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HomeMy WebLinkAboutCity Council Meeting - Council - Agenda - 03/16/2010 I o� CITY OF KENT 4 City Council Meeting i Agenda I March 16, 2010 Mayor Suzette Cooke 4 Y t Jamie Perry, Council President r Councilmembers Elizabeth Albertson Ron Harmon Dennis Higgins r Deborah Ranniger Debbie Raplee KENT WASHINGTON Les Thomas CITY CLERK w�umiss r KENT CITY COUNCIL AGENDAS KENT March 16, 2010 WnSHi HG'o. Council Chambers MAYOR: Suzette Cooke COUNCILMEMBERS: Jamie Perry, President Elizabeth Albertson Ron Harmon Dennis Higgins Deborah Ranniger Debbie Raplee Les Thomas ********************************************************************** COUNCIL WORKSHOP AGENDA 5:30 p.m. Item Description Sneaker Time 1. Intergovernmental Issues Michelle Witham 10 minutes 2. Solid Waste Contract Tim LaPorte 50 minutes i ********************************************************************** COUNCIL MEETING AGENDA 7:00 p.m. 1. CALL TO ORDER/FLAG SALUTE 2. ROLL CALL 3. CHANGES TO AGENDA A. FROM COUNCIL, ADMINISTRATION, OR STAFF B. FROM THE PUBLIC - Citizens may request that an item be added to the agenda at this time. Please stand or raise your hand to be recognized by the Mayor. 4. PUBLIC COMMUNICATIONS A. Public Recognition B. Community Events C. Introduction of Yangzhou Resident/Student D. 2009 Employee of the Year E. Legislative Update F. Public Safety Report G. Police Department Swearing In Ceremony I 5. PUBLIC HEARINGS None 6. CONSENT CALENDAR A. Minutes of Previous Meeting - Approve B. Payment of Bills - Approve C. Premera Blue Cross Administrative Services Contract - Authorize D. LifeWise Assurance Contract - Authorize E. Group Health Cooperative Contract - Authorize F. Washington Dental Service Administrative Services Contract - Authorize (Continued) COUNCIL MEETING AGENDA CONTINUED G. Print Shop Copiers One-Year Lease - Authorize H. Washington Traffic Safety Commission Grant - Authorize and Accept I. Edward Byrne Memorial Grant Award - Accept, Authorize and Establish Budget J. Washington Auto Theft Prevention Authority Grant Award - Accept and Establish Budget K. Purchase of Sperian Personal Protective Equipment - Authorize L. Demonstration Cottage Housing Amendment Ordinance - Adopt M. Van Ness Contract for Federal Lobbyist Services - Authorize N. Kent Downtown Partnership Annual Contract - Authorize O. 2008 Downtown Sidewalks Schedule A - Accept as Complete P. Little Property Acquisition - Authorize 7. OTHER BUSINESS None 8. BIDS A. Turnkey Park Improvements 1 9. REPORTS FROM STANDING COMMITTEES, STAFF AND SPECIAL COMMITTEES 10. CONTINUED COMMUNICATIONS 11. EXECUTIVE SESSION AND AFTER EXECUTIVE SESSION A. Contract Negotiations 12. ADJOURNMENT 1 i 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 and complete packet are 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. man QnD Q< D »°=33 3 •° `nn arc Ao ° c m � Om � w �� = owoov o o m m y ? ° Q-w n 3 a� ao n saa n_w m o o �o ° w. 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CT vi r9 m m a Om N S •L7�p fD -O- m m o m c NF ° 3m < y Og w n O O _Z- w m n 3 COUNCIL WORKSHOP 1) INTERGOVERNMENTAL ISSUES I2) SOLID WASTE CONTRACT i t f 1 1 1 f t 1 i 1 i t 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 r j 1 i 1 r 1 r PUBLIC COMMUNICATIONS A) PUBLIC RECOGNITION iB) COMMUNITY EVENTS C) INTRODUCTION OF YANGZHOU RESIDENT/STUDENT D) 2009 EMPLOYEE OF THE YEAR i E) LEGISLATIVE UPDATE F) PUBLIC SAFETY REPORT rG) POLICE DEPARTMENT SWEARING IN CEREMONY Kent City Council Meeting Date March 16, 2010 Item No. 6A - 6B CONSENT CALENDAR 6. City Council Action: Councilmember moves, Councilmember seconds to approve Consent Calendar Items A through P. Discussion Action 6A. Approval of Minutes. Approval of the minutes of the regular Council meeting of March 2, 2010. 1 6B. Approval of Bills. Approval of payment of the bills received through January 31 and paid on January 15 after auditing by the Operations Committee on February 2, 2010. IApproval of checks issued for vouchers: Date Check Numbers Amount 1/15/10 Wire Transfers 4033-4044 $1,772,503.25 1/15/10 Regular Checks 639941-640347 3,670,843.56 Void Checks ($175.00) Use Tax Payable 846.92 $5,444,018.73 1 Approval of checks issued for interim payroll: Date Check Numbers Amount 1/5/10 Void Advice # 261059 ($84.25) 1/6/10 Check # 315907 84.25 1/12/10 Void Check # 315206 ($710.25) 1/12/10 Check # 315908 710 25 $ 0.00 Approval of checks issued for payroll for January 1 through January 15 and paid on January 20, 2010. Date Check Numbers Amount 1/20/10 Checks 315909-316144 $ 180,127.91 1/20/10 Advices 261283-262048 1,910,983.88 $2,091,111.79 Kent City Council Meeting N"47KE4T March 2 wAs„I. ra. , 2010 The regular meeting of the Kent City Council was called to order at 7:00 p.m. by Mayor Cooke. Councilmembers present: Albertson, Harmon, Higgins, Perry, and Ranniger. Councilmembers Raplee and Thomas were excused from the meeting. (CFN-198) CHANGES TO THE AGENDA A. From Council, Administration, Staff. (CFN-198) Public Communications Item E and Consent Calendar Items P and Q were added to the agenda. B. From the Public. (CFN-198) Continued Communications Item A was added to the agenda. PUBLIC COMMUNICATIONS A. Public Recocinition. (CFN-198) Mayor Cooke reported that former Police Chief Jay Skewes recently passed away. B. Community Events. (CFN-198) Ranniger announced the upcoming Student Art Walk and Kent Kids Art Day. C. Kent Predators. (CFN-198) Director of Operations Jim Granacker and Head Coach McCarthy explained arena football, after which the players and members of the dance team introduced themselves. Mayor Cooke welcomed them to Kent and 1 encouraged everyone to attend the games. D. Economic and Community Development Report. (CFN-198) Ben Wolters gave an update of recent developments including opening a portion of the Kent Highlands Landfill for future development, construction of a large restaurant at the Kent Events Center, and the submission of a letter of interest regarding the Federal Aviation Administration Regional Headquarters. E. Legislative Report. (CFN-198) Doug Levy updated the status of issues including flooding, streamlined sales tax mitigation, brokered natural gas tax, street maintenance utility, transportation, and unfunded mandates, and answered questions about funding for State Route 509. CONSENT CALENDAR Perry moved to approve Consent Calendar Items A through Q. Ranniger seconded and the motion carried. A. Approval of Minutes. (CFN-198) Minutes of the regular Council meeting of February 16, 2010, were approved. B. Approval of Bills. (CFN-104) Figures were not available. ' 1 Kent City Council Minutes March 2, 2010 C. Joint Resolution Reauesting Local Voters Pamphlet on the Regional Fire Authority. (CFN-122) Resolution No. 1822 requesting the publication and distribution of a Local Voters' Pamphlet for Ballot Proposition No. 1, was adopted. D. Fiber Optic Installation Proiects Resolution. (CFN-1155) Resolution No. 1823, which authorizes the Mayor to enter into an agreement with other Washington municipalities for the sharing of fiber optic installation projects was adopted. E. 2009 Consolidated Annual Performance Evaluation Report. (CFN-118) , The Mayor was authorized to submit the 2009 Consolidated Annual Performance , and Evaluation Report to the U.S. Department of Housing and Urban Development. F. 2010 City Art Plan and Five-Year Art Plan. (CFN-118) The 2010 City Art Plan and Five Year Plan was approved. G. Energy Savings Performance Contract for Centennial Center HVAC Systems. (CFN-120) The Mayor was authorized to sign the Energy Savings Performance Contract with McKinstry Essention Incorporated in the amount of $1,435,208, to replace the HVAC system components in the Centennial Center, subject to final terms and conditions acceptable to the City Attorney. H. Jaswal Dental/Medical Clinic Bill of Sale. (CFN-484) The Bill of Sale for the Jaswal Dental/Medical Clinic, permit #2083712, for 2 watermain gate valves, 2 watermain hydrants, and 114.6 linear feet of water line was accepted. I. Kent Meridian High School Water Upgrades Bill of Sale. (CFN-484) The , Bill of Sale for Kent Meridian High School Water Upgrades, permit #2083936, for 16 watermain gate valves, 7 watermain hydrants, and 2000 linear feet of water line was accepted. J. Scalzo Intersection Bill of Sale. (CFN-484) The Bill of Sale for the Scalzo Intersection, permit #2052892, for 1,297.2 linear feet of new street; 2 storm sewer manholes, 2 catch basins, and 431.9 linear feet of storm sewer line was accepted. K. Clark Lake Estates Improvements. (CFN-1038) The Mayor was authorized to accept the improvements to the Clark Lake Estates as complete and cause the transfer of said infrastructure to the City. L. Cambridge Tower Site Lease Amendment. (CFN-122) The Mayor's execution of an addendum to Cambridge Tower Site Lease with Valley Communications was ratified. ' M. Goldfinch Communications Telecommunications License Agreement. (CFN-1155) The Mayor was authorized to sign a non-exclusive License Agreement , with Goldfinch Communications, LLC for it to construct, install, maintain, repair, and operate a telecommunications system using the City's rights-of-way, subject to final agreement terms and conditions acceptable to the City Attorney. Goldfinch Communications, LLC has completed the City's telecommunications license 2 ' II Kent City Council Minutes March 2, 2010 application and paid the applicable fee. The telecommunications system will allow the transmission of information through wire, radio, optical cable, electromagnetic, or other similar means. This License Agreement is non-exclusive and allows the City to terminate it at any time with 90 days advance written notice. N. Public Works Board Urban Vitality Grant for James Street at Union Pacific Railroad Non-motorized Improvements. (CFN-1038) The Mayor was authorized to sign the agreement with the Washington State Public Works Board for an Urban Vitality Grant in the amount of $235,000 for the James Street @ UPRR Non-motorized Improvements Project, inclusion of a capital line item in the 2011 budget in the amount of $235,000 for City matching funds was authorized, and expenditure of the funds was authorized. ' O. Water Treatment Chemical Supply Contract. (CFN-675) The Mayor was authorized to sign the 2010 Water Treatment Chemical Supply Agreement between the City of Kent and Cascade Columbia Distribution for Sodium Fluoride in the amount of $37,705. REPORTS A. Council President. (CFN-198) No report was given. B. Mayor. (CFN-198) Mayor Cooke gave an update on animal control, the library remodel, her appointment to the King County Transit Task Force, and the recent King County Flood Control District meeting. C. Operations Committee. (CFN-198) Perry noted that grandfathering of the casino in the Panther Lake annexation area will be discussed at the next meeting on March 16. 1 D. Parks and Human Services Committee. (CFN-198) Ranniger noted that an off-lease dog park will be coming to East Hill this summer. E. Economic & Community Development Committee. (CFN-198) Perry noted that the first public hearing on annexation zoning will be held by the committee at 5:00 p.m. on Monday, March 81t F. Public Safety Committee. (CFN-198) No report was given. G. Public Works Committee. (CFN-198) Harmon said at the last meeting they received an update on selection of garbage contractors and on the Howard Hanson Dam. H. Administration. (CFN-198) Hodgson distributed a fact sheet on the FAA project, and explained the choices the Council will have regarding gambling within ' the annexation area. CONTINUED COMMUNICATIONS A. Strenathenina the Community. (CFN-198) Pastor Daniels of Unified in Faith Ministries, 24624 1041h Place SE, Kent, gave the background of the church and said 3 Kent City Council Minutes March 2, 2010 they want to be part of the community. He offered to help the City resolve , problems, and noted that they will be doing a door-to-door survey to determine the ' needs of people in the community. Mayor Cooke offered to meet with him and introduce him to people and programs who could help. ADJOURNMENT The meeting adjourned at 8:00 p.m. (CFN-198) I Brenda Jacober, CMC City Clerk ' 4 i ' Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6C 1. SUBJECT: PREMERA BLUE CROSS ADMINISTRATIVE SERVICES CONTRACT - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign the Premera Blue Cross 2010 administrative contract. The City is self-insured for this program. The 2010 contract reflects a 6% increase in administrative fees by Premera Blue Cross and is budgeted in the Health & Welfare fund. 2010 is the second year of a three-year contract with Premera Blue Cross. Premera Blue Cross agreed to rate guarantees for each of the two consecutive years. Next year, the final year for rate guarantees from Premera Blue Cross, is 3.75% for 2011. The annual cost for 2010 is approximately $690,143 and the projected budget for the self-insured Premera Blue Cross program, including claims for 2010, is $10,008,504. 3. EXHIBITS: Premera Blue Cross 2010 Administrative Services Contract 4. RECOMMENDED BY: Operations Committee (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: ' Councilmember moves, Councilmember seconds DISCUSSION: iACTION: ' ADMINISTRATIVE SERVICE CONTRACT BETWEEN PREMERA BLUE CROSS AND CITY OF KENT ' EFFECTIVE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010 (The "Contract Period") ' This Contract is effective by and between the group named above (hereinafter referred to as the "Plan Sponsor'), and Premera Blue Cross (hereinafter referred to as the "Claims Administrator" or"we," "us," or"our") WHEREAS, the Plan Sponsor has established an employee benefit plan (hereinafter referred to as the "Plan") which provides for payment of certain welfare benefits to and for certain eligible individuals as defined in writing by the Plan Sponsor, such individuals being hereinafter referred to as "Members", and, ' WHEREAS, the Plan Sponsor has chosen to self-insure the benefit program(s) provided under the Plan, and WHEREAS, the Plan Sponsor desires to engage the services of the Claims Administrator to provide administrative services for the Plan, NOW THEREFORE, in consideration of the mutual covenants and conditions as contained herein the parties hereto agrae to the provisions in this Contract, including any Attachments and endorsements thereto The parties below have signed as duly authorized officers and have hereby executed this Contract If this Contract is not signed and returned to the Claims Administrator within sixty (60)days of its delivery to the Plan Sponsor or its agent, the Claims Administrator will assume the Plan Sponsor's concurrence and the Plan Sponsor will be bound by its terms IN WITNESS WHEREOF the parties hereto sign their names as duly authorized officers and have executed this Contract CITY OF KENT ' BY DATE. Title ADDRESS Premera Blue Cross BY DATE January 1, 2010 H.R. Brereton Barlow President and Chief Executive Officer P O Box 327 Seattle, WA 98111-0327 ' ADSERV-ASC (01-2010) r TABLE OF CONTENTS 1. DEFINITIONS..........................................................................................................................1 e 2. DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR.............................................1 21 Documentation 1 , 22 Plan Sponsor's Fiduciary Authority 1 23 Defense of the Plan 1 24 Administrative Duties 1 25 Taxes, Assessments, and Fees 2 ' 26 Compliance With Law 2 27 Appeals 3 28 Funding ... 3 3. DUTIES AND RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR ............................3 3 1 Administrative Duties 3 ' 3 2 Appeals 4 33 Claims Processing 4 34 Funding Support 4 35 Annual Accounting 4 4. LIMITS OF THE CLAIMS ADMINISTRATOR'S RESPONSIBILITY.......................................5 41 Recoveries 5 , 4 2 Independent Contractor 5 4 3 Limits of Liability 5 5. FEES OF THE CLAIMS ADMINISTRATOR ...........................................................................5 5 1 Payment Time Limits 5 5 2 Late Payments 5 5 3 Customization Fees 6 6. AUDIT......................................................................................................................................6 , 7. SUBROGATION......................................................................................................................6 8. TERM OF CONTRACT............................................................................................................6 8 1 Contract Period 6 ' 8 2 Changes to Fees 7 9. TERMINATION........................................................................................................................7 , 9 1 Termination With Notice 7 9 2 Contract Period Expiration 7 , 9 3 Termination Due to Insolvency 7 9 4 Termination Due to Inability to Perform 7 City of Kent January 1,2010 1018212 ' i y 9 5 Termination For Nonpayment 8 9 6 Plan Sponsor Liability Upon Termination 8 9 7 Final Accounting 8 i9 8 Claims Runout 8 10. DISCLOSURE .......................................................................................................................8 11. OTHER PROVISIONS...........................................................................................................8 11 1 Choice of Law 8 11 2 Proprietary Information 9 11 3 Parties To The Contract 9 i 114 Notice 9 115 Integration 9 116 Assignment. . 9 12. ATTACHMENTS TO THE ADMINISTRATIVE SERVICE CONTRACT..............................10 ATTACHMENT A — BLUECARD® PROGRAM.........................................................................11 Liability Calculation Method Per Claim 11 BlueCard Worldwide 12 ' BlueCard Fees and Compensation -Overview 12 Access Fees 12 ' How Access Fees Affect The Plan 12 ATTACHMENT B — CENSUS INFORMATION..........................................................................13 ATTACHMENT C — REPORTING..............................................................................................14 ATTACHMENT D — FEES OF THE CLAIMS ADMINISTRATOR.............................................. 15 i ATTACHMENT E — BUSINESS ASSOCIATE AGREEMENT...................................................17 ATTACHMENT F — CARE FACILITATION................................................................................18 ATTACHMENT G — EXTENDED POST-PAYMENT RECOVERY SERVICES.......................... 19 ATTACHMENT H — DISEASE MANAGEMENT ........................................................................21 Appendix 1 Program Selection 22 City of Kent January 1,2010 ' 1018212 i 1. DEFINITIONS ' Adverse Benefit Determination Any of the following a denial, reduction, or termination of, or a failure to ' provide or make payment(m whole or in part)for, a benefit, including payment that is based on a determination of the eligibility of a Member to participate in the Plan This includes any denials, reductions, or failures to provide or , make payment resulting from the application of utilization review or limitations on experimental and investigational services, medical necessity, or appropriateness of care Contract Period The period shown on the Face Page of this Contract The Contract Period begins at 12 01 a m on the starting date shown on the Face Page and ends at midnight on the ending date shown on the Face i Page Effective Date The date this Contract takes effect (the first day of the Contract Period) The Effective Date is ' shown on the Face Page of this Contract Member A Subscriber or dependent who is eligible for coverage as stated in the Plan and who is enrolled as required in the Plan PEPM "Per employee per month " Plan The employee benefit plan established and maintained by the Plan Sponsor that is being administered under this Contract i Subscriber A person who is eligible for coverage under the plan by virtue of an employee-employer relationship or other relationship between the person and the Plan Sponsor, and who is enrolled as required in the Plan 2. DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR ' 2.1. Documentation , The Plan Sponsor shall provide the Claims Administrator with a copy of any documents describing the benefit program(s)that the Claims Administrator needs to rely upon in performing its responsibilities under this Contract. , 2.2. Plan Sponsor's Fiduciary Authority The Plan Sponsor shall have final discretionary authority to determine the benefit provisions and to construe and interpret the terms of the Plan ' The Plan Sponsor shall have final discretionary authority to determine eligibility for benefits and the amount to be paid by the Plan 2.3. Defense of the Plan , The Plan Sponsor shall be responsible for defending any legal action brought against the Plan, including a claim for benefits by or on behalf of any individual or entity, including but not limited to any Member or former Member, , any fiduciary or other party This responsibility includes the selection and payment of counsel The Plan Sponsor shall not settle any legal action or claim without the prior consent of the Claims Administrator if the action or claim could result in the Claims Administrator being liable, including for example, any liability for contribution to or ' indemnification of the Plan Sponsor or other third party either directly or indirectly 2.4. Administrative Duties Unless specifically delegated to the Claims Administrator by this Contract, the Plan Sponsor shall be responsible ' for the proper administration of the Plan including the following a The Plan Sponsor shall provide the Claims Administrator a complete and accurate list of all individuals eligible for benefits under the benefit program(s) and to update those lists monthly The Claims ' Administrator shall be entitled to rely on the most recent list until it receives documentation of any change thereto Retroactive enrollments shall be effective on the earlier of two dates , City of Kent 1 January 1,2010 1018212 , r • The date the member's coverage would have been validly in force ' • The first day of the fifth full calendar month preceding the month in which the Claims Administrator receives the request for retroactive enrollment ' Retroactive terminations of coverage shall be effective on the earlier of two dates • The date the member's coverage would have been terminated, had notification been timely • The first day of the fifth full calendar month preceding the month in which the Claims Administrator ' receives the request for retroactive termination b The Plan Sponsor shall distribute to all eligible Members all appropriate and necessary materials and documents, including but not limited to benefit program booklets, summary plan descriptions, material ' modifications, enrollment applications and notices required by law or that are necessary for the operation of the Plan c The Plan Sponsor shall provide the Claims Administrator with any additional information necessary to perform its functions under this Contract as may be requested by the Claims Administrator from time to time d. If the Plan Sponsor writes or revises its benefit booklet, the Claims Administrator must review and approve in advance the draft of the benefit booklet that is printed and distributed to Members The Plan Sponsor must also include BlueCard disclosure language approved by the Blue Cross Blue Shield Association in its booklet ' 2.5. Taxes, Assessments, and Fees The Plan Sponsor shall be responsible for all taxes, assessments and fees levied by any local, state or federal ' authority in connection with the Claims Administrator's duties pursuant to this Contract 2.6. Compliance With Law • The Plan Sponsor shall be responsible for the Plan's continuing compliance with all applicable federal, state and local laws and regulations, as currently amended These include but are not limited to • The Internal Revenue Code ' The Health Insurance Portability and Accountability Act of 1996 (HIPAA) • The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) ' Law and regulations governing the treatment and benefits of members covered by Medicare These include, but are not limited to, the Medicare Secondary Payer law and regulations and the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) As required by MMSEA, the Plan Sponsor agrees to provide us the following information ' 0 Employer Tax Identification Number (TIN/EIN), • Social Security Numbers (SSNs)of all members (employees and dependents), and ' 0 Medicare Health Insurance Claim Numbers (HICNs)for all Medicare-entitled members To comply with the Medicare Secondary Payer law and regulations, the Plan Sponsor also agrees to notify us promptly if the Plan Sponsor experiences a change in total employee count that would change the order of liability according to federal guidelines The Plan Sponsor, and not the Claims Administrator, is the "plan administrator" and the "plan sponsor"for purposes of all federal laws that apply to the Plan Sponsor and impose duties or obligations on such entities The Plan Sponsor shall be responsible for determining whether it is subject to COBRA and, if so, for notifying Members of their COBRA rights both initially and upon the occurrence of a qualifying event, for calculating and collecting premiums for COBRA continuation of coverage and for promptly notifying the Claims Administrator when an individual is no longer eligible for COBRA continuation of coverage If the Plan Sponsor is subject to ERISA, the Plan Sponsor is responsible to prepare and maintain its ERISA plan document ' If the Plan Sponsor elects to opt out of compliance with certain federal mandates as allowed by HIPAA, the Plan Sponsor is responsible to file its opt-out with federal regulators for each contract period and to City of Kent 2 January 1,2010 1018212 notify Members of the opt-out in accordance with federal law and regulations then in effect The Plan ' Sponsor agrees to hold the Claims Administrator and the Network harmless for any and all consequences arising from the Plan Sponsor's failure to file an opt-out as required by law for a given contract period, errors in the opt-out filing, or failure to notify a Member as required by federal law 2.7. Appeals , If an adverse decision is made in the Claims Administrator's second level of review of a Member appeal, the Plan Sponsor shall offer the Member a review by an Independent Review Organization (IRO) The Plan Sponsor shall ' pay all costs of the IRO review 2.8. Funding The Plan Sponsor shall be solely liable for all benefits payable to members under the Plan that are subject to this ' Contract The Plan Sponsor agrees to the following a Provision Of Funds The Plan Sponsor shall maintain adequate funds from which the total cost of all claims for each preceding week will be paid to the Claims Administrator by electronic funds transfer ' (EFT) Funds must be provided within two (2) business days of notification by the Claims Administrator to a person designated by the Plan Sponsor b Late Payments If timely payment for the claims is not received by the Claims Administrator, the Plan Sponsor shall pay the Claims Administrator a daily late charge This late charge is calculated from the first day following the period of two (2) business days stated above This late charge is based on the average monthly prime rate posted by Claims Administrator's designated bank during the Contract ' Period, plus two (2) percent on the amount of the late payments for the number of days late Late charges are due at the end of the Contract Period as part of the annual accounting or, if earlier, upon termination of the Contract c Notices Notices required by this subsection and subsection 3 4 shall be by secure e-mail unless , another method is agreed upon in writing by the Plan Sponsor and the Claims Administrator 3. DUTIES AND RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR ' 3.1. Administrative Duties ' The Claims Administrator agrees to perform the following administrative services for the Plan Sponsor The Claims Administrator shall a assist in the preparation and printing of the benefit program booklets, identification cards, and other ' materials necessary for the operation of the Plan, and distribute identification cards to Members The Claims Administrator shall be responsible to include approved BlueCard program disclosure ' language in the booklets it prepares If the Plan Sponsor prepares its own booklets, the Claims Administrator shall provide approved language to the Plan Sponsor for inclusion in the booklets, b perform reasonable internal audits as stated in section 6 of this Contract, , c answer inquiries from the Plan Sponsor, Members, and service providers regarding the terms of the Plan, although final authority for construing the terms of the Plan's eligibility and benefit provisions is the Plan Sponsor's, ' d prepare and provide the Plan Sponsor with reports of the operations of the Plan in accordance with "Attachment C— Reporting", e coordinate with any stop-loss insurance carrier, , f when "preferred provider"or"network provider" benefits are provided, maintain a network of hospital and professional providers, paid claims will reflect any applicable provider discounts, g perform care facilitation services as identified in "Attachment F—Care Facilitation " h provide a Certificate of Group Health Coverage to Members when their coverage under this Plan terminates or upon their request within 24 months of termination ' City of Kent 3 January 1,2010 1018212 i i i. Prescription drug rebates are guaranteed on a per-prescription basis The Claims Administrator will pay to the Plan Sponsor the full amount of guaranteed rebates received by the Claims Administrator in connection with the Plan Sponsor's pharmacy benefit utilization Payment shall be made to the Plan Sponsor on a calendar year quarterly basis unless agreed upon otherwise i3.2. Appeals a Member Appeals 1 The Claims Administrator shall review and respond to the initial appeals made by Members of Adverse Benefit Determinations (see section 1) as described in the benefit booklet provided by the Claims Administrator for this Plan The Claims Administrator shall also provide a second review of adverse Member appeal decisions made after its initial review This review will be conducted as described in the benefit booklet provided by the Claims Administrator for this Plan 2 If an adverse decision on a Member appeal is made in the Claims Administrator's second level of review, the Claims Administrator also agrees to facilitate a review of the appeal by an Independent Review Organization (IRO)on behalf of the Plan Sponsor The Claims Administrator will submit all documentation regarding the appeal to the IRO and work with the IRO as needed to complete its review The Claims administrator shall pass all costs of the IRO review on to the Plan Sponsor b. Provider Appeals ' Physicians who are Doctors of Medicine and Doctors of Osteopathy have the right to appeal to the Claims Administrator when an Adverse Benefit Determination is made because the care was not medically necessary or was experimental or investigational as defined by the Plan ' 1 If an Adverse Determination in paragraph b above results in a Member appeal, the physician's appeal will be addressed as part of the Member appeal process 2 The Claims Administrator will provide one level of review for physician appeals The submission time limit for the physician appeal shall be 180 days from the date of the Adverse Benefit Determination The Claims Administrator's response time limit shall be 60 days from the receipt of the appeal 3 Physician appeal rights include the right to review by an Independent Review Organization (IRO) if the provider receives an adverse decision on the internal appeal The Plan Sponsor is not responsible for the cost of the IRO review itself However, the Plan Sponsor will remain responsible for the funding of plan benefits if the IRO overturns the decision made on the Claims Administrator's internal review ' 3.3. Claims Processing The Claims Administrator shall process all eligible claims incurred after the Effective Date of this Contract which are properly submitted in accordance with the procedures set forth in the Plan Sponsor's benefit booklet The Claims Administrator shall make reasonable efforts to determine that a claim is covered under the terms of the Plan as described in the benefit booklet, to apply the coordination of benefits provisions, identify subrogation claims, and make reasonable efforts to recover subrogated amounts administratively as stated in section 7 of this Contract, and prepare and distribute benefit payments to Members and/or service providers 3.4. Funding Support i The Claims Administrator shall follow the steps below to facilitate the Plan Sponsor's funding of its Plan a Claim payment checks will be issued on the Claims Administrator's check stock However, as stated in subsection 2 8 above, the responsibility for funding benefits is the Plan Sponsor's and the Claims ' Administrator is not acting as an insurer b Each week, the Claims Administrator shall notify the Plan Sponsor of the amount due for the prior week's claims Notice will be by secure e-mail unless another method is agreed upon in writing by the Claims Administrator and the Plan Sponsor 3.5. Annual Accounting i Within 120 days of the end of the Contract Period, we shall perform an annual accounting of claims activity and report to the Plan Sponsor City of Kent 4 January 1,2010 1018212 4. LIMITS OF THE CLAIMS ADMINISTRATOR'S RESPONSIBILITY , It is recognized and understood by the Plan Sponsor that the Claims Administrator is not an insurer and that the Claims Administrator's sole function is to provide claims administration services and the Claims Administrator shall have no liability for the funding of benefits The Claims Administrator is empowered to act on behalf of the Plan Sponsor in connection with the Plan only as expressly stated in this Contract or as mutually agreed to in writing by the Claims Administrator and the Plan Sponsor This Contract is between the Claims Administrator and the Plan Sponsor and does not create any legal relationship between the Claims Administrator and any Member or any other individual 4.1. Recoveries If, during the course of an audit performed internally by the Claims Administrator as described in subsection 3 1 b above or by the Plan Sponsor pursuant to section 6 below, any error is discovered the Claims Administrator shall use reasonable efforts to recover any loss resulting from such error The Plan Sponsor does not cover Foot Orthotics for any diagnosis, which includes but is not limited to diabetes or corrective purposes The Claims Administrator agrees to reimburse the Plan Sponsor any Foot Orthotics claim payment made in error throughout the duration of this agreement unless such payment is recovered as stated in this subsection Error! Reference source not found. 4.2. Independent Contractor The Claims Administrator is an independent contractor with respect to the services being performed pursuant to this Contract and shall not for any purpose be deemed an employee of the Plan Sponsor 4.3. Limits of Liability , It is recognized by the parties that errors may occur and it is agreed that the Claims Administrator will not be held liable for such errors unless they resulted from its gross negligence or willful misconduct The Plan Sponsor agrees to defend, indemnify and hold harmless the Claims Administrator from all claims, damages, liabilities, losses and expenses arising out of the Claims Administrator's performance of administration services under the terms of this Contract, so long as they did not arise out of the Claims Administrator's gross negligence or willful misconduct 5. FEES OF THE CLAIMS ADMINISTRATOR ' 5.1. Payment Time Limits By the first of each month, The Plan Sponsor shall pay the Claims Administrator in accordance with the fee schedule set forth in "Attachment D — Fees Of The Claims Administrator" that is incorporated herein by reference 5.2. Late Payments a If, for any reason whatsoever, the Plan Sponsor fails to make a timely payment required under this Contract by the tenth day of the month in which payment is due, the Claims Administrator may suspend performance of services to the Plan Sponsor, including processing and payment of claims, until such time as the Plan Sponsor makes the required payment, including interest as set forth in c below ' b. In the event of late payment, the Claims Administrator may terminate this Contract pursuant to subsection 9 5 below Acceptance of late payments by the Claims Administrator shall not constitute a waiver of its right to cancel this Contract due to delinquent or nonpayment of fees c The Claims Administrator will charge interest to the Plan Sponsor on all payments received after the tenth day of the month in which they are due, including amounts paid to reinstate this Contract after termination pursuant to subsection 9 5 below, at the average prime rate posted by Claims Administrator's designated bank during the Contract Period plus two(2) percent on the amount of the late payments for the number of days late Interest will be in addition to any other amounts payable under this Contract City of Kent 5 January 1,2010 1018212 5.3. Customization Fees The Plan Sponsor shall pay the Claims Administrator a "customization fee"when the Plan Sponsor requests either of the following a. A plan benefit configuration that the Claims Administrator has not determined to be standard for the plan type Customization fees for nonstandard plan benefits assessed at this Contract's Effective Date are listed in "Attachment D — Fees Of The Claims Administrator" b. An off-anniversary benefit change, regardless of whether the desired benefit is standard for the plan type The customization fee for each off-anniversary change shall be $2,000 Customization fees for off- anniversary changes shall be invoiced separately to the Plan Sponsor For purposes of customization fees, "benefits" include eligibility, termination, continuation and benefit payment provisions, benefit terms, limitations, and exclusions, funding arrangement changes, and any other standard provisions of the Plan Fees are computed based on current administrative costs to implement and administer the benefit Customization fees for custom benefits that take effect on the Effective Date shown on the Face Page of this Contract are due and payable prior to that Effective Date Customization fees for off-anniversary benefit changes are due and payable prior to the effective date of the change 6. AUDIT Within thirty (30) days of written notice from the Plan Sponsor, the Claims Administrator shall allow an authorized agent of the Plan Sponsor to inspect or audit all records and files maintained by the Claims Administrator which are directly pertinent to the administration of the Plan for the current or most recently ended contract period Such documents shall be made available at the administrative office of the Claims Administrator during normal business hours The Plan Sponsor shall be liable for any and all fees charged by the auditor All audits shall be subject to the Claims Administrator's audit policies and procedures then in effect To the extent that the Plan l� Sponsor requests data and reports that are beyond the scope of the Claim Administrator's audit policies and procedures, the Plan Sponsor shall reimburse the Claims Administrator for the additional administrative costs incurred in producing such data and reports Any agent or auditor who has access to the records and files maintained by the Claims Administrator shall agree not to disclose any proprietary or confidential information used in the business of the Claims Administrator 7. SUBROGATION The Claims Administrator shall make reasonable efforts to pursue subrogation claims administratively on behalf of the Plan However, the Claims Administrator shall have no affirmative duty to pursue subrogation claims beyond those specified in subsection 3 3 above The Plan Sponsor shall have the sole discretion to bring any legal claim or action to enforce the Plan's subrogation provisions The Claims Administrator will cooperate with the Plan Sponsor in the event the Plan Sponsor brings any legal action to enforce the subrogation provisions of the Plan Any costs and attorneys'fees incurred in pursuing such subrogation claims shall be the responsibility of the Plan Sponsor 8. TERM OF CONTRACT 8.1. Contract Period The term of this Contract shall be the Contract Period shown on the Face Page of this Contract Except as stated otherwise in this section and in subsection 8 2 below, the terms and conditions of this Contract and the fee schedule set forth in "Attachment D— Fees Of The Claims Administrator" are established for the Contract Period The Claims Administrator reserves the right to amend this Contract at any time if needed to comply with applicable law or regulation City of Kent G January 1,2010 1018212 8.2. Changes to Fees The Plan Sponsor acknowledges that the fee schedule set forth in "Attachment D— Fees Of The Claims Administrator" and the services provided for in this Contract are based upon the terms of the Plan and the enrollment as they exist on the Effective Date of this Contract Any substantial changes, whether required by law , or otherwise, in the terms and provisions of the Plan or in enrollment may require that the Claims Administrator incur additional expenses The parties agree that any substantial change, as determined by the Claims Administrator, shall result in the alteration of the fee schedule, even if the alteration is during the Contract Period The phrase "any substantial change" shall include, but not be limited to a a fluctuation of ten (10) percent or more in the number of Members as set forth on the census information included in "Attachment B—Census Information"which is herein incorporated by reference and made a part of this Contract, b the addition of benefit program(s)or any change in the terms of the Plan's eligibility rules, benefit provisions or record keeping rules that would increase administration costs by more than $10,000; c any change in claims administrative services, benefits or eligibility required by law that would increase administration costs by more than $10,000, d any change in administrative procedures from those in force at the inception of this Contract that is agreed upon by the parties, e any additional services which the Claims Administrator undertakes to perform at the request of the Plan Sponsor which are not specified in this Contract such as the handling of mailings or preparation of statistical reports and surveys not specified in the Claims Administrator's standard Employer Group Reporting set 9. TERMINATION 9.1. Termination With Notice The Plan Sponsor may terminate this Contract at any time by giving the Claims Administrator thirty (30)days written notice 9.2. Contract Period Expiration This Contract will terminate on the last day of the Contract Period or the last day of any extension of the Contract Period granted by the Plan Administrator 9.3. Termination Due to Insolvency Either party may terminate this Contract effective immediately by giving written notice to the other if a party becomes insolvent, makes a general assignment for the benefit of creditors, files a voluntary petition of bankruptcy, suffers or permits the appointment of a receiver for its business or assets, or becomes subject to any proceeding under any bankruptcy or insolvency law, whether foreign or domestic A party is insolvent if it has ceased to pay its debts in the ordinary course of business, cannot pay its debts as they become due, or the sum of its debts is greater than the value of its property at a fair valuation 9.4. Termination Due to Inability to Perform If loss of services is caused by, or either party is unable to perform any of its obligations under this Contract, or to enjoy any of its benefits because of natural disaster, action or decrees of governmental bodies or communication failure not the fault of the affected party, such loss or inability to perform shall not be deemed a breach The party who has been so affected shall immediately give notice to the other party and shall do everything possible to resume performance Upon receipt of such notice, all obligations under this Contract shall be immediately suspended If the period of nonperformance exceeds thirty (30) days from the receipt of such notice, the party whose performance has not been so affected may, as its sole remedy, terminate this Contract by written notice to the other party effective immediately In the event of such termination, the Plan Sponsor shall remain liable to the Claims Administrator for all payments due, together with interest thereon as provided for in subsection 5 2 c above City of Kent 7 January 1,2010 1018212 9.5. Termination For Nonpayment The Claims Administrator may, at its sole discretion, terminate this Contract if the period of nonpayment exceeds thirty (30)days from the date the payment becomes delinquent as outline in section 5 2 c 9.6. Plan Sponsor Liability Upon Termination In the event this Contract is terminated prior to the end of the Contract Period, the Plan Sponsor shall remain liable to the Claims Administrator for all delinquent sums together with interest thereon as provided for in subsection 5 2 c above Furthermore, the Claims Administrator will have incurred fixed costs which, but for the termination, would have been recouped over the course of the Contract Period Therefore, in the event that the Contract terminates pursuant to subsections 9 1 or 9 5 above, the Plan Sponsor shall also pay the Claims Administrator as liquidated damages, and not as a penalty, an amount equal to two (2) months administration fees This monthly fee shall be determined by multiplying the rate set forth in "Attachment D— Fees Of The Claims Administrator" multiplied by the average number of Members covered by the Plan for the immediately preceding six (6) month period or such shorter period if this Contract has not been in effect for a period of six (6) months The Plan Sponsor shall remain liable for claims incurred during the Contract Period but not paid during the Contract Period and for the claims run-out processing fee set forth in the "Fees Of The Claims Administrator' attachment 9.7. Final Accounting Within one hundred twenty (120)days of termination by either party, the Claims Administrator shall deliver to the Plan Sponsor an interim accounting Within fifteen (15) months of termination the Claims Administrator shall deliver to the Plan Sponsor a complete and final accounting of the status of the Plan At the expense of the Plan Sponsor, the Claims Administrator shall make available a record of deductibles and coinsurance levels for each Member and deliver this information to the Plan Sponsor or its authorized agent 9.8. Claims Runout The Plan Sponsor continues to be solely liable for claims received by the Claims Administrator after the Contract terminates For the fifteen (15)-month period following termination of this Contract, the Claims Administrator shall continue to process eligible claims incurred prior to termination, or adjustments to claims incurred prior to termination, that the Claims Administrator receives no more than twelve (12) months after the date of termination at the claims run-out processing fee rate set forth in "Attachment D—Fees Of The Claims Administrator" The runout processing charge will be due in full with the first request for claims reimbursement made during the runout period If the Claims Administrator receives claims for Plan benefits more than twelve (12) months after the date this Contract terminates, Claims Administrator shall deny those claims If the Plan Sponsor wants to negotiate a different arrangement, the Plan Sponsor must contact the Claims Administrator no later than the start of the fourteenth month after the date this Contract terminates This "Claims Runout" provision shall survive termination of this Contract 10. DISCLOSURE It is recognized and understood by the Plan Sponsor that the Claims Administrator is subject to all laws and regulations applicable to Claims Administrators and health care service contractors It is also recognized and understood by the Plan Sponsor that the Claims Administrator is not acting as an insurer and also is not providing stop-loss insurance 11. OTHER PROVISIONS 11.1. Choice of Law The validity, interpretation, and performance of this Contract shall be controlled by and construed under the laws of the state of Washington, unless federal law applies Any and all disputes concerning this Contract shall be resolved in King County Superior Court or federal court as appropriate City of Kent 8 January 1,2010 1018212 11.2. Proprietary Information The Claims Administrator reserves the right to, the control of, and the use of the words "Premera Blue Cross", "MSC Incorporated as Premera Blue Cross" and all symbols, trademarks and service marks existing or hereafter established The Plan Sponsor shall not use such words, symbols, trademarks or service marks in advertising, promotional materials, materials supplied to Members or otherwise without the Claims Administrator's prior written consent which shall not be unreasonably withheld The Claims Administrator's provider reimbursement information is proprietary and confidential to the Claims Administrator and will not be disclosed to the Plan Sponsor unless and until a separate Confidentiality Agreement is executed by the parties For the purposes of this section, "provider reimbursement information" means data containing, directly or indirectly (a) diagnostic, procedures or other code sets, and (b) billed amount, allowed amount, paid amount or any other financial information for network and non-network hospitals, clinics, physicians, other health care professionals, pharmacies and any other type of facility Such data may or may not specifically identify providers No other provision of this Contractor any other agreement or understanding between the parties shall supersede this provision 11.3. Parties To The Contract The Plan Sponsor hereby expressly acknowledges, on behalf of itself and all of its Members, its understanding that this Administrative Service Contract constitutes a Contract solely between the Plan Sponsor and the Claims Administrator, that the Claims Administrator is an independent corporation operating under a license with the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans (the "Association") permitting the Claims Administrator to use the Blue Cross Service Mark in the States of Washington and Alaska, and that the Claims Administrator is not contracting as the agent of the Association The Plan Sponsor further acknowledges and agrees that it has not entered into this Administrative Service Contract based upon representations by any person other than the Claims Administrator, and that no person, entity or organization other than the Claims Administrator shall be held accountable or liable to the Plan Sponsor for any of the Claims Administrator's obligations to the Plan Sponsor created under this Administrative Service Contract This provision shall not create any additional obligations whatsoever on the Claims Administrator's part other than those obligations created under other provisions of this Administrative Service Contract !� 11.4. Notice Except for the notice given pursuant to the "Funding"subsection of section 2, any notice required or permitted to be given by this Contract shall be in writing and shall be deemed delivered three (3) days after deposit in the United States mail, postage fully prepaid, return receipt requested, and addressed to the other party at the address as shown on the face page of this Contract or such other address provided in writing by the parties 11.5. Integration This Contract, including any appendices or attachments incorporated herein by reference, embodies the entire Contract and understanding of the parties and supersedes all prior oral and written communications between them Only a writing signed by both parties hereto hereof may modify the terms 11.6. Assignment Neither party shall assign this Contract or any of its duties or responsibilities hereunder without the prior written approval of the other City of Kent 9 January 1,2010 1018212 12. ATTACHMENTS TO THE ADMINISTRATIVE SERVICE CONTRACT The following attach to and become part of the body of this Contract and they are herein incorporated by reference ATTACHMENT A —BLUECARDO PROGRAM ATTACHMENT B —CENSUS INFORMATION ATTACHMENT C— REPORTING ATTACHMENT D— FEES OF THE CLAIMS ADMINISTRATOR ATTACHMENT E—BUSINESS ASSOCIATE AGREEMENT ATTACHMENT F—CARE FACILITATION ATTACHMENT G—EXTENDED POST-PAYMENT RECOVERY SERVICES ATTACHMENT H—DISEASE MANAGEMENT City of Kent 10 January 1,2010 1018212 ATTACHMENT A — BLUECARDO PROGRAM Premera Blue Cross, like all Blue Cross and/or Blue Shield Licensees, participates in a program called "BlueCard " Whenever Members access health care services in Clark County, Washington or outside Washington and Alaska, the claim for those services may be processed through BlueCard and presented to us for payment Payment is made according to the terms and limitations of your plan document and network access rules in the BlueCard Policies then in effect Under BlueCard, when Members receive covered services within the area served by another Blue Cross and/or Blue Shield Licensee (called the"Host Blue" in this section), Premera Blue Cross remains responsible for fulfilling our obligations under this contract The Host Blue will only be responsible for such services as contracting with providers and handling all interaction with contracting providers The Host Blue must perform these duties in accordance with applicable BlueCard Policies The financial terms of BlueCard are described generally below Liability Calculation Method Per Claim The amount the Member pays for covered services obtained in Clark County, Washington or outside Washington and Alaska through BlueCard is calculated on the lower of 1)the billed charges for the covered services, or 2) the "negotiated price"that the Host Blue passes on to Premera Blue Cross for the covered services Most often, the Plan Sponsor's liability for covered services processed through BlueCard is calculated on the same amount on which the Member's liability is calculated However, in rare cases required by the Host Blue's contract with the provider, the Plan Sponsor's liability will be calculated on the Host Blue's negotiated price even when that price exceeds the billed charge The methods used to determine the negotiated price will vary among Host Blues according to the terms of their provider contracts Often, the negotiated price will consist of a simple discount, which reflects the actual price allowed as payable by the Host Blue But, sometimes, it is an estimated price that factors in the Host Blue's expected settlements, withholds, any other contingent payment arrangements and non-claims transactions with the Member's health care provider or with a specified group of providers The negotiated price may also be a discount from billed charges that reflects an average expected savings with the Members health care provider or a specified group of providers The price that reflects average savings may result in greater variation above or below the actual price than will the estimated price In accordance with national BlueCard policy, these estimated or average prices will also be adjusted from time to time to correct for overestimation or underestimation of past prices However, the amount on which the Member's and the Plan Sponsor's payments are based remains the final price for the covered services billed on that claim In addition, if the Host Blue's negotiated price is an estimated or average price, as described above, some portion of the amount the Plan Sponsor pays may be held in a variance account by the Host Blue, pending settlement with its contracting providers Because all amounts paid are final, any funds held in a variance account do not belong to the Plan Sponsor and are eventually exhausted by provider settlements and through prospective adjustments to the negotiated prices Some states may mandate a surcharge or a method of calculating what Members must pay on a claim that differs from BlueCard's usual method noted above and is not pre-empted by federal law If such a mandate is in force on the date the Member received care in that state, the amounts the Member and the Plan Sponsor must pay for any covered services will be calculated using the methods required by that state's mandate Such methods might not reflect the entire savings expected on a particular claim The calculation methods described above in this section do not apply to BlueCard Worldwide claims Under BlueCard, recoveries from a Host Blue or from contracting providers of a Host Blue can arise in several ways Examples are antifraud and abuse audits, provider/hospital audits, credit balance audits, utilization review refunds, and unsolicited refunds In some cases, the Host Blue will engage third parties to assist in discovery or collection of recovery amounts The fees of such a third party are netted against the recovery Recovery City of Kent 11 January 1,2010 1018212 1 amounts, net of any fees, will be applied in accordance with applicable BlueCard Policies, which generally require correction on a claim-by-claim or prospective basis BlueCard Worldwide® If Members are outside the United States, the Commonwealth of Puerto Rico, Jamaica and the British and U S. Virgin Islands, they may be able to take advantage of BlueCard Worldwide BlueCard Worldwide is unlike the national BlueCard program in certain ways For instance, although BlueCard Worldwide provides a network of contracting hospitals, it offers only referrals to doctors When receiving care from doctors, Members will have to submit claim forms on their own behalf to obtain reimbursement for the services provided through BlueCard Worldwide BlueCard Fees and Compensation - Overview The Plan Sponsor understands and agrees to the following a. To pay certain fees and compensation to us which we are obligated under BlueCard to pay to the Host Blue, to the Blue Cross and Blue Shield Association, or to the BlueCard vendors These fees are billed to the Plan Sponsor as shown in "Attachment D— Fees Of The Claims Administrator " b That fees and compensation under BlueCard may be revised from time to time without the Plan Sponsor's prior approval in accordance with the Blue Cross and Blue Shield Association's standard provisions for revising fees and compensation under BlueCard Some of these fees and compensation are charged each time a claim is processed through BlueCard Examples of these are access fees (see "Access Fees" and "How Access Fees Affect The Plan" below), administrative 1 expense allowance fees, Central Financial Agency Fees and ITS Transaction Fees Also, some of these claim- based fees, such as the access fee and the administrative expense allowance fee, may be passed on to the Plan Sponsor as an additional claim liability Fees not charged for each claim are an 800 number fee and a fee for providing provider directories Access Fees Host Blues may charge the Claims Administrator an access fee for making their discounted rates and the resulting savings available on claims incurred by the Plan Sponsor's Members Access fees are based on the difference between the amount paid by the Host Blue and the amount this Plan would have paid if it had dealt with the out-of-area provider directly The access fee, if one is charged, may equal up to 10 percent of the Host Licensee's discount/differential savings, but may not exceed $2,000 per claim The access fee may be charged only if the Host Blue's arrangement with the provider prohibits billing Members for amounts in excess of the discounted rate However, providers may bill for deductibles, coinsurance, amounts in excess of stated benefit maximums, and charges for noncovered services In the event a participating provider discount cannot be passed along to the Member, no discount or access fee will apply How Access Fees Affect The Plan When the Claims Administrator is charged an access fee, it will be charged to the Plan Sponsor as a claims expense If the Claims Administrator receives an access fee credit, it will be given to the Plan Sponsor as a claims expense credit Access fees are considered a claims expense because they represent claims dollars the Plan Sponsor is unable to avoid paying Instances may occur in which the Claims Administrator does not pay a claim (or pays only a small amount) because the amounts eligible for payment were applied to the deductible and/or coinsurance In these instances, the Claims Administrator will pay the access fee and pass it along to the Plan Sponsor as a claims expense even though little or none of the claim was paid City of Kent 12 January 1,2010 1018212 ATTACHMENT B - CENSUS INFORMATION Administration Fees, effective January 1, 2010, are based on the following Number of Active and Retired Members: 2254 Employee Spouse Children Medical 856 516 882 Retiree 0 0 0 Number of COBRA Members: 14 Employee Spouse Children Medical 10 3 1 Other Carriers Offered: Group Health Cooperative City of Kent 13 January 1,2010 1018212 ATTACHMENT C - REPORTING A standard package of reports covering the Contract Period will be provided to the Plan Sponsor within the fees set forth in "Attachment D— Fees Of The Claims Administrator" The reports will cover • Earned premium • Paid claims • Census data • Claims summaries by • Provider type • Service type • Coverage type Please note that reports, format, and content may be modified from time to time as needed i t 1 t City of Kent 14 January 1,2010 1018212 i ATTACHMENT D — FEES OF THE CLAIMS ADMINISTRATOR Pursuant to the Administrative Service Contract, the Plan Sponsor shall pay the Claims Administrator the fees, as set forth below, for administrative services Administration Fee: $67 36 per employee per month Administration Fee Guarantee: Year 1/1/2010—12/31/2010 1/1/2011 — 12/31/2011 $61 68 PEPM (Stoploss not Administration Fee $58 39 PEPM (Stoploss purchased) purchased) $60 68 PEPM (Stoploss purchased) Disease Management $6 97 PEPM TBD Brokerage Fee $2 00 PEPM TBD Total Administration Fee $67 36 PEPM TBD Claims Runout Processing Fee: The charge for processing runout claims is an amount equal to the active administration fee at the time of termination, times the average number of subscribers for the 3-month period preceding the termination date, times two BlueCard Fee Amount: BlueCard Fees are tracked and billed monthly in addition to claims expense Care Facilitation: Included in Administration Fee See "Attachment F—Care Facilitation"for an overview of services provided Enhanced Disease Management (Package C) Extended Post-Payment Recovery Services: Claims Administrator will perform the services listed below on a pay-for-performance, contingent fee("Contingent Fee") basis, which shall be calculated as a percentage of the gross amount recovered with respect to any particular claim See "Attachment G — Extended Post-Payment Recovery Services" for an overview of services provided Post Payment Recovery Contingent Fee Category Coordination of Benefits 20% City of Kent 15 January 1,2010 1018212 Subrogation 20% unless claim requires engagement of outside counsel, in which case the Contingent Fee amount shall be 35% Provider Billing Errors 20% Credit Balance 20% Hospital Billing and Chart Review 20% a The Plan Sponsor may terminate the Calypso extended services section of this agreement at any point throughout the contract period within 30 days written notice to the Claims Administrator b. The Plan Sponsor can request that any subrogation case the Claims Administrator is pursuing on their behalf be dropped immediately with written notice from the Plan Sponsor c Continue Calypso Extended Recovery Services but reduce recovery fee to 20% d Remove Medicare COB and Other Insurance recoveries from the Extended Services Category on the basis, City of Kent works with Premera to provide accurate eligibility information on their Retiree population and capturing other coverage information from all City of Kent employees e Place a cap of$15,000 per claim which will only apply to the subrogation claims, with the caveat if claim has to go outside the typical recovery services and requires that legal council be involved, Premera can charge City of Kent for those related fees Premera has agreed to give City of Kent the option to approve claims that are referred out to legal council City of Kent 16 January 1,2010 1018212 ATTACHMENT E - BUSINESS ASSOCIATE AGREEMENT The Plan Sponsor should keep its signed business associate agreement behind this page City of Kent 17 January 1,2010 1018212 i ATTACHMENT F - CARE FACILITATION Claims Administrator agrees to provide the following care facilitation programs for the fees shown in"Attachment D— Fees Of The Claims Administrator " Service Description Care Management Prospective and retrospective review for medical Clinical review necessity, appropriate application of benefits Prospective review is not mandatory for provision of benefits Voluntary program to provide cost-effective alternatives for Case management care of complex or catastrophic conditions This service also educates members and assists members and providers in managing breast& lung cancer Includes preventive care programs for members Health Awareness Education immunization reminders, cancer screening reminders, and health education and information Includes provision of evidence-based clinical practice and Quality Programs preventive care guidelines to members and providers, chart tools, and quality of care program activities Prescription drug formulary Development of formulary and access to providers and promotion members on-line Physician-based pharmacy Physician education on cost-effective prescribing management ePocrates Software to provide physicians with up-to-date drug and plan formulary information Education for members using multiple drugs to review Polypharmacy prescriptions with their providers to decrease incidences of adverse drug interactions Follow-up with members and physicians to minimize Point-of-sale Pharmacy inappropriate or excessive drug therapies identified when drugs are dispensed Demand Management Round-the-clock access for members to RNs to answer questions about health care j City of Kent 18 January 1,2010 1018212 ATTACHMENT G - EXTENDED POST-PAYMENT RECOVERY SERVICES Claims Administrator shall provide a set of Extended Post Payment Recovery Services to the Plan Sponsor as described below Claims Administrator will perform these services on a pay-for-performance, contingent fee ("Contingent Fee") basis, which shall be calculated as a percentage of the gross amount recovered with respect to any particular claim Contingent Fees are shown in "Attachment D— Fees Of The Claims Administrator" Post Payment Recovery S Explanation of Services Category Claims Administrator's investigators and auditors will work to identify and pursue overpayments due to member's missing or inaccurate COB information Claims Administrator utilizes questionnaires and Coordination of Benefits interviews with providers, employers and members to determine if Plan Sponsor's plan is primary or secondary Claims Administrator's investigators, auditors and attorneys identify and pursue overpayments due to Subrogation opportunities Claims Administrator's research to obtain accurate subrogation information and determine group's subrogation rights include questionnaires and interviews with providers, employers and members as well as a review of medical records For verified overpayments Claims Administrator Subrogation manages attorney and member notification, files necessary liens, coordinates case documentation, and provides representation for arbitration hearings The Plan Sponsor will be pre-notified of Claims Administrator's intent to file suit and retains the right to authorize or deny any legal action Claims Administrator's post-payment editing programs and investigators and auditors perform additional screens and tests where billing information is inconsistent with age/services rendered or where Provider Billing Errors there appears to be up-coding or unbundling of services A recovery process is then employed to request and recover verified overpayments This service requires an on-site review of the provider's financial records and discussions with their staff Credit balances are verified as Credit Balance owed to Plan Sponsor and the source of the credit is determined The credit is reviewed with the provider and approved for payment back to Claims Administrator or the Plan Sponsor This service requires an on-site review of the member's medical charts ' and interviews with provider staff by registered nurses Calypso out- Hospital Billing and Chart sources the on-site review work to an independent vendor who ensures Review that • Service is consistent with diagnosis and billing is consistent with services City of Kent 19 January 1,2010 1018212 Post Payment Recovery Category Explanation of Services • There has been no unbundling of services, diagnosis up-coding or billing maximization • Services rendered were prescribed by the physician and the doctor's notes were signed • Standardized billing and payment policies were used jCalypso provides support for this vendor's efforts as well as processes i all recoveries City of Kent 20 January 1,2010 1018212 ATTACHMENT H — DISEASE MANAGEMENT Claims Administrator agrees to make available to the Group certain Disease Management Services provided by Healthways, Inc ("ANSI")as more particularly described in Appendix 1 attached hereto and incorporated herein (the"Services') Under its agreement with the Claims Administrator, AHSI, in its sole and absolute discretion, may upgrade or otherwise modify its Services Information and Data Initial Information. For Plan Sponsors who have had Administrative Services provided by the Claims Administrator for a period of 36 months or longer, the Claims Administrator will provide to AHSI on Plan Sponsor's behalf, a claims and eligibility data set determined necessary by AHSI and the Claims Administrator in mutually agreeable electronic format, for all Eligible Members for the prior thirty-six (36) months from anticipated Effective Date, or the period for which data is available, whichever is shorter This data shall be provided 90 days prior to the Plan Sponsor Effective Date through the date such file is produced For Plan Sponsors for whom the Claims Administrator does not have such data as determined necessary by AHSI and the Claims Administrator for the prior thirty-six(36) month period, the Plan Sponsor will attempt to obtain such data from the Plan Sponsors previous health plan(s), 90 days prior to the Plan Sponsor Effective Date AHSI and the Claims Administrator will cooperate with Plan Sponsor's effort in obtaining such data All such data shall be provided by the Plan Sponsor directly to AHSI in a mutually agreeable electronic format In the event AHSI charges the Claims Administrator for accepting such data, the Claims Administrator shall be entitled to pass such costs through to the Plan Sponsor Failure or Inability to Provide Data The Parties recognize that the provision of data referenced above is critical to the success of the disease management services Therefore, the Plan Sponsor agrees that its failure to provide all data referenced above in a timely fashion may, at the Claims Administrator's option, affect the terms, range and availability of Services available to the Plan Sponsor In the event that at least twenty-four (24) months of historical data is not available, then the Claims Administrator shall adjust reporting and measurement requirements for such Plan Sponsor General Provisions • The parties understand, acknowledge and agree that the services provided to the Plan Sponsor hereunder are designed for application generally to the entire population of Plan Sponsor members eligible for such services and not for application to each and every such member Neither the Claims Administrator nor AHSI represent or warrant that the services provided pursuant to this Attachment will be applied or made with respect to each and every eligible member The Claims Administrator and AHSI will, however, use commercially reasonable efforts in their attempt to apply such services so that as many eligible members receive such services as appropriate and practicable • Severability In the event that any provision hereof is found invalid or unenforceable pursuant to judicial decree or decision, the remainder of this Attachment shall remain valid and enforceable according to its terms City of Kent 21 January 1,2010 1018212 Appendix 1 Program Selection Elected Package Package C (Enhanced) Diabetes, Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Asthma, Impact Conditions I t i 1 - I City of Kent 22 January 1,2010 1018212 Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6D 1. SUBJECT: LIFEWISE ASSURANCE CONTRACT - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the transfer of the City's stop loss insurance coverage to LifeWise Insurance Company, authorize the Mayor to sign all documents necessary to implement the transfer, and ratify all acts consistent with the authority of this motion. The City currently contracts with Sun Life Assurance Company of Canada for stop loss coverage. Sun Life quoted a 10% increase for 2010 stop loss insurance while LifeWise Insurance Company's quote was a 5.5% increase for 2010. Moving the City's stop loss coverage to LifeWise Assurance Company provides an approximate savings of $30,000 for 2010. The total cost for stop loss coverage is $461,369 and is budgeted in the health and wellness fund. The City is self-insured for all medical claims through Premera Blue Cross. All City employees and their dependents that are enrolled in the City's self-insured medical program are covered under a stop loss insurance policy. This stop loss policy provides added coverage to the City for individual medical claims exceeding $150,000 per employee or dependent for each calendar year. All medical costs exceeding $150,000 per enrollee per year will be reimbursed to the City under this policy. 