HomeMy WebLinkAboutCity Council Meeting - Council - Agenda - 07/20/2004 MEWAL
City of Cent
City Council fleeting
Agenda
t
July 20, 2004
Mayor Jim White
Julie Peterson, Council President
Councilmembers
t Tim Clark Debbie Raplee
Ron Harmon Les Thomas
i Bruce White Deborah Ranniger
KEN
WASHINGTON
City Clerk's Office
SUMMARY AGENDA
44* KENT CITY COUNCIL MEETING
K E N T July 20, 2004
WASHINGTON Council Chambers
7:00 p.m.
MAYOR: Jim White COUNCILMEMBERS: Julie Peterson, President
Tim Clark Ron Harmon Deborah Ranniger
Debbie Raplee Les Thomas Bruce White
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. Don Wickstrom 35th Anniversary Presentation
B. Economic Development Update
C. Proclamation-National Night Out
D . (:-i na nCi",
5. PUBLIC HEARINGS
None
6 CONSENT CALENDAR
A. Minutes of Previous Meeting —Approve
B. Payment of Bills—Approve
C. Churches in Ml, Ml-C, and CM-1 Zoning Districts Zoning Code Amendment
Ordinance—Adopt 369l1
D. Hazardous Substance Land Use Facilities Zoning Code Amendment Ordinance—3700
Adopt
E. 2004 Comprehensive Plan Update Ordinance—Adopt 3&88
F. Brookside Court Final Plat—Approve and Authorize
G. National Night Out, Council Meeting Time Change—Authorize
H. Group Health Cooperative 2004 Contract—Authorize
I. Nationwide Deferred Compensation (457) Program—Authorize
J. International City/County Managers Association (ICMA) Administrative Services
Agreement—Authorize
K. Westview Terrace Sewer Extension Bill of Sale—Approve
L. Pineridge Subdivision Infrastructure Improvements Bill of Sale—Approve
M. McKenna Meadows Infrastructure Improvements Bill of Sale—Approve
N. Chelmsford Subdivision Infrastructure Improvements Bill of Sale—Approve
O. Gamson and East Hill Well Project—Accept as Complete
7. OTHER BUSINESS
A. Ruth Wiren Rezone
B. Kentara Rezone
(continued next page)
SUMMARY AGENDA CONTINUED
8. BIDS
A. 2004 Traffic Striping
9. REPORTS FROM STANDING COMMITTEES, STAFF AND SPECIAL COMMITTEES
t10. CONTINUED COMMUNICATIONS Pf• 8 uj rf
11. EXECUTIVE SESSIO AND AFTER EXECUTIVE SESSION
A. Pending Litigation
( B. Labor Negotiations
12. 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.
CHANGES TO THE AGENDA
Citizens wishing to address the Council will, at this time, make known the subject of
interest, so all may be properly heard.
A) FROM COUNCIL, ADMINISTRATION, OR STAFF
B) FROM THE PUBLIC
i
l
t
PUBLIC COMMUNICATIONS
A) DON WICKSTROM 35TH ANNIVERSARY PRESENTATION
B) ECONOMIC DEVELOPMENT UPDATE
i
C) NATIONAL NIGHT OUT
CONSENT CALENDAR
1 6. City Council Action:Councilmember Pam„� La moves, Councilmember UCr/14
seconds to approve Consent Calendar Items A through O.
Discussion
Action
6A. Approval of Minutes.
Approval of the minutes of the regular Council meeting of July 6, 2004.
6B. Approval of Bills.
Approval of payment of the bills received through May 28 and paid on May 28 after
auditing by the Operations Committee on July 6, 2004.
Approval of checks issued for vouchers:
Date Check Numbers Amount
5/28/04 Wire Transfers 1715-1724 $ 786,473.56
5/28/04 Prepays& 563308 485,549 48
5/28/04 Regular 563859 2,044,654.82
$3,316,677.86
Approval of payment of the bills received through June 15 and paid on June 15 after
auditing by the Operations Committee on July 6, 2004.
Approval of checks issued for vouchers:
Date Check Numbers Amount
6/15/04 Wire Transfers 1725-1742 $1,685,933.36
6115104 Prepays& 563860 1,340,128.55
6/15/04 Regular 564658 2,048,102.26
$5,074,164.17
Approval of payment of the bills received through June 30 and paid on June 30 after
auditing by the Operations Committee on July 6, 2004.
Approval of checks issued for vouchers-
Date Check Numbers Amount
6/30/04 Wire Transfers 1743-1754 $ 920,989.89
6/30/04 Prepays& 564659 238,357.22
6/30/04 Regular 565173 2,969,481.28
$4,128,828.39
(continued on back)
Approval of checks issued for payroll for May 1 through May 15 and paid on May 20, 2004:
Date Check Numbers Amount
5/20/04 Advices 164003-164662 $1,179,961.50
5/20/04 Checks 277072-277392 224,685.03
5/20/04 Interim Checks 277393 366.30
5120104 Voids 276955 (366.3
0)
$1,404,646.53
Approval of checks issued for payroll for May 16 through May 31 and paid on June 4,2004-
Date Check Numbers Amount
6/4/04 Advices 164663-165324 $1,178,954.30
6/4/04 Checks 277394-277676 218,696.39
6/4/04 Interim Checks 277677-277678 383.91
Voids (179 39)
$1,397,855.21
Approval of checks issued for payroll for June 1 through June 15 and paid on June 18, 2004:
Date Check Numbers Amount
6/18/04 Advices 165325-165984 $1,202,669.04
6/18/04 Checks 277679-277975 227,188.83
$1,429,857.87
Approval of checks issued for payroll for June 16 through June 30 and paid on July 2, 2004:
Date Check Numbers Amount
7/2/04 Advices 165985-166644 $1,202,859.20
7/2/04 Checks 277976-278284 250,038.96
7/2/04 Interim Checks 278285-278286 1,504.93
$1,454,403.09
Council Agenda
Item No. 6 A-B
KEN• T Kent City Council Meeting
WASNiNOTON July 6, 2004
The regular meeting of the Kent City Council was called to order at 7:00 p.m. by Mayor White.
Councilmembers present: Clark, Harmon, Ranniger, Raplee, Thomas and White. Council
President Peterson was excused from the meeting. (CFN-198)
CHANGES TO AGENDA
A From Council, Administration, or Staff. (CFN-198) Consent Calendar Item A(Approval
of Minutes) was corrected, E (West Nile Virus Response Plan) was removed from the Consent
1 Calendar, and V (Excused Council Absence)was added. Other Business Items C (Ballot
Proposition, Real Property Tax Levy Rate) and D (Budget Appropriation for Special Election)
were removed from the agenda.
B. From the Public. (CFN-198) Continued Communications Item A was added.
PUBLIC COMMUNICATIONS
A Get a Kick Out of Sharing Program. (CFN-118) Parks Director Hodgson explained the
program and encouraged everyone to donate soccer balls and pumps which will be shipped to
children in Africa.
B. Youth Board Public Services Announcements. (CFN-198) Sara Wood of the Police
Department explained the program and showed the public service announcements made by the
youth board.
C. Employee of the Month. (CFN-147) Shane Gilbertson, Project Manager in the Parks
Planning and Development Department, was named Employee of the Month.
jD Introduction of Appointees. (CFN-198) Mayor introduced his latest appointees, Kenneth
Wendling and George Adams.
PUBLIC HEARINGS
A Street Vacation, Portion of 145th Place SE. (CFN-102) This public hearing was continued
' from June 15,2004. Satterstrom explained the project and conditions. Dennis Alfredson from
Schneider Homes said they have no objection to the conditions. Condition No 8 was clarified for
Kris Muckerheide, 24418 147th Ave. SE. There were no further comments and CLARK MOVED
to close the public hearing. Harmon seconded and the motion carried. Martin explained that the
price will be worked out with Public Works. CLARK MOVED to approve staffs recommenda-
tion of approval with conditions of the application to vacate portions of 145th Place SE, as
referenced in Resolution No. 1668, and to direct the City Attorney to prepare the necessary
ordinance upon compliance with the conditions of approval. White seconded and the motion
carried.
B. 2004 Comprehensive Plan Update Policy Revision. (CFN-377) This public hearing is to
consider one revised comprehensive plan policy in accordance with the June 1 st Council remand
to staff and subsequent review by the Planning & Economic Development Committee The
Council will then consider approval of the entire 2004 Comprehensive Plan Update Gloria
1
Kent City Council Minutes July 6, 2004
Gould-Wesson of the Planning Department gave an overview of the process and the policy, and
pointed out that the changes to Policy LU-9.1 were not substantive and have been made. She then
read the proposed language for Policy TR-5.6 as follows: Foster connectivity of new development
with the surrounding neighborhood, allowing cul-de-sacs where appropriate. She recommended
approval of the entire Comprehensive Plan document including the revisions.
The Mayor opened the public hearing. Tom Sharp, P.O. Box 918, Maple Valley, spoke in support
of the revised language for TR-5.6. There were no further comments from the audience and
CLARK MOVED to close the public hearing. White seconded and the motion carried. CLARK
MOVED to approve and approved as modified the 2004 Comprehensive Plan Update as
recommended by the Planning &Economic Development Committee and to direct the City
Attorney to prepare the necessary ordinance. White seconded. After a brief discussion regarding
cul-de-sacs, the motion carved.
CONSENT CALENDAR
CLARK MOVED to approve Consent Calendar Items A, as corrected, through V, with the
exception of E. White seconded and the motion carried.
A. Approval of Minutes. (CFN-198) The minutes of the regular Council meeting of June 15,
2004 were approved.
B. Approval of Bills. (CFN-104) Bills and checks have not been approved for payment at this
time.
C. Pacific Highway South HOV Lanes. (CFN-1291) Ordinance No 3697 providing for
condemnation of property rights for real property between Kent-Des Moines Road and South
272°d Street adjacent to Pacific Highway South, in order to construct road improvements and
underground electrical systems for the Pacific Highway South HOV Lanes project was adopted.
D. Pacific Highway HOV Project Appraisal & Appraisal Review Service Contracts.
(CFN-1291) The Mayor was authorized to sign the Consultant Services Agreements for right of
way/easements acquisition appraisals with the Eastman Company and for appraisal review with
The Granger Company.
REMOVED FROM CONSENT CALENDAR j
E. West Nile Virus Response Plan. (CFN-1038) Mike Mactutis of Public Works explained the
Plan and the history of the virus. CLARK MOVED to adopt the City of Kent West Nile Virus
Response Plan. White seconded and the motion carried.
F. Russell Road & Utility Relocation Project. (CFN-1038) The Russell Road and Utility
Relocation project was accepted as complete and release of retainage to Ceccanti, Inc.upon
standard releases from the state and release of any liens was authorized.
G. Police Mobile Data Computer Replacements. (CFN-122) The Mayor was authorized to
sign purchase orders for replacement MDCs,payable to CDW-G, not to exceed $76,000.
2
Kent City Council Minutes July 6, 2004
H. Owest PBX Maintenance Contract. (CFN-1155) The Mayor was authorized to sign a
contract renewal with Qwest Interprise Services PBX Maintenance Services, subject to the City
Attorney's approval of the contract documents.
I. Homeland Security Supplemental Grant for Multi-Discipline Planning and Exercise
Coordinator. (CFN-122) The Mayor was authorized to accept a grant from State Homeland
Security Office of Domestic Preparedness, and sign a contract for services for Multi-discipline
Planning &Exercise Coordinator with said grant monies.
' J. Homeland Security Supplemental Grant for Interoperable Radio Ectuipment. (CFN-122)
The Mayor was authorized to accept a grant from State Homeland Security Office of Domestic
Preparedness, and sign a contact for purchase of interoperable radio equipment with said grant
monies.
K. Schick Shadel Hospital Consultant Services Agreement. (CFN-122) The Mayor was
authorized to sign a contract with Schick Shadel Hospital for a one year pilot project to provide
substance abuse relapse prevention treatment for offenders at the City of Kent Correctional
Facility.
L. Reduce Underage Drinking Grant Application. (CFN-122) The Drinking Driver Task
Force was authorized to apply for the Reduce Underage Drinking Grant for funds for police
overtime, a Washington State Liquor Control Board agent and youth operative expenses for
compliance checks.
M. Carl Perkins 1% Grant Application. (CFN-122) The Kent Police Department was
authorized to apply for$39,000 to contract with Renton Technical College to provide marketable
job skills classes to inmates at the City of Kent's Corrections Facility.
N. 2004 Local Law Enforcement Block Grant Application. (CFN-122) The Police
Department was authorized to apply for a grant to purchase ergonomic workstations for the
Records Unit of the Kent Police Department.
O. Washington Traffic Safety Commission Grant. (CFN-122) The Washington Traffic Safety
Commission Grant which will be used to conduct a"Cops in Shops"pilot program and to run
"Alcohol has Consequences"ads was accepted.
P. Corrections Facility Medical Services Agreement. (CFN-122) The Mayor was authorized
to sign the Corrections Facility Medical Services Agreement between the City of Kent and Valley
Medical Center Occupational Health Services.
Q. 2004 Western States Arts Federation Grant for The Actor's Gang. (CFN-118) The
$2,500.00 grant from Western States Arts Federation(WESTAF)was accepted and expenditure of
funds in the Arts Commission budget for the Actors' Gang performance was authorized.
R. 2005 Western States Arts Federation Grant for Keola Beamer. (CFN-118) The$2,500.00
grant from Western States Arts Federation (WESTAF)was accepted and expenditure of funds in
the Arts Commission budget for the Keola Beamer,Hawaiian Slack Key Guitar Festival was
authorized.
3
Kent City Council Minutes July 6, 2004
S. Vine County Conservation Futures Amendment for Clark Lake Park. (CFN-118) The
$300,000.00 grant from King County Conservation Futures was accepted, the Mayor was
authorized to sign the Amendment to the Interlocal Cooperation Agreement, and expending funds
in the Park Land Acquisition Budget for Clark Lake Park open space was authorized.
T. Kent Land Use& Planning Board Appointment. (CFN-174) The Mayor's appointment of
Mr. Kenneth Wendling to serve as a member of the Kent Land Use and Planning Board was
confirmed.
U. Kent Human Services Commission. (CFN-873) The Mayor's appointment of Mr George
Adams to serve as a member of the Kent Human Service Commission was confirmed.
ADDED ITEM
V. Council Absence. (CFN-198) An excused absence from tonight's meeting for Council
President Peterson was approved.
OTHER BUSINESS
A. Churches in M1,MI-C, And CM-1 Zoning Districts Zoning Code Amendment.
(CFN-131) After holding a public hearing, the Land Use & Planning Board recommends approval
of a zoning code amendment to allow churches to locate as Special Permit Uses in the Industrial
Park and Commercial Manufacturing zoning districts. Charlene Anderson, Planning Manager,
explained the amendment. CLARK MOVED to approve Zoning Code Amendment#ZCA-2004-2
as recommended by the Land Use &Planning Board and to direct the City Attorney to prepare the
necessary ordinance. White seconded and the motion carried.
B. Hazardous Substance Land Use Facilities Zoning Code Amendment. (CFN-131) After
holding a public hearing, the Land Use &Planning Board recommends approval of a zoning code
amendment related to hazardous substance land use facilities which replaces references to the
Uniform Fire Code. This amendment is needed because of the recent adoption of the International
Fire Code. Charlene Anderson explained that using"adopted Fire Codes"will prevent future
amendments. CLARK MOVED to approve Zoning Code Amendment#ZCA-2004-3 as
recommended by the Land Use &Planning Board and to direct the City Attorney to prepare the
necessary ordinance. White seconded and the motion carried.
BIDS
A. Pump Station No. 5 Generator Upgrade. (CFN-1038) The bid opening for this project
was held on June 25, 2004, with two bids received. The low bid was submitted by RTB
Contracting, Inc. in the amount of$84,102.40. WHITE MOVED to authorize the Mayor
to enter into a contract to award the Pump Station No. 5 Generator Upgrade contract to
RTB Contracting, Inc. in the amount of$84,102.40. Clark seconded and the motion carried.
B. S. 192nd/Sprinebrook Creek Culvert Replacement. (CFN-1038) The bid opening for this
project was held on June 28, 2004, with seven bids received. The low bid was submitted by Tn- ,
State Construction, Inc. in the amount of$131,860.16. WHITE MOVED to authorize the Mayor
to enter into a contract to award the South 192nd/Springbrook Creek Culvert Replacement
contract to Tri-State Construction, Inc. in the amount of$131,860.16. Hannon seconded and the '
motion carved.
4
Kent City Council Minutes July 6, 2004
C. Glenn Nelson Park Improvements. (CFN-118) The bid opening was held on June 22, 2004,
with four bids received. Clements Brothers,Inc. of Bonney Lake was the apparent low bidder.
The Parks Director recommends awarding the bid to Clements Brothers, Inc. for improvements to
Glenn Nelson Park in the amount of$278,745.00,plus Washington State Sales Tax and amending
the budget to include 10%contingency. RANNIGER SO MOVED. Harmon seconded and the
motion carved.
REPORTS
G. Administrative Reports. (CFN-198) Martin reminded Council members of an executive
session of approximately 15 minutes to discuss property acquisition and stated that action may be
taken afterward.
CONTINUED COMMUNICATIONS
A. Salaries. (CFN-198) Bob O'Brien, 1131 Seattle Street, distributed copies of a comparison of
salaries of firefighters in Kent and in New York City, and noted that Kent's salaries are higher.
He voiced concern about overtime and Martin agreed that it is an issue.
EXECUTIVE SESSION
The meeting recessed to Executive Session at 8.03 p.m. and reconvened at 8.23 p.m (CFN-198)
ACTION AFTER EXECUTIVE SESSION
Property Acquisition. (CFN-239) RANNIGER MOVED to authorize the Mayor to enter into a
Purchase and Sale Agreement for an amount not to exceed $160,000 for the Uhler Property, and to
authorize the Mayor to execute any and all documents necessary to close the purchase upon
review by the City Attorney, and to appropriate $160,000 plus feasibility and closing costs from
Ithe Park Land Acquisition account. Raplee seconded and the motion earned.
ADJOURNMENT
The meeting adjourned at 8:25 p.m. (CFN-198)
�a.lr►-�irt�
Brenda Jacober, CMC
City Clerk
5
Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: CHURCHES IN M1, MI-C, AND CM-1 ZONING DISTRICTS ZONING
CODE AMENDMENT ORDINANCE—ADOPT
2. SUMMARY STATEMENT: Adoption of Ordinance No. amending
Section 15.04.090 of the Kent City Code to add churches as special permit uses in
CM-1, Commercial Manufacturing-1; M1, Industrial Park; and M1-C Industrial Park—
Commercial zoning districts.
3. EXHIBITS: Ordinance
4. RECOMMENDED BY: Land Use and Planning Board
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? No Revenue? No
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6C
ORDINANCE NO.
AN ORDINANCE of the city council of the city
of Kent, Washington, amending section 15.04.090 of
the Kent City Code, adding churches as special permit
uses in CM-1, Ml, and MI-C zoning districts (ZCA
2004-2)
RECITALS
A. Under the Kent City Code churches are allowed as Special Permit
Uses in a number of zoning districts. On June 14, 2004, the Land Use & Planning
Board held a public hearing on the issue of expanding the list of zoning districts in
�I
which churches are allowed to located. At the conclusion of the public hearing, the
Land Use & Planning Board recommended adding churches as Special Permit Uses
in the CM-1, Commercial Manufacturing-1 District; M1, Industrial Park District; and
M1-C, Industrial Park—Commercial District (ZCA 2004-2).
B. On April 29, 2004, the City provided the required sixty (60) day
notification under RCW 36.70A.106 to the state of Washington of the City's
proposed amendment to the zoning code. This sixty (60) day period has since
expired.
I 1 Churches in M-1 Zoning District
Section 15.04.090
C. On July 6, 2004, the City Council voted to amend section 15.04.090 !
of the Kent City Code to permit churches in the CM-1, MI, and MI-C zoning
districts.
ORDINANCE
NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF
KENT,WASHINGTON, DOES HEREBY ORDAIN AS FOLLOWS:
SECTION 1. —Amendment. Section 15.04.090 of the Kent City Code !
is amended as follows:
!
2 Churches in M-1 Zoning District
Section 15.04.090
Sec. 15.04,190, Service Land Uses.
Zonine Districts
Key
P=Principally Permitted Uses o E
S=Special Uses 5 5
C=Conditional Uses ,o„ q e q
A=Accessory Uses E L F t u q 5
5 *2aE
iU u y 17 u
« m N q
E G C u E E
U
E E d C] Q 'a u
E Jr A
q BE
d E y an
E w " a a C 1� u^E, a_T tT nx�. U EE m m
E c 'c q q E
m m E u u O Y m m
!2v T T T T « L>' E E O 2 C E
O U o U 'm A E ,se `" y o
C m m ,Ea m D w—. ski E v 2 ¢t OF F o c`a„ n �, >,
E
u d e u = v .c a m EO E E A E �
E ) G v G E y 0
n. z U q q U Nr C� c � � V U
N rl q b W cK L�K+ rLL±� K CK cK = U U (Fl E � G U O cQ c - cN M 3
Q ¢ on V1 fA V] V) 'A L G G L F+ G .7. U I--� U U 0 0 L G 2 4 G L)
Finance,insurance,real estate P P P P P P P P P P P
services (22) (1) (2) (3)
(12)
Personal services.Laundry,dry P P P P P P C P P P P
cleaning,barber,salons,shoe repair, (22) (12) (10)(10) (2) (3)
launderettes I (10)
Mortuaries P P P C P
p z) (3)
Home day tare P P P P P P P P P P P P P P P P P P P P P P P P P P P P P
Day care center C C C C C C C C P P P P P P P P P P P P P P P P P P P P P
Business services,duplicating and P P P P P P P P P
blue printing,travel agencies and (12) (2) (3)
employment agencies
Budding maintenance and pest control P P P P P P
(2)
Outdoor Storage(including truck, P P A A A A A P
heavy equipment and contractor C
storage yards as allowed by (9)
Development Standards Sections
15 04 190&15 04 210)
Rental and leasing services for cars, P P P P P P
trucks,traders,furniture and tools (2)
Auto repair and washing services C P P P P P C
(including body work) (21) (5)
Repair services Watch,TV, P P P P P P P P P
electrical,electronic,upholstery (12) (2) (3)
Professional services Medical,climes P P P P P P P P I P P
and other health care related services (20) (2) (3)
Heavy Equipment and Truck Repair P P P C P
(9)
Contract Construction Service P P P P P P P P P
Offices Building construction; (16) (16) (17)(17) (2) (3)
plumbing,paving and landscaping (17)
Educational Services vocabonal, P P P P P P P P
trade,art;music;dancing,barber (2) (3)
and beauty
Churches S S S S 5 S S S S S S S S S S S S S S S S S S
(4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) f (4) (4) (4) �41 (4) (4l
! Administrative and professional P P I P I C P P P P P P P
offices—general (12) (2) (3)
Municipal uses and buildings P P n(IP3) (13)
P P P P p P P P P
(13)(13) (13) (13)(13)(13)(13) (2) (13) (13)
(13)
3
Key Zoning Districts
P=Principally Permitted Uses i5
S-Special Uses E E
C-ConditionalUses ti y q c q m E
A=Accessory Uses O F E E u
O Q h
E E Q F F a -> a U iz a
E E c c E id y
E q a A m m u a W a w E E
'O m
U >
rG o d cG w > > E E w
E ,,
EEO m E ;;-! � y° E yG 2 � V � - - o
u ' � m m E m eo 3 ID op E E 6 0 E 2 � d
° o o
Q < gL U o g q V U a�i tom". F z E u C7
N M I "° c0 q C F F C7 G W y U U S W U 0 c .] U U
c a x a a x U U U U U o ¢ N 3
Research,development and testing P P P P P P P
Planned Development Retail Sales C
(6)
Accessory uses and buildings A A A A A JA
A A A A A A A A A A A A A A A A A
customarily appurtenant to a (7) (18)(18) (19)(19) (18)(18)(18) (15)
permitted use
Boarding kennels and breeding C C C
establishments Veterinary clinks and veterinary C P P P P C P
hospitals (8) (8) (8) (8) (11)
Administrative or executive offices P P P P P
which are part of a predominant
industrial operation.
Offices incidental and necessary to the A A A A
conduct of a principally permitted use
P\Cmh0RDINANCE\15 04 090-ChumhesTable dm
4
SECTION Z - Savings. The existing sections 15.04.090 of the Kent
City Code, which are amended by this ordinance, shall remain in full force and effect
until the effective date of this ordinance.
SECTION 3. -Severability. 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 portions 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
ATTEST.
BRENDA JACOBER, CITY CLERK
I
APPROVED AS TO FORM:
TOM BRUBAKER, CITY ATTORNEY
PASSED: day of July, 2004.
APPROVED: day of July, 2004.
PUBLISHED: day of July, 2004
5 Churches in M-1 Zoning District
Section 15.04.090
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 10W ORDINANCEM 04 090-ChwchZonmg doc
J
i
6 Churches in M-1 Zoning District
Section 15.04.090
Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: HAZARDOUS SUBSTANCE LAND USE FACILITIES ZONING CODE
AMENDMENT ORDINANCE—ADOPT
2. SUMMARY STATEMENT: Adoption of Ordinance No. amending
Section 15.08.050(D)(9) of the Kent City Code which relates to hazardous substance or
waste to be consistent with the recently adopted International Fire Code.
3. EXHIBITS: Ordinance
4. RECOMMENDED BY: Land Use and Planning Board
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? No Revenue? No
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6D
' ORDINANCE NO.
AN ORDINANCE of the City Council of the City
of Kent, Washington, amending section 15.08.050(D)(9) to
be consistent with the recently adopted International Fire
Code.
' RECITALS
A. Section 15.08.050(D)(9) of the Kent City Code references the Uniform
Fire Code, which was replaced by the International Fire Code by vote of the Kent
City Council on May 4, 2004. This zoning code amendment changes the fire code
reference to the City's current fire code, whatever that code may be at the time
B. On April 29, 2004, the City provided the required sixty (60) day
notification under RCW 36.70A.106 to the state of Washington of the City's
proposed amendment to the zoning code. This sixty (60) day period has since
expired.
C. On July 6, 2004, the City Council voted to amend section
' 15 08.050(D)(9) of the Kent City Code to eliminate the reference to the Uniform Fire
Code and include a reference to the City's current fire code
NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF KENT,
WASHINGTON, DOES HEREBY ORDAIN AS FOLLOWS:
I Hazardous Substance Land Use Facilities
Amendment
ORDINANCE
SECTION 1. —Amendment Section 15.08.050(D)(9) of the Kent City Code, '
entitled"Hazardous substances or waste"is amended as follows: '
Sec. 15.08.050(D)(9). Hazardous substances or waste.
9. Hazardous substances or wastes No release of hazardous substances
or wastes as can contaminate any water supply, interfere with bacteria] processes in
sewage treatment or otherwise cause the emission of dangerous or offensive elements
shall be permitted at any point into any public sewer, private sewage disposal system,
watercourse or water body, or the ground, except in accordance with standards
approved by the State Department of Ecology or other appropriate state or federal ,
agency. The relevant provisions of federal, state and local laws and regulations shall
apply, and compliance shall be certified by applicants for permits under this title.
The following site development standards shall apply: ,
a. Hazardous waste facilities shall meet the location standards for
siting dangerous waste management facilities adopted pursuant to Chapter 70 105 '
RCW;
b. Hazardous substance land use facilities shall be located at least.
(1) Two hundred (200) feet from unstable soils or slopes which
are delineated on the hazard area development limitations map or as may be more '
precisely determined per KCC 15.08.224(B);
(2) Two hundred (200) feet from the ordinary high-water mark
of major or minor streams or lakes which are delineated on the hazard area
development limitations map or as may be more precisely determined per KCC
15.08.224(B), shorelines of statewide significance, or shorelines of the state;
(3) One-quarter (1/4) mile from public parks, public recreation
areas or natural preserves, or state or federal wildlife refuges; provided, that for
purposes of this section public recreation areas does not include public trails;
(4) Fifty (50) feet from any property line to serve as an onsite
hazardous substance land use facility buffer zone; '
(5) Five hundred (500) feet and one hundred (100) feet from a
residential zone and a residential unit respectively; and ,
(6) Five hundred (500) feet from a public gathering place or
agricultural land or zone, in the case of a nonagricultural hazardous substance land '
use facility;
2 Hazardous Substance Land Use Facilities '
Amendment
' C. Hazardous substance land use facilities shall not be located in a
one hundred(100) year floodplain;
d. Hazardous substance land use facilities which are not entirely
enclosed within a building shall provide a type I solid screen landscaping of a width
of at least ten (10) feet in the hazardous substance facility buffer zone required by
subsection(9)(b)(4) of this section;
e. Aboveground hazardous substance land use facilities shall be
constructed with containment controls which will prevent the escape of hazardous
substances or wastes in the event of an accidental release from the facility, and shall
' meet federal, state and local design and construction requirements;
f. Underground hazardous substance land use facilities shall meet
federal, state and local design and construction requirements;
g. Hazardous substance land uses shall comply with Ar4e-le 80 a
the T nif ffn Fire Gede as e ed in 1999 and 4hefea4ffadopted Fire Codes;
h. Hazardous substance land uses shall provide for review and
approval by the city fire department of a hazardous substance spill contingency plan
for immediate implementation in the event of a release of hazardous substances or
wastes at the facility;
i. Hazardous substance land uses should use traffic routes which
do not go through residential zones,
j Hazardous substance land uses in the O, NCC, CC and DC
zones shall be entirely enclosed within a building; and
k. Without limiting the application of the 'nt€ern3 lira
God adoptedFire Codes to diesel fuel tanks, above and below ground diesel fuel
storage tanks exclusively intended for use on stationary, on-site, oil burning
equipment (such as electrical power generator systems) in all nonresidential zoning
districts shall be exempt from the hazardous substance regulations of this section,
and above and below ground diesel fuel tanks of up to six thousand (6,000) gallons
intended exclusively for use on stationary, on-site, oil burning equipment (such as
electrical power generator systems) in residential zones shall be exempt from the
hazardous substance regulations of this section for essential governmental facilities
only. The hazardous substance zoning code regulations, including the existing five
hundred (500) gallon limit for hazardous substances for residential uses, shall
otherwise remain in force and effect. Additionally, all above-ground diesel fuel
tanks over five hundred (500) gallons exempted by this subsection are required to
have a five (5) foot minimum landscape buffer surrounding the tank to buffer the
visual impacts of these tanks. Moreover, the planning director shall have the
discretion to increase or modify tlus landscape buffer requirement depending upon
the specific circumstances posed by any particular tank location.
3 Hazardous Substance Land Use Facilities
Amendment
In case of conflict between any of these site development standards and the
development standards of specific zoning districts or other requirements of this title,
the more restrictive requirement shall apply.
SECTION 2. -Severabilm 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 3. -Effective Date This ordinance shall take effect and be
in force thirty(30) days from and after its passage as provided by law. '
JIM WHITE, MAYOR '
ATTEST:
f'
I I
BRENDA JACOBER, CITY CLERK
APPROVED AS TO FORM: '
TOM BRUBAKER, CITY ATTORNEY
PASSED: day of July, 2004.
APPROVED: day of July, 2004. '
PUBLISHED: day of July, 2004.
4 Hazardous Substance Land Use Facilities ,
Amendment
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
rc.�rocaHUK.E.we.m,smsv.wr.+<..
!
!
!
5 Hazardous Substance Land Use Facilities
Amendment
!
I
tKent City Council Meeting
Date July 20, 2004
Category Consent Calendar
M1. SUBJECT: 2004 COMPREHENSIVE PLAN UPDATE ORDINANCE—ADOPT
2. SUMMARY STATEMENT: Adoption of Ordinance No. relating to the
2002-2004 Comprehensive Plan Update (CPA-2002-1), which amends the City of Kent
Comprehensive Plan in compliance with the requirements of the Growth Management
Act, all as more specifically identified in the Ordinance.
3. EXHIBITS: Ordinance (Exhibit A is available for review in the Council Office)
4. RECOMMENDED BY: Planning Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
' Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
' Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6E
ORDINANCE NO.
AN ORDINANCE of the City Council of the City
of Kent, Washington, amending the City of Kent
Comprehensive Plan in compliance with the requirements
of the Growth Management Act (CPA-2002-1).
RECITALS
A. Per RCW 3 6.70A.13 0(4), the Growth Management Act (GMA)requires
the City of Kent to review and revise its Comprehensive Plan and development
regulations by December 1, 2004, to ensure that the Comprehensive plan and the
development regulations are in compliance with the requirements of the GMA
B. The GMA requires each jurisdiction to establish public participation
procedures whereby amendments and updates to the Comprehensive Plan are considered
by the City (RCW 36.70A.130(2)) During the current Comprehensive Plan update
process,the City provided a docketing procedure to solicit public input and publicized the
update efforts through direct mailings, news paper articles, and the City's website. In
accord with Kent City Code section 12.02.060, the City of Kent Land Use and Planning
Board held the following workshops and public hearings on the chapters of the
Comprehensive Plan designated below:
' 1 200212004
Comprehensive Plan Update
Chapter Workshop Public Hearing
Introduction 5/13/2002 10/28/2002
Community Profile 9/09/2002 10/28/2002
Framework Policies 5/13/2002 10/28/2002 '
Land Use Element 12/09/2002 7/28/2003
1/13/2002
2/10/2003 ,
3/10/2003
4/14/2003
Community Design 6/10/2002 7/22/2002 '
10/14/2002 5/27/2003
12/09/2002
3/24/2003 '
Housing Element 10/14/2002 11/25/2002
Human Services Element 10/14/2002 11/25/2002
Capital Facilities Element 4/28/2003 8/25/2003 '
Transportation Element 11/24/2003 12/08/2003
Park& Open Space Element 7/08/2002 8/26/2002
Utilities Element 9/23/2002 10/28/2002
Economic Development 7/08/2002 8/26/2002
Entire Comprehensive Plan 2/09/2004 3/08/2004
C. At the conclusion of the March 8,2004,public hearing,the Land Use and
Planning Board recommended approval of the updated Comprehensive Plan to the City
Council with itemized concerns.
D. On June 1, 2004, the City Council remanded two Comprehensive Plan '
policies to staff for re-review,clarification,and forwarding to the Council's Planning and
Economic Development Committee. On June 14, 2004, the Committee performed t
additional review,and on July 6,2004,the City Council held an additional public hearing
and then approved the updates to the Comprehensive Plan as shown in the attached
Exhibit A incorporated by this reference.
2 200212004
Comprehensive Plan Update
' E. The updates to the Comprehensive Plan address issues of compliance with
the GMA, demographic adjustments based on the City's expanded boundaries and new
2000 U.S. Census data, synthesized household and employment allocations, and
refinements based on new and updated regional planning documents. The updates include
language to reflect planning documents that the City has adopted such as the 2003-2007
' Consolidated Plan for Housing and Community Development; Interim 2000
Comprehensive Park,Recreation and Community Services Plan;the Downtown Strategic
Action Plan (1998); and the Kent Economic Development Strategic Plan 2003-2008.
Incorporated in the updates are the results from the Innovative Housing Workshop;
performance measures to evaluate levels-of-service, updates to the 6-year Capital
Facilities Project and the Transportation Capital Improvements Program; and the goals
1 and policies from the City's 1999 Shoreline Master Program.
i
F. In terms of specific chapters,the Framework Policies have been updated to
create new language in the Kent Planning Goals addressing best available science and
Ssupporting designated agricultural resource lands. The Land Use Element contains
updated inventories of land use designations,critical areas,and designated resource land.
The Potential Annexation Area map has been revised to reflect revisions made in the
jCountywide Planning Policies and the Land Use map has been revised to reflect changes
in City and County land use designations. In the Community Design Element a new
section has been added on Environmentally Sensitive Design and Construction Goals &
Policies in support of low impact development principles. The Capital Facilities Element
focuses on performance measures to achieve a level-of-service and updates funding for the
Capital Improvement Program.
G. The Washington State Environmental Policy Act (SEPA) requires that
amendments to the Comprehensive Plan be reviewed for their potential impacts on the
environment. On March 1, 2004, the City of Kent issued an Addendum to the
3 200212004
Comprehensive Plan Update
Environmental Impact Statement that was prepared for the Kent Comprehensive Plan(the
"SEPA Addendum"). This SEPA Addendum analyzed the potential impact of various
Comprehensive Plan amendments (#ENV-93-51).
H. On January 15, 2004, the City provided the required sixty (60) day
notification under RCW 36.70A.106 to the state of Washington of the City's proposed
update to the Comprehensive Plan. On February 11, 2004, the City received comments
regarding the update from the Washington State Department of Community, Trade &
Economic Development(CTED). CTED's comments indicated that the proposed update
demonstrated consistency with the requirements of the Growth Management Act and with '
the Countywide Planning policies. CTED stated that the update included a number of
excellent policies to support a vibrant and livable community, and CTED's concerns '
regarding density issues were analyzed by the City and subsequently addressed in the
update. ,
NOW, THEREFORE, THE CITY COUNCIL OF THE CITY OF KENT, ,
WASHINGTON, DOES HEREBY ORDAIN AS FOLLOWS-
ORDINANCE
SECTION I. - Update. The City of Kent Comprehensive Plan adopted by ,
Ordinance No. 3222, is hereby updated to comply with the requirements of the Growth
Management Act. The update to the Comprehensive Plan is attached-and incorporated as
Exhibit"A". ,
SECTION 2. -Severabdity. If any one 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.
4 200212004
Comprehensive Plan Update '
SECTION 3. -Effective Date. This Ordinance shall take effect and be in
force thirty(30) days from and after the date of passage as provided by law.
I
JIM WHITE, MAYOR
ATTEST:
` BRENDA JACOBER, CITY CLERK
APPROVED AS TO FORM:
TOM BRUBAKER, CITY ATTORNEY
PASSED day of 2004.
j I APPROVED day of , 2004.
PUBLISHED day of 92004.
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 kCiwRORDINANCEICaryPimUpdwc-2004 dm
5 200212004
Comprehensive Plan Update
Kent City Council Meeting
Date Jul 20, 2004
Category Consent Calendar
1. SUBJECT: BROOKSIDE COURT FINAL PLAT—APPROVE AND AUTHORIZE
2. SUMMARY STATEMENT: Approve the Final Plat Mylar for Brookside Court
and authorize the Mayor to sign the Mylar. 4`h and Union Associates proposes to
subdivide approximately 6.7 acres into 24 single-family residential lots. The property is
located at 27842 132"d Avenue SE.
