the Monthly Rate for Additional FlexPass Cards specified in Attachment
A,tunes the number of whole and partial months remaining in the Agreement.
44 Receipt and Security of FlexPass Cards
CITY agrees that all FlexPass Cards received from TRANSPORTATION PARTIES shall become the sole financial
responsibility of CITY upon receipt and signature by an employee,official or agent of CITY CITY agrees that it is
solely responsible for providing proper storage and security measures for any and all FlexPass Cards received by
CITY while in the custody of CITY CITY shall be held liable for the equivalent value of a combination King
County Metro/Sound Transit fare for each month remaining in this
FlexPass Agr nwnt Page 2 of 13
City of Kent
July 2003—June 2004
Agreement for each FlexPass Card that CITY cannot account for,either by distribution to an Eligible Employee,
storage in a secure area,for each FlexPass Card not collected from an Eligible Employee who terminates their
employment with CITY or otherwise becomes ineligible to receive and use a FlexPass Card under the terms of this
Agreement,or for each FlexPass Card CITY cannot return to TRANSPORTATION PARTIES upon termination of
this Agreement,as specified in Section 8
4.5 Reporting
CITY shall immediately report to each of the TRANSPORTATION PARTIES any FlexPass Cards that are lost,
stolen,damaged or otherwise not functioning property in TRANSPORTATION PARTIES transit coaches'
electronic registering fareboxes CITY shall return any and all FlexPass Cards to TRANSPORTATION PARTIES
that CITY believes to be defective. CITY shall report to TRANSPORTATION PARTIES all FlexPass usage,
changes to CITY's transportation program and other details as necessary.
46 Roster of FlexPass Card Recipients
CITY shall maintain a roster of Eligible Employees who have been provided a FlexPass Card by CITY Upon
demand,CITY shall provide to each of the TRANSPORTATION PARTIES a copy of the roster.
47 FlexPass Employee Use Agreement Form
Each Eligible Employee who receives a FlexPass Card front CITY shall be required to read,sign and return to their
employee transportation coordinator or department supervisor,an agreement form stipulating the uses and conditions
of a FlexPass Card The Employee Use Agreement Fortin, as set forth in Attachment C, is deemed mutually
acceptable to both CITY and TRANSPORTATION PARTIES CITY shall keep use Agreement Forms on file for
the term of this Agreement.
48 Collection of FlexPass Cards
CITY shall return to TRANSPORTATION PARTIES all FlexPass Cards issued to CITY within five(5)days of the
effective date of termination of this Agreement CITY shall be held liable for the equivalent value of a combination
King County Metro/Sound Transit fare for each month remaining in this Agreement for each FlexPass Card not
returned to TRANSPORTATION PARTIES upon termination of this Agreement.
49 Collection of Transit Ridership Data
CITY shall survey,or otherwise collect from CITY's Eligible Employees,any and all necessary daily transit
ridership and commute data that TRANSPORTATION PARTIES deem necessary to accurately and fairly estimate
Trip Revenue,Baselme Trips and Added Trips TRANSPORTATION PARTIES shall provide to CITY a mutually
agreed upon survey instrument or other suitable means in which to collect the most current and accurate ridership
and commute data possible
410 FlexPass Program EN aluation
CITY shall participate in any TRANSPORTATION PARTIES' evaluation of the FlexPass program,should such an
evaluation be deemed necessary by any of the TRANSPORTATION PARTIES Evaluation maybe through such
means as employee surveys, employee focus groups,and management interviews. TRANSPORTATION PARTIES
shall provide CITY at least thirty(30)days advance notice prior to beginning such an evaluation
4 It Vanpool Services
If an eligible employee elects to participate in KING COUNTY's vanpool program, CITY agrees to pay KING
COUNTY the amount stated in Attachment A for such vanpool services As stipulated in Attachment A,Eligible
Employees may use the FlexPass Card as partial or full payment of their vanpool fare If actual vanpool expenses
incurred by Eligible Employees exceed the amount paid in advance by CITY,as specified in Attachment A,plus any
vanpool incentive payment by KING COUNTY, also specified in Attachment A,KING COUNTY shall invoice
CITY for any amount owing once total vanpool costs for the term of this Agreement are calculated by KING
COUNTY
4 12 Home Free Guarantee
If CITY elects to participate in KING COUNTY's Home Free Guarantee program,CITY shall fulfill all conditions
and responsibilities of the Home Free Guarantee program in accordance with the terms attached hereto and made
part hereof as Attachment D
FlexPass Agreement Page 3 of 13
City of Kent
July 2003—June 2004
5 TRANSPORTATION PARTIES RESPONSIBILITIES
5 1 Transit Access
TRANSPORTATION PARTIES shall allow each CITY Eligible Employee displaying a valid FlexPass Card to nde
on all parts of its regular route transportation system without additional charge,for trips up to the value punted on
the card TRANSPORTATION PARTIES reserve the right to request additional payment at the time the transit trip
is taken,if the cost of a trip on any TRANSPORTATION PARTY's regular transit service exceeds the fare value
printed on the FlexPass Card FlexPass Cards are not valid on any Husky,Safeco Field,or other special event
service TRANSPORTATION PARTIES shall honor each Flexpass Card issued under this agreement up to the
expiration date on the Card or until this agreement is otherwise terminated
52 FlexPass Card Administration
TRANSPORTATION PARTIES'Designated Representative shall manage production,ordering,replacement and
delivery of FlexPass Cards to CITY,and other administrative tasks related to the FlexPass Card under this
Agreement,other than those responsibilities stated as CITY responsibilities in Section 4
53 Replacement FlexPass Cards
TRANSPORTATION PARTIES shall replace,at no additional cost to CITY,any FlexPass Cards deemed to be
defective or otherwise unusable or inoperative CITY may be issued temporary full passes until
TRANSPORTATION PARTIES can manufacture and deliver replacement FlexPass Cards TRANSPORTATION
PARTIES shall replace a lost or stolen FlexPass Card only once at a charge of$50 00 per replacement card.
54 Confiscation of FlexPass Cards
In addition to any other rights under law,TRANSPORTATION PARTIES reserve the right to cancel and confiscate
a FlexPass Card which is used out of date,altered,duplicated,counterfeited,transferred or distributed to
unauthorized persons or otherwise invalid under the terms of this Agreement
5 5 Collection of Transit Ridership Data
TRANSPORTATION PARTIES shall provide to CITY,at no additional cost to CITY,a mutually agreed upon
survey instrument or other suitable means in which to collect and measure the most current and accurate transit
ridership and commute data of CITY's Eligible Employees In addition,TRANSPORTATION PARTIES shall pay
for all costs incurred in processing this survey instrument,but not costs incurred by CITY in distributing to and
collecting from Eligible Employees,this survey instrument TRANSPORTATION PARTIES shall make available
to CITY, all data collected from CITY's Eligible Employees
56 Vanpool Services
CITY's employees are eligible to access KING COUNTY's vanpool program in accordance mth established
program procedures If applicable,KING COUNTY shall allow each Eligible Employee holding a FlexPass Card to
register as a vanpool participant subject to the availability of vanpool vehicles and minimum ridership requirements
If applicable, the FlexPass Card may be honored as full or partial payment of vanpool fares, as specified in
Attachments A and B
57 Home Free Guarantee
If CITY elects to participate in KING COUNTY's Home Free Guarantee program,KING COUNTY shall fulfill all
conditions and responsibilities of the Home Free Guarantee program in accordance with the terms attached hereto
and made part hereof as Attachment D
6 PAYMENTS AND BILLING
61 Payment for This Agreement
CITY agrees to pay TRANSPORTATION PARTIES the total amount stated in Attachment A for participation in
TRANSPORTATION PARTIES'FlexPass program KING COUNTY shall present an invoice for amounts due to
CITY's representative listed in Section 16 KING COUNTY shall invoice CITY for the amount(s)due for SOUND
TRANSIT. Payment shall be made in full by CITY according to the terms listed on the invoices,unless a payment
schedule is mutually agreed upon by both parties and incorporated into this Agreement, in Attachment A KING
COUNTY shall present individual invoices to CITY for additional FlexPass Cards purchased. KING COUNTY
shall invoice CITY for the amount(s)due for SOUND TRANSIT for additional FlexPass Cards purchased
FlexPass Agreement Page 4 of 13
City of Kent
July 2003—June 2004
62 Late Payment Penalty
If any scheduled payments are not made by their due date,then the entire amount due under this Agreement may
become immediately due and payable Any late payment shall be subject to a penalty accruing at the maximum rate
allowable by state law for each month that the payment remains due If any check made payable to any of the
TRANSPORTATION PARTIES by CITY is returned to a TRANSPORTATION PARTY for insufficient funds
(NSF)in CITY's checking account,then CITY shall be assessed a$25 (twenty-five)penalty by the
TRANSPORTATION PARTY receiving the NSF check.
7. TERM OF AGREEMENT
71 Term
This Agreement shall take effect upon the exact day and expire on the exact day specified in this paragraph,unless
terminated in accordance with the terms set forth in Section 8 This Agreement shall take effect at 12 00 a m on
July 1, 2003 and shall expue at 11 59 p.m on June 30,2004.
8. TERMINATION
81 Temmnation for Cause
Any party may terminate this Agreement in the event the other falls to perform its obligations as described in this
Agreement by providing,written notice not less than fourteen(14)days prior to the effective date of ternnauon.
82 Termination for Convenience
Any party may also terminate this Agreement for convenience and without cause by providing the other party with
written notice not less than sixty(60)days in advance If CITY has made payments in advance,CITY shall be
entitled to reimbursement from each TRANSPORTATION PARTY for each valid FlexPass Card returned to
TRANSPORTATION PARTIES Such reimbursement shall beat the monthly rate set forth in Attachment A for the
full months remaining in the original term of the Agreement.
If CITY has accrued additional financial obligations to any TRANSPORTATION PARTY as a result of the
provisions of this Agreement,either prior to termination or as a result of terunation,CITY agrees to pay any
outstanding amount due to that TRANSPORTATION PARTY The TRANSPORTATION PARTY shall invoice
CITY for the amount due according to the procedures outlined in Section 6
9 RECORDS
91 Rights of Review
Both CITY and TRANSPORTATION PARTIES shall retain the right to review records and documents related to
this Agreement If a records review is commenced more than sixty(60)days after the termination of the contract, the
TRANSPORTATION PARTY requesting the review shall give ten(10)days notice to CITY of the date on which
the records review will begin
10. SUCCESSORS AND ASSIGNS
101 Written Approval
This Agreement and all terms,provisions,conditions and covenants hereof shall be binding upon the parties hereto
and their respective successors and assigns All parties,however,agree that they will not assignor delegate the
duties to be performed under this Agreement without prior,written approval from the other parties
1 I LEGAL RELATIONS
11 1 No Partnership and No Third Party Beneficiaries
It is agreed by CITY and TRANSPORTATION PARTIES that this Agreement does not create a partnership orl0int
venture relationship between the parties,and does not benefit or create any rights in a third party
112 Force Maleure
TRANSPORTATION PARTIES shall be excused from performance of any responsibilities and obligations under
this Agreement,and shall not be liable for damages due to failure to perform,resulting directly or indirectly from
causes and circumstances beyond their control,including but not limited to late delivery or nonperformance by
vendors of materials or supplies,incidences of fire,flood,snow,earthquake or other acts of nature,accidents,no%
insurrection,terrorism,acts of war,order of any court or civil authority,and strikes or other labor actions
FlexPass Agreement Page 5 of 13
City of Kent
July 2003—June 2004
113 Costs of Legal Action
CITY shall be liable for any and all reasonable attorney fees,court costs and other expenses incurred by
TRANSPORTATION PARTIES in the event TRANSPORTATION PARTIES pursue legal action to obtain the
retina of any FlexPass Cards or amount owing under this Agreement
12 APPLICABLE LAW, FORUM
12.1 Terms
This Agreement shall be governed by and construed according to the laws of the State of Washington Nothing in
this Agreement shall be construed as altering or diminishing the tights or responsibilities of the parties as granted or
imposed by state law. In the event that any litigation may be filed between the parties regarding this Agreement,
CITY and TRANSPORTATION PARTIES agree that personal jurisdiction and venue shall rest in the Superior
Court of the county where the TRANSPORTATION PARTY pursuing the action resides
13 DISPUTES
13.1 Dispute Resolution Procedure
All claims or disputes ansing out of or relating to this Agreement shall be referred to a panel consisting of CITY's
Benefits Manager,RING COUNTY's Division Director,Transit Division,and SOUND TRANSIT's Executive
Director, or their designees
If this panel is unable to reach a mutually acceptable resolution,it shall appoint another person to serve as mediator
in the effort to resolve the claim or dispute Such mediation shall be required before an action may be filed to
adjudicate the claimer dispute in a court of law.
14. ENTIRE AGREEMENT AND AMENDMENT
141 Entire Agreement
Tlus Agreement constitutes the entire agreement between the parties and supersedes all prior negotiations,
representations and agreements between the parties relating to the subject matter hereof
142 Amendments and Modifications
This Agreement may be amended or modified only by written instrument signed by the parties hereto
15 SAVINGS
151 Definition
Should any provision of this Agreement be deemed invalid or mconsistent with any federal, state or local law or
regulation,the remaining provisions shall continue in full force and effect All parties agree to immediately attempt
to renegotiate such provision that is invalidated or superseded by such laws or regulations
16 CONTACTPERSONS
161 Definition
CITY and TRANSPORTATION PARTIES shall each designate a contact person for purposes of sending mquines
and notices regarding the execution and fulfillment of tlus Agreement,as well as the ordering of all fare media and
vouchers
Flex Pass Agreement Page 6 of 13
City of Kent
July 2003—June 2004
162 Designated Contact Persons
CITY KING COUNTY, FLEXPASS CARD
ORDERS &RETURNS
Contact Name Ellen Bradlev-Mak Jeff Won
Title Human Resource Analyst Transit Planner
Address City of Kent King County Metro Transit
220 4th Avenue S 400 Yesler Way,MS YES-TR-0600
Kent,WA 98032 Seattle,WA 98104-2615
Telephone 253-856-5297 206-263-3452
Fax 206-684-2058
E-Marl EBMak ci kent wa us Jeff-mkt-dev won etrokc gov
SOUND TRANSIT
Contact Name Brian Brooke i; X[ � 14 - M 'ex" ^4s
Title Fare Integration Project Manager ,'1 ION
Address Sound Transit
401 S Jackson Street
3 Jfv
Seattle,WA 98104-2826
Telephone 206-398-5229x y ;'-•} x ,"X, " s i
Fax 206-398-5215
E-Marl brookeb soundtransit or
17 EXECUTION OF AGREEMENT
171 Definition
This Agreement shall be executed in three(3)counterparts,each one of wluch shall be regarded for all purposes as
one original
In Witness whereof,the parties have executed this Agreement as of the date first wntten above
CITY KING COUNTY
BY BY
Eric Gleason
Title Title Manager,Service Development
Date Date
SOUND TRANSIT
BY King County per Agent Agreement
FlezPass Agreement Page 7 of 13
City of Kent
July 2003—June 2004
FlexAass Agreement Attachment A-Agreement Costs
Company City of Kent Start Date July 1,2003
KING COUNTY SERVICES
BUS
Baseline trips(Data source CTR Survey) 1,326
Added trips(Data source. CTR Survey) + 0
Discount of Added Tnps(Year#3 113 discount of xx inns) 0
Total trips = 1,326
Cost per trip x $ 139
King County Bus Cost = $ 1,843.00
CARD PRODUCTION
Number of F1exPass Cards produced 442
Rate per card x $ 1 00
Card Production Cost = $ 442.00
HOME FREE GUARANTEE
Number of covered employees 44200
Rate per covered emcee x $ 100
Home Free Guarantee Cost = S 442.00
COMMUTER BONUS PLUS VOUCHERS
Prepaid Commuter Bonus Plus vouchers $ 1,0000
Commuter Bonus Plus Vouchers = $ 1,000.00
KING COUNTY PREPAID VANPOOL SUBSIDY
July 2003—June 2004 $ 18,000 00
Prepaid VanpoolSubsidy = $ 18,000.00
CITY agrees to pay the vanpool subsidy rate for any and all vanpoolers over the initially covered number
KING COUNTY will invoice CITY for the amount due for the additional vanpoolers
CITY agrees to inform vanpooling employees of their responsrbrhty to pay vanpool bookkeepers any excess
vanpool fare due,over and above the CITY monthly subsidy amount
AGREEMENT COSTS FOR KING COUNTY SERVICES
Bus $ 1,84300
Card production + $ 44200
Home Free Guarantee + $ 44200
Commuter Bonus Plus + $ 1,00000
Prepaid vanpool subsidy + $ 18,000 00
Total King County Services Cost = $ 21,727.00
Payment schedule:Net 60, 180 days(50%each payment)
Number of FleaPass Cards provided by Transportation Parties = 442
King County Monthly Rate for ONE additional FlexPass Card = $ 051
($2,727/442 employees/ 12 months)
• Fle%Pass Agreement Page 8 of 13
City of Kent
July 2003—June 2004
FlexPass Agreement Attachment A -Agreement Costs (cont.)
Company City of Kent Start Date July 1.2003
SOUND TRANSIT SERVICES
BUS AND RAIL
Transit Trips(Data Source CTR Survey) 6,382
Cost per Trip x $ 158
Total Cost Of Sound Transit Services = $ 10,084.00
Payment schedule:Net 60, 180 days(50%each payment)
Number of F1e:Pass Cards provided by Transportation Parties 442
Sound Transit monthly rate for ONE additional FlexPass Card = $ 190
($10,084/442 employees/ 12 months)
TOTAL FLEXPASS AGREEMENT COST
King County $ 21,727 00
Sound Transit + $ 10,0840
Total FlexPass Agreement Cost = $ 31,811.00
TRANSPORTATION PARTIES ALLOCATION OF TRANSIT REVENUES
King County $ 2,72700
Sound Transit + $ 10,0840
Total Transit Revenues = $ 12,811.00
Number of FlexPass Cards / 442
Number of months in agreement / 12
Combined monthly rate for ONE additional FlexPass Card $ 2.41
Allocation King County=$0 51 Sound Transit=$1 90
FlexPass Agreement Page 9 of 13
City of Kent
July 2003—June 2004
FlexPass Agreement Attachment B - Employee Contributions and
Company Provided Benefits/incentives
Company City of Kent Start Date July 1, 2003
KING COUNTY I SOUND TRANSIT FLEXPASS
Amount contributed by each Eligible Employee $ 0 00
VANPOOL FARE SUBSIDY
Benefit per employee per month Up to$31 50
OTHER TRANSIT SYSTEM FARE SUBSIDIES
Benefit per employee per month NIA
EMERGENCY GUARANTEED RIDE HOME
King County's Home Free Guarantee Program-See Attachment D
CARPOOLERS AND NON-MOTORIZED COMMUTERS
Benefit per employee per month $ TBD
PARKING I OTHER
Benefit per employee per month in a carpool Freepnonty parking in garage
Benefit per employee per month in a vanpool Freepnonty narking in garage
Other NIA
FlezPass Agreement Page 10 of 13
City of Kent
July 2003—June 2DO4
FlexPass Agreement Attachment C - Employee Use agreement
CITY OF KENT
FlexPass Use Agreement •
As a FlexPass Holder, I agree to the following
1. The FlexPass is a benefit provided to me as an employee and is to be used only during the
period I am employed by the City of Kent.
2. 1 will use my FlexPass for my own transportation only I will not transfer my FlexPass to any
other person.
3. I will keep my FlexPass secure and in good condition. I will immediately report a lost,
stolen, or damaged FlexPass to the Transportation Coordinator. I understand a lost FlexPass
will be replaced only once per year at a charge of$50 00 A non-working FlexPass will be
replaced free of charge.
4. I will return my FlexPass upon request or when I leave my employment with my company. If
I do not return my FlexPass, I authorize the amount of$144 00 for each whole and partial
month remaining on the FlexPass to be withheld from my paycheck.
5. If my employer subsidizes a fixed amount for my vanpool fare via the FlexPass card,I
understand that I am responsible for the balance of the fare, payable to the vanpool
bookkeeper .
I acknowledge the receipt of my FlexPass, and understand and agree to the terms stated above on
using the FlexPass
Employee's Signature Date
Employee's Printed Name FlexPass Senal #
Transportation Coordinator Use Only-FlexPass returned:
Employee's Signature Date
FlexPass Senal #
FlexPass Agreement Page 11 of 13
Gty of Kent
July 2001—June 2004
FlexPass agreement Attachment D - Home Free Guarantee
Home Free Guarantee(hereinafter,"HFG")is a KING COUNTY program that guarantees payment for taxi fares
• incurred by employees deemed eligible by the CITY for emergency rides taken in accordance with the temis set forth
below,
D I DEFINTITIONS
D 1 I Approved Commute Modes
Eligible Employees must have commuted from their principal residence or Park&Ride to the CITY's worksite by
one of the following modes Bus,carpool,vanpool,walk-on or bicycle-on ferry,bicycle,or walk.
D 1 2 Eligible Reasons For Using HFG
The following are the only eligible reasons for using HFG:
a) Eligible Employee's or family member's unexpected illness or emergency
b) Unexpected schedule change such that the normal commute mode is not available for the return commute to the
starting place of their commute Unexpected means the employee learns of the schedule change that day
c) Missing the employee's normal return commute to the starting place of their commute for reasons, other than
weather, or act of nature which are beyond the employee's control and of which they had no prior knowledge
For example,the employee's carpool driver left work or worked late unexpectedly
D 1 3 Non-Eligible Reasons For Using HFG
Reasons which are not eligible for HFG use include,but are not limited to,the following
a) Pre-scheduled medical or other appointments.
b) To transport individuals who have incurred injury or illness related to their occupation. An HFG ride should
NEVER be used where an ambulance is appropriate,nor should an HFG ride replace CITY's legal
responsibility under workers' compensation laws and regulations
c) Other situations where,in the opinion of the CITY's Program Coordinator,alternate transportation could have
been arranged ahead of time
D 1 4 Eligible Destinations for an HFG Ride
a) From the CITY's worksite to the Eligible Employee's principal place of residence
b) From the CITY's worksite to the Eligible Employee's personal vehicle,e g vehicle located at a Park&Ride lot
c) From the CITY's worksite to the Eligible Employee's usual commute ferry terminal on the east side of Puget
Sound
D 1.5 Intermediate Stops
Intermediate stops are permitted only if they are of an emergency nature and are requested in advance by Eligible
Employee and are authorized in advance of the ride by the CITY's Program Coordinator(i a pick up a necessary
prescription at a pharmacy,pick up a sick child at school)
D 2 CITY RESPONSIBILITIES
D 2 1 HFG Program Payment
CITY's payment for HFG services is accounted for in the base price for FlexPass Cards as indicated in Attachment
A If a company's fare costs exceed amount listed in Attachment A at the end of 6 months,a sliding scale charge
will be applied as follows
a) If total fare costs average between$1 00 and$1 25/employee,Company may be charged$1 25/employee for
second six months of the agreement period
b) If total fare costs average between$1 25 and$1 50/employee,Company may be charged$1 50/employee for
second six months of the agreement period
c) and so on incrementally without lumt
D 2 2 Program Coordinator
CITY shall designate as many Program Coordinators as necessary to administer and perform the necessary HFG
program tasks set forth below
0
FlexPass Agreement Page 12 of 13
City of Kent
July 2003—June 2004
D 2 3 Number Of HFG Rides Per Eligible Employee
CITY shall ensure that each Eligible Employee does not exceed eight(8)HFG rides per twelve(12)month period
D 3 HFG Program Tasks
D 3 1 Process
To access HFG rides,Eligible Employees shall contact the Program Coordinator The Program Coordinator shall
call directly an answering service provider,contracted for by KING COUNTY. The phone number shall be supplied
to CITY by KING COUNTY CITY agrees to make information about how to access HFG ndes to all Eligible
Employees Eligible Employees shall supply the following information to the Program Coordinator, who shall in
turn provide the information to the answering service provider
a) Verify the Eligible Employee has commuted to the worksite by an eligible mode
b) Verify the Eligible Employee has an eligible reason and eligible destination for an HFG ride
c) Ensure the Eligible Employee has valid identification to show the taxi driver
d) Once an Eligible Employee takes the emergency taxi ride,the Eligible Employee shall provide a receipt from the
taxi trip to CITY'S Program Coordinator
e) CITY's Program Coordinator shall forward copies of such receipts to KING COUNTY at the end of each month
for record keeping and accounting purposes
f) The answering service provider shall arrange taxi ndes for the Eligible Employee
D 4 KING COUNTY RESPONSIBILITIES
D 4 1 Participating Taxi Company(s)
CITY agrees that neither KING COUNTY or answering service provider is responsible for providing transportation
services under the HFG program CITY further agrees that KING COUNTY makes no guarantee or warranty as to
the availability, quality or reliability of taxi service,and that the KING COUNTY's sole obligation under the
program is to make payment of the taxi provider for trips actually taken in accordance with the terms of this
Agreement. CITY agrees it shall make no claum of any kind or bring any suits of any kind against the KING
COUNTY for damages or injuries of any kind arising out of or in any way related to the HFG program Without
limiting the foregoing and by way of example only,the CITY agrees that KING COUNTY shall not be liable for any
injuries or damages caused by negligence or intentional acts occurring before,during or after a taxi ride or for any
inlunes or damages caused by failure of a taxi to provide a ride due to negligence,intentional acts or causes beyond
the taxi's control,including but not limited to incidence of fire,flood,snow,earthquake or other acts of nature,nots,
insurrection, accident,order of any court or civil authority,and strikes or other Iabor actions
D 4 2 Payment of Authorized HFG Taxi Fares
KING COUNTY shall pay the metered fare amount of a CITY's Program Coordmator-authorized HFG ride,as
defined in the DEFINITIONS section above,for a one-way distance of up to sixty(60)miles Any fare for a one-
way distance in excess of sixty(60)miles shall be paid by the individual taking the HFG ride KING COUNTY
shall not pay any taxi driver gratuity,which shall be paid by and at the sole discretion of the individual taking the
HFG ride.
D 4.3 Reporting
KING COUNTY shall keep a complete record of all authorized HFG ride requests on a serm-annual basis and
provide a copy of this record to the designated CITY contact person specified in Section 16 2
D 4.4 Program Abuse
KING COUNTY reserves the right to investigate and recover costs from the CITY of intentional abuse of the HFG
program by Eligible Employees Program abuse is defined as,but not hunted to,taking trips for inappropriate
reasons, unauthorized destinations and intermediate stops,and pre-scheduled appointments not defined in the
DEFINITIONS section above
FlexPass Agreement Page 13 of 13 16
City of Kent
July 2003—June 2004
Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: GROUP HEALTH COOPERATIVE CONTRACT RENEWAL—
AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the Group Health
Cooperative contract effective January 1, 2003 through December 31, 2003.
Renewal of the Group Health Cooperative contract for the City's insured Health
Maintenance Organization (HMO) The 2003 contract reflects an approximate 14.64%
increase in the health care premiums and is budgeted in the Health and Welfare Fund.
3. EXHIBITS: Contract
• 4. RECOMMENDED BY: Operations Committee 7/l/03 (3-0)
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS: Health and Welfare Fund
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6G
OFFICE OF THE MAYOR
Jun White, Mayor
� Phone 253-856-5700
KENT Fax 253-856-6700
w..s H H c.c u Address 220 Fourth Avenue S
Kent,WA 98032-5895
DATE: July 1, 2003
TO: Kent City Council Operations Committee
FROM: Becky Fowler, Benefits Manager
THROUGH- Sue Viseth, Employee Services Director
SUBJECT: Group Health Cooperative Contract Renewal
SUMMARY: Renewal of the Group Health Cooperative of Puget Sound contract for the City's
insured Health Maintenance Organization (HMO) The 2003 contract reflects an approximate
14 64% increase in the health care premiums charged by Group Health Cooperative and is
budgeted in the health and welfare fund
BUDGET IMPACT $ 247,751 00 (Health&Welfare Fund)
MOTION I move to recommend that council authorize the Mayor to sign the contract with
Group Health Cooperative effective January 1, 2003 through December 31, 2003
BACKGROUND:
The City purchases insurance with Group Health Cooperative care program Group Health is a
non-profit, health maintenance organization (HMO)providing primary care medical and
specialty centers throughout the Pacific Northwest Approximately 93 lives are covered under
our Group Health Cooperative plan which includes employees and dependents
Kent Council Operations Committee ] Group Health Cooperative Agreement
June 17, 2003
Enrollment Schedule The Special Enrollment Periods provision has been clarified
The automatic enrollment of newborns provisions have been deleted
An additional provision has been added to state that the Subscriber
enroll their newbom or newly adoptive child as a dependent to avoid
delays in payment of clatmc
A clarification has been made to state that Subscribers and covered
dependents who are eligible for Medicare(and residing inside the
Medicare+Choice service area,must,effective the date T'EFRA
eligibility ends or the date that Medicare would become the primary
paym,enroll in Medicare Parts A and B,and must participate in
GHC's Medicare plan
Claims Clarifications have been made to this provision based on federal
requirements
Blood A benefit change has been made to include blood coverage
Maternity A clarification was trade to reflect that treatment for postpartum
depression or psychosis is covered under the mental health benefit
The exclusion of bathing kits has also been removed.
A clarification was made at the request of the Insurance
Commissioner's office to state that prenatal testing is made in
accordance with Board of Health standards.
Plastic and Reconstructive Services A clarification has been trade to state that comphcations of covered
mastectomy services,mckuding lymphedemas, are covered.
Mental Health Care Services A clarification has been trade to more accurately reflect how these
services are administered Clarifications to exclusions have also
been made
Exclusions A clarification has been made to the sexual reassignment provision
The pre-existing condition provision has been clanfied to reflect
HIPAA requirements regarding portability,as well as state
requirements.
A clarification has been made to reflect that routine ultrasound to
determine fetal age,size or sex are excluded
Additional clarifications include Routine foot care except in the
presence of a non-related Medical Condition affecting the lower
limbs,complications of non-Covered Services,missed appointment
or cancellation fees,and treatment of obesity,except as otherwise
noted in the agreement.
@GroupHeafth
COOPERATIVE
GROUP MEDICAL COVERAGE
AGREEMENT
Group Health Cooperative(also referred to as"GHC","Group Health","GH" or the"Cooperative") is a nonprofit
health maintenance organization furnishing health care primarily on a prepayment basis
This Agreement states the terms of enrollment,payment and coverage under which a Group may secure GHC health
benefits. The Schedule of Benefits lists the benefits to which those enrolled under this Agreement are entitled
Words with special meaning are capitalized. They are defined in Section I.
Accessing Care
MEMBERS ARE ENTITLED TO COVERED SERVICES ONLY AT GH FACILITIES AND FROM GHC
PRIMARY CARE PROVIDERS EXCEPT AS FOLLOWS.