3. EXHIBITS: Stop Loss Insurance Policy and Amendment 4. RECOMMENDED BY: Operations Committee (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure'? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: Counalmember moves, Councilmember seconds i DISCUSSION: ACTION: i LifeWise Assurance Company LJFEWISE 7001 — 220th St S.W. Mountlake Terrace, WA 98043-2124 Life I Disability I Stop Loss STOP LOSS INSURANCE POLICY LifeWise Assurance Company, Mountlake Terrace, Washington (herein we, our, and us) agrees with the policyholder to pay benefits under the provisions of the Policy IPOLICY NUMBER: WA-518212-9999 POLICYHOLDER: City of Kent POLICY EFFECTIVE DATE: January 1, 2010 POLICY ANNIVERSARY: January first of each year This Policy is issued in consideration of the policyholder's application and payment of premiums and will take effect on the Policy effective date This Policy is delivered in, and governed by the laws of, the State of Washington. The policyholder's Plan, Schedule of Coverage, and all provisions in this and the following pages, and any amendments and endorsements included on the date of issue or added later, are part of this Policy Throughout this Policy, "you" and "your" refer to the policyholder. LifeWise Assurance Company has, by its President, executed this Policy as of 12 01am on the Policy Effective Date at Mountlake Terrace, Washington. Rick Grover President and Chief Executive Officer LifeWise Assurance Company SLP WA (09-08) i TABLE OF CONTENTS WA-518212-9999 Effective 01-01-10 Title Section Schedule of Coverage 1 Definitions 2 Aggregate Stop Loss 3 , Specific Stop Loss 4 General Provisions 5 Additional Provisions 6 Advance Funding for Individual Excess Loss Application 7 SLP WA (09-08) 1 Table of Contents SECTION 1 LJFEWISE SCHEDULE OF COVERAGE Policyholder: City of Kent WA-518212-9999 Life I Disability I Stop Loss POLICY PERIOD January 1, 2010 through December 31, 2010 COVERAGE PROVIDED (Provided if checked): 1.1 ® AGGREGATE STOP LOSS Attachment Level- ❑ 120% ❑ 125% ® Other 200% Aggregate Expense Incurral Period- From January 1, 2009 through December 31, 2010 Aggregate Expense Payment Period- From January 1, 2010 through December 31, 2010 A. Covered Benefits: ® Medical ❑ Dental ❑ Vision ❑ Weekly Disability Income ® Prescription Drugs B Aggregate Deductible (Composite) Composite Units Medical/Rx Aggregate Monthly Factor $1,865 51 C Minimum Annual Aggregate Deductible- Greater of- $19,095,000 or 95% of the First Monthly Aggregate Deductible times 12. D. Limit of Liability 100% of eligible expenses you pay under your Plan, in excess of the deductible, will be reimbursed to a maximum of$1,000,000 E Claim Review is ® end of Policy Period ❑ Monthly with $ threshold F. Monthly Premium Rate (Composite Units) $0 01 per Employee 1.2 ® SPECIFIC STOP LOSS Specific Expense Incurral Period From January 1, 2009 through December 31, 2010 Specific Expense Payment Period From January 1, 2010 through December 31, 2010 A. Covered Benefits ® Medical ❑ Dental ❑ Vision ❑ Weekly Disability Income ® Prescription Drugs B $150,000 Individual Specific Deductible per person C $N/A Aggregating Specific Deductible per contract year D Limit of Liability 100% of eligible expenses you pay under your Plan, in excess of the deductibles, will be reimbursed to a lifetime maximum of$2,000,000 E Specific Advanced Funding ® Yes ❑ No F. Monthly Premium Rate: t ❑ Employee Only $ Family Rate $ ® Composite Employee & Dependent $44 65 1.3 ❑ TERMINAL LIABILITY PROTECTION ❑ Yes ® No If yes, number of months SLP WA (09-08) 2 Schedule of Coverage SECTION 2 DEFINITIONS The following definitions apply unless otherwise required by the context With the exception of "we", "us", "our', "you" and "yours", these definitions are capitalized throughout the policy 21 Administrator means the third party administrator selected by you to perform certain functions for your Plan The term "administrator" as used in the Policy does not refer to the Plan administrator used in the Employee Retirement Income Security Act of 1974, unless you have specifically appointed the administrator as such We are not the Administrator We must approve the third party administrator selected by you 2.2 Aggregate Attachment Point is equal to the greater of A The sum of the Monthly Aggregate Attachment Points for the Policy Period shown in the Schedule, or B the Minimum Aggregate Attachment Point shown in the Schedule. 2.3 Covered Benefits means those services and/or supplies received or obtained by a Covered Person that are covered by the Plan and Incurred during the Expense Incurral Period as stated in the Schedule 2.4 Covered Person means an employee or his or her dependent that are enrolled in the Plan during the Expense Incurral Period 25 Expense Incurral Period means the period of time as stated in the Schedule for which a Covered Person may Incur Covered Benefits under the Plan In the event that the Policy terminates prior to the end of the Policy Period stated in the Schedule, the Expense Incurral Period is modified, separately for Aggregate and Specific, to end on that date rather than at the end of the Policy Period 26 Expense Payment Period means the period of time stated in the Schedule for which you may pay for Covered Benefits under the Plan In the event that the policy terminates prior to the end of the Policy Period stated in the Schedule, the Expense Payment Period is modified, separately for Aggregate and Specific, to end on that date rather than at the end of the Policy Period plus the length of time, if any, between the end of the Expense Incurral Period stated in the Schedule and the end of the Expense Payment Period stated in the Schedule. 27 Incur or Incurred means the date on which Covered Benefits was received and/or obtained by a Covered Person under your Plan 28 Initial Effective Date means the date specified in the Schedule when the Policy first becomes effective 29 Pay or Paid means the date your check or draft for payment of Covered Benefits is issued and mailed or electronically deposited directly to the payee, within the policy period, and that the account upon which the payment is drawn contains sufficient funds to permit the check or draft to be honored SLP WA (09-08) 3 Definitions SECTION 2 DEFINITIONS (Continued) 2.10 Plan means the employee benefit plan you have adopted in writing to provide benefits to your employees and their dependents, if applicable 211 Policy means this policy, any amendments to this policy, the policyholder application, Plan, and Schedule 2.12 Policy Period means the period of time that this Policy is effective as stated in the Schedule. 213 Schedule means the Schedule of Coverage that is part of your Policy 214 We, us and our means LifeWise Assurance Company 2.15 You and your means the Policyholder i SLP WA (09-08) 4 Definitions SECTION 3 AGGREGATE STOP LOSS INSURANCE 31. We will reimburse you or, if directed by you, the Administrator for a percentage of Covered Benefits Incurred during the Aggregate Expense Incurral Period and Paid by you during the Aggregate Expense Payment Period as stated in the Schedule subject to the limitations and exclusions outlined in Section 3 2 below We will only reimburse you or the Administrator for your payments that exceed the deductibles shown in the Schedule, however, the minimum risk you are required to retain is 120% of expected paid claims The percentage we will reimburse and our limits of liability are stated in the Schedule 32. There is no coverage for payments you make A which we have already reimbursed you, B which have been or will be reimbursed by another third party including, but not limited to, an insurance company or reinsurance company, or C the earlier of (i) after your Aggregate Expense Payment Period ends or (1i) if the Policy is terminated prior to the completion of the applicable Policy Period, after the Policy termination date In addition, if you are covered by Specific Stop Loss in addition to Aggregate Stop Loss, we will not reimburse you for payments under the Aggregate Stop Loss if A. you have been reimbursed for such payments under Specific Stop Loss, or B those payments exceed our limit of liability for Specific Stop Loss 3.3. The Aggregate Deductible is determined as follows A. The Aggregate Deductible is the sum of the monthly deductibles for the Policy Period stated in the Schedule B Each monthly deductible is determined by multiplying the number of covered units for that month by the factors shown in the Schedule The monthly deductible cannot be reduced by more than 5% per month for any reason C The deductible is subject to the minimum Aggregate Deductible stated in the Schedule. If claim review is monthly, as shown in the Schedule, the minimum Aggregate Deductible will be adjusted for the purpose of claim review to equal the minimum Aggregate Deductible stated in the Schedule multiplied by the result of the number of months elapsed in the Policy Period divided by the total number of months in the Policy Period D The monthly factors shown in the Schedule only apply to the Policy Period shown in the Schedule Factors for each Policy Period are shown in separate Schedules SLP WA (09-08) 5 Aggregate Insurance SECTION 4 SPECIFIC STOP LOSS INSURANCE 4.1 We will reimburse you or the Administrator for a percentage of Covered Benefits Incurred during the Specific Expense Incurral Period and Paid by you or the Administrator during the Specific Expense Payment Period as stated in the Schedule subject to the limitations and exclusions outlined in Section 2 below We will only reimburse you for your payments that exceed the Individual Specific Deductibles shown in the Schedule The percentage we will reimburse and our limits of liability are shown in the Schedule 42 A separate Specific deductible applies to each Policy Period for each Covered Person under your Plan There is no coverage for payments you make A. which we have already reimbursed you, B which have been or will be reimbursed by another third party including, but not limited to an insurance company or reinsurance company, or C. the earlier of i. after your Specific Expense Payment Period ends; or ii if the Policy is terminated prior to the completion of the applicable Policy Period, after the Policy termination date i i i SLID WA (09-08) 6 Specific Insurance SECTION 5 GENERAL PROVISIONS 5.1 Limitations of Coverage A. Regardless of any provisions to the contrary in your Plan, we will not provide coverage or accept liability under this Policy for the following persons. 1 Any employee who was not covered under your prior stop loss policy, if any, that immediately precedes the Initial Effective Date of this Policy unless the employee meets the eligibility and actively-at-work provisions of your Plan on the Initial Effective Date of this Policy. 2 Any dependent who was not covered under your prior stop loss policy, if any, that immediately precedes the Initial Effective Date of this Policy unless the dependent meets the eligibility and not-hospital-confined provisions of your Plan on the Initial Effective Date of this Policy B Payments you make for these persons may be applied toward either the Specific Stop Loss Deductible, Aggregating Specific Stop Loss Deductible or the Aggregate Stop Loss Deductible only under the following conditions 1. the employee meets the eligibility and actively-at-work provisions of your Plan and returns to work on a full-time basis Only payments you make during the Expense Payment Period for Covered Benefits Incurred after the date the employee becomes eligible under your Plan and during the Expense Incurral Period can be counted toward any deductible. 2 The dependent meets the eligibility and not-hospital-confined provisions of your Plan and is no longer hospital confined Only payments you make during the Expense Payment Period for Covered Benefits Incurred after the date the dependent becomes eligible under your Plan and during the Expense Incurral Period can be counted toward any deductible 52 Evidence of Insurability We will not accept liability under this Policy for certain persons until they have submitted satisfactory evidence of insurability and have been approved for coverage The following persons must submit evidence of insurability. A Persons who apply for or become eligible for coverage under your Plan while insured under Medical Conversion issued under this Policy B Persons who apply for coverage under your Plan more than 31 days after the date on which they become eligible This includes persons transferring from another employer-sponsored Plan such as a health maintenance organization (HMO) 53 Limitation of Liability Our liability under your Policy is limited to reimbursing you or, if directed by you, the Administrator for payments you have made during the Expense Payment Period for Covered Benefits Incurred during the Expense Incurral Period for Covered Persons. We will not reimburse any amounts Paid outside of your Plan We will not reimburse any Covered Person or provider of services or supplies We are not liable for punitive, exemplary, special or consequential damages SLP WA (09-08) 7 General Provisions SECTION 5 GENERAL PROVISIONS (Continued) 54 Indemnification You agree to indemnify and hold us harmless from and against any and all claims, losses, liabilities, damages, costs or expenses of any kind incurred by us, including, without limitation, reasonable attorney's fees, arising out of or in connection with a breach of this Policy or error or omission by you, your officers, employees, agents or Administrator under this Policy 55 War Exclusion We will not reimburse you for any loss or expense caused by or resulting from war. War means declared or undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature 5.6 Subrogation You may be entitled to recover from third parties for Covered Benefits that you pay under your Plan We will not reimburse you for any payments you recover or the cost associated with making such recovery You cannot use the recovered amount to meet any deductible under this Policy If we have reimbursed you for all or part of a particular Covered Benefit that you Paid and you later recover reimbursement from a third party, you must repay us within thirty (30) days of receipt of such recovery, regardless of whether your Policy is still in force on the date you recover Your repayment may be reduced prorata by the reasonable and necessary expenses you pay in recovering from the third party Within thirty (30) days following the end of each Policy Period, you must provide us with a list of all potential subrogation recoveries for payments that either you have already received reimbursement from us or you are submitting to us for reimbursement. 57 Administration If you use the services of an Administrator to perform any functions for your Plan, the Administrator performs as your agent We will not be held liable for any act, error or omission of an Administrator, including amounts Paid outside of your Plan Changes in Administrators must be approved in writing by us or we have the right to terminate coverage (See Section 5 21) j 5.8 Records and Review You must maintain appropriate records regarding administration of your Plan for a minimum period of six (6) years Within a reasonable time period following our request, you must allow us to review and copy, during normal business hours, all records affecting our liability under your Policy 59 Audit We have the right to inspect and audit all your records and procedures, as well as those of your Administrator and to require, upon request, proof satisfactory to us that the payments which are the basis of any claim have been made SLIP WA (09-08) 8 General Provisions SECTION 5 GENERAL PROVISIONS (Continued) 510 Claims Under This Policy If you submit a claim to us, you must do so in writing to our Home Office within 90 days after the end of the Expense Payment Period for which claim is made You must provide us with whatever information we need for proof of A covered Benefit Incurred during the Expense Incurred Period, B. payment by you for the Covered Benefit during the Expense Payment Period, and C meeting of any deductible We will not refuse to reimburse you merely because you were late in submitting the claim to us, as long as you submitted it as soon as reasonably possible and within one year We will not pay any benefits if we have not received all premiums due We will reimburse you under Aggregate Stop Loss after we receive your request for reimbursement but not sooner than the end of the Policy Period, unless the Monthly Claim Review is included in the Policy as indicated in the Schedule 511 Entire Contract This Policy, along with any Attachments, Riders, Endorsements or Amendments, and the Application completed by you constitutes the entire contract of insurance between us 5.12 Legal Action You cannot file suit until 60 days after the date on which you submit proof of claim as required by your Policy You cannot file suit more than six years after the date on which you must give us proof of claim The six year limitation is extended, if necessary, to agree with the time period allowed by the law of the jurisdiction in which this Policy is issued 513 Governing Law and Venue This Policy is delivered in, and governed by the laws of, the State of Washington, without regard to conflict of law principles You consent to personal jurisdiction and agree that all judicial proceedings shall be brought in the Superior Court in King County, Washington located in Seattle, Washington 514 Notice of Appeal You must notify us in writing if it appears benefits will be payable under the Policy due to any objection, notice of legal action, or complaint you or your Administrator receives 515 Worker's Compensation This Policy does not cover expenses your Plan covers that are also eligible expenses covered by Worker's Compensation or similar law whether or not such coverage is actually in force 5.16 Change in Plan Covered Benefits that are insured under your Stop Loss Insurance Policy constitute a part of your Stop Loss Insurance Policy Any changes to Covered Benefits made during the Policy Period must be approved by us in writing If you make changes in your Plan, those changes become a part of your Stop Loss Insurance Policy only after we approve them in writing Changes in Administrators must be approved in writing by us SLP WA (09-08) 9 General Provisions SECTION 5 GENERAL PROVISIONS (Continued) 517 Notice For the purpose of any notice required from us, notice to the Administrator will be considered notice to you and notice to you will be considered notice to the Administrator Any notice required from you shall be in writing and sent, postage prepaid, to us at 7001 — 220th Street SW, MS 225, Mountlake Terrace, Washington 98043. 518 Amendment Your Policy may be changed at any time by a written agreement signed by you and us Notice to any agent or knowledge possessed by any person cannot change your Policy or stop us from asserting our rights We will not change the rates or factors more often than once every Policy Period unless you change your Plan or add employees in other locations or industries 519 Premiums You must pay premiums to us at our Home Office We must receive payment within 15 calendar days from the date the premium statement was issued Your payment will only continue your insurance until the next premium due date. 520 Grace Period If, before any premium due date except the first, you have not given written notice to us of your intention to terminate the policy, a grace period of 31 days will be given in which to pay the premium then due The Policy will stay in effect during that time If the premium due is not paid by the end of the grace period, the Policy will automatically terminate on the last day for which premium was paid and any claims incurred after the premium due date will not be covered by the Policy, except that if you have given written notice in advance of an earlier date of termination, the Policy will terminate as of the earlier date 521 Termination A You may terminate your Policy at any time by giving us written notice Your Policy will end no sooner than the end of the month following the month the termination notice was received by us B. We may terminate your Policy at any time by giving you 45 days written notice for the following reasons 1 You fad to comply with a provision of your Policy; 2 You fail to perform your Policy obligations in good faith, or 3 If you fad to maintain a minimum of 50 Covered Persons in each of two consecutive months C. If this Policy terminates for any reason during the Policy Period, there will be no proration of the Minimum Aggregate Deductible D We may terminate the Policy if a change in Administrators is not approved in writing by us. (See Section 5 7) SLP WA (09-08) 10 General Provisions SECTION 5 GENERAL PROVISIONS (Continued) 5.22 Renewal We may refuse to renew your Policy by giving you 45 days written notice Otherwise, your Policy will automatically renew on each Policy anniversary if you continue to pay premiums at the rates we set We reserve the right to adjust our renewal offer if the average paid claims in the last two months of the Policy Period exceeds the average paid claims of the immediate prior three months by 20% or more 523 Clerical Error Clerical error, whether made by us or you or your Administrator, in keeping records will not invalidate coverage that otherwise should be in force or continue coverage that otherwise should be terminated 5.24 Conformity With Statutes If any time limitations with respect to giving notice of claim or furnishing proof of loss or bringing action is less than that permitted by law in the jurisdiction governing the Policy, that time limit is extended to the minimum permitted by law 525 Refund of Over-reimbursement If we, you, or your Administrator determine that we have over-reimbursed you under this Policy, You will promptly refund such over-reimbursement to us within sixty (60) days of such a determination If we are required to take legal action to collect such over-reimbursement, you agree to indemnify us for any costs of collection, including, but not limited to, attorneys fees and court costs The right to recovery shall survive the termination of this policy 5.26 Responsibility For Your Administrator You are solely responsible for the actions of your Administrator, and any other agent of yours Your Administrator acts on your behalf, not on our behalf Your Administrator is not our agent We are not responsible for any compensation owed to, or claimed by your Administrator or other agents for services provided to, or on behalf of, your Plan This Policy does not make us a party to any agreement between you and your Administrator, nor does it make your Administrator a party to this policy 5 27 Bankruptcy or Insolvency The bankruptcy, insolvency, dissolution, receivership or liquidation of you, your plan or your Administrator will not impose upon us any obligations other than those set forth in this Policy r r SLP WA (09-08) 11 General Provisions SECTION 6 ADDITIONAL PROVISIONS Advance Funding — Individual Excess Loss Advance funding is available to you for Covered Benefits Incurred during the Expense Incurral Period and paid by your Administrator during the Expense Payment Period upon meeting all of the following conditions A. The Individual Specific Deductible for a Covered Person has been met, and B. Covered Benefits eligible for advance funding are those that exceed the Individual Specific Deductible, and C Claims available for advance funding must be fully processed and Paid by your Administrator within the Expense Payment Period and according to your Plan, and D. Your Administrator must bill us monthly for claims Paid under the advanced funding request but in no event within 60 days after the end of the Expense Payment Period specified in this Policy Requests received after that date are not eligible for advance funding, and E We will remit payment for approved claims to your Administrator within 30 days of receipt of advanced funding request SLP WA (09-08) 12 Advance Funding LlfeWfse Assurance Company LJFEWISE PO Box 2272 Seatt€e,WA 98111-2272 ME! Life life 1015abdlty i Hop lout STOP LOSS INSURANCE APPLICATION The undersigned applicant(you and your)applies for the following coverage: Applicant Details Legal Name of Applicant City of!Cent Address 220 Fourth Ave S. Kent, WA 98032-5896 Name of Third Party Administrator_ Premer3 Blue Cross Address: 7001 2201`St$IN, Mountlake Terrace,WA 98043-2124 Proposed Effective Date 01I01MIG No insurance as in force until and unless approved by LifeWlse Assurance Company(we, us and our) at our Home Office Deposit based on 853 employees and 596 dependent units, of $38,095.00 is enctosed to apply to the first payment under the policy, if issued Aggregate stop Loss 2 Yes p No ❑ 120% ❑ 125% ®Other 200 % 1. Benefits to be covered. Medical ❑ Dental 0 Vision ❑Weekly Disability Income ® Prescription Drugs ❑ Other. 2 Aggregate Deductible Composite units Medical/Q UPO'lDentall Vision/ Rxf Other/ Monthly Factor $1,865 51 $ $ $ $ 3. We will reimburse you 100% of expenses you pay under your plan in excess of khe deductible The maximum we will reimburse you per policy period: 0 $1,000,000 ❑ Other. $ _ 4. Contract Basis- ❑ 12112 ❑ 12115 ❑ 15112 ® 24112 5. Claim Review: ❑ Monthly with a $ Threshold ® End of Policy Period 6 Monthly Premium Rate_ $0.01__ __-_ per Composite Employee 1 Specific Stop Loss M Yes ❑ No 1 Benefits to be covered: Z Medical ❑ Dental ©Vision ❑Weekly Disability Income ER Prescription Drugs ❑Other. 2. $150,000 deductible per person 3 We will reimburse you 100%of expenses you pay under your plan in excess of the deductible The maximum we wal reimburse you per person, llfebme; ❑ 51,000,000 Other $4-;�— *2,C iDO,ooO cp ( � 4. Contract Basis ❑ 12112 ❑ 12115 ❑ 15112 24112 5 Aggregating Specific ❑ Yes ® No If yes, $ deductible per contract year 6 Specific Advanced Funding_ 0 Yes ❑ No 7, Monthly Premium Elate, (check/complete only one) © Employee Only $ Dependents$ ® Composite: Employee&Dependent$44.65. - 6(Lu7ae� Terminal Liability Protection ©Yes ® No If yes, number of months: Please see reverse side for fraud statements. Signatures Date I Signed at ! ta4T Officer's Signature Officer's Name and Title to SLP App (09-08) Application Fraud Statements Arizona: Any life insurance producer, examining physician or other person who knowingly makes a false or fraudulent statement or representation on or relative to an application for life or disability insurance, or who makes any such statement to obtain a fee, commission, money or benefit is guilty of a Class 2 misdemeanor. California: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. Washington: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. All other states: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for Insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. i t , c t 1 SLP App(09-08) Application NAMENDMENT NO. 01 This amendment becomes a part of Stop Loss Policy No WA-518212-99999 issued to City of Kent, the Policyholder. It is stipulated and agreed that Effective January 1, 2010; revised January 20, 2010. The following pages are replaced: Page 3 —4, Definitions All other terms and conditions of the contract remain unchanged t t 1 t LifeWise Assurance Company Rick Grover President and Chief Executive Officer Instructions- Retain copy with your policy SLP WA AMD (09-08) Amendment r SECTION 2 DEFINITIONS Effective 01-01-10 Revised 01-20-10 The following definitions apply unless otherwise required by the context With the exception of "we", r "us", "our", "you" and "yours", these definitions are capitalized throughout the policy 21 Administrator means the third party administrator selected by you to perform certain functions for j your Plan The term "administrator' as used in the Policy does not refer to the Plan administrator used in the Employee Retirement Income Security Act of 1974, unless you have specifically , appointed the administrator as such. We are not the Administrator We must approve the third party administrator selected by you 2.2 Aggregate Attachment Point is equal to the greater of A. The sum of the Monthly Aggregate Attachment Points for the Policy Period shown in the Schedule, or B the Minimum Aggregate Attachment Point shown in the Schedule. 23 Covered Benefits means those services and/or supplies received or obtained by a Covered Person that are covered by the Plan and Incurred during the Expense Incurral Period as stated in the Schedule. 24 Covered Person means an employee or his or her dependent or a Leoff 1 retiree or his or her dependent that are enrolled in the Plan during the Expense Incurral Period 2.5 Expense Incurral Period means the period of time as stated in the Schedule for which a Covered Person may Incur Covered Benefits under the Plan In the event that the Policy terminates prior to the end of the Policy Period stated in the Schedule, the Expense Incurral Period is modified, separately for Aggregate and Specific, to end on that date rather than at the end of the Policy Period 26 Expense Payment Period means the period of time stated in the Schedule for which you may pay for Covered Benefits under the Plan In the event that the policy terminates prior to the end of the Policy Period stated in the Schedule, the Expense Payment Period is modified, separately for Aggregate and Specific, to end on that date rather than at the end of the Policy Period plus the length of time, if any, between the end of the-Expense Incurral Period stated in the Schedule and the end of the Expense Payment Period stated in the Schedule 27 Incur or Incurred means the date on which Covered Benefits was received and/or obtained by a Covered Person under your Plan 2.8 Initial Effective Date means the date specified in the Schedule when the Policy first becomes effective 2.9 Pay or Paid means the date your check or draft for payment of Covered Benefits is issued and mailed or electronically deposited directly to the payee, within the policy period, and that the account upon which the payment is drawn contains sufficient funds to permit the check or draft to be honored SLP WA (09-08) 3 Definitions SECTION 2 DEFINITIONS (Continued) Effective 01-01-10 Revised 01-20-10 2.10 Plan means the employee benefit plan you have adopted in writing to provide benefits to your employees and their dependents, if applicable 211 Policy means this policy, any amendments to this policy, the policyholder application, Plan, and Schedule 1 2.12 Policy Period means the period of time that this Policy is effective as stated in the Schedule 2.13 Schedule means the Schedule of Coverage that is part of your Policy 2.14 We, us and our means LifeWise Assurance Company. 2.15 You and your means the Policyholder. I SLP WA (09-08) 4 Definitions Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6E 1. SUBJECT: GROUP HEALTH COOPERATIVE CONTRACT - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign the Group Health Cooperative of Puget Sound Group Medical Coverage Agreement. Group Health Cooperative of Puget Sound is the City's insured health maintenance organization (HMO). The 2010 contract reflects an approximate 12 2% increase in the health care premiums for a total amount of $499,021 and is budgeted in the health and welfare fund. 3. EXHIBITS: 2010 Group Health Contract t4. RECOMMENDED BY: Operations Committee (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds DISCUSSION: ACTION: GroupHealth. Group Medical Coverage Agreement 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 Linder 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 • Premium Schedule Group Health Cooperative Signed Title President and Chief Executive Officer City of Kent,0036900 Signed Title This Agreement will continue in effect until terminated or renewed as herein provided for and is effective January 1, 2010 PA-113302 C29404-0036900 1 i Group Medical Coverage Agreement ! Table of Contents Standard Provisions Attachment 1 Benefit Booklet Attachment 2 Premium Schedule Attachment 3 Medicare Endorsement C29404-0036900 2 Standard Provisions 1. GHC agrees to provide benefits as set forth in the attached Benefit Booklet to enrollees of the Group 2. Monthly Premium Payments. For the initial term of this Agreement,the Group shall submit to GHC for each 1 Member the monthly premiums set forth in the current Premium Schedule and a verification of enrollment Payment must be received on or before the due date and is subject to a grace period of ten (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 This may include,but is not limited to,policies or procedures pertaining to benefit entitlement and coverage determinations 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 Atorney's fees,arising out of GHC's failure to perform, negligent performance 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,arising 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 1 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 wilt go into effect as required by the governmental agency All C29404-0036900 3 1 amendments are deemed accepted by the Group unless the Group gives GHC written notice of non-acceptance within thirty(30)days after receipt of 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,(it) pursuant to court order or(in)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, andjudgment on the award rendered by the arbitrator(s)may be entered in any court having jurisdiction thereof Except as may be required by law, neither party nor 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 to the Health Insurance Portability and Accountability Act of 1996 ("H1PAA") 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 subsection 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 rescind or terminate this Agreement upon written notice in the event that intentional misrepresentation,fraud or omission of information was used in order to obtain Group coverage Either party may terminate this Agreement in the event of intentional misrepresentation,fraud or omission of information by the other party in performance of its responsibilities under this Agreement C29404-0036900 4 c. Underwriting Guidelines.GHC may terminate 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. Federal or State Law.GHC may terminate this Agreement in the event there is a change in federal or state law that no longer permits the continued offering of the coverage described in this Agreement 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 non-renewal of the plan at least ninety(90)days prior to discontinuation ' C29404-0036900 5 Dear Group Health Subscriber This booklet contains important information about your healthcare plan. This is your 2010 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 Sections of this document maybe bolded and itaheized, which identifies changes that Group Health has made to the plan The benefits reflected in this booklet were approved by your employer or association who contracts with Gioup Health for your healthcare coverage if you are eligible for Medicare,please read Section 1V J as it may affect your prescription drug 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 at(206)901-4636 in the Seattle area,or toll-free in Washington, 1-888-901-4636 Thank you for choosing Group Health Cooperative We look forward to working with you to preserve and enhance your health Very truly yours, Scott Armstrong President PA-113302a, CA-3618, CA-139502,CA-2220,CA-1984,CA-2886,CA-1385,CA-6100 C29404-0036900a i 1 r i Benefit Booklet Table of Contents Section I. Introduction A Accessing Care B Cost Shares C Subscriber's Liability D. Claims Section If. Allowances Schedule Section 111. Eligibility,Enrollment and Termination A Eligibility I B Enrollment C Effective Date of Enrollment D Eligibility for Medicare E Termination of Coverage F Services After Termination of Agreement G Continuation of Coverage Options I Section IV. Schedule of Benefits A Hospital Care B Medical and Surgical Care C Chemical Dependency Treatment D Plastic and Reconstructive Services E. Home Health Care Services F Hospice Care G. Rehabilitation Services H. Devices,Equipment and Supplies 1 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 1 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 VIIL Definitions Attachment: Group Medicare Coverage C29404-0036900a 2 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 lI 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 Members may refer to Sections]V.A. and IV.C.for more information about inpatient admissions. Primary Care. GHC recommends that Members select a GHC Personal Physician when enrolling under the Agreement One Personal Physician may be selected for an entire family,or a different Personal Physician may be selected for each family 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)901-4636 or(988)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 provided access to the Personal Physician for up to sixty(60)days following 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 1V,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 Group Health-owned or-operated medical centers without a Referral from their Personal Physician Self-Referrals are available for the following specialty care area,, 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 C29404-0036900a 3 * Medicare patients need prior authorization 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 Midw ife,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 preauthorization and care coordination in accordance with applicable GHC requirements Second Opinions. The Member may access,upon request,a second opinion regarding a medical diagnosis or 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 Notif Lation Line within twents- 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 services In the GHC Service Area,urgent care is covered 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 Care received at urgent care facilities other than those listed above is only covered for emergency services, subject to the applicable Emergency Cost Share. Members may refer to ISection IV for more information about coverage of 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 1 Major Disaster or Epidemic. In the event of a major disaster or epidemic,GHC will provide coverage according to GHC's best judgment,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 C29404-0036900a 4 The Subscriber shall be liable for the following Cost Shares when services are received by the Subscriber and any of his/her Dependents. 1. 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 2. Coinsurance.Members shall be required to pay coinsurance for certain Covered Services as set forth in the Allowances Schedule 3. Out-of-Pocket Limit.Total Out-of-Pocket Expenses incurred during the same calendar year shall not exceed the Out-of-Pocket Limit 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 C. Subscriber's Liability The Subscriber is liable for(1)payment to the Group of his/her contribution toward the monthly premium,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 may be 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 healthcare 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,P O Box 34585, Seattle, WA 98124-1585 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 Timeframes 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 prior to the expiration of the initial timeframe C29404-0036900a 5 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 S2,000,000 per Member for Covered Services incurred,unless otherwise indicated Up to$5,000 is restored automatically each January 1 for benefits paid by GHC during the prior calendar year 1 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 lesser of GHC's charge or the applicable outpatient services Copayment. Outpatient Services • Covered outpatient medical and surgical services 1 Covered subject to the lesser of GHC's charge or a$10 outpatient services Copayment per Member per visit • Allergy testing ICovered subject to the lesser of GHC's charge or the applicable outpatient services Copayment • Oncology(radiation therapy,chemotherapy) ' Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment Drugs—Outpatient(including mental health drugs,contraceptive drugs and deices and diabetic supplies) • Prescription drugs,medicines, supplies and devices for a supply of thirty(30)days or less when listed in the GHC drug formuldry Covered subject to the lesser of GHC's charge or a$10 Copayment. • Over-the-counter drugs and medicines C29404-0036900a 6 Not covered • Injectables Injections that can be self-administered are subject to the lesser of GHC's charge or the applicable prescription drug Cost Share(as set forth above) Injections necessary for travel are not covered • Mail order drugs and medicines Covered subject to the lesser of GHC's charge or the applicable prescription drug Cost Share(as set forth above)for each thirty(30)day supply or less Out-of-Pocket Limit Limited to an aggregate maximum of$2,000 per Member or$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 lesser of GHC's charge or the applicable outpatient services Copayment for Self-Referrals to a GHC Provider up to a maximum of eight(8) visas per Member per medical diagnosis per calendar year When approved by GHC, additional visas are covered Ambulance Services • Emergency ground/air transport Covered at 80% i • Non-emergent ground/air interfacility transfer Covered at 80%for GHC-initiated transfers, except hospital-to-hospital ground transfers covered in full Chemical Dependency • Inpatient services(including Residential Treatment services) Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment. , • Outpatient services Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment. Acute detoxification covered as any other medical service. Dental Services (including accidental injury to natural teeth) C29404-0036900a 7 Not covered,except as set forth in Section 1V B 23 Devices,Equipment and Supplies(for home use) Covered at 80%for • Durable medical equipment • Orthopedic appliances • Post-mastectomy bras limited to two(2)every six(6)months Covered at 80% for • Ostomy supplies • Prosthetic devices When provided in a home health setting in lieu of hospitalization as described in Section 1V A 3 ,benefits will be the greater of benefits available for devices,equipment and supplies,home health or hospitalization See Hospice for durable medical equipment provided in a hospice setting Diabetic Supplies Insulin,needles,syringes and lancets—see Drugs-Outpatient External insulin pumps,blood glucose monitors, testing reagents and supplies-see Devices, Equipment and Supplies When Devices, Equipment and Supplies or Drugs—Outpatient are covered and have benefit limits, diabetic supplies are not subject to these limits Diagnostic Laboratory and Radiology Services Covered in full Emergency Services • At a GHC Facility Covered subject to the lesser of GHC's charge or a$75 Copayment per Member per Emergency visit Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department Emergency admissions are covered subject to the applicable inpatient services Cost Share ' • At a non-GHC Facility Covered subject to the lesser of GHC's charge or a$125 Copayment per Member per Emergency visit Copayment is waived if the Member is admitted as an inpatient to the hospital directly from the emergency department Emergency admissions are covered subject to the applicable inpatient services Cost Share ' Hearing Examinations and Hearing Aids • Hearing examinations to determine hearing loss Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment • Hearing aids, including hearing aid examinations Not covered Home Health Services 1 C29404-0036900a 8 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 lesser of GHC's charge or the applicable outpatient services Copayment for Self-Referrals to a GHC Provider for manipulative therapy of the spine and extremities in accordance with GHC clinical criteria up to a maximum of ten(10)visits per Member per calendar year Maternity and Pregnancy Services • Delivery and associated Hospital Care Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment. t • Prenatal and postpartum care Routine care covered in full Non-routine care covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment • Pregnancy termination Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment for involuntary/voluntary termination of pregnancy Mental Health Services • Inpatient services Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment at a GHC- ' approved mental health care facility • Outpatient services Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment Naturopathy Covered subject to the lesser of GHC's charge or the applicable outpatient services Copayment for Self-Referrals to a GHC Provider up to a maximum of three(3)visits per Member per medical diagnosis per calendar year When approved by GHC,additional visas are covered Nutritional Services • Phenylketonuria(PKU)supplements Covered in full C29404-0036900a 9 r r • 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, rEquipment and Supplies Obesity Related Services Covered subject to the lesser of GHC's charge or the applicable Copayment for bariatric 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. Optical Services • Routine eye examinations rCovered subject to the lesser of GHC's charge or the applicable outpatient services Copayment once every twelve(12) months. • Lenses, including contact lenses,and frames Not covered,except contact lens after catdiact surgery is covered in full when in lieu of an intraocular lens. Organ Transplants Covered subject to the lesser of GHC's charge or the applicable Copayment up to a$350,000 lifetime benefit maximum(including organ acquisition,matching and donor costs up to$50,000),and a six(6)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 lesser of GHC's charge or the applicable Copayment r • Cosmetic surgery, including complications resulting from cosmetic surgery Not covered. Podiatric Services • Medically Necessary foot care Covered subject to the lesser of GHC's charge or the applicable Copayment. • Foot care(routine) C29404-0036900a 10 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 and prostate,,colorectal cancer screening) Covered subject to the lesser of GHC's charge or the applicable 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 or license are not covered Rehabilitation Services • Inpatient physical,occupational and restorative speech therapy servIceb combined, including services for neurodevelopmentally disabled children age six(6)and under Covered subject to the lesser of GHC's charge or the applicable inpatient services Copayment for up to sixty (60) days 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 lesser of GHC's charge or the applicable outpatient services Copayment for up to sixty (60)visits per calendar year Sexual Dysfunction Services Not covered Skilled Nursing Facility(SNF) Covered in full up to thirty(30)days per condition per Member per calendar year. Sterilization(vasectomy,tubal ligation) Covered subject to the lesser of GHC's charge or the applicable Copayments Temporomandibular Joint(TMJ)Services • Inpatient and outpatient TMJ services Covered subject to the lesser of GHC's charge or the applicable Copayment up to$1,000 maximum per Member per calendar year • Lifetime benefit maximum Covered up to$5,000 per Member. Tobacco Cessation , • Individual/group sessions ' C29404-0036900a 11 Covered in full. • Approved pharmacy products Covered in full when prescribed as part of the GHC-designated tobacco cessation program and dispensed through the GHC mail order sernce 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,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 1. Subscribers.Bona fide employees and LEOFF II employees who have been continuously employed on a regularly scheduled basis of not less than twenty-one(21)hours per week,orjobshare,shall be eligible for enrollment Elected officials and council members shall be eligible for enrollment LEOFF I employees will not be covered under this Agreement 2. Dependents.The Subscriber may also enroll the following. a The Subscriber's legal spouse,including state-registered domestic partners as required by Washington state law, b. The Subscriber's domestic partner,other than a state-registered domestic partner,provided that the application has been submitted to and approved by the Group and GHC, and that the Subscriber and domestic partners i Share the same regular and permanent residence, u. Have a close personal relationship, in Are jointly responsible for"basic living expenses"as defined by the Group, iv Are not married to anyone, v Are each eighteen (18) years of age or older, w Are not related by blood closer than would bar marriage in the State of Washington; vu Were mentally competent to consent to contract when the domestic partnership began, and vm Are each other's sole domestic partner and are responsible for each other's common welfare Following termination of a domestic partnership a statement of termination must he filed with the Group Application for another domestic partnership cannot be filed for ninety(90)days following a filing of the statement of termination of domestic partnership with the Group,unless such termination is due to the death of the domestic partner ' c. Unmarried dependent children who are under the age of twenty-five(25). C29404-0036900a 12 "Children"means the children of the Subscriber,including adopted children, stepchildren,children of a domestic partner,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 Eligibility may be extended past the Dependent's limiting age as set forth above if 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 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 teriwnate 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 3. Temporary Coverage for Newborns. When a Member gives birth,the newborn will be entitled to the benefits set forth in Section 1V 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 Ill G B. Enrollment , 1. Application for Enrollment. Application for enrollment must be made on an application approved by GHC Applicants will not be enrolled or premiums accepted until the completed application has been approved by GHC The Group is responsible for submitting completed applications 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(3 t)days of becoming eligible b. New Dependents. A written application for enrollment of a newly dependent person,other than a newborn or adopted 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 total or partial financial support 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 j 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. 1) GHC will allow special enrollment for persons a) who initially declined enrollment when otherwise eligible because such persons had other health ' care coverage and have had such other coverage terminated due to one of the following events • cessation of employer contributions, • exhaustion of COBRA continuation coverage, ' • loss of eligibility,except for loss of eligibility for cause, or C29404-0036900a 13 b) who have had such other coverage exhausted because such person reached a Lifetime Maximum limit GHC or the Group may require 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 temmnation of previous coverage 2) GHC will allow special enrollment for individuals who are eligible to be a Subscriber,his/her spouse and his/her Dependents in the event one of the following occurs • marriage Application for coverage under the Agreement must be made within thirty-one(31) days of the date of marriage • birth Application for coverage under the Agreement for the Subscriber and Dependents other than the newborn child must be made within sixty(60)days of the date of birth • adoption or placement for adoption Application for coverage under the Agreement for the Subscriber and Dependents other than the adopted child must be made within sixty(60) days of the adoption or placement for adoption • eligibility for medical assistance provided such person is otherwise eligible for coverage under this Agreement,when approved and requested in advance by the Department of Social and Health Services (DSHS) • applicable federal or state law or regulation otherwise provides for special enrollment. 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 eligibility criteria are met and applications for 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 • Subscribers who return to work from a leave without pay status within ninety (90)days shall be eligible for enrollment on the first(I st)of the month following the date of return to work • Enrollment for a newly dependent person, other than a newborn or adoptive child, is effective on the first(1 st)of the month following application • Enrollment for newborns is effective from the date of birth ' • Enrollment for adoptive children is effective from the date that the adoptive child is placed with the Subscriber for the purpose of adoption and the Subscriber assumes total or partial financial support 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 I 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 I he 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 ' Actively Employed Members and Spouses. 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 whethei 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 C29404-0036900a 14 Members Residing Outside the GHC Medicare Advantage Service Area and Not Actively Employed. If a Member who is not actively employed or their spouse is or becomes eligible for Medicare,GHC requests that, effective the date that Medicare becomes the primary payer,the Member or their spouse enroll in and maintain both Medicare Parts A and B coverage 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 Advantage Service Area and Not Actively Employed. If a ' Member who is not actively employed 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 Advantage 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 Medicare Advantage 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.Individual Member coverage maybe terminated for any of the ' following reasons a. Loss of Eligibility. If a Member no longer meets the eligibility requirements set forth in Section III, 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 ten(10)working days written notice for. ' i Material misrepresentation,fraud or omission of information in order to obtain coverage. it 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 the event of termination for cause,GHC reserves the right to pursue all civil remedies allowable under federal and state law for the collection of claims, losses or other damages 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 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 C29404-0036900a 15 ' Services while an inpatient for the condition 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 1 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 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 I 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 111 E)may continue coverage for a period of up to three(3)months subject to notification to and self-payment of premnums 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 1 coverage under the Agreement through payment of monthly premiums duectly to the Group Coverage may be continued for the lesser of the term of the strike, lock-out or other labor dispute,or for six(6)months after the cessation of work If the 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. 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. C29404-0036900a 16 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 I1.,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 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 4. Drugs and medications administered during confinement ' 5 Special duty nursing,when prescribed as Medically Necessary , tf 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 C29404-0036900a 17 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 The well care schedule is available in GHC clinics, by accessing GHC's website at www ghc org,or upon request 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 I7. Radiation therapy services ' 8 Reduction of a fracture or dislocation of the jaw 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,and dietary formula for the treatment of phenylketonuna(PKU) Coverage for PKU formula is not subject to a Pre- Existing Condition 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 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 filling,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 C29404-0036900a 18 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 nontherapeutic)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 Covered Services must be directly associated with, and occur at the time of,the transplant. Services are limited to the following a Inpatient and outpatient medical expenses listed below for transplantation procedures. • Evaluation testing to determine recipient candidacy, • Donor matching tests, ' • Hospital charges, • Procurement center fees, • Professional fees, ' • Travel costs for a surgical team,and • Excision fees Transplantation expenses listed above are subject to the Member's organ transplant lifetime benefit maximum set forth in the Allowance Schedule from one(1) day prior to the date of the transplant (or the date of the hospital admission during which the transplant occurs) through one hundred (100)days after the transplant Services received during a hospital admission that are not related to the transplant will not count towards the transplant lifetime benefit maximum. Donor-related services received at any time also apply to the organ transplant lifetime benefit maximum. Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees b Follow-up services for specialty visits, ' c Rehospitalization,and d 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 and items shall be excluded until the Member has been ' continuously enrolled under the Agreement for six(6)consecutive months,except for children who have C29404-0036900a 19 ' 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 This benefit wait period will be reduced by the length of time the Member had prior creditable coverage. 