3. EXHIBITS: Memo with conditions and map
4. RECOMMENDED BY: Community Development& Public Works Dept. Staff
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? No Revenue? No
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
1 Item No. 6F
tCOMMUNITY DEVELOPMENT
Fred N Satterstrom, AICP, Director
PLANNING SERVICES
KEN T Charlene Anderson,AICP, Manager
ww5"'NGTON Phone 253-856-5454
Fax 253-856-6454
' Address 220 Fourth Avenue S
Kent,WA 98032-5895
DATE: July 12, 2004
TO: MAYOR JIM WHITE, COUNCIL PRESIDENT JULIE PETERSON AND CITY
COUNCIL MEMBERS
FROM: CHARLENE ANDERSON,AICP, PLANNING MANAGER
THROUGH: MAYOR JIM WHITE
SUBJECT: BROOKSIDE COURT FINAL PLAT (9FSU-2001-11/KIVA #2040878)
MOTION: Approve the final plat mylar for Brookside Court and authorize the Mayor to sign
the mylar.
SUMMARY: 4th and Union Associates proposes to subdivide approximately 6.7 acres
into 24 single-family residential lots. The property is located at 27842 132"d Avenue SE.
BUDGET IMPACT: None
BACKGROUND: On June 12, 2002, the Hearing Examiner issued Findings, Conclusions and a
Decision granting preliminary approval of a 24-lot subdivision, with 19 conditions. The City
subsequently approved a minor plat alteration. The applicant has complied with the conditions
required prior to recording.
S\Permit\Plan\longplats\200 1\2040878-FSU-200 1-11 cc.DOC
1 Enclosures Conditions of approval—Hearing Examiner
Conditions of approval—Minor plat alteration
Map
BROOKSIDE COURT
#SU-2001-11
ON JUNE 12, 2002, THE CITY OF KENT HEARING EXAMINER APPROVED
BROOKSIDE COURT #SU-2001-11 WITH THE FOLLOWING CONDITIONS: I
A. GENERAL CONDITIONS OF APPROVAL
1. The owner/subdivider shall implement all mitigation measures required by
the Mitigated Determination of Nonsignificance (MDNS) for the proposed
Brookside Court Preliminary Plat, file #ENV-2001-40.
B. PRIOR TO RECORDATION OF THE FINAL PLAT ,
1. The Owner/Subdivider shall pay all Charges in Lieu of Assessments
and/or Latecomer Fees, if any, prior to the scheduling of the Pre-
Construction Conference and/or prior to recording the plat, whichever
comes first.
2. The Owner/Subdivider shall submit and receive approval for engineering
drawings from the Department of Public Works, and shall then either '
construct or bond for the following:
a. A sanitary sewer system to serve all lots within the proposed
subdivision.
The City sewer system shall be extended from the existing City
sanitary sewer system and shall be sized to serve all off-site
properties within the same service area. In addition, the sanitary
sewer system shall be extended across the entire subdivision as
needed to serve adjacent properties within the same service area.
The septic system and drainfield serving the existing residence to
the north of the proposed subdivision shall be abandoned in
accordance with King County Health Department regulations.
Further, the Owner/Subdivider shall establish new sanitary sewer ,
service to said residence without any interruption in service. The
Owner/Subdivider shall provide documentation with civil
construction plans for the subdivision how this sanitary sewer
service will be provided without interruption.
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 1 of 12
S
b. A water system meeting domestic and fire flow requirements for all
lots.
rThe subject property is served by King County Water District#111.
I The existing water well serving the three existing properties east of
the proposed subdivision shall be abandoned in accordance with
the requirements of the Washington State Department of Ecology.
Further, the Owner/Subdivider shall establish new water service to
the three existing properties without any interruption in service.
The Owner/Subdivider shall provide documentation with civil
construction plans for the subdivision how this water service will be
provided without interruption.
C. Interim Street Improvement Plans for 132"d Avenue Southeast
along the entire property frontage thereon. These Street
Improvement Plans shall meet the requirements of the City of Kent
Construction Standards and Development Assistance Brochure #6-
2, Private and Public Street Improvements, for a public street
designated as a Minor Arterial Street Augmented With Bike Lanes
by the City of Kent Master Plan of Roadways. Initial guidance for
the necessary street improvements is given below: The applicant
may choose payment in lieu of improvements if agreed to by City
Public Works Department.
(1) Vertical concrete curbs & gutters, a 5-foot wide planter strip,
and 5-foot w ide c ement c oncrete s idewalks a long t he a ast
side of the street.
(2) A minimum of 33-feet of asphalt pavement as measured
from the centerline of the right-of-way or approved roadway
design centerline to the face of curb on the east side of the
street (includes a 5-foot wide bike lane), plus at least 12-feet
of asphalt pavement as measured from the approved design
centerline to the edge of the traveled lane on the west side
of the street.
(3) A City-approved shoulder on the west side of the street.
(4) A City-approved street lighting system.
' (5) Public stormwater conveyance, detention and treatment
facilities
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 2 of 12
(6) Street Trees installed within the 5-foot wide planting strips
constructed b etween the back of curb a nd t he f ront of the
cement concrete sidewalk. These Street Trees will be
located at least 30-feet from street lights, and the species
shall be selected from the Approved Street Tree List
contained within City of Kent Development Assistance
Brochure # 14, City of Kent Street Trees.
d. Street Improvement Plans for the new public Residential Street.
The Street Improvement Plans for this subdivision street shall be
designed in conformance with the requirements for a Residential
Street as required by City of Kent Construction Standards, and City
of Kent Development Assistance Brochure #6-2, Private and Public
Street Improvements, for an asphalt street 28-feet wide. Initial
guidance for these street improvements is given below:
(1) Vertical curbs & gutters, a 5-foot planting strip between the
curb and sidewalk, and 5-foot wide cement sidewalks on
both sides of the street.
(2) A minimum of 28-feet of asphalt pavement, measured from
face of curb to face of curb; except that with proper design, a
reduced asphalt street width of 20-feet may be permitted to ,
mitigate for adverse impacts to the adjacent Soosette Creek
and/or the associated wetland and wetland buffers.
(3) A street lighting system designed, constructed and
maintained by the IntoLight Division of Puget Sound Energy;
electrical bills shall be paid for by a Home Owner's
Association. The street lights shall not exceed a height of 18
feet.
(4) A public stormwater drainage system, including provisions
for conveyance, detention, and treatment facilities.
(5) Curb return radii of 25-feet at the intersection of the
subdivision street and 132nd Avenue Southeast, and for the
90 d egree i ntersection i f t his option i s u sed, a nd a 45-foot
radius to the edge of thickened asphalt pavement for the
interim cul-de-sac constructed at the south end of this street
(unless the Fire Marshal approves the design of the
residential s treet a nd t he a ast t o w est p rivate s treet a s a n
approved turnaround.)
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 3 of 12
t (6) The new Residential Street shall be redesigned as
necessary to meet the following criteria:
t (a) The maximum centerline radius for this subdivision
shall be 75-feet with a 50-foot radius or a 90 degree
intersection preferred.
(b) The west side of the right-of-way line shall be
' coincident with the extension of the west property line
for that parcel identified as Assessor's Parcel Number
342205-9197. This is necessary so that in the future
this Residential Street will be able to extend southerly
to 134th Place Southeast (currently a private street.).
The City Public Works Department may approve an
alternative configuration.
(c) This residential street shall include an approved
connection of a private street serving the adjacent
parcels to the east of the subdivision.
(7) Street Trees will be planted in the 5-foot wide planting strip
located between the curbs and the front of the sidewalk The
Street Tree species shall be selected from the list of
Approved Street Trees contained within City of Kent
Development Assistance Brochure # 14, City of Kent Street
Trees.
e Street Improvement Plans for the three or four new Private
Residential Streets connected to the new Residential Street and
serving all lots that do not abut that street. The Street Improvement
Plans for these streets shall be designed in conformance with the
requirements for a Private Residential Street as required by City of
Kent Construction Standards, and City of Kent Development
Assistance Brochure #6-2, Private and Public Street Improvements
and C ity o f Kent D evelopment A ssistance B rochure # 6-8, S treet
Improvement Plans for a street at least 20-feet wide. Initial
guidance for these street improvements is given below:
(1) A minimum of 20-feet of asphalt concrete pavement.
(2) A 5-foot wide cement concrete sidewalk constructed along
the one side of the street for all private streets serving more
than four lots.
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 4 of 12
t
(3) An approved cul-de-sac, or turnaround at its terminus,
unless otherwise determined by the City Fire Marshal.
(4) A private stormwater drainage system, including provisions
for collection, conveyance, detention, and treatment facilities
where applicable.
(5) Unless additional asphalt concrete pavement width is
provided for parking, all minimum width private streets
serving more than two lots shall have pavement markings
and traffic signs installed which clearly designate these
private streets as Fire Lanes, where no parking will be
permitted.
(6) Each private street, including sidewalk(s) shall be centered
within a private roadway tract or easement as approved by
the Public Works Director.
f. Street Light Plans for 132"d Avenue Southeast and for the new
Residential Street meeting the requirements of the City of Kent ,
Construction Standards, and City of Kent Development Assistance
Brochure #6-1, Street Lighting Requirements.
g. Detailed Drainage Plans meeting the requirements of the City of '
Kent Construction Standards, and City of Kent Development
Assistance Brochure #5-3, Detailed Drainage Plans. Initial
guidance is given in the conditions that follow
(1) The Owner/Subdivider shall construct two on-site public
detention/ retention pond systems to handle the storm
drainage from the two separate drainage basins on this
proposed development in accordance with the Kent
Construction Standards in order to mitigate for potential
impacts to both stormwater runoff quantity and quality. The
detention/retention pond storage volume and release criteria
for both drainage basins shall be that for SOOSETTE
CREEK.
(2) As development occurs within this subdivision, roof
downspouts for each roofed structure (house, garage,
carport, etc.) shall be directed to Roof Downspout Infiltration t
Trenches, or Perforated Stubouts, meeting the requirements
of the City of Kent Construction Standards, and City of Kent
Development Assistance Brochure #5-5, Roof Downspout
Infiltration Trench Systems, Downspout Dispersion System,
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 5 of 12
and Perforated Stubout Connections. These roof downspout
conveyance and infiltration systems shall include overflow
pipes connected to an approved conveyance system. The
Detailed Drainage Plans shall include an approved detail for
the Roof Downspout Infiltration Trench, or Perforated
1 Stubout, and will provide for private stormwater stubouts to
each lot for future connection from the Roof Downspout
Infiltration Trenches, or Perforated Stubouts The face of the
recorded plat shall contain the following restriction-
AS A CONDITION OF BUILDING PERMIT ISSUANCE,
RESIDENCES CONSTRUCTED ON LOTS OF THIS
SUBDIVISION MUST PROVIDE ROOF DOWNSPOUT
INFILTRATION TRENCH (PERFORATED STUBOUT)
SYSTEMS PER DETAILS SHOWN ON THE APPROVED
STORMWATER PLANS.
(3) A downstream analysis is required for each direction of
discharge from this development. The discharge from the
west drainage basin on this site shall include an analysis for
capacity, erosion potential, and water quality from the point
of discharge from the site downstream to the point where
stormwater discharges to Westside Soosette Creek Refer
to the City of Kent Watershed Maps for the location of this
creek. The discharge from the east drainage basin on this
site shall also include an analysis for capacity, erosion
potential, and water quality from the point of discharge from
the site downstream to the point where stormwater
discharges to the West Fork S oosette C reek. S ee City of
Kent Development Assistance Brochure #5-4, Downstream
Analyses, for the specific information required for
downstream analyses.
(4) If determined n ecessary b y t he C ity, t he O wner/Subdivider
shall provide public drainage easements meeting the
requirements of the City of Kent Construction Standards for
the specified downstream reach where adequate public
drainage easements do not currently exist.
(5) The Owner/Subdivider shall submit Landscape Plans for
within and surrounding the retention/detention facilities to the
Planning Services Division and to the Department of Public
Works for concurrent review and approval prior to, or in
conjunction with, the approval of the Detailed Drainage
Plans. These Landscape Plans shall meet the minimum
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 6 of 12
t
requirements of the City of Kent Construction Standards,
and the stormwater management landscaping requirements
contained within City of Kent Development Assistance
Brochure #5, Landscape Plans.
(6) The Owner/Subdivider shall execute Declaration of
Stormwater Facility Maintenance Covenants for the private
portions of the drainage system prepared by the Property
Management Section of the Department of Public Works. I
See City of Kent Development Assistance Brochure #5-17,
Declaration of Storrrrwater Facility Maintenance Covenants,
for information on what is contained within this document.
i. An open-to-the-air public stormwater treatment system in
accordance with the requirements of the Kent Construction
Standards, and published City of Kent Development Assistance
Brochures dealing with stormwater treatment, to mitigate for
potential impacts to stormwater runoff quality. Acceptable
stormwater treatment facilities meeting this requirement in their
preferred order include: infiltration after pretreatment; biofdtration
swales; wet ponds; extended detention ponds; and created
wetlands. See City of Kent Development Assistance Brochures #5-
1, through #5-15, for additional information on stormwater treatment
requirements.
(1) The stormwater treatment system shall be within the
approved public stormwater management tract.
(2) Easements for biofiltration swales across private lots will not
be acceptable to meet this requirement.
j. A Detailed Grading Plan for the entire subdivision meeting the
requirements of the Uniform Building Code, the City of Kent
Construction Standards, and City of Kent Development Assistance
Brochure #1-3, Excavation and Grading Permits & Grading Plans.
Initial guidance for these plans is given below:
(1) These plans will include provisions for utilities, roadways, ,
retention / detention ponds, stormwater treatment facilities,
and a building footprint for each lot.
k. A Temporary Erosion/Sedimentation Control Plan for the entire
subdivision meeting the requirements of the City of Kent
Construction Standards, and the Stormwater Management Manual
for Western Washington issued by the Washington Department of
Hearing Examiner Conditions t
Brookside Court#SU-2001-11
Page 7 of 12
Ecology. These plans must reflect the Detailed Grading Plan
discussed above, and the Planning Department approved Detailed
Tree Plan.
I. If necessary, a Wetland Mitigation Plan meeting the requirements
of the City of Kent Wetlands Management Ordinance, and City of
Kent Development Assistance Brochure #10, Wetland Mitigation
Plans. These plans shall pursue avoiding or minimizing impacts to
wetlands to the maximum extent possible by analyzing alternatives
that would avoid the impact, as stated in Kent City Code, Section
11.05.120 - Avoiding wetland impacts.
3. The Owner/Subdivider shall provide evidence that the existing private
easement for ingress, egress and utilities extending across the southern
portion of this proposed subdivision has been vacated by the appropriate
parties at or before the time of recording of the final plat. Should the
appropriate parties to the east refuse to vacate the private easement for
ingress, egress, and utilities, the Owner/Subdivider shall then revise the
Preliminary Plat as necessary to make the new residential street along the
south boundary of the subject subdivision.
4. Direct vehicular access from all lots abutting 132"d Avenue South -a Minor
Arterial Street - will be prohibited, and the face of the recorded plat shall
carry the following restriction:
DIRECT VEHICULAR ACCESS TO AND FROM ALL LOTS OF THIS
SUBDIVISION ONTO 132ND AVENUE SOUTHEAST IS PROHIBITED
5. The Owner/Subdivider shall dedicate or deed all public rights-of-way, and
otherwise convey all private and public easements necessary for the
construction and maintenance of the required improvements for this
subdivision development.
a. The private street serving properties to the east of the subject
subdivision shall be within a temporary easement granted to the
City if the Fire Marshal approves that private street as part of the
public turnaround for this subdivision.
b. The minimum right-of-way for the residential street shall be 50-feet,
with additional fillets of right-of-way required at all intersections with
that residential street.
c. The public right-of-way adjacent to Soosette Creek may be
reduced, as approved by the Public Works Director, to correspond
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 8 of 12
1
to the reduced street width permitted for the Residential Street to ,
mitigate for creek and/or wetland buffer impacts.
6. The Owner/Subdivider shall submit and receive approval for a Detailed
Tree Plan, meeting the requirements of the Kent Zoning Code, and City of
Kent Development Assistance Brochure #3, Detailed Tree Plans. Grading
Plans cannot be approved by the Department of Public Works without an
approved Detailed Tree Plan.
7. The Owner/Subdivider shall permanently protect the approved and
preserved, and/or enhanced, or created wetland(s) and its buffer(s) by
creating a separate Sensitive Area Tract and deeding the tract in fee
simple to the City, OR by granting a Sensitive Area Easement to the City
for the entire sensitive area, in conformance tothe requirements of the ,
City of Kent Wetlands Management Code. This Sensitive Area Tract or
Easement shall be consistent with the wetland and wetland buffer map
contained within the approved Wetland Delineation Report and/or
approved Wetland Mitigation Plan as appropriate. The Owner/Subdivider
shall provide a legal description of said easement or tract prepared by a
licensed land surveyor, prior to issuance of any Construction Permits. The
Sensitive Area Tract and the following language shall be included on the
face of the recorded plat:
SENSITIVE AREA TRACTS / EASEMENTS
DEDICATION OF A SENSITIVE AREA TRACT/EASEMENT CONVEYS
TO THE PUBLIC A BENEFICIAL INTEREST IN THE LAND WITHIN THE
TRACT. THIS INTEREST INCLUDES THE PRESERVATION OF NATIVE
VEGETATION FOR ALL PURPOSES THAT BENEFIT THE PUBLIC
HEALTH, SAFETY AND WELFARE, INCLUDING CONTROL OF
SURFACE WATER AND EROSION, MAINTENANCE OF SLOPE
STABILITY, VISUAL AND AURAL BUFFERING, AND PROTECTION OF
WATER QUALITY, PLANT ECOLOGY AND WILDLIFE HABITAT. THE
SENSITIVE AREA TRACT/ EASEMENT IMPOSES UPON ALL PRESENT
AND FUTURE OWNERS AND OCCUPIERS OF THE LAND SUBJECT
TO THE TRACT/EASEMENT THE OBLIGATION, ENFORCEABLE ON
BEHALF OF THE PUBLIC BY THE CITY OF KENT, TO LEAVE
UNDISTURBED ALL TREES AND OTHER VEGETATION WITHIN THE
TRACT. THE VEGETATION WITHIN THE TRACT MAY NOT BE CUT,
PRUNED, COVERED BY FILL, REMOVED OR DAMAGED WITHOUT
APPROVAL IN WRITING FROM THE CITY OF KENT.
THE COMMON BOUNDARY BETWEEN THE TRACT/EASEMENT AND
THE AREA OF DEVELOPMENT ACTIVITY MUST BE MARKED OR '
OTHERWISE FLAGGED TO THE SATISFACTION OF THE CITY OF
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 9 of 12
KENT PRIOR TO ANY CLEARING, GRADING, BUILDING
CONSTRUCTION OR OTHER DEVELOPMENT ACTIVITY. THE
REQUIRED MARKING OR FLAGGING SHALL REMAIN IN PLACE
UNTIL ALL DEVELOPMENT ACTIVITIES IN THE VICINITY OF THE
SENSITIVE AREA TRACT ARE COMPLETED.
NO BUILDING FOUNDATIONS, STRUCTURES, FILL OR
OBSTRUCTIONS (INCLUDING, BUT NOT LIMITED TO DECKS,
PATIOS, OUTBUILDINGS AND OVERHANGS) ARE ALLOWED WITHIN
15 FEET OF THE SENSITIVE AREA TRACT/EASEMENT BOUNDARY,
UNLESS OTHERWISE APPROVED BY THE CITY.
THE CITY OF KENT RESERVES THE RIGHT TO INSTALL PUBLIC
UNDERGROUND UTILITIES WITHIN THIS SENSITIVE AREA TRACT,
AND TO ENTER AND PERFORM DRAINAGE SYSTEM MAINTENANCE,
BUT IS REQUIRED TO RESTORE OR ENHANCE THE SENSITIVE
AREAS DISTURBED UPON THE COMPLETION OF THE
UNDERGROUND CONSTRUCTION, AND/OR DRAINAGE SYSTEM
MAINTENANCE.
I8. The Owner/Subdivider shall permanently protect the approved and
preserved, and/or enhanced, or relocated West Fork of Soosette Creek
and its buffer(s) by creating a separate Sensitive Area Tract and deeding
the tract in fee simple to the City, OR by granting a Sensitive Area
Easement to the City for the entire sensitive area, in conformance to the
requirements of the City of Kent Zoning Code This Sensitive Area Tract or
Easement shall be consistent with the creek and creek buffer map
contained within the approved topographic and boundary survey provided
for this short subdivision. The Owner/Subdivider shall provide a legal
description of said easement or tract prepared by a licensed land
surveyor, prior to issuance of any Construction Permits. The Sensitive
Area Tract or Easement shall be deeded or granted to the city for drainage
utility purposes for which said purposes shall take priority over all other
rights and restrictions (present or future) encumbering the described
property. In addition the following language for the Sensitive Area Tract or
Easement shall be included on the face of the recorded plat:
SENSITIVE AREA TRACTS / EASEMENTS
DEDICATION OF A SENSITIVE AREA TRACT/EASEMENT CONVEYS
TO THE PUBLIC A BENEFICIAL INTEREST IN THE LAND WITHIN THE
TRACT. THIS INTEREST INCLUDES THE PRESERVATION OF NATIVE
VEGETATION FOR ALL PURPOSES THAT BENEFIT THE PUBLIC
HEALTH, SAFETY AND WELFARE, INCLUDING CONTROL OF
SURFACE WATER AND EROSION, MAINTENANCE OF SLOPE
Heanng Examiner Conditions
Brookside Court#SU-2001-11
Page 10 of 12
STABILITY, VISUAL AND AURAL BUFFERING, AND PROTECTION OF
WATER QUALITY, PLANT ECOLOGY AND WILDLIFE HABITAT. THE
SENSITIVE AREA TRACT/ EASEMENT IMPOSES UPON ALL PRESENT
AND FUTURE OWNERS AND OCCUPIERS OF THE LAND SUBJECT
TO THE TRACT / EASEMENT THE OBLIGATION, ENFORCEABLE ON
BEHALF OF THE PUBLIC BY THE CITY OF KENT, TO LEAVE
UNDISTURBED ALL TREES AND OTHER VEGETATION WITHIN THE
TRACT. THE VEGETATION WITHIN THE TRACT MAY NOT BE CUT,
PRUNED, COVERED BY FILL, REMOVED OR DAMAGED WITHOUT
APPROVAL IN WRITING FROM THE CITY OF KENT.
THE COMMON BOUNDARY BETWEEN THE TRACT/EASEMENT AND
THE AREA OF DEVELOPMENT ACTIVITY MUST BE MARKED OR
OTHERWISE FLAGGED TO THE SATISFACTION OF THE CITY OF
KENT PRIOR TO ANY CLEARING, GRADING, BUILDING
CONSTRUCTION OR OTHER DEVELOPMENT ACTIVITY. THE
REQUIRED MARKING OR FLAGGING SHALL REMAIN IN PLACE
UNTIL ALL DEVELOPMENT ACTIVITIES IN THE VICINITY OF THE
SENSITIVE AREA TRACT ARE COMPLETED.
NO BUILDING FOUNDATIONS, STRUCTURES, FILL OR i
OBSTRUCTIONS (INCLUDING, BUT NOT LIMITED TO DECKS,
PATIOS, OUTBUILDINGS AND OVERHANGS) ARE ALLOWED WITHIN
15 FEET OF THE SENSITIVE AREA TRACT/EASEMENT BOUNDARY,
UNLESS OTHERWISE APPROVED BY THE CITY.
THE CITY OF KENT RESERVES THE RIGHT TO INSTALL PUBLIC
UNDERGROUND UTILITIES WITHIN THIS SENSITIVE AREA TRACT,
AND TO ENTER AND PERFORM DRAINAGE SYSTEM ,
MAINTENANCE, BUT IS REQUIRED TO RESTORE OR ENHANCE THE
SENSITIVE AREAS DISTURBED UPON THE COMPLETION OF THE
UNDERGROUND CONSTRUCTION, AND/OR DRAINAGE SYSTEM
MAINTENANCE.
9. After construction, the wetland and buffer areas shall be isolated from
intrusion and/or disturbance using landscaping, or other appropriate
screens, as well as an approved permanent wildlife-passable fence. In
addition, Wetland Information Signs approved by the Department of Public
Works shall be placed at the wetland buffer edge to inform and educate
owners and nearby residents about the value of wetlands.
10. The Owner/Subdivider shall provide the Department of Public Works with
a copy of an approved Hydraulic Project Approval (HPA), OR A WRITTEN
WAIVER THEREFROM issued by the Washington State Department of
Fish and Wildlife prior to approval of Construction Plans. Contact
Hearing Examiner Conditions
Brookside Court#SU-2001-11
Page 11 of 12
i
tLarry Fisher of the Washington State Department of Fish and Wildlife at
(425) 649-7042 for additional information.
t11. The Owner/Subdivider shall provide the Department of Public Works with
a c opy of a n a pproved N ational P ollutant D ischarge E limination S ystem
Permit (NPDES) OR A WRITTEN WAIVER THEREFROM issued by the
Washington State Department of Ecology prior to approval of Construction
Plans.
12. Prior to release of any construction bonds, and prior to the approval of any
Building Permits within the subject subdivision, the Department of Public
Works must receive and approve As-Built Drawings meeting the
requirements of the City of Kent Construction Standards, and City of Kent
Development Assistance Brochure #E-1, As-Built Drawings, for: Streets;
Street Lighting System; Water; Sewer; Stormwater Drainage Facilities;
and all off-site improvements where the locations and/or elevations are
deemed critical by the Department of Public Works.
13. A fee-in-lieu of park dedication shall be paid by the owner/subdivider in
conformance with KCC 12.04.780. To mitigate for impacts of this proposal
on parks and recreation, the applicant will be required to pay a fee in lieu
of dedication of land pursuant to Section 12.04.780 KCC. The fee in lieu
of a donation of five percent for open space parkland is $17,250.00 based
on current tax assessments from the King County Assessor's office
records for the year 2002.
j14. Mail boxes and mail stop locations are to be provided as shown by the US
Postal Service on the preliminary plat map dated March 15, 2002.
C. PRIOR TO THE ISSUANCE OF A BUILDING PERMIT ON ANY LOT IN THIS
SUBDIVISION, THE OWNER/ SUBDIVIDER SHALL:
1. Record the Plat.
2. Pay the Environmental Mitigation Fee for that lot.
3. Construct all of the improvements required above.
4. Submit and receive City approval for As-Built Drawings meeting the
requirements of City of Kent Development Assistance Brochure #E-1, As-
Build Drawings, for street improvements, stormwater management
system, street lighting system, and other off-site improvements where
determined necessary by the City.
S\Permit\Plan\longplats\2001\2040878-2001-Icondibons doc
Heanng Examiner Conditions
Brookside Court#SU-2001-11
Page 12 of 12
BROOKSIDE COURT '
#PTA-2003-3 KIVA#2033564
An Administrative Review Decision was approved on December 24, 2003 with the
following conditions:
1. The applicant/owner shall produce a revised plat drawing of the approved
alteration of the subdivision. The final plat drawing shall accurately reflect the
approved alteration and shall be filed with the King County Auditor as part of the
final plat process.
t
2. All conditions of approval of Brookside Court#SU-2001-11 and ENV-2001-40
remain valid and relevant to this minor plat alteration
S\Permit\Plan\Iongplats1200112040878-2001-lptaconditions.doc "`
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Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: NATIONAL NIGHT OUT, COUNCIL MEETING TIME CHANGE—
AUTHORIZE
2. SUMMARY STATEMENT: As recommended by the Operations Committee, the
time of the August 3, 2004 City Council meeting will be changed from its regular
meeting time of 7:00 p.m. to 5:00 p.m., and the City Clerk is directed to give notice of
the time change in the same manner as a special meeting.
National Night Out is an annual event designed to bring neighborhoods together for
community enhancement and crime prevention. Every year, the police department, City
Council, and other City representatives take this opportunity to thank the citizens that
make this neighborhood crime prevention program work. National Night Out occurs on
the first Tuesday in August, which conflicts with the City Council meeting scheduled
on the same night. In order to participate in this event, the City Council will need to
move the time for its regular meeting on August I" from 7 p.m. to 5 p.m.
3. EXHIBITS• None
4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6G
Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: GROUP HEALTH COOPERATIVE 2004 CONTRACT-AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the 2004 Group Health
Cooperative of Puget Sound contract for the City's insured HMO plan. The 2004
contract reflects an approximate 22.6% increase in the health care premiums charged by
Group Health and is budgeted in the health and welfare fund.
3. EXHIBITS: Group Health Contract
4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6H
@GroupHealth
COOPERATIVE
Group Medical Coverage Agreement
for
Kent, City Of
Group Health Cooperative(also referred to as"GHC")is a nonprofit health maintenance organization furnishing
health care coverage on a prepayment basis The Group identified below wishes to purchase such coverage. This
Agreement sets forth the terms under which that coverage will be provided,including the rights and responsibilities
of the contracting parties,requirements for enrollment and eligibility,and benefits to which those enrolled under this
Agreement are entitled
The Agreement between GHC and the Group consists of the following
• Standard Provisions
• Attached Benefit Booklet
• Signed Group application
• Premiums Schedule
• All attachments and endorsements included or issued hereafter
Group Health Cooperative
Signed
Title President and Chief Executive Officer
Kent,City Of,0036900
Signed
Title
This Agreement will become effective January 1,2004 and will continue in effect until terminated
or renewed as herein provided for
PA-113302
C22400-0036900 1
1
@CkoupHeafth
COOPERATIVE
Group Medical Coverage Agreement
Table of Contents
Standard Provisions
Attachment 1 Medicare Endorsement
Attachment 2 Benefit Booklet
Attachment 3 Premiums Schedule
i
1
C22400-0036900 2
Standard Provisions
1. GHC agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group
2. Monthly Premiums Payments. For the initial term of this Agreement,the Group shall submit to GHC for each
Member the monthly premiums set forth in the current Premiums Schedule and a verification of enrollment
Payment must be received on or before the due date and is subject to a grace period often(10)days Premiums
are subject to change by GHC upon thirty(30)days written notice Premium rates will be revised as a part of
the annual renewal process
In the event the Group increases or decreases enrollment at least twenty-five percent(25%)or more,GHC
reserves the right to require re-rating of the Group
3. Dissemination of Information. Unless the Group has accepted responsibility to do so,GHC will disseminate
information describing benefits set forth in the Benefit Booklet attached to this Agreement
4. Identification Cards.GHC will furnish cards,for identification purposes only,to all Members enrolled under
this Agreement
5. Administration of Agreement.GHC may adopt reasonable policies and procedures to help in the
administration of this Agreement GHC reserves the right to construe the provisions of this Agreement and to
make all determinations regarding benefit entitlement and coverage
6. Modification of Agreement. Except as required by federal and 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
7. Indemnification. GHC agrees to indemnify and hold the Group harmless against all claims,damages,losses
and expenses,including reasonable attorney's fees,ansmg out of GHC's failure to perform, negligent
performances or willful misconduct of its directors,officers,employees and agents of their express obligations
under this Agreement
The Group agrees to indemnify and hold GHC harmless against all claims,damages,losses,and expenses,
including reasonable attorney's fees,ansing out of the Group's failure to perform,negligent performances or
willful misconduct of its directors,officers,employees and agents of their express obligations under this
Agreement
The indemnifying party shall give the other party prompt notice of any claim covered by this section and
provide reasonable assistance(at its expense) The indemnifying party shall have the right and duty to assume
the control of the defense thereof with counsel reasonably acceptable to the other party Either party may take
part in the defense at its own expense after the other party assumes the control thereof
8. Compliance With Law. The Group and GHC shall comply with all applicable state and federal laws and
regulations in performance of this Agreement
This Agreement is entered into and governed by the laws of Washington State,except as otherwise pre-empted
by ERISA and other federal laws
9. Governmental Approval. If GHC has not received any necessary government approval by the date when
notice is required under this Agreement,GHC will notify the Group of any changes once governmental
approval has been received GHC may amend this Agreement by giving notice to the 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 as required by the governmental agency All
C22400-0036900 3
1
i
amendments are deemed accepted by the Group unless the Group gives GHC written notice of non-acceptance
within thirty(30)days after receipt of the amendment,in which event this Agreement and all rights to services
and other benefits terminate the first of the month following thirty(30)days after receipt of non-acceptance
10. 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 information,employee addresses,social security numbers,e-mail addresses,
phone numbers and other confidential information regarding the Group's employees(collectively the
"information") The information shall be kept strictly confidential and shall not be disclosed to any third party
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 required of 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,(u)
pursuant to court order,or(m)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 the disclosing party receives to disclose information pursuant to applicable legal
requirements,so that the other party may object to the request and/or seek an appropriate protective order
against such request Each party shall maintain the confidentiality of medical records and confidential patient
and employee information as required by applicable law
11. Arbitration. Any dispute,controversy or difference between GHC and the Group arising out of or relating to
this Agreement,or the breach thereof,shall be settled by arbitration in Seattle,Washington in accordance with
the Commercial Arbitration Rules of the American Arbitration Association,and judgment on the award
rendered by the arbitrator(s)maybe entered in any court having jurisdiction thereof Except as maybe required
by law,neither party nor an arbitrator may disclose the existence,content,or results of any arbitration hereunder
without the prior written consent of both parties
12. HIPAA.
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")
Transactions Accepted. GHC will accept Standard Transactions,pursuant to HIPAA,if the Group elects to
transmit such transactions If the Group sends transactions to GHC that do not comply with applicable HIPAA
standards,the Group will be deemed by such action to be representing and warranting that it is not a Covered
Entity or otherwise required to comply with HIPAA standards for electronic transactions,either directly,or 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 the Group,and the Group shall indemnify GHC
for any breach of this section
13. Termination of Entire Agreement. This is a guaranteed renewable Agreement and cannot be terminated
without the mutual approval of each of the parties except in the circumstances set forth below
a. Nonpayment or Non-Acceptance of Premium.Failure to make any monthly premium payment or
contribution in accordance with section 2 above shall result in termination of this Agreement as of the
premium due date The Group's failure to accept the revised premiums provided as part of the annual
renewal process shall be considered nonpayment and result in non-renewal of this Agreement The Group
may terminate this Agreement upon fifteen(15)days written notice of premium increase,as set forth in
subsection 2 above
b. Misrepresentation. GHC may terminate this Agreement upon written notice in the event that material i
misrepresentation,fraud,or omission of information was used in order to obtain Group coverage Either
party may terminate this Agreement in the event of material misrepresentation, fraud or omission of
information by the other party in performance of its responsibilities under this Agreement
C22400-0036900 4
f
c. Underwriting Guidelines.GHC may terminate or non-renew this Agreement in the event the Group no
longer meets underwriting guidelines established by GHC that were in effect at the time the Group was
accepted
d The Group may terminate this Agreement by giving thirty(30)days written notice to GHC
14. 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 Washington State Office of the Insurance Commissioner that GHC's clinical,financial,or
administrative capacity to service the covered Members would be exceeded
b GHC may determine to cease to offer the Group's current plan and replace the plan with another plan offered
to all covered Members within that line of business that includes all of the health care services covered under
the replaced plan and does not significantly limit access to the services covered under the replaced plan GHC
may also allow unrestricted conversion to a fully comparable GHC product
GHC will provide written notice to each covered Member of the discontinuation or nonrenewal of the plan at least
nmety(90)days pnor to discontinuation
f
f
C22400-0036900 5
i
Medicare
Endorsement
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(GHC) 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 GHC'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 GHC Medicare+Choice Plan upon such entitlement or eligibility
A condition of enrollment under the GHC 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 GHC or Medicare.
For additional information,the Member may refer to"Medicare& You handbook,"which can
be obtained from your local Social Security office
NEITHER GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC
FACILITIES UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE
MEMBER HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SERVICES OR OUT
OF AREA RENAL.DIALYSIS SERVICES ACCORDING TO SECTION III.D. OF THIS
MEDICARE ENDORSEMENT OR THE MEMBER HAS RECEIVED NON-EMERGENT
AND/OR NON-URGENTLY NEEDED CARE AT FACILITIES OUTSIDE THE SERVICE
C22400-0036900 1
AREA UNDER YOUR POINT OF SERVICE (POS)BENEFIT AS SET FORTH IN SECTION
III.F.
This Endorsement does not constitute a"Medicare supplemental" contract.
SECTION I. 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-GHC
Provider,be sure to show your GHC membership card. Although you never need to give up
your Medicare red,white and blue card,you must now use your GHC M+C Plan care to receive
Covered Services. It is important that you use only your GHC M+C plan membership card-----
NOT your 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
December 31 of the second calendar year following the calendar year in which the services
were rendered.
GHC 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,GHC 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 V. 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.
GHC may obtain information which it deems necessary concerning the medical care and
hospitalization for which payment is requested.
ISECTION II. DISENROLLMENT
Enrollment under the GHC 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 GHC is effective,neither
Medicare nor any other Medicare+Choice organization shall pay for services for which GHC is
responsible. While a Member is enrolled with GHC, GHC will only cover the following services
provided by non-GHC Providers or non-GHC Facilities. (1) Referrals authorized by a GHC
Provider, (2)Emergency services anywhere in the world, Urgently Needed Care, or out of the
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area renal dialysis services as set forth in Section III.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 III.F. Upon termination of membership in GHC, neither GHC nor
GHC 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 GHC Medicare+Choice Plan for any reason.
If you want to disenroll,write a letter or complete a disenrollment form and send it to the
GHC Medicare Enrollment and Reconciliation, P.O. Box 34255, Seattle, WA 98124-9986
Make sure you sign and date your letter and/or form. To get a disenrollment form, call GHC
Customer Service. 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
GHC Contracting Medical Providers until you are notified of the effective date of your
disenrollment. GHC will send you a letter that confirms when your disenrollment is effective
You will be covered by Original Medicare after you disenroll from GHC unless you have
joined another Medicare Managed Care Plan.
B. Involuntary Disenrollment.
GHC must disenroll you from the GHC M+C Plan if.
1. You move permanently out of the Service Area for more than six (6) months at a time
and do not voluntarily disenroll,
2 You do not stay continuously enrolled in both Medicare Part A and/or Part B; or
3. The contract between GHC and CMS under which the GHC M+C Plan is offered is
terminated, or the GHC M+C Plan Service Area is reduced.
GHC may disenroll you from the GHC 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 GHC M+C
Plan;
2. If you are disruptive,unruly, abusive or uncooperative to the extent that your
membership in the GHC M+C Plan seriously impairs our ability to arrange Covered
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t
' Services for you or 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 GHC 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.
I C. Persons Hospitalized on the Date of Termination.A Member who is a registered bed
patient receiving Covered Services in a GHC 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-
GHC Facility as a result of Emergency or Urgently Needed Services or Referral as set forth
in Section IV.B. of this Medicare Endorsement.
D. Services Provided After Termination.Any services provided by GHC after the effective
date of termination(except those services covered under Section ILC 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 Dependents.