• Emergency care,
• women's health care providers as set forth below,
• visits with GH-Designated Self-Referral Specialists,as set forth below
• other services as specifically set forth in the Allowances Schedule and Section X,
• care provided pursuant to a Referral Referrals must be requested by the Member's primary care provider
and approved by GHC
Primary Care. Members must select a GH Primary Care Provider when enrolling under this Agreement. One
primary care provider may be selected for the entire family,or a different primary care provider may be selected
for each famdy member. If the primary care provider is not selected at the time of enrollment, Group Health wig
assign a primary care provider,and a letter of explanation and an identification card wig be sent to the Member.
Selecting a primary care provider or changing from one Primary Care Provider to another can be accomplished by
contacting Group Health Customer Service, or accessing the GHC website at www.gh"rg The change will be
made within twenty-four(24)hours of the receipt of the request if the selected physician's caseload permits
A listing of GHC Primary Care Providers, referral specialists, women's health care providers, and GH-
designated Self-Referral Specialists is available by contacting GHC Customer Service at (206) 901-4636 (or 1-
888-901-4636),or by accessing GHC's website at www.ghe.org.
In the case that the Member's primary care provider no longer participates in GHC's network,the Member will
be provided a written notice offering the Member a selection of new primary care providers from which to
choose.
Specialty Care. Unless otherwise indicated in this section, the Allowances Schedule,or Section X, referrals are
required for specialty care and specialist.
GH Desienated Self-Referral Specialist. Members may make appointments directly with GH-Designated Self-
Referral Specialists at GH-owned or operated medical centers without a Referral from their primary care
provider. Self-Referrals are available for the following specialty care areas:allergy, audiology,cardiology,
PA-113302 -
0036900-C21431 1
GROUP HEALTH COOPERATIVE
CONTRACT REVISIONS
Effective January 1,2003
(Created 8/12/02;revised 2/26/03)
This is the most current list of revisions,but this fist is subject to change at any time.
CONTRACT EXPLANATION
LANGUAGEIBENEFIT CHANGE
General Information Numerous changes have been made throughout the agreement to
reflect the fact that the agreement is an insurance document,rather
than a care delivery document
Introduction Information concerning "Accessing Card'has been added to this
section in addition to referencing GH designated self-referral
specialists,and moving access to care provisions from the
Limitations section of the Agreement
Table of Contents The headings for Subrogation,Gnevance/Appeal Procedures and
Exclusions and Limitations has been revised,as well as throughout
the Agreement
Allowances Schedule The Allowances Schedule has been reformatted to combine similar
coverage under one heading,and clarifications have also been made
throughout the Allowances Schedule.
Self-referrals to GHC providers that are licensed acupunctansts and
naturopaths are now available. Five self-referred visits are available
for acupuncturists,and two self-referred visits are available for
natumpaths.
The benefit period allowance under chemical dependency services
has been increased in accordance with Washington state law The
dollar amount will be reflected in the Agreement
Skilled nursing facility services are now covered up to sixty(60)
days per Member per calendar year(in addition to coverage in heu
of hospitalization) Additional information concerning the benefit
can be found in Section X Schedule of Benefits (The 60-day
skilled nursing facility coverage is dependent on when the actual
renewal paperwork was provided to the group )
Enrolhnent/Ehgibthry Requirements The provision concerning persons hospitalized on the effective date
of coverage has been clarified to state that coverage for members
admitted to an inpatient facility prior to their enrollment under this
Agreement,and who do not have coverage under another
Agreement,will receive covered benefits beginning on their
effective date Also,GHC reserves the tight to require transfer of a
member to a GH facility in the event a member is hospitalized in a
non-GH facility or non-GH designated facility
Definitions A new deftmtion for GH designated self-referral specialists has been
added
The Stop Loss definition has been redefined under Out-of-Pocket
Lunit.
Termination An additional provision was added under Termination of Entire
Agreement to reflect that the group may be terminated if they no
longer meet underwriting guidelines established by GHC in effect at
the time the Group was accepted.
The provision concerning persons hospitalized on the date of
termination has been revised to state that the member shall continue
to be eligible for covered services while an inpatient for the
condition for which the member was hospitalized until the first of
the following events occur the member no longer meets medical
criteria to be an mpatient at the facility;the remaining benefits
available under this Agreement for the confinement are exhausted,
regardless of whether a new calendar year begins,the member
becomes covered under another Agreement with the group health
plan that provides benefits for the confinement,the member
becomes emolled under an Agreement with another carver that
would provide benefits for this confinement if this Agreement did
not exist,or Medicare eligibility
The Services provided after Termination provision has been
clarified to define what the certificate of creditable coverage is, as
well as to state that the group determines whether GHC or the group
provides the certificate of creditable coverage to members
Continuation coverage, conversion and A clarification has been made under eligibility for Group
transfer Conversion stating that any Subscriber or Family Dependent not
entitled to Medicare may convert to GHC's Croup Conversion plan
if his/her coverage under this Agreement is terminated for any
reason other than cause
In accordance with Washington state law,a continuation opnon
provision has been added which states"A Member no longer eligible
for coverage under this Agreement(except in the event of
termination for cause)may continue coverage for a period of up to
three(3)months subject to notification to and self-payment of
premium to the Group This provision will not apply if the Member
is eligible for the continuation coverage provisions of the
Consohdated Ommbus Budget Reconahauon Act of 1995
COBRA)"
Coordination of benefits The definition of"Plan"has been broadened to include sources of
benefits or services from individual policies
The"Effect of Medicare"section has been clarified to reflect how a
medicare-eligible person's benefits will be effected when the
member resides outside the GH Medicare+Choice service area
Subrogation and Reimbursement Rights This section has been modified to include ERISA requirements
Grievance Procedures Clarifications have been added at the request of the Insurance
Commissioner's office
Miscellaneous Provisions The confidentiality,indemnification, and governmental approval
provisions have been clarified
Provisions regarding arbitration,HIPAA transactions and
compliance with law have been added
chemical dependency, chiropractidmanipulative therapy, dermatology, gastronenterology, general surgery,
hospice, manipulative therapy, mental health, nephrologv, neurology, obstetrics and gynecology, occupational
medicine*,oncology/hematology, ophthalmology,optometry, orthopedics,otolaryngology(ear, nose,and throat),
physical therapy*,smoking cessation,speecklianguage and learning services*,and urology.
*Medicare patients need a Referral for these specialists
Women's Health Care Direct Access Providers Female Members may see a participating General and Family
Practitioner, Physician's Assistant, Gynecologist, Certified Nurse Midwife, Licensed Midwife, Doctor of
Osteopathy, Pediatrician, Obstetrician or Advanced Registered Nurse Practitioner who is contracted to provide
women's health care services directly,without a Referral from their Prunary Care Provider, for Medically Necessary
and appropriate maternity care, covered reproductive health services, preventive care (well care) and general
examinations, gynecological care, and medically appropriate follow-up visits for the above services Women's
health care services are covered as if your Primary Care Provider had been consulted, subject to any applicable
Copayments and/or Coinsurance as set forth in the Allowances Schedule If your women's health care provider
diagnoses a condition that requires referral to other specialists or hospitalization,you or your chosen provider must
obtain preauthorization and care coordination in accordance with applicable GHC requirements
Second Opinions The Member may access, upon request, a second opinion regarding a medical diagnosis or
treatmentplan from a GHC Provider.
Emergent and Urgent Care. Emergent and urgent care services are covered as set forth in Section XL. Contact
the Emergency Notification Line as indicated on your GH identification card
Recommended Treatment The Cooperative's Medical Director or his/her designee will determine the necessity,
nature, and extent of treatment to be covered in each individual case and the Judgment, made in good frah, will
be final Coverage decisions may be appealed as ser forth to Section VII.
Members have the right to participate in decisions regarding their health care. A Member may refuse any
recommended treatment or diagnostic plan to the extent permitted by law. In such case, GHC shall have no
further obligation to provide benefits for the condition in question.
Non-Recommended Treatment Members who obtain care not recommended by GHC, do so with the full
understanding that GHC has no obligation for the cost,or liability for the outcome,of such care.
Major Disaster or Epidemic In the event of a major disaster or epidemic, GHC will provide coverage according
to its best judgment within the Bmitauons of available facilities and personneL The Cooperative has no liability
for delay or failure to provide or arrange Covered Services to the extent facihres or personnel are unavailable
due to a major disaster or epidemic
Unusual Circumstances. If the provision of Covered Services is delayed or rendered impossible due to unusual
circumstances such as complete or partial destruction of facilities, military action,civil disorder, labor disputes,
or similar causes, GHC shall provide or arrange for services that, in the reasonable opinion of GHC's Medical
Director, or his/her designee, are emergent or urgently needed In regard to nonurgent and routine services,
GHC shall make a good faith effort to provide services through its then-available facilities and personnel. GHC
shall have the option to defer or reschedule services that are not urgent while its facilities and services are so
affected In no case shall the Cooperative have any Lability or obligation on account of delay or failure to provide
or arrange such services.
0036900-C21431 2
Table of Contents
Summary of Allowances and Enrollment/Eligibibty Requirements
I. Definitions
II Prermums,Fees and Copayments
M. Termination
IV. Continuation Coverage,Conversion,and Transfer
V Coordination of Benefits
VI. Subrogatioa and Reimbursement Righrs
VII, Grievance Procedures for Complaints and Appeals
VIII Miscellaneous Provisions
IX. Enrollment Schedule
X Schedule of Benefits
XI Exclusions
XII Claims
• Medicare Endorsements(if applicable)
• Premiums Schedule
0036900-C21431 3
ALLOWANCES SCHEDULE
The benefits described in this schedule are subject to all provisions, limitations and exclusions set forth in the Group
Medical Coverage Agreement
ANNUAL DEDUCTIBLE
No Annual Deductible
PLAN COINSURANCE
No Plan Coinsurance
LIFETIME MAXIMUM
No lifetime maximum unless otherwise indicated.
HOSPITAL SERVICES
• Covered inpatient services [medical and surgical services, including acute chemical withdrawal
(deroxificanon)]
Covered in full
. • Covered outpatient hospital surgery(including ambulatory surgical centers)
Covered subject to the outpatient services Copayment
OUTPATIENT SERVICES
• Covered outpatient medical and surgical services
$5 Copayment per visit per Member
• Allergy testing
Covered subject to the outpatient services Copayment
• Oncology(radiation therapy,chemotherapy)
Covered subject to the outpatient services Copayment.
DRUGS - OUTPATIENT (INCLUDING MENTAL HEALTH DRUGS, CONTRACEPTIVE DRUGS AND
DEVICES AND DIABETIC SUPPLIES)
• Prescription Drugs,medicines,supplies and devices for a supply of thirty(30)days or less When listed in the
GHC drug formulary.
0036900-C21431 4
Covered subject to the lesser of GHC's charge or a $5 Copayment for covered prescription drugs, medicines,
supplies and devices
• Over-the-counter drugs and medicines
Not covered
• Allergy serum
Covered subject to the prescription drug Copayment for each 30 day supply.
• Injectables
Injections that can be self-administered are subject to the prescription drug Copayment
• Mail order drugs and medicines
Covered subject to the prescription drug Copayment for each 30 day supply
• Growth hormones
Covered
OUT-OF-POCKET LIMIT(STOP LOSS)
Except as otherwise noted in this Allowances Schedule, total out-of-pocket expenses for the following Covered
Services
• Inpatient Services
• Outpatient Services
• Emergency Care at a GH,GH Designated or non-GH Facility
• Ambulance services
Lirmted to an aggregate maximum of$2,000 per Member and$4,000 per family per calendar year.
ACUPUNCTURE
Self-referrals to a GHC Provider covered up to a maximum of five (5) visits per Member per medical diagnosis
per calendar year, subject to the outpatient services copayment Additional visits are covered when approved by
GHC subject to the outpatient services copayment.
AMBULANCE SERVICES
• Emergency ground/air transport
Covered at 800/c.
• Non-emergent transfer to a GH or GH Designated Facility
Covered m full
0036900-C21431 5
CHEMICAL-DEPENDENCY
• Inpatient Services
Covered subject to the applicable inpatient Copayment
• Outpatient Seances
Covered subject to the applicable outpatient services Copayment
• Benefit Period Allowance
S11,285 maximum per Member per any 24 consecutive calendar month period
Acute detoxification covered as any other medical service Not subject to 24 month maxunums
DENTAL SERVICES(including accidental injury to natural teeth)
Not covered
DEVICES,EQUIPMENT AND SUPPLIES(for home use)-
Orthopedic appliances when listed as covered in the orthopedic appliance formulary
• Durable medical equipment when listed as covered in the durable medical equipment formulary
• Prosthetic devices when listed as covered in the prosthetic device formulary
• Ostomy supplies
• Oxygen and oxygen equipment
• P ost-mastectomy bras(limited to two every 6 months)
Covered at 80%Coinsurance,
DIABETIC SUPPLIES
Insulin, needles, syringes and lancets covered under Drugs-Outpatient External msulm pumps, blood glucose
monitors and supplies covered under Devices,Equipment and Supplies
DIAGNOSTIC LABORATORY AND RADIOLOGY SERVICES
Covered in full
EMERGENCY SERVICES
• At a GH or GH Designated Facility
$75 Copayment per Emergency visit per Member Copayment is waived if Member is admitted directly from the
Emergency department
• At a non-GH Designated Facility
0036900-C21431 6
S 125 Deductible per Emergency visit per Member.Emergency care deductible is not waived sfMember is admitted
to the hospital.
HEARING EXAMINATIONS AND HEARING AIDS
Hearing examinations to determine hearing loss are covered subject to the outpatient services copayment. Hearing
aids,including hearing aid examinations,are not covered.
HOME HEALTH SERVICES
Covered in full.No visit limit
HOSPICE SERVICES
Covered in full Inpatient respite care is covered for a maximum of five(5)consecutive days per occurrence
INFERTILITY SERVICES(INCLUDING STERILITY)
Not covered.
MANIPULATIVE THERAPY
Self-referrals to a GHC Provider for manipulative therapy of the spine covered in accordance with GHC clinical
criteria up to a maximum of ten (10) visits per Member per calendar year, subject to the outpatient services
copayment Additional manipulation visits are covered when approved by GHC
MATERNITY AND PREGNANCY SERVICES
• Delivery and associated hospital care
Covered subject to applicable inpatient copayment
• Routine prenatal and postpartum care
Covered subject to the outpatient services copayment
Pregnancy termination
Involuntary/voluntmy termination of pregnancy is covered subject to applicable Copayment
MENTAL HEALTH SERVICES
• Inpatient Services
Covered up to 12 days at 80% per Member per calendar year at a GH-approved mental health care facility when
authonzed in advance by GH -
• Outpatient Services
0036900-C21431 7
Twenty(20) visits covered per Member per calendar year subject to $20 Copayment per mdividual/famdy/couple
session and$10 per Member per group session, no coverage thereafter. Medication monitoring visits are subject to
the outpatient services copayment Copayments do not apply to Stop Loss.
NATUROPATHY
Self-referrals to a GHC Provider covered up to a maximum of two (2) visits per Member per medical diagnosis
per calendar year, subject to the outpatient services copayment Additional visits are covered when approved by
GHC subject to the outpatient services copayment
NUTRITIONAL SERVICES
• PSU supplements
Covered in full
• Enteral therapy(formula)
Elemental formulas covered at 80%L Necessary equipment and supplies covered under Devices, Equipment and
Supplies.
• Parenteral therapy(total parenteral nutrition)
Covered in full. Necessary equipment and supplies covered under Devices,Equipment and Supplies.
OBESITY RELATED SERVICES
Banatnc surgery covered subject to applicable copayment Weight loss programs and medications and related
physician visits for medication monitoring are not covered
ON THE JOB INJURIES OR ILLNESSES
Not covered, including mjunes or illnesses incurred as a result of self-employment
OPTICAL SERVICES
Routine eye exammations covered subject to the outpatient services copayment,once every 12 months Contact lens
after cataract surgery covered in full when in lieu of mnaocular lens Lenses, including contact lenses, and frames
are not covered.
ORGAN TRANSPLANTS
Covered up to a $200,000 lifetime benefit maximum subject to the applicable copayment
PLASTIC &RECONSTRUCTIVE SERVICES(Plastic Surgery,Cosmetic Surgery)
0036900-C21431 8
Surgery to correct a congenital disease or anomaly, or conditions resulting from injury or incidental to surgery,
covered subject to the applicable copaymenL Cosmetic surgery,including complications,is excluded.
PODIATRIC SERVICES
• Medically Necessary foot care
Covered subject to the applicable copayment
• Foot care(routine)
Not covered except in the presence of a non-related medical condition affecting the lower limbs.
PRE-EXISTING CONDITION
Covered,after no wait
PREVENTIVE (WELL ADULT AND WELL CHILD) SERVICES (Physicals, Immunizations, Pap Smears,
Well-care,Mammograms)
Covered subject to the outpatient services copayment when in accordance with well-care guidelines. Excluded are
physicals for travel,employment, insurance, license, etc Services provided during a preventive care visit which are
not in accordance with preventive care criteria are subject to the outpatient services Copayment
REHABILITATION SERVICES
• Inpatient physical, occupational and restorative speech therapy services combined, including services for
neurodevelopmentally disabled children age six (6) and under are covered up to 60 days per condition per
calendar year.
Covered subject to the inpatient Copayment
• Outpatient physical, occupational and restorative speech therapy services combined, including services for
neurodevelopmentally disabled children age six (6) and under are covered up to 60 visits per condition per
calendar year
Covered subject to the outpatient services Copayment
SEXUAL DYSFUNCTION SERVICES
Not Covered
SKILLED NURSING FACILITY(SNF)
Covered up to thirty(30)days per condition per Member
STERILIZATION(Vasectomy,Tubal Ligation)
0036900-C21431 9
Covered subject to applicable copayments.
TEMPOROMANDIBULAR JOINT(TMJ)SERVICES
• Inpatient and outpatient TMJ services.
$1,000 maximum per Member per calendar year
• Lifetime Maximum Benefit
$5,000 per Member
TOBACCO CESSATION
• Individual/Group Sessions
Covered at 100%of the total charges
• Approvedpharmacyproducts
Covered sub3ect to the Outpatient Prescription Drug Copayment for each(30)day supply or less of a prescription or
refill when provided at GH Facilities and prescribed by a GHC Provider
0036900-C21431 10
Enrollment(Eligibility Requirements
Effective Date of Enrollment.
a Provided application for enrollment is made as ser forth in Section IXA Lb.
• Enrollment for a newly eligible Subscriber and listed Dependents is effective on the date of hue
• Enrollment for a newly dependent person,other than a newborn or adoptive child,is effective the first(1st)
of the month following application.
• Enrollment for newborns is effective from the date of birth
• Enrollment for adoptive children is effective from the date that the adoptive child is placed with the
Subscriber for the purpose of adoption and the Subscriber has assumed financial responsibility for the
medical expenses of the child
b Commencement of Benefits for Persons Hospitalized on Effective Date. Members who are admitted to an
inpatient facility prior to their enrollment under this Agreement, and who do not have coverage under another
Agreement, will receive covered benefits beginning on their effective date If a Member is hospitalized in a
non-GH Facility or non-GH Designated Facility, GHC reserves the right to require transfer of the Member
to a GH Facility or GH Designated Facility. The Member will be transferred when a GHC Provider, in
consultation with the attending physician, determines that the Member is medically stable If the Member
refuses to transfer to a GH Facility or GH Designated Facility, all further costs incurred during the
hospitalization are the responsibility of the Member
Eligibility
In order to be accepted for enrollment and continuing coverage under the Group Agreement, individuals must reside
or work in the Service Area and meet all applicable requirements set forth below, except for temporary residency
outside the Service area for purposes of attending school,court-ordered coverage for Dependents, or when approved
in advance by GHC,other unique family arrangements GHC has the right to verify eligibility
1 Subscribers Bona fide LEOFF H employees who have been continuously employed on a regularly scheduled
basis of not less than twenty(20)hours per week shall be eligible for enrollment.
Elected officials and council members shall be eligible for enrollment.
LEOFF I employees will not be covered under this plan
2 Family Dependents The Subscriber may enroll any of the following
a The Subscriber's legal spouse,
b. Unmarred dependent children who are under the age of twenty-one (21), provided they reside regularly
with the Subscriber or are chiefly dependent on the Subscriber for support and maintenance,provided proof
of such dependency is furnished to GHC
"Children" means the children of the Subscriber including adopted children, stepchildren, foster children,
children for whom the Subscriber has a qualified court order to provide coverage, and any other children
for whom the Subscriber is the legal guardian
c Enrollment may be extended past the limiting age for an unmamed person enrolled as a Family Dependent
on his/her twenty-first(21 st)birthday if
0036900-C21431 11
i the Dependent is a full-time registered student at an accredited secondary school, college, or university
and under the age of twenty-three(23),or
it the Dependent is totally incapable of self-sustaining employment because of a developmental disability
or a physical handicap incurred prior to attainment of the limiting age as set forth in 2 b. (above), or
prior to anamment of the student limiting age as set forth in 2 c (above),and is chiefly dependent upon
the Subscriber for support and maintenance Enrollment for such a Dependent may be continued for
the duration of the continuous total incapacity, provided enrollment does not terminate for any other
reason.Medical proof of mcapacity and proof of financial dependency must be furnished to the GH
upon request, but not more frequently than annually after the two (2) year period following the
Dependent's attainment of the hurting age.
d Dependents of LEOFF I employees are eligible for coverage under this agreement
e Temporary Coverage for Newborns. When a Member gives birth, the newborn will be entitled to the
benefits set forth in Section X from birth through three(3) weeks of age After three(3)weeks of age, no
benefits are available unless the newborn child qualifies as a dependent and is enrolled under this
Agreement All contract provisions, limitations,and exclusions will apply except Section IV Continuation
of Coverage,Conversion,and Transfer
Continuation of Enrollment
While on a group approved leave of absence the Subscriber and listed Dependents can continue to be covered under
this Agreement, provided they remain eligible for coverage, such leave is in compliance with the employer's
established leave of absence policy consistently applied to all employees, the employer's leave policy is in
compliance with the Family and Medical Leave Act when applicable,and the employer or Group continues to remit
premiums for the Subscriber and Dependents to the Cooperative
Ineligible Persons. GHC reserves the right to refuse enrollment to any person whose coverage under any Medical
Coverage Agreement issued by Group Health Cooperative or Group Health Options, Inc has been terminated for
cause
0036900-C21431 12
Section I. Definitions
AGREEMENT: This Medical Coverage Agreement, including the Schedule of Benefits, Enrollment/Eligibility
Requirements,Premiums Schedule, Allowances Schedule, Group Master Application and Medicare endorsements.
ALLOWANCE: The maximum amount payable by GH for certain Covered Services under this Agreement, as set
forth in the Allowances Schedule.
COINSURANCE: An amount the Member is required to pay for Covered Services received under this Agreement,
which is a percentage of the Allowance for such services,as set forth in the Allowances Schedule
COPAYMENT: The specific dollar amount required to be paid by a Member for certain Covered Services under
this Agreement as set forth in the Allowances Schedule.
COVERED SERVICES: The services for which a Member is entitled to coverage under this Agreement.
DEDUCTIBLE: A specific nuximum amount paid by a Member for certain Covered Services before benefits are
payable under this Agreement. The applicable Deductible amounts are set forth in the Allowances Schedule
EMERGENCY: The sudden,unexpected onset of a medical condition that in the reasonable judgment of a prudent
person is of such a nature that failure to render immediate care by a licensed medical provider would place the
Member's life in danger,or cause serious impairment to the Member's health
FAMILY DEPENDENT: Any member of a Subscriber's family who meets all applicable eligibility requirements,
is enrolled hereunder,and for whom the premiums prescribed in the Premiums Schedule have been paid
FAMILY UNIT: A Subscriber and all his/her Family Dependents
FEE SCHEDULE A fee-for-service schedule adopted by GHC, setting forth the fees for medical and hospital
services
GH DESIGNATED FACILITY: A facility, not including a GH Facility, which GHC has specified to provide
health care services to its Members Designated Facilities may be changed by GH upon appropriate nonce
GH DESIGNATED SELF-REFERRAL SPECIALISTS: A designated self-referral specialist is a GHC specialist
specifically identified in the Accessing Care section of this Agreement
GH FACILITY: A hospital or medical center owned and operated by Group Health Cooperative
GH PRIMARY CARE PROVIDER: A provider(also referred to as "PCP"or 'primary care provider") who is
employed by or contracted with or GHC to provide primary care services to Members and is selected by each
Member to provide or arrange for the provision of all non-emergent Covered Services, except for services set forth
in this Agreement which a Member can access without referral Primary Care Providers must be capable of and
licensed to provide the majority of primary health care services mquued by each Member
GH MEDICARE PLAN: A plan of coverage for persons enrolled in Medicare Part A(hospital insurance)and Part
B (medical insurance)
GHC PROVIDER: The Medical Staff,Clinic Associate Staff, and allied health professionals employed by GHC
and any other health care professional or provider with whom GHC has contracted to provide health care services to
persons enrolled under this Agreement, and who at such time is providing services which have been authorized in
advance by GHC,including,but not limited to,podiatrists,nurses,physician assistants,social workers,optometrists,
psychologists, physical therapists and other professionals engaged in the delivery of healthcare services who are
licensed or certified to practice in accordance with Title 18 RCW
0036900-C21431 13
GROUP: An employer, union, welfare trust, or bona-fide association which has entered into a Group Medical
Coverage Agreement with GHC
HOSPITAL CARE: Those Medically Necessary services generally provided by acute general hospitals for
admitted patients Hospital care does not include convalescent or custodial care which can, in the opinion of the
GHC Provider,be provided by a nursing home or convalescent care center
MEDICAL CONDITION A medical condition is a disease,an illness or an injury
MEDICALLY NECESSARY: Appropriate and necessary services, as determined by the GHC's Medical Director,
or hisfher designee, according to generally accepted principles of good medical practice, which are rendered to a
Member for the diagnosis, care or treatment a Medical Condition Services must be medically and clinically
necessary for benefits to be provided under this Agreement The cost of services and supplies which are not
Medically Necessary shall be the responsibility of the Member In order to be Medically Necessary, servces and
supplies must meet the following requirements (a)are not solely for the convenience of the patient,his/her family,
or the provider of the services or supplies, (b)are the most appropriate level of service or supply which can be safely
provided to the patient,(c)are for the diagnosis or treatment of an actual or existing Medical Condition unless being
provided under GH's schedule for preventive services, (d) are not for recreational life-enhancing relaxation or
palliative therapy (except for treatment of terminal conditions), (e) are not primarily for research and data
accumulation, (f) are appropriate and consistent with the diagnosis and which, in accordance with accepted medical
standards in the State of Washington, could not have been omitted without adversely affecting the patent's
condition or the quality of health services rendered, (g) as to inpatient care, could not have been provided in a
provider's office, the outpatient department of a hospital, or a non-residential facility without affecting the patient's
condition or quality of health services rendered,and(h)are not experimental or investigational The length and type
of the treatment program and the frequency and modality of visits covered shall be determined by the GHC Medical
Director,or his/her designee
MEDICARE: The federal health insurance program for the aged and disabled.
iMEMBER: Any Subscriber or Family Dependent covered by this Agreement.
OPEN ENROLLMENT: An annual period, specified by the Group and GHC, during which an eligible person
may apply for coverage
OUT-OF-POCKET LIMIT(STOP LOSS): The maximum amount of Copayments, and expenses incurred and
paid, during the calendar year for Covered Services received by the Subscriber and his/her Family Dependents
within the same calendar year. The Out-of-pocket Limit amount is set forth in the Allowances Schedule.
Services in excess of any benefit level, and services not covered by this Agreement are not applied to the Out-of-
Pocket Limit
PRE-EXISTING CONDITION: A condition for which there has been diagnosis, treatment(including ptescn-bed
drugs), or medical advice within the three(3)month period prior to the effective date of coverage The Pre-existing
Condition wait period will begin on the first day of coverage, or the first day of the enrollment waiting period if
earlier
REFERRAL: A written temporary referral agreement requested in advance by a GHC Provider and approved by
GHC, which entitles a Member to receive Covered Services from a specified health care provider Entitlement to
such Services shall not exceed the limits of the Referral and is subject to all terms and conditions of the Referral and
this Agreement Members who have a complex or serious medical or psychiatric condition may receive a standing
Referral for specialist services
SERVICE AREA: Western Washington Counties of Island,King, Kitsap,Lewis, Mason, Pierce,San Juan,Skagit,
Snohomish, Thurston, and Whatcom, Eastern Washington Counties of Benton, Columbia, Franklin, Kimtas,
Spokane,Walla Walla,Whitman,and Yakima counties,Idaho Counties of Kootenai and Latah,and any otber areas
designated by GH.
0036900-C21431 14
SKILLED HOME HEALTH CARE: Reasonable and necessary care for the treatment of an illness or injury
which requires the skill of a nurse or therapist, based on the complexity of the service and the condition of the
patient, and which is performed directly by an appropriately licensed professional provider
STOP LOSS:See Out-of-Pocket Limit
SUBSCRIBER: A person employed by or belonging to the Group who meets all applicable eligibility
requirements, is enrolled hereunder, and for whom the premiums specified in the Premiums Schedule have been
paid.
URGENT CONDITION: The sudden, unexpected onset of a medical condition that is of sufficient seventy to
require medical treatment within twenty-four(24)hours of its onset
USUAL, CUSTOMARY, AND REASONABLE (UCR): A term used to define the level of benefits which are
payable by GHC when expenses are incurred from a non-GH Provider. Expenses are considered Usual,Customary,
and Reasonable if(1) the charges are consistent with those normally charged by the provider or organization for the
same services or supplies,and(2)the charges are within the general range of charges made by other providers in the
same geographical area for the same service or supplies.
Section H. Premiums, Fees, and Cooavments
A. MONTHLY PREMIUMS PAYMENTS. The Group shall submit to GHC for each Member the monthly
premiums set forth in the current Premiums Schedule and a verification of enrollment,on or before the due date,
subject to a grace period of ten (10) days Premiums are subject to change by GHC upon thirty(30) days
written notice
In the event the group increases enrollment at least twenty-five percent (25%) or more through acquisition or
merger,GHC reserves the right to require re-rating of the group
B. COPAYMENTS AND COINSURANCE.
1. Copayments At the t= of service, Members shall be required to pay Copayments as set forth in the
Allowances Schedule.
Payment of a Copayment does not exclude the possibility of an additional billing if the service is
determined to be a non-Covered Service
Total out-of-pocket expenses incurred during the same calendar year shall not exceed the aggregate
maximum amount (Stop Loss) as set forth in the Allowances Schedule Those out-of-pocket categories
which apply toward the aggregate maximum amount are set forth in the Allowances Schedule
2. Coinsurance. Members shall be required to pay Coinsurance for certain Covered Services as set forth in
the Allowances Schedule
C. SUBSCRIBER'S LIABILITY. The Subscriber is liable for(1) payment to the Group of his/her contribution
toward the monthly premiums, if any, (2) payment of Copayments and/or Coinsurance amounts for Covered
Services provided to the Subscriber and his/het Family Dependents, as set forth in the Allowances Schedule;
and (3) payment of any fees charged for non-Covered Services provided to the Subscriber and his/her Family
Dependents,at the time of service
Payment of an amount billed by GHC must be received within thirty(30)days of the billing date
D. SELF-PAYMENTS DURING A STRIKE,LOCK-OUT,OR OTHER LABOR DISPUTE.In the event of
suspension or termination of employee corripensation due to a strike, lock-out, or other labor dispute, a
Subscriber may continue uninterrupted coverage under this Agreement through payment of monthly premiums
0036900-C21431 15
directly to the Group Coverage may be continued for the lesser of the term of the strike,lock-out,or other labor
dispute,or for six(6)months after the cessation of work.