16 Manipulative therapy Self-Referrals for manipulative therapy of the spine and extremities are covered as set forth in the Allowances Schedule when provided by GHC Providers 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 and charges for any other services that do not meet GHC clinical criteria as Medically Necessary 17. Medical and surgical services and related hospital charges, including orthognathic(law)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 1V H 1 ,Orthopedic Appliances. ' Orthognathic(law)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 Excluded are the following• orthognathic(law)surgery in the absence of a TMJ or severe obstructive sleep apnea diagnosis except for congenital anomalies, treatment for cosmetic purposes,dental services, including orthodontic therapy and any hospitalizations related to these exclusions 18. Diabetic training and education. 19 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 care Cost Share The Member or person assuming responsibility for the Member must notify GHC by way of the GHC Notification Line 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 d 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 20 Circumcision 21 Bariatric 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 22 Sterilization procedures. ' 23 General anesthesia services and related facility charges for dental procedures will be covered for Members who are under seven(7)years of age,or are physically or developmentally disabled or have a Medical 1 Condition where the Member's health would be put at risk it 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 ' C29404-0036900a 20 Excluded dentist's or oral surgeon's fees ' 24. Self-Referrals to GHC acupuncturists and naturopaths for Covered Services,as set forth in the Allowances Schedule Additional visas 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 any services not within the scope of their licensure 25. Once Pre-Existing Condition wait periods, if any,have been met.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 unpaired 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 in the Allowances Schedule at a GHC Facility or G1IC-approved treatment program 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 inpatient Residential Treatment services, diagnostic evaluation and education, organized individual and group counseling and/or prescription drugs and medicines. Court-ordered treatment shall be covered only if determined to be Medically Necessary as defined above ' 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 not within 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 non-diseased breast to make it equivalent in ' size with the diseased breast 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 criteria 1. 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 C29404-0036900a 21 , 2. The Member requires intermittent skilled home healthcare 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 myury which requires the skill of a nurse or therapist,based on the complexity of the sere ice 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, durable medical equipment 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 recurring need for skilled home health care services Excluded custodial care and maintenance care,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 prov ided by or for a 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 writing 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 1 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 during periods of crisis Continuous care is covered only when a GHC Provider determines that the Member would otherwise require hospitalization in an acute care facility b. Inpatient Hospice Services. For short-term care,inpatient hospice services shall be covered in a faulity 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 ' C29404-0036900a 22 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 grver(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 u Medical appliances and supplies primarily for the relief of pain and symptom management ui. Durable medical equipment ry Counseling services for the Member and his/her primary care-giver(s) v 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 ' 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 fayruly. 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 b Services are limited to those necessary to restore or improve functional abilities when physical, sensory-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 inpatient Residential Treatment services;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 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 section,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 i ripiovement 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 inpatient Residential Treatment services; specialty rehabilitation programs not provided by GHC, long-term rehabilitation programs, physical therapy,occupational therapy and speech therapy C29404-0036900a 23 , services when such services are available(whether application is made or not)through 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 living, are covered as set 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 ' 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 1. 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 approved pharmacy products provided the Member is actively participating in a GHC-designated tobacco cessation program J. Drugs,Medicines, Supplies and Devices. This benefit,for purposes of creditable coverage, is actuarially equal to or greater than the Medicare Part D prescription drug benefit Eligible Members who are also eligible ' for Medicare Part D pharmacy benefits can remain covered under the Agreement and not be subject to Medicare-unposed late enrollment penalties should they decide to enroll in a Medicare Part D pharmacy plan at a later date. ' The Agreement may include Medicare Part D pharmacy benefits as part of the GHC Medicare Advantage Plan required for Medicare eligible Members who live in the GHC Medicare Advantage Service Area See Section Ill D for more information A Member who discontinues coverage under the Agreement must meet eligibility requirements in order to re-enroll 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 ' C29404-0036900a 24 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),contraceptive drugs and devices,diabetic supplies, including insulin syringes,lancets, urine-testing reagents,blood-glucose monitoring reagents and insulin,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 The prescription drug Cost Share,as set forth in the Allowances Schedule, applies to each thirty (30)day supply Cost Shares for single and multiple thirty(30)day supplies of a given prescription are payable at the time of delivery Injectables that can be self-administered are also subject to the prescription drug Cost Share Drug formulary (approved drug list) is defined as a list of preferred pharmaceutical products,supplies and devices developed and maintained by GHC A limited supply of prescription drugs obtained at a non-GHC pharmacy is covered when dispensed or prescribed in connection with covered Emergency treatment 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 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 A generic drug is 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 A brand name drug is 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 Association 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,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 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' right 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 GHC 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 Washington State Department of Health at(800) 525-0127 K. Mental Health Care Services. Services that are provided by a mental health practitioner will be covered as ' mental health care,regardless of the cause of the disorder 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 C29404-0036900a 25 ' 1 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 1V J 2. Inpatient Services. Charges for services described in this section,including psychiatric Emergencies resulting in inpatient services,are covered 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 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/involuntary Emergency inpatient psychiatric services is subject to the Emergency care benefit set forth in Section 1V L, including the twenty-four(24)hour notification and transfer provisions Outpatient electro-convulsive therapy treatment is covered subject to the outpatient surgery Cost Share 3. Exclusions and Limitations for Outpatient and Inpatient Mental Health Treatment Services. Covered Sen ices are limited to those authorized by GHC's Medical Director,or his/her designee,for covered clinical conditions for which the reduction or removal of acute clinical symptoms or stabilization can be expected given the most clinically appropriate level of mental health care intervention Excluded inpatient Residential Treatment services; 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,work or school ordered assessment and treatment not considered Medically Necessary,counseling for overeating, nicotine related disorders,relationship counseling or phase of life problems(V code only diagnoses), and custodial care rAny 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. 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 von-GHC Facility. Usual,Customary and Reasonable charges for Emergency care for Covered Services are covered subject to ' a Payment of the Emergency care Cost Share,and b. Notification of GHC byway of the GHC Notification Line within twenty-four(24)hours following inpatient admission,or as soon thereafter as medically possible ' 3. Waiver of Emergency Care Cost Share. 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 ' C29404-0036900a 26 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 Vlli for a definition of Urgent Condition.) Inside the GHC Service Area,care for Urgent Conditions is covered at GHC medical centers,GHC urgent care ' clinics or GHC Providers' offices, subject to the applicable Cost Share Urgent care received at any hospital emergency department is not covered unless authorized in advance by a GHC Provider Care received at urgent care facilities other than those listed above is only covered for Emergency services,subject to the applicable Emergency care Cost Share. Outside the GHC Service Area, Usual,Customary and Reasonable charges are covered for Urgent Conditions received at any medical facility,subject to the applicable Cost Share 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 any Facility. Each Emergency is covered as set forth in the Allowances Schedule 2. Interfacility Transfers GHC-mitiated 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 full- , time skilled nursing care is necessary in the opinion of the attending GHC Provider,is covered as set forth in the Allowances Schedule 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 t 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 1V 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 1V D ' 4 Convalescent or custodial care. C29404-0036900a 27 , ' 5. Durable medical equipment such as hospital beds,wheelchairs and walk-aids,except while in the hospital or as set forth in Section 1V B ,1V E,1V F or 1V 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 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 1V B 10 Any services to the extent benefits are"available"to the Member as defined herein 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 medical coverage,medical"no fault"coverage,Personal Injury Protection coverage or similar medical 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, or otherwise has the right to receive first party 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, or related to, the availability of other insurance coverage The Member and his/her agent shall permit GHC,at GHC's option,to associate with the Member or to intervene in any action filed against any party related to the injury The Member and his/her agents shall do nothing to prejudice GHC's right to enforce this exclusion In the event the Member fails to cooperate fully,GHC reserves the right to deny coverage and 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 undermsured 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 i GHC 11 Late term pregnancy termination except when the health ofthe mother is at risk 12 The cost of services and supplies insulting 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(1 e.,eye training) 14 Specialty treatment programs such as weight reduction,"behavior modification programs"and rehabilitation, including cardiac rehabilitation 15. Services or care needed for injuries or conditions resulting from active or reserve military service,whether such injuries or conditions result fiom war or otherwise This exclusion will not apply to conditions or injuries resulting from previous military service unless the condition has been determined by the U S Secretary of Veterans Affairs to be a condition or injury incurred during a period of active duty Further,this exclusion will not be interpreted to interfere with or preclude coordination of benefits under Tri-Care. it6 Procedures and services to reverse a therapeutic or nontherapeutic sterilization. If C29404-0036900a 28 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 service 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 asset forth in Section 1V 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 i 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 n. The service is the subject of a current new drug or new device application on file with the FDA in The service is provided as part of a Phase 1 or Phase 11 clinical tnal,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 vu 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 detenrine the safety,toxicity or efficacy of the service }� b In making determinations whether a service is experimental or investigational,the following sources of i 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, in Any consent document(s)the Member or Member's representative has executed or will be asked to execute,to receive the service, iv The files and records of the Institutional Review Board(IRB)or 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 IRB or similar body, v The published authoritative medical or scientific literature regarding the service,as applied to the Member's illness or injury,and vi Regulations,records,applications and any other documents or actions issued by, filed with or taken by, the FDA or other agencies within the United States Department of Health and Human Services,or any state agency performing similar functions Appeals regarding denial of coverage can be submitted to the Member Appeals Department,or to GHC's Medical Director at P O Box 34593, Seattle, WA 98124-1593 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 a delay would jeopardize the Member's life or health 20. Chemical dependency, rehabilitation services and mental health care,except as specifically provided in Sections IV.C.,IV.G. and IV K C29404-0036900a 29 I 21 Hypnotherapy,and all services related to hypnotherapy. 22 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 23. Follow-up visits related to a non-Covered Service 24 Fetal ultrasound in the absence of medical indications 25 Routine foot care, except in the presence of a non-related Medical Condition affecting the lower limbs. 26. Complications of non-Covered Services. 27 Obesity treatment and treatment for morbid obesity, including any medical services,drugs,supplies or any L bariatric surgery (such as gastroplasty or intestinal bypass),regardless of morbidities,complications of obesity or any other Medical Condition, except as set forth in Section 1V B. 28 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 29. Autopsy and associated expenses 30 Services provided by government agencies,except as required by federal or state law 31 Services related to temporomandibular Joint 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 1V B 32 Services covered by the national health plan of any other country. 33. Pre-Existing Conditions, except as specifically provided in Section IV B.25, 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 sei vice The appeals process is available for a Member to seek reconsideration of a denial of benefits. Complaint Process Step t: 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 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 state what he/she thinks would be a fair resolution to the problem A Customer Service Representative or Member Quality of Care 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 C29404-0036900a 30 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 Member Quality of Care 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 Member 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 Appeals should be directed to GHC's Member Appeals Department,P O Box 34593, Seattle,WA 98124-1593,toll free (866)458-5479 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 provider believes that the standard thirty(30)day appeal review process will seriously jeopardize the Member's life,health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment The Member can request an expedited appeal in writing to the above address,or by calling GHC's Member Appeals Department toll free(866)458-5479 The Member's request for an expedited appeal will be processed and a decision issued no later than seventy-two(72)hours after receipt Step 2: if the Member is not satisfied with the decision in Step 1 regarding a denial of benefits,or if GHC fails to grant or reject the Member's request within the applicable required timeframe,he/she may request a second level review by an external independent review organization as set forth under subsection A below The Member may also choose to pursue review by an appeals committee prior to requesting a review by an independent review organization as set forth under subsection B below This is not a required step in the appeals process A Request a review by 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 organization, the decision is final and cannot be appealed through GHC A request for a review by an independent review organization must be made within 180 days after the date of the Step 1 decision notice,or within 180 days after the date of a GHC appeals committee decision notice B Request an optional hearing by the GHC appeals committee The appeals committee hearing is an informal process The hearing will be conducted within thirty(30)working days of the Member's request and notification of the appeal committee's decision will be mailed to the Member within five(5)working days of the hearing Members electing the appeals committee maintain their right to appeal further to an independent review organization as set forth in paragraph A above Review by the appeals committee is not available if the appeal request is for an experimental or investigational exclusion or limitation A request for a hearing by the appeals committee must be made within thirty(30)days after the date of the Step 1 decision notice The request can be mailed to GHC's Member Appeals Department,P O Box 34593,Seattle, WA 98124-1593 C29404-0036900a 31 *11 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 Linder the plan at any point after completion of Step I of the appeals process Members may have other legal rights and remedies available under state or federal law Section V1I. General Provisions A. Coordination of Benefits The coordination of benefits (COB)provision applies when a Member has health care coverage under more than one plan Plan is defined below The order of benefit determination rules govern the order in which each plan will pay a claim for benefits The plan that pays first is called the primary plan The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses The plan that pays after the primary plan is the secondary plan The secondary plan must pay an amount which, together with the payment made by the primary plan,totals the higher of the allowable expenses. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan,the Member or the Member's provider should file all the Member's claims with each plan at the same time If Medicare is the Member's primary plan, Medicare may submit the Member's claims to the Member's secondary carrier 1. Definitions. a. Plan.A plan is any of the following that provides benefits or services for medical or dental care or treatment If separate contracts are used to provide coordinated coverage for Members of a Group,the separate contracts are considered parts of the same plan and there is no COB among those separate contracts However, if COB rules do not apply to all contracts,or to all benefits in the same contract, the contract or benefit to which COB does not apply is treated as a separate plan 1) Plan includes group,individual or blanket disability insurance contracts and group or individual contracts issued by health care service contractors or health maintenance organizations(HMO), closed panel plans or other forms of group coverage,medical care components of long-term care contracts,such as skilled nursing care,and Medicare or any other federall governmental plan, as permitted by law. 2) Plan does not include hospital indemnity or fixed payment coverage or other fixed indemnity or fixed payment coverage, accident only coverage, specified disease or specified accident coverage, limited benefit health coverage,as defined by state law, school accident type coverage,benefits for non-medical components of long-term care policies,automobile insurance policies required by statute to provide medical benefits,Medicare supplement policies, Medicaid coverage,or coverage under other federal governmental plans,unless permitted by law Each contract for coverage under subsection 1)or 2)is a separate plan.If a plan has two parts and COB rules apply only to one of the two,each of the parts is treated as a separate plan b. This plan means,in a COB provision,the part of the contract prov idmg the health care benefits to which the COB provision applies and which may be reduced because of the benefits of other plans Any other part of the contract pro,,idmg health care benefits is separate from this plan A contract may apply one COB provision to certain benefits, such as dental benefits,coordinating only with similar benefits,and may apply another COB provision to coordinate other benefits c. The order of benefit determination rules determine whether this plan is a primary plan or secondary plan when the Member has health care coverage under more than one plan When this plan is primary, it determines payment for its benefits first before those of any other plan without considering any other plan's benefits When this plan is secondary, it detenmines its benefits after those of another plan and must make payment in an amount so that,when combined with the C29404-0036900a 32 amount paid by the primary plan,the total benefits paid or provided by all plans for the claim equal 100%of the total allowable expense for that claim This means that when this plan is secondary,it must pay the amount which,when combined with what the primary plan paid, totals 100%of the highest allowable expense In addition,if this plan is secondary,it must calculate its savings(its amount paid subtracted from the amount it would have paid had it been the primary plan)and record these savings as a benefit reserve for the covered Member This reserve must be used by the secondary plan to pay any allowable expenses not otherwise paid,that are incurred by the covered person during the claim determination period d. Allowable Expense.Allowable expense is a health care expense,coinsurance or copayments and without reduction for ant,applicable deductible, that is covered at least in part by any plan covering the person When a plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid An expense that is not covered by any plan covering the Member is not an allowable expense The following are examples of expenses that are not allowable expenses 1) The difference between the cost of a semi-private hospital room and a private hospital room is not an allowable expense,unless one of the plans provides coverage for private hospital room expenses 2) If a Member is covered by two or more plans that compute their benefit payments on the basis of usual and customary fees or relative value schedule reimbursement method or other similar reimbursement method,any amount in excess of the highest reimbursement amount for a specific benefit is not an allowable expense 3) If a Member is covered by two or more plans that provide benefits or services on the basis of negotiated tees,an amount in excess of the highest of the negotiated fees is not an allowable expense 4) An expense or a portion of an expense that is not covered by any of the plans covering the person is not an allowable expense. e Closed panel plan is a plan that provides health care benefits to covered persons in the form of services through a panel of prov iders who are primarily employed by the plan, and that excludes coverage for services provided by other providers,except in cases of emergency or referral by a panel member f Custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation 2. Order of Benefit Determination Rules. When a Member is covered by two or more plans,the rules for determining the order of benefit payments are as follows a The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan b. Except as provided below, a plan that does not contain a coordination of benefits provision that is consistent with this chapter is always primary unless the provisions of both plans state that the complying plan is primary Coverage that is obtained by virtue of membership in a Group that is designed to supplement a part of a basic package of benefits and provides that this supplementary coverage is excess to any other parts of the plan provided by the Subscriber Examples include major medical coverages that are superimposed over hospital and surgical benefits,and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits c A plan may consider the benefits paid or provided by another plan in calculating payment of its benefits only when it is secondary to that other plan d Each plan determines its order of benefits using the first of the following rules that apply C29404-0036900a 33 t 1) Non-Dependent or Dependent The plan that covers the Member other than as a Dependent,for example as an employee,member,policyholder, Subscriber or retiree is the primary plan and the plan that covers the Member as a Dependent is the secondary plan However, if the person is a Medicare beneficiary and,as a result of federal law,Medicare is secondary to the plan covering the Member as a Dependent,and primary to the plan covering the Member as other than a Dependent(e g,a retired employee), then the order of benefits between the two plans is reversed so that the plan covering the Member as an employee,member, policyholder, Subscriber or retiree is the secondary plan and the other plan is the primary plan 2) Dependent child covered under more than one plan Unless there is a court decree stating otherwise,when a dependent child is covered by more than one plan the order of benefits is determined as follows a) For a dependent child whose parents are mamed or are living together,whether or not they have ever been marred • The plan of the parent whose birthday falls earlier in the calendar year is the primary plan,or • If both parents have the same birthday,the plan that has covered the parent the longest is the primary plan b) For a dependent child whose parents are divorced or separated or not living together,whether or not they have ever been married (1) If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms,that plan is primary This rule applies to claim determination periods commencing after the plan is given notice of the court decree, (2) If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses,the plan of the parent assuming financial responsibility is primary, (3) If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage,the provisions of a)above determine the order of benefits, (4) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subsection a) above determine the order of benefits,or (5) if there is no court decree allocating responsibility for the dependent child's health care expenses or health care coverage, the order of benefits for the child are as follows • The plan covering the custodial parent, first, • The plan covering the spouse of the custodial parent,second, • The plan covering the non-custodial parent,third,and then • The plan covering the spouse of the non-custodial parent, last c) For a dependent child covered under more than one plan of individuals who are not the parents of the child, the provisions of subsection a)or b)above determine the order of benefits as if those individuals were the paieuts of the child 3) Active employee or retired or laid-off employee The plan that covers a Member as an active employee,that is,an employee who is neither laid off nor retired, is the primary plan The plan covering that same Member as a retired or laid off employee is the secondary plan The same would hold true if a Member is a Dependent of an active employee and that same Member is a Dependent of a retired or laid-off employee If the other plan does not have this rule,and as a result,the plans do not agree on the order of benefits, this rule is ignored This rule does not apply if the rule under section d 1)can determine the order of benefits 4) COBRA or State Continuation Coverage If a Member whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another plan,the plan covering the Member as an employee,member, Subscriber or retiree or covering the Member as a Dependent of an employee,member, Subscriber or retiree is the primary plan and the ' C29404-0036900a 34 COBRA or state or other federal continuation coverage is the secondary plan If the other plan does not have this rule,and as a result, the plans do not agree on the order of benefits,this rule is ignored This rule does not apply if the rule under section d 1)can determine the order of benefits 5) Longer or shorter length of coverage The plan that covered the Member as an employee,member, Subscriber or retiree longer is the primary plan and the plan that covered the Member the shorter period of time is the secondary plan. 6) If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the plans meeting the definition of plan In addition, this plan will not pay more than it would have paid had it been the primary plan 3. Effect on the Benefits of this Plan. When this plan is secondary,it must make payment in an amount so that, when combined with the amount paid by the primary plan,the total benefits paid or provided by all plans for the claim equal one hundred percent of the total allowable expense for that claim.However,in no event shall the secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. In no event should the Member be responsible for a deductible amount greater than the highest of the two deductibles. Total allowable expense is the highest allowable expenses of the primary plan or the secondary plan In addition, the secondary plan must credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage 4. Right to Receive and Release Needed Information. Certain facts about health care coverage and services are needed to apply these COB rules and to determine benefits payable under this plan and other plans GHC may get the facts it needs from or give them to other organizations or persons for the purpose of applying these rules and determining benefits payable under this plan and other plans covering the Member claiming benefits GHC need not tell,or get the consent of, any Member to do this Each Member claiming benefits under this plan must give GHC any facts it needs to apply those rules and determine benefits payable 5. Facility of Payment. If payments that should have been made under this plan are made by another plan,GHC has the right, at its discretion,to remit to the other plan the amount it determines appropriate to satisfy the intent of this provision The amounts paid to the other plan are considered benefits paid under this plan To the extent of such payments,GHC is fully discharged from liability under this plan 6. Right of Recovery. GHC has the right to recover excess payment whenever it has paid allowable expenses in excess of the maximum amount of payment necessary to satisfy the intent of this provision GHC may recover excess payment from any person to whom or for whom payment was made or any other issuers or plans Questions about Coordination of Benefits? Contact the State Insurance Department 7. Effect of Medicare. I Members Residing Outside the GHC Medicare Advantage Service Area.Medicare primary/secondary payer guidelines and regulations will determine primary/secondary payer status When Medicare, Part A and Part B or Part C are primary,Medicare's allowable amount is the highest allowable expense. When GHC renders care to a Member who is eligible for Medicare benefits,and Medicare is deemed to be 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 C29404-0036900a 35 The benefits under this Agreement will be available to a Member for injury or illness caused by another party, subject to the exclusions and limitations of this Agreement If GHC provides benefits under this Agreement for the treatment of the injury or illness,GHC will be subrogated to any rights that the Member may have to recover compensation or damages related to the injury or illness This section VII B more fully describes GHC's 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 refer red to in this section,"GHC's Medical Expenses"means the expenses incurred and the reasonable value of the benefits 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 uninsured/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 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 However, in the case of Medicare Advantage Members,GHC's right of subrogation shall be the full amount of GHC's Medical Expenses and is limited only as required by Medicare Subject to the above provisions,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 party's liability insurance or umnsured/undennsured motorist funds,then GHC's Medical Expenses provided or to be provided to the Injured Person are secondary,not primary Asa 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 reirnburse GHC for the benefits the Injured Person received as a result of the events causing the injury 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 Parson 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 GIIC's Medical Expenses To the extent that the Injured Person recovers funds from any source that may serve to compensate for medical injuries or medical expenses, 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 attorneys' fees or collection costs to attorneys representing the Injured Person unless there is a written fee agreement signed by GHC prior to any collection efforts When reasonable collection costs have been incurred with GHC's prior written agreement to recover 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 or where no written fee agreement has been entered into with GHC C29404-0036900a 36 To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA, implementation of this section shall be deemed a part of claims administration under the Agreement and GHC shall therefore have 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 administration of the Agreement This may include,but is not limited to,policies or procedures pertaining to benefit entitlement and coverage determinations 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 recen,mg 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(in)to a designated public official or agency pursuant to the requirements of federal, state or local law, 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 Contracted Network Pharmacy: 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 Copayments, coinsurances 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 premium prescribed in the Premium Schedule has been paid Emergency: The emergent and acute onset of a symptom or symptoms, including severe pain,that would lead a prudent lay person acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily function or serious dysfunction of a bodily organ or part,or would place the Member's health in serious jeopardy Family Unit: A Subscriber and all his/her Dependents C29404-0036900a 37 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 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,clinic associate staff and allied health professionals employed by GHC,and any other health care professional or provider with whom GHC has contracted to provide health care services to 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 asset forth in the Allowances Schedule The value of Covered Services is based on the Fee Schedule,as defined above The lifetime maximum applies to this Agreement or in combination with any other medical coverage agreement between GHC and Group Medical Condition:A disease, illness or injury. Medically Necessary: Appropriate and clinically necessary services,as determined by 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 and which meet the standards set forth below 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 primarily 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 GHC's Medical Director,or his/her designee In addition to being medically necessary, to be covered, services and supplies must be otherwise included as a Covered Service as set forth in Section IV of the Agreement and not excluded from coverage The cost of non-covered services and supplies shall be the responsibility of the Member. Medicare: The federal health insurance program for the aged and disabled iC29404-0036900a 38 Member: Any Subscriber or Dependent enrolled under the Agreement 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: 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 Plan Coinsurance: The percentage amount 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 Pre-Existing Condition: A condition for which there has been diagnosis, treatment 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 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 Residential Treatment: A term used to define facility-based treatment, which includes twenty-four(24)hours per day,seven(7)days per week rehabilitation.Residential Treatment services are provided in a facility specifically licensed in the state where it practices as a residential treatment center. Residential treatment centers provide active treatment of patients in a controlled environment requiring at least weekly physician visits and offering treatment by a multi-disciplinary team of licensed professionals. 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: Washington counties of Benton,Columbia,Franklin,Island,King,Kitsap,Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane,Thurston,Walla Walla, Whatcom, Whitman and Yakima, Idaho counties of Kootenai and Latah,and any other areas designated by GHC 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 premium specified in the Premium Schedule has been paid Urgent Condition: The sudden, unexpected onset of a Medical Condition that is of sufficient severity 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 services or supplies C29404-0036900a 39 Z t EMPLOYER GROUP PROGRAMS � GROUP MEDICARE COVERAGE i 1 1 1 1 j � 1 T 1 i i i t t OGroupHealth. Group Health Cooperative Medicare Advantage Plan (GHMA Plan) Following is a brief outline of the benefits available to Group Members who are also enrolled in the Group Health Cooperative Medicare Advantage plan. A more detailed plan summary is provided to GHMA Plan Members directly. In no event shall the benefits of the GHMA plan duplicate the benefits under the Group Medical Coverage Agreement. The benefits available to persons enrolled in both the Group Health Cooperative Medical Coverage Agreement and the Group Health Cooperative Medicare Advantage Plan will be the higher level of benefit available under the plans, as determined by Group Health Cooperative Unless otherwise stated, the provisions, limitations and exclusions, including provider access requirements of the Group Medical Coverage Agreement apply to the benefits available under the Group Health Cooperative Medicare Advantage Plan The benefits described in this outline apply only to Members who are covered under Medicare 1 Part A and Part B, and who are enrolled in the Group Health Cooperative Medicare Advantage Plan as set forth in the Group Medical Coverage Agreement This includes those Members with Medicare Part B only, who have been continuously enrolled in the Group Health Cooperative Medicare Advantage Plan since December 31, 1998 t 1 SUMMARY OF BENEFITS Benefit Category Original Medicare GHC Medicare "inploy Group Plan INPATIENT CARE 1 - Inpatient In 2010 the amounts for each In-Network: Hospital Care benefit period are (Includes Substance Days 1 - 60 S 1100 deductible For Medicare-covered Abuse and Days 61 - 90. $275 per day hospital stays you pay the Rehabilitation Days 91 - 150 $550 per lesser of the Group cost share Services) lifetime or the following copayments• reserve day Days 1-5: $200 copay per Call1-800-MEDICARE day (1-800-633-4227) for Days 6-90: $0 copay per day information about lifetime reserve days $0 copay for additional hospital days Lifetime reserve days can only be used once No limit to the number of days covered by the plan each A"benefit period" starts the benefit period. day you go into a hospital or skilled nursing facility It ends Except in an emergency, your when you go for 60 days in a doctor must tell the plan that row without hospital or skilled you are going to be admitted nursing care. If you go into the to the hospital. hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period There is no limit to the number of benefit periods you can have. 2 - Inpatient Same deductible and copay as For Medicare-covered Mental Health inpatient hospital care (see hospital stays you pay the Care "Inpatient Hospital Care" lesser of the Group cost share above). or the following copayments: 190 day lifetime limit in a Days 1-5: $200 copay per Psychiatric Hospital. day Days 6-90• $0 copay per day You get up to 190 days in a Psychiatric Hospital in a lifetime. Except in an emergency, our Benefit Category Original Medicare GHC Medicare Empidy"e;Group Plan doctor must tell the plan that you are going to be admitted to the hospital. 3 - Skilled Nursing In 2010 the amounts for each There is no copayment for Facility (in a benefit period after at least a 3- services received at a Skilled Medicare-certified day covered hospital stay are. Nursing Facility skilled nursing Days 1 - 20 $0 per day facility) Days 21 - 100. $137.50 per No prior hospital stay is day required. 3 - Skilled Nursing Facility(continued) 100 days for each benefit You are covered for 100 days period each benefit period. A benefit period begins the day Authorization rules may you go to a hospital or skilled apply. nursing facility The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period There is no limit to the number of benefit periods you can have. 4 - Home Health SO copay Authorization rules may Care apply. (Includes medically necessary $0 copay for Medicare- intermittent skilled covered home health visits. nursing care, home health aide services, and rehabilitation services, etc. 5 -Hospice You pay part of the cost for You must receive care from a outpatient drugs and inpatient Medicare-certified hospice respite care. You must receive care from a Medicare-certified hospice OUTPATIENT CARE 6 - Doctor Office 20% coinsurance General Visits See "Physical Exams" for more information GHC Medicare Employer Benefit Category Original Medicare Group Plan Authorization rules may apply- In-Network You pay the lesser of the Group cost share or $20 copay for each primary care doctor office visa for Medicare-covered services. You pay the lesser of the Group cost share or$20 copay for each specialist visit for Medicare-covered services 7 - Chiropractic Routine care not covered In-Network Services You pay the lesser of the 20% coinsurance for manual Group cost share or$20 manipulation of the spore to copay for Medicare-covered correct subluxation (a visits. displacement or misalignment of a joint or body part) if you Medicare-covered get it from a chiropractor or chiropractic visits are for other qualified providers manual manipulation of the spine to correct subluxation(a displacement or misalignment of a joint or body part). 8 - Podiatry Routine care not covered. General Services Authorization rules may 20% coinsurance for medically apply. necessary foot care, including care for medical conditions In-Network affecting the lower limbs You pay the lesser of the Group cost share or$20 copay for Medicare-covered visits Medicare-covered podiatry benefits are for medically- necessary foot care. 9 - Outpatient 45% coinsurance for most General Mental Health outpatient mental health Authorization rules may Care services. apply. GHC Medicare Employe-' Be►tefii Category Original Medicare Group Plan In-Network You pay the lesser of the Group cost share or$20 copay for each Medicare- covered individual or group therapy visit 10 - Outpatient 20% coinsurance In-Network Substance Abuse $0 copay for Medicare- Care covered visits. 11 - Outpatient 20% coinsurance for the doctor General Services/Surgery Authorization rules may 20% of outpatient facility apply. charges In-Network You pay the lesser of the Group cost share or $200 copay for each Medicare- covered ambulatory surgical center visit. You pay the lesser of the Group cost share or$200 copay for each Medicare- covered outpatient hospital facility visa. 12 - Ambulance 20% coinsurance General Services Authorization rules may (medically apply. necessary ambulance In-Network services) You pay the lesser of the Group cost share or $150 copay for Medicare-covered ambulance services. 13 - Emergency 20% coinsurance for the doctor In-Network ! Care You pay the lesser of the (You may go to any 20% of facility charge, or a set Group cost share or $50 for emergency room if copay per emergency room each Medicare-covered you reasonably visit emergency room visits. believe you need emergency care.) You don't have to pay the Out-of-Network emergency room copay if you Worldwide coverage. are admitted to the hospital for the same condition within 3 Benefit�Category Original'M'e'dieare GHC Medicare Employer;,,; Grou Plan days of the emergency room visit. NOT covered outside the U.S. In and Out-of-Network except under limited If you are admitted to the circumstances. hospital within 1 day for the same condition, you pay $0 for the emergency room visit. 14 - Urgently 20% coinsurance, or a set You pay the lesser of the Needed Care copay Group cost share or$20 (This is NOT copay for each Medicare- emergency care, NOT covered outside the U.S covered urgently needed care and in most cases, except under limited visit is out of the service circumstances. area ) 15 - Outpatient 20% coinsurance General Rehabilitation Authorization rules may Services apply. (Occupational Therapy, Physical In-Network Therapy, Speech You pay the lesser of the and Language Group cost share or$20 Therapy) copay for Medicare-covered Occupational Therapy visits. You pay the lesser of the Group cost share or $20 copay for Medicare-covered Physical and/or Speech/Language Therapy visits OUTPATIENT MEDICAL SERVICES AND SUPPLIES 16 - Durable 20% coinsurance General Medical Authorization rules may Equipment apply. (Includes wheelchairs, In-Network oxygen, etc.) You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items 17 - Prosthetic 20% coinsurance General Devices Authorization rules may (Includes braces, apply „GHC Medicare Employ Benefit Category Original Medicare'; ”' '!i i; „ Group Plan artificial limbs and eyes, etc.) In-Network You pay the lesser of the Group cost share or 20% of the cost for Medicare-covered items. 18- Diabetes Self- 20% coinsurance General Monitoring Authorization rules may Training, Nutrition therapy is for people apply. Nutrition who have diabetes or kidney Therapy, and disease (but aren't on dialysis In-Network Supplies or haven't had a kidney $0 copay for Diabetes self- (includes coverage transplant) when referred by a monitoring training for glucose doctor These services can be monitors, test given by a registered dietitian $0 copay for Nutrition strips, lancets, or include a nutritional Therapy for Diabetes. screening tests, and assessment and counseling to self-management help you manage your diabetes You pay the lesser of the training) or kidney disease. Group cost share or 20% of the cost for Diabetes supplies. 19 - Diagnostic 20% coinsurance for General Tests, X-Rays, diagnostic tests and X-rays Authorization rules may Lab Services, and apply. Radiology Services $0 copay for Medicare-covered lab services In-Network $0 copay for Medicare- Lab Services: Medicare covered: covers medically necessary - lab services diagnostic lab services that are - diagnostic procedures and ordered by your treating doctor tests when they are provided by a - X-rays Clinical Laboratory - Diagnostic radiology Improvement Amendments services (not including X- (CLIA) certified laboratory rays) that participates in Medicare. - therapeutic radiology Diagnostic lab services are services done to help your doctor diagnose or rule out a 19 -Diagnostic suspected illness or condition. Tests, X-Rays, Medicare does not cover most Lab Services, and routine screening tests, like Radiology Services checking your cholesterol. (continued) PREVENTIVE SERVICES 20 - Bone Mass 20% coinsurance General j Benefit Category Original Medicare GHC Medicare Employe, Group Plan Measurement Authorization rules may (for people with Covered once every 24 months apply Medicare who are (more often if medically at risk) necessary) if you meet certain In-Network medical conditions. $0 copay for Medicare- covered bone mass measurement 21 - Colorectal 20% coinsurance General Screening Exams Authorization rules may (for people with Covered when you are high apply. Medicare age 50 risk or when you are age 50 and older) and older. In-Network $0 copay for Medicare- covered colorectal screenings. 22 - $0 copay for Flu and General Immunizations Pneumonia vaccines Authorization rules may (Flu vaccine, apply. Hepatitis B vaccine 20% coinsurance for Hepatitis - for people with B vaccine In-Network Medicare who are $0 copay for Flu and at risk, Pneumonia You may only need the Pneumonia vaccines. vaccine) Pneumonia vaccine once in your lifetime Call your doctor $0 copay for Hepatitis B for more information vaccine No referral necessary for Flu and Pneumonia vaccines. Referral required for other immunizations. 23 - 20% coinsurance In-Network Mammograms $0 copay for Medicare- (Annual Screening) No referral needed. covered screening (for women with mammograms Medicare age 40 Covered once a year for all and older) women with Medicare age 40 and older One baseline mammogram covered for women with Medicare between age 35 and 39 24 - Pap Smears $0 copay for Pap smears In-Network and Pelvic Exams $0 copay for Medicare- (for women with Covered once every 2 years. covered pap smears and Medicare) Covered once a year for pelvic exams women with Medicare at high risk GHC Medicare Employer Benefit Category Original Medicare Group Plan 20% coinsurance for pelvic exams 25 - Prostate 20% coinsurance for the digital General Cancer Screening rectal exam. Authorization rules may Exams apply. (For men with $0 for the PSA test; 20% Medicare age 50 coinsurance for other related In-Network and older.) services $0 copay for Medicare- covered prostate cancer Covered once a year for all screenings. men with Medicare over age 50. 26—End-Stage 20% coinsurance for renal General Renal Disease dialysis Authorization rules may apply. 20% coinsurance for Nutrition Therapy for End-Stage Renal Out-of-area Renal Dialysis Disease services do not require Authorization. L Nutrition therapy is for people who have diabetes or kidney In-Network disease (but aren't on dialysis $0 copay for renal dialysis or haven't had a kidney transplant) when referred by a $0 copay for Nutrition doctor These services can be Therapy for end-stage renal given by a registered dietitian disease or include a nutritional assessment and counseling to help you manage your diabetes or kidney disease. 27- Prescription Most drugs are not covered Your Employer Group Drugs under Original Medicare You Outpatient Prescription drug can add prescnption drug benefit applies. coverage to Original Medicare by joining a Medicare Please contact the plan for Prescription Drug Plan, or you details. can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage 28 - Dental Preventive dental services $0 copay for Medicare- GHC Medicare Employer Benefittaltegory Original Medicare Grou Plan Services (such as cleaning) not covered. covered dental benefits. In general, preventive dental benefits (such as cleaning) not covered. 29 - Hearing Routine hearing exams and Your Your Group benefit Services hearing aids not covered. applies. 20% coinsurance for diagnostic hearing exams 30—Vision 20% coinsurance for diagnosis Your Employer Group benefit Services and treatment of diseases and applies conditions of the eye. Routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery Annual glaucoma screenings covered for people at risk 31 - Physical 20% coinsurance for one exam $20 copay for routine exams. Exams within the first 12 months of your new Medicare Part B Limited to 1 exam(s) every coverage. two years. When you get Medicare Part $0 copay for Medicare- B, you can get a one time covered benefits. physical exam within the first 12 months of your new Part B coverage The coverage does not include lab tests. Health/Wellness Smoking Cessation. In-Network Education Covered if ordered by your This plan covers the following doctor Includes two health/wellness education counseling attempts within a benefits 12-month period if you are - Smoking Cessation diagnosed with a smoking- - Health Club related illness or are taking Membership/Fitness Classes medicine that may be affected - Nursing Hotline by tobacco. Each counseling attempt includes up to four $0 copay for each face-to-face visits You pay Medicare-covered smoking coinsurance, and Part B cessation counseling session. Benefit Category Original Medicare GAC Medicare Employer Grou Plan deductible applies. Transportation Not covered General (Routine) Authorization rules may apply- In-Network $150 copay for one-way trips to a Plan-approved location. US Non-emergent and/or non- Visitor/Traveler urgently needed care received Benefit while temporarily traveling outside GHC's Medicare Service Area is payable at Medicare benefit levels up to $3,000 per Member per calendar year. The GHC MA Plan pays 80% of Medicare allowable reimbursement US schedules for Medicare Visitor/Traveler covered services ONLY. Benefit Member is responsible for all (continued) Medicare inpatient and outpatient Deductibles and Comsurances. Member pays the lesser of the Group cost share or 20% of the cost for each stay in a non-network hospital or inpatient s chiatric hospital. I IMPORTANT INFORMATION ABOUT YOUR HOSPITAL CARE APPEAL RIGHTS For more information about your appeal rights, call us toll free at: 1-866-458-5479. How Do You Get an Immediate Review? QualisHealth is the name of the Quality Improvement Organization (QIO) authorized by Medicare to review the Hospital care provided to Medicare patients You or your authorized representative, attorney, or court appointed guardian must contact the QIO by telephone or in writing QualisHealth - QIO 10700 Meridian Avenue North Seattle, WA 98133 Toll Free 1-800-949-7536 Local. 206-364-9700 FAX 206-368-2419 1. If you file a written request, please write, "I want a "fast review". 2. Your request must be made no later than the day you are scheduled to be discharged from the hospital. If you meet this deadline, you may stay in the hospital after your discharge date without paying for it while you wait to get the decision from Qualis Health. 3. The QIO will make a decision within one full working day after it receives your request, your medical records, and any other information it needs to make a decision. 4. While you remain in the hospital, Group Health will continue to be responsible for paying the costs of your stay until noon of the calendar day following the day the QIO notifies you of its official Medicare coverage decision. What If the QIO Agrees With Our Coverage Decision? If the QIO agrees, you will be responsible for paying the cost of your hospital stay beginning at noon of the calendar day following the day the QIO notifies you of its Medicare coverage decision What If the QIO Disagrees With Our Coverage Decision? You will not be responsible for paying the full cost of your additional hospital days, except for certain convenience services or items not covered by your contract You will have to continue paying your share of the costs, such as copayments, if applicable What If You Don't Request an Immediate Review? If you remain in the hospital and do not request an immediate review by the QIO, you may be financially responsible for the cost of many of the services you receive beginning the day following the planned date of discharge. If you leave before the day following the date of this notice you will not be responsible for the cost of care As with all hospitalizations, you may have to pay for certain convenience services or items not covered by your Health Plan You will have to continue paying your share of the costs, such as copayments, if applicable. What If You Are Late Or Miss the Deadline To File For an Immediate Review? If you are late or miss the noon deadline to file for an immediate review by your QIO, you may still request an expedited (fast) appeal from Group Health. A "fast' appeal means Group Health will have to review your request within 72 hours. However, you will not have automatic financial protection during the course of your appeal. This means you could be responsible for paying the costs of your hospital stay beginning the day following the original planned discharge date. For a Fast Appeal: You or your authorized representative should contact us by telephone or fax- telephone 1-866-458-5479, fax. 206-901-7340 When you do so say or write- "I want a fast appeal." i 1 s IMPORTANT INFORMATION ABOUT YOUR OUTPATIENT CARE APPEAL RIGHTS For more information about your appeal rights call us toll free at: 1-866-458-5479. There Are Two Kinds of Appeals You Can File Standard (30 days)- You can ask for a standard appeal. We must give you a decision no later than 30 days after we get your appeal (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you ) Fast (72 hour review)-You can ask for a fast appeal if you or your doctor believes that your health could be seriously harmed by waiting too long for a decision We must decide on a fast appeal no later than 72 hours after we get your appeal (We may extend this time by up to 14 days if you request an extension, or if we need additional information and the extension benefits you.) • If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we will automatically give you a fast appeal. If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal If we do not give you a fast appeal, we will decide your appeal within 30 days What Do I Include With My Appeal? You should include: your name, address, Member ID number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors' letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish How Do I File An Appeal? For a Standard Appeal- You or your authorized representative should mail or deliver your written appeal to the addresses below. MAIL Group Health Cooperative GHC Appeals Department PO Box 34593 Seattle, WA 98124-1593 Attn.: Appeals Coordinator HAND DELIVER: 12400 E. Marginal Way South Tukwila, WA 98168 For a Fast Appeal: You or your authorized representative should contact us by telephone or fax: telephone 1-866-458-5479, fax 206-901-7340 What Happens Next? If you appeal, we will review our decision. After we review our decision, if any of the services you requested are still denied, Medicare will provide you with a new and impartial review of your case by a reviewer outside of your Medicare Advantage Organization If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens. Contact Information: If you need information or help, call us at- Toll Free. 1-888-901-4600 TTY/TTD 711 or 1-800-833-6388 1 Other Resources To Help You: Medicare Rights Center. 1-800-333-4114 Elder Care Locator Toll Free- 1-800-677-1116 1-800-MEDICARE (1-800-633-4227) TTY/TTD 1-877-486-2048 i I f GroupHealth. 1 2010 Medicare Endorsement Group Health Cooperative Medicare Advantage Plan This Endorsement does not constitute a"Medicare Supplemental'contract 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 benefits available to persons enrolled in both the Group Health Cooperative Medical Coverage Agreement and the Group I lealth Cooperative Medicare Advantage Plan will be the higher level of benefit available under the plans as determined by Group Health The benefits and exclusions described in this Endorsement apply only to members who are covered under Medicare Part A and Part B, and who are enrolled in the Group Health Cooperative Medicare Advantage Plan as set forth in Section III D,of the Group Medical Coverage Agreement This includes those members with Medicare Part B only, who have been continuously enrolled in the Group Health Cooperative Medicare Advantage Plan since December 31, 1998 Except as defined by federal regulations,all members entitled to,or eligible to purchase Medicare and who live in the Group Health Cooperative Medicare Advantage Plan service area, must enroll in the Group Health Cooperative Medicare Advantage Plan upon such entitlement or eligibility Incorporated into this endorsement is the GHC Medicare Advantage Plan Explanation of Coverage (EOC) The EOC sets forth the benefits,provisions and requirements of the GHC MA plan The EOC document has been approved by The Centers for Medicare and Medicaid(CMS) Services H5050 MLIOANOCE00001 F/U 09/2009 GroupHeathl January 1 —December 31, 2010 Evidence of Coverage: Your Medicare Health Benefits and Services as a Member of our Clear Care Basic HMO Plan This booklet gives you the details about your Medicare health coverage from January 1 —December 31, 2010 It explains how to get the health care you need This is an important legal document Please keep it in a safe place Group Health Customer Service: For help or information,please call Customer Service or go to our plan website at www ghe org/medicare 1-888-901-4600(Calls to these numbers are free) TTYITTD users call 711-or 1-800-833-6388 This plan is offered by Group Health Coopeiative,referred throughout the Evidence of Coverage as"we,""us,"or "our"Our Clear Care Basic Plan is referred to as"plan"or"our plan" A note on Group Health's Clear Care contract Group Health Cooperative's Clear Care plans have a contract with the Centers for Medicare and Medicaid Services (CMS),the branch of the federal government that administers Medicare They are coordinated care plans with a Medicare Advantage contract As a Clear Care member, all your medical services,with the exception of emergency, out-of-area urgently needed services, or out-of-area renal dialysis, must be provided or arranged for by Group Health Services rendered without Group Health's prior authorization,except for women's health care services, some specialty care, or emergency services anywhere in the world or urgently needed services outside the Group Health service area(or under unusual and extraordinary circumstances,provided when you are in the service area, but Group Health medical staff is temporarily unavailable or inaccessible),will not be covered by Group Health or Medicare Directory listings are subject to change Please call Customer Service if you have any questions This information may be available in a different format, including languages, large print, Braille and audio tapes. Please call Customer Service at the number listed above if you need plan information in another format or language H5050_ML l0AN0CE00001 F/U 09/2009 Z Table of Contents This list of chapters and page numbers is just your starting point. For more help in finding information you need, go to the first page of a chapter You will find a detailed list of topics at the beginning of each chapter. Chapter 1. Getting started as a member of our plan I Tells what it means to be in a Medicare health plan and how to use this booklet Tells about materials we will send you,your plan premium,your plan membership card,and keeping your membership record up to date Chapter 2. Important phone numbers and resources 6 Tells you how to get in touch with our plan(Clear Care Basic)and with other organizations including Medicare,the State Health Insurance Assistance Program, the Quality Improvement Organization, Social Security,Medicaid(a joint Federal and state program that helps with medical costs for some people with limited income and resources),and the Railroad Retirement Board Chapter 3. Using the plan's coverage for your medical services 14 Explains important things you need to know about getting your medical care as a member of our plan Topics include using the providers in the plan's network and how to get care when you have an emergency Chapter 4. Medical benefits chart(what is covered and what you pay)23 Gives the details about which types of medical care are covered and not covered for you as a member of our plan Tells how much you will pay as your share of the cost for your covered medical care Chapter 5. Asking the plan to pay its share of a bill you have received for medical services 50 Tells when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services Chapter 6. Your rights and responsibilities 53 Explains the rights and responsibilities you have as a member of our plan Tells what you can do if you think your rights are not being respected. Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 60 Tells you step-by-step what to do if you are having problems or concerns as a member of our plan • Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care you think is covered by our plan This includes asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon • Explains how to make complaints about quality of care,waiting times,customer service, and other concerns Chapter 8. Ending your membership in the plan 92 Tells when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership Chapter 9. Legal notices 98 Includes notices about governing law and about nondiscrimination 1 Chapter 10. Definitions of important words 1 Explains key terms used in this booklet i f Chapter 1. Getting started as a member of our plan SECTION 1 Introduction 2 Section 1 1 What is the Evidence of Coverage booklet about? 2 Section 12 What does this Chapter tell you9 2 Section 13 What if you are new to our plan" 2 Section 14 Legal information about the Evidence of Coverage 3 SECTION 2 What makes you eligible to be a plan member? 3 Section 2 1 Your eligibility requirements 3 Section 2 2 What are Medicare Part A and Medicare Part B? 3 Section 2 3 Here is the plan service area for our plan 4 SECTION 3 What other materials will you get from us? 4 Section 3 1 Your plan membership card—Use it to get all covered medical care 4 Section 3 2 The Provider Directory your guide to all providers in the plan's network 5 SECTION 4 Your monthly premium for our plan 5 Section 4 1 How much is your plan premmm'� 5 Section 4 2 There are several ways you can pay your plan premium 6 Section 4 3 Can we change your monthly plan premium during the year? 7 SECTION 5 Please keep your plan membership record up to date 7 Section 5 1 How to help make sure that we have accurate information about you 7 SECTION 1 Introduction Section 1.1 What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare medical care through our plan This booklet explains your rights and responsibilities,what is covered,and what you pay as a member of the plan • You are covered by Medicare, and you have chosen to get your Medicare healthcare coverage through our plan, Clear Care Basic Plan. • There are different types of Medicare Advantage Plans. Clear Care Basic Plan is a Medicare Advantage HMO Plan(HMO stands for Health Maintenance Organization). This plan is offered by Group Health Cooperative,referred throughout the Evidence of Coverage as"we,""us,"or "our"Clear Care Basic Plan is referred to as"plan"or"our plan" The word"coverage"and"covered services"refers to the medical care and services available to you as a member of our plan Section 1.2 What does this Chapter tell you? Look through Chapter 1 of this Evidence of Coverage to team: • What makes you eligible to be a plan member? • What is your plan's service area? • What materials will you get from us? • What is your plan premium and how can you pay it? • How do you keep the information in your membership record up to date? Section 1.3 What if you are new to our plan? If you are a new member,then it's important for you to learn how the plan operates—what the rules are and what services are available to you We encourage you to set aside some time to took through this Evidence of Coverage booklet If you are confused or concerned or just have a question, please contact our plan's Customer Service (contact information is on the cover of this booklet). Section_1.4 Legal information about the Evidence of Coverage It's part of our contract with you This Evidence of Coverage is part of our contract with you about how our plan covers your care Other parts of this contract include your enrollment form and any notices you receive from us about changes or extra conditions that can affect your coverage These notices are sometimes called"riders"or`amendments" The contract is in effect for months in which you are enrolled in our plan between January 1,2010 to December 31, 2010 Medicare must approve our plan each year Medicare(the Centers for Medicare&Medicaid Services)must approve our plan each year You can continue to get Medicare coverage as a member of our plan only as long as we choose to continue to offer the plan for the year in question and the Centers for Medicare&Medicaid Services renews its approval of the plan SECTION 2 What makes you eligible to be a plan member? Section 2.1 Your eligibility requirements You are eligible for membership in our plan as long as: • You live in our geographic service area(section 2 3 below describes our service area) • and--you are entitled to Medicare Part A • -and-- you are enrolled in Medicare Part B • and-- you do not have End Stage Renal Disease(ESRD),with limited exceptions,such as if you develop ESRD when you are already a member of a plan that we offer,or you were a member of a different plan that was terminated Section 2.2 What are Medicare Part A and Medicare Part B? When you originally signed up for Medicare, you received information about how to get Medicare Part A and Medicare Part B Remember • Medicare Part A generally covers services furnished by institutional providers such as hospitals, skilled nursing facilities or home health agencies. • Medicare Part B is for most other medical services, such as physician's services and other outpatient services. Section 2.3 Here is the plan service area for our plan Although Medicare is a Federal program.our plan is available only to individuals who live in our plan service area To stay a member of our plan,you must keep living in this service area The service area is described below Our service area includes these counties in Washington Island,King,Kitsap, Lewis, Pierce,San Juan, Skagit, Snohomish, Spokane, Thurston,and Whatcom Our service area includes these parts of counties in Washington Grays Harbor,the following zip codes only 98541, 98557,98559,98568,Mason,the following zip codes only 98524,98528,98546,98548,98555,98584,98588,and 98592 If you plan to move out of the service area,please contact Customer Service SECTION 3 What other materials will you get from us? Section 3.1 Your plan membership card — Use it to get all covered medical care While you are a member of our plan,you must use our membership card whenever you get any services covered by this plan Here's a sample membership card to show you what yours will look like John Q Sample Lire Threatening Brtergeny Call 911 orI ergency number ID 12345678 Urgent Care Call your Doctor s office:} - ClearCareHMO �.. 3 My Doctors Number trrt�af�rrx.ednremaungH� 2417 consulting Nurse 1-800-207,6877 ! Admitted to a Hospital You are requested to call 1-888-457-9516 within 24 hoursor assoon aspossible after admission Ihs does M apoyfcrosnbersvnih m Cpti reFPOplan CMS#H5050 001 Qustorner Serwo?1-888-901-4636 Submit a claim Claims R-oeeseng RxPC 38810 TrY Relay 1-800-833-6388 or 7ll FO Box 34585,Seattle,WA 98124 > Dedronic Payer ID 91051 ll 003585 Group#1234567 wWw.ghc org lal GroupHealtha ISsueT 80840 Group Health Cooperative As long as you are a member of our plan you must not use your red,white,and blue Medicare card to get covered medical services(with the exception of routine clinical research studies and hospice services) Keep your red,white, and blue Medicare card in a safe place in case you need it later Here's why this is so important: If you get covered services using your red,white,and blue Medicare card instead of using our membership card while you are a plan member, you may have to pay the full cost yourself If your plan membership card is damaged, lost, or stolen, call Customer Service right away and we will send you a new card Section 3.2 The Provider Directory- your guide to all providers in the plan's network _ Every year that you are a member of our plan,we will send you either a new Provider Directory or an update to Your Provider Directory This directory lists our network providers What are "network providers"? Network providers are the doctors and other health care professionals,medical groups,hospitals,and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full We have arranged for these providers to deliver covered services to members in our plan Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because,with limited exceptions,while you are a member of our plan you must use network providers to get your medical care and services The only exceptions are emergencies,urgently needed care when the network is not available(generally,out of the area),out-of-area dialysis services,and cases in which our plan authorizes use of non-network providers See Chapter 3 (Using the plan a coverage far your medical services)for more specific information about emergency, out-of-network,and out-of-area coverage If you don't have your copy of the Provider Directory,you can request a copy from Customer Service You may ask Customer Service for more information about our network providers, including their qualifications You can also see the Provider Directory at www ghc org/medicare,or download it from this website Both Customer Service and the website can give you the most up-to-date information about changes in our network providers SECTION 4 Your monthly premium for our plan Section 4.1 How much is your plan premium? As a member of our plan,you pay a monthly plan premium For 2010,the monthly premium for our plan is$17 00 In some situations, your plan premium could be more If you signed up for extra benefits,also called`optional supplemental benefits", then you pay an additional premium each month for these extra benefits If you have any questions about your plan premiums, please call Customer Service Many members are required to pay other Medicare premiums In addition to paying the monthly plan premium, some plan members will be paying a premium for Medicare Part A and most plan members will be paying a premium for Medicare Part B You must continue paying your Medicare Part B premium for you to remain as a member of the plan • Your copy of Medicare& You 2010 tells about these premiums in the section called"2010 Medicare Costs"This explains how the Part B premium differs for people with different incomes • Everyone with Medicare receives a copy of Medicare & You each year in the fall Those new to Medicare receive it within a month after first signing up You can also download a copy of Medicare & You 2010 from the Medicare website (http //tk tN t� medicare gov) Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. L.§ection 4.2 There are several ways you can pay your plan premium There are four ways you can pay your plan premium Option 1: You can pay by check You may decide to pay your premium directly to our plan You will receive a monthly billing statement, which you may pay by check Checks should be mailed to Group Health, P O Box 34900, Seattle, WA 98 1 24-1 900 by the I" of each month A S20 fee will be charged for NSF checks Option 2: You can have your plan premium automatically withdrawn from your bank account Instead of paying by check,you can have your monthly plan premium automatically withdrawn from your bank account each month Deductions will be made between the 7`1' and the 10`s of each month If you are interested in the Automatic Payment Plan(APP),please call Customer Service and ask for an application 1 Option 3: You can pay by credit card or debit card You may decide to pay your premium directly to oui plan You will receive a monthly billing statement,which you may pay by credit card or debit card If you wish to pay your premium by credit card or debit card call Customer Service at the number referenced in Chapter 2 and they will assist you Option 4: You can have the plan premium taken out of your monthly Social Security check You can have the plan premium taken out of your monthly Social Security check Contact Customer Service for more information on how to pay your monthly plan premium this way We will be happy to help you set this up What to do if you are having trouble paying your plan premium Your plan premium is due in our office by the 1"of the month If we have not received your premium by the I",we will send you a notice telling you that your plan membership will end if we do not receive your premium within 60 calendar days from the date of the past due notice If you are having trouble paying your premium on time,please contact Customer Service to see if we can direct you to programs that will help with your plan premium If we end your membership due to non-payment of premiums, you will have coverage under Original Medicare At the time we end your membership,you may still owe us for premiums you have not paid In the future, if you want to enroll again in our plan(or another plan that we offer), you will need to pay these late premiums before you can enroll Section 4.3 Can we change your monthly plan premium during the year? No. We are not allowed to change the amount we charge for the plan's monthly plan premium during the year If the monthly plan premium changes for next year we will tell you in October and the change will take effect on January 1 SECTION 5 Please keep your plan membership record up to date Section 5.1 How to help make sure that we have accurate information about you Your membership record has information from your enrollment form, including your address and telephone number It shows your specific plan coverage including your Primary Care Provider The doctors,hospitals,and other providers in the plan's network need to have correct information about you These network providers use your membership record to know what services are covered for you Because of this,it is very important that you help us keep your information up to date Call Customer Service to let us know about these changes: , • Changes to your name, your address, or your phone number • Changes in any other health insurance coverage you have (such as from your employer, your spouse's employer, workers' compensation, or Medicaid) • If you have any liability claims, such as claims from an automobile accident • If you have been admitted to a nursing home Read over the information we send you about any other insurance coverage you have Medicare requires that we collect information from you about any other medical or drug insurance coverage that you have That's because we must coordinate any other coverage you have with your benefits under our plan Once each year,we will send you a letter that lists any other medical or drug insurance coverage that we know about Please read over this information carefully if it is correct,you don't need to do anything if the information is incorrect, or if you have other coverage that is not listed,please call Customer Service(phone numbers are on the cover of this booklet) Chapter 2. Important phone numbers and resources SECTION I Group Health contacts (how to contact us, including how to reach Customer Service at the plan) 7 SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program) 9 SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) 10 SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare) 10 SECTION 5 Social Security 11 ISECTION 6 Medicaid(a joint Federal and state program that helps with medical costs far some people with limited income and resources) 12 ISECTION 7 How to contact the Railroad Retirement Board 12 SECTION 8 Do you have "group insurance"or other health insurance from an employer? 13 SECTION 1 Group Health contacts (how to contact us, Including how to reach Customer Service at the plan) I How to contact our plan's Customer Service For assistance with claims,billing or member card questions,please call or write to Group Health Customer Service ' We will be happy to help you ++__ -»---> ix4l ai aii§ii§ii3§ _ o-N« YINI AiM§sl Al4iav wfwA lxi YV AA AMW%+Li Tf an4inafuiaeee§ i Customer Service CALL 1-888-901-4600 Calls to this number are free Monday through Friday, 8 a in to 8 p in November 15 through February 28 we offer extended hours from 8 a m to 8 p in. seven days a week TTY 711 or TDD. 1-800-833-6388 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are free I L ...... FAX � t . 206-901-6205 WRITE Group Health Medicare Customer Service Departmerit P O Box 34590 Seattle,WA 98124-1589 E-mail wwwghc.org—"Contact LA . ,.WEBSITE,,.,,.,.,_ www ghc org How to contact us when you are asking for a coverage decision about your medical care You may call us if you have questions about our coverage decision process Coverage Decisions for Medical Care 1 CALL 1-888-901-46I Calls to this number are free k TTY 711 orTDD. 1-800-833-6388 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are free FAX 206-901-6205 WRITE Group Health Medicare Customer Servic116)6partft�neWtt ` P.O Box 34590 Seattle,WA 98124-1589 � , . . . , � For more information on asking for coverage decisions about your medical care, see Chapter 7(What to do f you have a problem or complaint(coverage decisions, appeals, complaints) How to contact us when you are making an appeal about your medical care Appeals for Medical Care CALL 1-966-4558-5479 Calls to this number are free. TTY 711 or TDD 1-800-833-6388 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are free FAX 7 � WRITE Group Health,Medicare Appeals Coordinator P O Box 34593 Seattle, WA 98124-1593 For more information on making an appeal about your medical care,see Chapter 7 (What to do of you have a problem or complaint(coverage decisions, appeals, complaints) How to contact us when you are making a complaint about your medical care Complaints about Medical Care CALL 1-888-901-4600 Calls to this number are free TTY 71 i or TDD: 1-800-833-6388 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are free. FAX 206-901-6205 WRITE Group Health Medicare Customer Service'6epariinen P O Box 34590 Seattle,WA98124-1589 For more information on making a complaint about your medical care,see Chapter 7(What to do f you have a problem or complaint(coverage decisions, appeals, complaints) Where to send a request that asks us to pay for our share of the cost for medical care you have received For more information on situations in which you may need to ask the plan for reimbursement or to pay a bill you have received from a provider, see Chapter 5 (Asking the plan to pay its share of a ball You have received for medical services) Please note: if you send us a payment request and we deny any part of your request,you can appeal our decision See Chapter 7 (What to do of you have a problem or complaint(coverage decivions, appeals, complaints)for more information Payment Requests ..............i ........,mr»w «iiii } CALL 1-888-90t-4600 Calls to this number are free ,';���,_ _ . „.f... . ....„„....... .F trrTDD. I-800-8$3-6388 TTY 7t1' This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are free FAX 206-901-6205 WRITE Group Health Medicare Customer Service Department P.O.Box 34585 Seattle, WA 98124-1585 SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program) Medicare is 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 (permanent kidney failure requiring dialysis or a kidney transplant). The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services t (sometimes called"CMS"). This agency contracts with and regulates Medicare health plans meluding our plan. 1 Medicare CALL 1-800-MEDICARE,or 1-800-633-4227 Calls to this number are free 24 hours a day,7 days a week TTY,,,,,,,. - 1-877-486-2048 „,,,,n...<.„, This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are free WEBSITE hitn,,/www medicare gov This is the official government website for Medicare It gives you up-to-date information about Medicare and current Medicare issues It also has information about hospitals,nursing homes,physicians,home health agencies,and dialysis facilities It includes booklets you can print directly from your computer It has tools to help you compare Medicare Advantage Plans and Medicare drug plans in your area You can also find Medicare contacts in your state by selecting"Helpful Phone Numbers and Websites" If you don't have a computer,your local library or senior center may be able to help YOU visit this website using its computer Or, you can call Medicare at the number above and tell them what information you are looking for They will find the information on the website,print it out,and send it to you SECTION 3 State Health Insurance Assistance Program (free help, Information, and answers to your questions about Medicare) The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state In Washington, the State Health Insurance Assistance Program is called Statewide Health Insurance Benefits Advisors (SHIBA). SHIBA is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. SHIBA counselors can help you with your Medicare questions or problems. They can help you understand your Medicare rights, help you make complaints about your medical care or treatment, and help you straighten out problems with your Medicare bills SHIBA counselors can also help you understand your Medicare plan choices and answer questions about switching plans. SHIBA CALL 1-800-562-6900 WRITE SHIBA HelpLme Office of Insurance Commissioner PO Box 40256 Olympia, WA 98504-0256 WEBSITE http//www insurance wa gov/shiba SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare) There is a Quality Improvement Orgamzation in each state In Washington, the Quality Improvement Organization is called Qualis Health. Qualls Health has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. Qualls Health is an independent organization It is not connected with our plan. You should contact Qualls Health in any of these situations• • You have a complaint about the quality of care you have received. ' • You think coverage for your hospital stay is ending too soon. • You think coverage for your home healthcare, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon. Qualis Health CALL �(206)364-9700 WRITE Qualis Health PO Box 33400 Seattle,WA 98133-0400 or Qualls Health, 10700 Meridian Ave N,Suite 100 Seattle,WA 9 8 1 3 3-9075 .........,.„..... WEBSITE www qualishealth org i ni e.. i ,ini »n i i a».a.�s---rx rrca wa« « nin,re irnxnxi .rnrrai«+�uuasswi<iiv.p SECTION 5 Social Security Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens who are 65 or older, or who have a disability or end stage renal disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic If you are not getting Social Security checks, you have to enroll in Medicare and pay the Part B premium Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office .,,.,. ...,..,,a,,,,.., Social Security Administration CALL 1-800-772-1213 Calls to this number are free. Available 7 00 am to 7 00 pm,Monday through Friday You can use our automated telephone services to get recorded information and conduct some business 24 hours a day . TTY 1800-325-0778 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are free Available 7 00 am to 7 00 pm,Monday through Friday. WEBSITE http,Iwww ssa¢ov SECTION 6 Medicaid � (a joint Federal and state program that helps with medical costs for some people with limited income and resources) Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Some people with Medicare are also eligible for Medicaid Medicaid has programs that can help pay for your Medicare premiums and other costs, if you qualify To find out more about Medicaid and its programs, contact Washington State Department of Social and Health Services (DSHS) Medical Assistance Administration �-16sH- S, , _CALL 1-800-562-3022 WRITE Customer Service Center PO Box 45505 Olympia, WA 98504-5505 WEBSITE maa dshs wa gov t SECTION 7 How to contact the Railroad Retirement Board The Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit programs for the nation's railroad workers and their families if you have questions regarding your benefits from the Railroad Retirement Board,contact the agency Railroad Retirement Board 1-877-772-5772 Calls to this number are free Available 9 00 am to 3 30 pm,Monday through Friday If you have a touch-tone telephone,recorded information and automated services are available 24 hours a day,including weekends and holidays „TTYs, 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking Calls to this number are not free WEBSITE hit;4ww rib eov SECTION 8 Do you have "group insurance" or other health insurance from an employer? If you(or your spouse) get benefits from your(or your spouse's)employer or retiree group,call the employer/union ' benefits administrator or Customer Service if you have any questions You can ask about your(or your spouse's) employer or retiree health benefits,premiums,or the enrollment period If you have other prescription drug coverage through your(or your spouse's)employer or retiree group,please ' contact that group's benefits administrator.The benefits admmistiator can help you determine how your current prescription drug coverage will work with our plan Chapter 3. Using the plan's coverage for your medical services SECTION I Things to know about getting your medical care as a member of our plan 15 Section 1.1 What are"network providers" and"covered services". 15 jSection 1.2 Basic rules for getting your medical care that is covered by the plan 15 SECTION 2 Use providers in the plans network to get your medical care 16 Section 2.1 You must choose a Primary Care Provider (PCP) to provide and arrange for your medical carel6 Section 2.2 What kinds of medical care can you get without getting approval in advance from your PCP? 17 Section 2.3 How to get care from specialists and other network prov'idersl7 SECTION 3 How to get covered services when you have an emergency or urgent need for care 18 Section 3.1 Getting care if you have a medical emergency 18 Section 3.2 Getting care when you have an urgent need for care 19 SECTION 4 What if you are billed directly for the full cost of your covered services? 19 Section 4.1 You can ask the plan to pay our share of the cost of your covered services 19 Section 4.2 If services are not covered by our plan,you must pay the full cost 20 SECTION 5 How are your medical services covered when you are in a "clinical research study"? 20 Section 5.1 What is a "clinical research study"? 20 Section 5.2 When you participate in a clinical research study,who pays for what? 21 SECTION 6 Rules for getting care in a "religious non-medical health care institution" 21 Section 6.1 What is a religious non-medical health care institution? 21 Section 6.2 What care from a religious non-medical health care institution is covered by our plan? 21 I i SECTION 1 Things to know about getting your medical care as a member of our plan This chapter tells things you need to know about using the plan to get your medical care covered It gives definitions of terms and explains the rules you will need to follow to get the medical treatments,services,and other medical care that are covered by the plan For the details on what medical care is covered by our plan and how much you pay as your share of the cost when you get this care,use the benefits chart in the next chapter,Chapter 4(Medical benefits chart, what is covered and what you pay) Section 1.1 What are "network providers" and "covered services"? Here are some definitions that can help you understand how you get the care and services that are covered for you as a member of our plan • "Providers" are doctors and other health care professionals that the state licenses to provide medical services and care The term "providers" also includes hospitals and other health care facilities • "Network providers"are the doctors and other health care professionals,medical groups,hospitals,and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full We have arranged for these providers to deliver covered services to members in our plan The providers in our network generally bill us directly for care they give you When you see a network provider,you usually pay only your share of the cost for their services • "Covered services" include all the medical care,health care services,supplies,and equipment that are covered by our plan Your covered services for medical care are listed in the benefits chart in Chapter 4. Section 1.2 Basic rules for getting your medical care that is covered by the plan Our plan will generally cover your medical care as long as • The care you receive is included in the plan's Medical Benefits Chart(this chart is in Chapter 4 of this booklet) • The care you receive is considered medically necessary. It needs to be accepted treatment for your medical condition. • You have a primary care provider (a PCP) who is providing and overseeing your care. As a member of our plan, you must choose a PCP (for more information about this, see Section 2.1 in this chapter). c In most situations, your PCP must give you approval in advance before you can use other providers in the plan's network, such as specialists,hospitals, skilled nursing facilities, or home health care agencies This is called giving you a"referral." For more information about this, see Section 2 2 of this chapter. o Referrals from your PCP are not required for emergency care or urgently needed care. There are also some other kinds of care you can get without having approval in advance from your PCP (for more information about this, see Section 2 3 of this chapter). • You generally must receive your care from a network provider (for more about this, see Section 2 in this chapter) In most cases, care you receive from a non-network provider(a provider who is not part of our plan's network) will not be covered. Here are two exceptions o The plan covers emergency care or urgently needed care that you get from a non- network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in this chapter. o If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from a non-network provider Authorization should be obtained from our plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider. SECTION 2 Use providers in the plan's network to get your medical care Section 2.1 You must choose a Primary Care Provider (PCP) to provide and arrange for your medical care What is a "PCP" and what does the PCP do for you? • What is a PCP° When you become a member of our Plan,you must choose a plan provider to be your PCP Your PCP is a health care professional who meets state requirements and is trained to give you basic medical care As we explain below,you will get your routine or basic, care from your PCP Your PCP will also coordinate the rest of the covered services you get as a plan member For example, in order to see a specialist,you usually ' need to get your PCP's approval first(this is called getting a"referral"to a specialist) • What types of providers may act as a PCP9 You may choose a PCP from any of our available Family Medicine or Internal Medicine physicians • What is the role of a PCP in your plan9 You will usually see your PCP first for most of your routine health care needs There are only a few types of covered services you can get on your own,without contacting your PCP first Your PCP will provide most of your care and will help arrange or coordinate the rest of the covered services you get as a plan member This includes your x-rays,laboratory tests, therapies,care from doctors who are specialists,hospital admissions,and follow-up care. • What is the role of the PCP in coordinating covered services9 "Coordinating"your services includes checking or consulting with other plan providers about your care and how it is going If you need certain types of covered services or supplies,you must get approval in advance from your PCP(such as giving you a referral to see a specialist) In some cases,your PCP will need to get prior authorization(prior approval)from us Since your PCP will provide and coordinate your medical care,you should have all of your past medical records sent to your PCP's office Section 3 tells you how ' we will protect the privacy of your medical records and personal health information When your PCP thinks that you need specialized treatment,he/she will give you a referral(approval in advance) to see a plan specialist or certain other providers A specialist is a doctor who provides health care services for a specific disease or part of the body Specialists that require referrals to visit include but are not limited to such doctors as ➢ Physical therapists, ➢ Occupational therapists, ➢ Radiologists It is very important to get a referral(approval in advance)from your PCP before you see certain specialists or certain other providers(there are a few exceptions, including routine women's health care that we explain later in this section) if you don't have a referral(approval in advance)before you get services from a specialist,you may have to pay for these services yourself. If the specialist wants you to come back for more care,check first to be sure that the referral (approval in advance)you got from your PCP for the first visit covers more visits to the specialist. How do you choose your PCP? t To get started using our plan,the most important thing for you to do first is to choose a Personal Care Physician You may do this by contacting the Group Health Medicare Customer Service Department at the phone number listed on the front cover of this booklet Some members choose a PCP close to home,others pick a PCP close to work There are no special rules to follow Your PCP should be in a convenient location for you If there is a particular Group Health specialist or hospital that you want to use,check first to be sure your PCP makes referrals to that specialist,or uses that hospital You should also ask whether the PCP has a referral relationship with any specialist or hospital you are currently seeing A list of providers and their telephone numbers are listed in your Provider Directory or you may contact Group Health Medicare Customer Service for details Changing your PCP You may change your PCP for any reason,at any time Also, it's possible that your PCP might leave our plan's network of providers and you would have to find a new PCP Simply call Group Health Medicare Customer Service and we will check to make sure the doctor you choose is accepting new patients Please let us know if you are getting home health agency services or using durable medical equipment so we can help with the transfer of your care or equipment We will make the change for you and tell you over the phone when this change will go into effect If your PCP leaves our Plan,we will let you know and help you choose another PCP so that you can keep getting , covered services Section 2.2 What kinds of medical care can you get without getting approval in advance from your PCP? You can get the services listed below without getting approval in advance from your PCP • Routine women's health care, which include breast exams, mammograms (x-rays of the breast), Pap tests, and pelvic exams, as long as you get them from a network provider. • Flu shots and pneumonia vaccinations as long as you get them from a network provider. • Emergency services from network providers or from non-network providers. • Urgently needed care from non-network providers when network providers are temporarily unavailable or inaccessible when you are temporarily outside of the plan's service area, e.g., when you are temporarily outside of the plan's service area. • Kidney dialysis services that you get at a Medicare-certified dialysis fact Itry when you are temporanly outside the plan's service area If possible,please let us know before you leave the service area where you are going to be so we can help arrange for you to have maintenance dialysis while outside the service area. • Chiropractic services (as long as you get them from a plan provider.) Section 2.3 How to get care from specialists and other network providers A specialist is a doctor who provides health care services for a specific disease or part of the body There are many kinds of specialists Here are a few examples 0 Oncologists, who care for patients with cancer. • Cardiologists, who care for patients with heart conditions. • Orthopedists, who care for patients with certain bone,joint, or muscle conditions. When your PCP thinks that you need specialized treatment,he/she will give you a referral(approval in advance)to see a plan specialist or certain other providers In some cases, the PCP will need to get prior authorization from the plan Services that require prioi authorization are set forth in Chapter 4 What if a specialist or another network provider leaves our plan? Sometimes a specialist,clinic, hospital or other network provider you are using might leave the plan If this happens, you will have to switch to another provider who is part of our Plan if your PCP leaves our plan, we will let you know and help you choose another PCP so that you can keep getting covered services SECTION 3 How to get covered services when you have an emergency or urgent need for care Section 3.1 Getting care if you have a medical emergency What is a "medical emergency" and what should you do if you have one? When you have a"medical emergency,"you believe that your health is in serious danger A medical emergency can include severe pain,a bad injury,a sudden illness,or a medical condition that is quickly getting much worse. If you have a medical emergency • Get help as quickly as possible. Call 911 for help or go to the nearest emergency room, I • hospital, or urgent care center Call for an ambulance if you need it You do not need to get approval or a referral first from your PCP. • As soon as possible, make sure that our plan has been told about your emergency. We need to follow up on your emergency care You or someone else should call to tell us about your emergency care, usually within 48 hours. The number to call is on the back of your plan membership card. What is covered if you have a medical emergency? You may get covered emergency medical care whenever you need it, anywhere in the United States For Emergencies of ambulance services outside of the country,see Chapter 4 for more information Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health For more information,see the medical benefits chart in Chapter 4 of this booklet If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan If your emergency care is provided by non-network providers, we will try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow What if it wasn't a medical emergency? Sometimes it can be hard to know if you have a medical emergency.For example,you might go in for emergency care—thinking that your health is in serious danger—and the doctor may say that it wasn't a medical emergency after all If it turns out that it was not an emergency,as long as you reasonably thought your health was in serious danger,we will cover your care However,after the doctor has said that it was not an emergency,we will generally cover additional care only if you get the additional care in one of these two ways • You go to a network provider to get the additional care. • —or—the additional care you get is considered"urgently needed care"and you follow the rules for getting this urgent care(for more information about this,see Section 3 2 below) Section 3.2 Getting care when you have an urgent need for care What is "urgently needed care"? "Urgently needed care"is a non-emergency situation when • You need medical care right away because of an illness, injury,or condition that you did not expect or anticipate,but your health is not in serious danger • Because of the situation, it isn't reasonable for you to obtain medical care from a network provider. What if you are in the plan's service area when you have an urgent need for care? Whenever possible,you must use our network providers when you are in the plan's service area and you have an urgent need for care (For more information about the plan's service area, see Chapter 1, Section 2 3 of this booklet) In most situations,if you are in the plan's service area,we will cover urgently needed care only if you get this care from a network provider and follow the other rules described earlier in this chapter If the circumstances are unusual or extraordinary,and network providers are temporarily unavailable or inaccessible,our plan will cover urgently needed care that you get from a non-network provider What if you are outside the plan's service area when you have an urgent need for care? Suppose that you are temporarily outside our plan's service area If you have an urgent need for care,you probably will not be able to find or get to one of the providers in our plan's network In this situation(when you are outside the service area and cannot get care from a network provider),our plan will cover urgently needed care that you get from any provider SECTION 4 What if you are billed directly for the full cost of your r covered services? Section 4.1 You can ask the plan to pay our share of the cost of your covered services Sometimes when you get medical care,you may need to pay the full cost right away Other times,you may find that you have paid more than you expected under the coverage rules of the plan In either case,you will want our plan to pay our share of the costs by reimbursing you for payments you have already made There may also be times when you get a bill from a provider for the full cost of medical care you have received In many cases,you should send this bill to us so that we can pay our share of the costs for your covered medical services If you have paid more than your share for covered services,or if you have received a bill for the full cost of covered medical services, go to Chapter 3,(Asking the plan to pay its share of a ball you have received for medical services) for information about what to do Section 4.2 If services are not covered by our plan, you must pay the full cost Our plan covers all medical services that are medically necessary,are covered under Medicare, and are obtained consistent with plan rules You are responsible for paying the full cost of services that aren't covered by our plan, either because they are not plan covered services,or they were obtained out of network where not authorized If you have any questions about whether we will pay for any medical service or care that you are considering,you have the right to ask us whether we will cover it before you get it If we say we will not cover your services,you have the right to appeal our decision not to cover your care Chapter 7(What to do i/you have o problem or complaint)has more information about what to do if you want a coverage decision from us or want to appeal a decision we have already made You may also call Customer Service at the number on the front cover of this booklet to get more information about how to do this For covered services that have a benefit limitation, you pay the full cost of any services you get after you have used up your benefit for that type of covered service These costs will not count toward your out-of-pocket maximum You can call Customer Service when you want to know how much of your benefit limit you have already used. SECTION 5 How are your medical services covered when you are in a "clinical research study"? Section 5.1 What is a "clinical research study"? A clinical research study is a way that doctors and scientists test new types of medical care,like how well a new cancer drug works They test new medical care procedures or drugs by asking for volunteers to help with the study I This kind of study is one of the final stages of a research process that helps doctors and scientists see if a new approach works and if it is safe Not all clinical research studies are open to members of our plan Medicare first needs to approve the research study If you participate in a study that Medicare has not approved,you will be responsible for paying all costs fo your participation in the study Once Medicare approves the study,someone who works on the study will contact you to explain more about the study and see if you meet the requirements set by the scientists who are running the study You can participate in the study as long as you meet the requirements for the study and you have a full understanding and acceptance of what is involved if you participate in the study If you participate in a Medicare-approved study, Original Medicare pays the doctors and other providers for the covered services you receive as part of the study When you are in a clinical research study,you may stay enrolled in our plan and continue to get the rest of your care(the care that is not related to the study) through our plan If you want to participate in a Medicare-approved clinical research study,you do not need to get approval from our plan or your PCP The providers that deliver your care as pai t of the clinical research study do not need to be part of our plan's network of providers Although you do not need to get our plan's permission to be in a clinical research study,you do need to tell us before you start participating in a clinical research study.Here is why you need to tell us I We can let you know whether the clinical research study is Medicare-approved. 2 We can tell you what services you will get from clinical research study providers instead of from our plan I3. We can keep track of the health care services that you receive as part of the study. If you plan on participating in a clinical research study,contact Customer Service(see Chapter 2, Section I of this Evidence of Coverage) Section 5.2 When you participate in a clinical research study, who pays for what? Once you join a Medicare-approved clinical research study,Medicare will pay for the covered services you , receive as part of the research study.Medicare pays for routine costs of items and services Examples of these items and services include the following • Room and board for a hospital stay that Medicare would pay for even if you weren't in a study. • An operation or other medical procedure if it is part of the research study • Treatment of side effects and complications of the new care. When you are part of a clinical research study, Medicare will not pay for any of the following • Generally, Medicare will not pay for the new item or service that the study is testing unless Medicare would cover the item or service even if you were not in a study • Items and services the study gives you or any participant for free. • Items or services provided only to collect data, and not used in your direct health care. For example, Medicare would not pay for monthly CT scans done as part of the study if your condition would usually require only one CT scan. You will have to pay the same coinsurance amounts charged under Original Medicare for the services you receive as a participant in the clinical research study. Because you are a member of our plan, you do not have to pay the deductibles for Original Medicare Part A or Part B Do you want to know more? To find out what your coinsurance would be if you joined a Medicare-approved clinical research study,please call us at Customer Service(phone numbers are on the cover of this booklet). You can get more information about joining a clinical research study by reading the publication"Medicare and Clinical Research Studies"on the Medicare website(http//www medicare gov) You can also call 1-800- MEDICARE(1-800-633-4227)24 hours a day, 7 days a week TTY users should call 1-877-486-2048 SECTION 6 Rules for getting care in a "religious non-medical health care institution" Section 6.1 What is a religious non-medical health care institution? A religious non-medical health care institution is a facility that provides care for a condition that would ordinarily be treated in a hospital or skilled nursing facility care If getting care in a hospital or a skilled nursing facility is against a member's religious beliefs,you must elect to have your coverage for care in a religious non-medical health care institution You may choose to pursue medical care at any time for any reason This benefit is provided only for Part A inpatient services(non-medical health care services) Medicare will only pay for non-medical health care services provided by religious non-medical health care institutions Section 6.2 What care from a religious non-medical health care institution is covered by our plan? To get care from a religious non-medical health care institution,you must sign a legal document that says you are conscientiously opposed to getting medical treatment that is"non-excepted" • "Non-excepted"medical care or treatment is any medical care or treatment that is voluntary and not required by any federal, state,or local law • "Excepted"medical treatment is medical care or treatment that you get that is not voluntary or is required under federal,state,or local law To be covered by our plan,the care you get from a religious non-medical health care institution must meet the following conditions • The facility providing the care must be certified by Medicare • Our plan's coverage of services you receive is limited to non-religious aspects of care • If you get services from this institution that are provided to you in your home,our plan will cover these services only if your condition would ordinarily meet the conditions for coverage of services given by home health agencies that are not religious non-medical health care institutions 1 • If you get services from this institution that are provided to you in a facility,the following conditions apply o You must have a medical condition that would allow you to receive covered services for inpatient hospital care or skilled nursing facility care o —and—you must get approval in advance from our plan before you are admitted to the facility or Your stay will not be covered Inpatient hospital services are unlimited as long as the criteria for this benefit has been met 1 1 t 1 L i I Chapter 4. Medical benefits chart (what is covered and what you pay) SECTION] Understanding your out-of-pocket costs for covered services 23 Section 1.1 What types of out-of-pocket costs do you pay for your covered services? 24 Section 1.2 What is the maximum amount you will pay for certain covered medical services? 24 ' SECTION 2 Use this Medical Benefits Chart to find out what is covered for you and how much you will pay 24 Section 2.1 Your medical benefits and costs as a member of the plan 24 Section 2.2 Extra "optional supplemental" benefit you can buy 39 Section 2.3 Getting care using our plan's traveler benefit 47 SECTION 3 What types of benefits are not covered by the plan? 48 Section 3.1 Types of benefits we do not cover(exclusions) 48 SECTION 1 Understanding your out-of-pocket costs for covered services This chapter focuses on your covered services and what you pay for your medical benefits.It includes a Medical Benefits Chart that gives a list of you covered services and tells how much you will pay for each covered service as a member of our plan Later In this chapter,you can find information about medwal services that are not covered It also tells about limitations on certain services Section 1.1 What types of out-of-pocket costs do you pay for your covered services? To understand the payment information we give you in this chapter,you need to know about the types of out-of- pocket costs you may pay for your covered services ' • The"deductible"means the amount you must pay for medical services before our plan begins to pay its share • A"copayment" means that you pay a fixed amount each time you receive a medical service You pay a copayment at the time you get the medical service • "Coinsurance"means that you pay a percent of the total cost of a medical service.You pay a coinsurance at the time you get the medical service Some people qualify for programs to help them pay their out-of-pocket costs for Medicare If you are enrolled in these programs, you may still have to pay the Medicaid copayment,depending on the rules in your state Section 1.2 What is the maximum amount you will pay for certain covered medical services? There is a limit to how much you have to pay out-of-pocket for certain covered health care services each year After this level is reached, you will have 100%coverage and not have to pay any out of pocket costs for the remainder of I the year for covered services You will have to continue to pay your premium if your plan has a premium Once the total costs for your services, including your co-payments, and coinsurance,reaches S2,500 then you won't have to continue paying for these expenses for the remainder of the year Cost shales for the following services apply to the out-of-pocket maximum Inpatient Hospital Care,Inpatient Mental Health Care,Skilled Nursing Facility(SNF) Care, Doctor Office Visits,Chiropractic Services,Podiatry Services,Outpatient Mental Health Care,Outpatient Substance Abuse Services, Outpatient Services/Surgery,Ambulance Services, Emergency Care, Urgently Needed Care, Outpatient Rehabilitation Services including Cardiac Rehabilitative Therapy,Durable Medical Equipment, I Prosthetic Devices,Diabetes Self-Monitoring Training and Supplies,Diagnostic Radiology Services Diagnostic Tests, X-Rays, and Lab Services, Bone Mass Measurement,Colorectal Screening Exam,Mammograms(Annual Screenings), Pap Smears and Pelvic Exams, Prostate Cancer Screening Exams,Hearing Services, Vision Services, Physical Exams,Transportation,Other Health Care Professional and Cardiovascular Screening Blood Tests SECTION 2 Use this Medical Benefits Chart to find out what is tcovered for you and how much you will pay Section 2.1 Your medical benefits and costs as a member of the plan The medical benefits chart on the following pages lists the services our plan covers and what you pay for each service The services listed in the Medical Benefits Chart are covered only when all coverage requirements are met • Your Medicare covered services must be provided according to the coverage guidelines established by Medicare • Except in the case of preventive services and screening tests,your services(including medical care, services, supplies, and equipment)must be medically necessary Medically necessary means that the services are an accepted treatment for your medical condition • You receive your care from a network provider In most cases, care you receive from a non-network provider will not be covered Chapter 3 provides more information about requirements for using network providers and the situations when we will cover services from a non-network provider • You have a primary care provider(a PCP) who is providing and overseeing your care In most situations, your PCP must give you approval in advance before you can see other providers in the plan's network. r This is called giving you a"referral."Chapter 3 provides more information about getting a referral and the situations when you do not need a referral • Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance(sometimes called"prior authorization')from us Covered services that need approval in advance are marked in the Medical Benefits Chart in italics Services that are covered for you What you must pay when you , get these services Inpatient hospital care • You pay ' $200 each day for day(s) 1-5 For a Medicare-covered stay at a network hospital or a hospital $0 each day for day(s)6-90 authorized by Group Health You are covered up to 365 days per . There is no copayment for additional year. Covered services include: days received at a network hospdal • Semi-private room (or a private room if medically . You are covered for unlimited days necessary) each benefit period • Meals including special diets Except in an emergency,your • Regular nursing services provider must obtain authorization • Costs of special care units (such as intensive or coronary from Group Health care units) • Drugs and medications If you get inpatient care at a • Lab tests non-network hospital after your emergency condition is • X-rays and other radiology services stabilized, your cost is the • Necessary surgical and medical supplies highest cost-sharing you would • Use of appliances, such as wheelchairs pay at a network hospital • Operating and recovery room costs • Physical, occupational, and speech language therapy • Under certain conditions, the following types of transplants Z are covered- corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and mtestinal/multivisceral If you need a transplant, we will arrange to have your case reviewed by a Medicare-approved transplant center that will decide whether you are a candidate for a transplant. If you are sent outside of your community for a transplant, we will arrange or pay for appropriate lodging and transportation costs for you and a companion. • Blood - including storage and administration Coverage begins with the first pint used. 0 Physician Services Services that are covered for you What you must pay when you get these services Inpatient mental health care • You pay: $200 each day for day(s) 1-5 • Covered services include mental health care services that -$0 each day for day(s)6-90 require a hospital stay for a Medicare-covered stay at a network hospital. You are • For a Medicare-covered stay at a network hospital, you are covered up to 365 days per ' covered up to 365 days per year year • Medicare beneficiaries may only receive 190 days in a Except in an emergency,your Psychiatric Hospital in a lifetime. The 190 day limit does provider must obtain authorization not apply to Mental Health services provided in a from Group Health psychiatric unit of a general hospital • Skilled nursing facility (SNF) care You pay (For a definition of"skilled nursing facility," see Chapter 12 of this -$0 each day for day(s) 1-10-$60 each day for day(s) 11-100 booklet Skilled nursing facilities are sometimes called"SNFs.") for services in a Skilled Nursing Facility You are covered for 100 days for each benefit period Covered . When a 3 day Medicare covered services include. hospital stay does not occur and the plan determines that the member • Semiprivate room (or a private room if medically necessary) otherwise meets all Medicare criteria • Meals, including special diets for an acute inpatient hospital stay at the time of admission to a Medicare • Regular nursing services Certified Skilled Nursing Facility, the • Physical therapy, occupational therapy, and speech therapy plan may authorize Medic are covered Skilled Nursing Facility Care up to • Drugs administered to you as part of your plan of care (This the Medicare skilled Nursing Facility includes substances that are naturally present in the body, day limit per benefit period such as blood clotting factors.) All Medicare criteria must be met • Blood - including storage and administration. Coverage and the stay mutt be authorized in begins with the first pint used. advance by the plan • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician services Generally,you will get your SNF care from plan facilities However,under certain conditions listed below,you may be able to pay in-network cost-sharing for a facility that isn't a plan provider, if the facility accepts our plan's amounts for payment • A nursing home or continuing care retirement commumty where you were living right before you went to the hospital (as long as it provides skilled Irrrru FServicese covered for you What you must pay when you get these services ility care) • A SNF where your spouse is living at the time you leave the hospital. Inpatient services covered when the hospital or SNF days When all other Medicare and Group Health criteria have been met,benefits aren't, or are no longer, covered will be covered subject to the following Covered services include: copayments and coinsurances • Physician services • Physician services—covered in full • Tests (like X-ray or lab tests) • Tests—covered in full • X-ray, radium, and isotope therapy including technician •X-ray and isotope therapy—Covered materials and services in full • Surgical dressings, splints, casts and other devices used to •Radium therapy-S20 copayment reduce fractures and dislocations • Surgical dressings, splints, casts and • Prosthetics and orthotics devices (other than dental) that other devises—20%coinsurance replace all or part of an internal body organ (including .Prosthetic devises—20%coinsurance contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body •Leg,arm,back, and neck braces, organ, including replacement or repairs of such devices trusses, and artificial legs,arms, and eyes including adjustments, repairs • Leg, arm, back, and neck braces, trusses, and artificial legs, and replacements required because of arms, and eyes including adjustments, repairs, and breakage,wear, loss, or a change in replacements required because of breakage, wear, loss, or a the patient's physical condition— change in the patient's physical condition 20%coinsurance • Physical therapy, speech therapy, and occupational therapy •Physical therapy,speech therapy,and occupational therapy-$20 copayment per office visit Services that are covered for you What you must pay when you get these services Home health a care • There is no copayment for Medicare- genc y covered home health visits Covered services include: •Prior authorization required • Part-time or intermittent skilled nursing and home health aide services (To be covered under the home health care ' benefit, your skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week) ' • Physical therapy, occupational therapy, and speech therapy • Medical social services • Medical equipment and supplies Hospice care When you enroll in a Medicare-certified You may receive care from any Medicare-certified hospice program. hospice program,your hospice services Original Medicare (rather than our Plan) will pay the hospice are paid for by Original Medicare,not provider for the services you receive. Your hospice doctor can be a our plan network provider or an out-of-network provider You will still be a plan member and will continue to get the rest of your care that is unrelated to your terminal condition through our Plan Covered services include. 