SECTION III. 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 GHC except for Emergency and Urgently Needed Services
as set forth in Section III.D. of this Medicare Endorsement; and
• must meet Medicare guidelines and limitations unless otherwise specified
GHC has procedures to assist GHC 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 GHC Personal Physician selected New Members may expect their health
status to be assessed within 90 days of their enrollment.
GHC will ensure that services are provided in a culturally competent manner GHC Providers
will provide information regarding treatment options in a culturally competent manner and will
accommodate Members with disabilities.
GHC 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.
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Services received at facilities outside the GHC 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. Inpatient Hospital Care
Covered services include,but are not limited to,the following:
• Semiprivate room(or a private room if Medically Necessary).
• Meals including special diets.
• Regular nursing services.
• Costs of special care units (such as intensive or coronary care units)
• Drugs and medications.
• Lab tests
• X-rays and other radiology services.
• Necessary surgical and medical supplies.
• Use of appliances, such as wheelchairs
• Operating and recovery room costs.
• Rehabilitation services, such as physical therapy, occupational therapy, and speech
therapy services
• Under certain conditions, the following types of transplants are covered corneal, kidney,
pancreas,heart, liver, lung,heart/lung, bone marrow, stem cell, intestinal/multi-visceral.
See the Group Medical Coverage Agreement for more information about transplants
• Blood-coverage of storage and administration begins with the first pint of blood that you
need
• Physician services.
B. Skilled Nursing Facility. Upon Referral and following a Medicare-certified three(3) day j
hospital stay, GHC 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. When a 3 day Medicare covered hospital stay does not occur and the
plan determines that the Member otherwise meets all Medicare criteria, the plan may
authorize Medicare covered Skilled Nursing care for up to 100 days.
C. 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 GHC 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 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.
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i
Covered Services. In addition to the hospice services provided under the Group Medical
ICoverage Agreement,the following hospice services shall be provided:
1. Home Services
Continuous care services per Member 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 may be 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 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
GHC 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.
D. 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.
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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 III.D. of this Medicare Endorsement.
E. Emergency/Urgently Needed Services. When an Emergency meets the Medicare defmition
for Emergency or Urgently Needed Services as defined in Section VII. of this Medicare
Endorsement, services are covered in full,subject to the applicable Copayments
F. If the Member is hospitalized in a non-GHC Facility and requires continued inpatient care
GHC will continue to cover the non-emergent care and services at the non-GHC Facility
needed by the Member to remain medically stable until- (1)the Member is discharged,(2)a
GHC Provider assumes responsibility for the Member's care; or(3) GHC 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 GHC Facility is
made at the discretion of GHC with the attending physician's concurrence.
Post-stabilization care at a non-GHC 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.
G. Point of Service(POS).Non-Emergent and/or non-Urgently Needed Care received while
temporarily traveling outside GHC'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 services received when traveling primarily for
the purpose of seeking medical care
H. 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.
I. Medical and Surgical Care.The following medical and surgical services are covered when
prescribed by GHC Medical Personnel and Medicare requirements are met
1. Eye exammations and treatment for eye pathology. j
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 standard eyeglasses or contact lenses, including examination and fitting,
following each cataract surgery with insertion of an intraocular lens(IOL). Covered
eyeglasses and contact lenses must be dispensed through GHC Facilities. Replacements
C22400-0036900 7
for Members following insertion of an itraocular lens are set forth in Section H.13.
below. Replacements in the absence of an mtraocular lens will be provided when needed
due to change in the Member's Medical Condition or when deemed appropriate by a
GHC physician.
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 GHC Personal
Physician) in the hospital, office,home, Skilled Nursing Facility, nursing home, or
convalescent center.
7. Outpatient Surgery in outpatient hospital facility or ambulatory surgical center covered
subject to applicable Copayment.
8 Restorative physical, occupational, speech and language therapy, and cardiac
rehabilitation following illness, injury, or surgery.
9. Immunizations and vaccinations that are listed as covered in the GHC drug formulary
(approved drug list)or approved by Medicare.
10 Services related to dysfunction of the jaw. When referred by a GHC Personal 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 IV.B.17. of the Group Medical Coverage Agreement for Covered Services
not meeting Medicare guidelines)
11. 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 cluropractor services from GHC's designated licensed providers in order to be
covered. A list of GHC-designated licensed practitioners is available by contacting any
GHC area medical center.
C22400-0036900 8
12. Podiatric care. Services are covered when all Medicare criteria are met and when
authorized in advance by your Personal Physician. 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 GHC's designated providers in order to be covered.
13. Home intravenous (IV)drug therapy services.
14. Routine eye examinations and refractions, limited to once every twenty-four(24)
months, except when Medically Necessary. Services for routine eye examinations must
be received at a GHC Facility and in accordance with GHC 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 GHC-approved Allowance
once every twenty-four(24)months, and replaced as specified below, when received at a
GHC Facility and in accordance with GHC 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.
15. Hearing examinations to determine hearing loss Hearing aids, including examinations
and fitting,must be received at a GHC Facility and are covered up to a maximum of$250
per Member once every 24 months.
16. Diabetic education and training, including glucose monitors testing strips and lancets ,
for all diabetics.
17. 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.
J. 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.
K. Medicat/Surgical Supplies,such as casts, splints,post-surgical dressings, and ostomy
supplies,are covered.
C22400-0036900 9
L. Rental or Purchase of Durable Medical Equipment, such as oxygen and oxygen
equipment,wheelchairs and other walk-aids, and hospital beds,is covered.
M. 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 GHC upon request
SECTION IV. 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
V 19. in the Group Medical Coverage Agreement).
2 Supportive devices (shoe inserts) for the feet, except therapeutic shoes for people with
diabetes who have severe diabetic foot disease,including fitting of shoes or inserts.
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 III D.AND
III F.,ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE
PROVIDED BY GHC MEDICAL PERSONNEL AT A GHC FACILITY UNLESS.
I the Member has received a Referral from GHC, or
2. the Member has received Emergency or Urgently Needed Services as defined in Section
VIl. and as set forth in Section III.D. of this Medicare Endorsement
SECTION V. 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. GHC 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.
C22400-0036900 10
1. Standard Request. The Member may request that care or a service be covered by GHC
on the basis that it is a Medicare covered service. GHC 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, GHC will
reach a decision within 72 hours. GHC'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. GHC's decision may also be postponed in the event information for a
non-GHC Provider has not been received in a timely manner. If GHC grants a Member's
request for an expedited decision, GHC will orally notify the Member and follow-up
within two(2) working days,with a written letter. If a Member disagrees with GHC'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 GHC declines to provide, cover,or !
pay for services that the Member believes are covered by Medicare. If GHC declines to
provide or to cover a service, GHC 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 GHC may submit a written appeal to GHC.
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 seriously jeopardize his/her health or ability to function.
Appeals will be reviewed by persons not involved in the initial decision. If GHC decides to
uphold the original adverse decision, either in whole or in part,the entire file will be
forwarded by GHC 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 GHC denies coverage for services already
provided or arranged by either GHC or a non-GHC Provider or Facility, or for future
services. Member must submit appeals in writing to GHC, 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 GHC's initial decision After receiving
all pertinent materials, GHC will conduct a formal review of the appeal. GHC will
notify the Member of its decision within 60 days of receipt If GHC decides fully in
C22400-0036900 11
1
the Member's favor, GHC will pay the claim(s)within 60 days of receipt of the
Member's appeal. If GHC upholds any part of the initial denial,the entire file will be
forwarded by GHC 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 GHC denies coverage for future services.
Members must submit appeals in writing to GHC, 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, GHC will conduct a formal review of the appeal. GHC will notify the
Member of its decision within 30 days of receipt. GHC'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 GHC upholds any part of the initial denial,the entire file will be
forwarded by GHC 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 Review 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 Qualls Health.
A Member may request a"QIO"review if GHC 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.
GHC 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.
C22400-0036900 12
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A Member may contact Qualis Health at P.O. 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 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 denies a Member's appeal, either the Member or GHC 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 GHC may request a review by the Department Appeals '
Board(DAB)
An initial, revised, or reconsideration determination made by GHC, 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)
901-7350 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 VI. SUBROGATION AND REIMBURSEMENT RIGHTS
"Injured Person"under this section means a Member covered by the Agreement who sustains an
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. When referred to in this section,"GHC's 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 by the Injured Person.
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal
liability against the third party and/or payment by the third party to the Injured Person and/or a
settlement between the third party and the Injured Person, GHC shall have the right to recover
GHC's 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 liability coverage and unmsured/undermsured motorist coverage. This right is commonly
referred to as "subrogation."GHC shall be subrogated to and may enforce all rights of the
Injured Person to the extent of GHC's Medical Expenses.
C22400-0036900 13
If the Injured Person is entitled to or does 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/undennsured motorist funds, 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 the Agreement As a condition of
receiving benefits under the 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 party for less than available policy limits, in which GHC is entitled to full
compensation of GHC's Medical Expenses
The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect
GHC's Medical Expenses. This cooperation includes,but is not limited to, supplying GHC with
information about any third parties,defendants and/or insurers related to the Injured Person's
claim and informing GHC of any settlement or other payments relating to the Injured Person's
injury. The Injured Person and his/her agents shall permit GHC, at GHC's option,to associate
with the Injured Person or to intervene in any legal,quasi-legal, agency or any other action or
claim 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, including, but not limited to,billing the Injured Person directly for GHC's Medical
Expenses
The Injured Person and his/her agents shall do nothing to prejudice GHC's subrogation and
reimbursement rights. The Injured Person shall promptly notify GHC of any tentative settlement
with a third party and shall not settle a claim without protecting GHC's interest. If the Injured
Person fails to cooperate fully with GHC in recovery of GHC's Medical Expenses,the Injured
Person shall be responsible for directly reimbursing GHC for GHC's Medical Expenses and
GHC retains the right to bill the Injured Person directly for GHC's Medical Expenses.
To the extent that the Injured Person recovers funds from any source,the Injured Person agrees
to hold such monies in trust or in their possession until GHC's subrogation and reimbursement
rights are fully determined
GHC shall not pay any attorney's 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 GHC's Medical Expenses, there shall be an equitable 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, which
do not benefit GHC and/or where no written fee agreement has been entered into with GHC
C22400-0036900 14
If it becomes necessary for GHC to enforce the provision of tlus section by initiating any action
against the Injured Person or his/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 the
Agreement and GHC shall therefore have sole discretion to interpret its terms.
SECTION VII, DEFINITIONS
CENTER for MEDICARE and MEDICAID SERVICES (CMS): The Federal Agency that
runs the Medicare program(CMS was formerly known as the Health Care Financing
Administration).
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 GHC M+C Plan or Medicare unless provided in
conjunction with Skilled Nursing Care and/or skilled rehabilitation services.
EMERGENCY CARE: Covered services that are 1) furnished by a provider qualified to furnish
emergency services; and 2)needed to evaluate or stabilize an Emergency Medical Condition
EMERGENCY MEDICAL CONDITION: A Medical Condition brought on 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 that not getting immediate
medical attention could result in 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.
MAXIMUM CHARGES: A term used to define the level of benefits which are payable by ,
GHC when expenses are incurred from a non-GHC Personal 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, some
people under age 65 with disabilities and people with End Stage Renal Disease(generally those
with permanent kidney failure who need dialysis or a kidney transplant).
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 GHC Medicare+Choice Plan is a Coordinated
Care Plan.
C22400-0036900 15
MEDICARE+CHOICE(M+C) ORGANIZATION: A public or private organization licensed
by the State as a risk-bearing entity that is under contract with the Center for Medicare and
Medicaid Services (CMS)to provide Covered Services. Medicare+Choice Organizations can
offer one or more Medicare+Choice Plans. GHC is a Medicare+Choice Organization
MEDICARE+CHOICE PLAN: A benefit package offered by a Medicare+Choice Organization
that offers a specific set of health benefits at a uniform premium and uniform level of cost-
sharing to all people with Medicare who live in the Service Area covered by the Plan. A
Medicare+Choice Organization may offer more than one plan in the same Service Area The
GHC Plan is a Medicare+Choice 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 GHC offers to its Medicare+ Choice Members
while temporarily traveling outside-of-the GHC Medicare+Choice 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 request by your Personal Physician for you to receive care from a Specialist,
Contracting Medical Provider, or Non-Contracting Medical Provider, or to receive certain
Covered Services.
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 GHC and approved by CMS, within which an
eligible individual may enroll in a particular plan offered by GHC.
SKILLED NURSING FACILITY: A facility(or distinct part of a facility) which is primarily
engaged in providing to its residents 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 CARE: Covered Services provided when you are temporarily absent
from the GHC Medicare+Choice 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.
C22400-0036900 16
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 GHC'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.
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 GHC Medicare+Choke Plan upon such entitlement or eligibility
A condition of enrollment under the GHC 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 GHC 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 GHC NOR MEDICARE MAY PAY FOR SERVICES PROVIDED AT NON-GHC
FACILITIES UNLESS THE MEMBER HAS BEEN REFERRED BY GHC OR THE
MEMBER HAS RECEIVED EMERGENCY OR URGENTLY NEEDED SERVICES OR OUT
OF AREA RENAL DIALYSIS SERVICES ACCORDING TO SECTION III.D. OF THIS
MEDICARE ENDORSEMENT OR THE MEMBER HAS RECEIVED NON-EMERGENT
C22400-0036900 17
AND/OR NON-URGENTLY NEEDED CARE AT FACILITIES OUTSIDE THE SERVICE
AREA UNDER YOUR POINT OF SERVICE(POS) BENEFIT AS SET FORTH IN SECTION
III.F.
This Endorsement does not constitute a"Medicare supplemental"contract.
SECTION 1. 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-GHC
Provider,be sure to show your GHC membership card. Although you never need to give up
your Medicare red,white and blue card,you must now use your GHC M+C Plan care to receive
Covered Services. It is important that you use only your GHC 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
linut 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.
GHC 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, GHC 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 V. 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.
GHC may obtain information which it deems necessary concerning the medical care and
hospitalization for which payment is requested
SECTION II. DISENROLLMENT
Enrollment under the GHC Medicare+Choice Plan for a specific Member,may be terrmnated in
the circumstances set forth below.
Until such time as a Member's termination of enrollment from GHC is effective,neither
Medicare nor any other Medicare+Choice organization shall pay for services for which GHC is
responsible While a Member is enrolled with GHC,GHC will only cover the following services
provided by non-GHC Providers or non-GHC Facilities. (1) Referrals authorized by a GHC
C22400-0036900 18
Provider; (2) Emergency services anywhere in the world, Urgently Needed Care,or out of the
area renal dialysis services as set forth in Section III.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 III.E. Upon termination of membership in GHC,neither GHC nor
GHC Providers shall have further liability or responsibility under this Agreement for Member's
health care services.
A. Voluntary Disenrollment j
You may choose to end your membership in GHC Medicare+Choice Plan for any reason If
you want to disenroll,write a letter or complete a disenrollment form and send it to the GHC
Medicare Enrollment and Reconciliation,P O Box 34255,Seattle,WA 98124-9986 Make sure you
sign and date your letter and/or form. To get a disenrollment form, call GHC Customer
Service. 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
GHC Contracting Medical Providers until you are notified of the effective date of your
disenrollment. GHC will send you a letter that confirms when your disenrollment is effective
You will be covered by Original Medicare after you disenroll from GHC unless you have
joined another Medicare Managed Care Plan.
B. Involuntary Disenrollment.
GHC must disenroll you from the GHC M+C Plan if.•
1. You move permanently out of the Service Area for more than six (6)months at a time
and do not voluntarily disenroll or choose Continuation of coverage;
2. You do not stay continuously enrolled in both Medicare Part A and/or Part B; or
3. The contract between GHC and CMS under which the GHC M+C Plan is offered is
terminated, or the GHC M+C Plan Service Area is reduced.
GHC may disenroll you from the GHC 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 GHC M+C
Plan;
2. If you are disruptive,unruly, abusive or uncooperative to the extent that your
membership in the GHC M+C Plan seriously impairs our ability to arrange Covered
C22400-0036900 19
Services for you or 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 GHC M+C Plan membership card to obtain
Covered Service;
4. You fail to pay the Plan basic Prermums. 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 GHC 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-
GHC Facility as a result of Emergency or Urgently Needed Services or Referral as set forth
in Section IV B. of this Medicare Endorsement.
D. Services Provided After Termination. Any services provided by GHC after the effective
date of termination(except those services covered under Section 11 C. of this Medicare
L 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 Dependents
SECTION 111. 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 GHC except for Emergency and Urgently Needed Services
as set forth in Section III C. of this Medicare Endorsement; and
• must meet Medicare guidelines and limitations unless otherwise specified
GHC has procedures to assist GHC 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 GHC Personal Physician selected. New Members may expect their health
status to be assessed within 90 days of their enrollment.
GHC will ensure that services are provided in a culturally competent manner. GHC Providers
will provide information regarding treatment options in a culturally competent manner and will
accommodate Members with disabilities.
GHC 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 earner's office.
C22400-0036900 20
Services received at facilities outside the GHC 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 GHC
physician and rendered pursuant to an approved hospice plan of treatment:
1. Home Services
Continuous care services per Member in the Member's home when prescribed by a GHC
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 GHC
physician detemunes 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 GHC's Hospice Program when Medically Necessary and authorized in advance by a
GHC physician and GHC'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.
C22400-0036900 21
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 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 IILC. 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 VII
of this Medicare Endorsement, services are covered in full,subject to the applicable
Copayments.
D. If the Member is hospitalized in a non-GHC Facility and requires continued inpatient care
GHC will continue to cover the non-emergent care and services at the non-GHC Facility
needed by the Member to remain medically stable until- (1)the Member is discharged; (2) a
GHC Provider assumes responsibility for the Member's care; or(3) GHC 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 GHC Facility is
made at the discretion of GHC with the attending physician's concurrence.
Post-stabilization care at a non-GHC 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 GHC's Medicare Service Area is payable at Medicare benefit
levels up to $2,000.00 per Member per calendar year The Plan pays 90%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 services received when 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 the
United States or the U.S. territories is covered only if transportation by any other vehicle
could endanger the patient's health.
C22400-0036900 22
G. Medical and Surgical Care.The following medical and surgical services are covered when
prescribed by GHC 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 standard eyeglasses or contact lenses, including
examination and fitting, following each cataract surgery with insertion of an intraocular
lens (IOL). Covered eyeglasses and contact lenses must be dispensed through GHC
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 GHC physician.
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, hrmted to those covered by Medicare when all Medicare criteria
have been met '
6. Physician calls (including consultations and second opinions by a GHC Personal
Physician) in the hospital, office, home, Skilled Nursing Facility, nursing home, or
convalescent center.
7. Outpatient Surgery in outpatient hospital facility or ambulatory surgical center covered
subject to applicable Copayment
8 Restorative physical, occupational, speech and language therapy, and cardiac
rehabilitation following illness, injury, or surgery.
9. Immunizations and vaccinations that are listed as covered in the GHC drug formulary
(approved drug list) or approved by Medicare.
10. Services related to dysfunction of the jaw. When referred by a GHC Personal
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
C22400-0036900 23
work performed. All such services and related hospitalization, including orthodontic
' therapy and orthognathic Oaw) surgery, are excluded regardless of origin or cause.
(See Section IV.B.17. of the Group Medical Coverage Agreement for Covered Services
' not meeting Medicare Guidelines).
I t. 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 chiropractic services from GHC's designated licensed providers in order to be
covered A list of GHC-designated licensed practitioners is available by contacting any
' GHC area medical center.
12. Podiatric care. Services are covered when all Medicare criteria are met and when
authorized in advance by your Personal Physician. 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 GHC's designated providers in order to be covered.
13. Home intravenous (IV) drug therapy services.
' 14 Routine eye examinations and refractions, limited to once every twenty-four(24)
months, except when Medically Necessary. Services for routine eye examinations must
be received at a GHC Facility and in accordance with GHC 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 GHC-approved Allowance
once every twenty-four(24)months, and replaced as specified below, when received at a
GHC Facility and in accordance with GHC 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.
' 15. Hearing examinations to determine hearing loss. Hearing aids, including examunations
and fitting,must be received at a GHC Facility and are covered up to a maximum of$250
per Member once every twenty-four(24)months
16. Diabetic education and training, including glucose monitors, testing strips and lancets
' for all diabetics
C22400-0036900 24
17. 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.
H. 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.
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 (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 GHC upon request. ,
L. Skilled Nursing Facility. Upon Referral and following a Medicare-certified three (3)day
hospital stay, GHC 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. When a 3 day Medicare covered hospital stay does not occur and the
plan determines that the Member otherwise meets all Medicare criteria, the plan may '
authorize Medicare covered skilled nursing care for up to 100 days.
SECTION 1V. EXCLUSIONS AND LIMITATIONS
A. Exclusions.
1 Investigational procedures, including medical and surgical services,drugs and devices t
until formally approved by Medicare unless specifically provided herein (See Section
V.19. in the Group Medical Coverage Agreement). ,
2. Supportive devices(shoe inserts) for the feet, except therapeutic shoes for people with
diabetes who have severe diabetic foot disease,including fitting of shoes or inserts '
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.
C22400-0036900 25
Conditions and Extent of Coverage.EXCEPT AS PROVIDED IN SECTIONS III D AND
III E., ALL SERVICES AND BENEFITS UNDER THIS AGREEMENT MUST BE
PROVIDED BY GHC MEDICAL PERSONNEL AT A GHC FACILITY UNLESS:
1 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 VII. and as set forth in Section III.0 of this Medicare Endorsement
SECTION V. 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. GHC 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 GHC
on the basis that it is a Medicare covered service. GHC 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, GHC will
reach a decision within 72 hours. GHC'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. GHC's decision may also be postponed in the event information for a
non-GHC Provider has not been received in a timely manner. If GHC grants a Member's
request for an expedited decision,GHC will orally notify the Member and follow-up
within two (2) working days, with a written letter. If a Member disagrees with GHC'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 GHC declines to provide, cover, or
pay for services that the Member believes are covered by Medicare. If GHC declines to
provide or to cover a service, GHC 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 GHC may submit a written appeal to GHC.
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
C22400-0036900 26
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 seriously jeopardize his/her health or ability to function.
Appeals will be reviewed by persons not involved in the initial decision. If GHC decides to ,
uphold the original adverse decision, either in whole or in part,the entire file will be
forwarded by GHC 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 GHC denies coverage for services already
provided or arranged by either GHC or a non-GHC Provider or Facility, or for future
services. Member must submit appeals in writing to GHC, 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 GHC's initial decision. After receiving
all pertinent materials,GHC will conduct a formal review of the appeal. GHC will ,
notify the Member of its decision within 60 days of receipt. If GHC decides fully in
the Member's favor, GHC will pay the claim(s)within 60 days of receipt of the
Member's appeal. If GHC upholds any part of the initial denial, the entire file will be
forwarded by GHC 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 GHC denies coverage for future services
Members must submit appeals in writing to GHC, 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,GHC will conduct a formal review of the appeal. GHC will notify the
Member of its decision within 30 days of receipt. GHC'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 GHC upholds any part of the initial denial, the entire file will be
forwarded by GHC 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").
C22400-0036900 27
"QIO" stands for Quality Improvement Organization(these organizations used to be called
"Peer Review 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 unprove 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 Qualls Health.
A Member may request a"QIO"review if GHC 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
deterrnation.
GHC 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 Qualls Health at P.O. Box 33400, Seattle, WA 98133-0400 or 10700
1 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 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 admhnstratve
' 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.
1 If the administrative law judge denies a Member's appeal,either the Member or GHC 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 GHC may request a review by the Department Appeals
' Board(DAB).
An initial, revised, or reconsideration determination made by GHC, 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)
901-7350 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
C22400-0036900 28
SECTION V1. SUBROGATION AND REIMBURSEMENT RIGHTS
"Injured Person"under this section means a Member covered by the Agreement who sustains an
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. When referred to in this section,"GHC's 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 by the Injured Person.
If the Injured Person's injuries were caused by a thud party giving rise to a claim of legal
liability against the third party and/or payment by the third party to the Injured Person and/or a
settlement between the thud party and the Injured Person, GHC shall have the right to recover
GHC's 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 liability coverage and uninsured/underinsured motorist coverage. This right is commonly
referred to as"subrogation."GHC shall be subrogated to and may enforce all rights of the
Injured Person to the extent of GHC's Medical Expenses ,
If the Injured Person is entitled to or does 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 '
umnsured/underinsured motorist funds, 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 the Agreement. As a condition of
receiving benefits under the 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 party for less than available policy limits, in which GHC is entitled to full
compensation of GHC's Medical Expenses
The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect
GHC's Medical Expenses. This cooperation includes, but is not limited to, supplying GHC with
information about any third parties, defendants and/or insurers related to the Injured Person's ,
claim and informing GHC of any settlement or other payments relating to the Injured Person's
injury. The Injured Person and his/her agents shall permit GHC,at GHC's option,to associate
with the Injured Person or to intervene in any legal, quasi-legal, agency or any other action or
claim 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, including,but not limited to,billing the Injured Person directly for GHC's Medical
Expenses.
The Injured Person and his/her agents shall do nothing to prejudice GHC's subrogation and
reimbursement rights. The Injured Person shall promptly notify GHC of any tentative settlement
with a third party and shall not settle a claim without protecting GHC's interest. If the Injured
C22400-0036900 29
Person fails to cooperate fully with GHC in recovery of GHC's Medical Expenses,the Injured
Person shall be responsible for directly reimbursing GHC for GHC's Medical Expenses and
GHC retains the right to bill the Injured Person directly for GHC's Medical Expenses.
To the extent that the Injured Person recovers funds from any source,the Injured Person agrees
to hold such monies in trust or in their possession until GHC's subrogation and reimbursement
rights are fully determmed.
GHC shall not pay any attorney's 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 GHC's Medical Expenses, there shall be an equitable 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,which
do not benefit GHC and/or where no written fee agreement has been entered into with GHC.
' If it becomes necessary for GHC to enforce the provision of this section by initiating any action
against the Injured Person or his/her agent,then the Injured Person agrees to pay GHC's
' attomy's fees and costs associated with the action.
Implementation of this section shall be deemed a part of claims adrninistration under the
Agreement and GHC shall therefore have sole discretion to interpret its terms
SECTION VII. DEFINITIONS
CENTER for MEDICARE and MEDICAID SERVICES(CMS): The Federal Agency that
runs the Medicare program(CMS was formerly known as the Health Care Financing
Administration.
1 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
1 as assistance in mobility,dressing,bathing, eating,preparation of special diets, and taking
medication Custodial Care is not covered by the GHC M+C Plan or Medicare unless provided
in conjunction with Skilled Nursing Care and/or skilled rehabilitation services.
' EMERGENCY CARE: Covered services that are 1) furnished by a provider qualified to furnish
emergency services; and 2)needed to evaluate or stabilize an Emergency Medical Condition.
EMERGENCY MEDICAL CONDITION: A Medical Condition brought on 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 that not getting immediate
medical attention could result in 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.
C22400-0036900 30
MAXIMUM CHARGES: A term used to define the level of benefits wluch are payable by
GHC when expenses are incurred from a non-GHC Personal 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, some
people under age 65 with disabilities, and people with End Stage Renal Disease (generally those
with permanent kidney failure who need dialysis or a kidney transplant).
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 GHC Medicare+Choice Plan is a Coordinated
Care Plan.
MEDICARE+CHOICE (M+C) ORGANIZATION: A public or private organization licensed
by the State as a risk-bearing entity that is under contract with the Center for Medicare and
Medicaid Services CMS to provide Covered Services. Medicare+Choice Organizations can offer
one or more Medicare+Choice Plans. GHC is a Medicare+Choice Organization ,
MEDICARE+CHOICE PLAN: A benefit package offered by a Medicare+Choice Organization
that offers a specific set of health benefits at a uniform prenuum and uniform level of cost- ,
sharing to all people with Medicare who live in the Service Area covered by the Plan. A
Medicare+Choice Organization may offer more than one plan in the same Service Area. The
GHC Plan is a Medicare+Choice 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 GHC offers to its Medicare+Choice Members
while temporarily traveling outside of the GHC Medicare+Choice 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 request by your Personal Physician for you to receive care from a Specialist, '
Contracting Medical Provider, or Non-Contracting Medical Provider, or to receive certain
Covered Services.
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 GHC and approved by CMS,within which an
eligible individual may enroll in a particular plan offered by GHC.
SKILLED NURSING FACILITY: A facility (or distinct part of a facility)which is primarily ,
engaged in providing to its residents which provides inpatient Skilled Nursing Care,
C22400-0036900 31 '
rehabilitation services, or other related health services and is certified by Medicare. The term
' "Slalled 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 CARE: Covered Services provided when you are temporarily absent
from the GHC Medicare+Choice 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.
' C22400-0036900 32
1
i
Dear Group Health Subscriber
This booklet contains important information about your healthcare plan.
This is your 2004 Group Health Benefit Booklet(Certificate of Coverage) It explains the services and benefits you
and those enrolled on your contract are entitled to receive from Group Health Cooperative The benefits reflected in
this booklet were approved by your employer or association who contracts with Group Health for your healthcare
coverage
We recommend you read it carefully so you'll understand not only the benefits,but the exclusions,limitations,and
eligibility requirements of this certificate Please keep this certificate for as long as you are covered by Group
Health We will send you revisions if there are any changes in your coverage
This certificate is not the contract itself,you can contact your employer or group administrator if you wish to see a '
copy of the contract(Medical Coverage Agreement)
We'll gladly answer any questions you might have about your Group Health benefits Please call our Group Health
Customer Service Center for general information at 901-4636 or for Medicare information at 901-4600 in the Seattle
area,or toll-free in Washington, 1-888-901-4636 or 1-888-901-4600
Thank you for choosing Group Health Cooperative We look forward to working with you to preserve and enhance
your health
Very truly yours,
Cheryl Scott
President
PA-1133a02
CA-139502,CA-1984,CA-107600,CA-1385,CA-6100
C22400-0036900 ,
i
Benefit Booklet
Table of Contents
Section I. Introduction
A Accessing Care
B Cost Shares
C Subscriber's Liability
iD Claims
Section II. Allowances Schedule
Section III. Eligibility,Enrollment, and Termination
A Eligibility
B Enrollment
i C Effective Date of Enrollment
D Eligibility for Medicare
E Termination of Coverage
F Services After Termination of Agreement
G Continuation of Coverage Options
Section IV. Schedule of Benefits
' A Hospital Care
B Medical and Surgical Care
C Chemical Dependency Treatment
D Plastic and Reconstructive Services
i E Home Health Care Services
F Hospice Care
G Rehabilitation Services
i H Devices,Equipment and Supplies
I Tobacco Cessation
J Drugs,Medicines,Supplies and Devices
K Mental Health Care Services
' L Emergency/Urgent Care
M Ambulance Services
N Skilled Nursing Facility
' Section V. General Exclusions
Section VI. Grievance Processes for Complaints and Appeals
Section VII. General Provisions
A Coordination of Benefits
B Subrogation and Reimbursement Rights
C Miscellaneous Provisions
Section VIII. Definitions
iAttachment:Group Medicare Coverage
C22400-0036900 1
Section I. Introduction ,
Group Health Cooperative(also referred to as"GHC")is a nonprofit health maintenance organization furnishing
health care primarily on a prepayment basis
Read This Benefit Booklet Carefully
This Benefit Booklet is a statement of benefits,exclusions and other provisions,as set forth in the Group Medical ,
Coverage Agreement("Agreement")between GHC and the employer or Group
A full description of benefits,exclusions,limits and Out-of-Pocket Expenses can be found in the Schedule of
Benefits,Section IV,General Exclusions,Section V,and Allowances Schedule,Section 11 These sections must be
considered together to fully understand the benefits available under the Agreement Words with special meaning are
capitalized They are defined in Section VIII
A. Accessing Care ,
Members are entitled to Covered Services only at GHC Facilities and from GHC Personal Physicians.
Except as follows:
• Emergency care,
• Self-Referral to women's health care providers as set forth below, '
• Visits with GHC-Designated Self-Referral Specialists,as set forth below,
• Care provided pursuant to a Referral Referrals must be requested by the Member's Personal
Physician and approved by GHC,and
• Other services as specifically set forth in the Allowances Schedule and Section IV
Primary Care. Members must select a GHC Personal Physician(formerly known as a primary care provider)
when enrolling under the Agreement One Personal Physician may be selected for the entire family,or a
different Personal Physician may be selected for each family member If the Personal Physician is not selected
at the time of enrollment, GHC will assign a Personal Physician,and a letter of explanation will be sent to the
Member
Selecting a Personal Physician or changing from one Personal Physician to another can be accomplished by
contacting GHC 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 Personal Physicians,Referral specialists,women's health care providers,and GHC- ,
Designated Self-Referral Specialists is available by contacting GHC Customer Service at(206)9014636 or
(888)901-4636,or by accessing GHC's website at www ghc org
In the case that the Member's Personal Physician no longer participates in GHC's network,the Member will be t
provided a written notice offering the Member a selection of new Personal Physicians from which to choose
Specialty Care. Unless otherwise indicated in this section,the Allowances Schedule,or Section IV.,Referrals
are required for specialty care and specialists
GHC-Designated Self-Referral Specialist. Members may make appointments directly with GHC-Designated
Self-Referral Specialists at GHC-owned or-operated medical centers without a Referral from their Personal
Physician Self-Referrals are available for the following specialty care areas allergy,audiology,cardiology,
chemical dependency,chiropractic/manipulative therapy,dermatology,gastroenterology,general surgery,
hospice,manipulative therapy,mental health,nephrology,neurology,obstetrics and gynecology,occupational
medicine*,oncology/hematology,ophthalmology,optometry,orthopedics,otolaryngology(ear,nose,and
throat),physical therapy*,smoking cessation,speech/language and learning services*,and urology
C22400-0036900 2 ,
s 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 by GHC
to provide women's health care services directly,without a Referral from their Personal Physician,for
Medically Necessary maternity care,covered reproductive health services,preventive care(well care)and
general examinations,gynecological care,and follow-up visits for the above services Women's health care
services are covered as if the Member's Personal Physician had been consulted,subject to any applicable Cost
Shares,as set forth in the Allowances Schedule If the Member's women's health care provider diagnoses a
condition that requires Referral to other specialists or hospitalization,the Member or her 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 GHC Provider
Emergent and Urgent Care. Emergent care is available at GHC Facilities If Members cannot get to a GHC
Facility,Members may obtain Emergency services from the nearest hospital Members or persons assuming
responsibility for a Member must notify GHC by way of the GHC Emergency Notification Line within twenty-
four(24)hours of admission to a non-GHC Facility,or as soon thereafter as medically possible Members may
refer to Section IV for more information about coverage of Emergency care services
In the GHC Service Area,urgent care is covered only at GHC medical centers,GHC urgent care clinics or GHC
Provider's offices Urgent care received at any hospital emergency department is not covered unless authorized
in advance by a GHC Provider Members may refer to Section IV for more information about coverage of
1 urgent care services
Outside the GHC Service Area,urgent care is covered at any medical facility Members may refer to Section
IV for more information about coverage of urgent care services
Recommended Treatment.GHC'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
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 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 Coverage decisions may be appealed as set forth in Section VI
Major Disaster or Epidemic.In the event of a major disaster or epidemic,GHC will provide coverage
according to its bestjudgment,within the limitations of available facilities and personnel GHC 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 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 GHC have any liability or obligation on account of delay or failure to provide or
arrange such services
B. Cost Shares
C22400-0036900 3
The Subscriber shall be liable for the following Cost Shares when services are received by the Subscriber and
any of his/her Dependents
Copayments Members shall be required to pay Copayments at the time of service 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.
Coinsurance.Members shall be required to pay Coinsurance for certain Covered Services as set forth in the
Allowances Schedule
Out-of-Pocket Limit.Total Out-of-Pocket Expenses incurred during the same calendar year shall not exceed
the Out-of-Pocket Limit as set forth in the Allowances Schedule Out-of-Pocket Expenses which apply toward
the Out-of-Pocket Limit are set forth in the Allowances Schedule
Deductibles. In addition to any applicable annual Deductible,there may be service-specific Deductibles 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 Cost Share amounts for Covered Services provided to the Subscriber and his/her
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 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. Claims
Claims for benefits maybe made before or after services are obtained To make a claim for benefits under the
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 services the Member believes are covered under the Agreement,the Member ,
must,within ninety(90)days of the date of service,or as soon thereafter as reasonably possible,either(1)
contact GHC Customer Service to make a claim or(2)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 claims for '
reimbursement to P O Box 34585,Seattle,WA 98124-1585,or if the Member is located east of the Cascade
Mountains submit claims to P O 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 date of service
GHC will generally process claims for benefits within the following timeframes after GHC receives the claims
• Pre-service claims—within fifteen(15)days.
• Claims involving urgently needed care—within seventy-two(72)hours
• Concurrent care claims—within twenty-four(24)hours
• Post-service claims—within thirty(30)days
Tirrieframes for pre-service and post-service claims can be extended by GHC for up to an additional fifteen(15) '
days Members will be notified in writing of such extension pnor to the expiration of the initial timeframe
C22400-0036900 4
' Section II. Allowances Schedule
The benefits described in this schedule are subject to all provisions,limitations and exclusions set forth in the Group
Medical Coverage Agreement
"Welcome"Outpatient Services Waiver
Not applicable
Annual Deductible
No annual Deductible
Plan Coinsurance
No plan Coinsurance
Lifetime Maximum
1 No Lifetime Maximum unless otherwise indicated
Hospital Services
• Covered inpatient medical and surgical services,including acute chemical withdrawal(detoxification)
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
Covered subject to a S5 outpatient services Copayment per Member per visit
• 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
Covered subject to the lesser of GHC's charge or a$5 Copayment
• Over-the-counter drugs and medicines
C22400-0036900 5
1
Not covered ,
• Allergy serum ,
Covered subject to the prescription drug Copayment for each thirty(30)day supply
• Injectables
Injections that can be self-administered are subject to the applicable prescription drug Copayment Injections
necessary for travel are not covered
• Mail order drugs and medicines
Covered subject to the prescription drug Copayment for each thirty(30)day supply or less
• Growth hormones
Covered in full ,
Out-of-Pocket Limit(Stop Loss)
Limited to an aggregate maximum of$2,000 per Member and$4,000 per family per calendar year Except as ,
otherwise noted in this Allowances Schedule,the total Out-of-Pocket Expenses for the following Covered Services
are included in the Out-of-Pocket Limit
• Inpatient services ,
• Outpatient services
• Emergency care at a GHC or non-GHC Facility
• Ambulance services
Acupuncture
Covered subject to the outpatient services Copayment for Self-Referrals to a GHC Provider up to a maximum of five '
(5)visits per Member per medical diagnosis per calendar year When approved by GHC,additional visits are
covered subject to the outpatient services Copayment
Ambulance Services ,
• Emergency ground/air transport
Covered at 80%
• Non-emergent ground/air mterfacility transfer
Covered at 80%for GHC-initiated transfers,except hospital-to-hospital ground transfers covered in full
Chemical Dependency
• Inpatient services
Covered subject to the applicable inpatient Copayment
• Outpatient services
C22400-0036900 6 ,
Covered subject to the applicable outpatient services Copayment
• Benefit period Allowance
Covered up to$11,841 per Member per any twenty-four(24)consecutive calendar month period
Acute detoxification covered as any other medical service Charges incurred are not subject to the twenty-four(24)
month maximum
Dental Services(including accidental injury to natural teeth)
Not covered,except as set forth in Section IV B 24
Devices,Equipment and Supplies(for home use)
Covered at 80%for
• Orthopedic appliances
• Durable medical equipment
• Ostomy supplies
• Post-mastectomy bras[limited to two(2)every six(6)months]
1 Covered at 80%for
• Prosthetic devices
Diabetic Supplies
Insulin,needles,syringes and lancets-see Drugs-Outpatient External insulin pumps,blood glucose monitors,
testing reagents and supplies are covered under Devices,Equipment and Supplies When Devices/Equipment have a
dollar maximum,diabetic supplies are not subject to this maximum benefit limit
Diagnostic Laboratory and Radiology Services
Covered in full
Emergency Services
• At a GHC Facility
Covered subject to a$75 Copayment per Member per Emergency visit Copayment is waived if Member is
admitted as an inpatient to the hospital directly from the emergency department Emergency admissions are
covered subject to the applicable inpatient Cost Share
• At a non-GHC Facility
Covered subject to a S125 Deductible per Member per Emergency visit Emergency care Deductible is waived
if Member is admitted as an inpatient to the hospital directly from the emergency department Emergency
admissions are covered subject to the applicable inpatient Cost Share.