If the Group Agreement is no longer available,the Subscriber shall have the opportunity to apply for individual
Group Conversion or, if applicable, continuation coverage (see Section IV), or an Individual and Family
Medical Coverage Agreement at the duly approved rates.
THE GROUP IS RESPONSIBLE FOR IMMEDIATELY NOTIFYING EACH AFFECTED SUBSCRIBER OF
HISMER RIGHTS OF SELF-PAYMENT UNDER THIS PROVISION
Section II1. Termination
A. TERMINATION OF ENTIRE AGREEMENT. This Agreement may be terminated in the following
circumstances
1. Termination on Notice. This is a guaranteed renewable contract and cannot be terminated without the
mutual approval of each of the parties except as set forth below(subsection 2 and 3)
2. Nonpayment.Failure to make any monthly premiums payment or comnbution in accordance with Section
H A shall result in termination of tlus Agreement as of the due date
3. Misrepresentation to Obtain Insurance. Group Health Cooperative may terminate this Agreement upon
written nonce in the event of material misrepresentation, fraud, or omission of information in order to
obtain Group Coverage
4 The Group may terminate this Agreement by giving thirty(30)days written notice to GHC
5. May terminate or non-renew in the event the Group no longer meets underwriting guidelines established
by GHC in effect at the time the Group was accepted
6. Withdrawal or Cessation of Services.
a GHC may determine to withdraw from a service area or from a segment of its service area after GHC has
demonstrated to the Office of the Insurance Commissioner that GHC's clinical, fitianctal, or
administrative capacity to service the covered members would be exceeded.
b GHC may determine to cease to offer the plan and replace the plan with another plan offered to all
covered persons within that line of business that includes all of the health care services covered under the
replaced plan and does not significantly Imut access to the services covered under the replaced plan
GHC may also allow unrestricted conversion to a fully comparable product
GHC will provide written notice to each covered person of the discontinuation or nonrenewal of the plan at
least 90 days prior to discontinuation.
B. TERMINATION OF SPECIFIC MEMBERS. This Agreement may be terminated as to a specific Member
for any of the following reasons
1. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in the
Enrollment/Eligibility Requirements, and is not enrolled for continuation coverage as described in Section
IV.A, coverage under this Agreement will terminate at the end of the month during which loss of
eligibility occurs, unless otherwise specified by the Group as set forth in the Enrollment/ Eligibility
Requirements
2. For Cause.Coverage of a Member may be termnated upon written notice for:
a Material Msrepresentation, fraud, or omission of information in order to obtain coverage This
includes failure to answer fully and correctly all questions contained in the application forms In such
0036900-C21431 16
event,the Cooperative may, within two (2)years from the date of the application, refuse to cover any
service for a condition(s) to which such question was relevant, or may nonrenew or cancel the
Members coverage upon ten(10)working days written notice.
b Permitting the use of a GHC identification card by another person, or using another person's
identification card to obtain care to which one is not entitled.
c Nonpayment of charges as set forth in Section II C
3 Nonpayment of premiums or contnbution for a specific Member by the Group.
4 In no event will a Member be terminated solely on the basis of their physical or mental condition provided
they meet all other eligibility requirements set forth in this Agreement.
5 The Member may appeal the termination decision through GHC's grievance process as set forth in Section
VII
C. PERSONS HOSPITALIZED ON THE DATE OF TERMINATION. A Member who is receiving Covered
Services as a registered bed patient in a GH Facility or GH Designated Facility on the date of termnation shall
continue to be eligible for Covered Services while an inpatient for the condition for which the Member was
hospitalized,until the first ofthefollowing events occur:
• The Member no longer meets medical criteria to be an inpatient at the facility;
• The remaining benefits available under this Agreement for the confinement are exhausted, regardless of
whether a new calendar year begins;
• The Member becomes covered under another Agreement with the group health plan that provides
benefits for the confinement
• The Member becomes enrolled under an Agreement with another carrier that would provide benefus for
this confinement if this Agreement dud not exist
• Medicare eligibility.
This provision will not apply if the Member is covered under an Agreement that provides benefas for the
confinement at the time coverage would terminate except as set forth in this section, or if the Member is
eligible for COBRA continuation coverage as set forth in Section IV
This continued coverage will also apply to a Member hospitalized in a non-GH Designated Facility as a result
of an Emergency or Referral.
D. SERVICES PROVIDED AFTER TERMINATION. Any services provided by GHC after the effective date
of termination (except those services covered under Section III C.) shall be charged according to the Fee
Schedule The Subscriber shall be liable for payment of all such charges for services provided to the Subscriber
and all Farmly Dependents
Unless the Group has chosen to accept this responsibility, a certificate of creditable coverage(which provides
information regarding the Member's length of coverage under this Agreement) will be issued automatically
upon termination of coverage,and may also be obtained upon request
Section IV. Continuation Coverne, Conversion, and Transfer
A. CONTINUATION COVERAGE UNDER FEDERAL LAW.
This subsection A only applies to employer groups who must offer continuation coverage under the applicable
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"),as amended,and only
applies to grant continuation of coverage rights to the extent required by federal law Upon loss of eligibility,
continuation of Group coverage may be available to a Member for a limited time after the Member would
0036900-C21431 17
otherwise-lose eligibility, if required by the federal Consolidated Omnibus Budget Reconciliation Act of 1985
and amendments thereto (collectively "COBRA") The Group shall inform Members of the COBRA election
process and how much the Member will be required to pay directly to the Group.
B. GHC GROUP CONVERSION PLAN.
1. Eligibility.Any Subscriber or Family Dependent not entitled to Medicare may convert to GHCs Group
Conversion Plan if his/her coverage under this Agreement is terminated for any reason other than cause
(See Section III B 2)Following termination of marriage or death of the Subscriber,all Family Dependents
are entitled to make such a conversion.
2. Application. Application for conversion must be made within thirty-one (31) days following termination
under this Agreement. Coverage under the GHC Group Conversion Plan is subject to all terms and
conditions of such plan, including premiums payment A physical examination or statement of health is not
required for enrollment in the Group Conversion Plan. The Pre-existing Condition limitation under the
Group Conversion Plan will apply only to the extent that the ]imitation remains unfulfilled under this
Agreement
By exercising Group Conversion rights, the Member may waive guaranteed issue and Pre-existing condition
waiver rights under Federal regulations
Persons wishing to purchase Group Health Individual and Family coverage should contact GH Marketing
C. CONTINUATION OPTION.A Member no longer eligible for coverage under this Agreement(except in the
event of termination for cause) may continue coverage for a period of up to three (3) months subject to
notification to and self-payment of premium to the Group. This provision will not apply if the Member is
eligible for the continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of
1985(COBRA).
Section V. Coordination of Benefits
A. BENEFITS SUBJECT TO THIS PROVISION: As described in subsection H, benefits provided under this
Agreement are subject to this provision
B. PLAN: The definition of a"Plan"includes the following sources of benefits or services
1. Individual, group or blanket disability insurance policies and health care service contractor and health
maintenance organization group or individual agreements, issued by insurers, health care service
contractors and health maintenance organizations,
2 Labor-management trusteed plans, labor organization plans, employer organisation plans or employee
benefit organization plans,
3 Governmental programs,and
4 Coverage required or provided by any statute
The term'Plan" shall be construed separately with respect to each policy, agreement or other arrangement
for benefits or services,and separately with respect to the respective portions of any such policy,agreement
or other arrangement which do and which do not reserve the right to take the benefits or services of other
policies,agreements or other arrangements into consideration in determining benefits
C. ALLOWABLE EXPENSE: "Allowable Expense" means any necessary, reasonable and customary items of
expense at least a portion of which is covered under at least one of the Plans covering the person for whom the
claim is made When a Plan provides benefits in the form of services rather thart cash payments, the reasonable
cash value of each service rendered shall be considered an Allowable Expense
0036%0-C21431 18
D. CLAIM DETERMINATION PERIOD: "Claim Determination Period" means a period beginning with any
January I and ending with the next following December 31 except that the first Claim Determination Period
with respect to any person shall begin on the effective date of coverage under this Agreement with respect to
such person and end on the following December 31. In no event will a Claim Determination Period for any
person extend beyond the last day on which such a person is covered under this Agreement
E. RIGHT TO RECEIVE AND RELEASE INFORMATION:For the purpose of determining the applicability
of and implementing this provision and any provision of similar purpose in any other Plan, the Cooperative
may, with such consent as may be necessary,release to or obtain from any other insurer,organization or person
any information,with respect to any person which the insurer considers necessary for such purpose Any person
claiming benefits under this Agreement shall furnish to the Cooperative the information necessary for such
purpose
F. FACILITY OF PAYMENT: Whenever coverage which should have been provided under this Agreement in
accordance with this provision has been provided or paid for under any other Plan, the Cooperative shall have
the right, exercisable alone and in its sole discretion, to pay over to any Plan malung such other payments any
amounts it shall determine to be warranted in order to satisfy the intent of this provision, and amounts so paid
shall be considered to be coverage or benefits paid under this Agreement and, to the extent of such payments,
the Cooperative shall be fully discharged from Inability under this Agreement
G. RIGHT OF RECOVERY: Whenever benefits have been provided by the Cooperative with respect to
Allowable Expenses in total amount, at any time, in excess of the maximum amount of payment necessary at
that time to satisfy the intent of this provision, the Cooperative shall have the right to recover the reasonable
cash value of such benefits,to the extent of such excess,from one or more of the following,as the Cooperative
shall determine any persons to or for or with respect to whom such benefits were provided,any other insurers,
any service plans or any other organization or other Plans
H. EFFECT ON BENEFITS:
1. This provision shall apply in determining the benefits for a person covered under this Agreement for a
particular Claim Determination Period if, for the Allowable Expenses incurred as to such person during
such period,the sum of
a. The reasonable cash value of the benefits that would be provided under the Agreement in the absence
of this provision, and
b The benefits that would be payable under all other Plans in the absence therein or provisions of similar
purpose to this provision would exceed such Allowable Expenses
2 As to any Claim Determination Period with respect to which this provision is applicable, the reasonable
cash value of the benefits provided under thus Agreement in the absence of this provision for the Allowable
Expenses incurred as to such person during such Claim Determination Period shall be reduced to the extent
necessary so that the sum of the reasonable cash value of benefits and all benefits payable for such
Allowable Expenses under all other Plans,except as provided in subparagraph(3)of this Section,shall not
exceed the total of such Allowable Expenses. Benefits payable under another Plan include benefits that
would have been payable had a claim been duly made therefor In determining liability under this
paragraph,the Plan is not required,and will not take into consideration, deductibles, copayments,or other
cost-sharing provisions
3 If
a another Plan which is involved in subparagraph (2) of this Section and which contains a provision
coordinating its benefits with those of this Agreement would, according to its rules, determine its
benefits after the benefits of this Plan have been deterund,and
0036900-C21431 19
b the rules set forth in subparagraph(4) of this Secuon would require tlus Agreement to determine its
benefits before such other Plan,then the benefits of such other Plan will be ignored for the purposes of
determining the benefits under this Agreement.
4. For the purposes of subparagraph (3) of this Section, the rules establishing the order of benefit
determination are
a. The benefits of a Plan which covers the person on whose expenses a claim is based other than as a
dependent shall be determined before the benefits of a Plan which covers such person as a dependent.
b In the case that a dependent is covered under both parents'medical Plan,the benefits of the Plan of the
parent whose birthday falls earlier in the year are determined before those of the Plan of a parent
whose birthday falls later in the year.This buthdate will refer only to the month and day,not the year
in which a person was bom. If both parents have the same birthday, the benefits of the Plan which
covered the parent longer are determined before those that covered the other parent for a shorter period
of tune, except that in the case of a person for whom claim is made as a dependent child,
i. when the parents are separated or divorced and the parent with custody of the child has not
remained, the benefits of a Plan which covers the child as a dependent of the parent with custody
of the child will be determined before the benefits of a Plan which covers the child as a dependent
of the parent without custody,and
n when the parents are divorced and the parent with custody of the child has remarried, the benefits
of a Plan winch covers the child as a dependent of the parent with custody shall be determined
before the benefits of a Plan which covers that child as a dependent of the stepparent, and the
benefits of a Plan which covers that child as a dependent of the stepparent will be determined
before the benefits of a Plan which covers that child as a dependent of the parent without custody
Notwithstanding items (i) and (it) above, if there is a court decree which would otherwise establish
financial responsibility for the medical, dental or other health care expenses with respect to the child,
the benefits of a Plan which covers the child as a dependent of the parent with such financial
responsibility shall be determined before the benefits of any other Plan which covers the child as a
dependent child
c When rules (a) and(b)do not establish an order of benefit determination, the benefits of a Plan which
has covered the person on whose expenses claim is based for the longer period of time shall be
determined before the benefits of a Plan which has covered such person the shorter period of time,
provided that
I The benefits of a Plan covering the person on whose expenses claim is based as a laid off or
retired employee, or dependent of such person shall be determined after the benefits of any other
Plan covering such person as an employee,other than a lard off or retired employee,or dependent
of such person,and
it If either Plan does not have a provision regarding laid off or retired employees, which results in
each Plan determining its benefits after the other,then the provisions of(i) of this subsection shall
not apply.
d. If none of the above rules determines the order of benefits, the benefits of the Plan which covered an
employee or Subscriber for the longer period of time shall be determined before those of the Plan
which covered that person for the shorter time period
5 When this provision operates to reduce the total amount of benefits otherwise to be provided to a person
covered under this Agreement during any Claim Determination Period, the reasonable cash value of each
benefit that would be provided in the absence of this provision shall be reduced proportionately,and such
reduced amount shall be charged against any applicable benefit limit of this Agreement
0036900-C21431 20
I. EFFECT OF MEDICARE (for those Members residing outside the Group Health Medicare+Choice service
area)-
For GHC Members eligible for Medicare, Medicare secondary payor guidelines and regulations will
determine who is primary.
When Group Health renders care to a GHC Member who is eligible for Medicare benefits, and Medicare is
deemed to be the primary bill payor under Medicare secondary payor guidelines and regulations,GHC will seek
Medicare reimbursement for all Medicare covered services.
Section Vl. Subro¢ation and Reimbursement Rights
"Injured person" tinder this section means a Member covered by this Agreement who sustains compensable injury
and any spouse, dependent, or other person or entity that may recover on behalf of such Member including the
estate of the Member and, if the Member is a minor, the guardian or parent of the Member. "GHCs medical
expenses" means the expense incurred and the reasonable value of the services provided by GHC for the care or
treatment of the injury sustained
If the injured person's injuries were caused by a thud party givmg rise to a claim of legal liability against the thud
parry, GHC shall have the tight to recover GHCs medical expenses from any source available to the injured
person as a result of the events causing the injury,including but not limited to funds available through applicable
third party liabdity coverage and uninsured/underinsured motorist coverage This right is commonly referred to as
"subrogation." GHC shall be subrogated to and may enforce all tights of the injured person to the extent of GHC's
medical expenses.
If the injured person who receives GHC's medical expenses is entitled to receive money from any source as a
result of the events causing the injury, including but not limited to any parry's liability insurance or .
uninsured/underinsured motorist proceeds, then GHC's medical expenses provided or to be provided to the
injured person are secondary, not primary, and will be paid only if the injured person fully cooperates with the
terms and conditions of this Agreement As a condition of receiving benefits under this Agreement' the injured
person agrees that acceptance of GHC services is constructive notice of this provision in its entirety and agrees to
reimburse GHC for the benefits the injured person received as a result of the events causing the injury. GHC's
subrogation and reimbursement rights shall be limited to the excess of the amount required to fully compensate
the injured person for the loss sustained, including general damages. Full compensation shall be measured on
an objective case by case basis unless the injured person settles with the at fault parry prior to trial for less than
available policy limits in which case full compensation shall be the amount of the settlement
The injured person and his or her agents must cooperate fully with GHC in its efforts to collect GHCs medical
expenses. This cooperation shall include supplying GHC with information about any defendants and/or insurers
related to the injured person's claim.The injured person and his or her agents shall permit GHC,at GHCs option,to
associate with the injured party or to intervene in any action filed If the injured person takes no action to recover
money from any source, then the injured person agrees to allow GHC to initiate its own direct action for
reimbursement or subrogation.
The injured person and his or her agents shall do nothing to prejudice GHC's subrogation and reimbursement
rights. The injured person shall promptly notify GHC of a tentative settlement and shall not settle a claim
without protecting GHC's interest If the Member fails to cooperate fully with GHC in recovery of medical
expenses as described above,the Member shall be responsible for reimbursing GHCfor such medical expenses.
To the extent that the injured person recovers from any available source, the injured person agrees to hold such
monies in trust or in theirpossession until GHC's subrogation and reimbursement rights are fully determined
GHC shall not pay any attorneys fees or collection costs to attorneys representing the-injured person unless there is
a written fee agreement signed by GHC prior to any collection efforts When reasonable collection costs have been
incurred with GHC's prior written agreement, to recover GHCs medical expenses, there shall be an equitable
0036900-C21431 21
apportionment of such collection costs between GHC and the injured person subject to a maximum responsibility of
GHC equal to one-third of the amount recovered on behalf of GHC Under no circumstance will GHC pay legal
fees for services which were not reasonably and necessarily incurred to secure recovery and/or which do not
benefit GHC
If it becomes necessary for GHC to enforce the provision of this section by initiating any action against the
injured person or his or her agent, then the injured person agrees to pay GHC's attorney's fees and costs
associated with the action.
Implementation of this section shall be deemed a part of claims administration under this Agreement and GHC
shall therefore have sole discretion to interpret its terms.
Section VII. Grievance Procedures for Complaints& Appeals
A grievance is a complaint or appeal as set forth below.
Filing a Complaint or Appeal
The complaint process is available for a Member to express dissatisfaction about customer service or the quality or
availabihty of a health service
The appeal process is available for a Member to seek reconsideration of a denial of benefits
Complaint Handling
Step 1 The Member should contact the person involved, explain his or her concerns and what he or she would like
to have done to resolve the problem The Member should be specific and make his or her position clear
Step 2 If the Member is not satisfied, or if he or she prefers not to talk with the person involved, the Member
should call the department head or the manager of the medical center or department where he or she is having a
problem. That person will investigate the Member's concerns Most concerns can be resolved in this way
However, of the Member is still dissatisfied,they should call the Customer Service Center
Step 3 Most concerns are handled by phone within a few days. In sorne cases the Member will be asked to write
down his or her concerns and to state what he or she thinks would be a fair resolution to the problem A customer
service representative or service quality coordinator will investigate the Member's concern by consulting with
involved staff and their supervisors,and reviewing pertinent records, relevant plan policies and the Member Rights
and Responsibilities statement. This type of complaint can take up to 30 days to resolve after receipt of your written
statement.
If the Member is dissatisfied with the resolution of the complaint, he or she may contact the service quality
coordinator or the Customer Service Center to appeal A decision regarding the appeal will be made within 30 days
and written notice of the decision will be provided to the Member
Appeals Process
Step 1: If the Member wishes to appeal a decision, he or she must submit a request for appeal either orally or in
writing within 180 days of the denial notice he or she received. The Member must specify why he or she disagrees
with the decision. GH will notify the Member of its determination or request the Member's written permission for an
extension of time within 30 days of receipt of the request for appeal
If the Member is located west of the of the Cascade mountains, to GH's Appeals Department, PO Box 3493, Seattle
WA 98124-1593, (206) 901-7359 (toll free 1-888-9014636), or if the Member is located east of the Cascade
mountains, to GH's Appeals Department, P O Box 204, Spokane, WA 99224-0204;(509) 838-9100 (toll free I-
800-497-2210).
0036900-C21431 22
If the appeal request is for an experimental or investigational exclusion or limitation,GH will make a detemunation •
and notify the Member in writing within 20 working days of receipt of a fully documented request. In the event that
additional time is required to make a determination, GH will notify the Member in writing that an extension in the
review nmeframe is necessary Under no circumstances will the review umeframe exceed 20 days without the
Member's written percussion.
There is an expedited appeals process in place for cases which meet criteria or where the Member's doctor states
clinical urgency exists If a delay would jeopardize the Member's life, or materially jeopardize the Member's
health, the Member can request an expedited appeal in writing to the above address, or by calling GH's Appeals
Department in western Washington at(206) 901-7359(toll free 1-888-9014600)or in eastern Washington at 1-509-
838-9100 (toll free 1-800497-2210)and ask to be connected with the Appeals Department The Member's request
for an expedited appeal will be processed and a decision issued no later than seventy-two hours after receipt
If GH fails to grant or reject the Member's request within the applicable required mneframe, the Member may
proceed as if the appeal had been rejected.
Step 2 If the Member is not satisfied with the decision reached by the appeals coordinator regarding a denial of
benefits, he or she may request a hearing by the appeals committee by submitting the appeal within 30 days of the
date of the decision letter if the Member is located west of the Cascade mountains,to GH's Appeals Department,
PO Box 34593, Seattle WA 98124-1593, or if the Member is located east of the Cascade mountains to GH's
Appeals Department,PO Box 204,Spokane, WA 99224-0204.'
The appeals committee is the final review authority within GH Its decisions are final Members are encouraged to
present their case to the appeals committee in person The hearing and written notification to the Member of the
appeals committee decision,will be made within thirty working days of the Member's request
Step 3 If the Member is not satisfied with the committee's decision, or if GH exceeds the timeframes stated in Step
I and 1 above without good cause and without reaching a decision, his or her final level of appeal is available
through an independent review organization An independent review organization is not legally affiliated or
controlled by GH.*
'If the member's health plan is governed by ERISA (most employment related health plans, other than those
sponsored by governmental entities or churches— ask your employer about your plan), the Member has the right to
file a lawsuit under section 502(a)of ERISA to recover benefits due to the Member under the plan at any point after
completion of step 1 of the appeals process Members may have other legal rights and remedies available under
state or federal law.
Section VHL Miscellaneous Provisions
A. DISSEMINATION OF INFORMATION. The Group is responsible for disseminating to Subscribers written
information concerning this Agreement which is provided by the Cooperative
B. IDENTIFICATION CARDS. The Cooperative will furnish cards, for identification only, to all persons
enrolled under this Agreement
C. ADMINISTRATION OF AGREEMENT.GHC may adopt reasonable policies and procedures to help in the
administration of this Agreement. Group Health Cooperative reserves the right to construe the provisions of this
Medical Coverage Agreement, and to determine any and all questions pertaining to benefit entitlement and
coverage
D. MODIFICATION OF AGREEMENT. Except as required by Washington state law,this Agreement may not
be modified without agreement between both parties
No oral statement of any person shall modify or otherwise affect the benefits, limitations, and exclusions of this
Agreement, convey or void any coverage, increase or reduce any benefits under this Agreement or be used in
the prosecution or defense of a claim under this Agreement
0036900-C21431 23
E. INDEMNIFICATION. GHC agrees to indemnify and hold the Group harmless against all claims,damages,
losses, and expenses, including reasonable attorney's fees, arising out of GHC's failure to perform or negligent
performances of its express obligations under the Group Medical Coverage Agreement
Group agrees to indemnify and hold GHC harmless against all claims, damages, losses, and expenses,
including reasonable attorney's fees,arising out of Group's failure to perform or negligent performances of
its express obligations under the Group Medical Coverage Agreement.
F. COMPLIANCE WITH LAW Group and GHC shall comply with all applicable state and federal laws and
regulations in performance of this Agreement
The Medical Coverage Agreement is entered into and governed by the laws of Washington State, except as
otherwise pre-empted by ERISA and other Federal laws
G. GOVERNMENTAL APPROVAL CLAUSE.If GHC has not received any necessary government approval
by the date when notice is required under this Agreement, GHC will notify Group of any changes once
governmental approval has been received, GHC may amend this Agreement by giving notice to group upon
receipt of government approved rates,benefits, limitations, exclusions, or other provisions, in which case such
rates, benefits, limitations, exclusions, or provisions will go into effect required by the governmental agency
All amendments are deemed accepted by group unless group gives GHC written notice of non-acceptance
within 30 days after receipt of the amendment, in which event this Agreement and all tights to services and
other benefits terminate the first of the month following 30 days after receipt of nonacceptance.
H. CONFIDENTIALITY.Each party acknowledges that performance of its obligations under this Agreement
may involve access to and disclosure of data,procedures,materials,lists,systems and information,including
medical records, employee benefits mformanon, employee addresses, social security numbers, e-mail
addresses,phone numbers and other confidential information regarding Group's employees(collectively the
Information",� The Information shall be kept strictly confidential and shall not be disclosed to any third
parry other than- (i) representatives of the receiving party(as permitted by applicable state and federal law)
who have a need to know such Information in order to perform the services to be performed by such party
pursuant to this Agreement, or for the proper management and administration of the receiving party,
provided that such representatives are informed of the confidentiality provisions of this Agreement and agree
to abide by them;(ii)pursuant to court order,or(iii)to a designated public official or agency pursuant to the
requirements of federal, state or local law, statute, rule or regulation. The disclosing party will provide the
other party with prompt notice of any request that the disclosing party disclose Information pursuant to
applicable legal requirements, so that the other party may object to the request and/or seek an appropriate
protective order. Each party shag maintain the confidentiality of medical records and confidential patient
and employee Information as required by applicable law.
I. NONDISCRIMINATION. Group Health Cooperative does not discriminate on the basis of physical or
mental handicaps in its employment practices and services.
J. ARBITRATION. Any dispute, controversy or difference between GHC and Group arising out of or relating
to this Agreement, or the breach thereof, shall be settled by arbitration in accordance with the Commercial
Arbitration Rules of the American Arbitration Association, and judgment on the award rendered by the
arbitrator(s) may be entered in any court having jurisdiction thereof. The place of arbitration shall be
Seattle, Washington. Except as may be required by law, neither party nor an arbitrator may disclose the
existence,conten4 or results of any arbitration hereunder without the prior written consent of both parties.
K. RIPAA TRANSACTIONS.
Transactions Accepted GHC win accept Standard Transactions, pursuant to HIPAA, if Group elects to
transmit such transactions. If Group sends transactions to GHC that do not comply with applicable HIPAA
standards, Group will be deemed by such action to be representing and warranting Mat it is not a Covered
Entity or otherwise required to comply with HIPAA standards for electronic transactions, either directly, or
0036900-C21431 24
as an agent of another individual or entity. The parties agree that all the terms, conditions, representations
and warranties contained in this section are express obligations of Group, and Group shall indemnify GHC
for any breach of this Section as specified in Section VU1.
Definition of Terms. Terms used,but not otherwise defined,in this Section shall have the same meaning as
those terms have in the Health Insurance Portability and Accountability Act of 1996("HIPAA").
Section IX.Enrollment Schedule
A. ENROLLMENT
1. Application for Enrollment. Application for enrollment shall be made on an application form furnished
and approved by GHC.No person shall be enrolled or premiums accepted until this completed application
has been received and approved by GHC. The Group is responsible for subtmtang completed application
formes to GHC.
a. Special Enrollment Periods.
i. Loss of Coverage GHC will allow special enrollment periods for persons who (a) initially
declined enrollment when newly eligible because such persons had another health care plan
available through Group or other insurance coverage and have had such other coverage
terminated due to cessation of employer contributions, exhaustion of COBRA continuation
coverage or loss of eligibility except for loss of eligibility for cause(GHC or Group may require
that when initially offered coverage such persons submitted a written statement declining because
of other coverage).Application must be made within thirty-one (31) days of the termination of
previous coverage or acquisition of a new dependent
A New Dependents. In the event a Subscriber or person eligible to be a Subscriber acquires a
person eligible to be a Family Dependent by birth, marriage, adoption or placement for adoption,
GHC will allow special enrollment periods for the person eligible to be a Subscriber, his or her
spouse and the newly-acquired Family Dependent Application must be made within thirty-one
(31) days of acquisition of the new Family Dependen; except that sixty(60) days is permitted to
enroll newborn and adopted children as described below.
b. Newly Eligible Persons. Newly eligible Subscribers may make written application for enrollment to
the Group within thirty-one (31) days of eligibility If the Subscriber wishes to enroll his/her eligible
Dependents,application mist be made during this same thirty-one(31)day penod.
Written application for enrollment for a newly dependent person, other than a newborn or newbom
adopted child, must be made to the Group within flurry-one (31)days after the dependency occurs and
will be subject to the Pre-existing Condition exclusion set forth in Section XI A.
In the event there is a change in the monthly premiums payment as a result of the addition of a
newborn child,the Subscriber must make written application for enrollment to the Group within sixty
(60)days following the date of birth.
In the event there is a change in the monthly prermums payment as a result of the addition of an
adoptive child, including adopted newborns, the Subscriber roust make written application for
enrollment within sixty (60) days from the day that the child is placed with the Subscriber for the
purpose of adoption and the Subscriber assumes financial responsibility for the medical expenses of
the child.
When there is me change in the monthly premium payment, it is strongly advised that you enroll
your newborn or newly adoptive child, including adopted newborns, as a dependent with your
employer to avoid delays in payment of claims.
0036900-C21431 25
c Open Enrollment. A person not enrolled as a Subscriber or Family Dependent when newly eligible,
as described above,may make written application during the Group's Open Enrollment period
2. Limitation on Enrollment This Agreement will be open for application as set forth in Section IX A 1.
Subject to prior approval by the Office of the Insurance Commissioner, GHC may limit enrollment,
establish quotas, or set priorities for acceptance of new applications if it determmes that its capacity, in
relation to its total enrollment,is not adequate to provide services to additional persons
B. PERSONS ENTITLED TO,OR ELIGIBLE TO PURCHASE MEDICARE.
For purposes of thus section,an individual shall be deemed eligible for Medicare when he or she has the option
to receive Part A Medicare benefits, urespective of whether the individual elects to enroll in Part B coverage
under the federal regulations
Under the Tax Equity and Fiscal Responsibility Act of 1982(TEFRA),actively employed Subscribers and their
spouses who are eligible for Medicare benefits must decide whether to choose the benefits of this Agreement or
the Medicare program as the primary source of health care coverage.The Group is responsible for providing the
Subscriber with necessary information regarding TEFRA eligibility and the selection process
Persons Residine Inside the Medicare+Choice Service Area. Except as defined by federal regulations (m e,
TEFRA), all Members who are eligible to purchase Medicare must enroll in both Medicare Parts A and B and
transfer to the GHC Medicare Plan upon eligibility and enrollment A condition of coverage under the GHC
Medicare Plan requires that a Member be continuously fully qualified and enrolled for the hospital(Part A) and
medical (Part B) benefits, available from the Social Security Administration, and sign any papers that may be
required by GHC or Medicare. All applicable provisions of the GHC Medicare Plan are fully set forth in the
Medicare Endorsement(s)attached to this Agreement(if applicable).