1 • Drugs for symptom control and pain relief, short-term respite care, and other services not otherwise covered by Original Medicare $20 copayment for each Medicare- covered Consultation • Home care Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn't elected the hospice benefit. tPhysician services, including doctor's office visits . You pay: Covered services include- $20 for each primary care doctor office visit for Medicare-covered • Office visits, including medical and surgical care in a services physician's office or certified ambulatory surgical center - $20 copayment for each Medicare- Consultation, diagnosis, and treatment by a specialist covered Consultation and certain • Hearing and balance exams, if your doctor orders it to see if Specialist visits you need medical treatment - $200 copayment for services r Serv7thate covered for you What you must pay when you get these services • th office visits including consultation, diagnoses and provided m aMedicare-covered nt by a specialist ambulatory surgical center and Medicare-covered Outpatient hospital • Second opinion by another network provider pnor to surgery services visit , • Outpatient hospital services . Prior authorization required • Non-routine dental care (covered services are limited to for ambulatory surgical center surgery of the jaw or related structures, setting fractures of and outpatient hospital service the jaw or facial bones, extraction of teeth to prepare the jaw visits for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a • Prior authorization not ' physician) required for self-referral visits to certain Group Health specialists at Group Health- operated medical centers only. See Section 2 for more information Chiropractic services • You pay$20 for each Medicare- Covered services include: covered visit(manual manipulation of • Manual manipulation of the spine to correct subluxation the spine to correct subluxation) • You pay 100%for routine chiropractic services • Must use plan providers No referral necessary for plan providers Podiatry services • You pay$20 for each Medicare- covered-visit(medically necessary Covered services include: foot care) • Treatment of injuries and diseases of the feet(such as • You pay 100%for routine podiatry I hammer toe or heel spurs) care • Routine foot care for members with certain medical • Prior authorization required ' conditions affecting the lower limbs For Medicare-covered Mental Health Outpatient mental health care servu,es,you pay$20 for each Covered services include: individual/group therapy visit , Mental health services provided by a doctor, clinical psychologist, . Serf-referral to Group Health clinical social worker, clinical nurse specialist, nurse practitioner, specialists only at Group physician assistant, or other Medicare-qualified mental health care Health-operated medical professional as allowed under applicable state laws centers only. i t Services that are covered for you What you must pay when you get Fthese services . Prior authorization required for any services received at non-Group Health- operated medical centers ' Partial hospitalization services • There is no copayment for Medicare- covered Partial Hospitalization "Partial hospitalization" is a structured program of active treatment services that is more intense than the care received in your doctor's or . Prior authorization required therapist's office and is an alternative to inpatient hospitalization. Outpatient substance abuse services • For Medicare-covered A ubstance abuse services,you pay$20 for each individual/group therapy visit. • Prior authorization required. ` Outpatient surgery, including services provided at • You pay$200 for each Medicare- ambulatory surgical centers covered visit to an ambulatory surgical center • You pay$200 for each Medicare- covered visit to an outpatient hospital facility • Prior authorization required Ambulance services A$150 co-payment per each one-way • Covered ambulance services include fixed wing, rotary trip applies except hospital to hospital wing, and ground ambulance services, to the nearest ambulance transfers initiated by Group appropriate facility that can provide care only if they are Health which are covered in full furnished to a member whose medical condition is such that other means of transportation are contraindicated (could endanger the person's health) The member's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. • Non-emergency transportation by ambulance is appropriate if it is documented that the member's condition is such that other means of transportation are contraindicated (could endanger the person's health) and that transportation by ' ambulance is medically required Emergency care You pay$50 for each Medicare- covered emergency ioom visit,you r FServicesre covered for you What you must pay when youget these servicesrage do not pay this amount if you are admitted to the hospital within 1 day for the same condition If you need inpatient care at an out-of- network hospital after your emergency condition m stabilized, you must have your inpatient care at the out-of-network hospital authorized by the plan and your cost is the cost-sharing you would pay at a network hospital Urgently needed care • You pay$20 for each Medicare- , covered urgently needed care visit Worldwide coverage , Outpatient rehabilitation services . You pay$20 for each Occupational Covered services include: physical therapy, occupational therapy, Therapy,Physical Therapy, speech language therapy, cardiac rehabilitative therapy, and Rehabilitation Speech uage Therapy and Cardiac lLangitation Therapy visit Comprehensive Outpatient Rehabilitation Facility (CORF) services. • There is no copayment for CORF visits . This is an unlimited benefit. . Prior authorization required. Durable medical equipment and related supplies ° . You pay 20/o of the cost for (For a definition of"durable medical equipment," see Chapter 12 each Medicare-covered item. of this booklet.) . Prior authorization required Covered items include, but are not limited to: wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and walker. Prosthetic devices and related supplies . You pay 20% of the cost for , Devices (other than dental) that replace a body part or function. each Medicare-covered item These include, but are not limited to: colostomy bags and supplies , Prior authorization required directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices. Also includes some coverage following cataract removal or cataract surgery—see "Vision Care" later in this section for more detail. r ` Services that are covered for you What you must pay when you get these services ' Diabetes self-monitoring, training, and supplies • There o i copayment for Diabetes self-momtonng training For all people who have diabetes (insulin and non-insulin users). . You pay 20%of the cost for each Covered services include Medicare-covered Diabetes supply • Blood glucose monitor, blood glucose test strips, lancet item devices and lancets, and glucose-control solutions for • A$20 copayment applies for each checking the accuracy of test strips and monitors separate office visit • One pair per calendar year of therapeutic custom-molded • Prior authorization required ' shoes (including inserts provided with such shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes) For people with diabetes who have severe diabetic foot disease, coverage includes fitting. • Self-management training is covered under certain conditions • For persons at risk of diabetes: Fasting plasma glucose tests at a frequency determined by you and your physician You may call the number in Chapter 2 of this booklet to contact ' Group Health Customer Service for information on how often we will cover these tests Medical nutrition therapy • There is no copayment for nutrition For people with diabetes, renal (kidney) disease (but not on therapy for diabetes dialysis), and after a transplant when referred by your doctor. • A$20 copayment applies for each separate office visit • Prior authorization required Outpatient diagnostic tests and therapeutic services and • There is no copayment for the supplies following Medicare-covered Covered services include: service(s) • X-rays - ClmicaUdiagnostic lab services • Radiation therapy Radiation therapy • Surgical supplies, such as dressings - X-ray visits s FServicesre covered for you What you must pay when you get these servicess, such as splints and casts . A $75 copayment applies for f • Laboratory tests Medicare-covered diagnostic • Blood. Coverage begins with the first pint of blood that you radiology services. need—you pay for the first 3 pints of unreplaced blood Coverage of storage and administration begins with the first • A S20 copayment apphes for pint of blood that you need. each separate physician's • Other outpatient diagnostic tests (Medicare-covered office visit diagnostic radiology services are also covered) . Prior authorization required Vision care • There is no copayment for the following items Covered services include - Medicare-covered eye wear • Outpatient physician services for eye care (one pair of eyeglasses or • For people who are at high risk of glaucoma, such as people contact lenses after each with a family history of glaucoma, people with diabetes, and cataract surgery) if obtained African-Americans who are age 50 and older- glaucoma from a Medicare certified screening once per year facility. • One pair of eyeglasses or contact lenses after each cataract - Group Health-covered surgery that includes insertion of an mtraocular lens routine eye exam, limited to 1 Corrective lenses/frames (and replacements) needed after a exam once every 12-months. cataract removal without a lens implant You pay: - $20 for each Medicare- , covered eye exam (diagnosis and treatment for diseases and conditions of the eye). r 7171 'er P ..,_ ,..., Abdominal aortic aneurysm screening A $75 copayment applies for A one-time screening ultrasound for people at risk. The plan only Medicare-covered diagnostic covers this screening if you get a referral for it as a result of your radiology services. "Welcome to Medicare" physical exam. . A $20 copayment applies for each separate office visit. Services that are covered for you What you must pay when you get these services Bone mass measurement There is no copayment for Medicare-covered Bone Mass For qualified individuals (generally, this means people at risk of losing bone Measurement. ' mass or at risk of osteoporosis),the following services are covered every 2 years or more frequently if medically necessary procedures to identify bone mass,detect bone loss, or determine bone quality, including a physician's A$20 copayment applies for each interpretation of the results separate office visit • Prior authorization required Colorectal screening • There is no copayment for ' For people 50 and older, the following are covered: Medicare-covered Colorectal Screening Exams. • Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months • A$20 copayment applies for each separate office visit • Fecal occult blood test, every 12 months • A$200 copayment applies for For people at high risk of colorectal cancer, we cover: services provided at either a Medicare-covered ambulatory • Screening colonoscopy (or screening barium enema as an surgical center visit or Medicare- alternative) every 24 months covered Outpatient hospital services For people not at high risk of colorectal cancer, we cover: VISIT • Screening colonoscopy every 10 years, but not within 48 • Prior authorization required months of a screening sigmoidoscopy Immunizations • There is no copayment for Pneumonia and Flu vaccines. Covered services include: (No referral necessary) ' • Pneumonia vaccine • There is no copayment for the • Flu shots, once a year in the fall or winter Hepatitis B vaccine Referral • Hepatitis B vaccine if you are at high or intermediate risk of required getting Hepatitis B • Referral required for other • Other vaccines if you are at risk immnmzations Please contact the Group Health Medicare Customer We also cover some vaccines under our outpatient prescription Service Department for more ' drug benefit. information Mammography screening • There is no copayment for Medicare- covered Screening Mammograms Covered services include • One baseline exam between the ages of 35 and 39 • No referral necessary for Medicare-covered screenings ®ewe FServicesre covered for you What you must pay when you get these services eening every 12 months for women age 40 and older A $20 copayment applies for i each separate office visit Pap test, pelvic exams, and clinical breast exams • There is no copayment , Covered services include: for Medicare-covered ' Pap Smears, • For all women, Pap tests, pelvic exams, and clinical breast • A$20 copayment applies for each exams are covered once every 24 months separate office visit for Pelvic Exams • If you are at high risk of cervical cancer or have had an abnormal Pap test and are of childbearing age. one Pap test every 12 months Prostate cancer screening exams • There is no copayment for Medicare-covered Prostate For men age 50 and older, covered services include the following - Cancer Screening Exam once every 12 months . A $20 copayment applies for • Digital rectal exam each separate office visit. • Prostate Specific Antigen (PSA) test .Prior authorization required Cardiovascular disease testing • There is no copayment for , Medicare-covered Blood tests for the detection of cardiovascular disease (or Cardiovascular screening blood abnormalities associated with an elevated risk of cardiovascular tests. disease) You may call the number in Chapter 2 of this booklet to contact Group Health Medicare Customer Service for information A $20 copayment applies for on how often we will cover these tests. each separate office visit. Prior authorization required • There is no copayment for routine ' Physician exams physical exams • A one-time physical exam for members within the first 12 . You are covered up to 1 exam(s) months that they have Medicare Part B. Includes every year measurement of height, weight and blood pressure; an electrocardiogram, education, counseling and referral with You pay: $20 for each Medicare-covered respect to covered screening and preventive services. routine physical exam Doesn't include lab tests • Must use plan providers No referral • Routine physical exams necessary for plan providers 1 Services that are covered for you What you must pay when you get these services ' Dialysis (kidney) . You are covered in full for Covered services include: each Medicare-covered visit. • Outpatient dialysis treatments (including dialysis treatments • Prior authorization required when temporarily out of the service area, as explained in except renal dialysis services Chapter 3)) out of our Plan Is service area ' • Inpatient dialysis treatments (if you are admitted to a hospital for special care) • Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) 1 • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) ' Medicare Part B prescription drugs There is no benefit limit on drugs covered under original Medicare These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan Covered drugs include- 0 Drugs that usually aren't self-administered by the patient and are injected while you are getting physician services • Drugs you take using durable medical equipment (such as nebulizers) that was authorized by the plan • Clotting factors you give yourself by injection if you have hemophilia r • Immunosuppressive Drugs, if you were enrolled in Medicare Part A at the time of the organ transplant • Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post- menopausal osteoporosis, and cannot self-administer the drug • Antigens ' • Certain oral anti-cancer drugs and anti-nausea drugs • Certain drugs for home dialysis, including heparin, the antidote for hepann when medically necessary, topical anesthetics, and erythropoisis-stimulating agents (such as Servi7Darbepoetin re covered for you What you must pay when you get these services ®, Procrit®, Epoetm Alfa, Aranesp®, or Alfa) • Intravenous Immune Globulin for the home treatment of ' primary immune deficiency diseases Dental SerVICeS • In general,you pay 100% for dental services Services by a dentist or oral surgeon are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, See se 2 2 for additional information about the Optional extraction of teeth to prepare the jaw for radiation treatments of Dental Benefit An additional neoplastic disease, or services that would be covered when provided premium applies for the Optional by a doctor. Dental Benefit Hearing services You pay ' - $20 for each diagnostic hearing • Diagnostic hearing exams exams(every 24 months) - $20 for each routine hearing test up , • Routine hearing test to I test once every 24-months - $0 for each hearing aid fitting evaluation up to I test once every 24-months (Hearing aids not covered) Health and wellness education programs You are covered in full for the S1lverSneakers Program Health Club • Health Club Membership Membership The Sil\,erSneakers fitness program is part of your Group Health Medicare coverage It's a fitness program designed with you in mind, and comes with a health club membership so you can keep yourself staying fit For more information, call the Group Health Resource Line toll-free at 1-800- 992-2279 or 206-326-2800, or the TTY lane at 711 or 1-800-833-6388 EnhanceFitness Group I lealth Medicare members can participate at no additional cost in the Lifetime Fitness program The classes meet three days a week The hour-long classes are a well-rounded combination of stretching, low-impact aerobics or , Services that are covered for you What you must 7balance get these service walking,strength trataught by profession Call the Group Health Resource Line toll-free at 1-800-992-2279, 206-326-2800 or Senior Services at 206- • EnhaneeFitness 727-6259, or the TTY line at 711 or I- 800-833-6388 to find the participating Lifetime Fitness program factltt) nearest you Must use plan providers Group I lealth Covered When member is enrolled and actively participating in the Free and Clear Program"',services provided through Group Health related to smoking and tobacco use cessation are covered, limited to Participation in individual or group programs, Educational materials covered in full Medicare Covered. Medicare will pay for two cessation- counseling attempts per year, each attempt includes 4 sessions each of either shorter visits of 3 to 10 minutes each,or longer visits(longer than 10 minutes each)depending on what the member and their doctor decide Must use plan providers • Smoking& Tobacco Use Cessation (Group Health Covered) • Smoking & Tobacco Use Cessation (Medicare Covered) Transportation (routine) A $150 co payment per each one-way trip applies. Limited to i Services that are covered for you What you must pay when you , get these services ambulance services ' only when medically necessary and ' authorized in advance by Group Health. All Group Health criteria must be met Home Infusion Therapy Services • Covered in full ' Chemotherapy • A$20 copaymenl applies for each Chemotherapy is covered when ordered by a Group Health provider and all separate office visit Group Health referral protocol has been met When providing care and services to Medicare patients,Group Health MUST use Medicare-certified providers and facilities Prior authorization required Out of Area Travel Non-emergent and/or non-urgently ' needed care received while temporarily traveling outside Group Health's Medicare Service Area is payable at Medicare benefit levels up to$3,000 per member per calendar year Our Plan pays 80%of Medicare allowable reimbursement schedules for Medicare covered services ONLY Enrollee is responsible for all Medicare inpatient and outpatient deductibles and comsurances Section 2.2 Extra "optional supplemental" benefit you can b_uy , Our Plan offers some extra benefits that are not covered by Original Medicare and not included in your benefits ' package as a plan member These extra benefits are called`Optional Supplemental Benefits." If you want these optional supplemental benefits,you must sign up for them and you may have to pay an additional premium for them The optional supplemental benefits included in this section are subject to the same appeals process as any other benefits Services that are covered for you What you must pay when you get these services Services that are covered for you What you must pay when you get these services Dental Services zmtuminformatton Covered services include: You pay$48 each month,for Optional Supplemental Dental Benefit in DIAGNOSTIC AND PREVENTIVE SERVICES (Class 1) addition to your monthly plan premium • Routine exams and cleanings and the Medicare Part B premium • Periodontal cleanings nual Maximum • Bitewing and complete x-rays You are covered up to a$1500 maximum for Diagnostic and • Flouride or preventive therapies Preventive Services (Class I), RESTORATIVE SERVICES (Class II) Restorative Services(Class 11)and/or Major Services(Class fit) for ALL ' • Fillings dental services each calendar year. • Stainless steel crowns nual Deductible • Root canals There is a$100 annual deductible per • Penodontal person(the deductible does not apply ' to Class 1 services) • Oral surgery MAJOR SERVICES (Class III) You pay the following: • Crowns, gold foils, inlays, onlays • There is no coinsurance for Diagnostic and Preventive Services • Bridges (Class I) • Dentures, fixed/removable partials, implants • There is no coinsurance for • Denture adjustments and reline Diagnostic and Preventive Services (Class 1) • Implants • There is a 20%coinsurance for Restorative Services(Class 11) • There is a 50%coinsurance for Major Services(Class 111) IT-OF-NETWORK ' u pay the following when services are received from an out-of-network provider i Services that are covered for you What you must pay when you ' get these services There is a 20%coinsurance for ' Diagnostic and Preventive Services (Class 1) There is a 30%coinsurance for Restorative Services(Class 11) ' There is a 60%coinsurance for Major Services(Class III) Optional Supplemental Dental Benefit ' The following are Class I, Class II and Class III Covered Dental Benefits under this Contract that are subject to the Limitations and Exclusions contained in this Contract. Such benefits (as defined) are available only when rendered by a licensed Dentist or other WDS-approved Licensed Professional when appropriate and necessary as determined by the standards of generally accepted dental practice and WDS. , The amounts payable by WDS for Class I, Class II and Class III Covered Dental Benefits are as set forth in Appendix C Class I , Diagnostic Covered Dental Benefits • Routine examination(periodic oral evaluation) • Comprehensive oral evaluation • X-rays ' • Emergency examination • Specialist examination performed by a Specialist in an American Dental Association recognized specialty • WDS-approved periodontal susceptibility/risk tests Limitations • Routine examination is covered twice in a Benefit Period • Comprehensive oral evaluation is covered once in a three-year period from the date of service per Eligible Person per dentist Additional comprehensive oral evaluations are allowed as routine examinations o Comprehensive oral evaluations and specialist examinations are considered as one of the two covered examinations per benefit period ' • Complete series(any number or combination of mtraoral X-rays,billed for same date of service, that equals or exceeds the allowed fee for a complete series is considered a complete series for payment purposes)or panorex X-rays are covered once in a three-year period from the date of service • Supplementary bitewing X-rays are covered twice in a Benefit Period • Diagnostic services and X-rays related to temporomandibular joints Oaw joints)are Not a Paid Covered Benefit under Class I Covered Dental Benefits Exclusions ' • Consultations or elective second opinions • Study models • Caries susceptibility/risk tests 1 Preventive ' Covered Dental Benefits • Prophylaxis(cleaning) • Periodontal maintenance ' • Topical application of fluoride or preventive therapies(e g fluoridated varnishes) Limitations • Prophylaxis and/or periodontal maintenance are limited to two covered procedures in a Benefit Period • Topical application of fluoride or preventive therapies(but not both)is limited to two covered procedures in a Benefit Period. Exclusions ' • Plaque control program(oral hygiene instruction,dietary instruction and home fluoride kits) • Fissure sealants • Cleaning of a prosthetic appliance "Rejer Also To General Limitations and General Exclusions" Class II General Anesthesia Covered Dental Benefits • General anesthesia when administered by a licensed Dentist or other WDS-approved Licensed Professional who meets the educational,credentialing and privileging guidelines estahlished by the Dental Quality Assurance Commission of the state of Washington or as determined by the state in which the services are provided Limitations • General anesthesia is covered in conjunction with certain covered endodontic, periodontic and oral surgery procedures, as determined by WDS, or when medically necessary, for children through age six, or a physically or developmentally disabled ' person, when in conjunction with Class I, II and III covered dental procedures • Either general anesthesia or intravenous sedation (but not both) are covered when performed on the same day. • General anesthesia for routine post-operative procedures is Not a Paid Covered Benefit. Intravenous Sedation Covered Dental Benefits • Intravenous sedation when administered by a licensed Dentist or other WDS-approved Licensed Professional who meets the educational,credentialmg and privileging guidelines established by the Dental Quality Assurance Commission of the state of Washington or as determined by the state in which the services are provided Limitations • Intravenous sedation is covered in conjunction with certain covered endodontic, periodontic and oral surgery procedures, as determined by WDS. • Either general anesthesia or intravenous sedation (but not both) are covered when performed on the same day • Intravenous sedation for routine post-operative procedures is Not a Paid Covered Benefit. Palliative Treatment Covered Dental Benefits • Palliative treatment for pain ' Restorative Covered Dental Benefits • Amalgam restorations(fillings)and, in anterior(front)teeth,resin-based composite or glass ionomer restorations are covered for the following reasons. o Treabrient of carious lesions(visible destruction of hard tooth structure resulting from the process of dental decay) o Fracture resulting in significant loss of tooth structure(missing cusp) o Fracture resulting in s,gmficant damage to an existing restoration 9 Resin-based composite or glass ionomer restorations placed in the buccal(facial)surface of bicuspids • Stainless steel crowns Limitations ' • Restorations on the same surface(s)of the same tooth are covered once in a two-year period from the date of service • if a resin-based composite or glass tonomer restoration is placed in a posterior tooth(except on , bicuspids as noted above),it will be considered as a cosmetic procedure and an amalgam allowance will be made,with any difference in cost being the responsibility of the patient • Restorations necessary to correct vertical dimension or to alter the morphology(shape)or occlusion are Not a Paid Covered Benefit • Stainless steel crowns are covered once in a two-year period from the seat date Exclusions , • Overhang removal,copings,re-contouring or polishing of restoration Oral Surgery Covered Dental Benefits • Removal of teeth • Preparation of the mouth for insertion of dentures • Treatment of pathological conditions and traumatic injuries of the mouth ' Exclusions • Bone replacement graft for ridge preservation • Bone grafts,of any kind,to the upper or lower jaws not associated with periodontal treatment of teeth , • Tooth transplants • Materials placed in tooth extraction sockets for the purpose of generating osseous filling Periodontics i Covered Dental Benefits • Surgical and nonsurgical procedures for treatment of the tissues supporting the teeth ' • Services covered include o Periodontal scaling/root planing o Gmgivectomy o Limited adjustments to occlusion(eight teeth or less) Limitations • Periodontal scaling/root planing is covered once in a 12-month period from the date of service • Limited occlusal adjustments are covered once in a 12-month period from the date of service • Crown and bridgework in conjunction with periodontal splinting and crowns as part of , periodontal therapy and periodontal appliances are Not a Paid Covered Benefit Exclusions • Gingival curettage • Occlusal guard(nightguard) ' • Major(complete)occlusal adjustment Endodontics Covered Dental Benefits • Procedures for pulpal and root canal treatment • Services covered include pulp exposure treatment,pulpotomy and apicoectomy Limitations ' • Root canal treatment on the same tooth is covered only once in a two-year period from the date of service. ' • Re-treatment of the same tooth is allowed when performed by a different dental office Exclusions • Bleaching of teeth ' **Refer Also To General Limitations and General Exclusions** Class III Restorative Covered Dental Benefits • Crowns,veneers,inlays(as a single tooth restoration—with Limitations)or onlays(whether they are gold,porcelain, WDS-approved gold substitute castings [except laboratory processed resin] or combinations thereof)for treatment of carious lesions(visible destruction of hard tooth structure resulting from the process of dental decay)or fracture resulting in significant loss of tooth structure(missing cusp), when teeth cannot reasonably be restored with filling materials such as amalgam or resin-based composites • Crown buildups,subject to Limitations • Post and core,subject to Limitations Limitations • Crowns,veneers,inlays(as a single tooth restoration—with Limitations)or onlays on the same teeth are covered once in a five-year period from the seat date • If a tooth can be restored with a filling material such as amalgam or resin-based composites, an allowance will be made for such a procedure toward the cost of any other type of restoiation that may be provided • WDS will allow the appropriate amount for an amalgam restoration(posterior tooth)or ' resin-based composite restoration(anterior tooth)toward the cost of a laboratory processed resin onlay, veneer,crown or inlay(as a single tooth restoration—with Limitations) • Payment for crowns, veneers, inlays(as a single tooth restoration—with Limitations)or onlays shall be paid upon the seat date • Inlays(as a single tooth restoration)will be considered as a cosmetic procedure and an amalgam allowance will be made,with any difference in cost being the responsibility of the patient • Crown buildups are a Covered Dental Benefit when more than 50 percent of the natural coronal tooth structure is missing or there is less than 2mm of vertical height remaining for 180 degrees or more of the tooth circumference and there is evidence of decay or other significant pathology o Crown buildups are covered once in a two-year period from the date of service o Crown buildups are Not a Paid Covered Benefit within two years of a restoration on the same tooth from the date of service o Crown buildups for the purpose of improving tooth form,filling in undercuts,or reducing bulk in castings are considered basing materials and are Not a Paid Covered Benefit • Post and core are covered once in a two-year period on the same tooth from the date of service. • A crown used for purposes of re-contouring or repositioning a tooth to provide additional retention for a removable partial denture is Not a Paid Covered Benefit unless the tooth is decayed to the extent that a crown would be required to restore the tooth whether or not a removable partial denture is part of the treatment • Crowns or onlays are Not a Paid Covered Benefit when used to repair micro-fractures of tooth structure when the tooth is asymptomatic(displays no symptoms)or there are existing restorations with defective margins when there is no decay or other significant pathology present • Crowns and/or onlays placed because of weakened cusps or existing large restorations without overt pathology are Not a Paid Covered Benefit • Crown and bridgework in conjunction with periodontal splinting or other periodontal therapy and periodontal appliances are Not a Paid Covered Benefit Exclusions • Copings Prosthodontics Covered Dental Benefits • Dentures • Fixed partial dentures(fixed bridges) • Inlays(only when used as a retainer for a fixed bridge) • Removable partial dentures • Adjustment or repair of an existing prosthetic device • Surgical placement or removal of implants or attachments to implants Limitations • Replacement of an existing prosthetic device is covered only once every five-years from the delivery date and only then if it is unserviceable and cannot be made serviceable • Inlays are a Covered Dental Benefit on the same teeth once in a five-year period from the delivery date only when used as a retainer for a fixed bridge • Payment for dentures,fixed partial dentures(fixed bridges), inlays(only when used as a retainer for a fixed bridge)and removable partial dentures shall be paid upon the delivery date • Replacement of implants and superstructures is covered only after five-years have elapsed from any prior provision of the implant • Crowns in conjunction with overdentures are Not a Paid Covered Benefit • Full,immediate and overdentures—WDS will allow the appropriate amount for a full, immediate or overdenture toward the cost of any other procedure that may be provided, such as ' personalized restorations or specialized treatment • Root canal treatment performed in conjunction with overdentures is limited to two teeth per arch and is paid at the Class III Payment Level • Temporary/interim dentures—WDS will allow the amount of a reline toward the cost of an interim partial or full denture After placement of the permanent prosthesis,an initial reline will be a benefit after six months • Partial dentures—If a more elaborate or precision device is used to restore the case, ' WDS will allow the cost of a cast chrome and acrylic partial denture toward the cost of any other procedure that may be pro\,ided • Denture adjustments and relines—Denture adjustments and relines done more than six ' months after the initial placement are covered Subsequent relines or rebases(but not both)will be covered once in a 12-month period from the date of service Exclusions • Duplicate dentures • Personalized dentures • Cleaning of prosthetic appliances • Copings "Refer Also To General Limitations and General Exclusions" Dental Accident Coverage Notwithstanding the amounts payable by WDS for Class I,Class Il and Class III benefits,as provided in Appendix D, WDS shall pay 100 percent of the Filed Fee or the Maximum Allowable Fees, up to the unused program maximum,for expenses for Covered Dental Benefits arising as a direct result of an accidental bodily injury that occurred while the patient was an Eligible Person hereunder A bodily injury does not include teeth broken or damaged during the act of chewing or biting on foreign objects Coverage includes necessary procedures for dental diagnosis and treatment rendered within 180 days following the date of the accident Additional Procedures In some cases, there may be two or more treatment options that meet the standard of care for dental needs covered by the program In such instances,the program will pay the proper percentage of the lowest fee The balance of treatment cost remains the Eligible Persons responsibility General Limitations I. Dentistry for cosmetic reasons is Not a Paid Covered Benefit. 2 Restorations or appliances necessary to correct vertical dimension or to restore the occlusion. Such procedures include restoration of tooth structure lost from attrition, abrasion or erosion and restorations for malalignment of teeth are Not a Paid Covered Benefit. 3 General anesthesia/intravenous (deep) sedation is Not a Paid Covered Benefit, except as specified by WDS for certain oral, periodontal, or endodontic surgical procedures General anesthesia is Not a Paid Covered Benefit except when medically necessary, for children through age six, or a physically or developmentally disabled person, when in conjunction with covered dental procedures. General Exclusions 1. Services for injuries or conditions that are compensable under Worker's Compensation or Employers' Liability laws, and services that are provided to the Eligible Person by any federal or state or provincial government agency or provided without cost to the Eligible Person by any municipality, county or other political subdivision, other than medical assistance in this state, under medical assistance RCW 74 09 500, or any other state, under 42 U S.C., Section 1396a, section 1902 of the Social Security Act. 2. Application of desensitizing agents 3. Experimental services or supplies: a. Experimental services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/observation. In determining whether services are experimental, WDS, in conjunction with the American Dental Association, shall consider if �> The services are in general use in the dental community in the state of Washington, n) The services are under continued scientific testing and research; nq The services show a demonstrable benefit for a particular dental condition; and IV) They are proven to be safe and effective. Any individual whose claim is denied due to this experimental exclusion clause shall be notified of the denial within 20 working days of receipt of a fully documented request b. Any denial of benefits by WDS on the grounds that a given procedure is deemed experimental may be appealed to WDS By law, WDS must respond to such appeal within 20 working days after receipt of all documentation reasonably required to make a decision. The 20-day period may be extended only with written consent of the Eligible Person. C. Whenever WDS makes an adverse determination and delay would jeopardize the Eligible Person's life or materially jeopardize the covered person's health, WDS shall expedite and process either a written or an oral appeal and issue a decision no later than seventy-two hours after receipt of the appeal. If the treating Licensed Professional determines that delay could jeopardize the Eligible Person's health or ability to regain maximum function, WDS shall presume the need for expeditious review, including the need for an expeditious determination in any independent review under WAC 284-43-630. 4. Analgesics such as nitrous oxide, conscious sedation, euphoric drugs or injections 5. Prescription drugs 6. In the event an Eligible Person fails to obtain a required examination from a WDS- appointed consultant Dentist for certain treatments, no benefits shall be provided for such treatment. 7. Hospitalization charges and any additional fees charged by the Dentist for hospital treatment 8. Broken appointments ' 9. Patient management problems 10. Completing claim forms 11 Habit-breaking appliances 12. Orthodontic services or supplies 13. TMJ services or supplies , 14. This program does not provide benefits for services or supplies to the extent that benefits are payable for them under any motor vehicle medical, motor vehicle no-fault, uninsured motorist, underinsured motorist, personal injury protection (PIP), commercial liability, homeowner's policy or other similar type of coverage. 15. All other services not specifically included in this Contract as Covered Dental Benefits Washington Dental Service shall determine whether services are Covered Dental Benefits in accordance with standard dental practice and the Limitations and Exclusions shown in this Contract. Should there be a disagreement regarding the interpretation of such benefits, the subscriber shall have the right to appeal the determination in accordance with the non-binding appeals process in this contract and may seek judicial review of any denial of coverage of benefits. Method of Payment — Dental Benefit Washington Dental Service shall pay one hundred percent(100%)of the Members Dentist's filed fee for allowable i Class I Covered Dental Benefits as they are described for in-network services,or eighty percent(80%)of the Member DentiSt's filed fee for allowable Class I Covered Dental Benefits as they are described for out-of-network services Washington Dental Service shall pay eighty percent(80%)of the Members Dentist's filed fee for allowable Class II Covered Dental Benefits as they are described for in-network services,or seventy percent(70%)of the Member Dentist's filed tee for allowable Class 11 Covered Dental Benefits as they are described for out-of-network services Washington Dental Service shall pay fifty percent(50%) of the Members Dentist's filed fee for allowable Class III Covered Dental Benefits as they are described for in-network services,or forty percent(40%)of the Member Dentist's filed fee for allowable Class Ill Covered Dental Benefits as they are described for out-of-network services The amounts payable by Washington Dental Service for Covered Dental Benefits provided by a Dentist who is not a Member Dentist in the State of Washington, shall be the above applicable percentages,applied to the lesser of the Prevailing Fee(the fee which is equivalent to the 51`percentile of fees of member Dentists in the State of Washington as determined by Washington Dental Service based upon confidential fee listings filed with and accepted by Washington Dental Service)or such Dentist's actual charges The amounts payable by Washington Dental Services for Covered Dental Benefits provided by a Dentist outside of Washington state shall be the above applicable percentages,applied to the lesser of the Usual,Customary and Reasonable fees(the 90`s)percentile of the Washington Dental Service approved filed fees for all Member Dentists in the State of Washington)or such Dentist's actual charges The maximum amount payable by Washington Dental Service for all classes of Covered Dental Benefits per Eligible Person during each twelve(12) month period January 1 through December 31 shall be one thousand five hundred dollars($1,500.00).Charges for dental procedures requiring multiple treatment dates shall be considered incurred on the date the service is completed Amounts paid for such procedures will be applied to the program maximum based on such incurred date Section 2.3 Gettin_g care using our plan's traveler benefit -� Non-emergent and/or non-urgently needed care received while temporarily traveling outside Group Health's Medicare Service Area for up to 6 months at a time is payable at Medicare benefit levels up to$3,000 per member per calendar year Our Plan pays 80%of Medicare allowable reimbursement schedules for Medicare covered services ONLY Enrollee is responsible for all Medicare inpatient and outpatient deductibles and cornsurances. You may get care when you are outside the service area.You may need to pay higher cost sharing for routine care from non-network providers,but you won't pay extra in a medical emergency or if your care is urgently needed If you have questions about your medical costs when you travel,please call Customer Service SECTION 3 What types of benefits are not covered by the plan? CSection 3.1 v Types of benefits we do not cover (exclusions) -1 This section tells you what kinds of benefits are"excluded"Excluded means that the plan doesn't cover these benefits The list below describes some services and items that aren't covered under any conditions and some that are excluded only under specific conditions If you get benefits that are excluded,you must pay for them yourself We won't pay for the medical benefits listed in this section(or elsewhere in this booklet),and neither will Original Medicare The only exception If a benefit on the exclusion list is found upon appeal to be a medical benefit that we should have paid for or covered because of your specific situation (For information about appealing a decision we have made to not cover a medical service,go to Chapter 9, Section 5 3 in this booklet) ti In addition to any exclusions or limitations described in the Benefits Chart,or anywhere else in this Evidence of Coverage,the following items and services aren't covered under Original Medicare or by our plan: • Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as a covered services • Experimental medical and surgical procedures,equipment and medications,unless covered by Original Medicare However,certain services may be covered under a Medicare-approved clinical research study See Chapter 3,Section 5 for more information on clinical research studies • Surgical treatment for morbid obesity,except when it is considered medically necessary and covered under Original Medicare • Private room in a hospital, except when it is considered medically necessary • Private duty nurses • Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television • Full-time nursing care in your home. • Custodial care,unless it is provided with covered skilled nursing care and/or skilled rehabilitation services Custodial care,or non-skilled care, is care that helps you with activities of daily living, such as bathing or dressing • Homemaker services include basic household assistance,including light housekeeping or light meal preparation • Fees charged by your immediate relatives or members of your household • Meals delivered to your home • Elective or voluntary enhancement procedures or services(including weight loss,hair growth, sexual performance,athletic performance, cosmetic purposes,anti-aging and mental performance),except when medically necessary • Cosmetic surgery or procedures because of an accidental injury or to improve a malformed part of the body However,all stages of reconstruction are covered for a breast after a mastectomy,as well as for the unaffected breast to produce a symmetrical appearance. • Routine dental care,such as cleanings,filings or dentures However,routine dental care is available under Optional Supplemental Benefits and non-routine dental care received at a hospital may be covered • Chiropractic care,other than manual manipulation of the spine consistent with Medicare coverage guidelines • Routine foot care,except for the minted coverage provided according to Medicare guidelines • Orthopedic shoes,unless the shoes are part of a leg brace and are Included in the cost of the brace or the shoes are for a person with diabetic foot disease • Supportive devices for the feet,except for orthopedic or therapeutic shoes for people with diabetic foot disease • Hearing aids and routine hearing examinations However,routine hearing examinations are covered under our basic benefit • Eyeglasses,routine eye examinations,radial keratotomy,LASIK surgery,vision therapy and other low vision aids However,eyeglasses are covered for people after cataract surgery However,routine eye examinations are covered under our basic benefit • Outpatient prescription drugs including drugs for treatment of sexual dysfunction, including erectile dysfunction, impotence,and anorgasmy or hyporgasmy • Reversal of sterilization procedures,sex change operations,and non-prescription contraceptive supplies. • Acupuncture • Naturopath services(uses natural or alternative treatments). • Services provided to veterans in Veterans Affairs(VA)facilities However,when emergency services are received at VA hospital and the VA cost-sharing is more than the cost-sharing under our plan We will reimburse veterans for the difference Members are still responsible for our cost-sharing amounts • Any services listed above that aren't covered will remain not covered even if received at an emergency facility 1 1 Chapter 5. Asking the plan to pay its share of a bill you have received for medical services SECTION] Situations in which you should ask our plan to pay our share of the cost of your covered services 51 Section 1.1 If you pay our plan's share of the cost of your covered services,or if you receive a bill,you can ask us for payment 51 SECTION 2 How to ask us to pay you back or to pay a bill you have received 52 Section 2.1 How and where to send us your request for payment 52 SECTION 3 We will consider your request for payment and say yes or no 52 Section 3.1 We check to see whether we should cover the service and how much we owe 52 Section 3.2 If we tell you that we will not pay for the medical care,you can make an appeal 52 SECTION 1 Situations in which you should ask our plan to pay our share of the cost of your covered services Section 1.1 If you pay our plan's share of the cost of your covered services, or if you receive a bill, you can ask us for payment Sometimes when you get medical care,you may need to pay the full cost right away Other times,you may find that you have paid more than you expected under the coverage rules of the plan In either case, you can ask our plan to pay you back(paying you back is often called"reimbursing"you) It is your right to be paid back by our plan whenever you've paid more than your share of the cost for medical services that are covered by our plan These may also be times when you get a bill from a provider for the full cost of medical care you have received In many cases,you should send this bill to us instead of paying it We will look at the bill and decide whether the services should be covered If we decide they should be covered,we will pay the provider directly Here are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received 1. When you've received emergency or urgently needed medical care from a provider who is not in our plan's network i You can receive emergency services from any provider,whether or not the provider is a part of our network When you receive emergency or urgently needed care from a provider who is not part of our network, you are only responsible for paying your share of the cost,not for the entire cost You should ask the provider to bill the plan for our share of the cost • If you pay the entire amount yourself at the time you receive the care, you need to ask us to pay you back for our share of the cost Send us the bill,along with documentation of any payments you have made • At times you may get a bill from the provider asking for payment that you think you do not owe Send us this bill,along with documentation of any payments you have already made o If the provider is owed anything, we will pay the provider directly o If you have already paid more than your share of the cost of the service,we will determine how much you owed and pay you back for our share of the cost 2. When a network provider sends you a bill you think you should not pay , Network providers should always bill the plan directly,and ask you only for your share of the cost But sometimes they make mistakes,and ask you to pay more than your share • Whenever you get a bill from a network provider that you think is more than you should pay,send us the bill We will contact the provider directly and resolve the billing problem • If you have already paid a bill to a network provider,but you feel that you paid too much, send us the bill along with documentation of any payment you have made and ask us to pay you back the difference between the amount you paid and the amount you owed under the plan All of the examples above are types of coverage decisions This means that if we deny your request for payment,you can appeal our decision Chapter 7 of this booklet(What to do f you have a problem or complaint(coverage decisions, appeals, complaints))has information about how to make an appeal L SECTION 2 How to ask us to pay you back or to pay a bill you have received tSection 2.1 How and where to send us your request for payment ® "v� Send us your request for payment, along with your bill and documentation of any payment you have made It's a good idea to make a copy of your bill and receipts for your records Mail your request for payment together with any bills or receipts to us at this address Group Health Medicare Customer Service department P O Box 34585 Seattle,WA 98124-1585 Please be sure to contact Customer Service if you have any questions If you don't know what you owe,or you receive bills and you don't know what to do about those bills, we can help You can also call if you want to give us more information about a request for payment you have already sent to us. SECTION 3 We will consider your request for payment and say yes or no Section 3.1 We check to see whether we should cover the service and how much we owe When we receive your request for payment,we will let you know if we need any additional information from you Otherwise,we will consider your request and decide whether to pay it and how much we owe 1 • If we decide that the medical care is covered and you followed all the rules for getting the care,we will pay for our share of the cost If you have already paid for the service,we will mail your reimbursement of our share of the cost to you If you have not paid for the service yet, we will mail the payment directly to the provider (Chapter 3 explains the rules you need to follow for getting your medical services) • If we decide that the medical care is not covered,or you did not follow all the rules,we will not pay for our share of the cost Instead,we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision Section 3.2 If we tell you that we will not pay for the medical care, you can make an appeal If you think we have made a mistake in turning you down your request for payment,you can make an appeal If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment For the details on how to make this appeal,go to Chapter 7 of this booklet(What to do ifyou have a problem or complaint(coverage decisions, appeals, complaints)) The appeals process is a legal process with detailed procedures and important deadlines If making an appeal is new to you, you will find it helpful to start by reading Section 4 of Chapter 7 Section 4 is an introductory section that explains the process for coverage decisions and appeals and gives definitions of terms such ah "appeal"Then after you have read Section 4,you can go to the Section 5 4 to learn how to make an appeal about getting paid back for a medical service ! Chapter 6. Your rights and responsibilities SECTION I Our plan must honor your rights as a member of the plan 53 Section 1.1 We must provide information in a way that works for you (in languages other than English that are spoken in the plan service area, in Braille,in large print, or other alternate formats, etc.) 53 Section 1.2 We must treat you with fairness and respect at all times 54 Section 1.3 We must ensure that you get timely access to your covered services 54 Section 1.4 We must protect the privacy of your personal health information 54 Section 1.5 We must give you information about the plan,its network of providers, and your covered services 55 Section 1.6 We must support your right to make decisions about your care 56 Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made 57 Section 1.8 What can you do if you think you are being treated unfairly or your rights are not being respected? 57 Section 1.9 How to get more information about your rights 57 SECTION 2 You have some responsibilities as a member of the plan 58 Section 2.1 What are your responsibilities? 58 SECTION 1 Our plan must honor your rights as a member of the plan Section 1.1 We must provide information in a way that works for you (in languages other than English that are spoken in the plan service area, in Braille, in large print, or other alternate formats_, etc.) To get information from us in a way that works for you,please call Customer Service(phone numbers are on the front cover) Our plan has people and translation services available to answer questions from non-English speaking members We can also give you information in Braille, in large print,or other alternate formats if you need it If you are eligible for Medicare because of disability, we are required to give you information about the plan's benefits that is accessible and appropriate for you J If you have any trouble getting information from our plan because of problems related to language or disability, L please call Medicare at 1-800-MEDICARE(1-800-633-4227),24 hours a day,7 days a week,and tell them that you want to file a complaint TTY users call 1-877-486-2048 1 ' Section 1.2 We must treat you with fairness and respect at all times Our plan must obey laws that protect you from discrimination or unfair treatment We do not discriminate based on a person's race,disability,religion,sex,health,ethnicity,creed(beliefs), age,or national origin If you want more information or have concerns about discrimination or unfair treatment,please call the Department of Health and Human Services' Office for Civil Rights 1-800-368-1019 (TTY 1-800-537-7697)or your local Office for Civil Rights If you have a disability and need help with access to care,please call us at Customer Service(phone numbers are on the cover of this booklet) If you have a complaint,such as a problem with wheelchair access,Customer Service can help tSection 1.3 We must ensure that you get timely access to your covered services As a member of our plan, you have the right to choose a primary care provider(PCP) in the plan's network to provide and arrange for your covered services(Chapter 3 explains more about this) Call Customer Service to learn which doctors are accepting new patients(phone numbers are on the cover of this booklet) You also have the right to go to a women's health specialist(such as a gynecologist) without a referral As a plan member,you have the right to get appointments and covered services from the plan's network of providers within a reasonable amount of time This includes the right to get timely services from specialists when you need that care j If you think that you are not getting your medical care within a reasonable amount of time,Chapter 7 of this booklet tells what you can do Section 1.4 We must protect the privacy of your personal health information 1 Federal and state laws protect the privacy of your medical records and personal health information We protect your personal health information as required by these laws • Your"personal health information"includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information • The laws that protect your privacy give you rights related to getting information and controlling how your health information is used We give you a written notice,called a"Notice of Privacy Practice"that tells about these rights and explains how we protect the privacy of your health information How do we protect the privacy of your health information? • We make sure that unauthorized people don't see or change your records. • In most situations,if we give your health information to anyone who isn't providing your care or paying for your care, we are required to get written permission Jrom you first Written permission can be given by you or by someone you have given legal power to make decisions for you • There are certain exceptions that do not require us to get your written permission first These exceptions are allowed or required by law o For example,we are required to release health information to government agencies that are checking on quality of care You can see the information in your records and know how it has been shared with others i You have the right to look at your medical records held at the plan,and to get a copy of your records You also have the right to ask us to make additions or corrections to your medical records If you ask us to do this,we will consider your request and decide whether the changes should be made You have the right to know how your health information has been shared with others for any purposes that are not routine , If you have questions or concerns about the privacy of your personal health information,please call Customer Service(phone numbers are on the cover of this booklet) Section 1.5 We must give you information about the plan, its network of providers, and your covered services As a member of our plan,you have the right to get several kinds of information from us (As explained above in Section 1 1,you have the right to get information from us in a way that works for you This includes getting the information in languages other than English and in large print or other alternate formats) If you want any of the following kinds of information,please call Customer Service (phone numbers are on the cover of this booklet) • Information about our plan This includes,for example, information about the plan's financial condition It also includes information about the number of appeals made by members and the plan's performance ratings, including how it has been rated by plan members and how it compares to other Medicare Advantage health plans • Information about our network providers. j o For example,you have the right to get information from us about the qualifications of the providers in our network and how we pay the providers in our network o For a list of the providers in the plan's network,see the Provider Directory o For more detailed information about our providers,you can call Customer Service(phone numbers are on the cover of this booklet)or visit our website at www ghc org/medicare • Information about your coverage and rules you must follow in using your coverage. o In Chapters 3 and 4 of this booklet,we explain what medical services are covered for you, any restrictions to your coverage,and what rules you must follow to get your covered medical ' services o If you have questions about the rules or restrictions,please call Customer Service(phone numbers are on the cover of this booklet) • Information about why something is not covered and what you can do about it. o If a medical service is not covered for you,or if your coverage is restricted in some way,you can ask us for a written explanation You have the right to this explanation even if you received the medical service from an out-of-network provider o If you are not happy or if you disagree with a decision we make about what medical care is covered for you,you have the right to ask us to change the decision For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 7 of this booklet It gives you the details about how to ask the plan for a decision about your coverage and how to make an appeal if you want us to change our decision (Chapter 7 also tells about how to make a complaint about quality of care, waiting times,and other concerns) o If you want to ask our plan to pay our share of a bill you have received for medical care,see Chapter 5 of this booklet I Section 1.6. We must support your right to make decisions about your care You have the right to know your treatment options and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers when you go for medical care Your providers must explain your medical condition and your treatment choices in a wav that you can understand. You also have the right to participate fully in decisions about your health care.To help you make decisions with your doctors about what treatment is best for you, your rights include the follow ing • To know about all of your choices.This means that you have the right to be told about all of the treatment options that are recommended for your condition,no matter what they cost or whether they are covered by our plan. • To know about the risks.You have the right to be told about any risks involved in your care You must be told in advance if any proposed medical care or treatment is part of a research experiment You always have the choice to refuse any experimental treatments • The right to say"no." You have the right to refuse any recommended treatment This includes the right to t leave a hospital or other medical facility,even if your doctor advises you not to leave Of course, if you refuse treatment,you accept full responsibility for what happens to your body as a result • To receive an explanation if you are denied coverage for care.You have the right to receive an explanation from us if a provider has denied care that you believe you should receive To receive this explanation,you will need to ask us for a coverage decision Chapter 7 of this booklet tells how to ask the plan for a coverage decision You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness You have the right to say what you want to happen if you are in this situation.This means that,f you want to,you ' can. • Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself • Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself The legal documents that you can use to give your directions in advance in these situations are called"advance directives"There are different types of advance directives and different names for them Documents called"living will"and"power of attorney for health care' are examples of advance directives If you want to use an"advance directive"to give your instructions,here is what to do • Get the form. If you want to have an advance directive,you can get a form from your lawyer, from a social worker,or from some office supply stores You can sometimes get advance directive forms from organizations that give people information about Medicare You can also contact Customer Service to ask for the forms(phone numbers are on the cover of this booklet) • Fill it out and sign it. Regardless of where you get this form,keep in mind that it is a legal document You should consider having a lawyer help you prepare it • Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can't You may want to give copies to close friends or family members as well Be sure to keep a copy at home If you know ahead of time that you are going to be hospitalized,and you have signed an advance directive,take a copy with you to the hospital • If you are admitted to the hospital,they will ask you whether you have signed an advance directive form and whether you have it with you • If you have not signed an advance directive form,the hospital has forms available and will ask if you want to sign one Remember,it is your choice whether you want to fill out an advance directive(including whether you want to sign one if you are in the hospital) According to law,no one can deny you care or discriminate against you based on whether or not you have signed an advance directive What if your instructions are not followed? If you have signed an advance directive,and you believe that a doctor or hospital hasn't followed the instructions in it, you may file a c omplamt with SHIBA at the Washington State Office of the Insurance Commissioner by writing to SHIBA HelpLine,Office of the Insurance Commissioner,P O Box 40256,Olympia, WA 98504-0256,or calling the toll-free SHIBA Helplme at 1-800-562-6900 Section 1.7 You have the right to make complaints and to ask us to 7 reconsider,decisions we have made If you have any problems or concems about your covered services or care,Chapter 7 of this booklet tells what you can do It gives the details about how to deal with all types of problems and complaints As explained in Chapter 7,what you need to do to follow up on a problem or concern depends on the situation You might need to ask our plan to make a coverage decision for you,make an appeal to us to change a coverage decision, or make a complaint Whatever you do—ask for a coverage deusion,make an appeal, or make a complaint- we are required to treat you fairly. You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past To get this information,please call Customer Service(phone numbers are on the cover of this booklet) Section 1.8 What can you do if you think you are being treated unfairly or your rights are not being respected? If it is about discrimination, call the Office for Civil Rights , If you think you have been treated unfairly or your rights have not been respected due to your race,disability, religion, sex,health,ethnicity, creed(beliefs), age,or national origin,you should call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697,or call your local Office for Civil Rights Is it about something else? If you think you have been treated unfairly or your rights have not been respected,and it's not about discrimination, you can get help dealing with the problem you are having • You can call Customer Service (phone numbers are on the cover of this booklet). • You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3 Section 1.9 How to get more information about your rights There are several places where you can get more information about your rights • You can call Customer Service (phone numbers are on the cover of this booklet) • You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3. • You can contact Medicare. I o You can visit the Medicare website (http://www.medicare.gov) to read or download the publication"Your Medicare Rights & Protections " ' o Or, you can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week TTY users should call 1-877-486-2048. SECTION 2 You have some responsibilities as a member of the plan Section 2.1 What are your responsibilities? Things you need to do as a member of the plan are listed below If you have any questions,please call Customer Service(phone numbers are on the cover of this booklet) We're here to help • Get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidenee of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered services. o Chapters 3 and 4 give the details about your medical services, including what is covered, what is not covered, rules to follow, and what you pay • If you have any other health insurance coverage beside our plan, or separate prescription drug coverage, you are required to tell us. Please call Customer Service to let us know. 1 o We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered services from our plan This is called"coordination of benefits" because it involves coordinating the health benefits you get from our plan with any other benefits available to you. We'll help you with it. • Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get ' your medical care. • Help your doctors and other providers help you by giving rthem information, asking questions, and following through on your care. o To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon. i o If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand If you ask a question and you don't understand the answer you are given, ask again • Be considerate. We expect all our members to respect the rights of ' other patients. We also expect you to act in a way that helps the smooth running of your doctor's office, hospitals, and other offices. • Pay what you owe. As a plan member, you are responsible for these payments: o You must pay your plan premiums to continue being a member of our plan. o For some of your medical services covered by the plan, you must pay your share of the cost when you get the service. This will be a copayment(a fixed amount) or coinsurance (a percentage of the total cost). Chapter 4 tells what you must pay for your medical services o If you get any medical services that are not covered by our plan or by other insurance you may have, you must pay the full cost. • Tell us if you move. If you are going to move, it's important to tell us right away. Call Customer Service (phone numbers are on the cover of this booklet). o if you move outside of our plan service area, you cannot remain a member of our plan. (Chapter I tells about our service area.) We can help you figure out whether you are moving outside our service area If you are leaving our service area, we can let you know if we have a plan in your new area o If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you • Call Customer Service for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan. o Phone numbers and calling hours for Customer Service are on the cover of this booklet o For more information on how to reach us, including our mailing address, please see Chapter 2. Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) i I BACKGROUND SECTION I Introduction 62 Section 1.1 What to do if you have a problem or concern 62 Section 1.2 What about the legal terms? 62 SECTION 2 You can get help from government organizations that are not connected with us 62 Section 2.1 Where to get more information and personalized assistance 62 SECTION 3 To deal with your problem, which process should you use? 63 Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints?63 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide to the basics of coverage decisions and appeals 64 Section 4.1 Asking for coverage decisions and making appeals: the big picture 64 Section 4.2 How to get help when you are asking for a coverage decision or making an appeal 64 Section 4.3 Which section of this chapter gives the details for your situation? 65 SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal 65 Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay,you back for our share of the cost of your care 66 Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) 67 Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan) 69 Section 5.4 Step-by-step: How to make a Level 2 Appeal 71 Section 5.5 What if you are asking our plan to pay you for our share of a bill you have received Ifor medical care? 73 SECTION 6 How to ask us to cover a longer hospital stay if you think the doctor is discharging you too soon 73 Section 6.1 During your hospital stay,you will get a written notice from Medicare that tells about your rights 74 Section 6.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date 74 Section 6.3 Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date 77 Section 6.4 What if you miss the deadline for making your Level 1 Appeal? 78 SECTION 7 How to ask us to keep covering certain medical services if you think your coverage is ending too soon 80 Section 7.1 This section is about three services only:Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services 80 Section 7.2 We will tell you in advance when your coverage will be ending 80 Section 7.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care for a longer time 81 Section 7.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time 83 Section 7.5 What if you miss the deadline for making your Level 1 Appeal? 84 SECTION 8 Taking your appeal to Level 3 and beyond 86 Section 8.1 Levels of Appeal 3,4, and 5 for Medical Service Appeals 86 MAKING COMPLAINTS SECTION 9 How to make a complaint about quality of care, waiting times, customer service, or other concerns 87 Section 9.1 What kinds of problems are handled by the complaint process? 87 Section 9.2 The formal name for"making a complaint" is "filing a grievance" 90 Section 9.3 Step-by-step: Making a complaint 90 Section 9.4 You can also make complaints about quality of care to the Quality Improvement Organization 91 BACKGROUND SECTION 1 Introduction Section 1.1 What to do if you have a problem or concern Please call us first Your health and satisfaction are important to us When you have a problem or concern,we hope you'll try an informal approach first Please call Customer Service(phone numbers are on the cover of this booklet) We will work with you to try to find a satisfactory solution to your problem You have rights as a member of our plan and as someone who is getting Medicare We pledge to honor your rights, to take your problems and concerns seriously, and to treat you with respect Two formal processes for dealing with problems Sometimes you imght need a formal process for dealing with a problem you are having as a member of our plan. This chapter explains two types of fonnal processes for handling problems • For some types of problems,you need to use the process for coverage decisions and making appeals • For other types of problems you need to use the process for making complaints Both of these processes have been approved by Medicare To ensure fairness and prompt handling of your problems, each process has a set of rules,procedures,and deadlines that must be followed by us and by you Which one do you use9 That depends on the type of problem you are having The guide in Section 3 will help you identify the right process to use Section 1.2 What about the legal terms? There are technical legal terms for some of the rules,procedures,and types of deadlines explained in this chapter Many of these terms are unfamiliar to most people and can be hard to understand To keep things simple,this chapter explains the legal rules and procedures using more common words in place of certain legal terms For example,this chapter generally says"making a complaint"rather than"film.-a grievance," "coverage decision"rather than"organization determination"and"Independent Review Organization"instead of "Independent Review Entity"It also uses abbreviations as little as possible However, it can be helpful-and sometimes quite important-for you to know the correct legal terms for the situation you are in Knowing which terms to use will help you communicate more clearly and accurately when you are dealing with your problem and get the right help or information for your situation To help you know which terns to use,we include legal terms when we give the details for handling specific types of situations SECTION 2 You can get help from government organizations that are not connected with us Section 2.1 Where to get more information and personalized assistance Sometimes it can be confusing to start or follow through the process for dealing with a problem This can be especially true if you do not feel well or have limited energy Other times,you may not have the knowledge you need to take the next step Perhaps both are true for you Get help from an independent government organization We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program This government program has trained counselors in every state. The program is not connected with our plan or with any insurance company or health plan The i counselors at this program can help you understand which process you should use to handle a problem you are having They can also answer your questions, give you more information, and offer guidance on what to do. Their services are free. You will find phone numbers in Chapter 2, Section 3 of this booklet You can also get help and information from Medicare For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare• • You can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. • You can visit the Medicare website (http•//www.medicare.gov). i SECTION 3 To deal with your problem, which process should you use? Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? _ If you have a problem or concern and you want to do something about it, you don't need to read this whole chapter. You lust need to find and read the parts of this chapter that apply to your situation The guide that follows will help To figure out which part of this chapter tells whatto do foryou r problem or concern, START HERE Is your problem or concern about your benefits and coverage? (Th is in clu des problems abou twh eth er particu lar medical care is covered or not,th e way in wh ich it is covered, an d problems related to payment for medical care ) Yes No — — Go on to the next section of Slip ah ead to Section 9 at th a en d of this ch apter, Section 4: -A guide thischapter -How to make a to the basics of coverage complaint about quality of care, decisions and making appeals " waiting times, customer service or other concerns," COVERAGE DECISIONS AND APPEALS SECTION 4 A guide to the basics of coverage decisions and appeals Section 4.1 Asking for coverage decisions and making appeals: the big picture The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment This is the process you use for issues such as whether something is covered or not and the way in which something is covered t Asking for coverage decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for Your medical services We make a coverage decision for you whenever you go to a doctor for medical care You can also contact the plan and ask for a coverage decision For example, if you want to know if we will cover a medical service before you receive It, you can ask us to make a coverage decision for you We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. • Usually, there is no problem. We decide the service is covered and pay our share of the cost. • But in some cases we might decide the service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Making an appeal If we make a coverage decision and you are not satisfied with this decision, you can"appeal"the decision An appeal is a formal way of asking us to review and change a coverage decision we have made When you make an appeal,we review the coverage decision we have made to check to see if we were being fair and following all of the rules properly When we have completed the review we give you our decision If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal The Level 2 Appeal is conducted by an independent organization that is not connected to our plan If you are not satisfied with the decision at the Level 2 Appeal,you may be able to continue through several more levels of appeal Section 4.2 How to get help when you are asking for a coverage decision or making an appeal _ Would you like some help?Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision • You can call us at Customer Service(phone numbers are on the cover) • To get free help from an independent organization that is not connected with our plan,contact your State Health Insurance Assistance Program(see Section 2 of this chapter) • You should consider getting your doctor or other provider involved if possible,especially if you want a"fast"or"expedited" decision. In most situations involving a coverage decision or appeal,your doctor or other provider must explain the medical reasons that support your request Your doctor or other prescriber can't request every appeal He/she can request a coverage decision and a Level I Appeal with the plan To request any appeal after Level 1, your doctor or other prescriber must be appointed as your i `representative"(see below about"representatives") • You can ask someone to act on your behalf If you want to,you can name another person to act for you as your"representative"to ask for a coverage decision or make an appeal o There may be someone who is already legally authorized to act as your representative under State law o If you want a friend,relative,your doctor or other provider,or other person to be your representative, call Customer Service and ask for the form to give that person permission to act on your behalf The form must be signed by you and by the person who you would like to act on your behalf You must give our plan a copy of the signed form • You also have the right to hire a lawyer to act for you. You may contact your own lawyer,or get the name of a lawyer from your local bar association or other referral service There are also groups that will give you free legal services if you qualify However,you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision , i Section 4.3 Which section of this chapter gives the details for your situation? There are three different types of situations that involve coverage decisions and appeals Since each situation has different rules and deadlines,we give the details for each one in a separate section Section 5 ofthis Section 6 of this Section 7 of this chapter chapter chapter "How to ask us to keep covering i "Your medical care "How to ask us to certain medical services if you think Hoag to ask for a cover a longer your coverage is ending too soon" coverage decision or hospital stay ifyou (Applies 1.©theseServices only make an appeal" think the doctor is home health care,skilled nursing dischargingyou too facility care,and Comprehensive soon" Outpatient Rehabilitation Facility (CORD") services) If you're still not sure which section you should be using,please call Customer Service(phone numbers are on the front cover) You can also get help or information from government organizations such as your State Health Insurance Assistance Program(Chapter 2, Section 3,of this booklet has the phone numbers for this program) SECTION 5 Your medical care: How to ask for a coverage decision or make an appeal A Have you read Section 4 of this chapter(A guide to "the basics"of _r coverage decisions and appeals)?If not.you may want to read it before 0 you start this section Section 5.1 This section tells what to do if you have problems getting tcoverage for medical care or if you want us to pay you back for our share of the cost of your care This section is about your benefits for medical care and services These are the benefits described in Chapter 4 of this booklet Medical benefas chart(what is covered and what you pay) To keep things simple,we generally refer to"medical care coverage"or"medical care"in the rest of this section, instead of repeating"medical care or treatment or services"every time This section tells what you can do if you are in any of the five following situations 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan 3. You have received medical care or services that you believe should be covered by the plan, but we have said we will not pay for this care. 4. You have received and paid for medical care or services that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. 5. You are being told that coverage for certain medical care you have been getting will be reduced or stopped, and you believe that reducing or stopping this care could harm your health • NOTE- If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation (CORF) services, you need to read a separate section of this chapter because special rules apply to these types of care. Here's what to read in those situations. o Chapter 7, Section 6• How to ask for a longer hospital stay if you think you are being asked to leave the hospital too soon o Chapter 7, Section 7: How to ask our plan to keep covering certain medical services if you think your coverage is ending too soon This section is about three services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services • For all other situations that involve being told that medical care you have been getting will be stopped, use this section (Section 5) as your guide for what to do. � i 1 Which of these situations are you in? Leo you want to find aut llas our plan already told Do you want to ask whether our pl"n will you that wv will pot cover our plan to pay you ,over the inedical care or pay iiir a inedical service hack for medical care or scry i,:es you NN ant? in the N+ay that you Ni ant it or set-vices You have to he CUVL:lcd ul paid tut° already reccivcu and pair] Cot' You need to ask our f plan to make a coverage You can nittke an appeal. decision for you (Chas mean~ yrau are aaknao You can send us the Goo on to the next us to reconsider,) bill Skip to ;ectinii of this chapter, Skip ahead to Section 5.3 Section 5.5 of Section 5.2. of tilts Chapterru5 chapter. l Section 5.2 Step-by-step: How to ask for a coverage decision (how to ask our plan to authorize or provide the medical care coverage you want) Legal A coverage decision is often called an"initial Terms determination"or"initial decision' When a coverage decision involves your medical care,the initial deteimination is called an"organization determination." Step 1: You ask our plan to make a coverage decision on the medical care you ' are requesting. If your health requires a quick response, you should ask us to make a "fast decision." Legal A"fast decision"is called an"expedited decision." Terms How to request coverage for the medical care you want • Start by calling,writing,or faxing our plan to make your request for us to provide coverage for the medical care you want You,or your doctor,or your representative can do this • For the details on how to contact us,go to Chapter 2,Section 1 and look for the section called,How to contact us when you are askingfor a coverage decision about your medical care. Generally we use the standard deadlines for giving you our decision When we give you our decision, we wall use the"standard"deadlines unless we have agreed to use the"fast" deadlines A standard decision means we will give you an answer within 14 days after we receive your request • However,we can take up to 14 more days if you ask for more time,or if we need information(such as medical records) that may benefit you If we decide to take extra days to make the decision, we will tell you in writing • If you believe we should not take extra days,you can file a"fast complaint"about our decision to take extra days When you file a fast complaint, we will give you an answer to your complaint within 24 hours (The process for making a complaint is different from the process for coverage decisions and appeals For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter) If your health requires it, ask us to give you a `fast decision" 1 • A fast decision means we will answer within 72 hours. o However,we can take up to 14 more days if we find that some information is missing that may benefit you,or if you need time to get information to us for the review If we decide to take extra days,we will tell you in writing I o If you believe we should not take extra days,you can file a"fast complaint"about our decision to take extra days (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter)We will call you as soon as we make the decision • To get a fast decision,you must meet two requirements: o You can get a fast decision only if you are asking for coverage for medical care you have not yet received (You cannot get a fast decision if your request is about payment for medical care you have already received) io You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function • If your doctor tells us that your health requires a"fast decision,"we will automatically agree to give you a fast decision. • if you ask for a fast decision on your own,without your doctor's support,our plan will decide whether your health requires that we give you a fast decision o If we decide that your medical condition does not meet the requirements for a fast decision,we will send you a letter that says so(and we will use the standard deadlines instead) o This letter will tell you that if your doctor asks for the fast decision,we will automatically give a fast decision o The letter will also tell how you can file a"fast complaint"about our decision to give you a standard decision instead of the fast decision you requested (For more information about the process for making complaints, including fast complaints, see Section 9 of this chapter) Step 2: Our plan considers your request for medical care coverage and we give you our answer. 1 Deadlines for a "fast"coverage decision • Generally, for a fast decision,we will give you our answer within 72 hours o As explained above, we can take up to 14 more days under certain circumstances If we take extra days, it is called"an extended time period" o If we do not give you our answer within 72 hours(or if there is an extended time period,by the end of that period),you have the right to appeal Section 5 3 below tells how to make an appeal • If our answer is yes to part or all of what you requested,we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request if we extended the time needed to make our decision,we will provide the coverage by the end of that extended period • If our answer is no to part or all of what you requested,we will send you a written statement that explains why we said no Deadlines for a "standard"coverage decision • Generally,for a standard decision,we will give you our answer within 14 days of receiving your request. o We can take up to 14 more days("an extended time period")under certain circumstances. o If we do not give you our answer within 14 days(or if there is an extended time period,by the end of that period),you have the right to appeal Section 5 3 below tells how to make an appeal • If our answer is yes to part or all of what you requested,we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request If we extended the time needed to make our decision,we will provide the coverage by the end of that extended period • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal. • if our plan says no,you have the right to ask us to reconsider—and perhaps change—this decision by making an appeal Making an appeal means making another try to get the medical care coverage you want • if you decide to make appeal, it means you are going on to Level 1 of the appeals process (see Section 5 3 below) Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a medical care coverage decision made by our plan) Legal When you start the appeal process by making an Terms appeal, it is called the "first level of appeal" or a "Level 1 Appeal." An appeal to the plan about a medical care coverage decision is called a plan"reconsideration." Step 1: You contact our plan and make your appeal. If your health requires a quick response, you must ask for a "fast appeal." What to do • To start an appeal you,your representative,or in some cases your doctor must contact our plan.For details on how to reach us for any purpose related to your appeal,go to Chapter 2, Section 1 look for section called,How to contact us when you are making an appeal about your medical care • Make your standard appeal in writing by submitting a signed request. • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision If you miss this deadline and have a good reason for missing it,we may give you more time to make your appeal • You can ask for a copy of the information in your appeal and add more information if you like. o You have the right to ask us for a copy of the information regarding your appeal o if you wish,you and your doctor may give us additional information to support your appeal If your health requires it, ask for a "fast appeal"(you can make an oral request) Legal A"fast appeal"is also called an"expedited appeal." Terms • If you are appealing a decision our plan made about coverage for care you have not yet received,you and/or your doctor will need to decide if you need a"fast appeal " • The requirements and procedures for getting a"fast appeal"are the same as those for getting a"fast decision"To ask for a fast appeal,follow the instructions for asking for a fast decision (These instructions are given earlier in this section) • If your doctor tells us that your health requires a 'fast appeal,"we will automatically agree to give you a fast appeal Step 2: Our plan considers your appeal and we give you our answer. • When our plan is reviewing your appeal,we take another careful look at all of the information about your request for coverage of medical care We check to see if we were being fair and following all the rules when we said no to your request • We will gather more information if we need it We may contact you or your doctor to get more information Deadlines for a "fast"appeal • When we are using the fast deadlines,we must give you our answer within 72 hours after we receive your appeal We will give you our answer sooner if your health requires us to do so. o However, if you ask for more time,or if we need to gather more information that may benefit you,we can take up to 14 more days. to If we do not give you an answer within 72 hours(or by the end of the extended time period if we took extra days),we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization Later in this section,we tell you about this organization and explain what happens al Level 2 of the appeals process. • If our answer is yes to part or all of what you requested,we must authorize or provide the coverage >� we have agreed to provide within 72 hours t • If our answer is no to part or all of what you requested,we will send you a written denial notice informing you that we have sent your appeal to the Independent Review Organization for a Level 2 Appeal Deadlines for a "standard" appeal • If we are using the standard deadlines,we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for sery ices you have not yet received We will give you our decision sooner if your health condition requires us to o However, if you ask for more time,or if we need to gather more information that may benefit you,we can take up to 14 more days. o If we do not give you an answer by the deadline above(or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process,where it will be reviewed by an independent outside organization Later in this section, we tell about this review organization and explain what happens at Level 2 of the appeals process • If our answer is yes to part or all of what you requested,we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal • If our answer is no to part or all of what you requested,we will send you a written denial notice informing you that we have sent your appeal to the Independent Review Organization for a Level 2 Appeal Step 3: If our plan says no to your appeal, your case will automatically be sent on to the next level of the appeals process. • To make sure we were being fair when we said no to your appeal,our plan is required to send your appeal to the"Independent Review Organization" When we do this,it means that your appeal is going on to the next level of the appeals process, which is Level 2 Section 5.4 Step-by-step: How to make pa_Level 2 Appeal v� If Our plan says no to your Level I Appeal,your case will automatically be sent on to the next level of the appeals process During the Level 2 Appeal,the Independent Review Organization reviews the decision our plan made when we said no to your first appeal This organization decides whether the decision we made should be changed Legal The formal name for the "Independent Review Terms Organization"is the"Independent Review Entity."It is sometimes called the"IRE." Step 1: The Independent Review Organization reviews your appeal. • The Independent Review Organization is an outside,independent organization that is hired by t Medicare This organization is not connected w ith our plan and it is not a government agency This organization is a company chosen by Medicare to handle the lob of being the Independent Review Organization Medicare oversees its work • We will send the information about your appeal to this organization This information is called your "case file"You have the right to ask us for a copy of your case rile • You have a right to give the Independent Review Organization additional information to support your appeal • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal If you had a "fast"appeal at Level 1, you will also have a "fast'appeal at Level 2 • If you had a fast appeal to our plan at Level 1 and requested a fast appeal at Level 2, the review organization must give you an answer to your Level 2 Appeal within 72 hours of when it receives your appeal • However,if the Independent Review Organization needs to gather more information that may benefit you,it can take up to 14 more days If you had a "standard"appeal at Level 1, you will also have a "standard"appeal at Level 2 • If you made a standard appeal to our plan at Level 1 and requested a standard appeal at Level 2,the review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal • However, if the Independent Review Organization needs to gather more information that may benefit you,it can take up to 14 more days Step 2: The Independent Review Organization gives you their answer. EThe Independent Review Organization will tell you its decision in writing and explain the reasons for it. • If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 days after we receive the decision from the ieview organization ' • if this organization says no to your appeal,it means they agree with our plan that your request for coverage for medical care should not be approved (This is called"upholding the decision "It is also called"turning down your appeal") o The notice you get from the Independent Review Organization will tell you in writing if your case meets the requirements for continuing with the appeals process For example, to continue and make another appeal at Level 3,the dollar value of the medical care coverage you are requesting must meet a certain minimum If the dollar value of the coverage you are requesting is too low,you cannot make another appeal,which means that the decision at Level 2 is final Step 3: If your case meets the requirements, you choose whether you want to take your appeal further. • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process,you must decide whether you want to go on to Level 3 and make a third appeal The details on how to do this are in the written notice you got after your Level 2 Appeal • The Level.3 Appeal is handled by an administrative law judge Section 8 in this chapter tells more about Levels 3,4,and 5 of the appeals process 1 Section 5.5 What if you are asking our plan to pay you for our share of a bill you have received for medical care? If you want to ask our plan for payment for medical care, start by reading Chapter 5 of this booklet Asking the plan to pay its share of a bill you have received for medical services Chapter 5 describes the situations in which you may need to ask for reimbursement or to pay a bill you have received from a provider It also tells how to send us the paperwork that asks us for payment Asking for reimbursement is asking for a coverage decision from our plan If you send us the paperwork that asks toy reimbursement,you are asking us to make a coverage decision(for more information about coverage decisions, see Section 4 1 of this chapter) To make this coverage decision,we will check to see if the medical care you paid for is a covered service(see Chapter 4 Medical benefits chart(what is covered and what you pay)) We will also check to see if you followed all the rules for using your coverage for medical care(these rules are given in Chapter 3 of this booklet Using the plan's coverage for your medical services) We will say yes or no to your request • If the medical care you paid for is covered and you followed all the rules,we will send you the payment for our share of the cost of your medical care Or,if you haven't paid for the services,we will send the payment directly to the provider When we send the payment, it's the same as saying yes to your request for a coverage decision) • if the medical care is not covered,or you did not follow all the rules,we will not send payment Instead,we will send you a letter that says we will not pay for the services and the reasons why (When we turn down your request for payment, it's the same as saying no to your request for a coverage decision) What if you ask for payment and we say that we will not pay? If you do not agree with our decision to turn you down,you can make an appeal If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment To make this appeal,follow the process for appeals that we describe in part 5.3 of this section Go to this part for step-by-step instructions When you are following these instructions,please note • If you make an appeal for reimbursement we must give you our answer within 60 calendar days after we receive your appeal (If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal) • If the Independent Review Organization reverses our decision to deny payment, we must send the payment you have requested to you or to the provider within 30 calendar days If the answer to your appeal is yes at any stage of the appeals process after Level 2,we must send the payment you requested to you or to the provider within 60 calendar days i SECTION 6 How to ask us to cover a longer hospital stay if you think the doctor is discharging you too soon When you are admitted to a hospital,you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury For more information about the plan's coverage for your hospital care,including any limitations on this coverage, see Chapter 4 of this booklet Medical benefits chart(what is covered and what you pay) During your hospital stay,your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital They will also help arrange for care you may need after you leave • The day you leave the hospital is called your"discharge date"Our plan's coverage of your hospital stay ends on this date • When your discharge date has been decided,your doctor or the hospital staff will let you know • If you think you are being asked to leave the hospital too soon,you can ask for a longer hospital stay and your request will be considered This section tells you how to ask Section 6.1 During your hospital stay, you will get a written notice from Medicare that tells about your rights During your hospital stay,you will be given a written notice called An Important Message from Medicare about Your Rights Everyone with Medicare gels a copy of this notice whenever they are admitted to a hospital Someone at the hospital is supposed to give it to you within two days after you are admitted 1. Read this notice carefully and ask questions if you don't understand it. It tells you about your rights as I a hospital patient, including • Your right to receive Medicare-covered services during and after your hospital stay,as ordered by your doctor This includes the right to know what these services are,who will pay for them, and where you Ican get them • Your right to be involved in any decisions about your hospital stay,and know who will pay for it • Where to report any concerns you have about quality of your hospital care. • What to do if you think you are being discharged from the hospital too soon Legal The written notice from Medicare tells you how you can"make an Terms appeal."Making an appeal is a formal, legal way to ask for a delay in your discharge date so that your hospital care will be covered for a longer time Section 7 2 below tells how to make this appeal 2. You must sign the written notice to show that you received it and understand your rights. • You or someone who is acting on your behalf must sign the notice (Section 4 of this chapter tells how you can give written permission to someone else to act as your representative) • Signing the notice shows only that you have received the information about your rights The notice does not give your discharge date(your doctor or hospital staff will tell you your discharge date) Signing the notice does not mean you are agreeing on a discharge date 3 Keep your copy of the signed notice so you will have the information about making an appeal(or reporting a concern about quality of care)handy if you need it. • If you sign the notice more than 2 days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged • To look at a copy of this notice in advance,you can call Customer Service or 1-800 MEDICARE(1- 800-633-4227 or TTY 1-877-486-2048) You can also see it online at http //www ems hhs gov Section 6.2 Step-by-step: How to make a Level 1 Appeal to change your hospital discharge date If you want to ask for your hospital sery ices to be covered by our plan for a longer time, you will need to use the appeals process to make this request Before you start, understand what you need to do and what the deadlines are • Follow the process.Each step in the first two levels of the appeals process is explained below. 1 • Meet the deadlines.The deadlines are important.Be sure that you understand and follow the deadlines that apply to things you must do t • Ask for help if you need it If you have questions or need help at any time,please call Customer Service(phone numbers are on the front cover of this booklet) Or call your State Health Insurance i Assistance Program,a government organization that provides personalized assistance(see Section 2 of this chapter) During a Level 1 Appeal,the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you Legal When you start the appeal process by making an appeal, it Terms is called the"first level of appeal'or a"Level I Appeal" I Step 1: Contact the Quality Improvement Organization in your state and ask for a "fast review" of your hospital discharge. You must act quickly. Legal A"fast review"is also called an"immediate review"or an Terms "expedited review" What is the Quality Improvement Organization? • This organization is a group of doctors and other health care professionals who are paid by the Federal government These experts are not part of our plan This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare This includes reviewing hospital discharge dates for people with Medicare How can you contact this organization? • The written notice you received(An Important Message from Medicare)tells you how to reach this organization (Or find the name,address,and phone number of the Quality Improvement Organization for your state in Chapter 2, Section 4,of this booklet) Act quickly. • To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date.(Your"planned discharge date"is the date that has been set for you to leave the hospital) o If you meet this deadline,you are allowed to stay in the hospital after your discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization o If you do not meet this deadline,and you decide to stay in the hospital after your planned discharge date,You may have to pay all of the costs for hospital care you receive after your planned discharge date • If you miss the deadline for contacting the Quality Improvement Organization about your appeal,you , can make your appeal directly to our plan instead For details about this other way to make your appeal,see Section 6 4 Step 2: The Quality Improvement Organization conducts an independent review of your case. What happens during this review? • Health professionals at the Quality Improvement Organization(we will call them"the reviewers"for short)will ask you(or your representative)why you believe coverage for the services should continue You don't have to prepare anything in writing, but you may do so if you wish • The reviewers will also look at your medical information, talk with your doctor,and review information Ithat the hospital and our plan has given to them • During this review process, you will also get a written notice that gives your planned discharge date and explains the reasons why your doctor,the hospital,and our plan think it is right (medically appropriate) for you to be discharged on that date Legal This written explanation is called the"Detailed Notice of Terms Discharge."You can get a sample of this notice by calling Customer Service or 1-800-MEDICARE (1-800-633-4227, 24 hours d day, 7 days a week TTY users should call l- 877-486-2048 Or you can get see a sample notice online at htt i/www ems hhs go)//BNI/ Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes? • If the review organization says yes to your appeal,our plan must keep providing your covered hospital services for as long as these services are medically necessary. ' • You will have to keep paying your share of the costs(such as deductibles or copayments,if these apply) In addition,there may be limitations on your covered hospital services (See Chapter 4 of this booklet) What happens if the answer is no? r • If the review organization says no to your appeal,they are saying that your planned discharge date is medically appropriate (Saying no to your appeal is also called turning down your appeal)If this I happens, our plan's coverage for your hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal • If you decide to stay in the hospital,then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal. Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal • If the Quality Improvement Organization has turned down your appeal,and you stay in the hospital after your planned discharge date, then you can make another appeal Making another appeal means you are going on to"Level 2"of the appeals process Section 6.3 _ Step-by-step: How to make a Level 2 Appeal to change your hospital discharge date ' If the Quality Improvement Organization has turned down your appeal.and you stay in the hospital after your planned discharge date,then you can make a Level 2 Appeal During a Level 2 Appeal,you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal Here are the steps for Level 2 of the appeal process Step 1: You contact the Quality Improvement Organization again and ask for another review • You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal You can ask for this review only if you stayed in the hospital after the date that your coverage for the care ended Step 2: The Quality Improvement Organization does a second review of your situation • Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal Step 3: Within 14 days, the Quality Improvement Organization reviewers will t decide on your appeal and tell you their decision. if the review organization says yes, • Our plan must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization Our plan must continue providing coverage for your hospital care for as long as it is medically necessary • You must continue to pay your share of the costs and coverage limitations may apply. if the review organization says no: • It means they agree with the decision they made to your Level 1 Appeal and will not change it This is called"upholding the decision"It is also called"turning down your appeal" • The notice you get will tell you in writing what you can do if you wish to continue with the review process It will give you the details about how to go on to the next level of appeal,which is handled by aludge Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3 • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal) If the review organization turns down your Level 2 Appeal,you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal At Level 3, your appeal is reviewed by aludge • Section 8 in this chapter tells more about Levels 3,4,and 5 of the appeals process. Section 6.4 What if you miss the deadline for making your Level 1 Appeal? You can appeal to our plan instead As explained above in Section 6 2,you must act quickly to contact the Quality Improvement Organization to start Your first appeal of your hospital discharge ("Quickly means belore you leave the hospital and no later than your planned discharge date) If you miss the deadline for contacting this organization, there is another way to make your appeal If you use this other way of making your appeal,the first two levels of appeal are different t Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization,you can make an appeal to our plan, asking for a"fast review"A fast review is an appeal that uses the fast deadlines instead of the standard deadlines Legal A"fast"review(or"fast appeal") is also called an ITerms "expedited"review(or"expedited appeal") Step 1: Contact our plan and ask for a "fast review." • For details on how to contact our plan,go to Chapter 2, Section I and look for the section called, How to contact us when you are making an appeal about your medical care 1 • Be sure to ask for a"fast review"This means you are asking us to give you an answer using the "fast"deadlines rather than the"standard"deadlines 1 Step 2: Our plan does a "fast' review of your planned discharge date, checking to see if it was medically appropriate. • During this review,our plan takes a look at all of the information about your hospital stay We check to see if your planned discharge date was medically appropriate We will check to see if the decision about when you should leave the hospital was fair and followed all the rules • In this situation,we will use the"fast'deadlines rather than the standard deadlines for giving you the answer to this review. Step 3: Our plan gives you our decision within 72 hours after you ask for a "fast review" ("fast appeal'). • If our plan says yes to your fast appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date,and will keep prov iding your covered services for as long as it is medically necessary It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end (You must pay your share of the costs and there may be coverage limitations that apply) • If our plan says no to your fast appeal,we are saying that your planned discharge date was medically appropriate Our coverage for your hospital services ends as of the day we said coverage would end • If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date You will be responsible for the cost of ' care starting from noon on the day after our plan says no to your appeal Step 4: If our plan says no to your fast appeal, your case will automatically be sent on to the next level of the appeals process. t • To make sure we were being fair when we said no to your fast appeal,our plan is required to send your appeal to the"Independent Review Organization."When we do this, it means that you are automatically going on to Level 2 of the appeals process Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process During the Level 2 Appeal,the Independent Review Organization reviews the decision our plan made when we said no to your"fast appeal"This organization decides whether the decision we made should be changed Legal The formal name for the"Independent Review Terms Organization"is the"Independent Review Entity."It is sometimes called the"IRE." Step 1: We will automatically forward your case to the Independent Review , Organization. • We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal (If you think we are not meeting this deadline or other deadlines,you can make a complaint The complaint process is different from the appeal process Section 9 of this chapter tells how to make a complaint) Step 2: The Independent Review Organization does a "fast review" of your appeal. The reviewers give you an answer within 72 hours. • The Independent Review Organization is an outside,independent organization that is hired by Medicare This organization is not connected with our plan and it is not a government agency This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization Medicare oversees its work • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal of your hospital discharge • If this organization says yes to your appeal,then our plan must reimburse you(pay you back)for our share of the costs of hospital care you have received since the date of your planned discharge We must also continue the plan's coverage of your hospital services for as long as it is medically necessary You must continue to pay your share of the costs If there are coverage limitations,these could limit how much we would reimburse or how long we would continue to cover your services • If this organization says no to your appeal, it means they agree with our plan that your planned hospital discharge date was medically appropriate (This is called"upholding the decision" It is also called"turning down your appeal") o The notice you get from the Independent Review Organization will tell you in writing what Z you can do if you wish to continue with the review process It will give you the details about how to go on to a Level 3 Appeal, which is handled by aludge Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further , • There are three additional levels in the appeals process after Level 2(for a total of five levels of appeal) If reviewers say no to your Level 2 Appeal,you decide whether to accept their decision or go ' on to Level 3 and make a third appeal • Section 8 in this chapter tells more about Levels 3,4,and 5 of the appeals process SECTION 7 How to ask us to keep covering certain medical ' services if you think your coverage is ending too soon Section 7.1 This section is about three services only: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services This section is about the following types of care only I • Home health care services you are getting. • Skilled nursing care you are getting as a patient in a skilled nursing facility. (To learn about requirements for being considered a "skilled nursing facility," see Chapter 10, Definitions of important words.) • Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation (For more information about this type of facility, see Chapter 10, Definitions of important words ) When you are getting any of these types of care,you have the right to keep getting your covered services for that type of care for as long as the care is needed to diagnose and treat your illness or injury For more information on your covered services, including your share of the cost and any limitations to coverage that may apply,see Chapter 4 of this booklet Medical benefits chart(what is covered and what you pay) When our plan decides it is time to stop covering any of the three types of care for you,we are required to tell you in advance When your coverage for that care ends,our plan will stop paying its share of the cost for your care if you think we are ending the coverage of your care too soon,you can appeal our decision This section tells you how to ask Section 7.2 We will tell you in advance when your coverage will be ending 1. You receive a notice in writing.At least two days before our plan is going to stop covering your care, the agency or facility that is providing your care will give you a notice • The written notice tells you the date when our plan will stop covering the care for you Legal In this written notice,we are telling you about a"coverage Terms decision"we have made about when to stop covering your care (For more information about coverage decisions, see Section 4 in this chapter • The written notice also tells what you can do if you want to ask our plan to change this decision about ' when to end your care,and keep covering it for a longer period of time Legal In telling what you can do, the written notice is telling how Terms you can"make an appeal."Making an appeal is a formal, legal way to ask our plan to change the coverage decision we have made about when to stop your care (Section 8 3 below tells how you can make an appeal L . Legal The written notice is called the"Notice of Medicare Non- Terms Coverage."To get a sample copy,call Customer Service or 1-800-MEDICARE(1-800-633-4227, 24 hours a day.7 days a week TTY users should call 1-877-486-2048) Or see a copy online at htt //www tins hhs ov/BNI/ 2. You must sign the written notice to show that you received it. • You or someone who is acting on your behalf must sign the notice (Section 4 tells how you can give written permission to someone else to act as your representative) • Signing the notice shows only that you have received the information about when your coverage will , stop Signing it does not mean you agree with the plan that it's time to stop getting the care Section 7.3 Step-by-step: How to make a Level 1 Appeal to have our plan cover your care_for a Longer time If you want to ask us to cover your care for a longer period of time,you will need to use the appeals process to make this request Before you start,understand what you need to do and what the deadlines are • Follow the process.Each step in the first two levels of the appeals process is explained below. , • Meet the deadlines.The deadlines are important Be sure that you understand and follow the deadlines that apply to things you must do There are also deadlines our plan must follow (If you think we are not meeting our deadlines,you can file a complaint Section 9 of this chapter tells you how to file a complaint) • Ask for help if you need it If you have questions or need help at any time, please call Customer Service(phone numbers are on the front cover of this booklet) Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance(see Section 2 of this chapter) During a Level 1 Appeal,the Quality Improvement Organization reviews your appeal and decides whether to change the decision made by our plan. Legal When you start the appeal process by making an appeal,it Terms is called the"first level of appeal"or"Level 1 Appeal" I Step 1: Make your Level 1 Appeal: contact the Quality Improvement Organization in your state and ask for a review. You must act quickly. What is the Quality Improvement Organization? • This organization is a group of doctors and other health care experts who are paid by the Federal government These experts are not part of our plan They check on the quality of care received by people with Medicare and review plan decisions about when it's time to stop covering certain kinds of medical care How can you contact this organization? 1 • The written notice you received tells you how to reach this organization (Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2, Section 4,of this booklet) What should you ask for? • Ask this organization to do an independent review of whether it is medically appropriate for our plan to end coverage for your medical services Your deadline for contacting this organization. • You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care • If you miss the deadline for contacting the Quality Improvement Organization about your appeal,you can make your appeal directly to our plan instead For details about this other way to make your appeal,see Section 8 4 1 1 I tStep 2: The Quality Improvement Organization conducts an independent review of your case. 1 What happens during this review? • Health professionals at the Quality Improvement Organization (we will call them"the reviewers"for short)will ask you(or your representative) why you believe coverage for the services should continue You don't have to prepare anything in writing, but you may do so if you wish • The review organization will also look at your medical information, talk with your doctor,and review information that our plan has given to them 1 • During this review process,you will also get a written notice from the plan that gives our reasons for wanting to end the plan's coverage for your services 1 Legal This notice explanation is called the"Detailed Terms Explanation of iNon-Coverage." ' Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. ' What happens if the reviewers say yes to your appeal? • If the reviewers say yes to your appeal, then our plan must keep providing your covered services ' for as long as it is medically necessary. • You will have to keep paying your share of the costs(such as deductibles or copayments, if these apply) In addition,there may be limitations on your covered services(see Chapter 4 of this booklet) i What happens if the reviewers say no to your appeal? , • If the reviewers say no to your appeal,then your coverage will end on the date we have told you.Our plan will stop paying its share of the costs of this care • If you decide to keep getting the home health care,or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF)senv ices after this date when your coverage ends,then you will have to pay the full cost of this care yourself Step 4: If the answer to your Level 1 Appeal is no, you decide if you want to make another appeal. , • This first appeal you make is"Level 1"of the appeals process If reviewers say no to your Level I Appeal—and you choose to continue getting care after your coves age for the care has ended—then you can make another appeal • Making another appeal means you are going on to"Level 2"of the appeals process. Section 7.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover your care for a longer time If the Quality Improvement Organization has turned down your appeal and you choose to continue getting care after your coverage for the care has ended.then you can make a Level 2 Appeal During a Level 2 Appeal,you ask the Quality Improvement Organization to take another look at the decision they made on your first appeal Here are the steps for Level 2 of the appeal process Step 1: You contact the Quality Improvement Organization again and ask for another review. • You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 Appeal You can ask for this review only if you continued getting care after the date that your coverage for the care ended rt Step 2: The Quality Improvement Organization does a second review of your situation. ' • Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal Step 3: Within 14 days, the Quality Improvement Organization reviewers will , decide on your appeal and tell you their decision. What happens if the review organization says yes to your appeal? , • Our plan must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end Our plan must continue providing coverage for the care for , as long as it is medically necessary • You must continue to pay your share of the costs and there may be coverage limitations that apply , ' What happens if the review organization says no*2 • It means they agree with the decision they made to your Level 1 Appeal and will not change it (This is called"upholding the decision 'It is also called"turning down your appeal") • The notice you get will tell you in writing what you can do if you wish to continue with the review process It will give you the details about how to go on to the next level of appeal,which is handled by aludge Step 4: If the answer is no, you will need to decide whether you want to take your appeal further. I • There are three additional levels of appeal after Level 2, for a total of five levels of appeal If reviewers turn down your Level 2 Appeal,you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal At Level 3, your appeal is reviewed by a judge • Section 8 in this chapter tells more about Levels 3,4,and 5 of the appeals process ' Section 7.5 What if you miss the deadline for making your Level 1 Appeal? You can appeal to our plan instead As explained above in Section 7 3,you must act quickly to contact the Quality Improvement Organization to start your first appeal(within a day or two,at the most) If you miss the deadline for contacting this organization, there is another way to make your appeal If you use this other way of making your appeal, the first two levels of appeal are different ' Step-by-Step: How to make a Level 1 Alternate Appeal If you miss the deadline for contacting the Quality Improvement Organization,you can make an appeal to our plan, asking for a"fast rev iew"A fast review is an appeal that uses the fast deadlines instead of the standard deadlines Here are the steps for a Level I Alternate Appeal I Legal A"fast"review (or"fast appeal") is also called an Terms "expedited" review(or"expedited appeal") Step 1: Contact our plan and ask for a "fast review." • For details on how to contact our plan,go to Chapter 2, Section 1 and look for the section called, How to contact us when you are making an appeal about your medical care • Be sure to ask for a"fast review"This means you are asking us to give you an answer using the "fast"deadlines rather than the"standard"deadlines Step 2: Our plan does a "fast" review of the decision we made about when to stop 1 coverage for your services. ' • During this review,our plan takes another look at all of the information about your case We check to see if we were being fair and following all the rules when we set the date for ending the plan's coverage for services you were receiving • We will use the"fast"deadlines rather than the standard deadlines for giving you the answer to this review (usually, if you make an appeal to our plan and ask for a` fast review,"we are allowed to decide whether to agree to your request and give you a"fast review"But in this situation,the rules require us to give you a fast response if you ask for it) I Step 3: Our plan gives you our decision within 72 hours after you ask for a "fast , review" ("fast appeal"). • If our plan says yes to your fast appeal,it means we have agreed with you that you need services , longer,and will keep providing your covered services for as long as it is medically necessary It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end (You must pay your share of the costs and there may be coverage limitations that apply) ' • If our plan says no to your fast appeal,then your coverage will end on the date we have told you and our plan will not pay after this date Our plan will stop paying its share of the costs of this care • If you continued to get home health care,or skilled nursing facility care,or Comprehensive Outpatient Rehabilitation Facility(CORF)services after the date when we said your coverage would your coverage ends,then you will have to pay the full cost of this care yourself Step 4: If our plan says no to your fast appeal, your case will automatically go on to the next level of the appeals process. • To make sure we were being fair when we said no to your fast appeal,our plan is required to send ' your appeal to the"Independent Review Organization."When we do this, it means that you are automatically going on to Level 2 of the appeals piocess. Step-by-Step: How to make a Level 2 Alternate Appeal If our plan says no to your Level I Appeal,your case will automatically be sent on to the next level of the appeals process During the Level 2 Appeal,the Independent Review Organization reviews the decision our plan made when we said no to your"fast appeal"This organization decides whether the decision we made should be changed Legal The fonnal name for the"Independent Review ' Terms Organization' is the"Independent Review Entity."It is sometimes called the"IRE." i Step 1: We will automatically forward your case to the Independent Review Organization. • We are required to send the information for your Level 2 Appeal to the Independent Review Organization within 24 hours of when we tell you that we are saying no to your first appeal (If you think we are not meeting this deadline or other deadlines,you can make a complaint The complaint process is different from the appeal process Section 9 of this chapter tells how to make a complaint) Step 2: The Independent Review Organization does a "fast review" of your , appeal. The reviewers give you an answer within 72 hours. • The Independent Review Organization is an outside,independent organization that is hired by , Medicare This organization is not connected with our plan and it is not a government agency This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization Medicare oversees its work • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal • If this organization says yes to your appeal,then our plan must reimburse you(pay you back)for our 1 • share of the costs of care you have received since the date when we said your coverage would end We must also continue to cover the care for as long as it is medically necessary You must continue to pay your share of the costs If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services • If this organization says no to your appeal,it means they agree with the decision our plan made to your first appeal and will not change it (This is called"upholding the decision"It is also called "turning down your appeal") o The notice you get from the Independent Review Organization will tell you in writing what you can do if you wish to continue with the review process It will give you the details about how to go on to a Level 3 Appeal Step 3: If the Independent Review Organization turns down your appeal, you choose whether you want to take your appeal further. • There are three additional levels of appeal after Level 2, for a total of five levels of appeal If reviewers say no to your Level 2 Appeal,you can choose whether to accept that decision or whether to go on to Level 3 and make another appeal At Level 3,your appeal is reviewed by aludge • Section 8 in this chapter tells more about Levels 3,4,and 5 of the appeals process SECTION 8 Taking your appeal to Level 3 and beyond Section 8.