Hearing Examinations and Hearing Aids
• Hearing examinations to determine hearing loss
C22400-0036900 7
Covered subject to the outpatient services Copayment
• Hearing aids,including hearing aid examinations
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 '
Covered subject to the outpatient services Copayment for Self-Referrals to a GHC Provider for manipulative therapy
of the spine in accordance with GHC clinical criteria up to a maximum of ten(10)visits per Member per calendar
year When approved by GHC,additional manipulation visits are covered subject to the outpatient services
Copayment
Maternity and Pregnancy Services
• Delivery and associated Hospital Care
Covered subject to the applicable inpatient Copayment `
• Routine prenatal and postpartum care
Covered subject to the outpatient services Copayment
• Pregnancy termination '
Covered subject to the applicable Copayment for involuntary/voluntary termination of pregnancy
Mental Health Services
• Inpatient services
Covered at 80%for up to twelve(12)days per Member per calendar year at a GHC-approved mental health
care facility Coinsurance does not apply to the Out-of-Pocket Limit
• Outpatient services
Covered subject to a$20 Copayment per individual session and a$10 Copayment per Member per group
session for up to twenty(20)visits per Member per calendar year Copayments do not apply to the Out-of-
Pocket Limit ,
Naturopathy
C22400-0036900 8 '
Covered subject to the outpatient services Copayment for Self-Referrals to a GHC Provider up to a maximum of two
(2)visits per Member per medical diagnosis per calendar year When approved by GHC,additional visits are
covered subject to the outpatient services Copayment
Nutritional Services
• Phenylketonuna(PKU)supplements
Covered in full
• Enteral therapy(formula)
Covered at 80%for elemental formulas Necessary equipment and supplies are covered under Devices,
Equipment and Supplies
• Parenteral therapy(total parenteral nutrition)
Covered in full for parenteral formulas Necessary equipment and supplies are covered under Devices,
Equipment and Supplies
Obesity Related Services
1 Covered subject to applicable Copayment for banatric surgery Weight loss programs,medications and related
physician visits for medication monitoring are not covered
On the Job Injuries or Illnesses
Not covered,including injuries or illnesses incurred as a result of self-employment
IOptical Services
• Routine eye examinations
Covered subject to the outpatient services Copayment once every twelve(12)months
• Lenses,including contact lenses,and frames
1 Not covered,except contact lens after cataract surgery is covered in full when in lieu of mtraocular lens
Organ Transplants
Covered subject to the applicable Copayment up to a$200,000 lifetime benefit maximum,subject to a twelve(12)
month benefit wait period
Plastic and Reconstructive Services(Plastic Surgery,Cosmetic Surgery)
• Surgery to correct a congenital disease or anomaly,or conditions following an injury or resulting from surgery
Covered subject to the applicable Copayment
• Cosmetic surgery,including complications resulting from cosmetic surgery
C22400-0036900 9
i
Not covered
Podiatric Services
• Medically Necessary foot care
Covered subject to the applicable Copayment
• Foot care(routine) t
Not covered,except in the presence of a non-related Medical Condition affecting the lower limbs
Pre-Existing Condition
Covered,with no wart
Preventive Services(Well Adult and Well Child Physicals,Immunizations,Pap Smears,Mammograms)
Covered subject to the outpatient services Copayment when in accordance with the well care schedule established
by GHC Eye refractions are not included under preventive care Physicals for travel,employment,insurance,
license,etc,are not covered Services provided during a preventive care visit which are not in accordance with the
well care schedule 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
Covered subject to the inpatient Copayment for up to sixty(60)days per condition per calendar year
• Outpatient physical,occupational and restorative speech therapy services combined,including services for
neurodevelopmentally disabled children age six(6)and under
Covered subject to the outpatient services Copayment for up to sixty(60)visits per condition per calendar year ,
Sexual Dysfunction Services
Not covered t
Skilled Nursing Facility(SNF)
Covered up to thirty(30)days per condition per Member per calendar year
Sterilization(vasectomy,tubal ligation)
Covered subject to applicable Copayments
Temporomandibular Joint(TMJ)Services
• Inpatient and outpatient TMJ services
Covered subject to the applicable Copayment up to S 1,000 maximum per Member per calendar year
C22400-0036900 10 ,
' • Lifetime maximum benefit
Covered up to$5,000 per Member
Tobacco Cessation
• Individual/group sessions
Covered in full
• Approved pharmacy products
Covered subject to the outpatient prescription drug Copayment for each thirty(30)day supply or less of a
prescnption or refill when provided at GHC Facilities and prescribed by a GHC Provider
Section III. Eligibility,Enrollment, and Termination
A. Eligibility
In order to be accepted for enrollment and continuing coverage under the Agreement,individuals must meet any
eligibility requirements imposed by the Group,and/or all applicable plan documents,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 other unique family
arrangements,when approved in advance by GHC GHC has the right to verify eligibility
I. Subscribers.Bona fide LEOFF 11 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. Dependents.The Subscriber may also enroll the following
a The Subscriber's legal spouse.
1 b Unnamed dependent children who are under the age of twenty-one(21)and are chiefly dependent on
the Subscriber for support and maintenance,provided proof of such dependency is furnished to GHC
upon request
i "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 Dependents of LEOFF I employees are eligible for coverage under this agreement
3. Temporary Coverage for Newborns. When a Member gives birth,the newbom will be entitled to the
benefits set forth in Section IV 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 the
Agreement All contract provisions,limitations,and exclusions will apply except Section III F and III G
C22400-0036900 I1
i
4. Limiting Age Extension. Eligibility may be extended past the limiting age for an unmarred person '
enrolled as a Dependent on his/her twenty-first(21 st)birthday if
a. 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
b The Dependent is totally incapable of self-sustaining employment because of a developmental or
physical disability incurred prior to attainment of the limiting age set forth in 2 b above,or prior to
attainment of the student limiting age set forth in 4 a 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 incapacity and proof of financial dependency must be furnished to GHC upon
request,but not more frequently than annually after the two(2)year period following the Dependent's
attainment of the limiting age
B. Enrollment
1. Application for Enrollment.Application for enrollment must be made on an application form furnished
and approved by GHC Applicants will not be enrolled or premiums accepted until the completed
application form has been received and approved by GHC The Group is responsible for submitting
completed application forms to GHC
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,as set forth in Section III E below
a. Newly Eligible Persons.Newly eligible Subscribers and their Dependents may apply for enrollment in
writing to the Group within thirty-one(31)days of becoming eligible.
b. New Dependents. A written application for enrollment of a newly dependent person,other than a
newborn or adopted newborn child,must be made to the Group within thirty—one(31)days after the
dependency occurs
A written application for enrollment of a newborn child must be made to the Group within sixty(60)
days following the date of birth,when there is a change in the monthly premium payment as a result of
the additional Dependent
A written application for enrollment of an adoptive child must be made to the Group within sixty(60)
days from the day 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,if there is a change in
the monthly premium payment as a result of the additional Dependent
When there is no change in the monthly premium payment,it is strongly advised that the Subscriber
enroll the newborn or newly adoptive child as a Dependent with the Group to avoid delays in the
payment of claims
c. Open Enrollment. GHC will allow enrollment of Subscribers and Dependents,who did not enroll
when newly eligible as described above,during a limited period of time specified by the Group and
GHC.
d. Special Enrollment. GHC will allow special enrollment for persons who initially declined enrollment
when newly eligible because such persons had other health care 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 the Group may require
C22400-0036900 12
confirmation that when initially offered coverage such persons submitted a written statement declining
because of other coverage Application for coverage under the Agreement must be made within thirty-
one(31)days of the termination of previous coverage
In the event a Subscriber or person eligible to be a Subscriber acquires a person eligible to be a
Dependent by birth,marriage,adoption or placement for adoption,GHC will allow special enrollment
for the person eligible to be a Subscriber,his/her spouse and the newly acquired Dependent
Application for coverage under the Agreement must be made within thirty-one(31)days of the
1 acquisition of the new Dependent,except that sixty(60)days is permitted to enroll newborn and
adopted children as described above
2. Limitation on Enrollment.The Agreement will be open for applications for enrollment as set forth in this
Section III B Subject to prior approval by the Washington State Office of the Insurance Commissioner,
GHC may limit enrollment,establish quotas,or set priorities for acceptance of new applications if it
determines that GHC's capacity,in relation to its total enrollment,is not adequate to provide services to
additional persons
C. Effective Date of Enrollment
1 Provided applications for eligibility and enrollment are made as set forth in Sections III A and III B above,
enrollment will be effective as follows
• Enrollment for a newly eligible Subscriber and listed Dependents is effective on the date of hire
provided the Subscriber's application has been submitted to and approved by GHC
• Enrollment for a newly dependent person,other than a newborn or adoptive child,is effective the first
(1st)of the month following the date of application
I • 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
2. Commencement of Benefits for Persons Hospitalized on Effective Date.Members who are admitted to
an inpatient facility prior to their enrollment under the Agreement,and who do not have coverage under
another agreement,will receive covered benefits beginning on their effective date,as set forth in subsection
C 1 above If a Member is hospitalized in a non-GHC Facility,GHC reserves the right to require transfer
of the Member to a GHC Facility The Member will be transferred when a GHC Provider,in consultation
with the attending physician,determines that the Member is medically stable to do so If the Member
refuses to transfer to a GHC Facility,all further costs incurred during the hospitalization are the
responsibility of the Member
D. Eligibility for Medicare
Under the Tax Equity and Fiscal Responsibility Act of 1982(TEFRA),actively employed Members and their
spouses who are eligible for Medicare benefits must decide whether to choose the benefits of the Agreement or
the Medicare program as their primary source of health care coverage The Group is responsible for providing
the Member with necessary information regarding TEFRA eligibility and the selection process
Members Residing Outside the GHC Medicare+Choice Service Area. Except as defined by federal
regulations(i e,TEFRA),if a Member or their spouse is or becomes eligible for Medicare,they must,effective
the date that Medicare becomes the primary payer,enroll in and maintain both Medicare Parts A and B
coverage Failure to enroll in both Medicare Parts A and B,upon the effective date of eligibility,will result in
termination of coverage under the Agreement.
t
' C22400-0036900 13
i
1
An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare ,
benefits
Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status
Members Residing Inside the GHC Medicare+Choice Service Area. Except as defined by federal
regulations,(i e.,TEFRA),if a Member or their spouse is or becomes eligible for Medicare,they must,effective
the date that Medicare becomes the primary payer,enroll in and maintain both Medicare Parts A and B
coverage and enroll in the GHC Medicare+Choice(M+C)Plan Failure to do so upon the effective date of
Medicare eligibility will result in termination of coverage under the Agreement
An individual shall be deemed eligible for Medicare when he/she has the option to receive Part A Medicare
benefits
All applicable provisions of the GHC M+C Plan are fully set forth in the Medicare Endorsement(s)attached to
the Agreement(if applicable)
E. Termination of Coverage
1. Termination of Specific Members.Specific Members may be terminated from the Agreement for any of
the following reasons
a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section
III A,and is not enrolled for continuation coverage as described in Section III G below,coverage
under the Agreement will terminate at the end of the month during which the loss of eligibility occurs,
unless otherwise specified by the Group
b. For Cause.Coverage of a Member may be terminated upon written notice for
i Material misrepresentation,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 event,GHC 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
Member's coverage upon ten(10)working days written notice 1
n Permitting the use of a GHC identification card or number by another person,or using another
Member's identification card or number to obtain care to which a person is not entitled
in Nonpayment of charges as set forth in Section I C
c. Premium Payments Nonpayment of premiums or contribution for a specific Member by the Group
In no event will a Member be terminated solely on the basis of their physical or mental condition provided 1
they meet all other eligibility requirements set forth in the Agreement
Any Member may appeal a termination decision through GHC's grievance process as set forth in Section
VI
2. Certificate of Creditable Coverage. 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 the Agreement)will be issued automatically upon termination of coverage,and may also be obtained
upon request.
F. Services After Termination of Agreement
1. Members Hospitalized on the Date of Termination.A Member who is receiving Covered Services as a
registered bed patient in a hospital on the date of termination shall continue to be eligible for Covered
C22400-0036900 14
Services while an inpatient for the condition for which the Member was hospitalized,until one of the
following events occurs
• According to GHC clinical criteria,it is no longer Medically Necessary for the Member to be an
inpatient at the facility
• The remaining benefits available under the Agreement for the hospitalization are exhausted,regardless
of whether a new calendar year begins
• The Member becomes covered under another agreement with a group health plan that provides benefits
for the hospitalization.
• The Member becomes enrolled under an agreement with another carrier that would provide benefits for
the hospitalization if the Agreement did not exist
• The Member becomes eligible for Medicare
This provision will not apply if the Member is covered under another agreement that provides benefits for
the hospitalization 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 subsection G below
2. Services Provided After Termination.The Subscriber shall be liable for payment of all charges for
services and items provided to the Subscriber and all Dependents after the effective date of termination,
except those services covered under subsection F 1 above Any services provided by GHC will be charged
according to the Fee Schedule.
G. Continuation of Coverage Options
1. Continuation Option. A Member no longer eligible for coverage under the Agreement(except in the
event of termination for cause,as set forth in Section III E)may continue coverage for a period of up to
I three(3)months subject to notification to and self-payment of premiums 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") This continuation option is not available if the Group no
longer has active employees or otherwise terminates
2. Leave of Absence. While on a Group approved leave of absence,the Subscriber and listed Dependents can
continue to be covered under the Agreement,provided.
• They remain eligible for coverage,as set forth in Section III A.,
• Such leave is in compliance with the Group's established leave of absence policy that is consistently
applied to all employees,
• The Group's leave of absence policy is in compliance with the Family and Medical Leave Act when
applicable,and
• The Group continues to remit premiums for the Subscriber and Dependents to GHC.
3. Self-Payments During Labor Disputes. In the event of suspension or termination of employee
compensation due to a strike,lock-out,or other labor dispute,a Subscriber may continue uninterrupted
coverage under the Agreement through payment of monthly premiums directly to the Group Coverage may
be continued for the lesser of the tern of the strike,lock-out,or other labor dispute,or for six(6)months
after the cessation of work.
If the Agreement is no longer available,the Subscriber shall have the opportunity to apply for an individual
GHC Group Conversion Plan or,if applicable,continuation coverage(see subsection 4 below),or an
Individual and Family Medical Coverage Agreement at the duly approved rates
The Group is responsible for immediately notifying each affected Subscriber of his/her rights of self-
payment under this provision.
jC22400-0036900 15
1
1
4. Continuation Coverage Under Federal Law. This section applies only to 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 otherwise lose eligibility,if required by 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
5. GHC Group Conversion Plan. Members whose eligibility for coverage under the Agreement, including
continuation coverage,is terminated for any reason other than cause,as set forth in Section III E 1 b,and
who are not eligible for Medicare or covered by another group health plan,may convert to GHC's Group
Conversion Plan If the Agreement terminates,any Member covered under the Agreement at termination
may convert to a GHC Group Conversion Plan,unless he/she is eligible to obtain other group health
coverage within thirty-one(31)days of the termination of the Agreement
An application for conversion must be made within thirty-one(31)days following termination of coverage
under the Agreement Coverage under GHC's Group Conversion Plan is subject to all terms and conditions ,
of such plan,including premium payments A physical examination or statement of health is not required
for enrollment in GHC's Group Conversion Plan The Pre-Existing Condition limitation under GHC's
Group Conversion Plan will apply only to the extent that the limitation remains unfulfilled under the
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 GHC's Individual and Family coverage should contact GHC Marketing i
Section IV. Schedule of Benefits
Benefits are subject to all provisions of the Group Medical Coverage Agreement,including,without
limitation,the Accessing Care provisions and General Exclusions. Members must refer to Section II.,the
Allowances Schedule,for Cost Shares and specific benefit limits that apply to benefits listed in this Schedule
of Benefits. Members are entitled to receive only benefits and services that are Medically Necessary and
clinically appropriate for the treatment of a Medical Condition as determined by GHC's Medical Director or
his/her designee,and as described herein. All Covered Services are subject to case management and ,
utilization review at the discretion of GHC.
A. Hospital Care
Hospital coverage is limited to the following services
1 Room and board,including private room when prescribed,and general nursing services
2. Hospital services(including use of operating room,anesthesia,oxygen,x-ray,laboratory,and radiotherapy I
services)
3 Alternative care arrangements may be covered as a cost-effective alternative in lieu of otherwise covered,
Medically Necessary hospitalization or other covered,Medically Necessary institutional care Alternative
care arrangements in lieu of covered hospital or other institutional care must be determined to be
appropriate and Medically Necessary based upon the Member's Medical Condition. Coverage must be
authorized in advance by GHC as appropriate and Medically Necessary Such care will be covered to the
same extent the replaced Hospital Care is covered under the Agreement
C22400-0036900 16
4 Drugs and medications administered during confinement
5 Special duty nursing,when prescribed as Medically Necessary
If a Member is hospitalized in a non-GHC Facility,GHC reserves the right to require transfer of the Member to
a GHC 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 coverage is 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 in accordance with the well care schedule
established by GHC Preventive care includes routine mammography screening,physical examinations
and routine laboratory tests for cancer screening in accordance with the well care schedule established by
GHC,and immunizations and vaccinations listed as covered in the GHC drug formulary(approved drug
list) A fee may be charged for health education programs
Covered Services provided during a preventive care visit,which are not in accordance with the GHC well
care schedule,are subject to the applicable Cost Shares
7 Radiation therapy services
S Reduction of a fracture or dislocation of the law or facial bones,excision of tumors or non-dental cysts of
the jaw,cheeks,lips,tongue,gums,roof and floor of the mouth,and incision of salivary glands and ducts
9 Medical implants
Excluded 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
11 Outpatient total parenteral nutritional therapy,outpatient elemental formulas for malabsorption,dietary
formula for the treatment of phenylketonuria(PKU) Coverage for PKU formula is not subject to a Pre-
Existing Conditions waiting period,if applicable
Equipment and supplies for the administration of enteral and parenteral therapy are covered under Devices,
Equipment and Supplies
Excluded.any other dietary formulas,oral nutritional supplements,special diets,prepared foods/meals and
formula for access problems.
C22400-0036900 17
12 Visits with GHC Providers,including consultations and second opinions,in the hospital or provider's
office
13 Optical services
Routine eye examinations and refractions received at a GHC Facility once every twelve(12)months,
except when Medically Necessary
When dispensed through GHC 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 covered only when needed due to a change in the Member's Medical
Condition,but no more than once in a twelve(12)month period
Excluded evaluations and surgical procedures to correct refractions not related to eye pathology and
complications related to such procedures,and contact lens fittings and related examinations,except as set
forth above
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,and in accordance with Board of Health
standards for screening and diagnostic tests during pregnancy
Hospitalization and delivery,including home births for low risk pregnancies Planned home births must be
authorized in advance by GHC
Voluntary(not medically indicated and non-therapeutic)or involuntary termination of pregnancy
The Member's physician,in consultation with the Member,will determine the Member's length of
inpatient stay following delivery Pregnancy will not be excluded as a Pre-Existing Condition under the
Agreement Treatment for post-partum depression or psychosis is covered only under the mental health
benefit
Excluded birthing tubs and genetic testing of non-Members for the detection of congenital and heritable
disorders
15 Transplant services,including heart,heart-lung,single lung,double lung,kidney,pancreas,cornea,
intestinal/multi-visceral,bone marrow,liver transplants and stem cell support(obtained from allogeneic or
autologous peripheral blood or marrow)with associated high dose chemotherapy Services are limited to
the following
a Evaluation testing to determine recipient candidacy,
b Matching tests,
c Inpatient and outpatient medical expenses listed below for transplantation procedures Covered
Services must be directly associated with,and occur at the time of,the transplant The following
transplantation expenses are subject to the organ recipient's lifetime benefit maximum as set forth in
the Allowances Schedule
• Hospital charges,
• Procurement center fees,
• Professional fees,
• Travel costs for a surgical team,
• Excision fees,and
C22400-0036900 18 1
' Donor costs for a covered organ recipient are limited to procurement center fees,travel costs for a
surgical team and excision fees
d Follow-up services for specialty visits,
e. Rehospitalization,and
f Maintenance medications
Excluded donor costs to the extent that they are reimbursable by the organ donor's insurance,treatment of
donor complications,living expenses,and transportation expenses,except as set forth under Section IV M
Coverage for all transplants and any related services,items,and drugs shall be excluded until the Member
has been continuously enrolled under the Agreement,or any prior GHC or GHO Medical Coverage
Agreement,for twelve(12)consecutive months without any lapse in coverage,except for children who
have been continuously enrolled with GHC since birth,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 Manipulative therapy.
Self-Referrals for manipulative therapy of the spine only are limited to one(1)evaluation and ten(10)
manipulations when provided by GHC Providers
Additional visits are covered when approved by GHC
Excluded 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,
charges for office visits other than the initial evaluation and any other services that do not meet GHC
clinical criteria as Medically Necessary
17 Medical and surgical services and related hospital charges,including orthognathic(jaw)surgery,for the
treatment of temporomandibular Joint(TMJ)disorders Such disorders may exhibit themselves in the form
of pain,infection,disease,difficulty in speaking,or difficulty in chewing or swallowing food TMJ
appliances are covered as set forth under Section IV H I ,Orthopedic Appliances
Orthognathic(Jaw)surgery for the treatment of TMJ disorders,radiology services and TMJ specialist
services,including fitting/adjustment of splints are subject to the benefit limit set forth in the Allowances
Schedule.
1 Excluded are the following,regardless of origin or cause orthognathic Oaw)surgery in the absence of a
TMJ or severe obstructive sleep apnea diagnosis,treatment for cosmetic purposes,dental services,
including orthodontic therapy,and any hospitalizations related to these exclusions
18 Treatment of growth disorders by growth hormones
19 Diabetic training and education.
20 Detoxification services for alcoholism and drug abuse
For the purposes of this section, "acute chemical withdrawal"means withdrawal of alcohol and/or drugs
from a Member for whom consequences of abstinence are so severe that they require medical/nursing
assistance in a hospital setting, which is needed immediately to prevent serious impairment to the Member's
health
Coverage for acute chemical withdrawal is provided without prior approval If a Member is hospitalized in
a non-GHC Facility/program,coverage is subject to payment of the Emergency Deductible The Member
or person assuming responsibility for the Member must notify GHC by way of the GHC Notification Line
C22400-0036900 19
within twenty-four(24)hours following inpatient admission,or as soon thereafter as medically possible '
Furthermore,if a Member is hospitalized in a non-GHC Facility/program,GHC reserves the right to require
transfer of the Member to a GHC Facility/program upon consultation between a GHC Provider and the
attending physician if the Member refuses transfer to a GHC Facility/program,all further costs incurred
during the hospitalization are the responsibility of the Member
21 Circumcision
22. Banatric surgery and related hospitalizations when GHC criteria are met
Excluded pre and post surgical nutritional counseling and related weight loss programs,prescribing and
monitoring of drugs,structured weight loss and/or exercise programs,and specialized nutritional
counseling
23 Sterilization procedures
24 General anesthesia services and related facility charges for dental procedures will be covered for Members
who are under seven(7)years of age,who are physically or developmentally disabled or who have a
Medical Condition where the Member's health would be put at risk if the dental procedure were performed
in a dentist's office Such services must be authorized in advance by GHC and performed at a GHC
hospital or ambulatory surgical facility
Excluded dentist's or oral surgeon's fees
25. Self-Referrals to GHC acupuncturists and naturopaths for Covered Services as set forth in the Allowances
Schedule Additional visits are covered when approved by GHC Laboratory and radiology services are
covered only when obtained through a GHC Facility
Excluded herbal supplements,preventive care visits to acupuncturists and naturopaths and any services not
within the scope of their hcensure
26 Pre-Existing Conditions are covered in the same manner as any other illness
C. Chemical Dependency Treatment.
Chemical dependency means an illness characterized by a physiological or psychological dependency,or both,
on a controlled substance and/or alcoholic beverages,and where the user's health is substantially impaired or
endangered or his/her social or economic function is substantially disrupted
For the purposes of this section,the definition of Medically Necessary shall be expanded to include those
services necessary to treat a chemical dependency condition that is having a clinically significant impact on a
Member's emotional,social,medical and/or occupational functioning
Chemical dependency treatment services are covered as set forth below at a GHC Facility or GHC-approved
treatment program,subject to the benefit period Allowance set forth in the Allowances Schedule Any Cost
Shares for chemical dependency services under the terms of the Agreement shall not be applied toward the
benefit period Allowance
1. Chemical Dependency Treatment Services.All alcoholism and/or drug abuse treatment services must be
(a)provided at a facility as described above,and(b)deemed Medically Necessary as defined above
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/or prescription
drugs and medicines,unless excluded under the Agreement.
Court-ordered treatment shall be covered only if determined to be Medically Necessary as defined above
C22400-0036900 20
2. Benefit Period.For the purposes 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 the Agreement remains in force All subsequent
benefit periods thereafter will begin on the first day Covered Services are received after the expiration of
the previous twenty-four(24)month benefit period
D. Plastic and Reconstructive Services.Plastic and reconstructive services are covered as set forth below
1 Correction of a congenital disease or congenital anomaly as determined by a GHC Provider A congenital
anomaly will be considered to exist if the Member's appearance resulting from such condition is notwithin
the range of normal human variation
2 Correction of a Medical Condition following an injury or resulting from surgery covered by GHC which
has produced a major effect on the Member's appearance,when in the opinion of a GHC Provider,such
services can reasonably be expected to correct the condition
3 Reconstructive surgery and associated procedures,including internal breast prostheses,following a
mastectomy,regardless of when the mastectomy was performed
Members 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
Excluded complications of noncovered surgical services
E. Home Health Care Services. Home health care services,as set forth in this section,shall be covered when
provided by and referred in advance by a GHC Provider for Members who meet the following cntena
i The Member is unable to leave home due to his/her health problem or illness Unwillingness to travel
and/or arrange for transportation does not constitute inability to leave the home
2 The Member requires intermittent skilled home health care services,as described below.
3 A GHC Provider has determined that such services are Medically Necessary and are most appropriately
rendered in the Member's home
For the purposes of this section,"skilled home health care"means 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
Covered Services for home health care may include the following 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 covered on an intermittent basis in the Member's home "Intermittent"means care that is to be
rendered because of a medically predictable recumng need for skilled home health care services
Excluded custodial care and maintenance ca e,private duty or continuous nursing care in the Member's home,
housekeeping or meal services,care in any nursing home or convalescent facility,any care provided by or for a
C22400-0036900 21
member of the patient's family,and any other services rendered in the home which do not meet the definition of
skilled home health care above or are not specifically listed as covered under the Agreement
F. Hospice Care. Hospice care is covered in lieu of curative treatment for terminal illness for Members who meet
all of the following criteria
• A GHC Provider has determined that the Member's illness is terminal and life expectancy is six(6)months
or less
• The Member has chosen a palliative treatment focus(emphasizing comfort and supportive services rather
than treatment aimed at curing the Member's terminal illness)
• The Member has elected in wnting to receive hospice care through GHC's Hospice Program or GHC's
approved hospice program
• The Member has available a primary care person who will be responsible for the Member's home care
• A GHC Provider and GHC's Hospice Director,or his/her designee,have determined that the Member's
illness can be appropriately managed in the home.
Hospice care shall mean a coordinated program of palliative and supportive care for dying Members by an
interdisciplinary team of professionals and volunteers centering primarily in the Member's home
1. Covered Services Care 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"means skilled nursing care provided in the home during a
period of crisis in order to maintain the terminally ill Member 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 covered up to
twenty-four(24)hours per day dunng penods of cnsis 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,inpatient hospice services shall be covered in a
facility designated by GHC's Hospice Program or GHC-approved hospice program when authorized in
advance by a GHC Provider and GHC's Hospice Program or GHC-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 covered hospice services may include the following
i Drugs and biologicals that are used primarily for the relief of pain and symptom management
ii Medical appliances and supplies primarily for the relief of pain and symptom management
iii Counseling services for the Member and his/her primary care-giver(s)
iv Bereavement counseling services for the family
2. Hospice Exclusions. All services not specifically listed as covered in this section are excluded,including
a Financial or legal counseling services
b Meal services
C22400-0036900 22
c Custodial or maintenance care in the home or on an inpatient basis,except as provided above.
d Services not specifically listed as covered by the Agreement
e Any services provided by members of the patient's family
f. All other exclusions listed in Section V,General Exclusions,apply
G. Rehabilitation Services.
1 Rehabilitation services are covered as set forth in this section,limited 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 the Agreement,including the following
a All services must be provided at a GHC or GHC-approved rehabilitation facility and must be
prescribed and provided by a GHC-approved rehabilitation team that may include medical,nursing,
physical therapy,occupational therapy,massage therapy and speech therapy providers
In, 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
significant,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 a,
above
c Coverage for inpatient and outpatient services is limited to the Allowance set forth in the Allowances
Schedule
Excluded specialty rehabilitation programs not provided by GHC,long-tern 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 as set forth in subsection 2 below),recreational,life-enhancing,
relaxation or palliative therapy,implementation of home maintenance programs,programs for treatment of
learning problems,any services not specifically included as covered in this secuon,and any services that
are excluded under Section V
2. Neurodevelopmental Therapies for Children Age Six(6)and Under. 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 inpatient and outpatient services is limited to the
Allowance set forth in the Allowances Schedule
Excluded 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,recreational,life-enhancing,relaxation or palliative therapy,implementation of home maintenance
programs,programs for treatment of learning problems,any services not specifically included as covered in
this section,and any services that are excluded under Section V
H. Devices,Equipment and Supplies.
Devices,equipment and supplies,which restore or replace functions that are common and necessary to perform
basic activities of daily Irving,are covered asset forth in the Allowances Schedule Examples of basic activities
of daily living are dressing and feeding oneself,maintaining personal hygiene,lifting and gripping in order to
prepare meals and carrying groceries
IC22400-0036900 23
t
1. Orthopedic Appliances.Orthopedic appliances,which are attached to an impaired body segment for the
purpose of protecting the segment or assisting in restoration or improvement of its function
Excluded arch supports,including custom shoe modifications or inserts and their fittings except for
therapeutic shoes,modifications and shoe inserts for severe diabetic foot disease,and orthopedic shoes that
are not attached to an appliance.
2. Ostomy Supplies.Ostomy supplies for the removal of bodily secretions or waste through an artificial
opening
3. Durable Medical Equipment. Durable medical equipment is equipment which can withstand repeated
use,is primarily and customarily used to serve a medical purpose,is useful only in the presence of an
illness or injury and used in the Member's home Durable medical equipment includes:hospital beds,
wheelchairs,walkers,crutches,canes,glucose monitors,external insulin pumps,oxygen and oxygen
equipment GHC,in its sole discretion,will determine if equipment is made available on a rental or
purchase basis
4. Prosthetic Devices. Prosthetic devices are items which replace all or part of an external body part,or
function thereof
When authorized in advance,repair,adjustment or replacement of appliances and equipment is covered
Excluded items which are not necessary to restore or replace functions of basic activities of daily living,and
replacement or repair of appliances,devices and supplies due to loss,breakage from willful damage,neglect or
wrongful use,or due to personal preference
I. Tobacco Cessation.When provided through GHC,services related to tobacco cessation are covered,limited 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
participating in the Group Health Free and Clear Program or GHC-designated tobacco cessation program
J. Drugs,Medicines,Supplies and Devices. Legend medications are drugs which have been approved by the
Food and Drug Administration(FDA)and which can,under federal or state law,be dispensed only pursuant to
a prescription order These drugs,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),insulin,diabetic supplies,including insulin syringes,lancets,unne-testing reagents,and
blood glucose monitoring reagents,and contraceptive drugs and devices and their fitting are covered as set forth
below
All drugs,supplies,medicines,and devices must be prescribed by a GHC Provider for conditions covered by
the Agreement,obtained at a GHC pharmacy and,unless approved by GHC in advance,be listed in the GHC
drug formulary(approved drug list) The prescription drug Copayment as set forth in the Allowances Schedule
applies to each thirty(30)day supply. Copayments for single and multiple thirty(30)day supplies of a given
prescription are payable at the time of delivery Inlectables 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 GHC
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
equivalent(if available),or if the Member elects to purchase a different brand-name or generic drug than that
C22400-0036900 24
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
"Standard reference compendia"means the American Hospital Formulary Service-Drug Information,the
American Medical Drug Evaluation,the United States Pharmacopoeia-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 reliability by unbiased independent experts. Peer-reviewed medical literature does not include in-
house publications of pharmaceutical manufacturing companies
' Excluded 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 IV B,drugs used in the
treatment of sexual dysfunction disorders, medicines and injections 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
The Member's Right to Safe and Effective Pharmacy Services.
State and federal laws establish standards to assure safe and effective pharmacy services,and to guarantee
Members'rights to know what drugs are covered under the Agreement and what coverage limitations are in the
Agreement Members who would like more information about the drug coverage policies under the Agreement,
or have a question or concern about their pharmacy benefit,may contact us at(206)901-4636 or(888)901-
4636
Members who would like to know more about their rights under the law,or think any services received while
enrolled may not conform to the terms of the Agreement,may contact the Washington State Office of Insurance
Commissioner at(800)562-6900 Members who have a concern about the pharmacists or pharmacies serving
them, may call the State Department of Health at(360)236-4825
K. Mental Health Care Services. GHC and Washington State law have established standards to assure the
competence and professional conduct of mental health service providers,to guarantee Members'rights to
informed consent to treatment,to assure the privacy of their medical information,to enable Members to know
which services are covered under the Agreement and to know the limitations on their coverage Members who
would like a more detailed description than is provided here of covered benefits for mental health services
under the Agreement,or have questions or concerns about any aspect of their mental health benefits,may
contact GHC at(888)9014636
Members who would like to know more about their rights under the law,or think any services received while
enrolled may not conform to the terms of the Agreement or their rights under the law may contact the
Washington State Office of the Insurance Commissioner at(800)562-6900 Members who have a concern
about the qualifications or professional conduct of their mental health provider may call the State Health
Department at(360)236-4902.
Services that are provided by a mental health practitioner will be covered as mental health care,regardless of
the cause of the disorder
C22400-0036900 25
1
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1. Outpatient Services.Outpatient mental 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 GHC's Medical Director,or his/her designee Treatment for clinical conditions
may utilize psychiatric,psychological and/or psychotherapy services to achieve these objectives
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,are covered as set forth in Sections IV B and IV J
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 This benefit shall include coverage for acute treatment and stabilization of psychiatric
Emergencies in GHC-approved hospitals When medically indicated,outpatient electro-convulsive therapy
(ECT)is covered in lieu of inpatient services Coverage for services incurred at non-GHC Facilities shall
exclude any charges that would otherwise be excluded for hospitalization within a GHC Facility
Partial hospitalization and outpatient electro-convulsive therapy treatments are covered subject to the
maximum inpatient benefit limit 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 GHC
Services for any involuntary court-ordered treatment program beyond seventy-two(72)hours shall be
covered only if determined to be Medically Necessary by GHC's Medical Director,or his/her designee
Coverage for voluntary/mvoluntary Emergency inpatient psychiatric services is subject to the Emergency i
care benefit as set forth in Section IV L,including the twenty-four(24)hour notification and transfer
provisions
3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services.