Subscribers and covered dependents who are eligible for Medicare must, effective the date TEFRA eligibility
ends or the date that Medicare would become the primary payor, enroll in Medicare Parts A and B,and must
participate in GHC's Medicare plan. Failure to do so upon the effective date of Medicare eligibility will result
m termination of coverage under this group Agreement
Persons Residing Outside the Medicare+Choice Service Area Except as defined by federal regulations(i e ,
TEFRA), all Members who are eligible to purchase medicare must enroll in and maintain both Medicare Parts A
and B. Failure to do so upon the effective date of Medicare eligibility will result in termination of coverage
under this group Agreement
C. PERSONS WHO ARE NOT ENTITLED TO, OR ELIGIBLE TO PURCHASE MEDICARE. If a
Member otherwise qualifies for Medicare but is not entitled to, or eligible to purchase Medicare, the Members
may continue coverage under this Agreement upon payment of the applicable premiums as set forth in the
Premiums Schedule
Section X. Schedule Of Benefits
Subject to all provisions of this Group Medical Coverage Agreement, including, without limitation, the
accessing care provisions, the Allowances Schedule, and Exclusions, Members are entitled to receive the
benefits and services that are Medically Necessary for the treatment of a Medical Condition as deternuned by
GHC's Medical Director or his/ber designee,and as described in this Schedule of Benefits.
A. HOSPITAL CARE
Hospital coverage is lurnted to the following services
1. Room and board,including private room when prescribed,and general nursing services
0036900-C21431 26
2. Hospital services (including use of operating room, anesthesia, oxygen, x-ray, laboratory, and radiotherapy
services)
3. As a cost-effective alternative in heu of otherwise covered, Medically Necessary hospitalization or other
covered,Medically Necessary institutional care,alternative care arrangements may be covered Alternative
care arrangements in hen of covered hospital or other institutional care must be determined appropriate and
Medically Necessary based upon the patient's medical condition. Such determination of medical
appropriateness and necessity, and authorization of coverage must be made in advance by GHC Such care
will be covered to the same extent that the replaced hospital care is covered as set forth in the Allowances
Schedule
4. Dings and medications which are administered during confinement.
5. Special duty nursing(when prescribed as Medically Necessary).
If a Member is hospitalized in non-GH Designated Facility or a non-GH Facility, GHC reserves the tight to
require transfer of the Member to a GH or GH-Designated Facility,upon consultation between a GHC Provider
and the attending physician If the Member refuses to transfer, all further costs incurred during the
hospitalization are the responsibility of the Member.
B. MEDICAL AND SURGICAL CARE
Medical and surgical services are covered,limited to the following
1 Surgical services
2. Diagnostic x-ray,nuclear medicine,ultrasound,and laboratory services
3 Family planning counseling services
4 Hearing examinations to determine hearing loss
5 Blood and blood derivatives and their administration.
6 Preventive care (well care) services for health maintenance, including routine mammography screening,
physical examinations and routine laboratory tests for cancer screening in accordance with criteria
established by GHC for the detection of disease, and immunizations and vaccinations which are listed as
covered in the GHC Drug Formulary (approved drug list). A fee may be charged for health education
programs
Services provided during a preventive care visit which are not in accordance with preventive care criteria
are subject to the Outpatient Services Copayment.
7. Radiation therapy services
8. The following services are covered by GHC when performed by a GHC Provider or GH oral surgeon.
reduction of a fracture or dislocation of the law or facial bones, excision of tumors or non-dental cysts of
the law,cheeks,lips,tongue,gums,roof and floor of the mouth,and incision of salivary glands and ducts
9 Medically Necessary uitplants,which are not experimental or investigational,are covered as determined by
GHC's Medical Director, or his/her designee Excluded are internally implanted insulin pumps, artificial
hearts, artificial larynx, and any other implantable device that has not been approved by GHC's Medical
Director,or his/her designee
10 Respiratory therapy
0036900-C21431 27
11. Dietary formula for the treatment of phenylketonuria (PKLn when determined Medically Necessary by
GHC's Medical Director, or his/her designee Coverage for this formula is not subject to a Pre-existing
Conditions waiting period,if any
Outpatient total parenteral nutritional therapy, when Medically Necessary and in accordance with medical
criteria as established by GHC
Outpatient elemental formulas for malabsorption are covered as set forth in the Allowances Schedule
Formulas for access problems are excluded. Equipment and supplies for the administration of enteral and
parenteral therapy is covered under Devices,Equipment and Supplies
Dietary formulas, oral nutritional supplements and special diets, except for treatment of phenylketonuna
(PKU)and total parenteral and enteral nutritional therapy as set forth above,are excluded
12 Visits by GHC Providers (including consultations and second opinions by a GHC Provider) in the hospital
or office.
13 Routine eye examinations and refractions we coveted, limited to once every twelve (12) months, except
when Medically Necessary Services for routine eye examinations roust be received at a GH Facility and in
accordance with GHC medical criteria in order to be covered.
Evaluations and surgical procedures to correct refractions which are not related to eye pathology are not
covered. Complications related to such surgery are also excluded.
Contact lens fittings and related examinations are not covered except as set forth below, Contact lens
examinations and fittings for eye pathology are covered subject to the applicable copayment When
dispensed through GH Facilities,one contact lens per diseased eye in lieu of an intraocular lens,including
exam and fitting, is covered for Members following cataract surgery performed by a GHC Provider,
provided the Member has been continuously covered by GHC since such surgery Replacement of a
covered contact lens will be provided only when needed due to change in the Member's medical condition
but may be replaced only one time within any twelve(12)month period.
14 Maternity care, including care for complications of pregnancy and prenatal and postpartum visits
Prenatal testing for the detection of congenital and heritable disorders when Medically Necessary as
determined by GHC's Medical Director, or his/her designee, in accordance with Board of Health
standards for screening and diagnostic tests during pregnancy. Genetic testing of non-Members for the
detection of congenital and heritable disorders is excluded.
Hospitalization and delivery,including home baths for low risk pregnancies when approved in advance and
provided by a GHC Provider Buthing tubs are not covered Voluntary(not medically indicated and non-
therapeutic) or involuntary termination of pregnancy is covered The Membei s physician, in consultation
with the mother, will determine the mother's length of inpatient stay following delivery Pregnancy will
not be considered a pre-existing condition exclusion under this Agreement Treatment for postpartum
depression or psychosis is covered only under the mental health benefit
15 Transplants When authorized as medically appropriate by GHC's Medical Director or his/her designee,
and m accordance with criteria established by the Cooperative,heart,heart-lung, single lung, double lung,
kidney, simultaneous pancreas/kidney, comes, bone marrow, and liver transplants High dose
chemotherapy and stem cell (obtained from the allogeneic or autologous peripheral blood or marrow as
medically appropriate) support is covered when authorized as medically appropriate by GHC's Medical
Director,or his/her designee Transplant services are lirmted to the following
a. evaluation testing to determine recipient candidacy,
b matching tests
0036900-C21431 28
c. transplantation procedures as follows for inpatient and outpatient medical expenses Covered
procedures must be directly associated with, and occur at the time of, the transplant Transplantation
procedures are subject to the organ recipient's lifetime maximum as set forth in the Allowances
Schedule
• Hospital charges,
• Procurement center fees;
• Travel costs for a surgical team;
• Excision fees;
• Donor costs for a covered organ recipient are limited to procurement center fees,travel costs for a
surgical team and excision fees.GHC shall exclude coverage for donor costs to the extent that the
donor costs are reimbursable by the organ donor's insurance
d. follow-up services for specialty visits,
e. rehospitalization,and
f maintenance medications
Exclusions
Transportation expenses,except as set forth under Section X M of this Agreement,and living expenses
Coverage for all transplants and any related services,items, and drugs shall be excluded until such time as
the Member has been continuously enrolled under this Agreement, or any prior GHC Medical Coverage
Agreement,for twelve(12)consecutive months without any lapse in coverage
This exclusion does not apply to children who have been continuously enrolled at GHC since bulb,or if the
Member requires a transplant as the result of a condition which had a sudden unexpected onset after the
Member's effective date of coverage.
16 Self-referrals for manipulative therapy of the spme limited to one evaluation and ten (10) spinal
manipulations only when provided by GHC Providers as set forth in the Allowances Schedule. Additional
visits available subject to approval.
The Medical Necessity for manipulative therapy must meet GHC clinical criteria as Medically Necessary
Excluded are services that do not meet GHC clinical criteria as Medically Necessary, including,but not
limited to, supportive care rendered primarily to maintain the level of correction already achieved, care
rendered primarily for the convenience of the Member, care rendered on a non-acute, asymptomatic basis,
or charges for office visits other than the initial evaluation
17. Medical and surgical services and related hospital charges, including orthognathic (law) surgery for the
treatment of temporomandibu lar joint (TMJ) disorders, are covered as set forth in the Allowances
Schedule when determined to be Medically Necessary and referred in advance by GHC Such disorders
may exhibit themselves in the form of pam, infection, disease, difficulty in speaking, or difficulty in
chewing or swallowing food TMJ appliances are covered as set forth under orthopedic appliances(Section
XH1 )
Orthognathic (law) surgery, radiology services and TMJ specialist services, including fitting/adjustment of
splints, is subject to the benefit limit set forth in the Allowances Schedule.
The following services including related hospitalizations,are excluded regardless of origin or cause
• orthognathic(law)surgery in the absence of a TMJ diagnosis,
0036900-C21431 29
• treatment for cosmetic purposes,and
• all dental services(except as noted above),including orthodontic therapy.
18 When authorized as medically appropriate by GHC's Medical Director, or his/'her designee, and in
accordance with criteria established by the Cooperative, treatment of growth disorders by growth
hormones.
19. Diabetic training and education.
20 Detoxification services for alcoholism and drug abuse
Coverage for acute chemical withdrawal is provided without pnor approval If a Member is hospitalized in
a non-GH Designated Facility/program, coverage is subject to payment of the emergency Deductible
shown in the Allowances Schedule, and notification of GH by way of the GH Notification Lmne within
twenty-four (24) hours following inpatient admission, or as soon thereafter as medically passible.
Furthermore, if a Member is hospitalized in a non-GH Designated Facility/program, GHC reserves the
tight to require transfer of the Member to a GH Facility/program upon consultation between a GHC
Provider and the attending physician. If the Member refuses transfer to a GH Facmhty/program, all further
costs incurred during the hospitalization are the responsibility of the Member
For the purpose of this section, "acute cbermcal withdrawal" means withdrawal of alcohol and/or drugs
from a person for whom consequences of abstinence are so severe as to require medical/nursing assistance
in a hospital setting, and which is needed unmediately to prevent serious impaument to the Members
health
21 Circumcision.
. 22 Banamc surgery and related hospitalizations when GHC criteria are met. All other services required (e g,
prescribing and monitoring of drugs, structured weight loss and/or exercise programs, speciahred
nutritional counseling)are excluded
23 Nontherapeutic sterilization procedures
24 General anesthesia services and related facility charges for dental procedures will be covered for Members
under seven (7) years of age, physically or developmentally disabled persons, or for Members with a
medical condition whose health would be put at risk if the dental procedure were performed in a dennst's
office Such services must be preauthonzed and determined Medically Necessary by GHC, and performed
at a GH or GH Designated hospital or ambulatory surgery facility
GHC will not cover the dentist's or oral surgeon's fees
25. Self-referrals for Covered Services provided by hcensed acupuncturists and licensed n arm ropaths with an
their scope of licensure, when provided by GHC Providers, as set forth in the Allowances Schedule.
Additional visits are covered as ser forth in the Allowances Schedule when approved by GHC.
Preventive care visits to acupuncturists and naturopaths are not covered Herbal supplements are not
covered Laboratory services are covered only when provided at a Group Health operated or contracted
laboratory.
26 Pre-existing Conditions are covered in the same manna as any other illness, except as provided under
Section X B.15 of this Agreement.
C. CHEMICAL DEPENDENCY TREATMENT
0
0036900-C21431 vn
Subject to all terms and conditions of this Agreement, care is provided as set forth below at a GH Facility, GH
Designated Facility, or GH-approved treatment program, subject to the Benefit Period Allowance as described
below and as shown in the Allowances Schedule
1. Chemical Dependency Treatment Services.
The GHC Medical Director or his/her designee shall make the final determination of the length and type of
program and frequency of visits.
For chemical dependency treatment services, Medical Necessity is defined as those services necessary to
treat a chemical dependency condition that is having a clinically significant impact on an m&vidual's
emotional,social,medical,and/or occupational functioning.
a. All alcoholism and/or drug abuse treatment services must be: (1) provided at a facility as described
above and must be authorized in advance, except for acute chemical withdrawal as described in
Section X B., and (2) deemed Medically Necessary as defined above by GHC's Medical Director or
his/her designee Chemical dependency treatment may include the following services received on an
inpatient or outpatient basis- diagnostic evaluation and education, organized individual and group
counseling,and prescription drugs and medicines(unless excluded under this Agreement)
b Court-ordered treatment shall be provided only if determined to be Medically Necessary by GHC's
Medical Director or his/ber designee
2. Benefit Period and Benefit Period Allowance.
a. Benefit Period. For the purpose of this section, "Benefit Period" shall mean a twenty-four (24)
consecutive calendar month period during which the Member is eligible to receive covered chemical
dependency treatment services as set forth in this section. The first Benefit Period shall begin on the
first day the Member receives covered chemical dependency services and shall continue for
twenty-four (24) consecutive calendar months, provided that coverage under this Agreement remains
in force All subsequent Benefit Penods thereafter will begin on the first day Covered Services are
received after expiration of the previous twenty-four(24)month Benefit Period
b. Benefit Period Allowance.The maximum allowance available for any Benefit Period shall be the total
of all chemical dependency benefits provided and payments made for chemical dependency treatment,
not to exceed the Benefit Period Allowance shown in the Allowances Schedule during the Member's
Benefit Period
Any Deductibles or Copayments which may be bome by the Member under the terms of this Agreement shall
not be applied toward the Benefit Period Allowance
D. PLASTIC AND RECONSTRUCTIVE SERVICES are covered.
1. to correct a congenital disease or congenital anomaly as determined by a GHC Provider,or
2. to correct a Medical Condition following an injury or incidental to surgery covered by GHC which has
produced a major effect on the Membees appearance when in the opinion of a GHC Provider,such services
can reasonably be expected to correct the condition.
In the case of a congenital condition which affects appearance,an anomaly will be considered to exist if the
Member's appearance resulting from such condition is not within the range of normal human variation
3. for reconstructive surgery and associated procedures following a mastectomy, regardless of when the
mastectomy was performed Internal breast prostheses required incident to the-surgery will be provided
0036900-C21431 31
A Member will be covered for all stages of reconstruction on the nondiseased breast to make it equivalent
in size with the diseased breast after definitive reconstructive surgery on the diseased breast has been
performed.
Complications of covered mastectomy services, including lymphedemas, are covered. Complmcauons of
noncovered surgical services are excluded
E. HOME HEALTH CARE SERVICES, as set forth in this section, shall be provided by GHC Home Health
Services or by a GH-authonzed home health agency when Referred in advance by a GHC Provider for
Members who meet the following criteria
1. The Member is unable to leave home due to his or her health problem or illness (unwillingness to travel
and/or arrange for transportation does not constitute mabihty to leave the home),
2. the Member requires intermittent Skilled Home Health Care services,as described below,and
3. a GHC Provider has determined that such services are Medically Necessary and are most appropriately
rendered in the Member's home.
Covered Services for home health care may include the following when prescribed by a GHC Provider and
when rendered pursuant to an approved home health care plan of treatment nursing care, physical therapy,
occupational therapy, respiratory therapy, restorative speech therapy, and medical social worker and limited
home health aide services Home health services are provided on an intermittent basis in the Member's home
"Intermittent" means care that is to be rendered because of a medically predictable recurring need for Skilled
Home Health Care services
Excluded are custodial care and maintenance care, private duty or continuous nursing care in the Members
home, housekeeping or meal services, care in any nursing home or convalescent facility, any care provided by
or for a member of the patient's family, and any other services rendered in the home which are not specifically
listed as covered under this Agreement.
F. HOSPICE
Members who elect to receive services from the GHC Hospice Program or GH-approved hospice program are
entitled to hospice services as provided under the Hospice Program Members who elect to receive hospice
services do so in heu of curative treatment for their terminal illness for the period that they are in the hospice
program. To receive hospice services,the Member is required to sign the Hospice Election Form
It is understood and agreed that the following fully sets forth the eligibility requirements and Covered Services
for a Member who elects to receive hospice services under the GHC Hospice Program
GHC Hospice Program or GH-approved hospice program
1. Eligibility.Hospice Services, as set forth below,shall be provided to Members for as long as the following
criteria are met
a A GHC Provider has determined that the Member's illness is terminal and life expectancy is six (6)
months or less;
b. the Member has chosen a palliative treatment focus (errrphasizng comfort and supportive services
rather than treatment armed at curing the Member's terminal illness),
c the Member has elected in writing to receive hospice care through GHC's Hospice Program or GH's
• approved hospice programs, _
0036900-C21431 32
d. the Member has available a primary care person who will be responsible for the Member's home care,
and
e a GHC Provider and GHCs Hospice Director, or hts/ber designee, determine that the Member's illness
can be appropriately managed in the home
2. Hospice care shall be defined as a coordinated program of palliative and supportive care for dying persons
by an interdisciplinary team of professionals and volunteers centering primarily in the Member's home
3. Covered Services Hospice services may include the following as prescribed by a GHC Provider and
rendered pursuant to an approved hospice plan of treatment
a. Home Services
I Intermittent care by a hospice interdisciplinary team which may include services by a physician,
nurse, medical social worker, physical therapist, speech therapist, occupational therapist,
respiratory therapist, limited services by a Home Health Aide under the supervision of a
Registered Nurse,and homemaker services.
u Continuous care services in the Member's home when prescribed by a GHC Provider, as set forth
in this paragraph Continuous care is defined as "skilled nursing care provided in the home during
a period of crisis in order to maintain the terminally ill patient at home" Continuous care may be
provided for pain or symptom management by a Registered Nurse, Licensed Practical Nurse, or
Home Health Aide under the supervision of a Registered Nurse.Continuous care is provided up to
twenty-four (24)hours per day during periods of crisis Continuous care is covered only when a
GHC Provider determines that the Member would otherwise require hospitalization in an acute
care facility •
b. Inpatient Hospice Services for short-term care shall be provided in a facility designated by GHCs
Hospice Program or GH-approved hospice program when Medically Necessary and authorized in
advance by a GHC Provider and GHC's Hospice Program or GH-approved hospice program Inpatient
respite care is covered for a maximum of five(5)consecutive days per occurrence in order to continue
care for the member in the temporary absence of the member's primary care giver(s)
c Other hospice services may include the following
I Dings and biologicals that are used primarily for the relief of pain and symptom management,
u. medical appliances and supplies primarily for the relief of pain and symptom management,
m counseling services for the Member and his/her primary care-giver(s);and
iv. bereavement counseling services for the family
4. Hospice Exclusions:All services not specifically listed as covered in tlus section including
a Financial or legal counseling services
b. Meal services
c. Custodial or maintenance care in the home or on an mpatient basis,except as provided above
d. Services not specifically listed as covered by this Medical Coverage Agreement.
e Any services provided by members of the patient's family
f All other exclusions listed in Section XI.,Exclusions of this Medical Coverage Agreement,apply
G. REHABILITATION SERVICES are covered as set forth in this section, lumted to the following physical
therapy, occupational therapy, and speech therapy to restore function following illness, injury, or surgery
Services are subject to all terms,conditions,and limitations of this Agreement,including the following
0036900-C21431 33
1. All services must be provided at GHC or a GH-approved rehabilitation facility and must be prescribed and
provided by a GH-approved rehabilitation team that may include medical, nursing, physical therapy,
occupational therapy,massage therapy and speech therapy providers.
2. The Member must be referred for rehabilitation services in advance by a GHC Provider
3. Services are limited to those necessary to restore or improve functional abilities when physical,
senson-perceptual and/or communication impairment exists due to injury,illness or surgery Such services
are provided only when GHC's Medical Director, or his/her designee, determines that sigmficant,
measurable improvement to the Member's condition can be expected within a sixty (60) day period as a
consequence of intervention by covered therapy services described in paragraph one(1)above
4 Coverage for inpatient and outpatient services is limited to the allowance set forth in the Allowances
Schedule.
Services excluded under this benefit include the following specialty rehabilitation programs not provided by
GHC, long-term rehabilitation programs, physical therapy, occupational therapy, and speech therapy services
when such services are available (whether application is made or not) through governmental programs,
programs offered by public school districts, therapy for degenerative or static conditions when the expected
outcome is primarily to maintain the Member's level of functioning(except for neurodevelopmental therapies),
recreational hfe-enhancmg relaxation or palliative therapy, implementation of home maintenance programs,
programs for treatment of learning problems, any other treatment not considered Medically Necessary by GHC,
any services not specifically included as covered in this Section, and any services that are excluded under
Section XI
Neurodevelopmental Therapies for Children Age Six (6) and Under. When determined to be Medically
Necessary by GHC's Medical Director, or his/her designee, physical therapy, occupational therapy, and speech
therapy services for the restoration and improvement of function for neurodevelopmentally disabled children
age six (6) and under shall be covered Coverage includes maintenance of a covered Member in cases where
significant deterioration in the Member's condition would result without the services.Coverage for mpatient and
outpatient services is limited to the allowance set forth in the Allowances Schedule
Services excluded under this benefit include specialty rehabilitation programs, long-term rehabilitation
programs,physical therapy, occupational therapy,and speech therapy services when such services are available
(whether application is made or not) through governmental programs, programs offered by public school
districts, except as set forth above, therapy for degenerative or static conditions when the expected outcome is
primarily to maintain the Membefs level of functioning; implementation of home maintenance programs;any
treatment not considered Medically Necessary,any services not specifically included as covered in this Section,
and any services that are excluded under Section M
H. DEVICES,EQUIPMENT AND SUPPLIES
1. Orthopedic Appliances.When Medically Necessary, orthopedic appliances(commonly known as a brace
or a splint),which are attached to an impaired body segment for the purpose of protecting the segment or
assisting in restoration or improvement of its function,are covered Medically Necessary repair,adjustment
or replacement of an orthopedic appliance is covered when authorized in advance by a GHC Provider
Covered Services are subject to the Coinsurance set forth in the Allowances Schedule Excluded are arch
supports including custom shoe modifications or inserts and them fittings except for therapeutic shoes,
modifications and shoe inserts for severe diabetic foot disease, orthopedic shoes that are not attached to an
appliance, or any orthopedic appliances that are not listed as covered in GHC's Orthopedic Appliance
Formulary.
2. Ostomy Supplies. Medically Necessary ostomy supplies for the removal of bodily secretions or waste
through an artificial opening are covered as set forth in the Allowances Schedule
0036900-C21431 34
3. Oxygen and Oxygen Equipment. When medical criteria as established by GHC are met, and upon
Referral,oxygen and oxygen equipment for home use is covered as set forth in the Allowances Schedule
4. Durable Medical Equipment which is Medically Necessary,prescribed by a GHC Provider, in accordance
with criteria established by GHC, and listed as covered in GHC's durable medical equipment formulary,
hmited to the following: rental(or purchase, if the cost of purchase is less than the anticipated total rental
charges as determined solely by GHC) of hospital beds, wheelchairs, walkers, crutches, canes, glucose
monitors, external insulin pumps and other durable medical equipment as specifically listed in GHC's
durable medical egmpment formulary Services are covered as set forth in the Allowances Schedule.
5. Prosthetic Devices. Prosthetic devices (which are not orthopedic appliances), commonly known as
artificial hubs, etc, which are listed as covered in the GHC prosthetic device formulary when Medically
Necessary and authorized in advance by a GHC Provider,as set forth in the Allowances Schedule
Replacement or repair of appliances, devices and supplies that are due to loss, breakage from willful damage,
neglect or wrongful use, or due to personal preference are excluded.
L TOBACCO CESSATION. When provided through GHC, services related to tobacco cessation are covered,
hunted to:
1 participation in one individual or group program per calendar year,
2 educational materials, and
3 one course of nicotine replacement therapy per calendar year,provided the Member is actively pamcipating
in the Group Health Free and Clear Program or GH-designated tobacco cessation program
Covered Services are subject to the Allowances set forth in the Allowances Schedule
J. LEGEND (PRESCRIPTION) DRUGS, MEDICINES, SUPPLIES AND DEVICES FOR OUTPATIENT
USE as prescribed by a GHC Provider for conditions covered by this Agreement, including off-label use of
FDA-approved drugs (provided that such use is documented to be effective in one of the standard reference
compendia; a majority of well-designed clinical trials published in peer-reviewed medical literature document
improved efficacy or safety of the agent over standard therapies,or over placebo if no standard therapies exist,
or by the federal secretary of Health and Human Services), msulm,diabetic supplies,including insulin syringes,
lancets, urine-testing reagents,and blood glucose monitoring reagents,and contraceptive drugs and devices and
their fitting.
All drugs, supplies,medicines,and devices must be obtained at a GH pharmacy and, unless approved by GHC
in advance, be listed in the GHC Drug Formulary(approved drug Itst) The prescription drug copayment as
set forth in the Allowances Schedule applies to each 30-day supply Copayments for single and multiple 30-day
supplies of a given prescription are payable at the tux of delivery Injectables that can be self-administered are
also subject to the prescription drug copayment Drug Formulary (approved drug list) is defined as a list of
preferred pharmaceutical products, supplies and devices developed and maintained by Group Heakk
Generic Drugs will be dispensed whenever available Brand name drugs will be dispensed if there is not a
generic equivalent. In the event the Member elects to purchase brand-name drugs instead of the generic (if
available), or if the Member elects to purchase a different brand-name or generic drug than that prescribed by
the Member's Provider, and it is not determined to be Medically Necessary, the Member will also be subject to
payment of the additional amount above the applicable pharmacy cost share set forth in the Allowances
Schedule. Generic drugs are defined as a drug that is the pharmaceutical equivalent to one or more brand
name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the
same standards of safety,purity,strength and effectiveness as the brand name drug. Brand name drugs are
defined as a prescription drug that has been patented and is only available through one manufacturer.
0036900-C21431 35
"Standard reference compendia" means the American Hospital Formulary Service-Drug Infomntion, the
American Medical Drug Evaluation,the United States Pbarmacopoeia-Drug Information, or other authoritative
compendia as identified from time to time by the federal secretary of Health and Human Services "Peer-
reviewed medical literature" means scientific studies printed in healthcare journals or other publications in
which original manuscripts are published only after having been critically reviewed for scientific accuracy,
validity, and rehability by unbiased independent experts Peer-reviewed medical literature does not include in-
house publications of pharmaceutical manufacturing companies.
Excluded are over-the-counter drugs,medicines,supplies and devices not requiring a prescription under state
law or regulations; dietary formulas and special diets, except as set forth in Section X B , drugs used in the
treatment of sexual dysfunction disorders; medicines and mjections for anticipated illness while traveling,
vitamins, including Legend(prescription) vitamins,and any other drugs, medicines and injections not listed as
covered in the GHC Drug Formulary (approved drug list) unless approved in advance by GHC as Medically
Necessary
The Member will be charged for replacing lost or stolen drugs,medicines or devices
YOUR RIGHT TO SAFE AND EFFECTIVE PHARMACY SERVICES.
State and federal laws establish standards to assure safe and effective pharmacy services, and to guarantee your
right to]mow what drugs are covered under this plan and what coverage limitations are in your Agreement If
you would like more information about the drug coverage policies under this plan, or if you have a question or
concern about your pharmacy benefit,please contact us at 206-9014636 or 1-888-9014636
If you would like to know more about your tights under the law,or if you think anything you received from this
plan may not conform to the terms of this Agreement, you may contact the Washington State Office of
Insurance Commissioner at 1-800-562-6900 If you have a concern about the pharmacists or pharmacies serving
you,please call the State Department of Health at 360-236-4825.
K. MENTAL HEALTH CARE SERVICES. GHC and state law have established standards to assure the
competence and professional conduct of mental health service providers, to guarantee your right to informed
consent to treatment, to assure the privacy of your medical information, to enable you to know which services
are covered under this Agreement and to know the limitations on your coverage If you would like a more
detailed description than is provided here of covered benefits for mental health services under this Agreement,
or if you have questions or concerns about any aspect of your mental health benefits, please contact GHC at
888-901-4636.
If you would like to know more about your rights under the law,or if you think anything you received from this
plan may not conform to the terms of your contract or your rights under the law, you may contact the Office of
the Insurance Commissioner at 800-562-6900. If you have a concern about the qualifications or professional
conduct of your mental health provider,please call the State Health Department at 360-236-4902
Services that are provided by a mental health practitioner, contracted or employed, to Members diagnosed as
having a mental disorder that meet GHC's clinical necessity criteria for treatment, will be covered as mental
health care,regardless of the cause of the disorder.
1. Outpatient Services. Outpatient mental health services provided by or authorized under Referral from
GHC Behavioral Health Services place priority on restoring the Member to his/her level of functioning
prior to the onset of acute symptoms or to achieve a clinically appropriate level of stability as determined
by the GHC Medical Director, or his/her designee. Treatment for clinical conditions may utilize
psychiatric, psychological and psychotherapy services to achieve these objectives. GHC's Medical
Director, or his/her designee, shall determine the length and type of treatment plan and/or program and
the frequency
Coverage for each Member is provided according to the Outpatient Mental Health Care Allowance set forth
in the Allowances Schedule Psychiatric medical services including medical management and prescriptions
0036900-C21431 36
are covered as set forth in Sections X B and X.J. GHC clinics and contracted practitioner offices may
have office policies that determine how missed appointments will be managed Payment for charges of
missed appointments are the responsibility of the Member.
2. Inpatient Services. Charges for services described in this section, including psychiatric Emergencies
resulting in inpatient services, shall be covered to the maximum benefit as set forth in the Allowances
Schedule Thts benefit shall include coverage for acute treatment and stabilization of psycluatric
emergencies in GHC-approved hospitals. When medically indicated, outpatient electro-convulsive therapy
(ECT) is covered in heu of inpatient services Payment of bills incurred at non-GH facilities shall exclude
any charges that would otherwise be excluded for hospitalization within a GH Facility
When authorized in advance by GHC's Medical Director, or his/her designee, partial hospitalization and
outpatient electro-convulsive therapy treatments are covered subject to the maximum inpatient benefit hurt
described in the Allowances Schedule Every two (2) partial hospitalization days or two (2)
electro-convulsive therapy treatments are equivalent to one inpatient hospital day The total maximum
annual benefit under this section shall not exceed the number of inpatient days described in the Allowances
Schedule
Subject to the maximum Inpatient Mental Health Care Allowance as set forth in the Allowances Schedule,
services provided under involuntary commitment statutes shall be covered at facilities approved by GH
Services for any court-ordered treatment program beyond the seventy-two(72)hours shall be covered only
if determined to be Medically Necessary by GHCs Medical Director,or his/her designee
Coverage for voluntary/mvoluntary Emergency inpatient psychiatric services is subject to the Emergency
care benefit as set forth in Section X L, including the twenty-four (24) hour notification and transfer
provisions All other voluntary psychiatric care must be authorized in advance by the Director of GHCs
Behavioral Health, or his/her designee, the facility must be approved by the Cooperative All voluntary
care not authorized in advance by GHCs Behavioral Health Service is not covered
3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services.Covered
Services are hutted to those considered to be Medically Necessary by GHC's Medical Duector,or his/her
designee Covered Services are limited to those provided for covered clinical conditions for which, in the
opinion of GHC's Medical Director, or his/her designee,reduction or removal of acute clinical symptoms
or stabilization can be expected.