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals This section may be appropriate for you if you have made a Level I Appeal and a Level 2 Appeal,and both of your appeals have been turned down If the dollar value of the item or medical service you have appealed meets certain minimum levels,you may be able to go on to additional levels of appeal if the dollar value is less than the minimum level.you cannot appeal any further If the dollar value is high enough, the written response you receive to your Level 2 Appeal will explain who to contact and what to do to ask for a Level Appeal For most situations that involve appeals,the last three levels of appeal work in much the same way Here is who handles the review of your appeal at each of these levels Level 3 Appeal A judge who works for the Federal government will review your appeal and give you an answer This judge is called an "Administrative Law Judge." • If the answer is yes,the appeals process may or may not be over-We will decide whether to appeal this decision to Level 4 Unlike a decision at Level 2(Independent Review Organization), we have the right to appeal a Level 3 decision that is favorable to you o If we decide not to appeal the decision,we must authorize or provide you with the service within 60 days after receiving the Judge's decision o If we decide to appeal the decision, we will send you a copy of the Level 4 Appeal request with any accompanying documents We may wait for the Level 4 Appeal decision before authorizing or providing the service in dispute • If the answer is no,the appeals process may or may not be over. o If you decide to accept this decision that turns down your appeal,the appeals process is over o If you do not want to accept the decision,you can continue to the next level of the review process If , the admimstratrve law judge says no to your appeal,the notice you get will tell you what to do next if you choose to continue with your appeal Level 4 Appeal The Medicare Appeals Council will review your appeal and give you an answer The Medicare Appeals Council works for the Federal government. • If the answer is yes,or if the Medicare Appeals Council denies our request to review a favorable Level 3 Appeal decision,the appeals process may or may not be over- We will decide whether to appeal this decision to Level 5 Unlike a decision at Level 2 (independent Review Organization), we have the right to appeal a Level 4 decision that is favorable to you o If we decide not to appeal the decision,we must authorize or provide you with the service within 60 days after receiving the Medicare Appeals Council's decision o Ifwe decide to appeal the decision,we will let you know in writing. • If the answer is no or if the Medicare Appeals Council denies the review request,the appeals process may or may not be over o If you decide to accept this decision that turns down your appeal,the appeals process is over o If you do not want to accept the decision,you might be able to continue to the next level of the t review process It depends on your situation If the Medicare Appeals Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal If the rules allow you to go on,the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal Level rJ Appeal Aludge at the Federal District Court will review your appeal This is the last stage of the appeals process • This is the last step of the administrative appeals process. MAKING COMPLAINTS , SECTION 9 How to make a complaint about quality of care, , waiting times, customer service, or other concerns If your problem is about decisions related to benefits,coverage,or payment,then this section is notor you Instead,you need to use the ' process for coverage decisions and appeals Go to Section 4 of this chapter Section 9.1 What kinds of problems are handled by the complaint process? This section explains how to use the process for making complaints The complaint process is used for certain types ' of problems only This includes problems related to quakily of care waiting times,and the customer sery ice you receive Here are examples of the kinds of problems handled by the complaint process. ' If you have any of these kinds of problems. � you can make a comp►laint" Ousilty of your medical care • Are you unhappy with the quality of the care you have received(including care in the hospital)? Respecting your privacy • Do you believe that someone did notrespect your right to privacy orshared 1 information about you thatyou feel should be confidential? Disrespect, poor customer service, or other negative behaviors j Has someone b eam rude or disrespectful to you? • Are you unhappy with how our Member Sery ices has dealt with you? • Do you feel you are being encouraged to leave ourp[an? Waiting times • Are you having trouble getting an appointment,orwaiting too long to get it? ' • Have you been keptwaiting too long by doctors orotherheaith professionals? Or by Member Services or other staff at our p lan? • Examples include waitingtoo tong on the phone,in the waiting room,or in the i eXamroom. 1 Cleanliness • Are you unhappy with the cleanliness orcondition of a clinic,hospital,or ' doctor's office? Information you get from our plan • Do you believe we have not given you a notice that we are required to give? • Do you think written information we have given you is hard to understand? The next page has more e=gples o,f passible Amonsformakft a camptab t Possible complaints , {continued} These types of complaints are all related to the timeliness of our actions related to coverage decisions and appeals The process of asking for a coverage decision and makingappeals is explained in sections4-8 of this chapter. If you are asking for a decision or making an appeal,you use thatprocess,not the complaint process. However, if you have already asked for a coverage decision ormade an appeal,and you think that our p lan is not responding quickly enough,you can also make a complaint about our slowness. Here are examples: G • If you have asked us to give you a"`fast response" for a coverage decision or appeal,and we have said we will not,you can makea i complaint. • If you believe our plan is not meeting the deadlines for giving you a coverage decision or an answer to an appeal you hay a made, you can ' make complaint. a0 When a coy erage decision we made is reviewed and our plan is told that we must cover or reimburse you for certain medical services,there are t deadlines that apply.If you think we are not meeting these deadlines,you can make a cocrip laant. , When our plan does not give you a decision on time, we are required to a z forward your case to the Independent Review Organization.If we do not do that within the required deadline,you can make a complaint. E ' Section 9.2 The formal name for "making a complaint" is "filing a grievance" Legal • What this section calls a"complaint"is also called a Terms «grievance." • Another term for"making a complaint"is"filing a grievance." ' • Another way to say"using the process for complaints" is"using the process for filing a grievance." Section 9.3 Step-by-step: Making a complaint Step 1: Contact us promptly — either by phone or in writing. • Usually, calling Customer Service is the first step. If there is anything else you need to ' do, Customer Service will let you know. Customer Service may be reached by calling 1- 888-901-4600 or TTY 711 Monday through Friday, 8 a.m to 8 p in (November 15 through February 28 we offer extended hours from 8 a in to 8 p in. seven days a week) • If you do not wish to call(or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our forma! procedure for answering grievances Here's how it works• o For this process your grievance requests must be in writing, and mailed to Group Health Medicare Customer Service Medicare Grievance, P.O Box 34590, Seattle WA 98124-1590 or fax: 206-901-6205, or From %N%vx% ghc or,-, click "Contact Us" or you may call the number in Chapter 2 of this booklet to contact Group Health Customer Service. We must address your grievance as quickly as your case requires based on your health Status,but no later than 30 days after receiving your complaint We may extend the time frame by up to 14 days if you ask for the extension,or if we justify a need for additional information and the delay is in your best interest • Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 days after you had the problem you want to complain about • If you are making a complaint because we denied your request for a "fast response" to a coverage decision or appeal, we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours. Legal What this section calls a"fast complaint" is also called a Terms "fast grievance." Step 2: We look into your complaint and give you our answer. • If possible, we will answer you right away. If you call us with a complaint, we may be , able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. • Most complaints are answered in 30 days, but we may take up to 44 days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint • If we do not agree with some or all of your complaint or don't take responsibility for the ' problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not. Section 9.4 You can also make complaints about quality of care to the ® Quality Improvement Organization ' You can make your complaint about the quality of care you received to our plan by using the step-by-step process outlined above. When your complaint is about quality of care, you also have two extra options* • You can make your complaint to the Quality Improvement Organization. If you ' prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan) To find the name, address, and phone number of the Quality Improvement Organization in your state, look in Chapter 2, Section 4, of this booklet If you make a complaint to this organization, we will work together with them to resolve your complaint. • Or, you can make your complaint to both at the same time If you wish, you can make I your complaint about quality of care to our plan and also to the Quality Improvement Organization. ' ' Chapter 8. Ending your membership in the plan ' SECTION I Introduction 93 Section 1.1 This chapter focuses on ending your membership in our plan 93 SECTION 2 When can you end your membership in our plan? 93 Section 2.1 You can end your membership during the Annual Enrollment Period 93 Section 2.2 You can end your membership during the Medicare Advantage Open Enrollment Period, but your plan choices are more limited 94 Section 2.3 In certain situations, you can end your membership during a Special Enrollment Period 94 Section 2.4 Where can you get more information about when you can end your membership? 95 ' SECTION 3 How do you end your membership in our plan? 95 Section 3.1 Usually, you end your membership by enrolling in another plan 95 SECTION 4 Until your membership ends,you must keep getting your medical services through our plan 96 ' Section 4.1 Until your membership ends,you are still a member of our plan 96 SECTION 5 Our plan must end your membership in the plan in certain situations 96 Section 5.1 When must we end your membership in the plan? 96 Section 5.2 We cannot ask you to leave our plan for any reason related to your health 97 ' Section 5.3 You have the right to make a complaint if we end your membership in our plan 97 SECTION 1 Introduction , Section 1.1 This chapter focuses on ending your membership in our plan r Ending your membership in our plan may be voluntary(your own choice)or involuntary(not your own choice) • You might leave our plan because you have decided that you want to leave ' o There are only certain times during the year,or certain situations,when you may voluntarily end your membership in the plan Section 2 tells you when you can end your membership in the plan. o The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing Section 3 tells you how to end your membership in each situation ' • There are also limited situations where you do not choose to leave,but we are required to end your membership Section 5 tells you about situations when we must end your membership If you are leaving our plan,you must continue to get your medical care through our plan until your membership ' ends SECTION 2 When can you end your membership in our plan? ' You may end your membership in our plan only during certain times of the year,known as enrollment periods All members have the opportunity to leave the plan during the Annual Enrollment Period and during the Medicare ' Advantage Open Enrollment Period In certain situations,you may also be eligible to leave the plan at other times of the year Section 2.1 You can end your membership during the Annual Enrollment Period :] You can end your membership during the Annual Enrollment Period (also known as the"Annual Coordinated , Election Period") This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year • When is the Annual Enrollment Period?This happens every year from November 15 to December 31 ' • What type of plan can you switch to during the Annual Enrollment Period? During this time, you can review your health coverage and your prescription drug coverage You can choose to keep your current coverage or make changes to your coverage for the upcoming year If you decide to change to a new plan,you can choose any of the following types of plans o Another Medicare Advantage plan (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs) I o Original Medicare with a separate Medicare prescription drug plan o —or—Original Medicare without a separate Medicare prescription drug plan ' • When will your membership end?Your membership will end when your new plan's coverage begins on January 1 ' Section 2.2 You can end your membership during the Medicare Advantage Open Enrollment Period, but your plan choices are more limited ' You have the opportunity to make one change to your health coverage during the Medicare Advantage Open Enrollment Period • When is the Medicare Advantage Open Enrollment Period?This happens every year from January 1 to March 31 • What type of plan can you switch to during the Medicare Advantage Open Enrollment Period? During this time, you can make one change to your health plan coverage However,you may not add or drop prescription drug coverage during this time Since you are currently enrolled in a Medicare Advantage plan that does not include prescription drug coverage, this means that you can enroll in either o Another Medicare Advantage plan that does not include prescription drug coverage. o —or—Original Medicare (You cannot enroll in a separate prescription drug plan during the Medicare Advantage Open Enrollment Period) ' • When will your membership end?Your membership will end on the first day of the month after we get your request to change plans Section 2.3 In certain situations, you can end your membership during a ' Special Enrollment Period ' In certain situations,members of our plan may be eligible to end their membership at other times of the year This is known as a Special Enrollment Period • Who is eligible for a Special Enrollment Period?If any of the following situations apply to you,you are eligible to end your membership during a Special Enrollment Period These are just examples for the full list you can contact the plan,call Medicare,or visit the Medicare website (http//www medicare gov) o Usually, when you have moved o If you have Medicaid o if you live in a facility,such as a nursing home. • When are Special Enrollment Periods?The enrollment periods vary depending on your situation. • What can you do?If you are eligible to end your membership because of a special situation,you can choose to change both your Medicare health coverage and prescription drug coverage This means you ' can choose any of the following types of plans o Another Medicare Advantage plan (You can choose a plan that covers prescription drugs or one that does not cover prescription drugs) ' o Original Medicare with a separate Medicare prescription drug plan o —or—Original Medicare without a separate Medicare prescription drug plan • When will your membership end?Your membership will usually end on the first day of the month after we receive your request to change your plan Section 2.4 Where can you get more information about when you can end , your membership? If you have any questions or would like more information on when you can end your membership ' • You can call Customer Service (phone numbers are on the cover of this booklet). • You can find the information in the Medicare & You 2010 Handbook. o Everyone with Medicare receives a copy of Medicare & You each fall Those new to Medicare receive it within a month after fist signing up. o You can also download a copy from the Medicare website (http //hkwu medicare go ). Or, you can order a printed copy by calling Medicare at the number below. • You can contact Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 ' days a week. TTY users should call 1-877-486-2048. SECTION 3 How do you end your membership in our plan? , Section 3.1 Usually, you end your membership by enrolling in another plan Usually,to end your membership in our plan, you simply enroll in another health plan during one of the enrollment periods(see Section 2 for information about the enrollment periods) One exception is when you want to switch from our plan to Original Medicare without a Medicare prescription drug plan In this situation,you must contact Group Health Customer Service and ask to be disenrolled from our plan The table below explains how you should end your membership in our plan Fplan ke to switch from This is what you should do: ' • Another Medicare Advantage • Enroll in the new Medicare Advantage plan. , plan. You will automatically be disenrolled from our plan when ' your new plan's coverage begins • Original Medicare with a • Enroll in the new Medicare prescription drug ' separate Medicare plan. prescription drug plan. You will automatically be disenrolled from our plan when ' your new plan's coverage begins tIf you would like to switch from This is what you should do: our plan to: • Original Medicare without a • Contact Customer Service and ask to be disenrolled separate Medicare prescription drug from the plan(phone numbers are on the cover of this plan booklet). • You can also contact Medicare at 1-900-MEDICARE(1- 800-633-4227) and ask to be disenrolled TTY users should call 1-877-486-2048 ' • You will be disenrolled from our plan when your coverage in Original Medicare begins. ' SECTION 4 Until your membership ends, you must keep getting your medical services through our plan Section 4.1 Until your membership ends, you are still a member of our ' plan If you leave our plan,it may take time before your membership ends and your new Medicare coverage goes into effect (See Section 2 for information on when your new coverage begins)During this time you must continue to ' get your medical care through our plan • If you are hospitalized on the day that your membership ends,you will usually be covered by our plan until you are discharged(even if you are discharged after your new health coverage begins) SECTION 5 Our plan must end your membership in the plan in ' certain situations ' Section 5.1 When must we end your membership in the plan? Our plan must end your membership in the plan if any of the following happen: • if you do not stay continuously enrolled in Medicare Part A and Part B ' • If you move out of our service area for than six months o If you move or take a long trip,you need to call Customer Service to find out if the place you are ' moving or traveling to is in our plan's area o Chapter 3 and Chapter 4 give more information about getting care when you are away from the service area ' o If you have been a member of our plan continuously since before January 1999 and you were living outside of our service area before January 1999,you may continue your membership However, if you move and your move is to another location that is outside of our service area,you will be disenrolled from our plan. 1 • If you intentionally give us incorrect information when you are enrolling in our plan and that information ' affects your eligibility for our plan. • If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan ' o We cannot make you leave our plan for this reason unless we get permission from Medicare first • If you let someone else use your membership card to get medical care , o If we end your membership because of this reason,Medicare may have your case investigated by the Inspector General • If you do not pay the plan premiums for 60 days ' o We must notify you in writing that you have 60 days to pay the plan premium before we end your membership ' Where can you get more information? If you have questions or would like more information on when we can end your membership , • You can call Customer Service for more information(phone numbers are on the cover of this booklet) Section 5.2 We cannot ask you to leave our plan for any reason related to your health , What should you do if this happens? If you feel that you are being asked to leave our plan because of a health-related reason,you should call Medicare at ' 1-800-MEDICARE(1-800-633-4227) TTY users should call 1-877-486-2048 You may call 24 hours a day, 7 days a week Section 5.3 You have the right to make a complaint if we end your ' membership in our plan If we end your membership in our plan,we must tell you our reasons in writing for ending your membership We must also explain how you can make a complaint about our decision to end your membership You can also look in ' Chapter 7, Section 9 for information about how to make a complaint r Chapter 9. Legal notices SECTION] Notice about governing law 98 SECTION 2 Notice about nondiscrimination 98 SECTION 3 Subrogation and Reimbursement Rights 98 SECTION 1 Notice about governing law Many laws apply to this Evidence of Coverage and some additional provisions may apply because they are required ' by law This may affect your rights and responsibilities even if the laws are not included or explained in this document The principal law that applies to this document is Title XV1II of the Social Security Act and the regulations created under the Social Security Act by the Centers for Medicare&Medicaid Services,or CMS In addition, other Federal laws may apply and,under certain circumstances,the laws of the state you live in SECTION 2 Notice about nondiscrimination We don't discriminate based on a person's race,disability,religion,sex,health,ethnicity,creed,age,or national ' origin All organizations that provide Medicare Advantage Plans, like our plan,must obey Federal laws against discrimination,including Tale VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973,the Age Discrimination Act of 1975,the Americans with Disabilities Act,all other laws that apply to organizations that get Federal funding,and any other laws and rules that apply for any other reason ' SECTION 3 Subrogation and Reimbursement Rights The benefits under this Agreement will be available to a Member for injury or illness caused by another party, subject to the exclusions and limitations of this Agreement If Group Health provides benefits under this Agreement for the treatment of the injury or illness,Group Health will be subrogated to any rights that the Member may have to recover compensation or damages related to the injury or illness This section more fully describes Group Health's 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. "Group Health's Medical Expenses"means the expenses incurred and the reasonable value of the benefits provided by Group Health 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,Group Health shall have the right to recover Group Health'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/undennsured motorist coverage This right is commonly referred to as"subrogation"Group Health shall be subrogated to and may enforce all rights of the Injured Person to the extent of Group Health's Medical Expenses Group Health'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 However, in the case of Medicare Advantage Members,Group Health's right of subrogation shall be the full amount of Group Health's Medical Expenses and is limited only as required by Medicare Subject to the above provisions, 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 party's liability insurance or uninsured/undernisured motorist funds, then Group Health's Medical Expenses provided or to be provided to the Injured Person are secondary, not primary Asa condition of receiving benefits under the Agreement,the Injured Person agrees that acceptance of Group Health services is constructive notice of this provision in its entirety and agrees to reimburse Group Health for the benefits the Injured Person received as a result of the events causing the inj ury The Injured Person and his/her agents shall cooperate fully with Group Health in its efforts to collect Group Health's Medical Expenses This cooperation includes,but is not limited to,supplying Group Health with information about any third parties,defendants andlor insurers related to the Injured Person's claim and informing Group Health of any settlement or other payments relating to the Injured Person's injury The Injured Person and his/her agents shall permit Group Health,at Group Health'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 Group Health to initiate its own direct action for reimbursement or subrogation,including,but not limited to,billing the Injured Person directly for Group Health's Medical Expenses The Injured Person and his/her agents shall do nothing to prejudice Group Health's subrogation and reimbursement rights The Injured Person shall promptly notify Group Health of any tentative settlement with a third party and shall not settle a claim without protecting Group Health's interest If the Injured Person falls to cooperate fully with Group Health in recovery of Group Health's Medical Expenses,the Injured Person shall be responsible for directly reimbursing Group Health for Group Health's Medical Expenses and Group Health retains the right to bill the Injured Person directly for Group Health's Medical Expenses To the extent that the Injured Person recovers funds from any source that may serve to compensate for medical injuries or medical expenses, the Injured Person agrees to hold such monies in trust or in their possession until Group Health's subrogation and reunbursement rights are fully determined Group Health shall not pay any attorneys' fees or collection costs to attorneys representing the Injured Person unless there is a written fee agreement signed by Group Health prior to any collection efforts When reasonable collection costs have been incurred with Group Health's prior written agreement to recover Group Health's Medical Expenses, there shall be an equitable apportionment of such collection costs between Group Health and the Injured Person subject to a maximum responsibility of Group Health equal to one-third of the amount recovered on behalf of Group Health Under no circumstance will Group Health pay legal fees for services which were not reasonably and necessarily incurred to secure recovery,which do not benefit Group Health or where no written fee agreement has been entered into with Group Health To the extent the provisions of this Subrogation and Reimbursement section are deemed governed by ERISA, ' implementation of this section shall be deemed a part of claims administration under the Agreement and Group Health shall therefore have sole discretion to interpret its terms Chapter 10. Definitions of important words Appeal—An appeal is something you do if you disagree with a decision to deny a request for health care services or payment for services you already received You may also make an appeal if you disagree with a decision to stop services that you are receiving For example,you may ask for an appeal if our Plan doesn't pay for an item or service you think you should be able to receive Chapter 7 explains appeals, including the process involved in making an appeal Benefit Period—For both our Plan and Original Medicare,a benefit period is used to determine coverage for inpatient stays in hospitals and skilled nursing facilities A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility The benefit period ends when you haven't been an inpatient at any hospital or SNF for 60 days in a row If you go to the hospital(or SNF)after one benefit period has ended,a new benefit period begins There is no limit to the number of benefit periods you can have The type of care that is covered depends on whether you are considered an ninatient for hospital and SNF stays You must be admitted to the hospital as an inpatient,not Just under observation You are an inpatient in a SNF only if your care in the SNF meets certain standards for skilled level of care Specifically,in order to be an inpatient in a SNF,you must need daily skilled-nursing or skilled-rehabilitation care,or both Centers for Medicare&Medicaid Services(CMS)—The Federal agency that runs Medicare Chapter 2 explains how to contact CMS Comprehensive Outpatient Rehabilitation Facility(CORF)—A facility that mainly provides rehabilitation services after an illness or injury,and provides a variety of services including physician's services,physical therapy, social or psychological services, and outpatient rehabilitation Cost-sharing—Cost-sharing refers to amounts that a member has to pay when services are received It includes any combination of the following three types of payments (1)any deductible amount a plan may impose before services are covered,(2)any fixed"copayment"amounts that a plan may require be paid when specific services are received, or(3)any"coinsurance"amount that must be paid as a percentage of the total amount paid for a service Covered Services—The general term we use to mean all of the health care services and supplies that are covered by our Plan Creditable Prescription Drug Coverage—Prescription drug coverage(for example,from an employer or union) that is expected to cover,on average,at least as much as Medicare's standard prescription drug coverage People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later Custodial Care—Care for personal needs rather than medically necessary needs Custodial care is care that can be provided by people who don't have professional skills or training This care includes help with walking,dressing, bathing,eating,preparation of special diets,and taking medication Medicare does not cover custodial care unless it is prov ided as other care you are getting in addition to daily skilled nursing care and/or skilled rehabilitation services Customer Service—A department within our Plan responsible for answering your questions about your membership, benefits,grievances,and appeals See Chapter 2 for information about how to contact Customer Service Deductible—The amount you must pay before our Plan begins to pay its share of your covered medical services Disenroll or Disenrollment—The process of ending your membership in our Plan Disenrollment may be voluntary (your own choice)or involuntary(not your own choice) Durable Medical Equipment—Certain medical equipment that is ordered by your doctor for use in the home Examples are walkers,wheelchairs,or hospital beds Emergency Care—Covered services that are 1)rendered by a provider qualified to furnish emergency services, and 2)needed to evaluate or stabilize an emergency medical condition. Evidence of Coverage(EOC)and Disclosure Information—This document,along with your enrollment form and any other attachments,riders,or other optional coverage selected, which explains your coverage, what we must do, your rights,and what you have to do as a member of our Plan Grievance-A type of complaint you make about us or one of our network providers, including a complaint concerning the quality of your care This type of complaint does not involve coverage or payment disputes Home Health Aide—A home health aide provides services that don't need the skills of a licensed nurse or therapist, such as help with personal care(e g,bathing, using the toilet,dressing,or carrying out the prescribed exercises) Home health aides do not have a nursing license or provide therapy Home Health Care—Skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury Covered services are listed in the Benefits Chart in Chapter 4 under the heading "Home health agency care"If you need home health care services,our plan will cover these services for you provided the Medicare coverage requirements are met Home health care c an include services from a home health aide if the services are part of the home health plan of care for your illness or injury They aren't covered unless you are also getting a covered skilled service Home health services don't include the services of housekeepers, food service arrangements,or full-time nursing care at home Hospice care—A special way of caring for people who are terminally ill and providing counseling for then families Hospice care is physical care and counseling that is given by a team of people who are part of a Medicare- certified public agency or private company Depending on the situation, this care may be given in the home,a hospice facility,a hospital,or a nursing home Care from a hospice is meant to help patients in the last months of life by giving comfort and relief from pain The focus is on care,not cure For more information on hospice care visit vvnvN mcdicaie yov and under"Search Tools"choose"Find a Medicare Publication"to view or download the publication"Medicare Hospice Benefits" Or, call 1-800-MEDICARE(1-800-633-4227 TTY users should call 1- 877-486-2048) Inpatient Care—Health care that you get when you are admitted to a hospital Medically Necessary—Dings, services,or supplies that are proper and needed for the diagnosis or treatment of your medical condition,are used for the diagnosis,direct care,and treatment of your medical condition, meet the standards of good medical practice in the local community, and are not mainly for your convenience or that of your doctor Medicare—The Federal health insurance program for people 65 years of age or older,some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant) Medicare Advantage(MA) Plan—Sometimes called Medicare Part C A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A(Hospital)and Part B(Medical)benefits A MA plan offers a specific set of health benefits at the same premium and level of cost-sharing to all people with Medicare who lime in the service area covered by the plan Medicare Advantage Organizations can offer one or more Medicare Advantage plan in the same service area A Medicare Advantage plan can be an HMO,PPO,a Private Fee-for-Service(PFFS)plan,or a Medicare Medical Savings Account(MSA)plan In most cases,Medicare Advantage plans also offer Medicare Part D(prescription drug coverage) These plans are called Medicare Advantage Plans with Prescription Drug Coverage Our plan does not offer Medicare prescription drug coverage Everyone who has Medicare Part A and Part B is eligible to join any Medicare Health Plan that is offered in their area,except people with End-Stage Renal Disease(unless certain exceptions apply) Medicare Prescription Drug Coverage(Medicare Part D)—Insurance to help pay for outpatient prescription drugs,vaccines, biologicals,and some supplies not covered by Medicare Part A or Part B "Medigap"(Medicare Supplement Insurance) Policy—Medicare supplement insurance sold by private insurance companies to fill"gaps"in Original Medicare Medigap policies only work with Original Medicare (A Medicare Advantage plan is not a Medigap policy) Member(Member of our Plan,or"Plan Member")—A person with Medicare who is eligible to get covered sery ices,who has enrolled in our Plan and whose enrollment has been confirmed by the Centers for Medicare& Medicaid Services(CMS) Network Provider—"Provider"is the general term we use for doctors,other health care professionals,hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services We call them"network providers"when they have an agreement with our Plan to accept our payment as payment in full,and in some cases to coordinate as well as provide covered services to members of our Plan Our Plan pays network providers based on the agreements it has with the providers or if the providers agree to provide you with plan-covered services Network providers may also be referred to as"plan providers" Optional Supplemental Benefits—Non-Medicare-covered benefits that can be purchased for an additional premium and are not included in your package of benefits If you choose to have optional supplemental benefits,you may have to pay an additional premium You must voluntarily elect Optional Supplemental Benefits in order to get them Organization Determination—The Medicare Advantage organization has made an organization determination when it,or one of its providers,makes a decision about whether services are covered and how much you have to be paid for covered services Original Medicare("Traditional Medicare"or"Fee-for-service"Medicare)—Original Medicare is offered by the government, and not a private health plan like Medicare Advantage plans and prescription drug plans Under Original Medicare,Medicare services are covered by paying doctors, hospitals and other health care providers payment amounts established by Congress You can see any doctor,hospital,or other healthcare provider that accepts Medicare You must pay the deductible Medicare pays its share of the Medicare-approved amount,and you pay your share Original Medicare has two parts Part A(Hospital Insurance)and Part B(Medical Insurance)and is available everywhere in the United States Out-of-network Provider or Out-of-network Facility—A provider or facility with which we have not arranged to coordinate or provide covered services to members of our Plan Out-of-network providei s are providers that are not employed,owned,or operated by our Plan or are not under contract to deliver covered services to you Using out-of- network providers or facilities is explained in this booklet in Chapter 3. Part C—see"Medicare Advantage(MA) Plan". Part D—The voluntary Medicare Prescription Drug Benefit Program (For ease of reference, we will refer to the prescuption drug benefit program as Part D) Primary Care Provider(PCP)—A health care professional you select to coordinate your health care Your PCP is responsible for providing or authorizing covered services while you are a plan member Chapter 3 tells more about PCPs Preferred Provider Organization Plan—A Preferred Provider Organization plan is an MA plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount A PPO plan must cover all plan benefits whether they are received from network or out-of-network providers Member cost-sharing will generally be higher when plan benefits are received from out-of-network providers Prior Authorization—Approval in advance to get services Some in-network medical services are covered only if your doctor or other network provider gets"prior authorization"from our Plan Covered services that need prior authorization are marked in the Benefits Chart in Chapter 4 Quality Improvement Organization(QIO)—Groups of practicing doctors and other health care experts that are paid by the Federal government to check and improve the care given to Medicare patients They must review your complaints about the quality of care given by Medicare Providers See Chapter 2 for information about how to contact the QIO in your stale and Chapter 7 for information about making complaints to the QIO Rehabilitation Services—These services include physical therapy, speech and language theiapy,and occupational therapy Service Area—"Service area"is the geographic area approved by the Centers for Medicare&Medicaid Services (CMS)within which an eligible individual may enroll in a certain plan, and in the case of network plans,where a network must be available to provide services Skilled nursing facility(SNF)care—A level of care in a SNF ordered by a doctor that must be given or supervised by licensed health care professionals It may be skilled nursing care,or skilled rehabilitation services,or both Skilled nursing care includes services that require the skills of a licensed nurse to perform or supervise Skilled rehabilitation services are physical therapy,speech therapy,and occupational therapy Physical therapy includes exercise to improve the movement and strength of an area of the body, and training on how to use special equipment,such as how to use a walker or get in and out of a wheelchair Speech therapy includes exercise to regain and strengthen speech and/or swallowing skills Occupational lhei apy helps you learn how to perform usual daily activities, such as eating and dressing by yourself Supplemental Security Income(SSI)—A monthly benefit paid by the Social Security Administration to people with Innited income and resources who are disabled,blind,or age 65 and older SSI benefits are not the same as Soual Security benefits Urgently Needed Care—Urgently needed care is a non-emergency situation when a you need medical care right away because of an illness, injury,or condition that you did not expect or anticipate,but your health is not in serious danger Because of the situation, it isn't reasonable for you to obtain medical tale from a network provider i Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6F 1. SUBJECT: WASHINGTON DENTAL SERVICE ADMINISTRATIVE SERVICES CONTRACT - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign the Washington Dental Services 2010-2011 Administrative Services Agreement. The City is self-insured for its dental program. The 2010 WDS contract reflects a 5.5% increase in administrative fees. The annual cost for 2010 for our administrative services contract is $53,654, and claims cost is projected at $930,502, for a total cost budgeted in the Health & Wellness Fund of $984,156. 3. EXHIBITS: 2010-2011 WDS Administrative Services Agreement 4. RECOMMENDED BY: Operations Committee (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds DISCUSSION: ACTION: I Washington Dental Service ,j Dental Care Service Contract WDS Program #00611 Name of Group City of Kent Herein called Group, agrees to a Dental Care Service Contract with Washington Dental Service, herein called WDS The effective date of this Contract shall be 12 01 a m Pacific Standard Time on the first day of January, 2009 at Seattle, Washington, and shall run for a period of one year This Contract is issued and delivered in the state of Washington and is governed by Washington state laws It is subject to the terms set forth on the subsequent pages, appendices and amendments, which are a part of this Contract Accepted by: Accepted by: City of Kent Washington Dental Service Post Office Box 75983 Seattle,Washington 98175-0983 By BY Title Title S for Vic resident Underwriting &Actuarial Date Date November 25, 2008 ' 2009-01-00611-NC-01 — 1 — Article I— Definitions For the purpose of this Contract, the following definitions shall apply: 1 01 "Administrative Fee" means the monthly amount payable by Group as designated in Appendix E 1 02 "Benefit Period" means the period beginning January 1 and ending December 31 1 03 'Contract" means this agreement between WDS and Group This Contract constitutes the entire Contract between the parties and supersedes any prior agreement, understanding or negotiation between the parties 1 04 "Contract Term" means the time period specified in Appendix E 1 05 "Covered Dental Benefits" means those dental services that are covered under this Contract, subject to the Limitations set forth in Appendix C 1 06 "Delta Dental Non-PPO Dentist" means any licensed Dentist who is a Delta Dental Participating Dentist and has not entered into a PPO Provider Agreement with a participating plan 1 07 "Delta Dental PPO Dentist" means a Delta Dental Participating Dentist who has agreed to render services and receive payment in accordance with the terms and conditions of a written Delta Dental PPO Dentist Agreement between the participating plan and such Dentist 1 08 "Delta Dental Participating Dentist" means a licensed Dentist who has agreed to render services and receive payment in accordance with the terms and conditions of a written Delta Dental Participating Dentist Agreement between WDS/Delta Dental and such Dentist , 1 09 "Delta Dental Participating Dentist Filed Fee" means the approved fee accepted by WDS for a specific dental procedure performed by a Delta Dental Participating Dentist Each Delta Dental Participating Dentist has agreed to accept such approved fees as payment in full 1 10 "Dentist" means a licensed Dentist legally authorized to practice dentistry at the time and in the place services are performed This Contract provides for covered services only if those services are performed by or under direction of a licensed Dentist or other WDS-approved Licensed Professional A"Licensed Dentist' does not mean a dental mechanic or any other type of dental technician 1 11 "Eligibility Date" means the date on which an Eligible Person's benefits become effective under the terms of this Contract 1 12 "Eligible Dependent" means any dependent of an Eligible Employee who meets the conditions of eligibility set forth in Appendix B 1 13 "Eligible Employee" means any employee who meets the conditions of eligibility set forth in Appendix A. 1 14 "Eligible Person" means an Eligible Employee or an Eligible Dependent 1 15 "Emergency Examination" means otherwise covered dental care services medically necessary to evaluate ' and treat an emergency dental condition 1 16 "Exclusions" means those dental services that are not a contract benefit set forth in Appendix C and all other services not specifically included as a Covered Dental Benefit set forth in Appendix C 1 17 "Filed Fee" means the approved fee accepted by WDS for a specific dental procedure performed by a Participating Dentist submitting that fee and performing the dental service 1 18 "Full-time Employment" means a minimum of 80 hours worked by an employee each month 1 19 "Group" means the employer or entity that is contracting for dental benefits for its employees 1 20 "Licensed Professional" means an individual legally authorized to perform services as defined in their license Licensed Professional includes, but is not limited to a denturist, hygienist and radiology technician 1 21 "Limitations" means those dental services that are subject to restricting conditions set forth in Appendix C 2009-01-00611-NC-01 --2 -- 1 22 "Maximum Allowable Fees' means the maximum dollar amount that will be allowed toward the reimbursement for any service provided for a Covered Dental Benefit 123 "Nonparticipating Dentist" means a licensed Dentist who has not agreed to render services and receive payment in accordance with the terms and conditions of a written Participating Dentist Agreement between WDS and such Dentist 1 24 "Not a Paid Covered Benefit" refers to any dental procedure that, under some circumstances, would be covered by WDS but is not covered under other conditions, examples of which are listed in Appendix C 1 25 "Payment Level" means the applicable percentage of Maximum Allowable Fees for Covered Dental Benefits that shall be paid by WDS as set forth in Appendix D 126 "Plan" means a Group contract that provides for coordination of benefits and contains a provision stating what benefits from that contract and other sources are to be recognized under the coordination provision Each such source shall be defined as a "Plan " 1 27 "Qualified Medical Child Support Order(QMCSO)" means an order issued by a court under which an employee must provide medical coverage for a dependent child QMCSO's are often issued, for example, following a divorce or legal separation 1 28 "Specialist" means a licensed Dentist who has successfully completed an educational program accredited by the Commission of Dental Accreditation, two or more years in length, as specified by the Council on Dental Education or be diplomates of an American Dental Association recognized certifying board 1 29 "WDS" means Washington Dental Service, a nonprofit corporation incorporated in Washington state Washington Dental Service is a member of the Delta Dental Plans Association Article II—Eligibility 201 Every person who meets the conditions of eligibility as set forth in Appendix A or Appendix B is eligible for dental benefits for the purposes of this Contract 202 Group eligibility shall be submitted to WDS prior to the beginning of each monthly eligibility period Article III—Monthly Payment 301 The monthly Administrative Fee, to be remitted fully by Group, is as set forth in Appendix E 302 Group is required to contribute 94 percent of the employee premium with the and 86 percent of the dependent premium with the employee contributing any portion not covered by Group 303 Initial Administrative Fee shall be paid in advance of the effective date of this Contract Subsequent Administrative Fees shall be paid to WDS on the first day of each calendar month for which benefits are to be provided No person shall be entitled to benefits under this Contract during any month for which Administrative Fee payment has not been received by WDS 304 Payment of Administrative Fee is due on or before the first day of the month If payment is not received by the 15th of the month, a late fee of one percent per month may be incurred If payment is not received within 30 days WDS may give written notice that payment is due and may, at its option, terminate all benefits and be released from all further obligations as set forth in Article X entitled "Notice and Termination " 305 WDS shall accept retroactive additions to eligibility (payments)that are received by WDS within 60 days of the requested effective date Exceptions may be made at the discretion of WDS on a case-by-case basis 306 WDS shall accept retroactive terminations of eligibility (credits)that are received by WDS within 60 days of the requested termination date, or to the end of the month of the last paid claim of termed subscriber, whichever is later 307 WDS shall not be obligated to refund paid claims for treatment from providers when the treatment was performed in good faith that eligibility was current and accurate at the time of treatment Exceptions may be made at the discretion of WDS on a case-by-case basis 2009-01-00611-NC-01 --3 -- Article IV—Benefits Provided, Limitations and Exclusions 401 Covered Dental Benefits, Limitations and Exclusions are described in Appendix C and are subject to the program maximum and deductible, as described in Appendix D 402 The amounts payable by WDS for Covered Dental Benefits provided to an Eligible Person by a Delta Dental Participating Dentist in the state of Washington are described in Appendix D, Method of Payment for Delta Dental Non-PPO Dentists 403 The amounts payable by WDS for Covered Dental Benefits provided to an Eligible Person by a Delta Dental PPO Dentist in the state of Washington are as set forth in Appendix D, Method of Payment for Delta Dental PPO Dentists 404 The amounts payable by WDS for Covered Dental Benefits provided to an Eligible Person by a Dentist who is not a Delta Dental Participating Dentist in the state of Washington shall be based on the applicable percentage, provided in Appendix D, Method of Payment for Delta Dental Non-PPO Dentists This shall be applied to the lesser of WDS's Maximum Allowable Fees for Nonparticipating Dentists, or such Dentist's actual charges 405 The amounts payable by WDS for Covered Dental Benefits provided to an Eligible Person by a Dentist outside of the state of Washington shall be based on the applicable percentage, provided in Appendix D, Method of Payment for Delta Dental PPO Dentists This will be applied to the lesser of WDS's Maximum Allowable Fees for out-of-state Dentists, or such Dentist's actual charges 406 WDS shall not be obligated to pay for treatment performed if claim forms are submitted for payment more than six months after the date of such treatment For orthodontia claims, the initial banding date is the treatment date considered in the timely filing 407 If there are two or more professionally acceptable plans of dental treatment, WDS will pay the appropriate percentage of the lowest fee The remaining amount will be the patient's responsibility 408 Payment for services provided by a Delta Dental Participating Dentist shall be made directly to the Dentist Contracts between Delta Dental and its Delta Dental Participating Dentists provide that if Delta Dental fails to pay the dentist, the Eligible Person shall not be liable to the dentist for any sums owed by Delta Dental Article V—Conditions for Benefits—Dispute Determination Procedures 501 Benefits are available for an Eligible Person from the Eligibility Date until such eligibility terminates 502 An Eligible Person may elect the services of any licensed Dentist WDS is not responsible for availability of any particular licensed Dentist 503 WDS shall be entitled to receive from any attending Dentist, or from hospitals in which a Dentist's care is rendered, any records relating to treatment rendered to an Eligible Person as may be required in the administration of claims 504 Provider dispute resolution process is available as outlined in individual provider contracts , 505 To determine Covered Dental Benefits for certain treatments, WDS may require an Eligible Person to obtain an examination from a WDS-appointed consultant Dentist WDS will pay 100 percent of the charges incurred for the examination Article VI—Coordination of Benefits (COB) 601 All of the benefits of this Contract are subject to the provision of this Article VI The COB provision applies when a person has health care coverage under more than one Plan 602 Whenever used in this Article VI, the following terms shall be defined as specified 2009-01-00611-NC-01 --4-- (i) Allowable Expense —A dental care expense, including deductibles, coinsurance and copayments, that is covered at least in part by any Plan covering the person When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service shall be considered an allowable expense and a benefit paid An expense that is not covered by any Plan covering the person is not an allowable expense In no event shall the allowable expense be greater than the actual expense incurred (ii) Claim Determination Period —Calendar year in which treatment was incurred (ui) Plan—Group contracts issued by health care service contractors or health maintenance organizations (HMO)that provides benefits or services for dental care or treatment Each of the other Plans under which a patient is covered, and each of the benefits within the other Plan shall be considered separately in administering this coordination of benefits provision The term "other Plan" shall not include accident-only coverage, school accident type coverage, Medicaid coverage, or coverage under other federal governmental plans, unless permitted by law (iv) Custodial Parent—The parent awarded custody by a court decree or, in the absence of a court decree, is the parent with whom the child resides more than one half of the calendar year excluding any temporary visitation (v) Primary Plan —A plan whose benefits for a person's dental care coverage must be determined without taking the existence of any other plan into consideration (vi) Secondary Plan—A plan that is not primary 603 General Provision — Benefits shall be provided under this Contract to the extent that the patient could not have received benefits for the same services under any other Plan, had claim been made If the other Plan has a coordination of benefits provision and if the benefits provided under this Contract and all other Plans under which the patient is covered would exceed the total of the highest allowable expenses, then this coordination of benefits provision shall apply This means that the benefits shall be reduced so that the sum of the benefits of all Plans shall not exceed the total of the highest allowable expense If the benefits of this Contract are reduced during any claim determination period because of this provision, each benefit that would be payable in the absence of this provision shall be reduced proportionately, and the amount reduced shall be applied toward any allowable expenses incurred during that claim determination period The benefits of the other Plan shall include all benefits that would have been payable had claim been duly made therefore 604 Order of Benefit Determination — If both this Contract and the other Plan provide that the benefits of this Contract must first be exhausted, the other Plan may be ignored in determining benefits under this Contract, but otherwise the following rules shall establish the order of benefit payment under this Contract and the other Plan (i) The benefits of the Plan that does not have a coordination of benefits provision shall be primary (n) The benefits of the Plan that covers the person as an employee, member, policyholder, subscriber or retiree shall be determined before the benefits of a Plan that covers the person as a dependent (ni) If the person is a child whose parents are not separated or divorced 1) The benefits of the Plan covering the parent whose month and day of birth occurs earlier in the calendar year shall be determined before the benefits of the Plan of the parent whose month and day of birth occurs later in the calendar year 2) If both parents have the same birthday, the Plan that has covered the parent the longest is the primary Plan (iv) If the person is a child of parents who are separated or divorced or not living together, whether or not they have ever been married, where there is no court order in place then the benefits are determined in the following order 1) The Plan covering the Custodial parent, first, 2) The Plan covering the spouse of the Custodial parent, second, 3) The Plan covering the non-custodial parent, third, and 4) The Plan covering the spouse of the non-custodial parent, last (v) If a court decrees that one parent has financial or health care expenses or health care coverage responsibility, that Plan is primary 2009-01-00611-NC-01 --5— (vi) The Plan covering the person as a retired or laid-off 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 This provision shall not apply 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 (wi) If a person whose coverage is provided under COBRA or under a right of continuation provided by state or other federal law is covered under another Plan, the Plan covering the person as an employee, member, subscriber or retiree or covering the person as a dependent of an employee, member subscriber or retiree is the Primary plan and the COBRA or state or other federal continuation coverage is the Secondary plan (vui) If none of the above rules determine the primary Plan, then the Plan that covered the patient the longest shall be primary 605 Limitations on Payments — In no event shall the Eligible Person recover more than the total of the T highest allowable expense of the benefits offered by this Contract and all other Plans combined The patient shall refund to WDS any excess payment WDS may have paid 606 Payment to Other Plans— If a payment that should have been made under this Contract was made by , another Plan, WDS shall have the right to pay the other Plan any amount WDS determines necessary to satisfy the provision of this Article VI Any amounts paid shall be considered benefits paid under this Contract, and, to the extent of such payments, WDS shall be fully discharged from liability under this Contract 607 Right of Recovery—Whenever payments have been made by WDS in excess of the maximum payment necessary to satisfy the provisions of this Article VI, WDS shall have the right to recover such excess payments from the patient, the employee, the provider, or the other Plan 608 Right to Receive and Release Necessary Information—As a condition of receiving benefits under this Contract, the patient agrees to provide any necessary information WDS requests, and authorizes WDS to release or obtain from any other insurer, organization, or person any information necessary to administer the provisions of Article VI 609 If the Eligible Person is covered by more than one health plan, they or their provider should file all claims with each plan at the same time If Medicare is the primary plan, Medicare may submit claims to a secondary carrier Article VII—WDS's Obligations t 701 WDS shall issue to Group—at no additional cost—standard WDS benefit booklets summarizing the program benefits If any amendment to this Contract materially affects any benefits described in such booklets, corrected booklets or booklet inserts showing the change shall be issued to Group A new booklet shall be created upon initial inception of Contract and every other year thereafter An insert will be created and sent in the year in which a booklet is not produced If Group requests a new or updated booklet for alternate years, Group shall incur the expense Group shall also incur any charges for ' variation in booklet size or paper WDS shall provide for Group one printed booklet for each enrolled employee pursuant to Office of the Insurance Commissioner regulation (WAC 284-44-050)with an additional 10 percent reserve supply Upon approval WDS shall have booklets delivered to Group within 15 business days 702 WDS shall provide predetermination, claim review, complaint and appeal procedures and grievance procedures in the benefit booklets issued to Groups 703 If a Dentist or an Eligible Person requests a predetermination of benefits, WDS shall predetermine benefits when satisfied that the patient is an Eligible Person Such predetermination of benefits shall be for a reasonable period of time, but no longer than such person's period of eligibility Predeterm i nations are not an authorization for services but a notification of benefits available and are not a guarantee of payment 704 WDS shall not be obligated to make payment for any services rendered to a patient who is not an Eligible Person at the time the services were performed 2009-01-00611-NC-01 --6 — 705 WDS may provide professional review of the adequacy and appropriateness of services rendered through its Quality Management and Clinical Review processes 706 WDS shall provide Participating Dentist Directories to Group This directory is also available on-line at www DeltaDentalWA com It is understood that the composition of such directory is subject to change WDS reserves the right to change the directory without notice Each Eligible Person is free to select a Dentist of his or her choice WDS shall not be held liable for any action or omission on the part of the selected Dentist Nothing contained in this Contract shall be construed as obligating WDS to render dental services, its sole obligation being to pay the agreed-upon portion of Dentist's charges for covered services in accordance with the terms of this Contract 707 Both parties will act in accordance with applicable state and federal privacy requirements and disclosure requirements, such as the Gramm-Leach-Bliley Act (GLBA) and the related regulations of the Health Insurance Portability and Accountability Act (HIPAA) Article VIII —GrouWs Obligations 801 Group shall provide information to all Eligible Employees as to the existence and terms of this Contract. Group shall make available to each Eligible Employee, booklets summarizing the program benefits 802 Group shall permit WDS, at WDS's expense, on reasonable advance written notice, to inspect eligibility records in order to verify the accuracy of information submitted to WDS An equitable adjustment of Administrative Fee shall be made in the event of inadvertent clerical errors or delays in reporting eligibility 803 Group shall sign and return any and all Contract documents within 30 days of the effective date or the date WDS mails the Contract document to Group, whichever is later 804 If a signed Contract or any changes affecting the Contract provisions are not received by WDS from the Group or the Group's legal representative(s)within the 30 daytime period as indicated in Article VIII, but Group remits Administrative Fee as stipulated in Appendix E for the first month of this Contract term, WDS will assume acceptance of the Contract as stated, including acceptance of rates, Contract language and provisions WDS will process claims on the effective date according to these Contract provisions Article IX-- General Provisions 901 No change in this Contract shall be valid unless evidenced by written amendment signed by the President of WDS, or his designee 902 Legal action to recover benefits provided for in this Contract may not be initiated prior to 60 days after receipt of claim by WDS In addition, such legal action must commence within six years from the date the claim was received by WDS 903 Any provision of this Contract that is in conflict with any governing law or regulation of the state of Washington is hereby amended to comply with the minimum requirements of such law or regulation Article X—Notice and Termination 1001 Any notice under this Contract shall be sufficient if given by either Group or WDS by regular mail to the 1 other addressed to the office stated on the front page of this Contract or to such other address as may be designated by written notice to the other 1002 This Contract may be terminated effective at the end of any Contract Term by either Group or WDS, by either party giving written notice to the other at least 30 days prior to the end of the Contract Term, except as otherwise provided in Article III or this Article X 1003 Upon default by Group in any of its obligations hereunder, WDS may elect to terminate this Contract, effective at the end of the month for which Administrative Fees have been received by WDS prior to the time of such election, by giving written notice thereof to Group If WDS elects to so terminate because of default by Group, then Group shall be indebted to and agrees to pay WDS the sum of all claims payments and expenses incurred for dental services rendered from the date of default until the date of termination, including costs of recovery 2009-01-00611-NC-01 --7 1004 If on termination of this n 0 at on Contract, Group has paid Administrative Fee to WDS applicable to a period of time after the termination date, WDS shall, within 30 days after termination, return such portion of Administrative Fee to Group together with amounts due on claims, if any, less any amounts due to WDS 1005 Acceptance by WDS of the proper amount of Administrative Fee, after termination of this Contract and without requiring a new application, shall reinstate the Contract as though it had never terminated, unless WDS shall, within five business days of receipt of such payment, either 1) Refund the payment so made, or 2) Issue to Group a new Contract accompanied by written notice stating clearly those respects in which the new Contract differs from the terminated Contract in benefits, coverage or otherwise 10 06 Upon termination of this Plan, all expenses incurred prior to the termination of the Plan, but not submitted to WDS within the timeframe as set forth in Article IV of the effective date of termination of this Plan, will be excluded from any benefit consideration Article XI—Subrogation 11 01 To the extent of any amounts paid by WDS for an Eligible Person on account of services made necessary by an injury to or condition of his or her person, WDS shall be subrogated to his or her rights against any third party liable for the injury or condition WDS shall, however, not be obligated to pay for such services unless and until the Eligible Person, or someone legally qualified and authorized to act for him or her, agrees to • Include those amounts in any insurance claim or in any liability claim made against the third party for the injury or condition, • Repay WDS those amounts included in the claim from the excess received by the injured party, after full compensation for the loss is received, and • Cooperate fully with WDS in asserting its rights under the Contract, to supply WDS with any and all information and execute any and all instruments WDS reasonably needs for that purpose 11 02 Provided the injured party is in compliance with the above, WDS will prorate any attorneys'fees incurred in the recovery 11 03 If an Eligible Person receives this program's benefits for an injury or condition possibly caused by another person, they must include in