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,the reduction or removal of acute clinical symptoms or
stabilization can be expected
Partial hospitalization programs and electro-convulsive therapy are covered only under subsection K 2
(Inpatient Services)
Excluded treatment specific to and solely for personality disorders,learning,communication and motor
skills disorders;mental retardation,academic or career counseling,sexual and identity disorders,and
personal growth or relationship enhancement Also excluded assessment and treatment services that are
primarily vocational and academic,court-ordered or forensic treatment,including reports and summaries,
not considered Medically Necessary, written information other than clinical records,work or school
ordered assessment and treatment not considered Medically Necessary,counseling for overeating,
psychoanalysis,nicotine related disorders,treatment or consultations provided by telephone,relationship
counseling or phase of life problems(V code only diagnoses),all forms of day treatment(non-partial
hospital programs),custodial care,and specialty programs for mental health therapy not specifically
authorized by Behavioral Health Services and approved by GHC
Any other services not specifically listed as covered in this section All other provisions,exclusions and
limitations under the Agreement also apply
L. Emergency/Urgent Care. j
C22400-0036900 26
All services are covered subject to the Cost Shares set forth in the Allowances Schedule
Emergency Care(See Section VIII for a definition of Emergency)
1. At a GHC Facility.GHC will cover Emergency care for all Covered Services
2. At a Non-GHC Facility.Usual,Customary, and Reasonable charges for Emergency care for Covered
Services are covered subject to
a Payment of the Emergency care Deductible,and
b Notification of GHC by way of the GHC 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 in the same Family Unit require
Emergency care as a result of the same accident,coverage for all Members will be subject to only
one(1)Emergency care Copayment/Deductible
b. Emergencies Resulting in an Inpatient Admission.if the Member is admitted to a GHC Facility
directly from the emergency room,the Emergency care Copayment is waived However,coverage
will be subject to the inpatient services Cost Share
4. Transfer and Follow-up Care.If a Member is hospitalized in a non-GHC Facility,GHC reserves the
right to require transfer of the Member to a GHC Facility,upon consultation between a GHC Provider
and the attending physician If the Member refuses to transfer to a GHC 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 has authorized such follow-up care from a non-GHC Provider in advance
Urgent Care(See Section Vlll for a definition of Urgent Condition)
Inside the GHC Service Area,care for Urgent Conditions is covered only at GHC medical centers,GHC
urgent care clinics,or GHC Providers'offices Urgent care received at any hospital emergency department
is not covered unless authorized in advance by a GHC Provider
Outside the GHC Service Area,Usual,Customary and Reasonable charges are covered for Urgent
Conditions received at any medical facility
M. Ambulance Services. 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 VIII)
1. Emergency Transport to a GHC Facility or non-GHC Facility.Each Emergency is covered as set forth
in the Allowances Schedule,
2. Interfacility Transfers GHC-initiated non-emergent transfers to or from a GHC Facility are covered as
set forth in the Allowances Schedule
N. Skilled Nursing Facility(SNF). Skilled nursing care in a GHC-approved skilled nursing facility when f ill-
time skilled nursing care is necessary in the opinion of the attending GHC Provider,is covered as set forth in
the Allowances Schedule
C22400-0036900 27
When prescribed by a GHC Provider,such care may include room and board,general nursing care,drugs,
biologicals,supplies,and equipment ordinarily provided or arranged by a skilled nursing facility,and short-term
physical therapy,occupational therapy,and restorative speech therapy
Excluded personal comfort items such as telephone and television,rest cures,and custodial,domiciliary or
convalescent care
Section V. General Exclusions
In addition to exclusions listed throughout the Agreement,the following are not covered:
1 Services or supplies not specifically listed as covered in the Schedule of Benefits,Section IV
2 Except as specifically listed and identified as covered in Sections IV B,IV D,IV H,and IV J,corrective
appliances and artificial aids including eyeglasses,contact lenses and services related to their fitting,
hearing devices and hearing aids,including related examinations,take-home drugs,dressings and supplies
following hospitalization,and any other supplies,dressings,appliances,devices or services which are not
specifically listed as covered in Section IV
3 Cosmetic services,including treatment for complications resulting from cosmetic surgery,except as
provided in Section IV D
4 Convalescent or custodial care
5 Durable medical equipment such as hospital beds,wheelchairs,and walk-aids,except while in the hospital
or as set forth in Section IV B,IV F or IV H
6 Services rendered as a result of work-related injuries,illnesses or conditions,including injuries,illnesses or
conditions incurred as a result of self-employment
7 Those parts of an examination and associated reports and immunizations required for employment,unless i
otherwise noted in Section IV B, immigration,license,travel,or insurance purposes that are not deemed
Medically Necessary by GHC for early detection of disease
8 Services and supplies related to sexual reassignment surgery,such as sex change operations or
transformations and procedures or treatments designed to alter physical characteristics
9 Diagnostic testing and medical treatment of sterility,infertility,and sexual dysfunction,regardless of origin
or cause,unless otherwise noted in Section IV B
10 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 (a)medical coverage,medical"no fault"coverage,Personal
Injury Protection coverage,or similar medical coverage contained in said policy,and/or(b)uninsured
motorist or undennsured 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 right to receive benefits under the policy
The Member and his/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/her agents shall permit GHC at GHC's option,to associate with the Member or to ,
intervene in any action filed agamst any party related to the injury The Member and his/her agents shall
C22400-0036900 28
do nothing to prejudice GHC's right 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 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 provisions of this section by initiating
any action against the injured person or his/her agent,then the injured person agrees to pay GHC's
attorneys'fees and costs associated with the action
11 Voluntary(not medically indicated and nontherapeutic)termination of pregnancy,unless otherwise noted
in Section IV B
12 The cost of services and supplies resulting from a Member's loss of or willful damage to appliances,
devices,supplies,and materials covered by GHC for the treatment of disease,injury or illness
13 Orthoptic therapy(i e,eye training)
14 Specialty treatment programs such as weight reduction,"behavior modification programs"and
rehabilitation,including cardiac rehabilitation
15 Services required as a result of war,whether declared or undeclared Care needed for injuries or conditions
resulting from active or reserve military service
16 Nontherapeutic sterilization,unless otherwise noted in Section IV 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,periodontal surgery,
and any other dental services not specifically listed as covered in Section IV GHC'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 Drugs,medicines,and injections,except as set forth in Section IV 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
GHC consults with GHC's Medical Director and then uses the criteria described below to decide if a
particular service is experimental or investigational
a A service is considered experimental or investigational for a Member's condition if any of the
following statements apply to it at the time the service is or will be provided to the Member
r The service 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
u The service is the subject of a current new drug or new device application on file with the FDA
C22400-0036900 29
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ur The service 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 service.
ry The service 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
v The service is under continued scientific testing and research concerning the safety,toxicity or
efficacy of services
vi The service is provided pursuant to informed consent documents that describe the service as
experimental or investigational,or in other terms that indicate that the service is being evaluated
for its safety,toxicity or efficacy
vii The prevailing opinion among experts,as expressed in the published authoritative medical or
scientific literature,is that(1)the use of such 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,
it The written protocol(s)or other document(s)pursuant to which the service has been or will be
provided,
ill 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 similar body that approves or
reviews research at the institution where the service has been or will be provided,and other
information concerning the authority or actions of the 1RB 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 or other agencies within the United States Department of Health and Human
Services,or any state agency performing similar functions
Appeals regarding dental of coverage can be submitted to the Member's regional Member Services
Department,or west of the Cascade Mountains to GHC's Appeals Department,Administration and
Operations Campus,P O Box 34593,Seattle,WA 98124-1593,or east of the Cascade Mountains to
GHC's Patient Relations Department,5615 West Sunset Highway,Spokane,WA 99224 GHC will
respond in writing within twenty(20)working days of the receipt of a fully documented appeal 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 IV K
21 Pre-Existing Conditions,except as specifically provided in Section IV B 26
22 Hypnotherapy,and all services related to hypnotherapy
23 Genetic testing and related services,unless determined Medically Necessary by GHC's Medical Director,
or his/her designee,and in accordance with Board of Health standards for screening and diagnostic tests,or
specifically provided in Section IV B Testing for non-Members is also excluded
24 Follow-up visits related to a non-Covered Service
25 Fetal ultrasound in the absence of medical indications
26 Missed appointments,billing fees,late payment fees,interest charges or cancellation fees
C22400-0036900 30
27 Routine foot care,except in the presence of a non-related Medical Condition affecting the lower limbs
28 Complications of non-Covered Services
29 Treatment of obesity,except as set forth in Section IV B
30 Services or supplies for which no charge is made,or for which a charge would not have been made if the
Member had no health care coverage or for which the Member is not liable,services provided by a member
of the Member's family
31 Autopsy and associated expenses
32 Services provided by government agencies,except as required by federal or state law.
33 Services related to temporomandibularjoint disorder(TMJ)and/or associated facial pain or to correct
congenital conditions including bite blocks and occlusal equilibration,except as specified as covered in
Section IV B
Section VI. Grievance Processes for Complaints and Appeals
The grievance processes to express a complaint and appeal a denial of benefits are 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
availability of a health service
The appeals process is available for a Member to seek reconsideration of a denial of benefits
Complaint Process
Step 1: The Member should contact the person involved,explain his/her concerns and what he/she would like to
have done to resolve the problem The Member should be specific and make his/her position clear.
Step 2: If the Member is not satisfied,or if he/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/she is having a problem That
person will investigate the Member's concerns. Most concerns can be resolved in this way
1 Step 3: If the Member is still not satisfied,he/she should call the GHC Customer Service Center toll free at(888)
901-4636 Most concerns are handled by phone within a few days In some cases the Member will be asked to
write down his/her concerns and to state what he/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 process can take up to thirty(30)days to resolve after receipt of the Member's
written statement
If the Member is dissatisfied with the resolution of the complaint,he/she may contact the Service Quality
Coordinator or the Customer Service Center
Appeals Process
Step 1: If the Member wishes to appeal a decision denying benefits,he/she must submit a request for an appeal
either orally or in writing to the Appeals Department,specifying why he/she disagrees with the decision The appeal
must be submitted within 180 days of the denial notice he/she received. If the Member is located west of the
Cascade Mountains,appeals should be directed to GHC's Appeals Department,P O Box 34593,Seattle,WA
C22400-0036900 31
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98124-1593,(206)901-7359 or toll free(888)901-4636;or if the Member is located east of the Cascade Mountains,
to GHC's Appeals Department,P O Box 204,Spokane,WA 99224-0204,(509)83 8-9 100 or toll free(800)497-
2210
An Appeals Coordinator will review initial appeal requests GHC will then notify the Member of its determination
or need for an extension of time within fourteen(14)days of receiving the request for appeal Under no
circumstances will the review timeframe exceed thirty(30)days without the Member's written permission
If the appeal request is for an experimental or investigational exclusion or limitation,GHC will make a
determination and notify the Member in writing within twenty(20)working days of receipt of a fully documented
request In the event that additional time is required to make a determination,GHC will notify the Member in
writing that an extension in the review timeframe is necessary Under no circumstances will the review timeframe
exceed twenty(20)days without the Member's written permission
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 GHC's Appeals
Department in western Washington at(206)901-7359 or toll free(888)901-4636,or in eastern Washington at(509)
838-9100 or toll free(800)497-2210,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(72)hours after receipt
If GHC fails to grant or reject the Member's request within the applicable required timeframe,the Member may
proceed as if the complaint has been rejected
Step 2:(Optional Step)If the Member is not satisfied with the decision reached by the Appeals Coordinator
regarding a denial of benefits,he/she may request a hearing by the appeals committee by submitting a request within
thirty(30)days of the date of the decision letter If the Member is located west of the Cascade Mountains,the
request can be mailed to GHC's Appeals Department,P O Box 34593,Seattle,WA 98124-1593,or if the Member
is located east of the Cascade Mountains to GHC's Appeals Department,P O Box 204,Spokane, WA 99224-0204
The appeals committee is the final review authority within GHC and its decisions are final The Member is
encouraged to present his/her 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(30)working days of the Member's request
As an alternative to this appeal step,the Member may proceed to Step 3 below
Step 3: If the Member is not satisfied with the decision made in Step I or Step 2 above,or if GHC exceeds the
timeframes stated in Step 1 or Step 2 above without good cause and without reaching a decision,a final level of
appeal is available through an independent review organization An independent review organization is not legally
affiliated or controlled by GHC Once a decision is made through an independent review,the decision is final and
cannot be appealed through GHC *
* If the Member's health plan is governed by the Employee Retirement Income Security Act,known as"ERISA"
(most employment related health plans,other than those sponsored by governmental entities or churches—ask
employer about 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 l of the appeals process Members may have
other legal rights and remedies available under state or federal law
Section VII. General Provisions
A. Coordination of Benefits
1. Benefits Subject to This Provision.As described in subsection 6.,all benefits provided under the
Agreement are subject to the provisions listed in this section
C22400-0036900 32
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2. Definitions.
a. Plan.The definition of a"plan"includes the following sources of benefits or services
i 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,
n Labor-management trusteed plans,labor organization plans,employer organization plans or
employee benefit organization plans,
tri Governmental programs,and
iv 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
b. 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 than cash
payments,the reasonable cash value of each service rendered shall be considered an allowable
expense
c. Claim Determination Period."Claim determination period"means a calendar year,except the
Member's first claim determination period shall begin on the Member's effective date of coverage
under the Agreement and end on December 31 of that same calendar year In no event will a claim
determination period for any Member extend beyond the last day the Member is covered under the
Agreement
3. 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,GHC may,with any
consent necessary,release to or obtain from any other insurer,organization or person any information,
regarding any person which GHC considers necessary for such purpose Any Member claiming benefits
under the Agreement shall provide GHC with the information necessary for such purpose
4. Facility of Payment.Whenever coverage has been provided or paid for under any other plan which should
have been provided under the Agreement in accordance with this provision,GHC shall have the right,
exercisable alone and in its sole discretion,to pay over to any plan making such payments any amounts
GHC shall determine to be warranted in order to satisfy the intent of this provision. Amounts so paid shall
be considered as coverage or benefits paid under the Agreement and,to the extent of such payments,GHC
shall be fully discharged from liability under the Agreement
5. Right of Recovery.Whenever benefits have been provided by GHC 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,GHC 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 GHC shall determine any persons to or
for or with respect to whom such benefits were provided,any other insurers,service plans,other
organizations or other plans
6. Effect on Benefits.
C22400-0036900 33
a This provision shall apply in determining the benefits for a Member covered under the Agreement for a
particular claim determination period if,for the allowable expenses incurred by the Member during
such period,the sum of
i The reasonable cash value of the benefits that would be provided under the Agreement in the '
absence of this provision,and
u 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
b As to any claim determination period with respect to which this provision is applicable,the reasonable
cash value of the benefits provided under the 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 c 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,GHC is not required,and will not take into consideration,Deductibles,
Copayments,or other Cost Share provisions
c If another plan which is involved in subparagraph b of this section and which contains a provision
coordinating its benefits with those of the Agreement would,according to its rules,determine its
benefits after the benefits of this plan have been determined,and the rules set forth in subparagraph d
of this section would require the 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 the
Agreement
d For the purposes of subparagraph c.of this section,the rules establishing the order of benefit
determination are
i The benefits of a plan which covers the person on whose expenses a claim is based as a Subscriber
shall be determined before the benefits of a plan which covers such person as a Dependent
u If a Dependent is covered under both parents'medical plans,the benefits of the plan of the parent
whose birthday,excluding year,falls earlier in the calendar year are determined before those of
the plan of a parent whose birthday,excluding year, falls later in the calendar year
a) 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
b) When the parents are divorced and the parent with custody of the child has remarried,the i
benefits of a plan which 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 a)and b)above,if there is a court decree which would otherwise establish
financial responsibility for the health care expenses of 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
C22400-0036900 34
in When rules t and it 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
' a) The benefits of a plan covering the person 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 laid off or retired employee,or Dependent of such person,and
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b) 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 a)of this
subsection shall not apply
iv If none of the above rules determines the order of benefits,the benefits of the plan which covered
an employee,Member 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
e When this provision operates to reduce the total amount of benefits otherwise to be provided to a
person covered under the 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 the
Agreement
7. Effect of Medicare.
Members Residing Outside the GHC Medicare+Choice Service Area. If a Member is or becomes
eligible for Medicare coverage and Medicare is determined to be the primary bill payer,the Member must
enroll in,and maintain both Medicare Part A and B coverage in order to be eligible for continuing coverage
under the Agreement
Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer
status
When GHC renders care to a Member who is eligible for Medicare benefits,and Medicare is deemed to be
1 the primary bill payer under Medicare primary/secondary payer guidelines and regulations,GHC will seek
Medicare reimbursement for all Medicare covered services
B. Subrogation and Reimbursement Rights
"Injured Person"under this section means a Member covered by the Agreement who sustains an 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 mmor,the guardian or parent of the Member When referred to in this
section,"GHC's 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 by the Injured Person
If the Injured Person's injuries were caused by a third party giving rise to a claim of legal liability against the
third party and/or payment by the third party to the Injured Person and/or a settlement between the third party
and the Injured Person,GHC shall have the right to recover GHC's 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
1 available through applicable third party liability coverage and uninsured/undennsured motorist coverage This
right is commonly referred to as"subrogation"GHC shall be subrogated to and may enforce all rights of the
Injured Person to the extent of GHC's Medical Expenses
If the Injured Person is entitled to or does 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 umnsured/undennsured motorist funds,
C22400-0036900 35
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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 the Agreement As a
condition of receiving benefits under the 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 party for less than available policy limits,in which GHC is entitled to full
compensation of GHC's Medical Expenses
The Injured Person and his/her agents shall cooperate fully with GHC in its efforts to collect GHC's Medical
Expenses.This cooperation includes,but is not limited to,supplying GHC with information about any third
parties,defendants and/or insurers related to the Injured Person's claim and informing GHC of any settlement
or other payments relating to the Injured Person's mjury The Injured Person and his/her agents shall permit
GHC,at GHC's option,to associate with the Injured Person or to intervene in any legal,quasi-legal,agency or
any other action or claim filed If the Injured Person takes no action to recover money from any source,then the
Injured Person agrees to allow GHC to mitiate its own direct action for reimbursement or subrogation,
including,but not limited to,billing the Injured Person directly for GHC's Medical Expenses,
The Injured Person and his/her agents shall do nothing to prejudice GHC's subrogation and reimbursement
rights The Injured Person shall promptly notify GHC of any tentative settlement with a third party and shall not
settle a claim without protecting GHC's interest If the Injured Person fads to cooperate fully with GHC in
recovery of GHC's Medical Expenses,the Injured Person shall be responsible for directly reimbursing GHC for
GHC's Medical Expenses and GHC retains the right to bill the Injured Person directly for GHC's Medical
Expenses
To the extent that the Injured Person recovers funds from any source,the Injured Person agrees to hold such
monies in trust or in their possession until GHC's subrogation and reimbursement rights are fully determined
GHC shall not pay any attorney's 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 GHC's Medical Expenses,there shall be an
equitable 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,
which do not benefit GHC and/or where no written fee agreement has been entered into with GHC
If it becomes necessary for GHC to enforce the provision of this section by initiating any action against the
Injured Person or his/her agent,then the Injured Person agrees to pay GHC's attomy's fees and costs
associated with the action
Implementation of this section shall be deemed a part of claims administration under the Agreement and GHC
shall therefore have sole discretion to interpret its terms
C. Miscellaneous Provisions
1. Identification Cards.GHC will furnish cards,for identification purposes only,to all Members enrolled
under the Agreement
2. Administration of Agreement.GHC may adopt reasonable policies and procedures to help in the i
administration of the Agreement.GHC reserves the right to construe the provisions of the Agreement and
to make all determinations regarding benefit entitlement and coverage
C22400-0036900 36
3. Modification of Agreement.No oral statement of any person shall modify or otherwise affect the benefits,
limitations,and exclusions of the Agreement,convey or void any coverage,increase or reduce any benefits
under the Agreement or be used in the prosecution or defense of a claim under the Agreement
4. Confidentiality. GHC and the Group shall keep Member information strictly confidential and shall not
disclose any information to any third party 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 required of such party pursuant to the Agreement,or for the proper management and
administration of the receiving party,provided that such representatives are informed of the confidentiality
provisions of the Agreement and agree to abide by them,(it)pursuant to court order,or(ni)to a designated
public official or agency pursuant to the requirements of federal,state or local taw,statute,rule or
regulation
5. Nondiscrimination.GHC does not discriminate on the basis of physical or mental disabilities in its
employment practices and services.
Section VIII. Definitions
Agreement: The Medical Coverage Agreement between GHC and the Group
Allowance: The maximum amount payable by GHC for certain Covered Services under the Agreement,as set forth
in the Allowances Schedule
Coinsurance: The percentage amounts the Member and GHC are required to pay for Covered Services received
under the Agreement Percentages for Covered Services are set forth in the Allowances Schedule
Contracted Pharmacy Network: A pharmacy that has contracted with GHC to provide covered legend
(prescription)drugs and medicines for outpatient use under the Agreement
Copayment: The specific dollar amount a Member is required to pay at the time of service for certain Covered
Services under the Agreement as set forth in the Allowances Schedule
Cost Share: The portion of the cost of Covered Services the Member is liable for under the Agreement Cost
Shares for specific Covered Services are set forth in the Allowances Schedule Cost Share includes,but is not
limited to,Copayments,Comsurances and/or Deductibles
Covered Services: The services for which a Member is entitled to coverage under the Agreement
Deductible: A specific amount a Member is required to pay for certain Covered Services before benefits are
payable under the Agreement The applicable Deductible amounts are set forth in the Allowances Schedule
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
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 Unit: A Subscriber and all his/her Dependents
Fee Schedule: A fee-for-service schedule adopted by GHC,setting forth the fees for medical and hospital services
GHC-Designated Self-Referral Specialist: A GHC specialist specifically identified by GHC to whom Members
may self-refer
C22400-0036900 37
GHC Facility: A facility(hospital,medical center,or health care center)owned,operated or otherwise designated
by GHC.
GHC Medicare Plan: A plan of coverage for persons enrolled in Medicare Part A(hospital insurance)and Part B
(medical insurance)
GHC Personal Physician: A provider who is employed by or contracted with 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 the Agreement which a Member can access without a Referral
Personal Physicians must be capable of and licensed to provide the majority of primary health care services required
by each Member
GHC Provider: The medical staff,clime 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
Members enrolled under the Agreement,including,but not limited to physicians,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 Revised Code of
Washington
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
Lifetime Maximum: The maximum value of benefits provided for Covered Services under the Agreement after
which benefits under the Agreement are no longer available as set forth in the Allowances Schedule The value of
Covered Services is based on the Fee Schedule,as defined above
Medical Condition:A disease,illness or injury
Medically Necessary: Appropriate and clinically necessary services, as determined by the GHC's Medical
Director,or his/her designee,according to generally accepted principles of good medical practice,which are
rendered to a Member for the diagnosis,care or treatment of a Medical Condition Services must be medically and
clinically necessary for benefits to be covered under the 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,services and
supplies must meet the following requirements (a)are not solely for the convenience of the Member,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 Member,(c)are for the diagnosis or treatment of an actual or existing Medical Condition
unless being provided under GHC's schedule for preventive services,(d)are not for recreational,life-enhancing,
relaxation or palliative therapy,except for treatment of terminal conditions,(e)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 Member's condition or the quality of health services rendered,(f)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 Member's condition or quality of health services rendered,(g)are not
pnmarily for research and data accumulation,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
Member: Any Subscriber or Dependent enrolled under the Agreement
C22400-0036900 38
Out-of-Pocket Expenses:Those Cost Shares paid by the Subscriber or Member for Covered Services,which are
applied to the Out-of-Pocket Limit
Out-of-Pocket Limit(Stop Loss): The maximum amount of Out-of-Pocket Expenses incurred and paid,during the
calendar year for Covered Services received by the Subscriber and his/her Dependents within the same calendar
year. The Out-of-Pocket Limit amount and Cost Shares that apply are set forth in the Allowances Schedule.
Charges in excess of UCR,services in excess of any benefit level,and services not covered by the Agreement are
not applied to the Out-of-Pocket Limit
Pre-Existing Condition: A condition for which there has been diagnosis,treatment(including prescribed drugs),or
medical advice within the three(3)month period prior to the effective date of coverage The Pre-Existing Condition
wart period will begin on the first day of coverage,or the first day of the enrollment waiting period if earlier
Referral: A written temporary agreement requested in advance by a GHC Provider and approved by GHC that
entitles a Member to receive Covered Services from a specified health care provider Entitlement to such services
1 shall not exceed the limits of the Referral and is subject to all terms and conditions of the Referral and the
Agreement Members who have a complex or serious medical or psychiatric condition may receive a standing
Referral for specialist services
Self-Referred:Covered Services received by a Member from a designated women's health care specialist or GHC-
Designated Self-Referral Specialist that are not referred by a GHC Personal Physician
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,Kittitas,
Spokane,Walla Walla,Whitman,and Yakima counties,Idaho Counties of Kootenai and Latah,and any other areas
designated by GHC
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 under the Agreement,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-GHC Provider Expenses are considered Usual,Customary,and
Reasonable if the charges are consistent with those normally charged to others by the provider or organization for
the same services or supplies,and the charges are within the general range of charges made by other providers in the
same geographical area for the same service or supplies
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C22400-0036900 39
EMPLOYER GROUP PROGRAMS
GROUP MEDICARE COVERAGE j
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C22400-0036900 1
This brief outline describes the benefits available to you when you combine your employer
Group healthcare benefits with Medicare. ALL MEDICARE GUIDELINES AND
CRITERIA MUST BE MET.
BENEFITS
OUT-OF-POCKET LIMIT(STOP LOSS)
Total Out-of-Pocket Expenses for the following services are limited to $300 maximum per
Member per calendar year
• Outpatient Services
• Emergency[Urgently Needed Care
INPATIENT HOSPITAL(Medical/Surgical)
Covered up to 365 days per year.
SKILLED NURSING FACILITY
• Group benefit or up to 100 days per benefit period after a 3 day Medicare certified hospital
stay.
Note. When a 3 day Medicare covered hospital stay does not occur and the plan determines
that the Member otherwise meets all Medicare criteria,the plan may authorize Medicare
covered skilled nursing care for up to 100 days
INPATIENT MENTAL HEALTH
• Group benefit or up to 190 days per lifetime benefit covered in full in a Medicare-certified
psychiatric hospital
INPATIENT ALCOHOLISM &DRUG ABUSE TREATMENT
• Covered in full when such services are provided in a hospital-based treatment center.
HOME HEALTH CARE (SUCH AS PART-TIME SKILLED NURSING CARE,
PHYSICAL THERAPY, SPEECH THERAPY, OCCUPATIONAL THERAPY)
• Covered in full, in accordance with Medicare guidelines.
MEDICAL CARE
• Physician care in a hospital and home covered in full,
• Office and outpatient hospital care covered, sub3ect to applicable Copayment
C22400-0036900 2
• Outpatient Surgery in outpatient hospital facility or ambulatory surgical center covered
subject to applicable Copayment
• Alcoholism and substance abuse treatment services covered in full.
AMBULANCE
• Covered in full.
CARDIAC REHABILITATION
• Covered in full
CHIROPRACTIC & PODIATRIC CARE (Medical Need)
• Covered, subject to the applicable Copayment.
EMERGENCY AND OUT-OF-AREA URGENTLY NEEDED SERVICES
• You pay$50 for each hospital emergency room visit; you do not pay this amount if you are
admitted directly to the hospital from the emergency room
• Worldwide coverage is provided.
HEARING EXAMINATIONS & HEARING AIDS
• Hearing exams to determine hearing loss are covered, subject to the applicable Copayment
Purchase of hearing aids covered once every 24 months limited to $250 hearing aid purchase
Allowance
HEALTHIWELLNESS EDUCATION
• Health club services (SilverSneakers®)and/or lifetime fitness programs at participating
network health clubs are covered in full.
• Services related to tobacco cessation and education materials are covered in full, limited to•
1. One individual or group program per calendar year.
2. When participating in the GHC Tobacco Cessation program,your employer Group
covers one course of nicotine replacement or other approved pharmacy products once per
calendar year. Your employer Group outpatient prescription drug Copayment applies
ORGAN TRANSPLANT
• Medicare covered organ transplants covered in full.
C22400-0036900 3
OUTPATIENT MENTAL HEALTH CARE
• Covered, subject to the applicable Copayment.
OUTPATIENT PRESCRIPTION DRUGS
• Medicare covered outpatient prescription drugs are covered in full. Your employer Group
may cover outpatient prescription drugs.Please see the employer Group section of this
Certificate of Coverage for more information.
POINT OF SERVICE (POS)
• Non-emergent and/or non-Urgently Needed Care received while temporarily traveling
outside GHC's Medicare Service Area is payable at Medicare benefit levels up to$2,000 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
PHYSICAL, OCCUPATIONAL, SPEECH AND LANGUAGE THERAPY
• Covered subject to the applicable Copayment.
PROSTHETIC DEVICES, PACEMAKERS,BRACES,ARTIFICIAL LIMBS & EYES
• Covered in full.
RENTAL OR PURCHASE OF DURABLE MEDICAL EQUIPMENT
• Covered in full.
URGENTLY NEEDED SERVICES
• Urgently needed services are covered, subject to applicable Copayment
• Worldwide coverage is provided.
VISION CARE (Eye Care Medical Need)
• Examinations for illness and injury covered in full, subject to the applicable Copayment.
• One pair of standard eyeglasses or contact lenses are covered after each cataract surgery with
insertion of an mtraocular lens(IOL).
• Routine eye exams for glasses covered subject to the applicable Copayment once every 24
months
C22400-0036900 4
• One pair of standard vision lenses, or contact lenses will be covered subject to the GHC-
approved Allowance once every twenty-four(24) months.
• Frames are covered by Group benefit or up to $100 once every 24 months.
Please see your employer Group Certificate of Coverage for more information.
Please contact our Group Health Customer Service Center for more information and the location
of participating reciprocal facilities at 206-901-4636,toll-free 1-888-9014636, or TTY/TDD
711 or 1-800-833-6388 for the"hearing impaired,"Monday-Fnday, 7:30 a.m. to 5:00 p.m
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C22400-0036900 5
Kent City Council Meeting
Date J11y 20, 2004
Category Consent Calendar
1. SUBJECT: NATIONWIDE DEFERRED COMPENSATION (457)PROGRAM -
AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the amended Plan
Document implementing the deferred compensation (457) loan program option for
employees and delegating certain administrative duties regarding loans to Nationwide.
3. EXHIBITS: Nationwide Retirement Solutions Amended Plan Document
4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? None Revenue? _
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6I
THE UNITED STATES CONFERENCE OF MAYORS
DEFERRED COMPENSATION PROGRAM
' THE DEFERRED COMPENSATION PLAN FOR PUBLIC EMPLOYEES
LOANS TO PARTICIPANTS AMENDMENT TO PLAN DOCUMENT
WHEREAS,PLAN SPONSOR executed the above referenced Plan Document, as
amended: and
WHEREAS, effective ,PLAN SPONSOR now desires to further amend
the plan document.
The following Section 8.06 is hereby added:
8.06 Loans to PARTICIPANTS
(a) PLAN SPONSOR has elected to make loans available to PARTICIPANTS and
has delegated certain administrative duties regarding loans from the PLAN to the
ADMINISTRATOR.
(b) Any loan by the PLAN to a PARTICIPANT under this Section shall be subject to
' the loan administrative procedures established by the ADMINISTRATOR as well
as the following requirements:
' (i) Loan Eligibility. Any actively employed PARTICIPANT may apply
for a loan from the PLAN. A PARTICIPANT who has defaulted on a
previous loan from the PLAN shall not be eligible for another loan
' from the PLAN until all defaulted loans are repaid in full, including
accrued interest and fees.
' (h) Loan Application and Loan Agreement. A PARTICIPANT must
complete and return to ADMINISTRATOR a loan application. A non-
refundable application fee established by ADMINISTRATOR will be
' deducted from the PARTICIPANT'S ACCOUNT(s) at the time of
loan origination. Before a loan is issued, the PARTICIPANT must
enter into a legally enforceable loan agreement as provided for by the
' ADMINISTRATOR.
(iii) Loan Repayment. The PARTICIPANT receiving a loan shall be
1 required to furnish to ADMINISTRATOR any information and
authorization necessary to effectuate repayment of the loan prior to the
commencement of a loan. Loan repayments will be made by payroll
deduction with after-tax income. The repayments will be invested
based upon the PARTICIPANT's current investment specifications.
' 1
(iv) Loan Term and Interest Rate. The maximum term over which a loan '
may be repaid is five (5) years (fifteen(15) years if the PLAN
SPONSOR permits loans for the purchase of a PARTICIPANT'S
principal residence). Each loan shall be amortized in substantially
equal payments consisting of principal and interest during the term of
the loan, except that the amount of the final payment may be higher or ,
lower. The ADMINISTRATOR shall establish the interest rate for any
loan.
(v) Loan Frequency. Each Participant may have only one (1) PLAN loan
outstanding at any given time. A PLAN loan which is in default, even
if the defaulted loan was treated as a "deemed distribution" under
federal regulations, shall be treated as an outstanding loan until such
PARTICIPANT'S account balance is offset by the amount of principal '
and accrued interest under the loan. A PARTICIPANT will be granted
a loan no more frequently than two (2) times in any twelve (12)month
period. ,
(vi) Default. The PARTICIPANT must pay the full amount of each loan
payment (principal and interest) on the date that it is due. Failure to '
make such a payment by the due date, or within any cure period
established by the ADMINISTRATOR, shall cause the
PARTICIPANT to be in default for the entire amount of the loan, ,
including any accrued interest. A loan will also be in default if the
PARTICIPANT either refuses to execute,revoke, or rescind any
agreement necessary to comply with the provisions of this Section or ,
the loan administrative procedures established by the
ADMINISTRATOR , commences or has commenced against
PARTICIPANT a bankruptcy case, upon the PARTICIPANT's ,
SEVERANCE FROM EMPLOYMENT, or upon the death of the
PARTICIPANT
(vii) Loan Security. By accepting a loan, the PARTICIPANT is giving a '
security interest in their vested PLAN balance as of the loan process
date, together with all additions thereof, to the PLAN that shall at all ,
times be equal to 100% of the unpaid principal balance of the loan
together with accrued interest.
(viii) Loan Amount. The maximum amount of any loan permitted under the '
PLAN is the lesser of(i) 50% of the PARTICIPANT'S vested account
balance less any outstanding loan balances under the PLAN or(ii)
$50,000 less the highest outstanding loan balance during the
preceding one-year period. The ADMINISTRATOR shall establish the
minimum loan amount. The PARTICIPANT and not the
ADMINISTRATOR shall at all times remain responsible for ensuring
2 ,
' that any loan received under the PLAN is in accordance with these
limits with regard to any other loans received by the PARTICIPANT
under any other plans of the PARTICIPANT's employer.
(ix) Loan Maintenance Fee. Until a loan is repaid in full, an annual loan
maintenance fee established by ADMINISTRATOR will be deducted
from the PARTICIPANT'S ACCOUNT(s).
(x) Loan Default Fee. At the time when a default occurs, a loan default
fee established by ADMINISTATOR will be deducted from the
PARTICIPANT'S ACCOUNT(s).
(c) The ADMINISTRATOR shall fix such other terms and conditions necessary to
the administrative maintenance of the provisions of this Section and as necessary
to comply with the IRC and regulations there under.
IN WITNESS WHEREOF, the undersigned has executed this Amendment this
' day of 20_
' (Name of PLAN SPONSOR) By:
3
' Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: INTERNATIONAL CITY/COUNTY MANAGERS ASSOCIATION
(ICMA)ADMINISTRATIVE SERVICES AGREEMENT—AUTHORIZE
2. SUMMARY STATEMENT: Authorize the Mayor to sign the amended ICMA-RC
Deferred Compensation (457) Plan Administrative Services Agreement for a five year
administration services agreement beginning on the execution date and ending 5 years
after the execution date, reducing the plan administration fee to .29%.
3. EXHIBITS: ICMA-RC Amended Administrative Services Agreement
t4. RECOMMENDED BY: Operations Committee
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? None Revenue?
Currently in the Budget? Yes No
If no:
' Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
' ACTION:
Council Agenda
Item No. 6J
THE UNITED STATES CONFERENCE OF MAYORS
DEFERRED COMPENSATION PROGRAM
PARTICIPANT LOAN ADMINISTRATIVE PROCEDURES
Nationwide Retirement Solutions, Inc. ("NRS"), as Third Party Administrator of the United States
Conference of Mayors Deferred Compensation Program, administers your Deferred Compensation Plan for
Public Employees ("Plan"). Recently issued proposed regulations under Internal Revenue Code Section
457 provide that eligible governmental 457(b) plans may permit loans to Participants NRS recommends
that you, as Plan Sponsor and/or Employer(hereinafter collectively referred to as "Plan Sponsor"), consult
with your own legal advisor in determining whether you wish to add this optional feature to your Plan.
In the event that you decide to offer loans from your Plan to Participants, you will need to return to NRS at
[INSERT CONTACT INFO] a fully executed original of this document and a fully executed original of the
enclosed Plan Document Amendment. NRS cannot begin processing Participant loans from your Plan until
it receives fully executed originals of both of these documents.
NRS may need from time-to-time to make changes to the administrative procedures set forth herein and in
the Plan Document Amendment. In such a case, NRS will provide you with timely notice of such changes
as they become necessary.
The following administrative procedures shall govern the making of loans from your Plan-
1 Loan Administration. Plan Sponsor delegates to NRS certain administrative duties regarding the
administration of loans from the Plan,which are set forth herein and which may be modified by NRS upon
timely notice to Plan Sponsor.
2 Loan Eligibility. Any actively employed Plan Participant is eligible to receive a loan from the Plan
Each Participant is entitled to one (1) loan at any time In addition, a Participant who has defaulted on a
previous loan shall not be eligible for another loan from the Plan until all defaulted loans are repaid in full,
including accrued interest and fees.
3 Loan Application and Loan Agreement. In order to receive a loan from the Plan, an eligible
Participant must complete a loan application and return it to NRS A loan application fee of$50.00* will be
deducted from the Participant's account(s). Before a loan is issued, the Participant must enter into a legally
enforceable loan agreement as provided by NRS If the Plan Sponsor permits loans for the purchase of the
Participant's p rincipal r esidence, t he P articipant w ill b e r equired t o s ign a P nmary R esidence C ertificate
form a nd p rovide N RS w ith a c opy o f the c ontract o r o ther d ocuments relating to t he a cquisition o f the
dwelling u nit. If t he s ource for a s mgle I oan i ncludes b oth the P articipant's D eferred C ompensation a nd
Eligible Rollover Accounts, the Participant will be required to complete a loan application and loan
agreement for each account which will be treated as separate and distinct for all purposes herein except
that they will be considered a single loan for purposes of Sections 2, 6 and 10 herein
4 Loan Repayment/Maximum Loan Term. Repayment of any loan made to a Participant shall be
made in a manner and pursuant to the terms set forth in the loan agreement. The Participant receiving a
loan shall be required to furnish the information and authorization necessary to effectuate the foregoing
payments prior to the commencement of a loan. The maximum term over which a loan may be repaid is
five (5) y ears (fifteen (15) y ears i f t he P Ian S ponsor p ermits I oans f or t he p urchase o f t he P articipant's
principal residence).
In the event that a Participant elects to receive a distribution from the Plan (other than a distribution due to
*These fees,rates, and minimums are subject to change by NRS upon reasonable notice to Plan Sponsor Loan fees will appear
as administrative charges on Participant Statements.
an unforeseeable emergency or other in-service withdrawal) at a time when such person has a Plan loan '
outstanding, the principal and any accrued interest with respect to such loan shall be taxable.
5. Loan Amortization. Each loan shall be amortized in substantially equal payments consisting of '
principal and interest during the term of the loan Payments of principal and interest shall be made in a
manner and pursuant to the terms set forth in the loan agreement on a monthly basis in equal amounts,
except that the amount of the final payment may be higher or lower. Before the loan is made, the Participant
will be notified of the date on which the first payment will be deducted and the dates on which subsequent
payments are due.
6. Loan Frequency/Renegotiations. Each Participant may have only one (1) Plan loan outstanding ,
at any given time. A Plan loan which is in default, even if the defaulted loan was treated as a "deemed
distribution" under federal regulations, shall be treated as an outstanding loan until such Participant's
account balance is offset by the amount of principal and accrued interest under the loan A Participant will
be granted a loan no more frequently than two (2) times in any twelve (12) month period. Under no
circumstances may loan terms be renegotiated. A new loan shall not be granted prior to the repayment of
an outstanding loan.