Partial hospitalization programs and electro-convulsive therapy are covered only under subsection K2
(Inpatient Services)
Excluded from Behavioral Health coverage are all forms of day treatment (non partial hospital
programs) and custodial care. Treatment specfc to and solely for personality disorders, learning,
communication and motor skills disorders, mental retardation, academic or career counseling, are not
covered under Behavioral Health coverage. Treatment specific to and solely for sexual and identity
disorders,personal growth or relationship enhancement are not covered Specialty programs for mental
health therapy which are not specifically authorized by Behavioral Health Services and approved by
GHC, court-ordered treatment which is not specifically described above, or any other services not
specifically listed as covered in this section. All other provisions, exclusions and limitations under this
Agreement also apply
L. EMERGENCY/URGENT CARE
Emergency Care(See Section I for a defmmon of Emergency)
1. At a GH Facility or GH Designated Facility.GHC will cover Emergency care for all Covered Services as
set forth in the Allowances Schedule
0036900-C21431 37
2. At a-Non-GH Designated Facility.Usual, Customary, and Reasonable charges for Emergency care for
Covered Services are covered subject to
a. payment of the Emergency Care Deductible shown in the Allowances Schedule,and
b. notification of GH by way of the GH Notification Line within twenty-four (24) hours following
inpatient admission,or as soon thereafter as medically possible.
Outpatient medications prescribed by a non-GHC Provider are excluded
3. Waiver of Emergency Care Copayment/Deductible.
a. Waiver for Multiple Injury Accident. If two or more members of the Family Unit require
Emergency care as a result of the same accident, only one Emergency Care Copayment/Deductible
will apply
b. Emergencies Resulting in an Inpatient Admission. If the Member is admitted to a GH or GH
Designated Facility directly from the emergency room, the Emergency Care Copayment is waived.
However,the first day's Hospital Care Copayment,if any,will be charged.
4. Transfer and Follow-up Care.If a Member is hospitalized in a non-GH Facility, GHC reserves the right
to require transfer of the Member to a GH Facility or GHDesignated Facility,upon consultation between a
GHC Provider and the attending physician. If the Member refuses to transfer to a GH Facility or GH
Designated Facility, all further costs incurred during the hospitalization are the responsibility of the
Member
Follow-up care which is a direct result of the Emergency must be obtained from GHC Providers,unless a
GHC Provider his authorized such follow-up care in advance.
Urgent Care(See Section I for a definition of Urgent Condition).
Urgent Care.Care for Urgent Conditions received inside the GHC Service Area is covered only at GH medical
centers, GH urgent care clinics,or network providers' offices Urgent care received at any hospital emergency
department is not covered unless authorized in advance by a GHC Provider
M. AMBULANCE SERVICES are covered as set forth below,provided that the service is authorized in advance
by a GHC Provider or meets the definition of an Emergency (See Section I)
1. Emergency Transport to a GH Facility, GH Designated Facility, or non-GH Designated Facility.
Each Emergency is covered as set forth in the Allowances Schedule
2. GH-Initiated Transfers GH-initiated non-emergent transfers to or from a GH Facility or GH Designated
Facility are covered
N. SKILLED NURSING FACILITY care in a GH-approved skilled nursing facility when full-time skated
nursing care is necessary in the opinion of the attending GHC Provider, as set forth in the Allowances
Schedule
When prescribed by a GHC Provider, such care may include board and room;general nursing care; drugs,
biologicals,supplies, and equipment ordinardy provided or arranged by a skilled nursing facility;and short-
term physical therapy,occupational therapy,and restorative speech therapy.
Excluded from coverage are personal comfort items such as telephone and television; and rest cures,
custodial, domiciliary or convalescent care _
Section XI. Exclusions
0036900-C21431 38
In addition to exclusions listed in the previous sections,the following are excluded-
1 Except as specifically listed and identified as covered in Sections X B, X D., X H, and X J, corrective
appliances and artificial aids including eyeglasses; contact lenses, including services related to their
fitting, hearing devices, hearing aids and examinations in connection therewith, take-home dressings and
supplies following hospitalization, or any other supplies, dressings, appliances, devices or services which
are not specifically listed as covered in Section X.
2 Cosmetic services, including treatment for complications of cosmetic surgery, except as provided in
Section X D
3. Convalescent or custodial care
4 Durable medical equipment such as hospital beds,wheelchairs, and walk-aids, except while in the hospital
or as set forth in Section X B.,X.F or X H
S Services rendered as a result of work-related injuries, illnesses or conditions,including injuries,illnesses or
conditions incurred as a result of self-employment
6 Those parts of an examination and associated reports and immunizations required for employment(unless
otherwise noted in Section X.B), immigration, license, travel, or insurance purposes that are not deemed
Medically Necessary by GHC for early detection of disease
7 Services and supplies related to sexual reassignment surgery, such as sex change operations or
transformations and procedures or treatments designed to alter physical characteristics
8 Regardless of origin or cause, diagnostic testing and medical treatment of sterility, infertility, and sexual
dysfunction,unless otherwise noted in Section X B
9 Any services to the extent benefits are available to the Member under the terms of any vehicle,
homeowner's, property or other insurance policy, except for individual or group health insurance,whether
the Member asserts a claim or not, pursuant to- (1) medical coverage, medical "no fault" coverage,
Personal Injury Protection coverage, or similar medical coverage contained in said policy, and/or (2)
iminsured motorist or underinsured motorist coverage contained in said policy. For the purpose of this
exclusion, benefits shall be deemed to be "available" to the Member if the Member is a named insured,
comes within the policy definition of insured, is a third-party donee beneficiary under the terms of the
policy,or otherwise has the tight to receive benefits under the policy.
The Member and his or her agents must cooperate fully with GHC in its efforts to enforce this exclusion.
This cooperation shall include supplying GHC with information about any available insurance coverage
The Member and his or her agents shall permit GHC at GHC's option, to associate with the Member or to
intervene in any action filed against any party related to the injury The Member and his or her agents shall
do nothing to prejudice GHC's tight to enforce this exclusion In the event the Member fails to cooperate
fully,the Member shall be responsible for reimbursing GHC for such medical expenses.
GHC shall not enforce this exclusion as to coverage available under uninsured motorist or underinsured
motorist coverage until the Member has been made whole,unless the Member fails to cooperate fully with
GHC as described above
GHC shall not pay any attorneys' fees or collection costs to attorneys representing the injured person where
it has retained its own legal counsel or acts on its own behalf to represent its interests and unless there is a
written fee agreement signed by GHC prior to any collection efforts. Under no circumstances will GHC
pay legal fees jar services which were not reasonably and necessarily incurred to secure recovery and/or
which do not benefit GHC If it becomes necessary for GHC to enforce the provisions of this section by
0036900-C21431 39
initmting any action against the injured person or his or her agent,then the injured person agrees to pay
GHC's attorneys'fees and costs associated with the action.
10. Services or supplies not specifically listed as covered in the Schedule of Benefits.
11. Voluntary(not medically indicated and nontherapeutic) termination of pregnancy, unless otherwise noted
in Section X B
12 The cost of services and supplies resulting from a Member's loss of or willful damage to covered
appliances,devices,supplies,and materials provided by GHC for the treatment of disease,injury,or illness
13. Orthoptic(eye training)therapy.
14 Specialty treatment programs such as weight reduction, rehabilitation (including cardiac rehabilitation),
and"behavior modification programs"
15 Services required as a result of war, whether declared or not declared Care needed for mltmes or
conditions resulting from active or reserve military service
16 Nontherapeutic sterilization (unless otherwise noted in Section X B) and procedures and services to
reverse a therapeutic or nontherapeutic sterilization.
17 Dental care, surgery, services, and appliances, including treatment of accidental injury to natural teeth,
reconstructive surgery to the jaw in preparation for dental implants, dental implants, penodontal surgery,
and any other dental services not specifically listed as covered in Section X The Cooperative's Medical
Director, or his/her designee, will determine whether the care or treatment required is within the category
of dental care or service.
18 Dings, medicines, and injections, except as set forth in Section X.J Any exclusion of drugs, medicines,
and injections,including those not listed as covered in the GHC Drug Formulary(approved drug list), will
also exclude their administration
19 Experimental or investigational services
(a) A service is experimental or investigational for a Member's condition if any of the following
statements apply to it as of the time the service is or will be provided to the Member The service(i)
cannot be legally marketed in the United States without the approval of the Food and Drug
Administration("FDA") and such approval has not been granted, or(u) is the subject of a current new
drug or new device application on file with the FDA; or(ui) is provided as part of a Phase I or Phase
II clinical trial, as the experimental or research arm of a Phase III clinical trial, or in any other manner
that is intended to evaluate the safety,toxicity,or efficacy of the semce; or(iv)is provided pursuant to
a written protocol or other document that lists an evaluation of the service's safety,toxicity,or efficacy
as among its objectives, or(v)is under continued scientific testing and research concerning the safety,
toxicity, or efficacy of services, or (vi) is provided pursuant to informed consent documents that
describe the service as experimental or investigational,or in other terns that indicate that the service is
being evaluated for its safety, toxicity, or efficacy, or As to the service (vu) the prevailing opinion
among experts as expressed m the published authoritative medical or scientific literature is that(1)use
of the service should be substantially confined to research settings, or(2) further research is necessary
to determine the safety,toxicity,or efficacy of the service
(b) In making determinations whether a service is experimental or investigational,the following sources of
information will be relied upon exclusively (i ) the Member's medical records, (m) the written
protocol(s) or other document(s)pursuant to which the service has been or will be provided, (in) any
consent document(s)the Member or Member's representative has executed or will be asked to execute,
to receive the service, (iv) the files and records of the Institutional Review Board (IRB) or sirmlar
body that approves or reviews research at the institution where the service has been or will be
0036900-C21431 40
-provided,and other information concerning the authority or actions of the IRB or similar body,(v)the .
published authoritative medical or scientific literature regarding the service, as applied to the
Member's illness or injury, and (vi) regulations, records, applications, and any other documents or
actions issued by, filed with, or taken by, the FDA, the Office of Technology Assessment, or other
agencies within the United States Department of Health and Human Services, or any state agency
performing similar functions.
(c) GHC consults with GHC's Medical Director and then uses the criteria described above to decide if a
particular service is experimental or investigational
Appeals regarding denial of coverage must be submitted to your regional Member Services Department, or
west of the Cascade mountains to GHCs Appeals Department at Administration and Operations Campus,
PO Box 34593, Seattle WA 98124-1593 or east of the Cascade mountains to GH's Patient Relations
Department at 5615 West Sunset Highway, Spokane, WA 99224. GHC will respond in writing within
twenty(20)working days of the receipt of a fully documented request. An expedited appeal is available if
delay would jeopardize the Member's life or health
20. Mental health care,except as specifically provided in Section X IC
21 Hypnotherapy,and all services related to hypnotherapy
22. Genetic testing and related services are excluded unless determined Medically Necessary by GHC's
Medical Director, or his/her designee, in accordance with Board of Health standards for screening and
diagnostic tests,or specifically provided in Section X B Testing for non-Members is also excluded
23. Follow-up visits related to a non-Covered Service
24 Routine ultrasound to determine fetal age,size or sex
25. Missed appointment or cancellation fees.
26 Routine foot care except in the presence of a non-related Medical Condition affecting the lower limbs.
17. Complications of non-Covered Services.
2& Treatment of obesity,except as set forth in Section KB.
Section MI. Claims
Claims for benefits maybe made before or after services are obtained To make a claim for benefits under this
agreement, a Member (or the Member's authorized representative) must contact GHC Customer Service, or
submit a claim for reimbursement as described below. Other inquiries, such as asking a health care provider
about care or coverage,or submitting a prescription to a pharmacy,will not be considered a claim for benefits.
If a Member receives a bill for Covered Services,the Member must,within sixty(60)days of the service date,or as
soon thereafter as is reasonably possible, either a) contact GHC Customer Service to make a claim or b)pay the
bill and submit a claim for reimbursement of Covered Services to GHC. If the Member is located west of the
Cascade mountains,submit clauns for reimbursement to PO Box 34585, Seattle, WA 98124-1585,if the Member
is located east of the Cascade mountains submit claims to PO Box 200, Spokane, WA 99210-0200 In no event,
except in the absence of legal capacity,shall a claim be accepted later than one(1)year from the service date
GHC will generally process claims for benefits within the following timeframes after GHC receives the claims.
• Pre-service claims-within 15 days,or an extension of up to 15 days will be requested
• Claims involving urgently needed care-within 71 hours
0036900-C21431 41
Concurrent care claims—within 24 hours
. . Post-service claims—within 30 days,or an extension of up to 15 days will be requested.
In some circumstances, timeframes may be wended if GHC requests additional information.
0036900-C21431 42
Medicare
Endorsement 40
For Persons Covered by Parts A and B of Medicare
THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL
REMAIN IN EFFECT EXCEPT AS MODIFIED BY THE ADDITION OF THE PROVISIONS,
EXCLUSIONS, AND LIMITATIONS CONTAINED IN THIS MEDICARE ENDORSEMENT.
IN NO EVENT SHALL THE BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE
BENEFITS UNDER THE GROUP MEDICAL COVERAGE AGREEMENT. THE HIGHER
LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THIS GROUP MEDICAL
COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL AND HOSPITAL
BENEFITS ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS
AMENDED, AND REFERRED TO AS "MEDICARE." THE BENEFITS AND EXCLUSIONS
DESCRIBED IN THIS ENDORSEMENT APPLY ONLY TO MEMBERS WHO ARE
COVERED UNDER BOTH PART A AND PART B OF MEDICARE.
Group Health Cooperative offers two parts of Medicare arrangements for employer group
members living in the Group Health service area
1) If you are a member living in the service area where the Group Health Medicare+Choice
Plan is available you must have both Parts A & B of Medicare and be enrolled in this plan.
Those enrolled under GH's Medicare plan, as set forth in this Endorsement, may be subject
to copayment.
2) If you are a member living in the service area where the Medicare+Choice plan is not
available, you must still enroll in and maintain both Medicare Parts A & B in order for your
employer group plan to coordinate benefits with Medicare.
3) In order to be eligible for Part B Only benefits members must have been enrolled in Group
Health prior to January 1, 1999.
Except as defined by Federal Regulations, all Members entitled to, or eligible to purchase
Medicare must transfer to the GH Medicare+Choice Plan upon such entitlement or eligibility A
condition of enrollment under the GH Medicare+Choice Plan requires that a Member be
continuously enrolled for the hospital (Part A) and medical (Part B) benefits available from the
Social Security Administration, and sign any papers that may be required by GH or Medicare.
For additional information, the Member may refer to "Medicare & You handbook,"which can
be obtained from your local Social Security office
NEITHER GH NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GH
FACILITIES UNLESS THE MEMBER HAS BEEN REFERRED BY GH OR THE MEMBER
HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SERVICES OR OUT OF AREA
RENAL DIALYSIS SERVICES ACCORDING TO SECTION V.D OF THIS MEDICARE
ENDORSEMENT OR THE MEMBER HAS RECEIVED NON-EMERGENT AND/OR NON-
0036900-C21431 43
URGENTLY NEEDED CARE AT FACILITIES OUTSIDE THE SERVICE AREA UNDER
YOUR POINT-OF SERVICE(POS)BENEFIT AS SET FORTH IN SECTION V.F.
Tlus Endorsement does not constitute a"Medicare supplemental'contract.
SECTION I. HEALTHCARE TERMS
CENTER for MEDICARE and MEDICAID SERVICES (CMS) formerly known as
HCFA: The Federal Agency responsible for admuustenng Medicare.
CUSTODIAL CARE: Care furnished for the purpose of meeting non-Medically Necessary
personal needs which could be provided by persons without professional skills or training, such
as assistance in mobility, dressing, bathing, eating, preparation of special diets, and taking
medication. Custodial Care is not covered by the GH M+C Plan or Medicare unless provided in
conjunction with Skilled Nursing Care and/or skilled rehabilitation services. .
EMERGENCY CONDITION: A medical condition manifesting itself by acute symptoms of
sufficient seventy (including severe pain) such that a prudent lay person with an average
knowledge of health and medicine could reasonably expect the absence of immediate medical
attention to result 1) Serious jeopardy to the health of the individual or, in the case of a pregnant
woman, the health of the woman or her unborn child; 2) Serious impairment to bodily functions;
or 3) Serious dysfunction of any bodily organ or part
EMERGENCY SERVICES: Covered inpatient and outpatient services that are furnished by a
provider qualified to furrush emergency services needed to evaluate or stabilize an emergency
medical condition
MAXIMUM CHARGES: A term used to define the level of benefits which are payable by GH
when expenses are incurred from a non-GH physician or provider Expenses are considered
Maximum Charges if(1) the charges are consistent with those normally charged by the provider
or organization for the same services or supplies, and(2) the charges are within the general range
of charges made by other providers in the same geographical area for the same services or
supplies
MEDICARE. The federal health insurance program for people 65 years of age or older, certain
younger people with disabilities, and people with End Stage renal Disease (generally those with
permanent kidney failure who need dialysis).
MEDICARE+CHOICE(M+C) COORDINATED CARE PLANS:These are M+C Plans that
use a network of providers that are under contract or arrangement with a Medicare+Choice
Organization to provide covered benefits. The GH M+C Plan is a Coordinated Care Plan.
MEDICARE+CHOICE (M+C) ORGANIZATION• A public or private entity organized and
licensed by the State as a nsk-bearing entity that is certified by CMS as meeting M+C contract
requirements. M+C Organizations can offer one or more M+C Plans GH is an M+C
Organization.
0036900-C21431 44
MEDICARE+CHOICE PLAN (M+C): A policy or benefit package offered by a
Medicare+Choice Organization under which a specific set of health benefits offered at a uniform
premium and umform level of cost-sharing to all Medicare beneficiaries residing in the service
area covered by the Plan. An M+C Organization may offer more than one benefit Plan in the
same Service Area. The GH Plan is an M+C plan.
PERMANENT MOVE: A permanent change of residence out of the service area or an
uninterrupted absence of more than six (6)months from GHC's Service Area.
POINT OF SERVICE (POS): A benefit that GH offers to its M+C Members while temporarily
traveling outside-of-the GH M+C Plan Service Area for non-emergent and/or non-urgently
needed care. In return for this flexibility, members have higher cost-sharing requirements for
these services.
REFERRAL: A formal recommendation by your Primary Care Physician or his/her Contracting
Medical Group that you receive care from a Specialist, Contracting Medical Provider, or Non-
Contracting Medical Provider.
SERVICE AREA: The geographic area comprised of parts of Grays Harbor, Island, King,
Kitsap, Lewis, Pierce, parts of Mason, San Juan, Skagit, Snohomish, Thurston, and Whatcom
Counties, and any other areas designated by GH and approved by the Health Care Financing
Administration.
SKILLED NURSING FACILITY A facility (or distinct part of a facility) which is primarily
engaged in providing to its residents mpatient Skilled Nursing Care, rehabilitation services, or
other related health services and is certified by Medicare The term "Skilled Nursing Facility"
does not include a convalescent nursing home, rest facility, or facility for the aged which
finnishes primarily Custodial Care, including traming in routines of daily living.
URGENTLY NEEDED CONDITION Covered Services provided when you are temporarily
absent from the GH M+C Plan Service Area(or, under unusual and extraordinary circumstances,
provided when you are in the Service Area but your Contracting Medical Group is temporarily
unavailable or inaccessible) when such services are Medically Necessary and immediately
required 1) as a result of an unforeseen illness, injury, or condition, and 2) it is not reasonable,
given the circumstances, to obtain the services through your Contracting Medical Group.
SECTION 11. DISENROLLMENT
Enrollment under the GH M+C Plan for a specific Member may be terminated in the
circumstances set forth below.
Until such time as a Member's termination of enrollment from GH is effective,neither Medicare
nor any other Medicare+Choice organization shall pay for services for which GH is responsible
While a Member is enrolled with GH, GH will only cover the following services provided by
non-GH Providers,non GH-Facilities, or non-GH Designated Facilities: (1) Referrals authorized
0036900-C21431 45
by a GH Provider; (2) Emergency services anywhere in the world, Urgent Care, or out-of the
area renal dialysis services as set forth in Section V.D., or (3) Non-Emergent and/or Non-
Urgently Needed care at facilities outside the Service area under your point-of service (pos)
benefit, as set forth in Section V.F. Upon termination of membership in GH,neither GH nor GH
Providers shall have further liability or responsibility under this Agreement for Member's health
care services.
A. Voluntary Disenrollment
You may choose to end your membership in the GH M+C Plan for any reason. If you want to
disenroll,write a letter or complete a disenrollment form and send it to the GH Customer Service
Department. You may also disenroll through any Social Security Administration or Railroad
Retirement Board office or you can call 1 (800)MEDICARE.
The date of your disenrollment will depend on when your request to disenroll is received In
general, requests to disenroll will be effective the first day of the month after the month the
disenrollment request is received
Even though you have requested disenrollment, you must still get all routine services from GH
Contracting Medical Providers until you are notified of the effective date of your disenrollment
GH will send you a letter that confirms when your disenrollment is effective. You will be
covered by Original Medicare after you disenroll from GH unless you have joined another
Medicare Managed Care Plan.
B. Involuntary Disenrollment.
GH must disenroll you from the GH M+C Plan if.
1 You move permanently out of the service area and do not voluntarily disenroll or choose
Continuation of coverage,
Z You live outside the plan's service area for more than six months at a time.
3 You do not have Medicare Part A and/or Part B, or
4. The contract between GH and CMS under which the GH M+C Plan is offered is
terminated,or the GH M+C Plan service area is reduced.
GH may disenroll you from the GH M+C Plan under the following conditions
1. If you supply fraudulent information or make misrepresentations on your individual
election form which materially affects your eligibility to enroll in the GH M+C Plan,
2 If you are disruptive, unruly, abusive or uncooperative to the extent that your membership
in the GH M+C Plan seriously mipaus our ability to arrange Covered Services for you or
other individuals enrolled in the plan. Involuntary Disenrollment on this basis is subject to
prior approval by CMS;
0036900-C21431 46
3. If you allow another person to use your GH M+C Plan membership card to obtain Covered
Services,
4. You fail to pay the Plan basic Premiums. We will notify you of a 90-day grace period to
pay the premiums before you are disenrolled. Your 90-day grace period will start as of the
date you are notified of the delinquent payment.
C. Persons Hospitalized on the Date of Termination. A Member who is a registered bed
patient receiving Covered Services in a GH Facility or GH Designated Facility on the date of
termination shall continue to receive covered inpatient services, until discharge from the
facility. This continued coverage will also apply to a Member hospitalized in a Medicare-
certified non-GH Designated Facility as a result of Emergency or Urgently Needed Services
or Referral as set forth in Section VI.B. of this Medicare Endorsement.
D. Services Provided After Termination.Any services provided by GH after the effective date
of termination (except those services covered under Section II.C. of this Medicare
Endorsement) shall be charged according to the fee schedule. The Subscriber shall be liable
for payment of all such charges for services provided to the Subscriber and all Family
Dependents
SECTION III. COORDINATING OTHER BENEFITS YOU MAY HAVE
Who Pays First?
If you are age 65 or older and have coverage under an employer group plan of an employer of
twenty (20) or more employees, either based on your own current employment or the current
employment of a spouse, you must use the benefits under that plan. Similarly, if you have Medi-
care based on disability and are covered under an employer group plan of an employer of one
hundred(100) or more employees (or a multiple employer plan that includes an employer of one
hundred or more employees) either through your own current employment or that of a family
member, you must use the benefits under that plan. In such cases, you will only receive benefits
not covered by your employer group plan through our contract with Medicare. A special rule
applies if you have or develop End-Stage Renal Disease(ESRD).
If any no-fault or any liability insurance (or payment from a liable third party) is available to
you, then benefits under that plan (or from that liable third party) must be applied to the costs of
health care covered by this plan. Where we have provided benefits and a judgment or settlement
is made with a no-fault or liability insurer (or liable third party), you must reimburse us. How-
ever, our reimbursement may be reduced by a share of procurement costs (e.g , attorney fees and
costs). Workers' compensation for treatment of a work-related illness or injury should also be
applied to covered health care costs by thus plan.
If you have (or develop) ESRD and are covered under an employer group plan, you must use the
benefits of that plan for the first thirty(30)months after becoming eligible for Medicare based on
ESRD. Medicare is the primary payer after this coordination period. (However, if your employer
0036900-C21431 47
group plan coverage was secondary to Medicare when you developed ESRD because it was not
based on current employment as described above, Medicare continues to be primary payer.)
Because of this, we may ask you for information about other insurance you may have. If you
have other insurance, you can help us obtain payment from the other insurer by providing the
information we request promptly. Coordination of benefits protects you from higher Plan
Premiums The end result is more affordable health care.
SECTION IV. APPEAL AND GRIEVANCE PROCEDURES
A. Grievances.
If a member is dissatisfied with care or services received at a Medical or Dental Office or
Hospital, or a Member disputes amounts owed, eligibility or membership status, the Member
may submit a written grievance to GHC. GH will conduct a formal review and provide a
written response within 60 days of the time all pertinent materials are received
B. Standard Expedited Requests for Care or Service.
1. Standard Request. The Member may request that care or a service be covered by GH
on the basis that it is a Medicare covered service. GH will reach a decision within 14
days. GHC's decision may be delayed an additional 14 days if it is in the Member's best
interest or upon the Member's request
2. Expedited Request If a member requests care or a service they believe is covered by
Medicare and the Member believes and/or his/her physician states that a delay in making
a determination about coverage could jeopardize the Member's health or ability to
function, the Member may request an expedited decision In most instances, GH will
reach a decision within 72 hours. GH's decision may be delayed an additional 14
working days if it is in the Member's best interest to delay a decision or upon the
Member's request. GH's decision may also be postponed in the event information for a
non-GH provider has not been received in a timely manner. If GH grants a Member's
request for an expedited decision, GH will orally notify the Member and follow-up within
two (2) working days, with a written letter. If a Member disagrees with GH's decision
not to expedite his/her request,the Member may file a grievance
C. Appeals.
Members have a right to appeal any decision in which GH declines to provide, cover, or pay
for services that the Member believes are covered by Medicare If GH declines to provide or
to cover a service, GH will provide the Member with a Notice of Non-coverage containing
the reason(s) for the denial and an explanation of the Member's appeal rights.
Members who disagree with a decision by GH may submit a written appeal to GH. Members
appealing a denied claim for payment for a service already provided or arranged may request
a standard 60-day appeal. Members appealing a request for a future service may ask for
0036900-C21431 48
either a standard 30 day appeal or an Expedited (72-hour) appeal if the Member believes (or
the Member's Provider states) that a delay in responding to the Member's appeal could
seriously jeopardize his/her health or ability to function
Appeals will be reviewed by persons not involved in the initial decision. If GH decides to
uphold the original adverse decision, either in whole or in part, the entire file will be
forwarded by GH to CHDR for review.
1. Standard Appeal.
a. 60-Day Appeals for Claim for Payment. A member may submit an appeal requesting a
second review at any time GH denies coverage for services already provided or arranged
by either GH or a non-GH provider or facility, or for future services Member must
submit appeals in writing to GH, or to any Social Security Office, or in the case of a
railroad retirement annuitant, a Railroad Retirement Board Office, within 60 days of
receiving notice of GH's initial decision After receiving all pertinent materials,GH will
conduct a formal review of the appeal. GH will notify the Member of its decision within
60 days of receipt. If GH decides fully in the Member's favor, GH will pay the claim(s)
within 60 days of receipt of the member's appeal If GH upholds any part of the initial
denial, the entire file will be forwarded by GH to CHDR for review. CHDR will make a
reconsideration decision and advise the Member of its decision, the reasons for the
decision and the right to additional appeal rights.
b. 30-Day Appeals for Denials of Future Services. A Member may submit an appeal
requesting a second review at any time GH denies coverage for future services Members
must submit appeals in writing to GH, or to any Social Security Office, or in the case of a
railroad retirement annuitant, a Railroad Retirement Board Office, within 60 days of the
date of GHC's initial decision. After receiving all pertinent materials, GH will conduct a
formal review of the appeal GH will notify the Member of its decision within 30 days of
receipt. GH's decision may be extended an additional 14 days if it is in the Member's
best interest or upon the Member's request. If GH upholds any part of the initial denial,
the entire file will be forwarded by GH to CMS's contractor, The Center for Health
Dispute Resolution (CHDR) for review CHDR will make a reconsideration decision
and advise the Member of its decision, the reason for the decision, and the right to
additional appeal rights.
2. Filing an Expedited (72-hour)Appeal (does not apply to denied claims for payment)
If a delay in receiving a decision could jeopardize the Member's health or ability to
function, the Member or his/her Physician may submit a request for an expedited appeal
either orally or in writing to GHC
D. Quality Improvement Organization("QIO").
"QIO" stands for Quality Improvement Organization (these organizations used to be
called "Peer Reivew Organizations" or PROs). The QIO is a group of doctors and other
0036900-C21431 49
health care experts paid by the Federal Government to check on and help improve the care
given to Medicare patients. There is a QIO in each state. QIOs have different names,
depending on which state they are in. In Washington State, the QIO is called Qualis
Health.
A Member may request a"QIO" review if GH denies coverage of a continued inpatient stay
in a hospital on the basis of medical necessity. A Member may request immediate QIO
review by phone or in writing. If a Member requests a QIO review by noon of the first
business day after a Member has received a Notice of Non-coverage, the Member will not be
financially responsible for the cost of the continued hospitalization until the QIO's
determination.
GH will provide the Member written notice of procedures by which to request a QIO review.
If a Member requests a QIO review, the Member may not pursue the Standard Appeal
Procedure and/or the Expedited Appeal Procedure with respect to denial of the same hospital
stay.
A Member may contact Qualis Health at PO Box 33400, Seattle, WA 98133-0400 or 10700
Meridian Ave N, Suite 100, Seattle, WA 98133-9075, telephone number(206) 364-9700 or
Fax: (206) 368-2419.
E. Additional Appeal Rights.
If CMS upholds GH's initial determination and denies the appeal and if the amount in
controversy is $100 00, or more the Member may request a hearing before an administrative
law judge of the Social Security Administration. The Member may request a hearing before
an administrative law judge by writing to GH, CMS, or a Social Security Office within 60
days after the date of notice of an adverse reconsideration decision.
If the administrative law judge denies a Member's appeal, either the Member or GH may request
a review by the Social Security Administration's Appeals Council.
If a Member's appeal is denied by the Appeals Council and if the amount in controversy is
$1,000 00,or greater the Member or GH may request a review by the Department Appeals Board
(DAB).
An initial, revised, or reconsideration determination made by GH, CMS, an administrative law
judge, or the Appeals Council can be reopened (a) within twelve months, (b) within four years
for just cause, or(c) at any time for clerical correction or in the case of fraud
The Medicare Appeals Coordinator can be reached by writing to Group Health Cooperative, c/o
Medicare Appeals Coordinator, P.O. Box 34593, Seattle WA 991324, or by calling (206) 901-
7350 or toll-free at 1-(888)-901-4636 or TTY/TDD 711 or 1-800-833-6388, for the "hearing
impaired"or by fax at(206) 901-7340
. SECTION V. SCHEDULE OF MEDICAL BENEFITS
0036900-C21431 50
All benefits and services listed in this Schedule of Benefits:
• are subject to all provisions of this Agreement and Medicare Endorsement;
• must be approved in advance by GH except for Emergency and Urgently Needed
Services as set forth in Section V.D. of this Medicare Endorsement, and
• must meet Medicare guidelines and limitations unless otherwise specified.
GH has procedures to assist GH Providers in establishing a treatment plan for Members with
complex or serious medical conditions New Members should discuss all his/her medical
concerns with the GH Primary Care Provider selected. New members may expect their
health status to be assessed within 90 days of their enrollment.
GH will ensure that services are provided in a culturally competent manner GH Providers
will provide information regarding treatment options in a culturally competent manner and
will accommodate Members with disabilities
GH covers all Medicare deductibles and coinsurance. The booklet, "Medicare & You"provides
additional information about Medicare benefits and can be obtained from your local Social
Security office, or your Washington State Part B camer's office.
Services received at facilities outside the GH Service Area may be covered for non-emergent
and/or non-urgently needed care subject to the Point of service benefits set forth in the Summary
of Medical Benefits. All Medicare non-covered expenses, including deductibles and
coinsurance, are the responsibility of the Member.
A. Skilled Nursing Facility. Upon Referral and followmg a Medicare-certified three (3) day
hospital stay, GH will cover 100 days of Medicare covered Skilled Nursing Facility care per
benefit period. All Medicare criteria must be met and the stay must be authorized in advance
by the plan.
B. Hospice.
Members with Part A and Part B of Medicare who elect to receive Medicare-covered hospice
services may select any Medicare-certified hospice program Members who elect to receive
services from the GH Hospice Program are entitled to hospice services as provided under the
Medicare Hospice Program. Members who elect to receive hospice services do so in lieu of
curative treatment for their temunal illness for the penod that they are in the hospice
program. To receive hospice services, the Member is required to sign the Hospice Election
Form.
Covered Services. In addition to the hospice services provided under the Group Medical
Coverage Agreement, the following hospice services shall be provided:
0036900-C21431 51
1. Home Services
Continuous care services per Member in the Member's home when prescribed by a GH
provider, as set forth in this paragraph. Continuous care is defined as "skilled nursing care
provided in the home during a period of crisis in order to maintain the terminally ill patient at
home." Continuous care may be provided for pain or symptom management by a Registered
Nurse, Licensed Practical Nurse, or Home Health Aide under the supervision of a Registered
Nurse. Continuous care may be provided up to twenty-four (24) hours per day dunng penods
of crisis. Continuous care is covered only when a GH provider determines that the Member
otherwise would require hospitalization in an acute care facility.
2. Inpatient Hospice Services for short-term care shall be provided through a Medicare-
certified Hospice Program when Medically Necessary, and authorized in advance by a GH
provider. Respite care is covered for a maximum of five (5) consecutive days per occurrence
in order to continue care for the Member in the temporary absence of the Member's primary
care-giver(s).
3. Other hospice services may include the following:
a. drugs and biologicals that are used primarily for the relief of pain and symptom
management,
• b. medical appliances and supplies primarily for the relief of pain and symptom
management;
c counseling services for the Member and his/her primary care-giver(s), and
d. bereavement counseling services for the family.
C. Mental Health Care, Alcoholism and Drug Abuse Treatment Services.
1. Outpatient mental health, alcoholism and substance abuse treatment services are
covered for each Member in accordance with Medicare Guidelines.
2. Inpatient mental health care services are covered in full up to a 190-day lifetime
benefit when such services are provided in a Medicare-certified psychiatric hospital
3. Inpatient alcoholism and drug abuse treatment services are covered in full when such
services are provided in a hospital-based treatment center.
Coverage for Medical Emergencies incident to alcoholism and drug abuse or for acute
alcoholism or drug abuse, including acute detoxification, is provided as set forth in
Section V D. of this Medicare Endorsement.
0036900-C21431 52
D. Emergency/Urgently Needed Services. When an Emergency meets the Medicare definition
for Emergency or Urgently Needed Services as defined in Section I. of this Medicare
Endorsement, services are covered in full,subject to the applicable copayments.
E. If the Member is hospitalized in a non-GH Facility and requires continued inpatient care GH
will continue to cover the non-emergent care and services at the non-GH Facility needed by
the Member to remain medically stable until: (1) the Member is discharged; (2) a GH
Provider arrives and assumes responsibility for the Member's care; or (3) GH and the
Member's treating physician decide the member may be transferred without harmful medical
consequences wluchever occurs first. A decision to transfer the member to a GH Facility is
made at the discretion of GH with the attending physician's concurrence.
Post-stabilization care at a non-GH facility will be covered when: (a) Pre-approved by Group
Health; or (b)Not pre-approved because Group Health did not respond to the request for pre-
approval within one (1) hour after being requested to approve such care, or Group Health
could not be contacted for pre-approval.
F. POINT OF SERVICE (FOS). Non-Emergent and/or non-urgently needed care received
while temporarily traveling outside GH's Medicare Service Area is payable at Medicare
benefit levels up to $2,000.00 per member per calendar year. The plan pays 80% of the
Medicare allowable reimbursement schedules for Medicare covered services only. The
enrollee is responsible for all Medicare deductibles and coinsurance. Coverage under this
benefit does NOT include coverage of prescription drugs or traveling primarily for the
purpose of seeking medical care.
G. Medicare Ambulance Benefit (including air, water, or ground transport) Medically
Necessary ambulance transportation to or from a hospital or Skilled Nursing Facility is
covered in full Medically necessary emergency ambulance transportation outside the United
States or the U S. territories is covered only if transportation by any other vehicle could
endanger the patient's health.
H. Medical and Surgical Care. The following medical and surgical services are covered when
prescribed by GH Medical Personnel and Medicare requirements are met
1. Eye examinations and treatment for eye pathology.
Evaluations and surgical procedures to correct refractions which are not related to eye
pathology are not covered. Complications related to such surgery are also excluded
2. One pair of eyeglasses or contact lenses, including examination and fitting, following
each cataract surgery with insertion of an introcular lens (10L). Covered eyeglasses and
contact lenses must be dispensed through GH Facilities. Replacements for Members
following insertion of an intraocular lens are set forth in Section H.13 below.
Replacements in the absence of an intraocular lens will be provided when needed due to
change in the Member's medical condition or when deemed appropriate by a GH
physician.
0036900-C21431 53
3. Blood, blood derivatives, including storage, and their administration.
4 Maternity and pregnancy-related services, including visits before and after birth;
involuntary termination of pregnancy; and care for any other complication of pregnancy.
5. Organ transplants, limited to those covered by Medicare when all Medicare criteria have
been met.
6. Physician calls (including consultations and second opinions by a GH physician) in the
hospital,office,home, Skilled Nursing Facility, nursing home, or convalescent center.
7. Restorative physical, occupational, speech and language therapy, and cardiac
rehabilitation following illness,injury,or surgery.
8. Immunizations and vaccinations that are listed as covered in the GH Drug Formulary
(approved drug list) or approved by Medicare.
9. Services related to dysfunction of the jaw. When referred by a GH physician, evaluation
and treatment by a GHC-approved temporomandibular joint (TMJ) care provider
All TMJ appliances, other than the occlusal splint and its fitting, are excluded.
Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when
the dysfunction is related to malocclusion or when TMJ services are needed due to dental
work performed. All such services and related hospitalization, including orthodontic
therapy and orthognathic (law) surgery, are excluded regardless of origin or cause
(See Section X B.17 of the Group Medical Coverage Agreement for Covered Services
not meeting Medicare guidelines).
10. Chiropractic care limited to spinal manipulations. Excluded are any other diagnostic or
therapeutic services, including x-rays, furnished by a chiropractor Members must receive
all chiropractor services from GHC's designated licensed providers in order to be
covered A list of GHC-designated licensed practitioners is available by contacting any
GH area medical center.
11. Podiatric care. Services are covered when all Medicare criteria are met and when
authorized in advance by your Primary Care Provider. Excluded is treatment of flat feet
or other misalignments of the feet; removal of coms and calluses; and routine foot care
such as hygienic care, except in the presence of a non-related medical condition affecting
the lower limbs. Members must utilize GHC's designated providers in order to be
covered.
• 12.Home intravenous (IV)drug therapy services. _
0036900-C21431 54
13. Ro-atine eye examinations and refractions, limited to once every twenty-four (24) M
months, except when Medically Necessary Services for routine eye examinations must
be received at a GH Facility and in accordance with GH medical criteria in order to be
covered and are not subject to Medicare requirements.
Lenses One pair of standard glass single vision, lenticular, or non-blended bifocal or
trifocal lenses, or contact lenses, will be covered subject to the GH-approved allowance
once every twenty-four(24) months, and replaced as specified below, when received at a
GH facility and in accordance with GH medical criteria.
Frames. An Allowance of up to $100 per Member once every 24 months will be
provided for frames.
Replacements. Lens replacement for any reason (including loss, breakage or change in
prescription) will be provided not more often than once every 24 months.
Replacement of frames will be provided subject to the frames Allowance set forth above
not more often than once every 24 months.
14. Hearing examinations to determine hearing loss. Hearing aids, including examinations
and fitting, must be received at a GH Facility and are covered up to a maximum of$250
per Member once every 24 months.
15. Diabetic education and training, including glucose monitors testing strips and lancets
for all diabetics.
16. Renal dialysis services required while temporarily away from the Service Area will be
covered if provided in a Medicare-approved facility when Medicare criteria is met.
I. Prosthetic Devices, such as cardiac devices, intraocular lenses, artificial joints, breast
prostheses, artificial eyes, and braces, are covered. Excluded are: orthopedic shoes unless
they are part of leg braces; dental plates or other dental devices, and experimental devices
Therapeutic shoes for those suffering from diabetic foot disease are covered.
J. Medical/Surgical Supplies, such as casts, splints, post-surgical dressings, and ostomy
supplies, are covered.
K. Rental or Purchase of Durable Medical Equipment, such as oxygen and oxygen
equipment,wheelchairs and other walk-aids, and hospital beds, is covered.
L. Health Club Services (SilverSneakers®) and/or lifetime fitness at participating network
health clubs in the Service Area are provided to Members without charge. Unlimited
covered services include- traditional weight and cardiac equipment,pools, aerobics, and court
facilities. In addition to club member privileges, a Member may bring a guest who is
Medicare eligible for one visit up to four times per year without charge. A list of
participating network health clubs may be obtained from GH upon request.
0036900-C21431 55
SECTION VI. EXCLUSIONS AND LIMITATIONS
A. Exclusions.
1. Investigational procedures, including medical and surgical services, drugs and devices
until formally approved by Medicare unless specifically provided herein (See Section
XI.19. in the Group Medical Coverage Agreement).
2. Supportive devices (shoe inserts) for the feet
3 Services directly related to obesity except as provided by Medicare.
4. Services or supplies not specifically listed as covered by Medicare or GHC.
B. Limitations.
Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS V.D. AND
V.F., ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE
PROVIDED BY GH MEDICAL PERSONNEL AT A GH OR GH DESIGNATED
FACILITY UNLESS:
1. the Member has received a Referral from GHC,or
2. the Member has received Emergency or Urgently Needed Services as defined in Section
I and as set forth in Section V.D. of this Medicare Endorsement.
SECTION VII.CLAIMS PROCEDURE
Claims for services or supplies and explanation of Medicare benefits for services or supplies
should be sent to Medicare Claims, Group Health Cooperative, P.O Box 34585, Seattle, WA
98124-1585. If you must receive Emergency or Urgently Needed Services from a non-GH
provider, be sure to show your GH membership card. Although you never need to give up your
Medicare red, white and blue card, you must now use your GH M+C Plan care to receive
covered services It is important that you use only your GH M+C plan membership card-----
NOTyour Medicare card.
A The Provider must file claims for services rendered during the first nine (9) months of a
calendar year by December 31 of the following calendar year.
B. The Provider must file claims for services rendered in the last three (3) months of a
calendar year the same as if the services had been fiunished in the subsequent calendar
year. The time limit on filing claims for services furnished in the last three (3) months of
the calendar year is December 31 of the second calendar year following the calendar year
in which the services were rendered.
0036900-C21431 56
GH-will notify the Member and Provider of its decision within 60 days after receipt of the
claim. If the claim is denied in whole or in part, GH will provide the member a reason
for the denial and an explanation of the Member's right to appeal the denial, as set forth
in Section IV Of this Agreement.
See "Medicare & You" handbook for additional information regarding filing claims, which can
be obtained from your local Social Security office, or your Washington State Part B carrier's
office, or call 1-800-772-1213, or online @ www.Medicare.gov
GH may obtain information which it deems necessary concerning the medical care and
hospitalization for which payment is requested
0036900-C21431 57
- Medicare
Endorsement
For Persons Covered by Part B only of Medicare
THE PROVISIONS OF THE GROUP MEDICAL COVERAGE AGREEMENT SHALL
REMAIN IN EFFECT EXCEPT AS MODIFIED BY THE ADDITION OF THE PROVISIONS,
EXCLUSIONS AND LIMITATIONS CONTAINED IN THIS MEDICARE ENDORSEMENT.
IN NO EVENT SHALL THE BENEFITS UNDER THIS ENDORSEMENT DUPLICATE THE
BENEFITS UNDER THE GROUP MEDICAL COVERAGE AGREEMENT. THE HIGHER
LEVEL OF BENEFIT WILL APPLY. COVERAGE UNDER THE GROUP MEDICAL
COVERAGE AGREEMENT IS INTEGRATED WITH THE MEDICAL BENEFITS
ESTABLISHED BY TITLE 18 OF THE SOCIAL SECURITY ACT AS AMENDED, AND
REFERRED TO AS "MEDICARE." THE BENEFITS AND EXCLUSIONS DESCRIBED IN
THIS ENDORSEMENT APPLY ONLY TO MEMBERS WHO ARE COVERED UNDER
PART B ONLY OF MEDICARE.
Group Health Cooperative offers two parts of Medicare arrangements for employer group
members living in the Group Health service area
1) If you are a member living in the service area where the Group Health Medicare+Choice
Plan is available you must have both Parts A&B of Medicare and be enrolled in this plan
Those enrolled under GH's Medicare plan, as set forth in this Endorsement, maybe subject to
copayment.
2) If you are a member living in the service area where the Medicare+Choice plan is not
available,you must still enroll in and maintain both Medicare Parts A&B in order for your
employer group plan to coordinate benefits with Medicare
In order to be eligible for Part B benefits members must have been enrolled in Group Health
prior to January 1, 1999.
Except as defined by Federal Regulations, all Members entitled to, or eligible to purchase
Medicare must transfer to the GH Medicare+Choice Plan upon such entitlement or eligibility. A
condition of enrollment under the GH Medicare+Choice Plan requires that a Member be
continuously enrolled for medical (Part B) benefits available from the Social Security
Administration, and sign any papers that may be required by GH or Medicare+Choice For
additional information, the Member may refer to "Medicare & You," handbook which can be
obtained from your local Social Security office.
NEITHER GH NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GH
FACILITIES UNLESS THE MEMBER HAS BEEN REFERRED BY GH OR THE MEMBER
HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SERVICES OR OUT-OF AREA
RENAL DIALYSIS SERVICES ACCORDING TO SECTION V D: OF THIS MEDICARE
ENDORSEMENT OR THE MEMBER HAS RECEIVED NON-EMERGENT AND/OR NON-
0036900-C21431 58
URGENTLY NEEDED CARE AT FACILITIES OUTSIDE THE SERVICE AREA UNDER
YOUR POINT-OF SERVICE (POS)BENEFIT AS SET FORTH IN SECTION V.F.
This Endorsement does not constitute a"Medicare supplemental'contract
SECTION I. HEALTHCARE TERMS
CENTER for MEDICARE and MEDICAID SERVICES (CMS) formerly known as
HCFA: The Federal Agency responsible for administering Medicare
CUSTODIAL CARE: Care fuimshed for the purpose of meeting non-Medically Necessary
personal needs which could be provided by persons without professional skills or training, such
as assistance in mobility, dressing, bathmg, eating, preparation of special diets, and taking
medication. Custodial Care is not covered by the GH M+C Plan or Medicare unless provided in
conjunction with Skilled Nursing Care and/or skilled rehabilitation services.
EMERGENCY CONDITION: A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent lay person with an average
knowledge of health and medicine could reasonably expect the absence of immediate medical
attention to result 1) Serious jeopardy to the health of the individual or, in the case of a pregnant
woman, the health of the woman or her unborn child; 2) Serious impairment to bodily functions;
or 3) Serious dysfunction of any bodily organ or part. 0
EMERGENCY SERVICES: Covered mpatient and outpatient services that are furrushed by a
provider qualified to furnish emergency services needed to evaluate or stabilize an emergency
medical condition.
MAXIMUM CHARGES: A term used to define the level of benefits which are payable by GH
when expenses are incurred from a non-GH physician or provider Expenses are considered
Maximum Charges if(1) the charges are consistent with those normally charged by the provider
or organization for the same services or supplies, and (2) the charges are within the general range
of charges made by other providers in the same geographical area for the same services or
supplies.
MEDICARE. The federal health insurance program for people 65 years of age or older, certain
younger people with disabilities, and people with End Stage Renal Disease (generally those with
Permanent kidney failure who need dialysis).
MEDICARE+CHOICE (M+C) COORDINATED CARE PLANS: These are M+C Plans
that use a network of providers that are under contract or arrangement with a Medicare+Choice
Organization to provide covered benefits The GH M+C Plan is a Coordinated Care Plan
MEDICARE+CHOICE (M+C) ORGANIZATION A public or private entity organized and
licensed by the State as a nsk-bearing entity that is certified by CMS as meeting M+C contract
requirements. M+C Organizations can offer one or more M+C Plans. GH is an M+C
Organization.
0036900-C21431 59
MEDICARE+CHOICE PLAN (M+C): A policy or benefit package offered by a
Medicare+Choice Organization under which a specific set of health benefits offered at a uniform
premium and umform level of cost-sharing to all Medicare beneficiaries residing in the service
area covered by the Plan. An M+C Organization may offer more than one benefit Plan in the
same Service Area. The GH Plan is an M+C plan.
PERMANENT MOVE: A permanent change of residence out of the service area or an
uninterrupted absence of more than six (6) months from GHC's Service Area.
POINT OF SERVICE (POS): A benefit that GH offers to its M+C Members while temporarily
traveling outside of the GH M+C Plan Service Area for non-emergent and/or non-urgently
needed care. In return for this flexibility, members have higher cost-shanng requirements for
these services.
REFERRAL: A formal recommendation by your Primary Care Physician or his/her Contracting
Medical Group that you receive care from a Specialist, Contracting Medical Provider, or Non-
Contracting Medical Provider
SERVICE AREA: The geographic area comprised of parts of Grays Harbor, Island, King,
Kitsap, Lewis, Pierce, parts of Mason, San Juan, Skagit, Snohomish, Thurston, and Whatcom
Counties, and any other areas designated by GH and approved by the Health Care Financing
Administration. (See Service Area Map.)
SKILLED NURSING FACILITY: A facility (or distinct part of a facility) wluch is primarily
engaged in providing to its residents which provides inpatient Skilled Nursing Care,
rehabilitation services, or other related health services and is certified by Medicare. The term
"Skilled Nursing Facility" does not include a convalescent nursing home, rest facility, or facility
for the aged which furnishes primarily Custodial Care, including training in routines of daily
living.
URGENTLY NEEDED CONDITION: Covered Services provided when you are temporarily
absent from the GH M+C Plan Service Area(or, under unusual and extraordinary circumstances,
provided when you are in the Service Area but your Contracting Medical Group is temporarily
unavailable or inaccessible) when such services are Medically Necessary and immediately
required 1) as a result of an unforeseen illness, mjury, or condition, and 2) it is not reasonable,
given the circumstances, to obtain the services through your Contracting Medical Group
SECTION II. DISENROLLMENT
Enrollment under the GH M+C Plan for a specific Member, may be terminated in the
circumstances set forth below
Until such time as a Member's termination of enrollment from GH is effective, neither Medicare
nor any other Medicare+Choice organization shall pay for services for which GH is responsible.
While a Member is enrolled with GH, GH will only cover the following services provided by
0036900-C21431 60
non-GH Providers, non GH-Facilities, or non-GH Designated Facilities- (1)Referrals authorized
by a GH Provider; (2) Emergency services anywhere in the world, Urgent Care, or out-of the
area renal dialysis services as set forth in Section V.C.; or (3) Non-Emergent and/or Non-
Urgently Needed care at facilities outside the Service area under your point-of service (POS)
benefit, as set forth in Section V E. Upon termination of membership in GH, neither GH nor GH
Providers shall have further liability or responsibility under this Agreement for Member's health
care services
A. Voluntary Disenrollment
You may choose to end your membership in GH M+C Plan for any reason. If you want to
disenroll, write a letter or complete a disenrollment form and send it to the GH Customer Service
Department You may also disenroll through any Social Security Administration or Railroad
Retirement Board office or you can call 1 (800)MEDICARE.
The date of your dmsenrolhnent will depend on when your request to disenroll is received. In
general, requests to disenroll will be effective the first day of the month after the month the
drsenrollment request is received.
Even though you have requested disenrollment, you must still get all routine services from GH
Contracting Medical Providers until you are notified of the effective date of your disenrollment.
GH will send you a letter that confirms when your disenrollment is effective. You will be
covered by Original Medicare after you disenroll from GH unless you have joined another
Medicare Managed Care Plan.
B. Involuntary Disenrollment
GH must disenroll you from the GH M+C Plan if.
1. You move permanently out of the service area and do not voluntarily disenroll or choose
Continuation of coverage,
2. You live outside the plan's service area for more than six months at a time.
3 You do not have Medicare Part A and/or Part B, or
4. The contract between GH and CMS under which the GH M+C Plan is offered is
terminated, or the GH M+C Plan service area is reduced
GH may disenroll you from the GH M+C Plan under the following conditions:
1 If you supply fraudulent information or make misrepresentations on your individual
election form which materially affects your eligibility to enroll in the GH M+C Plan;
2. If you are disruptive, unruly, abusive or uncooperative to the extent that your membership
in the GH M+C Plan seriously impairs our ability to arrange Covered Services for you or
0036900-C21431 61
other individuals enrolled in the plan. Involuntary Disenrollment on this basis is subject to
prior approval by CMS,
3. If you allow another person to use your GH M+C Plan membership card to obtain Covered
Service;
4. You fail to pay the Plan basic Premiums We will notify you of a 90-day grace period to
pay the premiums before you are disenrolled. Your 90-day grace period will start as of the
date you are notified of the delinquent payment.
C. Persons Hospitalized on the Date of Termination. A Member who is a registered bed
patient receiving Covered Services in a GH Facility or GH Designated Facility on the date of
termination shall continue to receive covered inpatient services, until discharge from the
facility. This continued coverage will also apply to a Member hospitalized in a Medicare-
certified non-GH Designated Facility as a result of Emergency or Urgently Needed Services
or Referral as set forth in Section VI.B. of this Medicare Endorsement,
D. Services Provided After Termination. Any services provided by GH after the effective date
of termination (except those services covered under Section H.0 of this Medicare
Endorsement) shall be charged according to the fee schedule. The Subscriber shall be liable
for payment of all such charges for services provided to the Subscriber and all Family
Dependents.
SECTION III. COORDINATING OTHER BENEFITS YOU MAY HAVE
Who Pays First?
If you are age 65 or older and have coverage under an employer group plan of an employer of
twenty (20) or more employees, either based on your own current employment or the current
employment of a spouse, you must use the benefits under that plan Sirmlarly,if you have Medi-
care based on disability and are covered under an employer group plan of an employer of one
hundred (100) or more employees (or a multiple employer plan that includes an employer of one
hundred or more employees) either through your own current employment or that of a family
member, you must use the benefits under that plan. In such cases, you will only receive benefits
not covered by your employer group plan through our contract with Medicare A special rule
applies if you have or develop End-Stage Renal Disease(ESRD).
If any no-fault or any liability insurance (or payment from a liable third party) is available to
you, then benefits under that plan (or from that liable third party) must be applied to the costs of
health care covered by this plan. Where we have provided benefits and a judgment or settlement
is made with a no-fault or liability insurer (or liable third party), you must reimburse us. How-
ever, our reimbursement may be reduced by a share of procurement costs (e g, attorney fees and
costs). Workers' compensation for treatment of a work-related illness or injury should also be
applied to covered health care costs by this plan.
0036900-C21431 62
If you have (or develop) ESRD and are covered under an employer group plan, you must use the
benefits of that plan for the first thirty (30)months after becoming eligible for Medicare based on
ESRD. Medicare is the primary payer after this coordination period. (However, if your employer
group plan coverage was secondary to Medicare when you developed ESRD because it was not
based on current employment as described above, Medicare continues to be primary payer)
Because of this, we may ask you for information about other insurance you may have If you
have other insurance, you can help us obtain payment from the other insurer by providing the
information we request promptly. Coordination of benefits protects you from higher Plan
Premiums. The end result is more affordable health care.
SECTION IV.APPEAL AND GRIEVANCE PROCEDURES
A. Grievances.
If a member is dissatisfied with care or services received at a Medical or Dental Office or
Hospital, or a Member disputes amounts owed, eligibility or membership status, the Member
may submit a written grievance to GH. GH will conduct a formal review and provide a
written response within 60 days of the time all pertinent materials are received
B. Standard Expedited Requests for Care or Service.
I. Standard Request. The Member may request that care or a service be covered by GH
on the basis that it is a Medicare covered service. GH will reach a decision within 14
days. GH's decision may be delayed an additional 14 days if it is in the Member's best
interest or upon the Member 7s request.
2. Expedited Request If a member requests care or a service they believe is covered by
Medicare and the Member believes and/or his/her physician states that a delay in making
a determination about coverage could jeopardize the Member's health or ability to
function, the Member may request an expedited decision. In most instances, GH will
reach a decision within 72 hours GH's decision may be delayed an additional 14
working days if it is in the Member's best interest to delay a decision or upon the
Member's request. GH's decision may also be postponed in the event information for a
non-GH provider has not been received in a timely manner If GH grants a Member's
request for an expedited decision, GH will orally notify the Member and follow-up within
two (2) working days, with a written letter. If a Member disagrees with GH's decision
not to expedite his/her request, the Member may file a grievance.
C. Appeals.
Members have a right to appeal any decision in which GH declines to provide, cover, or pay
for services that the Member believes are covered by Medicare If GH declines to provide or
to cover a service, GH will provide the Member with a Notice of Non-coverage containing
the reason(s) for the denial and an explanation of the Member's appeal rights
0036900-C21431 63
Members who disagree with a decision by GH may submit a written appeal to GH. Members
appealing a denied claim for payment for a service already provided or arranged may request
a standard 60-day appeal. Members appealing a request for a future service may ask for
either a standard 30 day appeal or an Expedited (72-hour) appeal if the Member believes (or
the Member's Provider states) that a delay in responding to the Member's appeal could
senouslyjeopardize his/her health or ability to function
Appeals will be reviewed by persons not involved in the initial decision. If GH decides to
uphold the original adverse decision, either in whole or in part, the entire file will be
forwarded by GH to CHDR for review.
1. Standard Appeal.
a. 60-Day Appeals for Claim for Payment. A member may submit an appeal
requesting a second review at any time GH denies coverage for services already
provided or arranged by either GH or a non-GH provider or facility, or for future
services. Member must submit appeals in writing to GH, or to any Social Security
Office, or in the case of a railroad retirement annuitant, a Railroad Retirement Board
Office, within 60 days of receiving notice of GH's initial decision After receiving all
pertinent materials, GH will conduct a formal review of the appeal GH will notify
the Member of its decision within 60 days of receipt. If GH decides fully in the
Member's favor, GH will pay the claim(s) within 60 days of receipt of the member's
appeal. If GH upholds any part of the initial denial, the entire file will be forwarded
by GH to CHDR for review CHDR will make a reconsideration decision and advise
the Member of its decision, the reasons for the decision and the right to additional
appeal rights.
b. 30-Day Appeals for Denials of Future Services A Member may submit an appeal
requesting a second review at any time GH denies coverage for future services.
Members must submit appeals in writing to GH, or to any Social Security Office, or
in the case of a railroad retirement annuitant, a Railroad Retirement Board Office,
within 60 days of the date of GH's initial decision After receiving all pertinent
materials, GH will conduct a formal review of the appeal GH will notify the
Member of its decision within 30 days of receipt. GH's decision may be extended an
additional 14 days if it is in the Member's best interest or upon the Member's request.
If GH upholds any part of the initial denial, the entire file will be forwarded by GH
to CMS's contractor, The Center for Health Dispute Resolution(CHDR) for review.
CHDR will make a reconsideration decision and advise the Member of its decision,
the reason for the decision, and the right to additional appeal rights
2. Filing an Expedited (72-hour)Appeal (does not apply to denied claims for payment).
If a delay in receiving a decision could jeopardize the Member's health or ability to
function, the Member or his/her Physician may submit a request for an expedited appeal
either orally or in writing to GH _
0036900-C21431 64
D. Quality Improvement Organ ization("QIO").
"QIO" stands for Quality Improvement Organization (these organizations used to be
called "Peer Reivew Organizations" or PROS). The QIO is a group of doctors and other
health care experts paid by the Federal Government to check on and help improve the care
given to Medicare patients. There is a QIO in each state. QIOs have different names,
depending on which state they are in. In Washington State, the QIO is called Qualis
Health.
A Member may request a "QIO"review if GH denies coverage of a continued inpatient stay
in a hospital on the basis of medical necessity. A Member may request immediate QIO
review by phone or in writing. If a Member requests a QIO review by noon of the first
business day after a Member has received a Notice of Non-coverage, the Member will not be
financially responsible for the cost of the continued hospitalization until the QIO's
determination.
GH will provide the Member written notice of procedures by which to request a QIO review.
If a Member requests a QIO review, the Member may not pursue the Standard Appeal
Procedure and/or the Expedited Appeal Procedure with respect to demal of the same hospital
stay.
A Member may contact Qualis Health at PO Box 33400, Seattle, WA 98133-0400 or 10700
Meridian Ave N, Suite 100, Seattle, WA 98133-9075, telephone number(206) 364-9700 or
Fax: (106) 368-2419.