7. Default. The Participant must pay the full amount of each payment (principal and interest) on the
date that it is due. The Participant shall be in default for the entire amount of the loan UNLESS the
Participant does each of the following: 1) contacts NRS at the Deferred Compensation Service Center, 2)
mutually agrees with NRS on a date, which is within 30 days of the missed payment, to pay the missed
payment and; 3) actually pays the missed payment. Failure to make such a payment through mutually ,
agreeable terms shall cause the Participant to be in default for the entire amount of the loan. The loan also
shall be defaulted upon the Participant's severance from employment, upon the death of the Participant, or
if the Participant commences or has commenced against Participant a bankruptcy case. No additional
loans shall be made to a Participant who has defaulted on a Plan loan and who has not repaid all defaulted
loans in full, including accrued interest and fees.
8. Loan Prepayment. The entire amount of a loan, including outstanding principal and any accrued ,
interest, may be paid without penalty prior to the end of the term of the loan in the manner prescribed by
NRS. However, payments made that are less than the remaining principal amount of the loan and any ,
accrued interest with respect to the loan, or which are not paid in the form prescribed by NRS, are not
permitted
9. Loan Security. By accepting a loan, the Participant is giving a security interest in his or her vested r
Plan balance as of the date of the Loan Process Date, together with all additions thereof, to the Plan that
shall at all times be equal to 100% of the unpaid principal balance of the loan together with accrued interest.
10. Maximum/Minimum Loan Amount. The maximum amount of any loan permitted under the Plan is
the lesser of (i) 50% of the Participant's vested account balance (not including any value attributable to
applicable life insurance or deemed IRA account) less any outstanding loan balances under the Plan or (ii) ,
$50,000 less the highest outstanding loan balance during the preceding one-year period. The minimum loan
amount permitted is $1,000.00* Loans shall be made in accordance with these limits and those limits
imposed under federal regulations without regard to any other loans received by the Participant from any
other investment provider under the Plan or any other plans of the employer The Participant and not NRS
shall remain at all times responsible for ensuring that any loan received under the Plan is in accordance with
these limits with regard to any other loans received by the Participant under any other plans of the '
Participant's employer. Any tax reporting required as a result of the receipt by a Participant of a loan that
exceeds the limits imposed by federal regulations shall not be the responsibility of NRS, unless it is
determined that such limits were exceeded solely as a result of a loan made through NRS as service '
provider. Consequently, NRS shall not be required to account for loans made pursuant to a plan other than
*These fees,rates,and nummums are subject to change by NRS upon reasonable notice to Plan Sponsor. Loan fees will appear
as admimstratrve charges on Participant Statements. ,
i
this Plan or loans made under this Plan that are made by an investment provider other than Nationwide Life
Insurance Company.
' 11. Suspension of Loan Payments. NRS m ay s uspend a P articipant's obligation t o repay a ny loan
under the Plan during the period in which the Participant is performing service in the uniformed services as
may be required by law. At the expiration of any suspension of loan payments period, the outstanding loan
balance, including any accrued interest and fees, will be re-amortized and the Participant will be required to
execute an amended Loan Agreement.
12. Loan Interest Rate The interest rate for any loan shall be established by NRS. These interest
rates shall commensurate with interest rates being charged by entities in the business of lending money
under similar circumstances. Generally, the rate assumed will be Prime Rate + 1.00%*. The Prime Rate
shall be the prime rate published by the Wall Street Journal two weeks prior to the end of the most recent
' calendar-year quarter. NRS may adjust the loan interest rate for loans to Participants entering active duty in
the military services as may be required by law.
' 13. Annual Loan Maintenance and Asset Fees. An annual loan maintenance fee of $50 00* will also
be deducted from the Participant's account until the loan is repaid in full The amount of the outstanding
loan balance will be subject to the maximum Variable Account Annual Expense Fee applicable under the
Plan at the time the loan is issued.
14 Loan Default Fee. At the time when a default occurs, a $50.00' loan default fee will be deducted
from the Participant's account This charge will only affect Participants who fail to make a required loan
payment
' 15 Loans for the Purchase of a Principal Residence. All loans issued by the Plan will be general
loans to be repaid in five (5) years unless the Plan Sponsor affirmatively elects to offer loans for the
purchase of the Participant's principal residence, which may be repaid in fifteen (15) years Such loans
shall be solely secured by the Participant's vested account balance. All administrative procedures set forth
herein shall apply to such loans
If the Plan Sponsor elects to permit loans for the purchase of the Participant's principal residence,
please check this box. ❑
The undersigned Plan Sponsor hereby adopts these Participant Loan Administrative Procedures, effective
for loans issued on or after the effective date set forth in the Loans to Participants Amendment to Plan
Document, and instructs NRS to administer loans made to Plan Participants in accordance with these
terms.
The Plan Sponsor acknowledges the following: (i) that the Plan Sponsor has decided to offer loans under
the Plan and is instructing NRS to administers loans under the Plan, (ii) that it understands that, as a result
' of offering loans under the Plan, the Plan Sponsor, its Participants, and/or the Plan could be subject to
adverse tax consequences; (ni) that the Plan Sponsor has independently weighed this risk and has
determined that offering loans under the Plan is in the best interest of the Plan Sponsor, its Participants,
and the Plan; and (iv) NRS shall not be liable for any adverse tax consequences described in (n), except as
specifically stated under paragraph 10 herein, resulting from the Plan Sponsor's decision to offer loans
under the Plan
Piari`Spolttsor
or Errlp_[oyer"�
*These fees,rates,and rmm m mus are subject to change by NRS upon reasonable notice to Plan Sponsor Loan fees will appear
eas adnumstranve charges on Participant Statements.
Street Add
:1�/r Stater =Qd
PJa'rk Na'm"e.,-
lts
E=i afl Address;
Date:--
*These fees, rates,and immmunts are subject to change by NRS upon reasonable notice to Plan Sponsor. Loan fees will appear
as administrative charges on Participant Statements
Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: WESTVIEW TERRACE SEWER EXTENSION BILL OF SALE—
APPROVE
' 2. SUMMARY STATEMENT: Accept the Bill of Sale for Westview Terrace Sewer
Extension submitted by Neal Jacques for continuous operation and maintenance of 76
feet of sewers. Bonds are to be released after the maintenance period. This project is
located at 21215 97"'Place South.
3. EXHIBITS: Vicinity map
4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
I
DISCUSSION:
ACTION:
Council Agenda
Item No. 6K
�264ih St
I-
�'t YiJ 7 •� 4 I` `,,�tF F`r��S III C,ti ,D' '0.t� 'L� £ ���� o (
'tA '�- '-�•�r SE�061hS:
�t� lice I tnJ Tt� �?061n P1 �'r+ 8 iy � _ •--�- i
W _
9E 20`1H t-'
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s 2WO St SE 20Bih St L
— -- - - - - -- �I - -
ot fSE 248th P1l l •�
3m I p ��Fj{Ith PI
r S2101h Pi �i +F�101h F'
SE2111hS_ -.�
ry •' 11 � .__ — -
i '
S 212th St
3!3-II, St
- 3:1-ith5-• SEf'{131h 0
-F1 �Id SE!",1'j't4
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S
Itlij 8. Wr i 7 1 V
a r 1 u} trek Pad SE P I?t�t 01
li �
r SE_2Gth�t
� S 2LGtR;9 t _
5220thP VICINITY MAP
N.T 5
Westview Terrace Sewer Extension
21215 97`'Place South
Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
I. SUBJECT: PINERIDGE SUBDIVISION INFRASTRUCTURE IMPROVEMENTS
BILL OF SALE—APPROVE
2. SUMMARY STATEMENT: Accept the Bill of Sale for Pineridge Subdivision
Infrastructure Improvements submitted by Baima & Holmberg for continuous operation
and maintenance of 1264 feet of sewers, 540 feet of street improvements and 1,300 feet
of storm sewer. Bonds are to be released after the maintenance period. This project is
located at I I8 h Ave SE and SE 234d.
w3. EXHIBITS: Vicinity map
4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6L
NORTH
UER1DIAN
PARK
w SE 227TH P
SE 228TH PARK
ORCHWZD
' � a
o SE 231ST PL
u
e 232ND ST
sts SE ST
SE Z35�
SE 2341H P1 V)
a S
o
� N
SE 240TH ST
VICINITY MAP
N T 5.
Pineridge Subdivision Infrastructure
118h Avenue SE/SE 234th Street
i -
Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: MCKENNA MEADOWS INFRASTRUCTURE IMPROVEMENTS BILL
OF SALE—APPROVE
2. SUMMARY STATEMENT: Accept the Bill of Sale for McKenna Meadows
Subdivision Infrastructure Improvements submitted by Shupe Holmberg for continuous
operation and maintenance of 809 feet of sewers, 650 feet of street improvements and
1588 feet of storm sewer. Bonds are to be released after the maintenance period. This
project is located at 124t'Ave. SE and SE 259t' St.
3. EXHIBITS: Vicinity map
4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6M
256TH ST.
S.E.
2g8'M
4i
N S
SR
16
S.E. 2641H ST
S.E WSTH S?
ON
VICINITY MAP
N T.S.
McKenna Meadows Subdivision Infrastructure Improvements
124`h Avenue SE/ SE 259`h Street
Kent City Council Meeting
Date July 20, 2004
Category Consent Calendar
1. SUBJECT: CHELMSFORD SUBDIVISION INFRASTRUCTURE IMPROVEMENTS
BILL OF SALE—APPROVE
2. SUMMARY STATEMENT: Authorization to accept the Bill of Sale for
Chelmsford Subdivision Infrastructure Improvements submitted by Shupe Holmberg
for continuous operation and maintenance of 1,654 feet of watermain, 4,185 feet of
sewers, 775 feet of street improvements and 2,239 feet of storm sewer. Bonds to be
released after the maintenance period. This project is located at SE 234 h Street/ 11611'
Avenue SE.
a3. EXHIBITS: Vicinity map
4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? N/A Revenue? N/A
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 6N
NORTH
11�ERlDUW
PARK
SE 227TH P
O SE 228TH
PARK to
DRCWARD a
SE 231 ST Pl.
4E�t2 32ND ST
E TH ST
235� �
En SE 2 sW
a SF
o
N
SE 240T14 ST
j
t
VICINITY MAP
N T.5
Chelmsford Subdrvcsion Infrastructure Improvements
SE 234' / I I&Avenue SE
Kent City Council Meeting
Date July 20 2004
Category Consent Calendar
1. SUBJECT: GARRISON AND EAST HILL WELL PROJECT—ACCEPT AS
COMPLETE
2. SUMMARY STATEMENT: As recommended by the Public Works Director,
accept as complete the Garrison and East Hill Well project and release the retainage to
Hokkaido Drilliing, Inc. upon standard releases from the state and release of any liens.
The original contract amount was $273,196.80. The final contract amount was
$2091377.45.
3. EXHIBITS: None
4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?_
Currently in the Budget? Yes X No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
iCouncilmember moves, Councilmember seconds
DISCUSSION:
ACTION:
Council Agenda
Item No. 60
Kent City Council Meeting
Date July 20, 2004
Category Other Business
1. SUBJECT: RUTH WIREN REZONE
2. SUMMARY STATEMENT: This request by Ruth Wiren is to rezone 3.97 acres of
property from SR-4.5, Single Family Residential, to SR-6, Single Family Residential.
The property is located at the northwest corner of 1361s Avenue SE and SE 253`d Street.
The Kent Hearing Examiner held a Public Hearing on June 16, 2004, and issued
Findings, Conclusions and a recommendation for approval on June 30, 2004.
3. EXHIBITS: Staff report with map & Hearing Examiner Findings, Conclusions and
Recommendation
4. RECOMMENDED BY: Hearing Examiner
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? No Revenue? No
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember Ct A4 moves, Councilmember 7if)k4_� seconds
to acceptkefeeVinodify the Findings, Conclusions and Decision of the Hearing
Examiner on the Ruth Wiren Rezone and to direct the City Attorney to prepare the
necessary ordinance.
DISCUSSION:
ACTION:
Council Agenda
Item No. 7A
COMMUNITY DEVELOPMENT
Fred N Satterstrom, Director
PLANNING SERVICES
Charlene Anderson,AICP,Manager
•
K E N T Phone:253-856-5454
W A S ENT
G T O N Fax 253-856-6454
Address 220 Fourth Avenue S
Kent,WA 98032-5895
KENT PLANNING SERVICES
(206) 856-5454
STAFF REPORT
FOR HEARING EXAMINER MEETING OF
JUNE 16, 2004
FILE NO. Ruth Wiren Rezone
#RZ-2004-1 KIVA#2040659
APPLICANT Ruth Wiren
254 North Gold Creek Loop
Hamilton, MT 59840
REQUEST A request to rezone 3.97 acres of property from SR-
4 5 single family residential to SR-6, single family
residential
STAFF
REPRESENTATIVE- Sharon Clamp, Planner
STAFF
RECOMMENDATION APPROVAL
I GENERAL INFORMATION
A Description of the Proposal
The applicant proposes to rezone 3.97 acres from the current zoning of SR-4 5
single family residential to SR-6 single family residential
B. Location
The subject property is located at the northwest corner of 136`" Avenue SE and
SE 253` Street and is identified by King County Tax Parcel number 2222059148
C. Size of Property
The property consists of a 3 97 acre parcel
Staff Report
Ruth Wiren Rezone
#RZ-2004-1 KIVA#2040659
D. Zoning
Properties to the north, south and east of the subject site are zoned SR-4.5
Single Family Residential. The adjacent property to the west is zoned SR-6.
E. Land Use t
The property is vacant and undeveloped. The City of Kent Comprehensive Plan
designates the property as SF-6, Single Family six units per acre.
F. History
The property is part of 891 acres annexed to the City of Kent on July 1, 1997
under Ordinance No. 3344
if. ENVIRONMENTAL CONSIDERATIONS
A. Environmental Assessment
A Determination of Nonsignificance (#ENV-2004-8) for the rezone proposal was
issued on May 14, 2004.
B. Significant Physical Features
Topography. Wetlands and Vegetation
The site slopes approximately six percent from east to west. There is an
elevation change of approximately 30 feet across the property The site is
vegetated with a mixture of trees and grass cover.
C. Significant Social Features
1. Street System
The subject property is located at the northwest corner of
130h Avenue SE and SE 253'd Street However, under current conditions
access to serve a future development is not available from this
intersection due to the location of the property comer in relation to the
existing rights-of-way of those streets. If developed in the future, the
property will take access f rom the west through the approved Tahoma
Vista subdivision (SU-2001-6) that accesses from 132nd Avenue SE
Road improvements to 132"d Avenue SE adjacent to the Tahoma Vista
property north to SE 24Vh Street were completed in 2002 in conjunction
with the construction of the City of Kent Wilson Ball Fields located at the
southwest corner of 132nd Avenue SE and SE 2481h Street This section
of 132"d Avenue SE is improved with bike lanes, cement concrete curbs
and gutters, cement concrete sidewalks, a planter strip, streetlights, and a
Page 2 of 10
Staff Report
Ruth Wiren Rezone
#RZ-2004-1 KIVA#2040659
left hand turn lane on the west side of the street. A southbound right turn
lane was also installed between SE 248"' Street and SE 253rd Street.
2 Water System
The site receives water service from Water District 111.
3 Sanitary Sewer System
The site receives sanitary sewer service from Soos Creek Water and
Sewer.
4. Stormwater System
A stormwater system will be necessary to accommodate any subsequent
development. The developer will be required to complete a drainage
analysis and develop and submit drainage plans prepared in accordance
with the 2002 City of Kent Surface Water Design Manual and the 1998
King County Surface Water Design Manual.
D CONSISTENCY ANALYSIS
The proposed rezone is consistent with the goals and policies of the City of Kent
Comprehensive Plan.
Ill. CONSULTED DEPARTMENTS AND AGENCIES
The following departments and agencies were advised of this application.
Police Department Economic Develop Manager
Director of Public Works Fire Chief
Parks & Recreation Director City Clerk
City Attorney Kent School District
U.S Post Master WA Dept of Ecology
Washington State DOT K. C Wastewater Treatment
Puget Sound Energy King Co. Environmental Health
Qwest King Co. Transit Division
Water District 111 Soos Creek Water& Sewer
In addition to the above, all persons owning property which lies within 300 feet of the site
were notified of the application and of the public hearing. A Notice of Application was
posted on the site and published in the King County Journal on April 1, 2004.
A comment letter was received on April 16, 2004 from James F. Garner, adjacent
property owner to the north Mr. Garner expressed concerns regarding the impacts of
future development of the site. Amending the City's zoning map is considered a non-
project action under the State Environmental Policy Act, and any subsequent
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development proposal for the property will require additional review in conjunction with
the project specific proposal.
Comments have been incorporated in the staff report where applicable.
IV. PLANNING SERVICES REVIEW
A. Comprehensive Plan
In 1995, the Kent City Council adopted the Kent Comprehensive Plan, which
represented a complete revision to the City's 1977 comprehensive plan. The
1995 plan was prepared under the provisions of the Washington State Growth
Management Act The Comprehensive Plan, through its goals and policies,
presents a clear expression of the City's vision of growth for citizens, the
development c ommunity, a nd o ther p ublic a gencies. T he p Ian i s u sed b y t he
Mayor, City Council, Land Use and Planning Board, Hearing Examiner, and City
departments to guide decisions on amendments to the City's zoning code and
other development regulations, which must be consistent with the plan, and also
guide decisions regarding the funding and location of capital improvement
projects.
LAND USE ELEMENT
The Land Use Element of the plan contains a Land Use Plan Map, which
designates the type and intensity of land uses throughout the city, as well as in
the entire potential annexation area. The Land Use Plan Map designates the
subject p roperty a s S F-6, S Ingle F amily R esidential w hich a(lows s ix u nits p er
acre. The land use element also contains goals and policies relating to the
location, density, and design of future development in the City and in the
Potential Annexation Area.
Overall Goal: Encourage a future growth and development pattern which
implements the community's vision, protects environmentally sensitive areas,
and enhances the quality of life of all of Kent's residents.
Goal LU-8: The City of Kent adopts a 20-year housing target of 7,500 new
dwelling units within the existing city limits. Coordinate with King County through
an interlocal agreement on housing targets in the unincorporated area within
Kent's Potential Annexation Area.
Policy LU-8.1: Provide in the land use plan adequate land and densities to
accommodate both city and county housing targets within the Potential
Annexation Area. Average net residential densities throughout the Potential
Annexation Area s hould be at least four u nits per acre i n order to adequately
support urban services
Policy LU-8.3: Located housing opportunities within close proximity to
employment, shopping, transit and human and community services.
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Goal LU-9: Provide opportunities for a variety of housing types, options, and
densities throughout the city and the Potential Annexation Area.
Policy LU-9.4: Allow single f amily housing on a variety of lot s izes, including
5,000 square foot lots. Locate smaller lot sizes within close proximity to the
urban activity centers.
Planning Services Comment-
The goals and policies of the land use element support the proposed rezone. The
proposed location is easily served by existing urban services and is in convenient
proximity to urban services along SE 24dh Street and Kent Kangley Road. Also,
the proposed rezone is consistent with the Land Use Plan Map which allows up
to six dwelling units per acre.
HOUSING ELEMENT
The primary goal of the housing element is to meet the current and future need
for housing in the Kent area.
Overall Goal: Ensure opportunities for affordable housing and an appropriate
living environment for Kent citizens.
Goal H-1. Promote healthy neighborhoods by providing a wide range of housing
options throughout the community that are accessible to community and human
services, employment opportunities, and transportation and by being sensitive to
the environmental impacts of development
Policy H-1.1: Ensure that community and human services, including, but not
limited to, fire, police, library facilities, medical services, neighborhood shopping,
child care, food banks, and recycling facilities are easily accessible to
neighborhood residents
Planning Services Comment
The proposed rezone is supported by relevant goals and policies of the housing
element. Appropriate services, including, but not limited to, fire, police, medical
services, neighborhood shopping and child care are easily accessible to
neighborhood residents upon development of the subject property
TRANSPORTATION ELEMENT
Goal TR-1: Coordinate land use and transportation planning to meet the
needs of the City and the requirements of the Growth Management Act.
Policy TR-1.2: Coordinate new commercial and residential development in Kent
with transportation projects to improve affected roadways
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Policy TR-1.5: Ensure consistency between land use and transportation plans so
that land use and adjacent transportation facilities are compatible.
Planning Services Comment:
The Growth Management Act requires consistency between land use and
transportation planning. As noted, the Land Use Plan identifies the area of the
rezone as SF 6 Single Family Residential. If developed in the future, the
property will access from the west through the approved Tahoma Vista
preliminary subdivision that accesses from 132"d Avenue SE. Road
improvements to 132d Avenue SE at this location and north to SE 2451h Street
were completed in 2002 in conjunction with the construction of the City of Kent
Wilson Ball Fields located at the southwest comer of 132"d Avenue SE and SE
248t" Street. This section of 132"d Avenue SE is improved with bike lanes,
cement concrete curbs and gutters, cement concrete sidewalks, a planter strip,
streetlights, and a left hand turn lane and on the west side of the street. A
southbound right lane was also installed between SE 248th Street and SE 253`d
Street. Additionally, SE 256th Street, an east/west minor arterial located within
one-third mile of the subject property, is improved to its full design standard
between 132"d Avenue SE and 116t"Avenue SE
B. Standards and Criteria for Granting a Request for Rezone
The following standards and criteria (Kent Zoning Code, Section 15.09 050) are
used by the Hearing Examiner and City Council to evaluate a request for a
rezone. Such an amendment shall only be granted if the City Council determines
that the request is consistent with these standards and criteria
1. The proposed rezone is consistent with the Comprehensive Plan,
Planning Services Comment
The Comprehensive Plan Land Use Plan Map designates the subject property as
SF 6, Single Family Residential which allows up to six units per acre A rezone
of the site from SR-4.5 Single Family Residential to SR-6 Single family
Residential will allow residential development up to six units per acre, which is
also allowed under the Comprehensive Plan. As previously mentioned, the
proposed rezone is also consistent with the applicable goals and policies of the
Comprehensive Plan.
2. The proposed rezone and subsequent development of the site would
be compatible with development in the vicinity.
Planning Services Comment
The proposed rezone and subsequent development of the site would be
compatible and integrate well with the existing development in the vicinity.
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Development in the immediate vicinity is a mix of platted subdivisions and
unplatted parcels of single family residences zoned SR-4.5, Single Family
Residential Adjacent property to the west was granted a rezone on July 1, 2003
from SR4.5 to SR-6 and received preliminary plat approval for a 19-lot
subdivision, the 30-lot Heather Glen Subdivision to located to the south, Meridian
Valley Country Club to the north, and Country Club North and Country Club
North Division 2 subdivisions totaling 52 lots are located to the east
3. The proposed rezone will not unduly burden the transportation
system in the vicinity of the property with significant adverse
impacts which cannot be mitigated.
Planning Seances Comment
A rezone of this property to SR-6 Single Family Residential will not generate
additional trips onto the existing transportation system. However, future
development of a subdivision will add trips to the local street system. Upon
future development of the site, road and street frontage improvements to meet
the City of Kent roadway standards will be required as conditions of approval.
These improvements include but are not limited to curb, gutter, sidewalks,
planting strips, street lighting, paving, necessary street improvements, and public
stormwater conveyance. The applicant will be required to participate in other
City transportation improvement projects by providing an environmental
mitigation fee for the impacts created by future development.
4. Circumstances have changed substantially since the establishment
of the current zoning district to warrant the proposed rezone.
Planning Services Comment
The subject parcel was annexed to the City of Kent on July 1, 1997 and is vacant
and undeveloped.
In 1995 the City of Kent adopted its Comprehensive Plan which designated this
area as SF-6 Single Family Residential. Along with the Land Use Plan Map and
Policies, the plan also contains a target for the number of new households the
City must accommodate for the 20-year time horizon of the plan The GMA also
states the City's development regulations must implement, and be consistent
with the Comprehensive Plan. Higher density single family development with
smaller lot sizes while recognizing significant environmental features is
consistent with the goals and policies of the Comprehensive Plan.
Upon annexation in 1997, zoning for the area was set at SR-4.5 which was
consistent with existing land use patterns and represented what was actually built
at that time. Since that time significant improvements to roadway infrastructure
in the immediate area were completed. Improvements to SE 240`h Street,
approximately three-fourths of a mile north of the site, were completed in 1999;
improvements to SE 25e Street, approximately one-third mile south of the
A Page 7 of 10
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project site, were completed in 2002; and improvements to 132nd Avenue SE, as
noted elsewhere in this report, were completed in 2002 All three of the above
referenced roadways are classified as minor arterials and provide access to the
subject project site. In addition, in July 2003 the Kent City Council granted a
rezone request from SR-4.5 to SR-6 for two adjacent parcels to the west totaling
4 84 acres.
5. The proposed rezone will not adversely affect the health, safety and
general welfare of the citizens of the City of Kent.
Planning Services Comment
The proposed rezone is consistent with the intent of the Comprehensive Plan
Subsequent development on the site will be required to meet applicable codes
and regulations, including mitigation of anticipated environmental impacts.
Therefore, the rezone proposal will not adversely affect the health, safety and
general welfare of the citizens of the City of Kent.
V. CITY STAFF RECOMMENDATION t
Upon review of the merits of this request and the Code criteria for granting a rezone, the
City staff recommends APPROVAL without conditions of the Ruth Wiren rezone
KENT PLANNING SERVICES
June 9, 2004
S\Permit\Plan\rezone\2004\2040659-2004-ireport.doc
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APPLICATION NAME: RUTH WIREN REZONE
REQUEST: #RZ-2004-1
SITE MAP
i
t
a. Application received March 5, 2004
b. Correspondence
i. Letter from Sharon Clamp to
Ivana Halvorsen dated April 30, 2004 (1
page)
ii. Letter from Sharon Clamp to Aaron Meilleur
dated June 25, 2002 (1 page)
iii. Letter from Garet Munger to Dick Gilroy
dated January 31, 2002 (9 pages)
iv. Letter from James Garner to Sharon Clamp
dated April 15, 2004 (7 pages)
v. Boundary line adjustment L93L0041, dated
April 12, 1003 (2 pages)
vi. Copy of Easement, dated received May 10,
2004 (2 pages)
c. City Routing
d. Public Notice
e. Notice of Application and Notice of Complete
Application
f. SEPA Determination of Nonsignificance and
Environmental Checklist issued May 14,
2 Detailed Site Plan
3. Tahoma Vista Plat Site Plan
Upon consideration of the testimony and exhibits submitted at the open record hearing,
the Hearings Examiner enters the following Findings, Conclusions and Decision:
FINDINGS
2. The Applicant requests a zoning map amendment to change the zoning on a
3.97-acre parcel of property from Single-Family Residential (SR-4.5) to Single-
Family Residential (SR-6) The subject property is located northwest corner of
136th Avenue SE and SE 253rd Street.' Exhibit 1, Staff Report, page 1; Exhibit
1, Attachment a, Application.
3. The property is part of 891 acres annexed to the City of Kent on July 1, 1997
under ordinance 3344. It is undeveloped and vegetated with trees and grass
cover. The site slopes approximately six percent to the west. Land to the east,
north, and south of the subject property is zoned SR-4.5, while the property to
the west is SR-6. Exhibit 1, Staff Report, page 2.
' The subject property is known as tax parcel number 2222059148 Exhibit 1, Staff Report,page 1
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Ruth Wiren Rezone
RZ 2004-1 KlVA RPP4-2040659
Page 2 of 8
4. The purpose of single-family residential zoning districts is to stabilize and
preserve single-family residential neighborhoods, as designated in the
comprehensive plan. The single-family zoning districts in Kent also encourage a
range of densities and lot sizes in order to promote diversity and recognize a
variety of residential environments. KCC 15.03.010.
5. The subject property is situated east of the approved five-acre Tahoma Vista
subdivision. T ahoma Vista will contain 19 residential lots. It will take a ccess
from 132nd Avenue SE. The owner of Tahoma Vista confirmed that the public
road to serve that plat will stub out at the boundary of the Wiren property Sewer
and water will also be installed up to the boundary of the Wiren property, as well
as to the property to the south. Testimony of Ms. Gill-More; Testimony of
Mr. Gill-More.
6. The City of Kent Comprehensive Plan designates the subject property as Single-
Family Residential (SF-6), which allows six units per acre. The proposed rezone
would amend the zoning district designation to SR-6. The rezone would increase
the total number of possible lots in any future development on the subject
property from 18 to 24, for a maximum possible increase of six lots. However, it
is to be noted that the maximum possible number of lots would be limited by any
on-site critical areas or on-site buffers of off-site critical areas and all other
development regulations including yard setbacks, etc.. For example, Tahoma
Vista, zoned SR-6 and totaling five acres, was only allowed 19 lots. Exhibit 1,
Staff Report, page 2; Testimony of Ms. Halvorsen.
i 7. The Comprehensive Plan contains goals and policies that relate to the location,
density, and design of future development. Applicable goals and policies of the
Comprehensive Plan include:
• Provide in the land use plan adequate land and densities to accommodate
both city and county housing targets within the Potential Annexation Area.
Average net residential densities throughout the Potential Annexation
Areas should be a least four units per acre in order to adequately support
urban services. City of Kent Comprehensive Plan, Polcy LU 8.1
• Locate housing opportunities within close proximity to employment,
shopping, transit and human and community services. City of Kent
Comprehensive Plan, Policy L U-8.3.
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Ruth Wiren Rezone
RZ 2004-1 KIVA RPP4-2040659
Page 3 of 8
• Provide opportunities for a variety of housing types, options, and densities
throughout the city and the Potential Annexation Area. City of Kent
Comprehensive Plan, Land Use Goal L U-9.
• Allow single family housing on a variety of lot sizes, including 5,000
square foot lots. Locate smaller lot sizes within close proximity to the i
urban activity centers. City of Kent Comprehensive Plan, Policy LU-9.4.
• Promote healthy neighborhoods by providing a wide range of housing
options throughout the community that are accessible to community and
human services, employment opportunities, and transportation and by
being sensitive to the environmental impacts of the development. City of
Kent Comprehensive Plan, Goal H-1.
• Ensure that community and human services, including, but not limited to,
fire, police, library facilities, medical services, neighborhood shopping,
child care, food banks, and recycling facilities are easily accessible to
neighborhood residents. City of Kent Comprehensive Plan, Policy H-1.1.
• Protect and enhance environmentally sensitive areas via the adoption of
the City regulations and programs which encourage well-designed land
use patterns such as clustering and planned unit development. Use such
land use patterns to concentrate higher urban land use densities and
intensity of uses in specified areas in order to preserve natural features
such as large wetlands, streams, steep slopes, and forests. City of Kent
Comprehensive Plan, Goal LU-20.
• Ensure that the City's environmental policies and regulation comply with
state and federal environmental protection regulations regarding air and
water quality, noise and wildlife and fisheries resources and habitat
protection. Demonstrate support for environmental quality in land use
plans, development regulations, and site plan review to ensure that local
land use management is consistent with the City's overall natural resource
goals. City of Kent Comprehensive Plan Goal LU-22.
• Coordinate land use and transportation planning to meet the needs of the
City and the requirements of the Growth Management Act. City of Kent
Comprehensive Plan, Goal TR-1.
• Coordinate new commercial and residential development in Kent with
transportation projects to improve affected roadways. City of Kent
Comprehensive Plan, Policy TR-1.2
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Ruth Wiren Rezone
RZ 2004-1 KIVA RPP4-2040659
Page 4 of 8
i
• Ensure consistency between land use and transportation plans so that
land use and adjacent transportation facilities are compatible. City of Kent
Comprehensive Plan, Policy TR-1.5.
8. If the site is developed, potable water would be provided by connection to Water
District 111. The site would receive sanitary sewer service from Soos Creek
Water and Sewer. Certificates of water and sewer availability are contained in
the application materials. Exhibit 1, Staff Report, page 3; Exhibit 1, Attachment
a, Application.
9. While the property is located at the intersection of 136th Avenue SE and SE 253rd
Street, access to any future development is not available from this intersection
due to the location of the corner of the property relative to the existing rights-of-
way for those two streets. If future development were to be proposed, access
would be from the west through the approved subdivision of Tahoma Vista (SU
2001-6)which takes its primary access via 132"d Avenue SE. From the Tahoma
Vista plat entrance north to SE 245th Street, 132"d Avenue SE was improved in
2002 with bike lanes, curbs and gutters, sidewalks, planter strips, lighting, and a
left hand turn lane in conjunction with the City of Kent Wilson Ball Fields. Future
development of the subject property would be required to comply with City of
Kent roads and transportation development standards and would be subject to
environmental review. Exhibit 1, Staff Report, pages 2-3 & 6; Testimony of
Ms. Clamp.
10. Neighboring property owners expressed a concern about whether wetlands might
exist in the southwest corner of the site. There are two wetlands on the adjacent
Tahoma Vista plat. Exhibit 3. There may have at one time been a wetland in the
southwest corner of the subject property, potentially associated with the wetland
in the southeast comer of Tahoma Vista. The subject property acts as a water
recharge area for private wells on adjacent properties and contains large cedar
trees. Testimony of Mr. Garner; Testimony of Mr. Smith. Because no
development is currently proposed for this site, a wetlands delineation has not
been performed. Approval of any future development should be conditioned to
ensure that appropriate wetland delineation reports are submitted and reviewed
prior to construction on the subject property.
11. The City of Kent, acting as lead agency for environmental review of the proposed
non-project rezone, issued a Determination of Non-Significance on May 14,
2004. No appeal was filed. Exhibit 1,Attachment f, SEPA DNS.
12. The City provided reasonable notice to the public of the application for rezone by
hearing by posting notice on the subject property and publishing notice in the
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Ruth Wiren Rezone
RZ 2004-1 KIVA RPP4-2040659
Page 5 of 8
King County Journal on April 1, 2004, and by mailing notice of the public hearing
to property owners within 300 feet on June 4, 2004. Exhibit 1, Attachment d,
Public Notice.
13. The City received a public comment letter from adjacent landowner James F.
Garner, who expressed concerns regarding impacts potentially resulting from
future development of the site, which is located directly south of his property.
Public comment at the hearing included expression of concerns regarding a
potential wetland in the southwest corner of the subject property, the potential
impacts of new development on adjacent private wells, traffic impacts on what
neighbors characterized as congested roads, and opposition to the possibility of
access via the existing dirt road running north/south adjacent to the subject
property's eastern boundary. Exhibit 1, Staff Report, pages 3-4; Testimony of
Mr. Gamer, Testimony of Mr. Smith.
14. Public comment concerns did not pertain to the rezone, but rather to any future
development of the site. The concerns expressed by neighboring property
owners would be addressed at the time of future development. Approval of any
future development of the subject property should be conditioned to protect
neighboring private water supplies. This can be done by requiring the future
developer to stub water and sewer to the properties adjacent to the east and
south. Concerns regarding wetlands, water supply and recharge, traffic impacts,
and adequacy of access would all be addressed in the environmental review of
any proposed development of the subject property. Any future development
would have to comply w ith all development regulations in the Kent City C ode.
Testimony of Ms. Clamp; Testimony of Mr. Gill.
CONCLUSIONS
Jurisdiction
The Hearing Examiner has jurisdiction to hold an open record hearing on this rezone
request, and to issue a written recommendation to the Council, pursuant to RCW
35A.63.170, and Chapter 2.32 and Section 15.09.050 of the Kent City Code.
Criteria for Review
Section 15.09.050(C) of the Kent zoning code sets forth the standards and criteria the
Hearing Examiner must use to evaluate a request for a rezone. A request for a rezone
shall only be granted if.
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Ruth Wiren Rezone
RZ 2004-1 KIVA RPP4-2040659
Page 6 of 8
a. The proposed rezone is consistent with the Comprehensive Plan;
b. The proposed rezone and subsequent development of the site would be
compatible with development in the vicinity;
C. The proposed rezone will not unduly burden the transportation system in the
vicinity of the property with significant adverse impacts which cannot be
mitigated;
d. Circumstances have changed substantially since the establishment of the current
zoning district to warrant the proposed rezone; [and]
Ie. The proposed rezone will not adversely affect the health, safety, and general
welfare of the citizens of the city.
KCC 15.09.050(F)(1).
Conclusions Based on Findings
1. The proposed rezone is consistent with the Kent Comprehensive Plan. The
proposed rezone is consistent with the Comprehensive Plan's designation for the
subject property as SF-6. In addition, the rezone would be consistent with
several policies and goals of the Comprehensive Plan. It would allow additional
density to accommodate City population targets in an area that is close to
commercial use, human services and employment opportunities It would allow
single-family housing on a variety of lot sizes, which would be within close
proximity to urban activity centers. Findings of Fact Nos. 5 and 6
2. The proposed rezone and subsequent development of the site would be
compatible with development in the vicinity. Development within the vicinity
includes residential uses in SR-4.5 and SR-6 zones. The rezone and proposed
development would be consistent and compatible with this existing development.
A condition of approval on any future development of the subject property would
be necessary to ensure that appropriate protection is afforded to private wells on
adjacent properties. This condition could require current hydrologic studies of
the site and might require the developer of the subject property to stub sewer and
water utilities to the east and south boundaries of the site. Findings of Fact Nos.
2, 3, 4, 8, 9, 12, and 13.
3. The proposed rezone will not unduly burden the transportation system in
the vicinity of the property with significant adverse impacts which cannot
be mitigated. Access to any development proposed on the subject property
would connect to the public road constructed in the adjacent Tahoma Vista
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Ruth Wiren Rezone
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Page 7 of 8
subdivision. Tahoma Vista takes primary access via 1 32nd Avenue SE, which
has been improved with bike lanes, curbs and gutters, sidewalks, planter strips,
lighting, and a left hand turn lane. Conditions of approval and environmental
review of any future development on-site would address potential traffic impacts
and ensure that roads in the vicinity satisfy City standards. Finding of Fact No. 8.
4. Circumstances have changed substantially since the establishment of the j
current zoning district to warrant the proposed rezone. Since the City
annexed the subject property in 1997, the area has experienced an increased
density of housing. The proposed rezone would allow residential development at
a density consistent with other property in the area. In addition, the approval of
the adjacent subdivision of Tahoma Vista provides convenient access and
utilities connections to the subject property. Findings of Fact Nos. 2, 4, and 8.
5. The proposed rezone will not adversely affect the health, safety, and
general welfare of the citizens of the City of Kent. Although the proposed
rezone could result in higher density development, there are services in place to
accommodate the growth. Water a nd sewer are available f rom W ater District
#111 and Soos Creek Water and Sewer. A condition of approval on any future
development of the subject property would be necessary requiring accurate and
up to date wetland delineation reports to ensure that critical areas are
appropriately protected. Findings of Fact Nos. 4, 7, 8, 9, 10, 12, and 13.