E. Additional Appeal Rights.
If CMS upholds GHC's initial determination and denies the appeal and if the amount in
controversy is $100.00, or more the Member may request a hearing before an administrative
law judge of the Social Security Administration. The Member may request a hearing before
an administrative law judge by writing to GHC, CMS, or a Social Security Office within 60
days after the date of notice of an adverse reconsideration decision
If the administrative law judge demes a Member's appeal, either the Member or GH may request
a review by the Social Security Admimstration's Appeals Council
If a Member's appeal is denied by the Appeals Council and if the amount in controversy is
$1,000 00, or greater the Member or GH may request a review by the Department Appeals Board
(DAB)
An initial, revised, or reconsideration determination made by GH, CMS, an administrative law
judge, or the Appeals Council can be reopened (a) within twelve months, (b) within four years
for just cause, or(c) at any time for clerical correction or in the case of fraud.
The Medicare Appeals Coordinator can be reached by writing to Group Health Cooperative, c/o
Medicare Appeals Coordinator, P.O. Box 34593, Seattle WA 981324, or by calling (206) 901-
0036900-C21431 65
7350 or toll-free at 1-(888)-901-4636 or TTY/TDD 711 or 1-800-833-6388, for the "hearing
impaired"or by fax at(206) 901-7340.
SECTION V. SCHEDULE OF MEDICAL BENEFITS
All benefits and services listed in this Schedule of Benefits•
• are subject to all provisions of this Agreement and Medicare Endorsement,
• must be approved in advance by GH except for Emergency and Urgently Needed
Services as set forth in Section V.C. of this Medicare Endorsement; and
• must meet Medicare guidelines and limitations unless otherwise specified
GH has procedures to assist GH Providers in establishing a treatment plan for Members with
complex or serious medical conditions. New Members should discuss all his/her medical
concerns with the GH Primary Care Provider selected. New members may expect their
health status to be assessed within 90 days of their enrollment.
GH will ensure that services are provided in a culturally competent manner. GH Providers
will provide information regarding treatment options in a culturally competent manner and
will accommodate Members with disabilities.
GH covers all Medicare deductibles and coinsurance The booklet, "Medicare & You"provides
additional information about Medicare benefits, and can be obtained from your local Social
Security office, or your Washington State Part B carrier's office.
Services received at facilities outside the GH Service Area may be covered for non-emergent
and/or non-urgently needed care subject to the point-of service benefit set forth in the Summary
of Medical Benefits. All Medicare non-covered expenses, including deductibles and
coinsurance, are the responsibility of the Member.
A. Hospice.
It is understood and agreed that the following fully sets forth Covered Services for a Member
with Part B Medicare only who elects to receive hospice services Members who elect to
receive hospice services do so in lieu of curative treatment for their terminal illness for
the period that they are in the hospice program. To receive hospice services, the
Member is required to sign the Hospice Election Form.
Covered Services. Hospice services may include the following as prescribed by a GH
physician and rendered pursuant to an approved hospice plan of treatment
1. Home Services
0036900-C21431 66
Continuous care services per Member in the Member's home when prescribed by a GH
physician, as set forth in this paragraph Continuous care is defined as "skilled nursing
care provided in the home during a period of crisis in order to maintain the terminally ill
patient at home." Continuous care may be provided for pain or symptom management by
a Registered Nurse, Licensed Practical Nurse, or Home Health Aide under the
supervision of a Registered Nurse. Continuous care may be provided up to twenty-four
(24) hours per day during periods of crisis. Continuous care is covered only when a GH
physician determines that the Member otherwise would require hospitalization in an
acute care facility.
2. Inpatient Hospice Services for short-term care shall be provided in a facility designated
by GH's Hospice Program when Medically Necessary and authorized in advance by a
GH physician and GH's Hospice Program. Respite care is covered for a maximum of five
(5) consecutive days per occurrence in order to continue care for the Member in the
temporary absence of the Member's primary care-giver(s).
3. Other hospice services may include the following:
a. drugs and biologicals that are used primarily for the relief of pain and symptom
management;
b. medical appliances and supplies primarily for the relief of pain and symptom
management;
c. counseling services for the Member and his/her primary care-giver(s); and
d. bereavement counseling services for the family.
B. Mental Health Care, Alcoholism and Drug Abuse Treatment Services.
1. Outpatient mental health, alcoholism and substance abuse treatment services are
covered for each Member in accordance with Medicare Guidelines.
2. Inpatient mental health care services are covered in full up to a 190-day lifetime
benefit when such services are provided in a Medicare-certified psycluatric hospital
3. Inpatient alcoholism and drug abuse treatment services are covered in full when such
services are provided in a hospital-based treatment center.
Coverage for Medical Emergencies incident to alcoholism and drug abuse or for acute
alcoholism or drug abuse, including acute detoxification, is provided as set forth in
Section V C. of this Medicare Endorsement.
C. Outpatient Emergency/Urgently Needed Services. When an Emergency meets the
Medicare definition for Emergency or Urgently Needed Services as defined in Section I of
0036900-C21431 67
this lvtedicare Endorsement, services are covered in full, subject to the applicable
copayments.
D. If the Member is hospitalized in a non-GH Facility and requires continued inpatient care GH
will continue to cover the non-emergent care and services at the non-GH Facility needed by
the Member to remain medically stable until: (1) the Member is discharged; (2) a GH
Provider arrives and assumes responsibility for the Member's care; or (3) GH and the
Member's treating physician decide the member may be transferred without harmful medical
consequences whichever occurs first. A decision to transfer the member to a GH Facility is
made at the discretion of GH with the attending physician's concurrence
Post-stabilization care at a non-GH facility will be covered when: (a) Pre-approved by Group
Health; or (b)Not pre-approved because Group Health did not respond to the request for pre-
approval within one (1) hour after being requested to approve such care, or Group Health
could not be contacted for pre-approval.
E. POINT OF SERVICE (POS). Non-Emergent and/or non-urgently needed care received
while temporarily traveling outside GH's Medicare Service Area is payable at Medicare
benefit levels up to $2,000 00 per member per calendar year. The Plan pays 80% of
Medicare allowable reimbursement schedules for Medicare covered services only The
enrollee is responsible for all Medicare deductibles and coinsurance. Coverage under this
benefit does NOT include coverage of prescription drugs or traveling primarily for the
purpose of seeking medical care.
F. Medicare Ambulance Benefit (including air, water, or ground transport) Medically
Necessary ambulance transportation to or from a hospital or Skilled Nursing Facility is
covered in full. Medically necessary emergency ambulance transportation outside theUmted
States or the U.S. territories is covered only if transportation by any other vehicle could
endanger the patient's health.
G. Medical and Surgical Care. The following medical and surgical services are covered when
prescribed by GH Medical Personnel and Medicare requirements are met
1. Eye examinations and treatment for eye pathology.
Evaluations and surgical procedures to correct refractions which are not related to eye
pathology are not covered. Complications related to such surgery are also excluded.
2 Frames and Lenses One pair of eyeglasses or contact lenses, including examination and
fitting, following each cataract surgery with insertion of an introcular lens (IOL).
Covered eyeglasses and contact lenses must be dispensed through GH Facilities.
Replacements for Members following insertion of an intraocular lens are set forth in
Section G.13. below Replacements in the absence of an intraocular lens will be provided
when needed due to change in the Member's medical condition or when deemed
appropriate by a GH physician.
3 Blood, blood derivatives, including storage, and their administration.
0036900-C21431 68
4 Maternity and pregnancy-related services, including visits before and after birth;
involuntary termination of pregnancy, and care for any other complication of pregnancy.
5. Organ transplants, limited to those covered by Medicare when all Medicare criteria
have been met.
6. Physician calls (including consultations and second opimons by a GH physician) in the
hospital, office,home, Skilled Nursing Facility,nursing home, or convalescent center.
7. Restorative physical, occupational, speech and language therapy, and cardiac
rehabilitation following illness, injury, or surgery.
8. Immunizations and vaccinations that are listed as covered in the GH Drug Formulary
(approved drug list) or approved by Medicare.
9. Services related to dysfunction of the jaw. When referred by a GH physician,
evaluation and treatment by a GH-approved temporomandibular joint (TMJ) care
provider.
All TMJ appliances, other than the occlusal splint and its fitting, are excluded.
Treatment of jaw dysfunction, including TMJ dysfunction, will NOT be provided when
the dysfunction is related to malocclusion or when TMJ services are needed due to dental
work performed All such services and related hospitalization, including orthodontic
therapy and orthognatluc (jaw) surgery, are excluded regardless of origin or cause
(See Section X.13 17. of the Group Medical Coverage Agreement for Covered Services
not meeting Medicare Guidelines)
10. Chiropractic care limited to spinal manipulations. Excluded are any other diagnostic or
therapeutic services, including x-rays, furrushed by a chiropractor. Members must receive
all chiropractic services from GH`s designated licensed providers in order to be covered
A list of GH-designated licensed practitioners is available by contacting any GH area
medical center.
11. Podiatric care. Services are covered when all Medicare criteria are met and when
authorized in advance by your Primary Care Provider. Excluded is treatment of flat feet
or other misalignments of the feet; removal of corns and calluses; and routine foot care
such as hygienic care, except in the presence of a non-related medical condition affecting
the lower limbs. Members must utilize GH's designated providers in order to be covered
12. Home intravenous (W)drug therapy services.
13 Routine eye examinations and refractions, limited to once every twenty-four (24)
months, except when Medically Necessary. Services for routine eye examinations must
0036900-C21431 69
be Yeceived at a GH Facility and in accordance with GH medical criteria in order to be
covered and are not subject to Medicare requirements.
Lenses. One pair of standard glass single vision, lenticular, or non-blended bifocal or
trifocal lenses, or contact lenses, will be covered subject to the GH-approved allowance
once every twenty-four(24) months, and replaced as specified below, when received at a
GH facility and in accordance with GH medical criteria.
Frames. An Allowance of up to $100 per Member once every twenty-four (24) months
will be provided for frames.
Replacements. Lens replacement for any reason (including loss, breakage or change in
prescription)will be provided not more often than once every 24 months
Replacement of frames will be provided subject to the frames Allowance set forth above
not more often than once every twenty-four (24) months.
14. Hearing examinations to determine hearing loss. Hearing aids, including exammations
and fittmg, must be received at a GH Facility and are covered up to a maximum of$250
per Member once every twenty-four(24) months.
15. Diabetic education and training, including glucose monitors, testing strips and lancets
for all diabetics.
16. Renal dialysis services required while temporarily away from the Service Area will be
covered if provided in a Medicare-approved facility when Medicare cnteria is met
H. Prosthetic Devices, such as cardiac devices, mtraocular lenses, artificial joints, breast
prostheses, artificial eyes, and braces, are covered. Excluded are: orthopedic shoes unless
they are part of leg braces; dental plates or other dental devices, and experimental devices
Therapeutic shoes for those suffering from diabetic foot disease are covered
I. Medical/Surgical Supplies, such as casts, splints, post-surgical dressings, and ostomy
supplies, are covered.
J. Rental or Purchase of Durable Medical Equipment, such as oxygen and oxygen
equipment,wheelchairs and other walk-aids, and hospital beds, is covered.
K Health Club Services(SilverSneakers0) and/or lifetime fitness at participating network
health clubs in the Service Area are provided to Members without charge. Unlimited
covered services include traditional weight and cardiac equipment,pools, aerobics, and court
facilities. In addition to club member privileges, a Member may bring a guest who is
Medicare eligible for one visit up to four times per year without charge A list of
participating network health clubs may be obtained from GH upon request.
0036900-C21431 70
L. Skilled-Nursing Facility. Upon Referral and following a Medicare-certified three (3) day
hospital stay, GH will cover 100 days of Medicare covered Skilled Nursing Facility care per
benefit period All Medicare criteria must be met and the stay must be authorized in
advance by the plan.
SECTION VI. EXCLUSIONS AND LIMITATIONS
A. Exclusions.
1. Investigational procedures, including medical and surgical services, drugs and devices
until formally approved by Medicare unless specifically provided herein (See Section
XI.19. in the Group Medical Coverage Agreement).
2. Supportive devices (shoe inserts) for the feet.
3. Services directly related to obesity except as provided by Medicare.
4 Services or supplies not specifically listed as covered by Medicare or GHC.
B. Limitations.
Conditions and Extent of Coverage. EXCEPT AS PROVIDED IN SECTIONS V D. AND
V.E , ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE
PROVIDED BY GH MEDICAL PERSONNEL AT A GH OR GH DESIGNATED
FACILITY UNLESS:
1 the Member has received a Referral from GHC,or
2. the Member has received outpatient Emergency or Urgently Needed Services as defined
in Section I and as set forth in Section V C of tlus Medicare Endorsement
Section V11. CLAIMS PROCEDURE
Claims for services or supplies and explanation of Medicare benefits for services or supplies
should be sent to: Medicare Claims, Group Health Cooperative, P.O. Box 34585, Seattle, WA
98124-1585. If you must receive Emergency or Urgently Needed Services from a non-GH
provider, be sure to show your GH membership card. Although you never need to give up your
Medicare red, white and blue card, you must now use your GH M+C Plan care to receive
covered services. It is important that you use only your GH M+C plan membership card-----
NOTyour Medicare card.
A. The Provider must file claims for services rendered during the first nine (9) months of a
calendar year by December 31 of the following calendar year.
B The Provider must file claims for services rendered in the last three (3) months of a calendar
year the same as if the services had been furnished in the subsequent calendar year. The time
limit on filing claims for services furnished in the last three (3) months of the calendar year is
0036900-C21431 71
December 31 of the second calendar year following the calendar year in which the services
were rendered
GH will notify the Member of its decision within 60 days after receipt of the claim If the
claim is denied in whole or in part, GH will provide the member a reason for the denial and
an explanation of the Member's right to appeal the denial, as set forth in Section IV of this
Agreement.
See "Medicare &You" handbook for additional information regarding filing claims, which can
be obtained from your local Social Security office, or your Washington State Part B carrier's
office, or call 1-800-772-1213, or online @ www.Medicare.gov.
GH may obtain information which it deems necessary concerning the medical care and
hospitalization for which payment is requested.
0036900-C21431 72
GROUP HEALTH COOPERATIVE
By
Title President
GROUP
Kent, City Of, #0036900
By
Title
This Agreement will become effective January 1, 2003 and will continue
in effect until terminated as herem provided for.
CA-1814R
PA-113302
CA-1936
CA-1385
CA-6100
CA-107600
CA-1395
0036900-C21431 73
CITY OF KENT
Group # 00369
For attachment to Group Medical Coverage Agreement
BENEFIT DESCRIPTION
INSIDE THE NETWORK:
MANAGED HEALTH CARE
$5 Outpahent/Office Visit
$5 Outpatient Prescription Drugs
$75 Emergency Room
No pre-existing condition wait
MONTHLY HEALTH CARE PREMIUM:
This schedule reflects Group Health Cooperative monthly premium effective
January 1,2003 and guaranteed to January 1,2004
Subscriber $230 62 permonth
Subscriber and spouse $515,98 per month
Subscriber and child(Ten) $465 Mr per month
Subscriber and family $738 per month
MEDICARE SUPPLEMENTAL HEALTH CARE DUES
NOTE Medicare rates do not apply to TEFRA eligible enrollees
12 0 percent(12"/u)of each month's medical dues for each member and each family enrollee,as
scheduled above,is the budgeted prepayment for cost of all pharmaceuticals and prescriptions to be
dispersed on written orders of the Managed Healthcare Network providers for the next fiscal year
under coverage of your medical coverage agreement
Rates are quoted on a dual choice basis
Regardless of the effective date of enrollment for a Subscriber and Family Dependents,
the Group will not be required to submit premiums to the Cooperative for the month of
enrollment, and these Members will appear on the subsequent month's billing at the
regular charge. When the Subscnber's enrollment terminates,the group will submit the
full amount of premiums to the Cooperative regardless of the specific date of termination
for that month.
GROUP HEALTH COOPERATIVE
CONTRACT REVISIONS
Effective January 1,2003
(Created 8/12102,revised 2/26/03)
This is the most current list of revisions,but this list is subject to change at any time
CONTRACT EXPLANATION
LANGUAGE/BENEFIT CHANGE
General Information Numerous changes have been made throughout the agreement to
reflect the fact that the agreement is an insurance document,rather
than a care delivery document
Introduction Information contenting "Accessing Care"has been added to this
section in addition to referencing GH designated self-referral
specialists, and moving access to care provisions from the
Linutations section of the Agreement,
Table of Contents The headings for Subrogation,Gnevance/Appeal Procedures and
Exclusions and Limitations has been revised,as well as throughout
the Agreement
Allowances Schedule The Allowances Schedule has been reformatted to combine sundar
coverage under one heading,and clarifications have also been made
throughout the Allowances Schedule
Self-referrals to GHC providers that are licensed acupuncturists and
naturopaths are now available Five self-referred visits are available
for acupuncturists, and two self-referred visits are available for
natumpaths
The benefit period allowance under chemical dependency services
has been increased in accordance with Washington state law The
dollar amount will be reflected in the Agreement
Skilled nursing facility services are now covered up to sixty(60)
days per Member per calendar year(m addition to coverage in lieu
of hospitalization).Additional information concerning the benefit
can be found in Section X Schedule of Benefits (The 60-day
skilled nursing facility coverage is dependent on when the actual
renewal paperwork was provided to the group)
Enrolhnent/Ehgibihty Requirements The provision concerning persons hospitalized on the effective date
of coverage has been clarified to state that coverage for members
admitted to an inpatient facility prior to their enrollment under this
Agreement,and who do not have coverage under another
Agreement,will receive covered benefits beginning on their
effective date. Also,GHC reserves the tight to require transfer of a
member to a GH facility in the event a member is hospitalized in a
non-GH facility or non-GH designated facility.
Definitions A new definition for GH designated self-referral specialists has been
added
The Stop Loss definition has been redefined under Out-of-Pocket
Limit.
Temmnauon An additional provision was added under Termination of Entire
Agreement to reflect that the group may be terminated if they no
longer meet underwriting guidelines established by GHC in effect at
the time the Group was accepted
Ile provision concerning persons hospitalized on the date of
termination has been revised to state that the member shall continue
to be eligible for covered services while an mpanent for the
condition for which the member was hospitalized until the first of
the following events occur the member no longer meets medical
criteria to be an inpatient at the facility,the remaining benefits
available under this Agreement for the confinement are exhausted,
regardless of whether a new calendar year begins;the member
becomes covered under another Agreement with the group health
plan that provides benefits for the confinement;the member
becomes enrolled under an Agreement with another tamer that
would provide benefits for this confinement if this Agreement did
not exist;or Medicare eligibility
The Services provided after Termination provision has been
clarified to define what the certificate of creditable coverage is,as
well as to state that the group determines whether GHC or the group
provides the certificate of creditable coverage to members
Continuation coverage, conversion and A clarification has been made under eligibility for Group
transfer Conversion stating that any Subscriber or Family Dependent not
entitled to Medicare may convert to GHC's Group Conversion plan
if his/her coverage under this Agreement is terminated for any
reason other than cause
In accordance with Washington state law,a continuation option
provision has been added which states"A Member no longer eligible
for coverage under this Agreement(except in the event of
termination for cause)may continue coverage for a period of up to
three(3)months subject to notification to and self-payment of
premium to the Group This provision will not apply if the Member
is eligible for the continuation coverage provisions of the
Consolidated Omnibus Budget Reconcihanon Act of 1985
COBRA)"
Coordination of benefits The definition of"Plan"has been broadened to include sources of
benefits or services from individual policies.
The"Effect of Medicare"section has been clarified to reflect how a
medicare-eligible person's benefits will be effected when the
member resides outside the GH Medreare+Choice service area
Subrogation and Reimbursement Rights Rus section has been modified to include ERISA requirements
Grievance Procedures Clarifications have been added at the request of the Insurance
Commissioner's office
Miscellaneous Provisions The confidentiality,indemnification,and governmental approval
provisions have been clarified
Provisions regarding arbitration,HIPAA transactions and
compliance with law have been added
• Enrollment Schedule The Special Enrollment Periods provision has been clarified.
The automatic enrollment of newborns provisions have been deleted
An additional provision has been added to state that the Subscnber
enroll their newborn or newly adoptive child as a dependent to avoid
delays in payment of claims
A clarification has been made to state that Subscribers and covered
dependents who are eligible for Medicare(and residing inside the
Medicare+Choice service area,must, effective the date TEFRA
eligibility ends or the date that Medicare would become the primary
payor,enroll in Medicare Parts A and B,and must participate in
GHC's Medicare plan
Claims Clarifications have been made to this provision based on federal
requirements
Blood A benefit change has been made to include blood coverage
Maternity A clarification was made to reflect that treatment for postpartum
depression or psychosis is covered under the mental health benefit
The exclusion of buthmg kits has also been removed
A clarification was trade at the request of the Insurance
Commissioner's office to state that prenatal testing is made in
accordance with Board of Health standards
Plastic and Reconstructive Services A clarification has been made to state that complications of covered
mastectomy services, including lymphedemas, are covered
Mental Health Care Services A clarification has been made to more accurately reflect how these
services are administered Clarifications to exclusions have also
been made.
Exclusions A clarification has been made to the sexual reassignment provision
The pre-existing condition provision has been clarified to reflect
HIPAA requirements regarding portability, as well as state
requirements
A clarification has been made to reflect that routine ultrasound to
determine fetal age,size or sex are excluded.
Additional clarifications include.Routine foot care except in the
presence of a non-related Medical Condition affecting the lower
limbs,complications of non-Covered Services,missed appointment
or cancellation fees,and treatment of obesity,except as otherwise
noted in the agreement
®GroupHealth
COOPERATIVE
GROUP MEDICAL COVERAGE
AGREEMENT
Group Health Cooperative (also referred to as "GHC", "Group Health", "GH"or the "Cooperative")is a nonprofit
health maintenance organization famishing health care primarily on a prepayment basis
This Agreement states the terms of enrollment,payment and coverage under which a Group may secure GHC health
benefits The Schedule of Benefits lists the benefits to which those enrolled under this Agreement are entitled
Words with special meaning are capitalized They are defined in Section I
Accessing Care
MEMBERS ARE ENTITLED TO COVERED SERVICES ONLY AT GH FACILITIES AND FROM GHC
PRIMARY CARE PROVIDERS EXCEPT AS FOLLOWS:
• Emergency care,
• women Is health care providers as ser forth below,
• visits with GH-Designated Self-Referral Specialists, as set forth below
• other services as specifically set forth in the Allowances Schedule and Section X,
• care provided pursuant to a Referral. Referrals must be requested by the Member's primary care provider
and approved by GHC.
Primary Care. Members must select a GH Primary Care Provider when enrolling under this Agreement. One
primary care provider may be selected for the entire family, or a different primary care provider may be selected
for each family member. If the primary care provider is not selected at the time of enrollment, Group Health wig
assign a primary care provider,and a letter of explanation and an identification card will be sent to the Member.
Selecting a primary care provider or changing from one Primary Care Provider to another can be accomplished by
contacting Group Health Customer Service, or accessing the GHC website at www.ghc.org. The change will be
made within twenty-four(24)hours of the receipt of the request if the selected physician's caseload permits
A listing of GHC Primary Care Providers, referral specialists, women's health care providers, and GH-
designated Self-Referral Specialists is available by contacting GHC Customer Service at (106) 901-4636 (or I-
888-901-4636),or by accessing GHC's website at www.ghr-org.
In the case that the Member's primary care provider no longer participates in GHC's network,the Member will
be provided a wriden notice offering the Member a selection of new primary care providers from which to
choose.
specialty Care. Unless otherwise indicated in this section, the Allowances Schedule, or Section Y, referrals are
required for specialty care and specialist
GH Designated Self-Referral Specialist Members may make appointments directly with GH-Designated Selj-
Referral Specialists at GH-owned or operated medical centers without a Referral from their primary care
provider. Self-Referrals are available for the following specialty care areas:allergy,audiology,cardiology,
PA-113302 -
0036900-C21431 1
chemical dependency, chiropracticimampulanve therapy, dermatology, gastronenterology, general surgery,
hospice, manipulative therapy, mental health, nephrology, neurology, obstetrics and gynecology, occupational
medicine* oncologylhematology, ophthalmology,optometry, orthopedics, otolaryngology(ear, nose, and throat),
physical therapy*,smoking cessation,speech4anguage and learning services* and urology.
*Medicare patients need a Referral for these specialists.
Women's Health Care Direct Access Providers Female Members may see a participating General and Faintly
Practitioner, Physician's Assistant, Gynecologist, Certified Nurse Midwife, Licensed Midwife, Doctor of
Osteopathy, Pediatrician, Obstetrician or Advanced Registered Nurse Practitioner who is contracted to provide
women's health care services directly,without a Referral from their Primary Care Provider,for Medically Necessary
and appropriate maternity care, covered reproductive health services, preventive care (well care) and general
examinations, gynecological care, and medically appropriate follow-up visits for the above services Women's
health care services are covered as if your Primary Care Provider had been consulted, subject to any applicable
Copayments and/or Coinsurance as set forth in the Allowances Schedule if your women's health care provider
diagnoses a condition that requires referral to other specialists or hospitalization, you or your chosen provider must
obtain preauthonzation and care coordination in accordance with applicable GHC requirements
Second Opinions. The Member may access, upon request, a second opinion regarding a medical diagnosis or
treatment plan from a GHCProvider.
Emergent and Urgent Care. Emergent and urgent care services are covered as set forth in Section XL. Contact
the Emergency Notification Line as indicated on your GH identification card
Recommended Treatment The Cooperative's Medical Director or his/her designee will determine the necessity,
nature, and extent of treatment to be covered in each individual case and the judgment, made in good faith,will
be final Coverage decisions may be appealed as set forth in Section ViI
Members have the right to participate in decisions regarding their health care. A Member may refuse any
recommended treatment or diagnostic plan to the extent permuted by law. In such case, GHC shall have no
further obligation to provide benefus for the condition in question.
Non Recommended Treatment Members who obtain care not recommended by GHC, do so with the full
understanding that GHC has no obligation for the cost,or Gabihry for the outcome,of such care.
Major Disaster or Epidemic. In the event of a major disaster or epidemic, GHC will provide coverage according
to its best judgment, within the limitations of available facilities and personnel. The Cooperative has no liability
for delay or failure to provide or arrange Covered Services to the extent facilities or personnel are unavailable
due to a major disaster or epidemic.
Unusual Circumstances. If the provision of Covered Services is delayed or rendered impossible due to unusual
circumstances such as complete or partial destruction of facilities, military action, civil disorder, labor disputes,
or similar causes, GHC shall provide or arrange for services that, in the reasonable opinion of GHC's Medical
Director, or his/her designee, are emergent or urgently needed In regard to nonargent and routine services,
GHC shall make a good fauh effort to provide services through its then-available facilities and personnel GHC
shall have the option to defer or reschedule services that are not urgent while its facilities and services are so
affected In no case shall the Cooperative have any liability or obligation on account of delay or failure to provide
or arrange such services.
0036900-C21431 2
Table of Contents
Summary of Allowances and Enrollment/Eligibility Requirements
I Definitions
II Premiums,Fees and Copayments
III. Termination
IV. Continuation Coverage,Conversion,and Transfer
V. Coordination of Benefits
VI Subrogation and Reimbursement Rights
VII Grievance Procedures for Complaints and Appeals
VIII Miscellaneous Provisions
IX Enrollment Schedule
X. Schedule of Benefits
XI Exclusions
XII Clauns
• Medicare Endorsements(if applicable)
• Premiums Schedule
0036900-C21431 3
Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: ALEXANDER SEWER EXTENSION BILL OF SALE—ACCEPT
2. SUMMARY STATEMENT: As recommended by the Public Works Director,
accept the Bill of Sale for the Alexander Water and Sewer Extension submitted by
Wendell Alexander for continuous operation and maintenance of 125 feet of watermain
and 117 feet of sewers. The bonds are to be released after the maintenance period.
This project is located at 11808 SW 236 h Street.
3. EXHIBITS: Vicinity map
. 4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5 UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION
ACTION:
Council Agenda
Item No 6H
Alexander Water and Sewer Extension
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VICINITY MAP
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Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: TORKLIFT PARKING LOT STREET IMPROVEMENT BILL OF
SALE—ACCEPT
2. SUMMARY STATEMENT: As recommended by the Public Works Director,
accept the Bill of Sale for Torklifr Parking Lot Street Improvements submitted by Kay
Partnership LLC for continuous operation and maintenance of 120 feet of street
improvements and 51 feet of storm sewers. The bonds are to be released after the
maintenance period This project is located at 524 Railroad Ave N.
3 EXHIBITS: Vicinity map
4 RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6 EXPENDITURE REOUIRED: $
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
• DISCUSSION
ACTION:
Council Agenda
Item No. 6I
Torklift Parking Lot Street Improvements
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Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1 SUBJECT: KENT VALLEY ICE ARENA UTILITY IMPROVEMENT BILL OF
SALE—ACCEPT
2. SUMMARY STATEMENT: As recommended by the Public Works Director,
accept the Bill of Sale for Kent Valley Ice Arena Utility Improvements submitted by
Lexi Doner for continuous operation and maintenance of 150 feet of watermain, 25 feet
of sewers, 100 feet of street improvements and 120 feet of storm sewers. The bonds are
to be released after the maintenance period. This project is located at 6015 S 2401h
Street.
3. EXHIBITS: Vicinity map
. 4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
• DISCUSSION:
ACTION:
Council Agenda
Item No. 6J
Kent Valley Ice Arena Utility Improvements
LAKE5'O�°G KENT
W. JAMES ST
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VICINITY MAP
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Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1 SUBJECT: PROPOSED LID 356, 111TH AVENUE SANITARY SEWERS, SET
PUBLIC HEARING DATE, RESOLUTION—ADOPT
2. SUMMARY STATEMENT: As recommended by the Public Works Committee,
adoption of Resolution No. I LW 7 setting a public hearing date of August 190' for the
LID formation.
3. EXHIBITS: Public Works Director memorandum, vicinity map and resolution
• 4. RECOMMENDED BY: Public Works Committee 7/l/03 (3-0)
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7 CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION-
Council Agenda
Item No. 6K
COMMUNITY DEVELOPMENT
Mike H Martin, Deputy Chief Adnunistraum e Officer
PUBLIC RORKS DEPARTMENT
Don E Wickstrom, P E. Public Works Director
•
K E N T
W•SNIMGT OM
Address 220 Fourth Avenue S
Kent,WA 98032-5895
Date June 26, 2003
To- Public Works Committee
�
From: Don Wickstrom 4
Regarding. Proposed L.I D - 1 11'h AN e Sanitary Sewers (SE 256'h Street to 850 feet north)
The City received a petition for the installation of sanitary sewers in the �icimty of 1 i i i'Ave S E and
SE 2561h St. in the residential plat of Coates Addition as shown on the attached map Subsequently, all
property owners n ithm the project area n ere contacted and there appears to be adequate support to
proceed with the L I D formation The project area is inside the City hmmts and Kent's seer service
area
The City deg eloped a proposal to service elem en unsewered lots All other lots on this portion of i i 1'h
Ave S E. already have sewer connections The mfomiation including cost was given to the petitioner
The petitioner sent the information to the neighbors in the area and confinned interest in the L I D with
new signatures on a new petition Seven of the eleven lots (64%) signed the petition These parcels are
indicated on the map.
The total L I D assessment is estimated at $165,000 All lots are platted single family lots receiving one
side sewer connection so all are assessed equally The estimated assessment is $15,000 per lot
The project area consists an older residential plats (1965) developed with septic systems Fie of the
eleven lots remain vacant needing sewer to be developed it is not known how many existing septic
systems are technically in a state of failure, howe%er, we understand from the residence that there are
septic problems in the area. One owner said his system is near total failure and needs frequent punmpng
of the septic tank. He is unable to get a permit to rebuild his drain field
Usually it is difficult to repair septic problems, especially on small lots such as these with lunited space
Sanitary sewers are usually the most feasible, economical and long term method for addressing these
problems, especially when numerous property owners in a neighborhood support serer installation as is
the case with this proposal
The Department of Public health has told us that the life expectancy of a septic system is tmvenly to thirty
years depending on use and maintenance and that they are a short tenn disposal method until public
sewets become available The piodect area has ;really exceeded this time frame andthe reports of
failures substantiate that these systems are at or are near the end of their useful hi e They also say that
the cost of septic repairs may be as high as comerling to public sewers. The latest stale codes make
septic repairs moredifficult and expensne.
The soil type within the project area is poorly rated for septic system use According to the soil
Conservation Service (US Dept of Agriculture) Soil survey for King County, the soil type as mapped is
rated severe limitation for septic drain fields The soil series is designated as Ag13 (Aldemood gravelly
sandy foam, 0 to 6% slopes). This soil exhibits very slow permeability below a depth of 24-40 inches
and a seasonal high water table. Effluent and drainage move laterally over the imperious layers
Effluent may come to the surface in yards and in roadside ditches
Five of the eleven lots in the proposed L I D are vacant. Sanitary sewer is needed to make these lots
developable. Without sewer, the owners caimot develop the lots or realize the full valueof the property
upon selling There is interest in improving these lots with sewer. However, one owner of an
undeveloped lot said she doesn't want the local improvement district
There are no City owned properties within the proposed project therefore no assessments to be paid by
the City Hoxve%er, the proposal is for the City to contribute $91,500 sewer utility funds Nine of the
twenty lots along the proposed sewer have already obtained ser%ice from a sewer east of the plat
Therefore, there are only 1 i of the 20 lots remaining to share the cost of the proposed sewer If all 20
lots were included, the estimated assessment would be approximately $15,000 per lot. The proposal is
for the City to fund the costs in excess of the $15,000 per lot assessment.
ACTION REQUESTED
Recommend adoption of the Resolution of Intent setting a public Bearing date on the formation of
the L.I.D. for the 11 properties shov%n on the attached map.
Attachments
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� PROPOSED SANITARY SEWER L.I.D. VICINITY MAP
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CITY Of KENT CNGINEERINO DEPARTMENT l00 W. GOWE ST KENT. WA. 9E032
PROPOSED SANITARY SEWER L.I.D. BOUNDARY MAP
KENT iiiTH AVENUE S.E.
(S.Eo256TH STREET TO 850 FT. NORTH)
u
Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: CHANGE OF CITY COUNCIL MEETING TIME—APPROVE
2. SUMMARY STATEMENT: Adopt Ordinance No. _, which changes the City
Council meeting time on August 5, 2003, from 7:00 p.m. to 5:00 p.m., and to direct the
City Clerk to provide the necessary notices as provided by law.
On August 5, 2003, the City of Kent, along with other cities all across the country, will
recognize "National Night Out," an event designed to bring neighborhoods together for
the purpose of community enhancement and crime prevention. The police department,
City Council, and other city representatives take this opportunity to thank the citizens
that make this neighborhood crime prevention program work. In order to attend this
event, the Council will need to cancel its regular meeting at 7:00 p.m. on August 5,
2003, and change it to a special meeting at 5:00 p.m. on that same day.
• 3. EXHIBITS: Ordinance
4 RECOMMENDED BY: Mayor
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7 CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6L
I
I
ORDINANCE NO.
AN ORDINANCE of the city council of the city of
Kent,Washington,changing the time of the August 5,2003,
city council meeting from 7 00 p m to 5 00 p in
WHEREAS, pursuant to section 2 01 020 of the Kent City Code, the
currently established time and date for regular council meetings of the city council are the
first and third Tuesday of each month at 7 00 p m , and
WHEREAS,National Night Out is an important function councilmembers
wish to attend, and
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WHEREAS,National Night Out is scheduled to occur on August 5,2003,
during the time of the city council's meeting, and
WHEREAS, by scheduling the regular council meeting on that date at
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5 00 p in , instead of 7 00 p m , councilmembers will have an opportunity to participate
i in National Night Out, NOW THEREFORE,
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1 City Council Meeting Schedule
For August 5, 2003
THE CITY COUNCIL OF THE CITY OF KENT, WASHINGTON,
DOES HEREBY ORDAIN AS FOLLOWS
I
SECTION 1. — Meeting Tune Rescheduled The time of the regularly
scheduled council meeting for August 5, 2003, is changed from 7:00 p m to 5 00 p m ,
i
effective only for this council meeting Except to the extent it affects the city council's
August 5, 2003, meeting, this ordinance does not amend Section 2 01 020 of the Kent
City Code.
SECTION 2. - Severabtluy If anyone or more sections, subsections, or
sentences of this ordinance are held to be unconstitutional or invalid, such decision shall
not affect the validity of the remaining portion of this ordinance and the same shall remain
in full force and effect.
SECTION 3. - Effective Date This ordinance shall take effect and be in
I
force five (5) days from and after its publication as provided by law.
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JIM WHITE, MAYOR
ATTEST
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BRENDA JACOBER, CITY CLERK
I j
i
APPROVED AS TO FORM
' I 1
TOM BRUBAKER, CITY ATTORNEY
I
2 City Council Meeting Schedule
For August 5, 2003
PASSED- day of July, 2003
1 APPROVED day of July, 2003
PUBLISHED. day of July, 2003.
I hereby certify that this is a true copy of Ordinance No passed
by the city council of the city of Kent,Washington, and approved by the mayor of the city
of Kent as hereon indicated
(SEAL)
BRENDA JACOBER, CITY CLERK
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3 City Council Meeting Schedule
For August S, 2003
Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: TAHOMA VISTA REZONE ORDINANCE—ADOPT
2. SUMMARY STATEMENT: Adoption of Ordinance No. relating to land
use and zoning, rezoning property comprised of approximately 4.84 acres of property
located at 25206 and 25230 132nd Avenue Southeast, from Single Farmly Residential
(SR-4.5), to Single Family Residential (SR-6), (Tahoma Vista Rezone, #RZ-2002-5).
3. EXHIBITS: Ordinance
• 4. RECOMMENDED BY: Hearing Examiner
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7 CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION-
Council Agenda
Item No. 6M
ORDINANCE NO.
AN ORDINANCE of the city council of the city of
I
Kent, Washington, relating to land use and zoning,
specifically the rezoning of approximately 4 84 acres of
I property located at 25206 and 25230 132"d Avenue
Southeast from Single Family Residential (SR-4 5), to
Single Family Residential (SR-6) (Tahoma Vista Rezone,
#RZ-2002-5)
WHEREAS, an application to rezone approximately 4 84 acres from the
current zoning of Single Family Residential (SR-4 5)to Single Family Residential(SR-6)
was filed on November 15, 2002 (Tahoma Vista Rezone, #RZ-2002-5), and
WHEREAS,the city's SEPA responsible official issued a Determination of
Nonsigmficance (DNS) for the proposed rezone on April 21, 2003, and
WHEREAS, a public hearing on the Tahoma Vista Rezone was held before
the hearing examiner on May 21, 2003, and
WHEREAS, on June 4, 2003, the hearing examiner issued findings and
conclusions that the Tahoma Vista Rezone is consistent with the city's Comprehensive
' Plan,that the proposed rezone and subsequent development activity would be compatible
with the development in the vicinity, that the proposed rezone will not unduly burden the
'transportation system in the vicinity of the property with significant adverse impacts which
cannot be mitigated,that circumstances have changed since the establishment of the current
1
Tahoma Vista Rezone
'zoning district to warrant the proposed rezone, and that the proposed rezone will not
I�
!adversely affect the health, safety, and general welfare of the citizens of the city of Kent,
and
WHEREAS, the findings are consistent with the standards for rezone set
forth in sections 15 09 050(A)(3) and 15 09 050(C) of the Kent City Code, and
WHEREAS, the Kent Hearing Examiner recommended approval of the
Tahoma Vista Rezone on June 4, 2003, and
WHEREAS,on July 1, 2003,the city council moved to accept the findings
of the hearing examiner and the hearing examiner's recommendation for approval of the
Tahoma Vista Rezone from Single Family Residential (SR-4 5) to Single Family
I
Residential (SR-6), NOW, THEREFORE,
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THE CITY COUNCIL OF THE CITY OF KENT,WASHINGTON,DOES
HEREBY ORDAIN AS FOLLOWS-
SECTION 1. - Rezone The property located at 25206 and 25230 132nd
Avenue Southeast, Kent, Washington consisting of approximately 4 84 acres depicted in
Exhibit "A" (marked "Site"), attached and incorporated by this reference, and legally
described in Exhibit"B"attached and incorporated by this reference,is rezoned as follows
King County tax parcel numbers 2222059126 and 2222059031 located in
Kent,Washington,shall be rezoned from Single Family Residential(SR-4.5)
to Single Family Residential (SR-6)
The city of Kent zoning map shall be amended to reflect the rezone granted above
I
2
Tahoma Vista Rezone
!I
SECTION 2. - Severabahty If anyone or more sections, sub-sections, or
sentences of this ordinance are held to be unconstitutional or invalid, such decision shall
not affect the validity of the remaining portion of this ordinance and the same shall remain
in full force and effect
SECTION 3. -Effective Date This ordinance shall take effect and be in
force five(5)days from and after its passage,approval and publication as provided by law
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JIM WHITE, MAYOR
ATTEST
BRENDA JACOBER, CITY CLERK
APPROVED AS TO FORM
i
TOM BRUBAKER, CITY ATTORNEY
PASSED day of 2003
APPROVED day of 12003
i
PUBLISHED day of 2003
3 �
Tahoraa Vista Rezone
I hereby certify that this is a true copy of Ordinance No passed
by the city council of the city of Kent,Washington, and approved by the mayor of the city
,of Kent as hereon indicated
(SEAL)
BRENDA JACOBER, CITY CLERK
P\CrvdONmvmeV czom.TNomoVismdoc
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4
Tahoma Vista Rezone
EXHIBIT "A"
SITE � SE 249TH PL
SE 248TH S �—
cw SE 233RD PL
w
0
d SE 253RD PL
SE 256TH ST
APPLICATION NAME: TAHOMA VISTA
REQUEST. #SU-2001-6 (KIVA #2020890) AND #RZ-2002-5 (KIVA#2023606)
EXISTING LEGAL DESCRIPTIONS FOR TAHOMA VISTA
SUBDIVISION, KENT WA
LOT A
LOT A OF KING COUNTY SHORT PLAT NO. 874039, RECORDED UNDER
RECORDING NUMBER 7412200293, RECORDS OF KING COUNTY, WASHINGTON.
SITUATE IN THE COUNTY OF KING, STATE OF WASHINGTON.
SUBJECT TO- (1) EASEMENT FOR THE RIGHT TO MAKE SLOPES FOR CUTS OR
FILLS ALONG THE STREET MARGIN OF SAID PREMISES ABUTTING 132ND AVE
SE, AS GRANTED BY DEED RECORDED UNDER RECORDING NOS. 4164202,
4164208, AND 7412100432,2)TERMS, COVENANTS, CONDITIONS AND
RESTRICTIONS ANC CONTAINED IN SHORT PLAT NO. 874039, RECORDED UNDER
RECORDING NUMBER 7412200293
LOT B
LOT B, KING COUNTY SHORT PLAT NUMBER 874039, RECORDED UNDER
RECORDING NUMBER 7412200293 IN KING COUNTY, WASHINGTON, BEING A
PORTION OF THE SOUTHWEST QUARTER OF THE SOUTHWEST QUARTER OF
SECTION 22, TOWNSHIP 22 NORTH, RANGE 5 EAST, WILLAMETTE MERIDIAN, IN
KING COUNTY WASHINGTON. SUBJECT TO
(1) EASEMENT RECORDED UNDER COUNTY NO. 684527,
(2) RIGHT FOR SLOPES, CUTS OR FILLS RECORDED UNDER NO. 4164202
(3) RIGHTS FOR SLOPE CUTS OR FILLS UNDER NO. 7412100432
EXHIBIT "B"
Kent City Council Meeting
Date July 15, 2003
Category Consent Calendar
1. SUBJECT: U.S. DEPARTMENT OF EDUCATION GRANT —AUTHORIZE
2. SUMMARY STATEMENT: The Public Safety Committee recommends that the
Kent Police Department's application for the U.S. Department of Education, Life Skills
for State and Local Prisoners Program Grant be authorized.
This grant's goal is to "reduce recidivism through the department and improvement of
life skills necessary for reintegration of adult prisoners into society." The Kent Police
Department plans to use this funding to expand alternatives to incarceration working
with New Connections and the Renton Technical Institute. The Kent Police
Department total grant funding request is $161,500 per year. The project period can
extend up to 36 months, with a total grant funding amount of$484,500. The deadline
to apply for this grant is July 14, 2003.
3. EXHIBITS: Executive summary attachment for grant application and description of
Life Skills for State and Local Prisoners Program
4. RECOMMENDED BY: Police Department
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCALIPERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS:
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6N
POLICE DEPARTMENT
Ed Crawford, Chief of Police
Phone 253-856-5888
Fax 253-856-6802
KEN T Address 220 Fourth Avenue S
WASHINGTON Kent,WA 98032-5895
DATE: July 8, 2003
TO: Public Safety Committee
SUBJECT: Kent Police Department requests authorization to apply for U S
Department of Education, Life Skills for State and Local Prisoners Program Grant
SUMMARY: This grant's goal is to "reduce recidivism through the development and
improvement of life skills necessary for reintegration of adult prisoners into society" The Kent
Police Department plans to use this funding to expand alternatives to incarceration working with
New Connections and the Renton Technical Institute
The Kent Police Department total grant funding request is $161,500 per year The project period
can extend up to 36 months, with a total grant funding amount of$484,500
The deadline to apply for this grant is July 14, 2003
EXHIBITS: Executive Summary attachment for grant application
Description of Life Skills for State and Local Prisoners Program
BUDGET IMPACT None—No matching funds required
MOTION I move to recommend that this item be placed on the Consent Calendar of the July
15, 2003 Council Meeting recommending that Council authorize the Kent Police Department's
application for the U S Department of Education, Life Skills for State and Local Prisoners
Program Grant
Kent City Council-Public Safety Committee 1 U S Department of Education Grant
July 8,2003
Executive Summary
The City of Kent's population more than doubled from 1990 to 2000. The city's
current population is estimated at 85,651. From 1998 to present the daily
population at the City of Kent Corrections Facility (CKCF) has grown steadily
hitting a high of 210 inmates in 2001. Currently, the Kent Jail average daily
population is between 130 to 140 inmates, including the electronic home
detention (EHD), work release and work time credit and work crew lad programs.
In 1997, the Kent City Jail allocated one full time officer to Programs. Due to
focused staff efforts, participation in these programs has increased steadily since
1997. In 1999, the jail added another officer to the Programs Division and the
current program participation averages approximately 20 inmates on EHD, 12 to
14 inmates on work time credit, and 4 to 6 inmates on work release. The
programs have hit a high of 35 to 40 on EHD, 20 on work time credit, and 15 on
work release. The work crew program was developed in 2002. This program
continues to evolve and contact additional businesses to participate in this
program.
The Kent City Jail Programs staff work closely with New Connections of South
King County. New Connections is the only agency in the greater Kent area
offering life skills classes to inmates and transitional counseling and referrals
once the offenders are released from Jail. New Connections assisted 330 clients
in their office in 2001. The clientele served in their office grew to 1,421 in 2002.
In addition, Lana Matthew of New Connections assisted 1,854 jail inmates at the
King County regional Jail in Kent and the CKCF navigate through the justice
system in 2002.
Criminal offenders need education and vocational training in order to succeed
upon their release from custody. The Renton Technical Institute (RTI) offers
vocational instruction that can create a culture of achievement, improve student
achievement and enhance the quality and access to adult education. The RTI
offers flagger training and food handler card classes to incarcerated offenders.
Life Skills for
State and Local Prisoners Program
The Kent Police Department requests authorization to apply for the U.S.
Department of Education, Life Skills for State and Local Prisoners Program. The
grant program's goal is to "reduce recidivism through the development and
improvement of life skills necessary for reintegration of adult prisoners into
society." The project period can extend up to 36 months. The Department of
Education estimates funding is available for 12 awards ranging from $315,000 to
$475,000 annually. There are no matching funds required. The deadline to
apply for this grant is July 14, 2003.
The Kent Police Department plans to use this funding to expand alternatives to
incarceration. This project will provide City of Kent Corrections Facility offenders
with life skills training, counseling resources and vocational education. The Kent
Police Department will partner with New Connections to provide life skills, stress
reduction and employment skills classes to incarcerated offenders. Relapse
Prevention treatment will also be offered to lad inmates. New Connections will
also provide aftercare services to CKCF offenders upon their release from ]ail.
The Renton Technical Institute will provide flagger training and food handler card
classes to Jail inmates. Funding will also purchase additional work crew
equipment and safety gear. This funding will purchase the necessary jail
classroom equipment to support these additional educational programs. The
Kent Police Department total grant funding request is $161,500 per year. If
funding is available for three years the total grant amount would be $484,500.
Life Skills for State and Local Prisoners Program
CFDA#84 255A
Information and Application Procedures for Fiscal Year 2003
OMB No. 1890-0009 Expiration Date: 6/30/2005
Application Deadline- 7/14/2003
Dear Colleague:
Thank you for your interest in applying for a grant under the Life Skills for State and Local
Prisoners Program Tlus program offers life skills training grants to eligible entities to assist
them in establishing and operating programs designed to reduce recidivism through the
development and improvement of life skills necessary for reintegration into society
As the U S prison and Jails population has recently climbed above two million for the first time
in our Nation's history, it is important to prepare institutionalized offenders for a successful
return to communities. We are committed to broad implementation of the fundamental
principles of the President's education reform agenda as reflected in the No Cluld Left Behind
Act of 2001 in all aspects of our work. The four basic principles are stronger accountability for
results, increased flexibility and local control, choice, and an emphasis on determining what
educational programs and practices have been clearly demonstrated to be effective through
rigorous scientific research
The Department has designed this Life Skills for State and Local Prisoners Program competition
to support the President's vision for educational reform Successful applicants will receive
funding to establish or expand pnson-based and Jail-based instructional programs that utilize
proven strategies and/or that are specifically designed to scientifically test promising strategies
These programs will be characterized by rigorous accountability systems against clearly defined
results and transparent reporting systems. Successful programs will demonstrate instructional
practices that serve to restore inmates to productive citizenship.
We look forward to receiving your application for support under the Life Skills for State and
Local Prisoners Program
Cordially,
���tit1T OFFdG�
Judge Eric Andell
A z
SATES OF
U.S. Department of Education
Kent City Council Meeting
Date July 15, 2003
Category Other Business
1. SUBJECT: KENT STATION PRELIMINARY PLAT, CLOSED RECORD
APPEAL (#SU-2002-9/KIVA#RPP3-2023555)
2. SUMMARY STATEMENT: This is a closed record appeal hearing of the decision
of the hearing examiner, approving a preliminary plat for Kent Station applied for by
Kent Station, LLC. The hearing examiner's Findings, Conclusion, and Decision were
issued on January 30, 2003.
3 EXHIBITS: Complete copy of the Hearing Examiner's record and Appellant's
request for appeal are contained in a separate binder
4. RECOMMENDED BY: Hearing Examiner
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPACT: NO X YES
6. EXPENDITURE REQUIRED: $
SOURCE OF FUNDS.
7. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
to sustain/revelse/m"mod the Hearing Examiner's January 30, 2003, Fmdmgs,
Conclusions, and Decision.
DISCUSSION:
ACTION:
Council Agenda
Item No. 7A
Kent City Council Meeting
40 Date July 15, 2003
Category Bids
1. SUBJECT: REITH ROAD WATER MAIN IMPROVEMENTS, 42ND AVENUE
SOUTH TO PUMP STATION#4
2. SUMMARY STATEMENT: The bid opening for this project was held on July 2,
2003 with four bids received. The low bid was submitted by Kar-Vel Construction Co
in the amount of$212,289.96. The Engineer's estimate was $328,787.07. The Public
Works Director recommends awarding this contract to Kar-Vel Construction Co.
3. EXHIBITS:
4. RECOMMENDED BY:
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL I ACT: NO X YES
6. EXPENDITURE REQUIRED: $2 12 9.96
SOURCE OF FUNDS: W20102
7 CITY COUNCIL ACTION: p
Councilmember l:f Get moves, Councilmember 4 dzmm seconds
that the Reith Road Watermain Improvement contract be awarded to Kar-Vel
Construction Co. for the low bid amount of$212,289 96.
DISCUSSION:_
ACTION:
Council Agenda
Item No. 8A
PUBLIC WORKS DEPARTMENT
Don E Wickstrom, P E Public Works Director
Phone 253-856-5500
Fax 253-856-6500
K E N T Address 220 Fourth Avenue S
WASHINGTON
Kent,WA 98032-5895
DATE: July 1 , 2 03
TO: May 1 tie and Kent City Council
FRONT: Don strom, Public Works Director
SUBJECT: Reith Road Water Main Improvements Project—Award Bid
SUDIMARY: Bid opening for this project was held on July 2, 2003 with four bids recen ed The
lowest bid was submitted by Kar-Vel Construction in the amount of$212,289 96 The
Engineer's estimate was $328,787 07 The Public Works Director recommends awarding this
contract to Kar-Vel Construction
Bid Summary
Kar-Vel Construction $212,289 96
Westwater Construction Co $265,705 92
Construct Co , LLC $271,632 52
Laser Underground S284,865 60
Engineer's Estimate $328,787 07
BUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact
MOTION. Councilmember moves, Councdmember seconds that
the Reith Road Water Main Improvements contract be awarded to Kar-Vel Construction for the
low bid amount of$212,289 96
Mayor White and Kent City Council Reith Road Water Main Improvements-Award Bid
July 15,2003
1
Kent City Council Meeting
Date July 15, 2003
Category Bids
1. SUBJECT: GARRISON WELL & EAST HILL WELL REPLACEMENT WELLS
2 SUMMARY STATEMENT: The bid opening for this project was held on July 7,
2003 with two bids received. The low bid was submitted by Hokkaido Drilling, Inc. in
the amount of$273,196.80. The Engineer's estimate was $270,933.76. The Public
Works Director recommends awarding this contract to Hokkaido Drilling, Inc. for
$273,196.80, subject to contract reduction for contingency items 1084 through 1096
3 EXHIBITS:
4. RECOMMENDED BY:
(Committee, Staff, Examiner, Commission, etc.)
5. UNBUDGETED FISCAL/PERSONNEL IMPAC NO X YES
6. EXPENDITURE REQUIRED: $273 196.8
SOURCE OF FUNDS: W20102
7 CITY COUNCIL ACTION:
Councilmember UA4,k moves, Councilmember pR ""`m%-' seconds
that the Garrison and East Hill Well Replacement contract be awarded to Hokkaido
Drilling, Inc for the low bid amount of$273,196 80 subject to contract reduction for
contingency items 1086 through 1096.
DISCUSSION:
ACTION:
Council Agenda
Item No. 8B
PUBLIC WORKS DEPARTMENT
Don E Wickstrom, P E Public Works Director
• Phone 253-856-5500
K ENT Fax 253-856-6500
w.s �,o� Address 220 Fourth Avenue S
Kent,WA 98032-5895
DATE: Jul&15, 2 03
TO: Maite and Kent City Council
FROM: Dotrom, Public Works Director
SUBJECT: Garrison and East Hill Well Replacement Project—Award Bid
SUMMARY: Bid opening for this project was held on July 7, 2003 with two bids received The
lowest bid was submitted by Hokkaido Drilling, Inc in the amount of $273,196 80 The
Engineer's estimate was $270,933 76 The Public Works Director recommends awarding this
contract to Hokkaido Dnlhng, Inc subject to contract reduction for contingency items 1084
through 1096.
Bid Summary
Hokkaido Drilling, Inc $273,196 80
Holt Drilling, Inc. 5327,705.60
Engineer's Estimate $270,933.76
BUDGET IMPACT No Unbudgeted Fiscal/Personnel Impact
MOTION- Councilmember moNes, Councilmember seconds that
the Garrison and East Hill Well Replacement contract be awarded to Hokkaido Drilling, Inc for
the low bid amount of $273,196 80, subject to contract reduction for contingency items 1084
through 1096
• Mayor White and Kent City Council Garrison& East Hill Well Replacement-Award Bid
July 15,2003
1
REPORTS FROM STANDING COMMITTEES AND STAFF
A. COUNCIL PRESIDENT
B. OPERATIONS COMMITTEE
C. PUBLIC SAFETY COMMITTEE
D. PUBLIC WORKS
E. PLANNING COMMITTEE
F PARKS COMMITTEE
off"
G. ADMINISTRATIVE REPORTS
REPORTS FROM SPECIAL COMMITTEES �e�
le
Operations Committee Minutes
June 17, 2003
Committee Members: Leona Orr, Tim Clark, Judy Woods, sitting in for Rico Yingling
The meeting was called to order by Acting Chair Judy Woods at 4:00 PM.
Approval of Minutes of June 6, 2003
Leona Orr moved to approve the minutes of the June 6, 2003, Operations Committee
meeting. The motion was seconded by Tim Clark and passed 3-0.
Approval of Vouchers Dated June 15, 2003
Tim Clark moved to approve the vouchers dated June 15, 2003. The motion was
seconded by Leona Orr and passed 3-0.
Data Center Power Supply Unit Proiect
Information Technology Director Marty Mulholland said that all computers need"clean"
power for smooth operations. The current UPS system is running at 90% capacity and
additional equipment cannot be added unless that capacity is increased. This project
would be the first use of contingency monies identified to support unforeseen projects
as part of Technology Plan 2002.
Leona Orr moved to recommend that Council authorize the Mayor to sign
purchase orders for purchase and installation of additional power supply
units for the data center using contingency funds from Technology Plan
2002. The motion was seconded by Tim Clark and passed 3-0.
Lodging Advisory Board Members— Reappointment
Economic Development Manager Nathan Torgelson presented the Lodging Tax Advisory
Board's recommendation that Kathy Madison and Andy Wangstad be reappointed to
additional 3-year terms on the Board.
Tim Clark moved to recommend that Council approve the reappointment of
Kathy Madison and Andy Wangstad for additional three year terms on the
Lodging Tax Advisory Board. The motion was seconded by Leona Orr and
passed 3-0.
Kent Lodging Association Budget
Nathan Torgelson presented an amendment to the Kent Lodging Association contract to
add $14,120 to the contract for the continuation of services from July through
December 2003.
Operations Committee, 6/17/03 2
Leona Orr moved to recommend that Council approve an amendment to the
Kent Lodging Association Budget, which extends the contract through the
end of 2003. The amendment adds $14,120 to the budget for a total amount
of $53,910. Tim Clark seconded the motion which passed 3-0.
Public Market Development Authority—Transfer of Property
City Attorney Tom Brubaker said that since the Public Market had ceased to exist, the
Public Development Authority that was created to help the market, had lost its reason
for existence. The PDA will transfer all its real and personal property assets to the City
of Kent, and the PDA will then be dissolved. Mr. Brubaker handed out an amended
motion.
Tim Clark moved to recommend that Council authorize the Mayor to accept
all property, real and personal, that the PDA offers to transfer to the City of
Kent, to authorize the Mayor to execute any and all necessary documents in
order to effect the property transfer, and to set a public hearing on the
proposed dissolution of the PDA before the City Council at its July 15, 2003,
meeting. The motion was seconded by Leona Orr and passed 3-0.
The meeting adjourned at 4:15 PM.
Jackie Bicknell
Council Secretary
•
PUBLIC WORKS COMMITTEE MINUTES
JUNE 169 2003
COMMITTEE MEMBERS PRESENT- Leona Orr sitting in for Chair Tim Clark ,
Conine Epperly sitting in for Rico Yingling, Julie Peterson,
The meeting was called to order by Leona Orr at 5 00 P M
Approval of Minutes of June 2, 2003
Connie Epperly moved to approve the minutes of June 2, 2003 The motion was
seconded by Committee Member Julie Peterson and passed 3-0
Declare Equipment Surplus
Public Works Director Don Wickstrom said the list of surplus equipment and materials
are no longer of use or necessary to the City Public Works Operations requested they be
declared surplus and sold at the annual Cornucopia Days Celebration Because some of
the equipment is Water Utility owned a public hearing will be required on these items
Julie Peterson moved to declare the listed equipment as surplus equipment and
authorize Public Work Operations to place these items on the auction list for
Cornucopia Days. In the event these items are not sold at the auction then they will
be sold for scrap metal or disposed of as authorized by Kent City Code or those
regulations governing disposal of surplus equipment. The motion was seconded by
Connie Epperly and passed 3-0.
Restrictive Covenant Kent Highlands Landfill- Authorize
Don Wickstrom said in the early 1970's the City was deeded about 5 acres of property
within Kent Highlands landfill site for park purposes. At that time the end use of landfill
property for park purposes was probably standard practice Seattle subsequently bought
the property and went through a voluntary cleanup and closure action They did so to
avoid the site being declared as a Federal superfund site and then being ordered by EPA
to clean it up and close it To complete the closure of the site certain documents must be
recorded on the site to let future owners of the site know what the restrictions are
regarding potential use Seattle has recoded these documents on their property and in
order to finalize their closure these same documents must be recorded on the City's
property Since the City could be forced to record them by court action the Public Works
Department recommends that we do so
Connie Epperly moved to recommend that Council authorize the Mayor to sign the
Restrictive Covenant Kent Highlands Landfill document and record the Declarative
Statement and the attached Cleanup Action Plan on the City's Kent Highlands
property. The motion was seconded by Julie Peterson and passed 3-0.
Public Works Committee, 6/16/03 2
Partial Termination and Relinquishment of Wetland Protection Easement and
Reservation with Boeing Companv- Authorize .
Don Wtckstrom said the Wetland Protection Easement and Reservation conveyed to the
City of Kent by the Boeing Company for the Pacific Gateway Business Park may be
terminated if and when a permit to fill wetlands area subject to Wetland Protection
Easement has been issued by the United States Army Corps of Engineers, the COE issued
the permit on August 23, 2002 allowing the wetlands areas to be filled that are designated
on the Plat as Wetland Area G,H, M and SW.
Julie Peterson moved to recommend that Council authorize the mayor to sign the
Partial Termination and Relinquishment of Wetland Protection Easement and
Reservation therein upon concurrence of the language therein by the City Attorney
and the Public Works Director. The motion was seconded by Connie Epperly and
passed 3-0.
The meeting adjourned at 5 08 P M
Janet Perschek
Administrative Assistant
c CONTINUED COMMUNICATIONS
A.
•
• EXECUTIVE SESSION
A) Property Acquisition
i
ACTION AFTER EXECUTIVE SESSION
A)