RECOMMENDATION
Based upon the preceding Findings and Conclusions, the Hearing Examiner
recommends that this application for the rezone from Single Family Residential (SR-4 5)
to Single-Family Residential (SR-6) on approximately 3.97 acres of property located the
northwest corner of 136th Avenue SE and SE 253rd Street in Kent, Washington be
APPROVED. It is the Hearing Examiner's opinion that the rezone request, as
proposed, meets the criteria for approval established by the Council. The Hearing
Examiner further recommends that any future development of the subject property be
conditioned as described herein to protect adjacent properties from potential adverse
impacts associated with development.
Dated this 30d' day of June, 2004.
THEODORE PAUL HUNTER
Hearing Examiner
ch S•\Permit\Plan\rezone\2004\2040659-2004-1findmgs.doc
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Hearing Examiner for City of Kent
Ruth Wiren Rezone
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Kent City Council Meeting
Date July 20, 2004
Category Other Business
1. SUBJECT: KENTARA REZONE
2. SUMMARY STATEMENT: This request by Ken Peckham is to rezone 6.4 acres
of property from SR-4.5, Single Family Residential, to SR-6, Single Family Residential.
The property is located south of the intersection of 104`h Avenue SE and SE 272°d
Street. The Kent Hearing Examiner held a Public Hearing on June 9, 2004, and issued
Findings, Conclusions and a recommendation for approval on June 23, 2004.
3. EXHIBITS: Staff report with map & Hearing Examiner Findings, Conclusions and
Recommendation
4. RECOMMENDED BY: Hearing Examiner
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? No Revenue? No
Currently in the Budget? Yes No
If no:
Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
^^
Councilmember I a"x moves, Councilmember _Wk/ ," seconds
to accept/rojoeeniedify-the Findings, Conclusions and Recommendation of the Hearing
Examiner on the Kentara Rezone and to direct the City Attorney to prepare the
necessary ordinance.
DISCUSSION: N°
ACTION:
Council Agenda
Item No. 7B
COMMUNITY DEVELOPMENT
Fred N. Satterstrom, Director
PLANNING SERVICES
Charlene Anderson,AICP, Manager
KENT Phone 253-856-5454
WASHINGTON
Fax 253-856-6454
Address 220 Fourth Avenue S
Kent,WA 98032-5895
KENT PLANNING SERVICES
(206) 856-5454
STAFF REPORT
FOR HEARING EXAMINER MEETING OF
June 9, 2004
FILE NO: KENTARA
#RZ-2003-1 KIVA#2030262
#SU-2002-7 KIVA#2030261
APPLICANT Mr Ken Peckham
Schneider Homes, Inc
6510 Southcenter Blvd.
Tukwila, WA 98188
■ REQUEST. A request to subdivide, and rezone a portion of, an
11.6 acre site The applicant is requesting
preliminary plat approval to create 41 single family
lots based on a zoning change from SR-4 5 to SR-6
on the western 6.4 acre portion of the site
STAFF
REPRESENTATIVE: Matt Gilbert, Planner
STAFF
RECOMMENDATION: Rezone: APPROVAL
Subdivision: APPROVAL, with conditions
I. GENERAL INFORMATION
A Description of the Proposal
The applicant proposes to subdivide four existing parcels, or portions
thereof, totaling approximately 11.6 acres into 41 single family residential
lots. There are two single-family residences, a duplex building and
associated accessory buildings currently located on the site Of these
Staff Report
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buildings, only the single family home located in the southwest corner of
the site will be retained. Substantial areas of slopes over 40% are
located on the western portion of the subject site, which will not be
developed. Three residential roads constructed to City of Kent
standards, will be required to serve this plat. Approval of this application
will produce 38 new building lots, as well as six tracts for sensitive areas,
stormwater detention, access and utilities.
In conjunction with the request for preliminary subdivision approval, the
applicant proposes to rezone the approximately 6.4 acre western parcel ■
from the current zoning of SR-4.5, Single Family Residential to SR-6, j
Single Family Residential.
B. Location
The subject site is located south of the intersection of 104th Avenue SE
and SE 272"d Street in Kent.
C. Size of Property
The subject site consists of four parcels, or portions thereof, totaling
approximately 11 6 acres. Parcels include: 322205-9049, 322205-9022,
a portion of 322205-9192 and a portion of 322205-9190. The remaining
portions of parcels -9190 and -9192 are owned by the City of Kent and
are generally part of the S 272/S 277th Street Corridor.
D. Zoning
Three zoning districts are represented on the subject site. Parcels
3222059192 and 3222059022, located to the east are zoned SR-6,
Single Family Residential. Parcel 322205-9049, the western parcel which
is proposed for rezone, is currently zoned SR-4.5, Single Family
Residential. A portion of parcel 322059190, located in the southern
portion of the site, is zoned SR-1. This area is contained within proposed
lot 21 as shown on the submitted preliminary plat map. With the
exception of proposed lot 21, which is designed to meet the development
standards of the SR-1 zoning district, all lots in the proposed subdivision
are designed to meet SR-6 standards.
Properties to the north of the site are zoned SR 4.5 and SR-6. The
property to the east of the subject site is zoned SR-6. Properties located
to the south and west are SR-1 and SR-2.
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E. Land Use
With the exception of the smaller southern piece contained within
proposed lot 21, the City of Kent Comprehensive Land Use Map
designates the site as SF-6 Single Family Residential, 6 Units per acre.
The portion of this site within lot 21 is designated SF-1 Single Family
Residential. Existing development in the vicinity of the site consists of
generally low to medium density single family residential uses. The
existing home on proposed lot 20 will be retained.
1 The subject site is located north of, and adjacent to the South
272nd/South 277"' Street corridor. Land to the north is developed with
single family homes on generally large lots. A twenty lot subdivision
known as Autumn Glen has recently been developed directly east of the
subject site.
tF. Histo
The subject property was annexed to the City of Kent on June 27, 1994
as part of the 594 acre Ramstead annexation (Ordinance No. 3171).
In 1996, the Kent City Council adopted ordinance 3331 which changed
the Comprehensive Plan designation of the western parcel (3222059049)
from Single Family Residential-1 to Single Family Residential-6. The
associated zoning ordinance, number 3332 changed the zoning
designation from Single Family (SR-1) to Single Family (SR-4.5).
Il. ENVIRONMENTAL CONSIDERATIONS
A. Environmental Assessment
The applicant's SEPA application requested both a non-project analysis
(rezone) and project-specific (subdivision) analysis. A Mitigated
Determination of Nonsignificance (#ENV-2003-2) for the non-project
rezone proposal as well as a project-specific proposal for a 40 lot
subdivision was issued on April 21, 2003. No conditions were proposed
for the rezone portion of the SEPA application.
The proposed project portion of the checklist contemplates a 40-lot
subdivision. On-site environmental impacts associated with the proposed
project specific development have been analyzed and conditioned in the
above referenced determination. The project specific proposal is
dependent upon the outcome of the rezone application.
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The project portion of the submitted environmental checklist f
contemplated the impacts of a 40 lot subdivision. However, the applicant
has amended his plans and is proposing 41 lots through this subdivision
application. This change impacts only the transportation section of the
SEPA analysis for this proposal. Condition #1 of the April 16, 2004
MDNS gives the applicant the option of identifying and constructing
appropriate traffic mitigation measures, or paying a fee in lieu of these
improvements based on the new PM Peak Hour Trips generated by the
proposed development, identified in the SEPA analysis as 38. Based on
the two existing homes recognized on the subject site, the applicant
received credit for two existing PM Peak Hour trips. Although the
proposal has added one lot to the subdivision, condition #1 of the
April 16, 2004 MDNS remains effective in requiring mitigation for the
traffic impacts associated with 41 lots, as the final mitigation measures or
fees are based upon actual new lots created, minus two for the existing
homes.
B. Significant Physical Features
Topography, Wetlands and Vegetation
The project has significant areas of slopes that are 40% or greater on the
westerly portion of the project site. These slopes are classified in the Kent
Zoning Code as Severe Hazard Areas. No development is proposed in
this area. The remainder of the site slopes to the northeast at
approximately 5%. No wetlands are located on the subject site.
A wide range of vegetation exists on the subject site. Deciduous and
evergreen trees, shrubs and grasses have all been identified in various
plant communities. The applicant has indicated that approximately 38%
of t he s ite w ill b e c feared for road, u tility a nd h ome c onstruction. T he
applicant will submit a survey of significant on-site trees and, as part of
civil construction plan review, will be required to submit and receive
approval of a detailed tree plan that shows trees to be retained.
Vegetation located within the protected steep slope area will not be
disturbed as part of this proposal.
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C. Significant Social Features
1. Street System
The proposed development project is located within the Ramsted
Annexation area of the City and will take its primary access from
104th Avenue S E. This street has a n existing r ight-of-way of 60-
feet, while the existing portion of the street has an asphalt width of
about 20-feet to 24-feet. The existing portion of the street provides
for two lanes of traffic, but none of the following improvements:
cement concrete curbs & gutters; a stormwater drainage system;
cement concrete sidewalks; or a street lighting system. The
existing asphalt pavement section of this portion of the street is
inadequate to provide an expected 20-year service life and may be
in need of an asphalt overlay/rebuild in order to maintain an
acceptable level of service while accommodating the increased
volume of trips being generated by this proposal
This subdivision will have frontage along SE 272"d Street This
street has an existing public right-of-way width of about 60-feet,
while the asphalt street width is currently about 20 to 22-feet wide.
The existing street provides for two lanes of traffic, but none of the
following other improvements: cement concrete curbs & gutters; a
stormwater drainage system; cement concrete sidewalks; or a
street lighting system. The existing asphalt pavement section of
this portion of the street is inadequate to provide an expected 20-
year service life and may be in need of an asphalt overlay/rebuild
in order to maintain an acceptable level of service while
accommodating the increased volume of trips being generated by
this proposal.
While 104th Avenue SE north of the intersection with SE 272"d
Street is classified as a Residential Collector Street Augmented
with Bike Lanes on the City's Master Plan of Roadways, the
extension of this street south of SE 272"d Street will be classified
as a Residential Street A Residential Street requires a minimum of
50-feet of right-of-way; a 28-foot wide asphalt roadway including
two traffic lanes; vertical cement concrete curbs & gutters, 5-foot
wide planter strips and 5-foot wide cement concrete sidewalks on
both sides of the street; a stormwater drainage system; a City-
approved street lighting system; public utilities, and other street
appurtenances when fully improved.
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Southeast 272"d Street is classified as a Residential Collector
Street Augmented with Bike Lanes on the City's Master Plan of
Roadways, which will require: a minimum of 70-feet of public right-
of-way; a 44-foot wide asphalt roadway including two 17-foot wide
traffic lanes and two 5-foot wide in-street bike lanes; vertical
cement concrete curbs & gutters, 5-foot wide planting strips and 5-
foot wide cement concrete sidewalks on both sides of the street; a
stormwater drainage system; a City-approved street lighting
system; public utilities, and other street appurtenances when fully
improved.
As stated in the SEPA decision document, this development will
cause significant and/or additional congestion at the intersections
of 104th and SE 272"d 108th and SE 272"d 108t' and SE 2691"
Court and 108th and SE 277th. The intersection of SE 272"d Street
and 108th Avenue SE, located approximately 1200 feet east of
Kentara, does not meet current City sight distance guidelines for
eastbound vehicles traveling on SE 272nd Street entering the
intersection, and for northbound to westbound vehicles on 108th
Avenue SE. The issue of additional impacts created at this sub-
standard intersection by the proposed subdivision was addressed
through condition # 4 of the April 16, 2004 MDNS, which required
payment to the City of a pro-rated share of the cost to remedy the
sight distance issues at this intersection. As conditions of approval
of the proposed subdivision, other street improvements also will be
required.
This Proposed Kentara subdivision abuts the Preliminary Plat of
Autumn Glen, and the street system from Kentara will be required
to match the street system of the Autumn Glen Subdivision at their
common property line. There is also an opportunity to construct a
single stormwater management system and street lighting system
that will serve both subdivisions, and otherwise provide an
economy of scale for both.
This development is within an area which is characterized by
streets with narrow traffic lanes and narrow or no shoulders, and
the area has been identified as having substandard pedestrian
facilities. This development will require off-site sidewalks /
walkways to provide safe travel for school-age pedestrians to and
from Meadow Ridge Elementary School, which is located
approximately one-half mile southeast of the subject site.
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2. Water System
The site is located within the City of Kent water service area. A
12-inch water main is currently located under SE 272"d Street and
is available to serve the site.
3. Sanitary Sewer System
The site is located within the City of Kent sanitary sewer service
area. An existing sanitary sewer main is located within SE 272nd
Street and will be extended prior to or in conjunction with future
development of the site.
4. Stormwater System
A stormwater system will be necessary to accommodate any
subsequent development. The developer will be required to
complete a drainage analysis then develop and submit drainage
plans prepared in accordance with the 2002 City of Kent surface
Water design Manual and the 1998 King County Surface Water
Design Manual.
III. CONSULTED DEPARTMENTS AND AGENCIES
The following departments and agencies were advised of these applications:
Chief Administrative Officer Police Department
Director of Public Works Fire Chief
Parks & Recreation Director City Clerk
City Attorney Kent School District
U.S. Post Master WA State Dept. of Ecology
Washington State DOT K. C. Wastewater Treatment
Puget Sound Energy King Co. Environmental Health
Qwest King Co. Transit Division
In addition to the above, all persons owning property located within 300 feet of
the site were notified of the application and of the public hearing.
One public comment letter was received regarding these applications. In a letter
dated April 30, 2004, Walter and Cheryl Johnsen of 27412 Green River Road
express their concerns regarding additional storm water runoff onto their
property that may be created by lots located in the northwest part of the
�j proposed development, associated with the steep slopes. The Johnsen's
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property is located to the west of, and approximately 300 feet downhill from
Kentara.
The Johnsen's concern is addressed in part, through condition #2 of the
April 16, 2004 MDNS, which restricts development in and around the hazardous
slope area referenced in their letter. As discussed in the condition, the purpose
of limiting development on and around this hillside area is in part to minimize
stormwater runoff created by rooftops, driveways, roads, etc. that may impact
surrounding properties. Stormwater impacts created by the proposed
development will further be addressed through construction of a City approved
stormwater management system as described on page 22 of this report.
Comments received from the above listed agencies and departments have been ■'
incorporated in the staff report where applicable.
IV. PLANNING SERVICES REVIEW
A. Comprehensive Plan
In 1995, the Kent City Council adopted the Kent Comprehensive Plan
(Ordinance #3222 — April 18, 1995), which represented a complete
revision to the City's 1977 comprehensive plan. The 1995 plan was
prepared under the provisions of the Washington State Growth
Management Act. The Comprehensive Plan, through its goals and
policies, presents a clear expression of the City's vision of growth for
citizens, the development community, and other public agencies. The
plan is used by the Mayor, City Council, Land Use and Planning Board,
Hearing Examiner, and City departments to guide decisions on
amendments to the City's zoning code and other development
regulations, which must be consistent with the plan, and also guide
decisions regarding the funding and location of capital improvement
projects.
The City of Kent Comprehensive Plan is comprised of eleven elements
which contain written goals and policies as well as a land use map. The
proposed subdivision supports several goals and policies in the Land Use
element, most notably goals LU-1, LU-8 and LU-9 and policies LU 1.1,
LU 8.1 and LU 9.4 related to accommodating growth and providing a
variety of single family lot sizes. The proposed plat is located near
existing urban services and infrastructure. The City supports the
development of close-in vacant or underdeveloped properties which limits
further urban sprawl on the edges of the planning area. In addition, in-fill
development provides a more efficient means of providing services and
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enhancing pedestrian mobility. The proposed Kentara preliminary plat
provides an acceptable level of net density (approximately 6.4 units per
acre, depending on the final number of lots approved) to support urban
services. Furthermore, one of the objectives of the Comprehensive Plan
is to provide a wide variety of housing types and opportunities to
accommodate projected population growth (Goal H-2 of the Housing
Element). Development of single family subdivisions on underdeveloped,
single family zoned land is consistent with this objective.
LAND USE ELEMENT
The Land Use Element of the plan contains a Land Use Plan Map, which
designates the type and intensity of land uses throughout the city, as well
as in the entire potential annexation area Except for the area contained
within proposed lot 21 that is designated as SF-1, the Land Use Plan
Map designates the subject property as SF-6, Single Family Residential
which allows six units per acre. In addition to the Land Use Plan Map,
the Land Use Element also contains goals and policies relating to the
location, density, and design of future development in the City and in the
Potential Annexation Area.
Overall Goal: Encourage a future growth and development pattern
which implements the community's vision, protects environmentally
sensitive areas, and enhances the quality of life of all of Kent's residents.
Policy LU-8.1: Provide in the land use plan adequate land and densities
to accommodate both city and county housing targets within the Potential
Annexation Area. Average net residential densities throughout the
Potential Annexation Area should be at least four units per acre in order
to adequately support urban services.
Policy LU-8.3. Locate housing opportunities within close proximity to
employment, shopping, transit and human and community services.
Goal LU-9: Provide opportunities for a variety of housing types, options,
and densities throughout the city and the Potential Annexation Area.
Policy LU-9.4: Allow single family housing on a variety of lot sizes,
including 5,000 square foot lots. Locate smaller lot sizes within close
proximity to the urban activity centers.
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Planning Services Comment:
The proposed rezone and subdivision are supported by relevant goals
and policies contained within the Land Use Element of the
Comprehensive Plan. The development proposed through this
subdivision request seeks to establish residential lots at a net density of
approximately 6.4 units per acre, which is sufficient to support urban
services. The proposed location is easily served by existing urban
services and is in convenient proximity to commercial areas along 104`�'
Avenue SE. Also, the proposed rezone is consistent with the Land Use
Plan Map, which allows up to six dwelling units per acre on the proposed
rezone parcel.
HOUSING ELEMENT
The primary goal of the housing element is to meet the current and future
need for housing in the Kent area.
Overall Goal: Ensure opportunities for affordable housing and an
appropriate living environment for Kent citizens.
Goal H-1: Promote healthy neighborhoods by providing a wide range of
housing options throughout the community that are accessible to
community and human services, employment opportunities, and
transportation and by being sensitive to the environmental impacts of
development.
Policy H-1.1: Ensure that community and human services, including, but
not limited to, fire, police, library facilities, medical services, neighborhood
shopping, child care, food banks, and recycling facilities are easily
accessible to neighborhood residents.
Planninca Services Comment
The proposed rezone and subdivision are supported by relevant goals
and policies contained within the Housing Element of the Comprehensive
Plan. Appropriate services, including, but not limited to, fire, police,
medical services and neighborhood shopping are easily accessible to
neighborhood residents upon development of the subject property.
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NATURAL RESOURCES GOALS AND POLICIES:
Goal LU-20: Protect and enhance environmentally sensitive areas via
the adoption of the City regulations and programs which
encourage well-designed land use patterns such as
clustering and planned unit development. Use such land
use patterns to concentrate higher urban land use densities
and intensity of uses in specified areas in order to preserve
natural features such as large wetlands, streams, steep
slopes, and forests.
Goal LU-22: Ensure that the City's environmental policies and
regulations comply with state and federal environmental
protection regulations regarding air and water quality, noise
and wildlife and fisheries resources and habitat protection.
r� Demonstrate support for environmental quality in land use
�j plans, development regulations, and site plan review to
ensure that I ocal I and u se management i s consistent w ith
the City's overall natural resource goals.
Planning Services Comment:
The proposed rezone and subdivision are supported by relevant goals
and policies contained within the Natural Resources Section of the
Comprehensive Plan. The western portion of the property is encumbered
by significant areas of hazardous slopes. Any subsequent development
on the property will be subject to the requirements outlined in Chapters
15.08 of the Kent City Code. Future development of the site will include
slope buffer areas which preserve the natural features of the site and
protect environmentally sensitive areas.
TRANSPORTATION ELEMENT:
Goal TR-1: Coordinate land use and transportation planning to meet
the needs of the City and the requirements of the Growth
Management Act.
Policy TR-1.2: Coordinate new commercial and residential development
in Kent with transportation projects to improve affected
roadways.
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Policy TR-1.5: Ensure consistency between land use and transportation
plans so that land use and adjacent transportation
facilities are compatible.
Planninci Services Comment:
The Growth Management Act requires consistency between land use and
transportation planning. As noted, the Land Use Plan identifies the area
of the rezone as SF-6 Single Family Residential. The Public Works
Department has identified improvements to the local transportation
network necessary to accommodate the proposed higher density These
improvements will be required through the conditions of approval
proposed for this subdivision.
B. Standards For Granting A Subdivision
The purpose of the City of Kent Subdivision Code is to provide rules,
regulations, requirements, standards and procedures for subdividing land
in the City of Kent, ensuring that the highest feasible quality in
subdivisions will be attained; that the public health, safety, general
welfare, and aesthetics of the City of Kent shall be promoted and
protected; that orderly growth, development, and the conservation,
protection and proper use of land shall be promoted; that proper
provisions for all public facilities, including connectivity, circulation,
utilities, and services shall be made; that maximum advantage of site
characteristics shall be taken into consideration; and that the process
shall be in conformance with provisions set forth in the City of Kent
Zoning Code and Kent Comprehensive Plan (KCC 12.04.015).
The procedures regulating subdivisions are established to ensure quality
development which promotes orderly and efficient growth, the
conservation and proper use of land; protects the public health, safety,
general welfare, and aesthetics of the city; makes adequate provisions for
public facilities in conformance with provisions set forth in KCC Title 15,
Zoning, and the Kent Comprehensive Plan; and complies with the
provisions of this chapter and Chapter 58.17 RCW (KCC 12.04.600).
No subdivision shall be approved unless the following principles of
acceptability are met; the subdivision shall:
1. Create legal building sites which comply with all provisions of KCC
Title 15, Zoning, and health regulations;
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2. Establish access to a public road for each segregated parcel;
3. Have suitable physical characteristics; a proposed plat may be
denied because of flood, inundation or wetland conditions; slope,
soil stability and/or capabilities; or the construction of protective
improvements may be required as a condition of approval;
4. If adjacent to another municipality or King County, take into
consideration the subdivision standards of that jurisdiction as well
as the requirements of this chapter;
5. Make adequate provision for stormwater detention, drainageways,
water supplies, sanitary wastes, and other public utilities and
services, as deemed necessary;
6. Make adequate provision for the connectivity of streets, alleys,
pedestrian accessways and other public ways (KCC 12.04.635).
As evidenced by the General Information in Section I. and the following
responses to the criteria for approving subdivisions, the proposal is in
general conformance with the Kent Subdivision Code
Furthermore, Section 12.04.685 of the Kent Subdivision Code indicates
that a subdivision shall not be approved unless the City finds that:
1. Appropriate provisions have been made for:
a. The public health, safety and general welfare of the
community;
Except for I of 21, the p roposed plat i s consistent with the
Comprehensive Plan designation of SF-6. A portion of the
proposed subdivision contained within lot 21 is designated
SF-1. The proposed density and lot dimensions are
consistent with the respective zoning districts, as proposed
through this application.
b. Protection of environmentally sensitive lands and habitat;
The hazardous slope boundaries and associated buffers
have been delineated by Spears Engineering and Technical
Services in a report completed March 23, 2003. This report
has been reviewed and approved by the Public Works
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Department. The hazardous slopes and associated buffer
areas identified in this report will be protected in a sensitive
area tract/ easement.
C. Open spaces;
Provisions for open space will be made through payment of
a fee in lieu of dedication of on-site open space as
discussed in section d. below.
d. Community parks and recreation;
The P arks D epartment h as commented that t he p roposed
subdivision does impact existing park facilities. No open
space is shown on the site plan for this project. The
owner/applicant will be required to pay a fee in lieu of
dedication of land pursuant to Section 12.04.780. This fee
is based on the value of the subject land at the time of
application for preliminary subdivision approval. As this
application was submitted and deemed complete in May of
2003, land values from that date have been used to
determine that a fee of approximately $30,500 will be
required in lieu of dedication of open-space within the
proposed plat (based on the values provided by the King
County Department of Assessments) Funds collected in
lieu of an on site dedication of open space will be used for
construction of an as yet undeveloped park at the corner of
SE 274th Street and 114th Avenue SE, approximately one-
half mile from the proposed subdivision. This park is
identified on the City of Kent Capital Facilities Plan for
2004-2009 with construction scheduled to begin in 2008.
e. Neighborhood tot lots and play areas;
Provisions for these areas will be accomplished by the fee
paid under section d. above.
f. Schools and school grounds;
The subject property lies within the Kent School District.
Pursuant to KCC 12.13.160, a school impact fee (currently
assessed at $4,292 per single family residence) will be
assessed in association with the subdivision of land. The
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impact fee will be assessed and collected for each
individual lot at the time of construction permit issuance and
will be based upon the adopted impact fee at that time.
g. Drainageways;
Each individual residence will be required to provide on-site
infiltration as well as an overflow connection to an approved
conveyance system.
h. Stormwater Detention;
The City of Kent Public Works Department has reviewed the
incremental increase in impervious area and determined the
proposed stormwater system to be adequate.
' i. Connectivity of sidewalks, pedestrian pathways, traffic
calming features and devices, and other planning features
that assure safe walking conditions within and between
subdivisions for residents and students who walk to and
from s chools, p arks, t ransit s tops a nd o ther n eighborhood
eservices;
Sidewalks will be required along both sides of the proposed
' public streets. Additionally, the applicant will be required to
contribute to a fund for construction of an off-site asphalt
walkway to serve Meadow Ridge Elementary School
j. Connectivity of streets or roads, alleys, pedestrian
accessways, and other public ways within and between
subdivisions and neighborhoods;
The recently developed Autumn Glen subdivision is located
immediately east of the subject site and incorporates a new
public street that terminates at the shared boundary. As
proposed, the applicant will connect the new internal public
' roadway to the terminus of the existing Autumn Glen
roadway. Additionally, the applicant has proposed to serve
the s ite w ith a n e xtension o f 104`h Avenue from the north
1 and an extension of SE 272 Street from the east. The
proposed plat is adjacent on its western and southern
boundaries to severe hazard slope areas that render
connectivity of pedestrian ways or roads infeasible.
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k. Transit stops;
Transit service is available less than 0.33 mile from the site
at the intersection of 104m Avenue SE and SE 267"' Street.
The East Hill Park and Ride transit facility is located
approximately 2 miles northeast of the subject site.
I. Potable water supplies;
All homes within the proposed plat will be connected to
water service provided by the City of Kent.
M. Sanitary wastes;
All homes within the proposed plat will be connected to '
sanitary sewer service provided by the City of Kent.
n. Other public utilities and services, as deemed necessary-
Power and natural gas lines will be installed during plat
construction. Garbage service will be established by the
individual residents.
2. The city has considered all other relevant facts; and '
determined that the proposed plat will be in conformance
with all of the criteria listed above.
3. The public use and interest will be served by the platting of
such subdivision and dedication.
4. The City has considered the physical characteristics of the ,
proposed subdivision site and may deny a proposed plat
because of flood, inundation, or wetland conditions; slope,
or soil stability and/or capabilities. Construction of
protective improvements may be required as a condition of
approval, and such improvements shall be noted on the ,
final plat.
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C. ZONING CODE
' 1. Feasibility of Development
If the proposed rezone from SR-4.5 to SR-6, Single Family
Residential is approved, development on all lots in the proposed
subdivision will be subject to Zoning Code requirements in the SR-
6, Single Family Residential zoning district, except for lot 21. As
' proposed, lot 21 will be zoned both SR-1 and SR-6, but will
conform to the more restrictive development standards of the SR-1
designation. All proposed lots within the subdivision area meet the
' minimum lot size and width requirements for the SR-6, Single
Family Residential district, again with the exception of lot 21, which
meets SR-1 development standards. The applicant has indicated
that the existing home located on proposed lot 20, will be retained
This home is in conformance with the residential development
standards of KCC 15.04.170.
Numerous significant trees are located on the site Zoning
regulations encourage the retention of significant trees where
roads, utilities, and site improvements are not proposed. Tree
retention plans will be required for the plat and development of
each lot where trees are located (per KCC Section 15.08.240).
' 2. Criteria for Granting a Request for Rezone
' The following standards and criteria (Kent Zoning Code, Section
15.09.050) are used by the Hearing Examiner and City Council to
evaluate a request for a rezone. Such an amendment shall only
' be granted if the City Council determines that the request is
consistent with these standards a nd criteria. Note. The following
analysis refers only to parcel 3222059049.
a. The proposed rezone is consistent with the Comprehensive
' Plan.
Planning Services Comment
' The Comprehensive Plan Land Use Plan Map designates the
subject property as SF-6, Single Family Residential which allows
' up to six units per acre. A rezone of the site from SR-4.5 Single
Family Residential to SR-6 Single Family Residential will allow
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residential development up to 6.05 units per acre, which is also
allowed under the Comprehensive Plan. As previously discussed,
the proposed rezone is also consistent with the applicable goals
and policies of the Comprehensive Plan. '
b. The proposed rezone and subsequent development of the
site would be compatible with development in the vicinity. '
Planning Services Comment
The proposed rezone and subsequent single family residential ,
development of the site would be compatible and integrate well
with the existing development in the vicinity. Development in the '
immediate vicinity is a mix of platted subdivisions and unplatted
parcels developed with single family homes and zoned SR-4.5,
and SR-6, Single Family Residential. The subject property is
adjacent to the 20-lot Autumn Glen plat, which will connect to
Kentara via an extension of SE 273rd Street. Autumn Glen is
developed to SR-6 standards. Several of the residential properties '
in the immediate vicinity are zoned SR-6 and have potential for
future subdivision. Further, this subdivision proposes to create '
41 residential lots at a net density of 6.4 units per acre This
density of residential development is sufficient to support existing
local urban services.
C. The proposed rezone will not unduly burden the
transportation system in the vicinity of the property with '
significant adverse impacts which cannot be mitigated.
Planning Services Comment ,
A rezone of this property to SR-6 Single Family Residential will not
generate additional trips onto the existing transportation system.
However, subsequent development of a proposed 41-lot
subdivision will add a net 38 PM peak hour trips to the local street
system. As detailed in section V of this report, road and street '
frontage improvements to meet the City of Kent roadway
standards are recommended as conditions of approval. These
improvements include curb, gutter, sidewalks, planting strips,
street lighting, paving, and public stormwater conveyance. The
applicant will be also be required to participate in other City
transportation improvement projects by providing an environmental ,
mitigation fee for the impacts created by development.
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d. Circumstances have changed substantially since the
establishment of the current zoning district to warrant the
proposed rezone.
Planning Services Comment
The subject parcels were annexed to the City of Kent on June 27,
1994 as part of the 594 acre Ramstead annexation (Ord. 3210)
and are developed with two single family residences and one
duplex building.
In 1995, after the Ramsead annexation, the City of Kent adopted
its Comprehensive Plan which designated the subject site as RA,
Residential Agricultural. In 1996, through Ordinance 3331, the City
Council amended this plan to designate the site SF-6. Along with
the Land Use Plan Map and Policies, the Comprehensive Plan
contains a target for the number of new households the City must
accommodate for the 20-year time horizon of the plan. Also, the
Washington State Growth Management Act states the City's
development regulations must implement, and be consistent with
the Comprehensive Plan. This proposal, which seeks to establish
higher density single family development with smaller lot sizes
while recognizing significant environmental features, is consistent
with the goals and policies of the Comprehensive Plan.
' Further, since establishment of the current SR-4.5 zoning,
significant improvements to sanitary sewer infrastructure in the
immediate area have been completed. Specifically, the recent
extension of a sanitary sewer line located east of the subject site
has made further extension of sanitary sewers to this site feasible.
These extensions were necessary to provide for the higher
densities allowed under SR-6 zoning. Additionally, work along the
SE 272"d and 277'h Street Corridor has improved access to this
site and the surrounding area. Improved access will support a
' higher density residential zoning designation. Conditions of
approval require the owner/subdivider to improve the existing
transportation network.
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e. The proposed rezone will not adversely affect the health,
safety and general welfare of the citizens of the City of
Kent.
Planning Services Comment '
The proposed rezone is consistent with the vision of the '
Comprehensive Plan. Subsequent development on the site will
have to meet applicable codes and regulations, including
mitigation of anticipated environmental impacts. Therefore, the
rezone proposal will not adversely affect the health, safety and
general welfare of the citizens of the City of Kent.
D. CONSISTENCY ANALYSIS
The proposed rezone and subdivision are consistent with the goals and '
policies of the City of Kent Comprehensive Plan.
1. Type of Land Use Allowed '
The development of single family home sites is a principally
permitted use on land zoned SR-1, SR-4 5 and SR-6, Single '
Family Residential.
2. Level of Development Allowed '
The proposed subdivision of approximately 11.6 acres into 41 '
building sites is consistent with the designated Comprehensive
Plan designation of SF-6 Single Family/6 units per acre and with
the zoning designation of SR-6 (pending the outcome of RZ-2003- '
1). The portion of the proposed subdivision located in the SR-1
zoning district is consistent with the Comprehensive Plan
designation of SF-1 and with the SR-1 zoning designation. '
3. Adequacy of Infrastructure
The proposed subdivision will place increased demands on '
existing transportation, water and sanitary sewer systems in the
general vicinity. The project will also result in a significant net
increase of impervious surface area among the four parcels
involved. When fully developed, the impact of 38 new homes being
occupied will result in an estimated 380 daily and 38 new PM peak '
hour trips to the local street system.
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The effects on the domestic water supply, sanitary sewer service,
stormwater run-off, conveyance, storage, treatment and discharge
and transportation impacts have been analyzed through the SEPA
process and the associated MDNS.
4. Characteristics of the Proposed Subdivision
The proposed subdivision, as presented, appears to be in general
' conformance with the Kent City Code with respect to the required
minimum lot area, minimum lot width and access to a public right
of way.
E. PROPOSED FINDINGS
Planning Services has reviewed these applications in relation to the
Comprehensive Plan, zoning, land use, street system, flood control
problems and comments from other departments and finds that:
1. The Kent Comprehensive Plan Land Use Map designates the
majority of this site SF-6, Single Family Residential, 6 units per
acre maximum density. The portion of parcel 3222059190
contained within proposed lot 21 and incorporated in the proposed
subdivision is designated SF-1 Single Family Residential, 1 unit
per acre maximum density.
2. The site is currently zoned SR-1, SR-4.5, SR-6, Single Family
' Residential. If RZ-2003-1 is approved, the majority of this site will
be zoned SR-6, Single Family Residential. The portions of this site
zoned SR-6 will be subject to the development standards which
include 5,700 square foot minimum lot size and 50 foot minimum
lot width. The area zoned SR-1 will continue to be subject to
development standards that include 35,700 square foot minimum
' lot size and 60 foot minimum width.
3. Land uses in the immediate area are predominantly low and
medium density single family residential.
4. A Tentative Plat meeting was held for the proposed subdivision on
' November 5, 2002 (#TSU-2002-7).
5. A M itigated D etermination o f N onsignificance w as issued f or t he
plat on April 16, 2004 (#ENV-2003-2).
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6. There are significant trees of six inch or greater caliper located on '
the property.
7. The site has access to 104th Avenue SE and SE 272"d Street. ,
8. The subject property would receive water service from the City of '
Kent.
9. The subject property would receive sewer service from the City of
Kent.
V. CITY STAFF RECOMMENDATIONS ,
1. ZONING MAP AMENDMENT (#RZ-2003-1)
Upon review of the merits of this request and the Code criteria for
granting a rezone, the City staff recommends APPROVAL without
conditions of the Kentara rezone. '
2. PRELIMINARY SUBDIVISION (#SU-2002-7)
Based on the merits of this request and the code criteria for granting a
preliminary subdivision, staff recommends APPROVAL of the proposed
Kentara preliminary plat subject to the following conditions '
A. PRIOR TO RECORDING THIS SUBDIVISION: ,
1. The Owner / Subdivider shall pay all Charges in Lieu of
Assessments and/or Latecomer Fees, if any, prior to
scheduling the Pre-Construction Conference and/or prior to
recording this plat, whichever comes first.
2. The Owner / Subdivider shall provide Public Works with a ,
digital plat map prepared with a CAD program. The digital
information can be formatted in either *.DWG (AutoCad) or '
*.DXF (Drawing Exchange File), but must be based upon
State Plane coordinates: an assumed coordinate system is
not permitted. The State Plane Coordinates shall be on the ,
NAD 83/91 datum and relate to at least two City of Kent
reference points within one half mile of the subdivision. In
addition, the project shall be tied into at least two City of ,
Kent NAD 88 vertical benchmarks and two additional
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' permanent benchmarks shall be established within the
project. The elevations of these benchmarks will be
reported at the time as-built drawings are submitted along
with field notes sufficient to verify their accuracy.
3. The Owner / Subdivider shall submit and receive City
approval of engineering drawings from the Department of
Public Works, and shall then either construct or bond for the
following:
' a. A gravity sanitary sewer system to serve all lots.
The City sanitary sewer system shall be extended
from the existing City sanitary sewer system within
SE 272nd Street and shall be deep enough to serve
off-site properties within the same service area
including p roperties to the north of S E 2 72nd S treet
along 104th Avenue SE; in addition, the sanitary
sewer system shall be extended across the entire
subdivision as needed to serve adjacent properties
within the same service area.
' The septic system serving the existing home(s)
within the proposed plat - if any - shall be abandoned
in a ccordance w ith K ing C ounty H ealth D epartment
Regulations.
1 b. A water system meeting domestic and fire flow
requirements for all lots.
The City water system shall be extended as
determined necessary by the Public Works
Department and shall be sized to serve all off-site
properties within the same service area; in addition,
the water system shall be extended through the
entire subdivision to connect with the system
installed within the Autumn Glen Subdivision. The
Fire Department requests that the existing 12 inch
water main in SE 272nd Street be looped to 108th
Avenue SE. This may not be necessary if fire flows
are adequate as determined by the Fire Department
' and Public Works. The Owner / Subdivider shall
provide fire flow test results for the nearest existing
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hydrant on which to base fire flow calculations for the '
proposed subdivision. If flows are deemed sufficient,
the Public Works Director, at his discretion, may
waive the looping requirement with the approval of ,
the Fire Department.
Existing wells — if any - shall be abandoned in ,
accordance with the requirements of the Department
of Ecology.
C. A stormwater system. The Engineering Plans must '
meet the minimum requirements of the City of Kent
Construction Standards and 2002 City of Kent ,
Surface Water Design Manual (KSWDM). Initial
guidance for the Engineering Plans is given below
(See Chapter 2 of KSWDM for detailed submittal
requirements):
(1) The Engineering Plans will include at a
minimum: Site improvement plans which
include all plans, details, notes and
specifications necessary to construct road,
drainage, and other related improvements.
The engineering plans shall include a
technical information report (TIR) which ,
contains all the technical information and
analysis to develop the site improvement ,
plans.
(2) An erosion and sedimentation control (ESC) '
plan shall be included in the engineering
plans. The ESC shall meet the requirements
of the City of Kent Construction Standards, ,
and the 2002 City of Kent Surface Water
Design Manual. These plans must reflect the
Detailed Grading Plan discussed below, and '
Planning Services approved Detailed Tree
Plan
(3) The retention / detention and release standard
that will be met by the subdivision is Level
Two. The water quality menu that will be met ,
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by the subdivision is the Resource Stream
Protection Menu.
' (4) The site improvement plans and technical
information report will contain drainage
calculations and a drawing of the retention /
' detention pond tract at an appropriate
engineering. The site improvement plans will
also show that all required stormwater
management facilities will be outside of
delineated wetlands and their buffers, as well
as outside of creeks and rivers and their
buffers.
(5) A downstream analysis is required for this
development and it will include an analysis for
capacity, erosion potential, and water quality
Refer to the requirements of Technical
Information Reports in Section 3. "Offsite
Analysis", of the 2002 City of Kent Surface
Water Design Manual for the specific
information required for downstream analyses.
(6) As development occurs within this subdivision,
roof downspouts for each roofed structure
(house, garage, carport, etc.) shall be directed
to Roof Downspout Controls per Chapter 5.1
of the 1998 King County Surface Water
Design Manual.
(7) If determined necessary by the Public Works
Department, the Owner / Subdivider shall
provide public drainage easements meeting
t the requirements of the City of Kent
Construction Standards for the specified
downstream reach where adequate public
drainage easements do not currently exist.
(8) The Owner / Subdivider shall submit
Landscape Plans for within and surrounding
the retention / detention facility to Planning
Services and to the Department of Public
Works for concurrent review and approval
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prior to, or in conjunction with, the approval of
the Engineering Plans. These Landscape
Plans shall meet the minimum requirements of
the City of Kent Construction Standards, and
the stormwater management landscaping
requirements contained within the 1998 King
County Surface Water Design Manual.
Landscape Plans are required to show
adjacent Street Trees so that the City arbodst
can a ssess p otential a dverse stress u pon a 11
types of vegetation. Landscape Plans are to
be used to show required Street Trees along
SE 272nd Street. ,
(9). The Owner / Subdivider shall execute
Declaration of Stormwater Facility ,
Maintenance Covenants for the private
portions of the drainage system prepared by
the Property Management Section of the
Department of Public Works. See Reference
8-F, Declaration of Stormwater Facility
Maintenance Covenant, to the 2002 City of '
Kent Surface Water Design Manual for
information on what is contained within this
document.
d. A Detailed Grading Plan for the entire subdivision ,
meeting the requirements of the Uniform Building
Code, the City of Kent Construction Standards, and
City of Kent Development Assistance Brochure #1-3,
Excavation and Grading Permits & Grading Plans.
Initial guidance for these plans is given below:
(1) These plans shall include provisions for ,
utilities, roadways, retention / detention ponds,
stormwater treatment facilities, and a building
footpad for each lot.
(2) These plans shall be designed to eliminate the
need for processing several individual Grading
Permits upon application for Building Permits.
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(3) In conjunction with the intersection
improvement plans required below, these
plans will clearly indicate that the necessary
' Entering Sight Distance requirements are met
for the intersection of SE 272"d Street and
108th Avenue SE, AND for the intersection of
104th Avenue SE and SE 272"d Street. A
profile shall be provided along the sight
distance triangles to indicate that vertical
obstructions are not obscuring the minimum
Entering Sight Distance required by the 2001
AASHTO "Green Book".
te. Interim Street Improvement Plans for SE 272"d Street
east of 104th Avenue SE along the entire property
frontage thereon. These Street Improvement Plans
shall meet the requirements of the City of Kent
Construction Standards, and City of Kent
Development Assistance Brochures #6-2, Private
and Public Street Improvements, and # 6-8, Street
Improvement Plans, for a street designated as a
Residential Collector Street Augmented by Bike
Lanes by the City of Kent Master Plan of Roadways
between 104th Avenue SE and 1081h Avenue SE.
Initial guidance for the necessary interim street
improvements is given below:
' (1) Combined vertical concrete curbs & gutters, a
5-foot wide planter strip, and a 5-foot cement
concrete sidewalk on the south side of the
' street.
(2) A minimum of 22-feet of asphalt pavement as
1 measured from the centerline of the right-of-
way to the face of curb on the south side of
the street, plus at least 12-feet of asphalt
pavement as measured from the centerline of
the right-of-way to the edge of the traveled
lane on the north side of the street.
(3) A City-approved shoulder on the north side of
the street.
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(4) A City-approved street lighting system.
(5) Public stormwater conveyance, detention and
treatment facilities as applicable. ,
(6) 20-foot radius curb returns at the intersections
of all public streets.
(7) Street Trees installed within the 5-foot wide
planting strips constructed between the back
of curb and the front of the cement concrete
sidewalk. These Street Trees will be located
as approved by the Public Works Department, ,
and the species shall be selected from the
Approved Street Tree List contained within
City of Kent Development Assistance
Brochure #14, City of Kent Street Trees.
f. Street Improvement Plans for the new public
Residential Streets within the subdivision. The Street
Improvement Plans for these streets shall be
designed in conformance with the requirements for
Residential Streets as required by City of Kent
Construction Standards, and City of Kent
Development Assistance Brochures #6-2, Private
and Public Street Improvements and City of Kent
Development Assistance Brochure # 6-8, Street
Improvement Plans for a street 28-feet wide, with the
exception of SE 272"d Street extending westerly of
104t' Avenue SE which shall be constructed to a 20
foot wide partial street improvement as defined
below. Initial guidance for these street improvements
is given below: ,
(1) Combined vertical curbs & gutters, 5-foot wide
planting strips constructed between the backs
of curb and the fronts of the sidewalk and 5-
foot wide cement concrete sidewalks on both
sides of the street, except SE 272"d Street ,
shall be constructed with the above
improvements on only the south side of the
street. '
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(2) A minimum of 28-feet of asphalt pavement,
measured from face of vertical curb to face of
vertical curb, except SE 272"d Street which
shall be constructed with a minimum 20 feet of
asphalt pavement as measured from the face
of the south curb line.
I (3) A street lighting system designed to the City's
standards, constructed and maintained by
the IntoLight Division of Puget Sound Energy;
all electrical and maintenance bills shall be
paid for by a Home Owner's Association
(4) A public stormwater drainage system,
including provisions for collection,
conveyance, detention, and treatment
facilities.
(5) Curb return radii of 20-feet at the intersection
of the subdivision streets and all other
public Streets, and a 45-foot radius to the face
of curb for the cul-de-sacs; and a 45-foot
radius to the edge of pavement for any
temporary cul-de-sacs, where applicable, or
other temporary turnaround acceptable to the
Public Works Department and the Fire
Department.
(6) Street Trees installed within the 5-foot wide
planting strips. These Street Trees will be
located as approved by the Public Works
Department, and the species shall be selected
from the Approved Street Tree List contained
within City of Kent Development Assistance
Brochure #14, City of Kent Street Trees.
(7) SE 273'd Street shall be aligned to match the
alignment of the same street in the Autumn
Glen Subdivision at their match line at the east
property line of this subdivision.
g. Street Improvement Plans for new Private
Residential Streets with cul-de-sacs or approved
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turnarounds or at their terminus. The Street
Improvement Plans shall be designed in
conformance with the requirements for a Private
Residential Street as required by City of Kent
Construction Standards, and City of Kent
Development Assistance Brochure #6-2, Private and
Public Street Improvements and City of Kent ,
Development Assistance Brochure # 6-8, Street
Improvement Plans for a street at least 20-feet wide.
Initial guidance for these street improvements is ,
given below:
(1) A minimum of 20-feet of asphalt concrete
pavement for private streets serving four lots
or less, and an additional 5-foot paved
walkway along one side for private streets ,
serving more than four lots.
(2) An approved cul-de-sac, or turnaround at its
terminus, unless otherwise determined by the
City Fire Marshal.
(3) A private stormwater drainage system,
including provisions for collection,
conveyance, detention, and treatment facilities
where applicable.
(4) Unless additional asphalt concrete pavement
width is provided for parking, all minimum
width private streets serving more than two
lots shall have pavement markings and traffic
signs installed which clearly designate these
private streets as Fire Lanes, where no
parking will be permitted.
h. Pedestrian Walkway Improvement Plans for a 6-foot
wide vertically separated asphalt walkway from the
east end of the 5-foot wide sidewalk constructed
along the south side of SE 272"d Street to the
sidewalks serving Meadow Ridge Elementary
School, or if approved by the Public Works
Department, payment of a fee in lieu of construction. '
A fee in lieu of construction in the amount of $1500
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per gross acre of property will only be considered if
the Kent School District provides bus service to the
subject property.
ti. Interim Street Improvement Plans for the intersection
of 104'h Avenue SE and SE 272"d Street These
Street Improvement Plans shall provide for adequate
entering intersection sight distance as specified by
the 2001 version of the AASHTO "Green Book."
' j. Street Lighting Plans for all public streets meeting the
requirements of the City of Kent Construction
Standards, and City of Kent Development Assistance
Brochure #6-1, Street Lighting Requirements. The
Street Lighting Plans for this development will
conform with the approved Street Lighting Plans for
Autumn Glen, for both the internal street system and
along SE 272"d Street.
4. The Owner / Subdivider shall create a Homeowner's
Association for this subdivision to ensure that the property
owners within this subdivision are advised of their
requirement to pay for the provided street lighting system.
Those sections of the required document written to govern
I that association as they relate to any IntoLight Division of
Puget Sound Energy street lighting systems, shall be
reviewed and approved by the Department of Public Works,
prior to the recording these documents.
5. The pubic ingress and egress and utility easement along
1 the south side of subdivision shall include language on the
face of the plat, approved by Public Works, prohibiting the
construction thereon of fences, structures, concrete pads,
' decks, and landscaping other than grass
6. The face of the final plat shall clearly identify all private
streets and which lots have an undivided interest in the
tracts or easements defining each streets. The face of the
final plat will also specify that the maintenance of this
private street is the sole responsibility of the property
owners who are served by that private street.
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7. Direct vehicular access to and from Lots 37, 38, 39 and 40
onto SE 272"d Street is prohibited, and the face of the final
plat will carry the following restriction:
DIRECT VEHICULAR ACCESS TO AND FROM LOTS 37, 38, 39 t
AND 40 ONTO SE 272ND STREET ARE PROHIBITED.
VEHICULAR ACCESS AND DRIVEWAY LOCATIONS FOR
THOSE LOTS ARE RESTRICTED TO THAT PRIVATE STREET
SHOWN IN TRACT A THE FACE OF THE RECORDED PLAT
8. The Owner / Subdivider shall deed all public rights-of-way, '
and otherwise convey all private and public easements
necessary for the construction and maintenance of the '
required improvements for this subdivision development.
9. The Owner / Subdivider shall submit and receive approval of
a Detailed Tree Plan, meeting the requirements of the Kent
Zoning Code, and City of Kent Development Assistance
Brochure #3, Detailed Tree Plans, prior to the issuance of
any Construction Permits for the subdivision. Grading Plans
cannot be approved by the Department of Public Works
without an approved Detailed Tree Plan. Detailed Tree Plans
are not to be confused with required Street Tree Plans,
which have an entirely different purpose.
10. The Owner / Subdivider shall permanently protect
Hazardous Area Slopes as defined by Section 15.08.224 of
the Kent City Code by creating a separate Sensitive Area
Tract (SAT) and deeding the tract in fee simple to the City,
OR by granting a Sensitive Area Easement (SAE) to the City
for the entire sensitive area and ten foot buffer via
documents prepared by the Property Management Section
of the Department of Public Works. This SAT or SAE shall
be consistent with the lines for the top of or bottom of bank
setback lines, and the top and bottom of Hazard Area Slopes
shown on an approved topographic map prepared, stamped,
and signed by a licensed land surveyor. Hazard Area
Slopes shall include areas proposed to be graded during
construction of this subdivision which will have slopes in
excess of forty percent.
11. Prior to release of any construction bonds, and prior to the
approval of any Building Permits within the subject
subdivision, the Department of Public Works must receive
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and approve As-Built Drawings meeting the requirements of
the City of Kent Construction Standards, and City of Kent
Development Assistance Brochure #E-1, As-Build Drawings,
for: Streets; Street Lighting System; Water; Sewer;
Stormwater Drainage Facilities; and all off-site improvements
where the locations and/or elevations are deemed critical by
the Department of Public Works.
12. The owner/subdivider shall construct mailbox clusters per
the standards and at locations approved by the Public Works
Department and the Kent Postmaster.
I B. PRIOR TO THE ISSUANCE OF A BUILDING PERMIT ON ANY
LOT IN THIS SUBDIVISION, THE OWNER / SUBDIVIDER
SHALL:
t1. Record the Plat.
2. Pay the Environmental Mitigation Fee for that lot
3 Construct all of the improvements required above
4. Submit and receive City approval for As-Built Drawings
meeting the requirements of City of Kent Development
Assistance Brochure #E-1, As-Build Drawings, for street
improvements, stormwater management system, street
lighting system, and other off-site Improvements where
determined necessary by the City.
' KENT PLANNING SERVICES
August 27, 2003
S 1PermitlPlanVezone1200312030262-2003-1 staffrpt doc
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83
Q 24
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APPLICATION NAME: KENTARA
REQUEST: #SU-2002-7 AND#RZ-2003-1
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APPLICATION NAME: KENTARA
REQUEST: #SU-2002-7
SITE MAP
OFFICE OF THE LAND USE HEARING EXAMINER
Theodore P. Hunter
Hearing Examiner
FINDINGS, CONCLUSIONS AND RECOMMENDATION
FILE NO. KENTARA
#RZ-2003-1 KIVA #2030262
APPLICANT: Ken Peckham
Peckham Homes
REQUEST: A request to rezone 6.4 acres from SR-4.5 to SR-6,
Single Family Residential.
LOCATION: South of the intersection of 104th Avenue SE and '
SE 272"d Street.
APPLICATION FILED: January 24, 2003
DETERMINATION OF
NONSIGNIFICANCE ISSUED: April 16, 2004
MEETING DATE: June 9, 2004
RECOMMENDATION ISSUED: June 23, 2004
RECOMMENDATION- APPROVED
STAFF REPRESENTATIVE: Matt Gilbert, Planning Services t
Gary Gill, Public Works
PUBLIC TESTIMONY: Hans Korve for applicant ,
Ken Peckham
EXHIBITS: 1. Staff Report dated June 9, 2004, with Attachments: t
a. Application
b. City Routing and Comment
c. Public Notice of Hearing
d. Notice of Completeness of Application/ Notice
of Application
e. SEPA Mitigated Determination of
Nonsignificance issued April 16, 2004
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Kentara Rezone '
RZ 2003-1, KIVA #RPP4-2030262
Page 1 of 8
iUpon consideration of the testimony and exhibits admitted at the open record hearing,
the Hearings Examiner enters the following Findings and Conclusions:
FINDINGS
1. The Applicant requests a Zoning Map Amendment to change the zoning on
one parcel of property from Single-Family Residential (SR-4.5) to Single-
Family Residential (SR-6). The property subject to this rezone request
1 consists of 6.4 acres located at the intersection of 104th Avenue SE and SE
272nd Street in Kent, Washington. In addition to the rezone request, the
Applicant requests preliminary subdivision approval to develop 11.6 acres
with 41 single-family residential lots. Both requests were reviewed at the
June 9, 2004 public hearing. The proposed rezone is considered as a "project
rezone." Review of a proposed project rezone must consider the impacts
from both the rezone itself and the associated land use change proposed by
the Applicant. Exhibit 1, Staff Report, pages 1-2;Attachment a, Application.
2. The property under consideration for preliminary subdivision consists of four
parcels or portions thereof. The parcels are numbered 322205-9049,
322205-9022, a portion of 322305-9192 and a portion of 322205-9190. The
portions of parcels —9192 and 9190 that a re excluded from the preliminary
subdivision proposal are owned by the City of Kent and are part of the S
272/S 277th Street Corridor. The proposed subdivision contains area in three
different zoning districts. Parcels —9022 and —9192, in the eastern portion of
the site, are zoned SR-6. A portion of Lot 21 is zoned SR-1. Parcel —9049,
the western parcel proposed for rezone, is zoned SR-4 5. Exhibit 1, Staff
Report, page 2.
3 Properties to the north of the site are zoned SR-4.5 and SR-6 and are
primarily developed with single-family homes on larger lots. Property to the
east is zoned SR-6. Immediately east of the proposed plat is a 20 lot
1 subdivision called Autumn Glen. Properties to the south and west are zoned
SR-1 and SR-2. The South 272nd/South 277th Street Corridor is immediately
south of the proposed plat. Under the Kent Comprehensive Plan, the entire
proposed plat, except for the SR-1 portion of proposed Lot 21, is zoned SR-6.
Exhibit 1, Staff Report, pages 2-3.
4. The parcel proposed for rezone contains significant areas of slopes of 40% or
greater along the west boundary. These slopes are classified under the Kent
City Code as Severe Hazard Areas. No development is proposed in this area
and vegetation on the steep slopes will not be disturbed. The rest of the site
slopes to the northeast at approximately 5%. There are no wetlands and no
other critical areas on the subject property. The site contains a wide range of
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
' Kentara Rezone
RZ 2003-1; KIVA #RPP4-2030262
Page 2 of 8
vegetation, consisting of evergreen and deciduous trees, shrubs and grasses. ,
The Applicant proposes to clear approximately 38% of the site for roads,
homes, and utility construction. The Applicant would submit a survey of
significant trees to be retained, which would require approval by the City.
Exhibit 11 Staff Report, page 4.
5. The purpose of single-family residential districts is to stabilize and preserve
single-family residential neighborhoods, as designated in the comprehensive
plan. The single family zoning d istricts i n Kent also a ncourage a range of
densities and lot sizes in order to promote diversity and recognize a variety of
residential environments. KCC 15.03.010.
6. The SR-6 zone would establish a maximum density of 6.05 dwelling units per
acre; a minimum lot area of 5,700 square feet; and a maximum building
height of 35 feet. KCC 15.04.170.
7. The 6.4-acre parcel proposed for rezone is now zoned SR-4.5. Exhibit 1, Staff
Report, page 2. If its entire area could be developed, it could contain up to 28
residential lots. If the rezone was approved, and the entire area could be
developed, the 6.4 acres could contain 38 lots. Thus, the maximum possible
increase in the number of lots that could result from the rezone is ten. KCC
15.04.020.1 The Applicant proposes to construct 20 residential lots within the
area proposed for rezone if the rezone is approved. Testimony of Mr. Gilbert
8. Autumn Glen, a 20-lot subdivision being built to the east, will extend water
and utility services up to the eastern boundary of the site proposed for
subdivision by making subdivision easier and more affordable. Testimony of
Mr. Gilbert. The subject property is within the City of Kent water service area.
The City of Kent would also provide sanitary sewer service. Exhibit 1, Staff
Report, page 7.
9. The proposed subdivision would take primary access from 104th Avenue SW.
The plat would have frontage along SE 272nd Street, as well. In order to be
approved, the subdivision would be required to provide frontage
improvements including widening of right-of-way, curbs, gutters, sidewalks,
drainage systems, and street lighting on to satisfy development standards
applicable to both roads to address increase traffic volume generated by the
subdivision. The developer would also be required to mitigate the anticipated ,
The Hearing Examiner takes note that under either zoning district designation, the actual number of lots
would be less than the maximum allowed by the area due to the on-site steep slopes and associated
buffers that cannot be developed.
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Kentara Rezone
RZ 2003-1; KIVA #RPP4-2030262
Page 3 of 8
t
traffic impacts on existing roadways in the surrounding area. Exhibit 1, Staff
Report, pages 5-7.
10. The City of Kent Comprehensive Plan designates the subject property as
Single-Family Residential (SR-6), which allows six units per acre. The Plan
I also contains goals and policies that relate to the location, density, and design
of future development. Applicable provisions of the City Comprehensive Plan
include:
• The City of Kent adopts a 20-year housing target of 7,500 new dwelling
units within the existing city limits.... City of Kent Comprehensive Plan,
Land Use Goal LU-8.
• Locate housing opportunities within close proximity to employment,
shopping, transit and human and community services. City of Kent
Comprehensive Plan, Policy LU-8.3.
• Provide opportunities for a variety of housing types, options, and
densities throughout the city and the Potential Annexation Area. City
of Kent Comprehensive Plan, Land Use Goal LU-9.
• Allow s ingle f amily h ousing o n a v ariety o f lot s izes, i ncluding 5,000
square foot lots. Locate smaller lot sizes within close proximity to the
urban activity centers. City of Kent Comprehensive Plan, Policy LU-
9.4.
• Promote healthy neighborhoods by providing a wide range of housing
options throughout the community that are accessible to community
and human services, employment opportunities, and transportation
and by being sensitive to the environmental impacts of the
development. City of Kent Comprehensive Plan, Goal H-1
1 Ensure that community and human services, including, but not limited
to, fire, police, library facilities, medical services, neighborhood
I shopping, child care, food banks, and recycling facilities are easily
accessible to neighborhood residents. City of Kent Comprehensive
Plan, Policy H-1.1.
• Protect and enhance environmentally sensitive areas via the adoption
of the City regulations and programs which encourage well-designed
land use patterns such as clustering and planned unit development.
Use such land use patterns to concentrate higher urban land use
Findings, Conclusions & Recommendation
Heanng Examiner for City of Kent
Kentara Rezone
RZ 2003-1; KIVA #RPP4-2030262
Page 4 of 8
1
densities and intensity of uses in specified areas in order to preserve '
natural features such as large wetlands, streams, steep slopes, and
forests. City of Kent Comprehensive Plan, Goal LU-20.
Ensure that the City's environmental policies and regulation comply
with state and federal environmental protection regulations regarding
air and water quality, noise and wildlife and fisheries resources and
habitat protection. Demonstrate support for environmental quality in
land use plans, development regulations, and site plan review to ,
ensure that local land use management is consistent with the City's
overall natural resource goals. City of Kent Comprehensive Plan Goal
LU-22. ,
• Coordinate land use and transportation planning to meet the needs of
the City and the requirements of the Growth Management Act. City of
Kent Comprehensive Plan, Goal TR-1.
• Coordinate new commercial and residential development in Kent with i
transportation projects to improve affected roadways. City of Kent
Comprehensive Plan, Goal TR-1.2.
• Ensure consistency between land use and transportation plans so that
land use and adjacent transportation facilities are compatible. City of
Kent Comprehensive Plan, Policy TR-1.5.
11. Because the Applicant requested a rezone with the intent to develop a 40-lot j
subdivision, the City issued a SEPA Mitigated Determination of
Nonsignificance (MDNS) on April 16, 2004 which addressed the rezone and
the preliminary subdivision request. No MDNS conditions were
recommended for the requested rezone. The MDNS contains conditions
related to the proposed subdivision that address potential traffic impacts and
protection of the severe hazard steep slope area, including dedication of a
sensitive areas easement and enclosure within a split rail fence. No appeals
were filed during the 14-day appeal period provided for the MDNS. Exhibit 1,
Attachment e, SEPA MDNS.
12. Notice of the completed application for rezone was routed to City review
agencies. No comments were submitted by review agencies pertaining to the
rezone. Exhibit 1, Attachment b.
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Kentara Rezone
RZ 2003-1; K1VA #RPP4-2030262
Page 5 of 8
13. The City provided reasonable notice of the open record hearing. It mailed
notice to property owners within 300 feet and posted on site on May 28, 2004.
Exhibit 1, Attachment d, Public Notice.
CONCLUSIONS
iJurisdiction
The Hearing Examiner has jurisdiction to hold a public hearing on this rezone, and to
issue a written recommendation to the Council, pursuant to RCW 35A.63.170, and
Chapter 2.32 and Section 15.09.050 of the Kent City Code.
Criteria for Review
Section 15.09.050(C) of the Kent zoning code sets forth the standards and criteria
the Hearing Examiner must use to evaluate a request for a rezone. A request for a
rezone shall only be granted if:
a. The proposed rezone is consistent with the Comprehensive Plan;
b. The proposed rezone and subsequent development of the site would be
compatible with development in the vicinity;
C. The proposed rezone will not unduly burden the transportation system in the
vicinity of the property with significant adverse impacts which cannot be
mitigated,
d. Circumstances have changed substantially since the establishment of the
current zoning district to warrant the proposed rezone; [and]
e. The proposed rezone will not adversely affect the health, safety, and general
welfare of the citizens of the city.
KCC 15.09.050(F)(1).
Conclusions Based on Findings.
1. The proposed rezone is consistent with the Comprehensive Plan. In the
1 Kent Comprehensive Plan, the property is designated SR-6. Thus, the
rezone is consistent with the Comprehensive Plan in a direct manner. The
proposed rezone is also consistent with several of the policies and goals of
the Comprehensive Plan. The proposed rezone would allow for more intense
development in an existing residential area that is in close proximity to
employment, shopping, transit, and community services. The rezone will
Findings, Conclusions & Recommendation
Hearing Examiner for City of Kent
Kentara Rezone
RZ 2003-1; K1VA #RPP4-2030262
Page 6 of 8
i
preserve the single-family residential character of the area. The area is
served by community services, such as fire, police, and library facilities.
Finding of Fact No 10.
2. The proposed rezone and subsequent development of the site would be
compatible with development in the vicinity. Development within the
vicinity includes residential uses in SR-1, SR-2, SR-4,5, and SR-6 zones.
The rezone and proposed development will be consistent and compatible with
this existing development. Findings of Facts Nos. 2 and 3.
3. The proposed rezone will not unduly burden the transportation system
in t he vicinity o f t he p roperty w ith significant a dverse i impacts which
cannot be mitigated. Direct access to the subject property would be
provided from 104th Avenue SE. Although the rezone would increase density
from SR-4.5 to SR-6, the number of lots within the rezone area is limited by
the presence of severe hazard areas. Significant impacts to traffic circulation
are not likely to occur given the traffic impact mitigation requirements in the
MDNS. Findings of Facts Nos.3 and 9.
4. Circumstances have changed substantially since the establishment of
the current zoning district to warrant the proposed rezone. The
development of Autumn Glen on the adjacent property to the east will make
provision of water and sewer service to the rezoned area more efficient.
Although the proposed rezone will result in a relatively minor alternation from
the SR-4 5 zone originally established, it will result in more intense
development within city limits as envisioned in the Comprehensive Plan.
Finding of Fact No.8.
5. The p roposed r ezone will n of a diversely a ffect t he h ealth, s afety, a nd
general welfare of the citizens of the City of Kent. Although the proposed
rezone will result in higher density development, the number of new
residences is limited by the presence of sensitive areas. Services are in
place to accommodate the growth. The City of Kent will provide water and
sewer service. In addition to the road improvements along 1042h Avenue SE
and SE 272nd Street, mitigation conditions in the MDNS require additional
contributions from the Applicant to mitigate potential adverse traffic impacts
on circulation in the surrounding area. Findings of Facts Nos. 3, 4, 7, 8, 9, 10,
and 11.
RECOMMENDATION
Based upon the preceding Findings and Conclusions, the Hearing Examiner
recommends that this application for the rezone from Single Family Residential (SR-
Findings, Conclusions &Recommendation
Hearing Examiner for City of Kent
Kentara Rezone '
RZ 2003-1; KIVA #RPP4-2030262
Page 7 of 8
i
4.5) to Single-Family Residential (SR-6) on approximately 6.4 acres of property
located at the intersection of 104"' Avenue SE and SE 272"d Street in Kent,
Washington -be APPROVED. It is the Hearing Examiner's opinion that the rezone
request, as proposed, meets the criteria for approval established by the Council.
iDated this 23rd day of June 2004.
THEODORE PAUL HUNTER
Hearing Examiner
S:1PenmflPlanlrezone1200312030262-2003-1findings doc
Findings, Conclusions &Recommendation
Hearing Examiner for City of Kent
Kentara Rezone
RZ 2003-1;KIVA #RPP4-2030262
Page 8 of 8
Kent City Council Meeting
Date July 20, 2004
Category Bids
1. SUBJECT: 2004 TRAFFIC STRIPING
2. SUMMARY STATEMENT: The bid opening for this project was held on July 2,
2004, with four bids received. The low bid was submitted by Stripe Rite, Inc. in the
amount of$42,190.00. The Engineer's estimate was $44,467.00. The Public Works
Director recommends awarding the contract to Stripe Rite, Inc. in the amount of
$42,190.00.
3. EXHIBITS: Public Works Director's memorandum
4. RECOMMENDED BY: Public Works Director
(Committee, Staff, Examiner, Commission, etc.)
5. FISCAL IMPACT
Expenditure? X Revenue?
Currently in the Budget? Yes X No
If no:
I Unbudgeted Expense: Fund Amount $
Unbudgeted Revenue: Fund Amount $
6. CITY COUNCIL ACTION:
Councilmember moves, Councilmember seconds ,
d2oo� Tra-F{-,c S�i'�P�r�
to authorize the Mayor to enter into a contract award the South 192nd/Springbrook
ts
Creek Culvert Replacement contract to N. �' , Inc. in the amount of
DISCUSSION:
ACTION:
Council Agenda
Item No. 8A
PUBLIC WORKS DEPARTMENT
I Don E. Wickstrom, P E Public Works Director
• Phone 253-856-5500
Fax 253-856-6500
KEN T Address 220 Fourth Avenue S
WASHINGTON
Kent,WA 98032-5895
July 20 2004
TO- Mayor White and Kent City Council
FROM. Don Wickstrom, Public Works Director
RE 2004 Traffic Striping
Bid opening for this project was held on July 2, 2004 with four bids received. The low bid was
submitted by Stripe Rite, Inc. in the amount of $42,190 00 The Engineer's estimate was
$44,467.00 The Public Works Director recommends awarding this contract to Stripe Rite, Inc
Bid Surnin
Stripe Rite, Inc. $42,190.00
Apply-A-Line, Inc $44,595 00
Road Runner Striping, Inc. $44,796 80
Specialized Pavement Marking, Inc $46,710 00
Engineer's Estimate $44,467.00
i
1
1
REPORTS FROM STA ING�COMMITTEES AND STAFF
A. COUNCIL PRESIDENT U
B. OPERATIONS COMMITTEE o� uCe�✓1 �� """�� ' `"' U
C. PUBLIC SAFETY COMMITTEE h y��- Q=:LA�
D. PUBLIC WORKS
E. PLANNING AND ECONOMIC DEVELOPMENT COMMITTEE
F. PARKS AND HUMAN SERVICES COMMITTEE
G. ADMINISTRATIVE REPORTS
REPORTS FROM SPECIAL COMMITTEES
OPERATIONS COMMITTEE MINUTES
JUNE 15,2004
Committee Members Present: Chair Tim Clark and Bruce White
Julie Peterson was absent, however, had previously concurred with Chair Tim Clark on agenda
items 1, and 2.
The meeting was called to order by Tim Clark, Chair at 4.02 p.m.
APPROVAL OF MINUTES DATED MAY 18, 2004
Bruce White moved to approve the minutes of the May 18, 2004, Operation Committee
meeting. The motion was seconded by Tim Clark and passed 3-0. Julie Peterson previously
concurred on this agenda item.
APPROVAL OF VOUCHERS DATED MAY 31,2004
Chief Administrative Officer Mike Martin presented the vouchers for May 31, 2004, for approval.
Bruce White moved to approve the vouchers dated May 31, 2004. Tim Clark seconded the
motion,which passed 3-0. Julie Peterson previously concurred on this agenda item.
POLICE MDC REPLACEMENTS
Information Technology Director Stan Waldrop presented the Police MDC Replacements request
to purchase 34 semi-ruggedized laptop computers from CDW*G to replace existing mobile data
computers in Police vehicles. The Police Department has 47 mobile data computers (MDCs).
These are semi-ruggedizd laptop computers used for data communication with Valley
Communication Center which have a normal replacement interval of 4 years. These workstations
are on a 3-year replacement cycle due to the more strenuous environment in which they operate
The laptops would be paid from the 2002 Technology Plan in the amount of$76,000.
Bruce White moved to recommend the Council authorize the Mayor to sign purchase orders
for replacement MDCs, payable to CDW*G, not to exceed $76,000. Tim Clark seconded the
motion,which passed 2-0.
OWEST PBX MAINTENANCE CONTRACT
Information Technology Director Stan Waldrop presented the Qwest PBX Maintenance Contract
A competitive RFP process was conducted to procure a vendor to maintain the City's PBX
telephone system. The City received responses from seven (7) vendors and Qwest Interprise
Services was the successful vendor from this process The process resulted in a reduction of the
City's PBX maintenance costs by over$15,000. Mr Waldrop advised the budget impact would be
approximately $33,000 annually, which is currently included in the 2004 Operating Budget,
depending on equipment placed in or removed from service.
Bruce White moved to recommend the Council authorize the Mayor to sign a contract
renewal with Qwest Interprise Services PBX Maintenance Services subject to City Attorney
approval of the contract documents. Tim Clark seconded the motion,which passed 2-0.
BUDGET APPROPRIATION FOR SPECIAL ELECTION ORDINANCE AND THE
BALLOT PROPOSITION—REAL PROPERTY TAX LEVY RATE ORDINANCES
Chief Administrative Officer Mike Martin presented the Budget Appropriation For Special
Election Ordinance together with the Ballot Proposition — Real Property Tax Levy Rate
Ordinances.
He advised that the King County Department of Records and Election Bureau has estimated that
the cost of a special election for the purpose of the consideration of a Levy Lid Lift for the City of
Kent will cost approximately $100,000. There are no funds currently in the budget for this
purpose. This ordinance will appropriate that amount from the fund balance in the General Fund
As a potential exists of a significant reduction in the property tax levy of the City, the
administration recommends that we make contingency plans in the event this occurs This
planning may include this special election and potentially planning for a second election in
November depending on other events that may occur in early July. The administration believes
that this planning is a prudent step given the potential impact that could occur to governmental
services This budget ordinance will reduce the General Fund balance by $100,000.
Mr. Martin further advised the Operations Committee that if approved at the November 2, 2004,
general election, proposed Imtiative 864 would reduce the City's income tax revenue by twenty-
five (25) percent, which will cause a reduction in the City's general fund budget of over $5
million. If Initiative 864 is approved, the City will be forced to implement further significant
reductions in its labor force and in the services the City provides. However, if Kent voters were to
vote to permanently increase the City's maximum allowable regular real property tax levy rate by
about one cent per $1,000 of assessed value—from $2.76 to $2.77—the City's property tax rate
and revenues will then be exempt from the twenty-five (25) percent reduction proposed by
Initiative 864 In order for the proposition to be put before the voters at the September 14, 2004
special election and the November 2, 2004 general election, the City Council must pass a separate
ordinance for each election directing the City Clerk to submit the proposition to the King County
Records and Elections Division. The budget impact is estimated at $100,000 reduction in the
general fund balance. Committee members had numerous questions and comments regarding
agenda items 5 and 6 and wished to discuss both in further detail with the full Committee present
Bruce White moved to delay action on Items 5 and 6 of today's agenda and move them to the
next Operations Committee of June 6, 2004, with the intention that they would be placed on
Other Business for the July 6`" Council meeting, without a recommendation from the
Operations Committee. Tim Clark seconded the motion,which passed 2-0.
The meeting was adjourned at 4:28 p.m.
Renee Cameron
Operations Committee Secretary
3
PLANNING&ECONOMIC DEVELOPMENT COMMITTEE MINUTES
May 17,2004
COMMITTEE MEMBERS: Chair Tun Clark,Ron Harmon,Bruce White
The meeting was called to order by Chair Clark at 4.00 P.M.
Approval of Minutes of April 19,2004
Committee Member White moved and Committee Member Harmon seconded a motion to approve the
minutes of the April 19,2004 meeting The Motion carved 3-0
2004 Comprehensive Plan Update(#CPA-2002-1)
Planner Gloria Gould-Wessen explained the process by which Kent's Comprehensive Plan (the Plan) had
been updated. She summarized the update and focused on concerns identified in Council Study Sessions.
Ms. Gould-Wessen and Community Development Director Fred Satterstrom addressed the Committee's
concerns with the proposed language in Policy TR-6.6 for cul-de-sac streets and the history on connectivity
After discussion,the Committee agreed to return the original word "Limit"and remove the word"Prohibit'
Ms. Gould-Wessen explained the need for the Policy LU-9 1 on urban density and responded to the
Committee's concerns. After discussion, the Committee agreed to keep the word "Encourage" from an
earlier edited version of the policy and remove the word "Consider", so as to read "Encourage increasing
residential densities to four(4)units per net acre,...".
Council President Julie Peterson expressed concerns with either wording for Policy LU-9.1 Assistant City
Attorney Kim Adams Pratt responded to the Committee's questions concerning changing the language
further without holding a public hearing, and reaffirmed the aforementioned changes could be made with no
additional public hearings.
Ms. Gould-Wessen identified three (3) options for moving forward on Policy LU-9 1 The Committee
unanimously favored adding to Planning Services' 2004 Work Program the item to analyze all SF-1 and
SF-3 land use designations based on case law from the Growth Management Hearings Board on urban
density This matter would be brought forward in the following "Supporting Regulations (#CPA-2004-1)".
Ron Harmon moved and Bruce White seconded a motion to recommend approval of#CPA-2002-1 2004
Comprehensive Plan Update as recommended by the Land Use and Planning Board and forward to the full
City Council for adoption with amendments. Motion Carried 3-0.
2004 Comprehensive Plan Update-Supporting Regulations(#CPZ-2004-1)
Ms. Gould-Wessen outlined completed regulatory actions that support the 2004 Comprehensive Plan Update
(the Plan) and State GMA legislation, as well as regulatory actions presently in progress
Ms Gould-Wessen identified existing and future strategic or operating plans that support the Plan. She
announced that Public Works is generating a Comprehensive Transportation Plan and that Planning Services
is in the process of updating the Downtown Strategic Action Plan
Ms. Gould-Wessen explained that Titles 11, 12 and 15 of the City Code will be reviewed to assess
compliance with updates in the Plan and GMA legislation She described how staff proposes to take a
strategic approach in the development of regulations, using tools provided by state and regional agencies
involved in GMA.
Chair Clark voiced his concerns over County land use actions in Kent's PAA that conflict with the City's
land use policy on casinos and wanted to know how to protect the City's interests within the PAA Planning
Manager Charlene Anderson addressed Chair Clark's issues, stating that the GMA directs the City to
coordinate efforts with adjacent cities as well as the County
Bruce White moved and Ron Harmon seconded a motion to recommend approval of the process for review
of implementing regulations for the 2004 Comprehensive Plan Update via a resolution to be considered by
the City Council on June 15,2004. Motion Carried 3-0
Chair Clark adjourned the meeting at 5:10 p m.
Pamela Mottram,
Admin Secretary,Planning Services
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EXECUTIVE SESSION
A) PENDING LITIGATION
B) LABOR NEGOTIATIONS
ACTION AFTER EXECUTIVE SESSION