their insurance claim or liability claim the amount of those benefits. After they have been fully compensated for their loss, any money recovered in excess of that loss must be used to reimburse WDS WDS shall prorate any attorneys' fees against the amount owed to WDS Article XII— List of Appendices 1201 The attached appendices are a part of this Contract Appendices are identified as follows- Appendix A— Employee Eligibility Requirements Appendix B— Dependent Eligibility Requirements Appendix C—Covered Dental Benefits, Limitations and Exclusions Appendix D—Method of Payment Appendix E—Group's Financial Obligations Appendix F—Continuation of Coverage"COBRA" Appendix G —MySmile°Personal Benefits Center 2009-01-00611-NC-01 - 8 -- Appendix A Employee Eligibility Requirements A. Definition of Eligible Employee An employee of the City of Kent is eligible to enroll on the date he or she satisfies the following • Becomes an active full-time nonuniformed employee who regularly works a minimum of 40 hours a week • Becomes an active part-time nonumformed employee who regularly works a minimum of 21 hours a week but less than 40 hours a week on a continuous service basis • An approved lob share employee working at least 20 hours per week 1 . Becomes an active uniformed employee o Uniformed employees are defined as follows • LEOFF I Employees - Full-time active law enforcement officers or fire fighters who established membership in the LEOFF system as defined in Sections (3)and (4), CH131, Law of 1972 list Ex Sess prior to October 1, 1977 * j • LEOFF II Employees - Full-time active law enforcement officers or fire fighters who established membership in the LEOFF System as defined in Sections (3) and (4), CH131, Law of 1972 1 st Ex Sess on or after October 1, 1977 • Becomes an elected Council Member for the City of Kent • The benefit provisions of this policy are available to City of Kent Council members only as a secondary source of insurance benefit If the insured Council member does not have insurance from a primary source, benefits in this policy will be primary *Retired LEOFF I employees and retired disabled LEOFF I employees who are eligible to receive a retirement benefit under the LEOFF I Retirement Plan may enroll in the City of Kent Retiree Plan B. Effective Date of Coverage Eligible Employees (as defined in Section A)are eligible on the effective date of this Contract An employee hired after the effective date of this Contract shall become eligible on the date of hire WDS will waive the waiting period for an employee hired after the effective date of this Contract and who is transferring into the dental program from any other WDS dental program Enrollment for such employee must be completed within 30 days of said transfer and the employee must have been eligible for benefits under the prior WDS dental program in the month coinciding with or immediately preceding the month of transfer The effective date of coverage for such employee shall be the first day of the calendar month following enrollment Notification of previous coverage is required at the time of enrollment C. Continuation of Coverage An employee shall continue to be eligible during the time this Contract is in effect as long as the employee remains an Eligible Employee as defined above While satisfying the various requirements of the law rests primarily with Group, WDS intends to fully cooperate with Group in complying with the law In the event of a suspension or termination of compensation directly or indirectly as a result of a strike, lockout or other labor dispute, an Eligible Employee may pay the applicable premium directly to Group for a period not to exceed six months, and Group shall pay the premium to WDS Payment of the premium must be made when due or the coverage may be terminated by WDS 2009-01-00611-NC-01 -9- Appendix A Employee Eligibility Requirements Leave of Absence Coverage for a subscriber and enrolled dependents may be continued for up to 180 days when the employer grants the subscriber a leave of absence and subscription charges continue to be paid If a medical leave is granted, the City of Kent may pay the required monthly charge for the employee and enrolled dependents for up to 180 days The 180-day leave of absence period counts toward the maximum COBRA continuation period, except as prohibited by the Family and Medical Leave Act of 1993 D. Termination of Coverage An employee shall cease to be eligible at the end of the calendar month in which the employee ceases to be an Eligible Employee as defined above or upon termination of this Contract, whichever occurs first In the event an Eligible Person ceases to be eligible, or in the event of termination of this Contract for any cause, WDS shall not be required to pay for services beyond the termination date, except for the completion (within three weeks)of single procedures requiring multiple visits to complete, that were started while this coverage was in effect, which are otherwise benefits under the terms of this plan The Eligible Person should call customer service to see if their procedure qualifies for this extension E. Enrollment Requirements All Eligible Employees enrolled in the Group-sponsored medical Plan must be enrolled in this dental program regardless of whether or not enrolled as a dependent in another dental program Employees who are not enrolled in the Group-sponsored medical Plan may not enroll in this dental program Each Eligible Employee must complete an enrollment form WDS must receive the completed form within 60 days of the employee's Eligibility Date as defined in Section B If the enrollment form is not received within 60 days, enrollment will not be accepted until the next open enrollment period If this Contract provides coverage for dependents, as defined in Appendix B, all such employee's Eligible Dependents must be listed on the enrollment form unless they are enrolled in another Dental Program 2009-01-00611-NC-01 -10- Appendix B Dependent Eligibility Requirements A. Definition of Eligible Dependent To be a dependent under this plan, the family member must be. The lawful spouse of the subscriber, unless legally separated An eligible child under 25 years of age and unmarried who is also partially or totally dependent on the subscriber for support (Eligibility and enrollment requirements for children placed for adoption and children covered because of a court decree can be found later in this section ) o An eligible child is one of the following ■ A natural offspring of either or both the subscriber or spouse ■ A legally adopted child of either or both the subscriber or spouse ■ A child placed with the subscriber for the purpose of legal adoption in accordance with state law "Placed"for adoption means assumption and retention by the subscriber of a legal obligation for total or partial support of a child in anticipation of adoption of such child A legally placed ward of the subscriber or spouse living permanently in the home of the subscriber Foster children aren't eligible for coverage To enter into a state registered domestic partnership the two persons involved must meet the following requirements 1) Both persons share a common residence, 2) Both persons are at least eighteen years of age, 3) Neither person is married to someone other than the party to the domestic partnership and neither person is in a state registered domestic partnership with another person, 4) Both persons are capable of consenting to the domestic partnership, 5) Both of the following are true a) The persons are not nearer of kin to each other than second cousins, whether of the whole or half blood computing by the rules of the civil law, and b) Neither person is a sibling, child, grandchild, aunt, uncle, niece, or nephew to the other person, and 6) Both persons are members of the same sex Following termination of a domestic partnership a statement of termination must be filed with Group's Human Resources Department within 30 days of termination Termination of domestic partnership includes death of a partner A newborn shall be covered from and after the moment of birth and an adopted child shall be covered from the date of placement as shown in Section E below Dental coverage provided shall include, but is not limited to, coverage for congenital anomalies of such infant children from the moment of birth A child shall be considered an Eligible Dependent as an adopted child if the following conditions are met- 1)the child has been placed with the Eligible Employee for the purpose of adoption under the laws of the state in which the employee resides, and 2)the employee has assumed a legal obligation for total or partial support of the child in anticipation of adoption Notification of placement of a child for adoption and payment of any additional required monthly Administrative Fees must be furnished to WDS within 60 days from the date of placement Coverage for an unmarried dependent child over the limiting age will not be terminated if the child is and continues to be both 1) incapable of self sustaining employment by reasons of developmental disability or physical handicap and 2)chiefly dependent upon the employee or member for support and maintenance, provided proof of incapacity and dependency is furnished to WDS within 31 days of the child's attainment of the limiting age and the child was an Eligible Dependent upon attainment of the limiting age 2009-01-00611-NC-01 --11 -- Appendix B Dependent Eligibility Requirements Pursuant to the terms of a Qualified Medical Child Support Order(QMCSO), the plan also provides coverage for an Eligible Employee's child, even if the Eligible Employee does not have legal custody of the child or the child is not dependent on them for support, and regardless of any enrollment season restrictions that might otherwise exist for dependent coverage If Eligible Employee is not enrolled in dental benefits, they must enroll for coverage for themselves and the child If the plan receives a valid QMCSO and they do not enroll the dependent child, the custodial parent or state agency may enroll the affected child A QMCSO may be either a National Medical Child Support Notice issued by a state child support agency or an order or judgment from a state court or administrative body directing the company to cover a child under the plan Federal law provides that a QMCSO must meet certain form and content requirements to be valid The custodial parent, a state agency or an alternate recipient may enroll a dependent child pursuant to the terms of a valid QMCSO A child who is eligible for coverage pursuant to a QMCSO may not enroll dependents for coverage under the plan B. Effective Date of Coverage Coverage for an Eligible Dependent shall become effective on the date the Eligible Employee's coverage becomes effective or on the first day of the calendar month following the month in which such person became an Eligible Dependent of the Eligible Employee, except newborn infants shall be covered as provided in Section E of this Appendix B C. Continuation of Coverage When a dependent no longer meets the eligibility requirements due to death or divorce of the employee, or does not meet the age requirements for children, coverage may continue up to three years, or until the dependent is covered under another Group Plan by self-paying the required premium While satisfying the various requirements of the law rests primarily with Group, WDS intends to fully cooperate with Group in complying with the law A dependent shall continue to be eligible during the time this Contract is in effect as long as the dependent remains an Eligible Dependent as defined above and Group has made timely payment of the monthly premiums on behalf of the dependent to WDS D. Termination of Coverage A dependent shall cease to be eligible at the end of the calendar month during which the Eligible Employee's eligibility terminates or the dependent no longer meets the definition of an Eligible Dependent, whichever occurs first In any event, eligibility for a dependent shall terminate at the end of the calendar month for which timely payment of the monthly premiums were last received by WDS from Group, or upon termination of this Contract, whichever occurs first In the event an Eligible Person ceases to be eligible, or in the event of termination of this Contract for any cause, WDS shall not be required to pay for services beyond the termination date, except for the completion (within three weeks) of single procedures requiring multiple visits to complete, that were started while this coverage was in effect, which are otherwise benefits under the terms of this plan The Eligible Person should call customer service to see if their procedure qualifies for this extension E. Enrollment Requirements Eligible Dependents enrolled in the Group-sponsored medical program of the Eligible Employee must also be enrolled in the dental program providing they satisfy the dental eligibility requirements as provided in Section A of this Appendix B A family member not covered under the Group-sponsored medical program cannot be covered under the dental program 2009-01-00611-NC-01 -- 12 -- Appendix B Dependent Eligibility Requirements Any new family member, with the exception of newborns and adopted children, acquired by an employee after his/her coverage is in effect(such as a lawful spouse, stepchildren or foster children) must be enrolled within 30 days from the date of acquisition or not until the next open enrollment period A newborn shall be covered from and after the moment of birth, and an adopted child shall be covered from the date of placement for the purpose of adoption, provided, however, that if this Contract requires payment of an additional monthly Administrative Fee for coverage of such child, enrollment of the newborn or adopted child, and payment to WDS of all applicable Administrative Fees, must be completed within 60 days after the date of birth or placement to assure coverage If no additional monthly Administrative Fee is required, WDS requests completion of the enrollment process for the newborn or adopted child within 60 days after the date of birth or placement, but coverage will be provided in any event To enroll a newborn or adopted child, a parent must complete a new enrollment form provided by WDS If an additional Administrative Fee for coverage is required and enrollment and payment is not completed for a newborn or adopted child within said 60 days, such child may be enrolled coincident with any renewal or extension of this Contract A new enrollment form must be filed for new family members When a family member is dropped from either the medical program or the dental program, the family member must also be dropped from the other program .i t t I t f t t 2009-01-00611-NC-01 -- 13 -- Appendix C Covered Dental Benefits, Limitations and Exclusions The following are Class I, Class II and Class III Covered Dental Benefits under this Contract that are subject to the Limitations and Exclusions contained in this Contract Such benefits (as defined) are available only when rendered by a licensed Dentist or other WDS-approved Licensed Professional when appropriate and necessary as determined by the standards of generally accepted dental practice and WDS The amounts payable by WDS for Class I, Class II and Class III Covered Dental Benefits are as set forth in Appendix D , Dental Accident Coverage Notwithstanding the amounts payable by WDS for Class I, Class II and Class III benefits, as provided in Appendix D, WDS shall pay 100 percent of the Filed Fee or the Maximum Allowable Fees, up to the unused program maximum, for expenses for Covered Dental Benefits arising as a direct result of an accidental bodily injury that occurred while the patient was an Eligible Person hereunder A bodily injury does not include teeth broken or damaged during the act of chewing or biting on foreign objects Coverage includes necessary procedures for dental diagnosis and treatment rendered within 180 days following the date of the accident Class I Diagnostic Covered Dental Benefits — Routine examination (periodic oral evaluation) — Comprehensive oral evaluation — X-rays — Emergency examination — Specialist examination performed by a Specialist in an American Dental Association-recognized specialty — WDS-approved caries (tooth decay)and periodontal susceptibility/risk tests Limitations , — Routine examination is covered twice in a Benefit Period — Comprehensive oral evaluation is covered once in a three-year period from the date of service as one of the two covered examinations in a Benefit Period per Eligible Person per dental office Additional comprehensive oral evaluations will be allowed as routine examinations The patient will not be responsible for any difference in cost when services are provided by a participating Dentist — Complete series (any number or combination of intraoral X-rays, billed for same date of service that equals or exceeds the allowed fee for a complete series is considered a complete series for payment purposes) or panorex X-rays are covered once in a five-year period from the date of service — Supplementary bitewing X-rays are covered once in a Benefit Period — Diagnostic services and X-rays related to temporomandibular joints (Jaw joints)are Not a Paid Covered Benefit under Class I Covered Dental Benefits Exclusions — Consultations or elective second opinions — Study models Preventive Covered Dental Benefits Prophylaxis (cleaning) — Penodontal maintenance — Fissure sealants — Topical application of fluoride or preventive therapies (e g fluoridated varnishes) — Space maintainers when used to maintain space for eruption of permanent teeth 2009-01-00611-NC-01 -- 14-. Appendix C Covered Dental Benefits, Limitations and Exclusions Limitations — Prophylaxis and/or periodontal maintenance procedures will be limited to two covered procedures in a Benefit Period — Under certain conditions of oral health, prophylaxis or periodontal maintenance (but not both)may be covered up to a total of four times in a Benefit Period — Topical application of fluoride or preventive therapies (but not both) is covered twice in a Benefit Period — Payment for application of sealants will be for permanent maxillary (upper) or mandibular (lower) molars with incipient or no caries (decay)on an intact occlusal surface The application of fissure sealants is a Covered Dental Benefit only once in a three-year period per tooth from the date of service — Replacement of a space maintainer previously paid for by WDS is Not a Paid Covered Benefit Exclusions — Plaque control program (oral hygiene instruction, dietary instruction and home fluoride kits) — Cleaning of a prosthetic appliance Periodontics Covered Dental Benefits — Prescription strength fluoride toothpaste — Antimicrobial mouth rinse Limitations Prescription strength fluoride toothpaste and antimicrobial mouth rinse is a Covered Dental Benefit following periodontal surgery or other covered periodontal procedures when dispensed in a dental office Proof of a periodontal procedure must accompany the claim or the patient's WDS history must show a I periodontal procedure within the previous 180 days — Antimicrobial mouth rinse is covered once per periodontal treatment — Antimicrobial mouth rinse is available for women during pregnancy without any periodontal procedure **Refer Also To General Limitations and General Exclusions** Class II General Anesthesia Covered Dental Benefits — General anesthesia when administered by a licensed Dentist or other WDS-approved Licensed Professional who meets the educational, credentialing and privileging guidelines established by the Dental Quality Assurance Commission of the state of Washington or as determined by the state in which the services are rendered Limitations General anesthesia is covered in conjunction with certain covered endodontic, periodonti and oral surgery procedures, as determined by WDS, or when medically necessary, for children through age six, or a physically or developmentally disabled person, when in conjunction with Class I, Il, III and Orthodontic covered dental procedures — Either general anesthesia or intravenous sedation (but not both)are covered when performed on the same day — General anesthesia for routine post-operative procedures is Not a Paid Covered Benefit Intravenous Sedation Covered Dental Benefits Intravenous sedation when administered by a licensed Dentist or other WDS-approved Licensed Professional who meets the educational, credentialing and privileging guidelines established by the Dental Quality Assurance Commission of the state of Washington or as determined by the state in which the services are rendered 2009-01-00611-NC-01 -- 15 -- Appendix C Covered Dental Benefits, Limitations and Exclusions Limitations — Intravenous sedation is covered in conjunction with certain covered endodontic, penodontic and oral surgery procedures, as determined by WDS — Either general anesthesia or intravenous sedation (but not both)are covered when performed on the same day — Intravenous sedation for routine post-operative procedures is Not a Paid Covered Benefit. Palliative Treatment Covered Dental Benefits — Palliative treatment for pain Limitations — Postoperative care and treatment of routine post-surgical complications is included in the initial cost for surgical treatment if performed within 30 days Restorative Covered Dental Benefits — Amalgam restorations (fillings)and, in anterior teeth, resin-based composite or glass ionomer restorations for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) or fracture resulting in significant loss of tooth structure (missing cusp) — Resin-based composite or glass ionomer restorations placed in the buccal (facial) surface of bicuspids — Stainless steel crowns Limitations — Restorations on the same surface(s)of the same tooth are covered once in a two-year period from the date of service — If a resin-based composite or glass ionomer restoration is placed in a posterior tooth (except on bicuspids as noted above), it will be considered as a cosmetic procedure and an amalgam allowance will be made, with any difference in cost being the responsibility of the patient — Restorations necessary to correct vertical dimension or to alter the morphology (shape)or occlusion are Not a Paid Covered Benefit — Stainless steel crowns are covered once in a two-year period from the date of service — Refer to Class III Limitations if teeth are restored with crowns,veneers, inlays or onlays Exclusions — Overhang removal, copings, re-contouring or polishing of restoration Oral Surgery Covered Dental Benefits — Removal of teeth — Preparation of the mouth for insertion of dentures — Treatment of pathological conditions and traumatic injuries of the mouth — Refer to Class II General Anesthesia or Intravenous Sedation for additional information Exclusions Bone replacement graft for ridge preservation Bone grafts, of any kind, to the upper or lower jaws not associated with periodontal treatment of teeth Tooth transplants Materials placed in tooth extraction sockets for the purpose of generating osseous filling 2009-01-00611-NC-01 --16-- Appendix C Covered Dental Benefits, Limitations and Exclusions Periodontics Covered Dental Benefits — Surgical and nonsurgical procedures for treatment of the tissues supporting the teeth Services covered include periodontal scaling/root planing and periodontal surgery Limited adjustments to occlusion (eight teeth or less) — WDS-approved localized delivery of antimicrobial agents — Refer to Class I Covered Dental Benefits and Limitations for periodontal maintenance benefits — Refer to Class III Periodontics for benefits and Limitations on complete occlusal equilibration and occlusal guard (rnghtguard) t Limitations — Periodontal scaling/root planing is covered once in a three-year period from the date of service — Periodontal surgery (per site) is covered once in a three-year period from the date of service — Soft tissue grafts (per site)are covered once in a three-year period from the date of service Limited occlusal adjustments are covered once in a 12-month period from the date of service. Localized delivery of antimicrobial agents approved by WDS is a Covered Dental Benefit under certain conditions of oral health Localized delivery of antimicrobial agents is limited to two teeth per quadrant and up to two times (per tooth) in a Benefit Period Penodontal surgery and localized delivery of antimicrobial agents must be preceded by scaling and root planing a minimum of six weeks and a maximum of six months, or the patient must have been in active supportive periodontal therapy, prior to such treatment Localized delivery of antimicrobial agents is Not a Paid Covered Benefit when used for the purpose of maintaining non-covered dental procedures — Crown and bridgework in conjunction with periodontal splinting or other periodontal therapy and periodontal appliances are Not a Paid Covered Benefit Exclusions — Periodontal splinting — Gingival curettage Endodontics Covered Dental Benefits — Procedures for pulpal and root canal treatment — Services covered include pulp exposure treatment, pulpotomy and apicoectomy. Limitations Root canal treatment on the same tooth is covered only once in a two-year period from the date of service — Re-treatment of the same tooth is allowed when performed by a different dental office Refer to Class III Limitations if the root canals are placed in conjunction with a prosthetic appliance Exclusions — Bleaching of teeth "'Refer Also To General Limitations and General Exclusions" 2009-01-00611-NC-01 -- Appendix C Covered Dental Benefits, Limitations and Exclusions Class III , Note: For new hires enrolling in the 100 percent and Group Health medical plan, each Eligible Person must be on this dental plan for 12 months before they become eligible for Class 111 Benefits For new hires enrolling in the HSA and 80 percent medical plan, each Eligible Person must be on this dental plan for 12 months before they become eligible for Class 111 Benefits Periodontics Covered Dental Benefits — Under certain conditions of oral health, services covered are occlusal guard (nightguard), repair and relines of occlusal guard (nightguard)and complete occlusal equilibration Limitations — Occlusal guard (nightguard) is covered once in a three-year period from the date of service — Repair and relines done more than six months from the date of service after the initial placement are covered — Complete occlusal equilibration is covered once in a lifetime Restorative Covered Dental Benefits — Crowns, veneers, inlays (as a single tooth restoration—with Limitations)or onlays (whether they are gold, porcelain, WDS-approved gold substitute castings [except laboratory processed resin] or combinations thereof)for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) or fracture resulting in significant loss of tooth structure (missing cusp), when teeth cannot reasonably be restored with filling materials such as amalgam or resin-based composites — Crown buildups, subject to Limitations — Post and core, subject to Limitations Limitations Crowns, veneers, inlays (as a single tooth restoration—with Limitations)or onlays on the same teeth are covered once in a seven-year period from the seat date — If a tooth can be restored with a filling material such as amalgam or resin-based composites, an allowance will be made for such a procedure toward the cost of any other type of restoration that may be provided — WDS will allow the appropriate amount for an amalgam restoration (posterior tooth)or resin-based composite restoration (anterior tooth)toward the cost of a laboratory processed resin inlay (as a single tooth restoration—with Limitations), onlay, veneer or crown — Payment for crowns, veneers, inlays(as a single tooth restoration—with Limitations)or onlays shall be paid upon the seat date — Inlays (as a single tooth restoration) will be considered as a cosmetic procedure and an amalgam allowance will be made, with any difference in cost being the responsibility of the patient — Crown buildups are a Covered Dental Benefit when more than 50 percent of the natural coronal tooth structure is missing or there is less than 2mm of vertical height remaining for 180 degrees or more of the tooth circumference and there is evidence of decay or other significant pathology — Crown buildups are covered once in a seven-year period from the date of service — Crown buildups are Not a Paid Covered Benefit within two years from the date of service of a restoration on the same tooth — Crown buildups for the purpose of improving tooth form, filling in undercuts or reducing bulk in castings are considered basing materials and are Not a Paid Covered Benefit — Past and core are covered once in a seven-year period on the same tooth from the date of service — A crown used for purposes of re-contouring or repositioning a tooth to provide additional retention for a removable partial denture is Not a Paid Covered Benefit unless the tooth is decayed to the extent that a crown would be required to restore the tooth whether or not a removable partial denture is part of the treatment 2009-01-00611-NC-01 18 -- Appendix C Covered Dental Benefits, Limitations and Exclusions — Crowns or onlays are Not a Paid Covered Benefit when used to repair micro-fractures of tooth structure when the tooth is asymptomatic (displays no symptoms) or there are existing restorations with defective margins when there is no decay or other significant pathology present — Crowns and/or onlays placed because of weakened cusps or existing large restorations without overt pathology are Not a Paid Covered Benefit — Crown and bridgework in conjunction with periodontal splinting or other periodontal therapy and periodontal appliances are Not a Paid Covered Benefit Exclusions — Copings Prosthodontics Covered Dental Benefits — Dentures, fixed partial dentures (fixed bridges), inlays (only when used as an abutment for a fixed bridge), removable partial dentures and the adjustment or repair of an existing prosthetic device Surgical placement or removal of implants or attachments to implants Limitations Replacement of an existing prosthetic device is covered only once every seven years from the date of service and only then if it is unserviceable and cannot be made serviceable — Inlays are a Covered Dental Benefit on the same teeth once in a seven-year period from the delivery date only when used as an abutment for a fixed bridge Payment for dentures, fixed partial dentures (fixed bridges), inlays(only when used as an abutment for a fixed bridge)and removable partial dentures shall be paid upon the delivery date — Replacement of implants and superstructures is covered only after seven years from the delivery date have elapsed from any prior provision of the implant Crowns in conjunction with overdentures are Not a Paid Covered Benefit — Full, immediate and overdentures—WDS will allow the appropriate amount for a full, immediate or overdenture toward the cost of any other procedure that may be provided, such as personalized restorations or specialized treatment — Temporary/interim dentures--WDS will allow the amount of a reline toward the cost of an interim partial or full denture After placement of the permanent prosthesis, an initial reline will be a benefit after six months — Root canal treatment performed in conjunction with overdentures is limited to two teeth per arch and is paid at the Class III Payment Level Partial dentures— If a more elaborate or precision device is used to restore the case, WDS will allow the cost of a cast chrome and acrylic partial denture toward the cost of any other procedure that may be provided — Denture adjustments and relines—Denture adjustments and relines done more than six months after the initial placement are covered Subsequent relines or rebases (but not both)will be covered once in a 12-month period Exclusions — Duplicate dentures — Personalized dentures — Cleaning of prosthetic appliances — Copings "Refer Also To General Limitations and General Exclusions" 2009-01-00611-NC-01 -- 19— Appendix C Covered Dental Benefits, Limitations and Exclusions Orthodontic Benefits for Adults and Eligible Children ' Orthodontic treatment is defined as the necessary procedures of treatment, performed by a licensed Dentist, involving surgical or appliance therapy for movement of teeth and post-treatment retention For enrollees in the 100 percent. Group Health, HSA and 80 percent medical plans The lifetime maximum amount payable by WDS for Orthodontic Benefits rendered to an Eligible Person shall be $1,800 Not more than $900 of the maximum, or one-half of WDS's total responsibility shall be payable for treatment during the "construction phase". Subsequent payments of WDS's responsibility shall be made on a monthly basis, throughout the length of treatment submitted, providing the employee is eligible and the dependent is in compliance with the age limitation For retirees The lifetime maximum amount payable by WDS for Orthodontic Benefits rendered to an Eligible Person shall be $1,000 Not more than $500 of the maximum, or one-half of WDS's total responsibility shall be payable for treatment during the"construction phase" Subsequent payments of WDS's responsibility shall be made on a monthly basis, throughout the length of treatment submitted, providing the employee is eligible and the dependent is in compliance with the age limitation Notwithstanding the Payment Levels set forth in Appendix D and the provision of Article IV, the amount payable by WDS for Orthodontic treatment shall be 50 percent of the lesser of the Maximum Allowable Fees or the fees actually charged It is strongly suggested that an orthodontic treatment plan be submitted to, and a predetermination be made by, WDS prior to commencement of treatment A predetermination is not a guarantee of payment Additionally, payment for orthodontic benefits is based upon eligibility If individuals become ineligible prior to the subsequent payment of benefits, subsequent payment is not covered Covered Dental Benefits — Treatment of malalignment of teeth and/or taws Orthodontic records Exams (initial, periodic, comprehensive, detailed and extensive), x-rays (intraoral, extraoral, diagnostic radiographs, panoramic), diagnostic photographs, diagnostic casts (study models)or cephalometric films Limitations — Payment is limited to ■ Completion, or through limiting age (refer to Appendix B), whichever occurs first ■ Treatment received after coverage begins (claims must be submitted to WDS within the time limitation (as stated in Article IV)of the start of coverage) For orthodontia claims, the initial banding date is the treatment date considered in the timely filing — Treatment that began prior to the start of coverage will be prorated • Payment is made based on the balance remaining after the down payment and charges prior to the date of eligibility are deducted ■ WDS will issue payments based on our responsibility for the length of the treatment The payments are issued providing the employee is eligible and the dependent is in compliance with the age limitation — In the event of termination of the treatment plan prior to completion of the case or termination of this program, no subsequent payments will be made for treatment incurred after such termination date Exclusions — Charges for replacement or repair of an appliance — No benefits shall be provided for services considered inappropriate and unnecessary, as determined by WDS *`Refer Also To General Limitations and General Exclusions" 2009-01-00611-NC-01 --20 -- Appendix C Covered Dental Benefits, Limitations and Exclusions ' General Limitations 1 Dentistry for cosmetic reasons is Not a Paid Covered Benefit 2 Restorations or appliances necessary to correct vertical dimension or to restore the occlusion Such procedures include restoration of tooth structure lost from attrition, abrasion or erosion and restorations for malalignment of teeth are Not a Paid Covered Benefit 3 General anesthesia/intravenous (deep) sedation is Not a Paid Covered Benefit, except as specified by WDS for certain oral, periodontal, or endodontic surgical procedures General anesthesia is Not a Paid Covered Benefit except when medically necessary, for children through age six, or a physically or developmentally disabled person, when in conjunction with covered dental procedures General Exclusions 1 Services for injuries or conditions that are compensable under Worker's Compensation or Employers' Liability laws, and services that are provided to the Eligible Person by any federal or state or provincial government agency or provided without cost to the Eligible Person by any municipality, county or other political subdivision, other than medical assistance in this state, under medical assistance RCW 74 09 500, or any other state, under 42 U S C , Section 1396a, section 1902 of the Social Security Act 2 Application of desensitizing agents 3. Experimental services or supplies a Experimental services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/observation In determining whether services are experimental, WDS, in conjunction with the American Dental Association, shall consider if i) The services are in general use in the dental community in the state of Washington; n) The services are under continued scientific testing and research, nQ The services show a demonstrable benefit for a particular dental condition, and iv) They are proven to be safe and effective Any individual whose claim is denied due to this experimental exclusion clause shall be notified of the denial within 20 working days of receipt of a fully documented request b Any denial of benefits by WDS on the grounds that a given procedure is deemed experimental may be appealed to WDS By law, WDS must respond to such appeal within 20 working days after receipt of all documentation reasonably required to make a decision The 20-day period may be extended only with written consent of the Eligible Person 4. Analgesics such as nitrous oxide, conscious sedation, euphoric drugs or injections 5 Prescription drugs 6 In the event an Eligible Person fails to obtain a required examination from a WDS-appointed consultant Dentist for certain treatments, no benefits shall be provided for such treatment 7 Hospitalization charges and any additional fees charged by the Dentist for hospital treatment 8 Broken appointments 9 Patient management problems 10 Completing claim forms 11 Habit-breaking appliances 12 TMJ services or supplies 13 This program does not provide benefits for services or supplies to the extent that benefits are payable for them under any motor vehicle medical, motor vehicle no-fault, uninsured motorist, underinsured motorist, personal injury protection (PIP), commercial liability, homeowner's policy or other similar type of coverage 14 All other services not specifically included in this Contract as Covered Dental Benefits WDS shall have the discretionary authority to determine whether services are Covered Dental Benefits in accordance with the general Limitations and general Exclusions shown in this Contract, but It shall not exercise this authority arbitrarily or capriciously or in violation of the provisions of the Contract 2009-01-00611-NC-01 --21 -- Appendix D Method of Payment For enrollees in the 100 percent Group Health, HSA and 80 percent medical plans For a PPO Participating Dentist, WDS Shall Pay: 100 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class I Covered Dental Benefits as they are described in Appendix C 80 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class II Covered Dental Benefits as they are described in Appendix C 80 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class III Covered Dental Benefits as they are described in Appendix C The amounts payable by WDS with respect to dental services rendered by a Dentist out of the State of Washington are the above applicable percentages applied to WDS's Maximum Allowable Fees for out-of- state Dentists, or to such Dentist's actual charges, whichever shall be less Expenses for all Covered Dental Benefits arising as a direct result of an accidental bodily injury shall be payable at 100 percent, up to the unused program maximum For a Delta Dental Participating Dentist or a Nonparticipating Dentist, WDS Shall Pay: 100 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class I Covered Dental Benefits as they are described in Appendix C 80 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class II Covered Dental Benefits as they are described in Appendix C 80 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class III Covered Dental Benefits as they are described in Appendix C Expenses for all Covered Dental Benefits arising as a direct result of an accidental bodily injury shall be payable at 100 percent, up to the unused program maximum For retirees For a PPO Participating Dentist, WDS Shall Pay: 100 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class I Covered Dental Benefits as they are described in Appendix C 80 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class II Covered Dental Benefits as they are described in Appendix C 50 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class III Covered Dental Benefits as they are described in Appendix C The amounts payable by WDS with respect to dental services rendered by a Dentist out of the State of Washington are the above applicable percentages applied to WDS's Maximum Allowable Fees for out-of- state Dentists, or to such Dentist's actual charges, whichever shall be less Expenses for all Covered Dental Benefits arising as a direct result of an accidental bodily injury shall be payable at 100 percent, up to the unused program maximum For a Delta Dental Participating Dentist or a Nonparticipating Dentist,WDS Shall Pay: 100 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class I Covered Dental Benefits as they are described in Appendix C 80 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class II Covered Dental Benefits as they are described in Appendix C 50 percent of the Maximum Allowable Fees as set forth in Article IV for allowable Class III Covered Dental Benefits as they are described in Appendix C Expenses for all Covered Dental Benefits arising as a direct result of an accidental bodily injury shall be payable at 100 percent, up to the unused program maximum 2009-01-00611-NC-01 --22 -- IAppendix D Method of Payment Plan Maximum For enrollees in the 100 percent and Group Health medical plan The maximum amount payable by WDS for Class I, II and III Covered Dental Benefits (including Dental Accident Benefits) per Eligible Person during the period beginning January 1 through December 31 shall be $1,500 Charges for dental procedures requiring multiple treatment dates shall be considered incurred on the date the service is completed Amounts for such procedures shall be applied to the program maximum based on such incurred date For enrollees in the HSA and 80 percent medical plan The maximum amount payable by WDS for Class I, II and III Covered Dental Benefits (including Dental Accident Benefits) per Eligible Person during the period beginning January 1 through December 31 shall be $1,800 Charges for dental procedures requiring multiple treatment dates shall be considered incurred on the date the service is completed Amounts for such procedures shall be applied to the program maximum based on such incurred date For retirees The maximum amount payable by WDS for Class I, II and III Covered Dental Benefits (including Dental Accident Benefits) per Eligible Person during the period January 1 through December 31 shall be $1,500 Charges for dental procedures requiring multiple treatment dates shall be considered incurred on the date the service is completed Amounts for such procedures shall be applied to the program maximum based on such incurred date Plan Deductible WDS shall not be obligated to pay the first$50 of fees for Covered Dental Benefits received by an Eligible Person during each period January 1 through December 31 Such deductible amount shall not exceed $150 during each period for all Eligible Persons in a single family consisting of an Eligible Employee and Eligible Dependents Once the maximum deductible per family has been satisfied, no further deduction shall apply until the next succeeding period The deductible does not apply to Class I Covered Dental Benefits, Orthodontic Benefits or Dental Accident Benefits 2009-01-00611-NC-01 —23— Appendix E Group's Financial Obligations WDS shall notify Group, on the last WDS payment day of each calendar month, the actual amount of claims paid by WDS for that month Notification will be via Fax letter which will constitute an invoice Group will then have two business days to wire transfer to the appropriate WDS bank account an amount equal to total claims paid for the month Funds are due on the date notified If the funds are not transferred within five days of notification, a late fee of one percent of claims will be charged An additional late charge of one percent of claims will be charged for each subsequent 30 day period for which payment is not received The charges shall be submitted by WDS with a subsequent payment notification 2009 Contract Year The monthly Administration fee payable by Group under this Contract during the period January 1, 2009 through December 31, 2009 shall be $4 73 per Eligible Employee Group's payment shall be in the form of an electronic transfer and shall accompany the eligibility listing WDS will then update the files and send a new billing to Group for the next month of coverage 2010 Contract Year The monthly Administration fee payable by Group under this Contract during the period January 1, 2010 through December 31, 2010 shall be $4 99 per Eligible Employee Group's payment shall be in the form of an electronic transfer and shall accompany the eligibility listing WDS will then update the files and send a new billing to Group for the next month of coverage 2011 Contract Year The monthly Administration fee payable by Group under this Contract during the period January 1, 2011 through December 31, 2011 shall be $5 30 per Eligible Employee Group's payment shall be in the form of an electronic transfer and shall accompany the eligibility listing WDS will then update the files and send a new billing to Group for the next month of coverage Broker commission for each year is $0 38 per employee per month of the composite fee listed above Legislative Surcharge Clause— If any governmental unit shall impose any new tax or assessment or increases the rate of any current tax or assessment that is measured directly by the payments made to WDS by Group, then WDS is authorized to increase the monthly Administrative Fee by the amount of such new tax, assessment or increase 2009-01-00611-NC-01 --24 -- i Appendix F Continuation of Coverage "COBRA" Federal Health Benefit Continuation Provision Applicable to Group Health Care Plans effective Jan 1, 1987, provided the Group employs at least 20 employees on a "typical business day"during the preceding calendar year (Part of the Consolidated Omnibus Budget Reconciliation Act known as COBRA Public Law 99-272 and as amended by Public Law 104-191) An employee (and his/her family members) employed by an employer affected by the above law, should be aware of the following terms, conditions and of this law as it applies to temporary continuation of Group dental coverage upon the occurrence of certain qualifying events An employee of an employer covered by the Group Health Care Plan has a right to choose this continuation coverage, if Group dental coverage is lost because of a reduction in hours of employment or the termination of employment for reasons other than gross misconduct on the part of the employee The dependents of an employee covered by the Group Health Care Plan have the right to choose continuation coverage, if Group dental coverage under the Group Health Care Plan is lost for any of the following five reasons 1) The death of the employee, 2) A termination of the employee's employment (for reasons other than gross misconduct) or reduction in the employee's hours of employment, 3) Divorce or legal separation from the employee 4) The employee becomes entitled to Medicare, or 5) The dependent ceases to be an "Eligible Dependent" under the Group Health Care Plan Under the law, the employee or a family member has the responsibility to inform the employer of a divorce, legal separation, or a child losing dependent status under the Group Health Care Plan COBRA coverage begins on the date that coverage would otherwise have been lost due to a qualifying event Coverage will end at the end of the maximum period When the employer is notified that one of these events has happened, the employer will, in turn, notify the employee of his or her right to choose continuation coverage Under the law, the employee has at least 60 days from the date he or she would lose coverage because of one of the events described above to inform the employer that continuation coverage has been chosen If continuation coverage is not chosen, the Group health care coverage will end If continuation coverage is chosen, the employer is required to give the employee coverage that, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or family members The law requires that the employee be afforded the opportunity to maintain continuation coverage for three years unless the loss of Group dental coverage was because of a termination of employment or reduction in hours In that case, the required continuation coverage period is 18 months If continuation of coverage is chosen, the employer is required to give coverage that, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or family members I If the covered employee's eligibility under this Contract ends when he or she becomes entitled to Medicare benefits then coverage may not be continued for the employee But coverage may be continued for any dependents for up to 36 months, from the covered employee's Medicare entitlement date If the covered employee's eligibility under the contract continues beyond Medicare entitlement, but later ends upon termination of employment or retirement, then any Dependents may continue coverage for up to 1)36 months from the covered employee's Medicare entitlement date, or 2) 18 months from the date the insured persons employment ended (whichever is later) Disabled individuals, either employees or dependents, who are disabled at the time the employee terminates employment or has a reduction in hours, or if disability occurs at any time during the first 60 days of COBRA coverage, are eligible for an additional 11 months of continuation coverage The total continuation coverage period will not exceed 29 months The individual must be determined to be disabled by the Social Security Administration and must notify Group within 60 days of Social Security's determination date 2009-01-00611-NC-01 --25-- Appendix F Continuation of Coverage "COBRA" If the Eligible Employee has a child or adopts a child during the period of COBRA coverage, such employee may elect to cover that child Generally, COBRA participants lose coverage when they become eligible under another Group plan However, if the new plan has pre-existing Limitations and Exclusions, affected individuals may continue coverage under the former plan until the pre-existing condition(s) is no longer limited or the continuation coverage period ends, whichever is earlier COBRA payments are due within 45 days from the date of application Payments must be made retroactively from the date of COBRA eligibility up through the current month of eligibility If a dependent is actively participating in COBRA and the covered employee becomes entitled to Medicare benefits then coverage may not be continued for the employee But coverage may be continued for any dependents for up to 36 months, from the covered employee's Medicare entitlement date If the covered employee's eligibility under the contract continues beyond Medicare entitlement, but later ends upon termination of employment or retirement, then any Dependents may continue coverage for up to 1) 36 months from the covered employee's Medicare entitlement date, or 2) 18 months from the date the insured persons employment ended (whichever is later) Dependents experiencing second qualifying events while under COBRA may extend coverage for an additional 18 months Continuation coverage may be ended according to the law for any of the following reasons • The employer no longer provides Group health care coverage to any of its employees, • The premium for continuation coverage is not paid, or not paid on time, as provided by law, • The Eligible Person becomes covered under another Group health care plan after the date the Eligible Person elects COBRA coverage If, however, the new plan contains an exclusion or limitation for a pre- existing condition (as explained above), coverage does not end for this reason until the exclusion or limitation no longer applies, • The Eligible Person becomes entitled to Medicare after the date the Eligible Person elects COBRA coverage, or • The spouse is divorced from a covered employee and subsequently remarries and is covered under any Group health care plan unless a pre-existing condition described above takes precedence Proof of insurability is not required to choose continuation coverage However, under the law, the employee may have to pay all or part of the premium for the continuation coverage 2009-01-00611-NC-01 -- 26 — Appendix G MySmile®Personal Benefits Center The MySmile®personal benefits center is an online tool that provides personalized strategies for employees to improve their oral health and that of their family members Here are examples of what MySmile can do for employees • Allow them to check their plan coverage and eligible benefits • Let them search for dentists near their homes or work places • Lets them check the status of current claims and view previous payments • Provide access to printable ID cards • Provide personalized ways to improve their oral health WDS will provide Group with a series of communications encouraging Group to use this program Group understands that any cost savings they may see on the treatment side are directly related to employee usage rates i i t 2009-01-00611-NC-01 --27 -- Kent City Couhcd Meeting Date March 16, 2010 Category Consent Calendar - 6G 1. SUBJECT: PRINT SHOP COPIERS ONE-YEAR LEASE - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign a one-year lease agreement with Xerox Corporation for one black and white and one color high- speed copier/printer, at a total annual lease cost of $55,561.82. The effect of this agreement is to extend the expired five-year lease on two of the three copiers in the print shop through mid-April 2011 with reduced lease costs and improved lease terms. The print shop has traditionally had one color and two black & white high-end production copier(s). Copiers are leased through an RFP process that is conducted approximately every five years for both copiers in the print shop. The ' print shop lease for the existing copiers has expired and the remaining copiers are now being leased on a month-to-month basis at a higher lease rate. Due to current economic conditions, the desire to reduce copies (i.e. council's interest in a paperless city), and the need to reduce costs, Information Technology has done the following: (a) Eliminated one black & white copier from the print shop at the end of the prior lease term. (b) Negotiated a reduced price on a 12-month lease extension on the two remaining copiers, rather than complete an RFP process that will commit the City to another five-year lease term. (c) Reduced the 2010 print shop copier budget by $25,000. The attached purchase order and agreement reflects the renegotiated pricing and lease terms. The terms of the contract have been reviewed and approved through the City's legal department. 3. EXHIBITS: Memo dated 3/2/10, Purchase Order, and Lease Agreement 4. RECOMMENDED BY: Operations Committee 3/2/10 (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds DISCUSSION: ACTION: INFORMATION TECHNOLOGY Mike Carrington, Director KEN T Phone: 253-856-4600 W A 9 N I N OT O N Fax: 253-856-4700 220 Fourth Avenue S. Kent, WA 98032-5895 DATE: March 2, 2010 TO: Kent City Council Operations Committee FROM: Dea Drake, Multimedia Manager Mike Carrington, IT Director THROUGH: Tom Brubaker, Kent City Attorney John Hodgson, CAO SUBJECT: Print Shop Copier(s) One-Year Lease MOTION: I move to authorize the Mayor to enter into a one-year lease agreement with Xerox Corporation for one black and white and one color high-speed copier printer(s) per the attached agreement. SUMMARY: This agreement extends the expired five-year lease on two of the three copiers in the print shop - by 12 months through mid April 2011. DETAILS: The print shop has traditionally had one color and two black & white high-end production copier(s). Copiers are leased through an RFP process approximately every five years both in the print shop and as fleet copiers through the City. The print shop lease for the existing copiers has expired and we are on a month to month lease with the remaining equipment. Due to the current economy, the desire to reduce copies (i.e. council's interest in a 1 paperless city) and the need to reduce costs; we have done the following: a) Eliminated one black & white copier from the print shop at the end of the lease. b) Negotiated a reduced price on a 12 month lease extension on the two remaining copiers; rather than complete an RFP process that will commit the City to another five year lease. c) Reduced the 2010 Print Shop copier budget by $25,000. The attached purchase order and agreement reflects the renegotiated pricing and lease terms. The terms of the contract have been reviewed and approved through our legal department. BUDGET IMPACT: Funding for this is covered in line item (64510) "equipment rental" in the approved 2010 print shop budget (52001760.1820). i It S R R § & & 2 �o - ° ^ ƒ / ƒ Q 2 S 0 § § ° 4 e g g @ k D } rD< Cl) R ) � E ) ^ � y\ / � g B I o k k m m 0 g $ O o � / LO $ o x 2 c 2 ) / c on o0 2 d 2 ® \ oW c \ } \ \ \ q 2 m m § OD a s ` a C - ^ k m % \w / § m 2 L:C)0 \ k a) \ \ k 9 C\l CM CM CIJ (D - - - - o O O > x = Ia_ @ 2 ° \ 2 @ k m/ / J J2 Lm $ M ƒ k � � (f) U) OL / { ƒ 0 IcLm / $ ° ) \ 2 0 \ L - £ a 0 / � E * U \ \ / \ \ aca 2 % 2 \ g , ° ° 0 / 2 / @ \ u \ - 2 \ / _ a \ \ \ Q $ « / 0 & -0 :3 � ) \ / ) / \ / \ § @ ° a) ^ I 3 a) 055 / � \ 2 © U m < « � = { \ \ @ / _ 0 _ g = & R § j \ / / f 0 \ \ § t \ f 7 R = -0 : 2 ® n } ` 0 z 3 j / E / % ES U » Sf s ok � : \ \ { { o- \ § @ ez; = = £ � 2 $ a § ` @ ® e % = n © n � Q \ 2 k @ �3: 0 - e o « e \ 0 v § / a < 2 a ) � ^ k -0 � � akk \ f o 0 @ � £ § oo = = § F52 U) Z \ / $ 1mn m a 2 LLp �I xeroA Customer KENT,CITY OF PARKS&RECREATION Billi CITY OF KENT Install CITY OF KENT PRINT SHOP LOCATION 22041h Ave S 220 4th Ave S Kent,WA 98032 Kent,WA 98032 Tax ID# Exempt State or Local Government ProductDescription ... Agreement Information, 1.DIGIPC4(SOT DIGIPATH PC) S/N PUW786646 Lease Term 12 months 2/15/2010 Make Ready Table Purchase Option FMV This agreement modifies the current Xerox Agreement 956672752 for DIGIPC4 S/N PUW786646 as of payment 56 2 PPS2MKRC(SOT PPS MAKEREADY) SIN VCP000501 Lease Term 12 months 2/15/2010 Production Scanner Purchase Option FMV This agreement modifies the current Xerox Agreement 956672844 for PPS2MKRC S/N VCP000501 as of payment 56 TTTVMI M,m I lrnir pt . Hill' Print Charges Maintenance Plan Features 1 DIGIPC4 $2810 N;A `v-A NA -Full Sevice Maintenance Included -Meters Reconciled Quarterly 2 PPS2MKRC $29810 N/A NIA N/A -Full Service Maintenance Included -Meters Reconciled Quarterly Total $326 20 Minimum Payments(Excluding Applicable Taxes) i„ :n I°IIII, r rCustomer acknowledges receipt of the terms of this agreement Thank You for your businessl )-- which consists of 5 pages including this face page This Agreement is proudly presented by Xerox and TO IF j Signer Suzette Cooke Phone (253)856-4646 Howard Chiu I T , (425)780.0686 JR j� For information on your Xerox Account,go to GUARANTEE Signature Date wwwxeioxcom'AccountkIanacement _J QL- WS 1.109747 '7 J 2010 14 36 17 tr r - bpi idontinl CopyrighKD 2008 XEROX CORPORATION All rightsreserved ige 1 of 5 i INTRODUCTION: only unmodified Cartridges purchased(hrectly from Xerox or its aulnorized resellers in 1 TOTAL SATISFACTION GUARANTEE. It you are not totally satisfied with any the U S Cartridges packed with Equipment and replacement Cartridges may,be new, Xerox Cram Egdromerl delivered tinder this Agreement, Xerox will,at your request remanuiaciured or rapns-essed Remai)ufachred and reprocessed Cartridges meet replace it vwhout charge with at, identical made!or, at Xerox opl,on,�ailh Xerox Xeroxs near Carindge .;e`onal standards and wntain neat or reprocessed Equipment a.ln comparable features and caeau lilies This Guarantee app,res only to components To enhance prim quality Certndge(si for many models of Equ pmeN have I Xerox band Eau pment the, has been catto,.ously maintained by Xerox under this been designed to cease fancttonmg at a predetermined po nt in addit oo, many Agreement ar a Xerox mamumance agreemon[ For'Pevtously Inslallea'Eculoment, Ent a onenl €yodels are designed to function or=y v✓4h Cartridges that are newly ih s G waritee wi,be etfactve for i year after insiallatior For all other Equipment this manufacture;Ongiral Xerox Cartridges or:wrh Cartridges o'ended for use m fare U S 1 Guarantee will be effective for 3 years after ristallation unless the Equ,pmen'is being T MAINTENANCE SERVICES Except for Equipment denb'led as'No Sac',Xerox financed under this Agreement for mere than 3 years,in which event It v.11 expire at the (or a designated serviced will keep the Equipmor:,n goOJ,workurg order("Maintenance end of the initial Term of it s Agreement Services") Maintenance Servleas will be provided during Xerox's standard working i 2 MODIFICATION OF PRIOR AGREEMENT This Agreement modifies a prior hours -n areas open for repair service for Ine Equipment Maintenance Services agreement between you and Xerox for life Products idenit'ieo as 'Modifies Prior excludes repairs due to (4 misuse,regec or abuse (v)falure of the installation&Ie or Agree=rent' The prior agreement will remain it effect except that any!arms in this the PC or workstation used ivdh the Equipment to comply with Xerox s published Agreement that conflict'+i`h o'are additive to the prior agreement Vvil control You may specifications,fin)use of options,acixssOrlas or products not sec died by Xerox (iv) i be cnargeo a one-lirme admnrstmt,vo✓process rig foe lot the modification of a pnor non-Xerox alieratons,relocation,service or supplies,or(0 failure to pedorm operator agreerent mamfenanco procedures identified in operator manuals Replacement palls may be GOVERNMENT TERMS hey„reprocessed or recovered and all replaced parts become XO'rA s property Xerox ( 3 REPRESENTATIONS&WARRANTIES You represent and warrant,as of the date ix0,as your exclusive remold, for Xerox s lad.,re to provide Maalenance Services, p of th,s Agremenl [flat (1)you area Stale or a l qy constituted oalit,cal subdrvisidn or replace'ne Equipment iSrin an adenflcal model or,at Xerox s option,another model with t agency of the State in which you are located and are authorized to enter into,and carry comparable features ane capaledi'tes There wil, be no additional charge for the out,your om,gakons under Iris Agreement are any otter documents reposed to he replace,rient Eau parent durr,g the remainder of the initial Terri It meter reads are a delivered in connection with Ins Agreemen:(co'Iaei€wrey, the'Documents'), (21 the comporent of your Maintenance Plan,you rill provide them using the method and Occumer,ts have been duly aalhorized execu ell and oxe€ivered by you,n accordance frequency identified by Xerox If you do not provide a meter reading, Xerox may with all applicable laws noes ord canoes and regu'ahons t'nclucrmg all applicable!awls estimate the reading and but you accordingly gover^ing open mile'mgs pub[c bidding tend appropriations required in connection with 8.EQUIPMENT STATUS-Unless you are acquiring'Previously,Installed'Equipment, this Agreement and 'he acqutslmn of the Products; and are valid, legal, binding Equipment:1.be{[)'Newly Marufachued',which may contain some reconditioned agreements,enforceable m accordance with their terms (3f the persons)signing the components, (2)'Factory Produced New Model',which is mant0actured and newly I Documents have me authority to do so,are acting with me full at,thdnzauon of your serialized at a Xerox 'actpry, adds functions and %stores to a product prevously governing body and he d tie o"ces indicated below finer signatures each of which are disassemoled to a Xerox predetermined stardard,and contains new and reconditioned ' genuine (4) the Products are essential to the immed€ate performance of a components,or(3) 'Remanufaetured", which has been factory produced following 1 governmental 01 piap irc.1y fdnCkdn by you wdhn the scope of your authority and wit disassembly to a Xerox predetermined standard and contains new and reconditioned be used during the Tenn only by you and cn'y to perform such function and i,5)your components t paymen'obligations uncer this Agreement con,lilite a curent mxil se and not a debt 9 SOFTWARE LICENSE Xerox grants you a non exclusive,non transferable kdel under applcabie stale last and no provision of this Agtmammt consb,i-tes a pledge of to us=w the„S (a)software and accompanying dor.umentation provided with Xerox- your tax or genera,reven„es and any provision trial is so eonstnled by a court of brand Equipment('Base Sott✓,are)only with the Xerox brand Eau pmeril vil which it ' c0mosleni lunsooron s void from the inception of this Agreement was delivered and ibl software and accdn•pary rig documentation identified m this I L FUNDING You represent and warrant that at payments due and to become due Agreement as"Application So`tware'Orly on any single unit 01 equiprnem for as long drringy(xurcurrentflscalyeararevlhinIrefiscalbudge-ofsuchyearandaremctuded as you are current in the payment of all appicable soft✓rare license fees 'Base within an onresmoulo and unerci-mbered approcration curie^tkt n,adabla for the Software'and 'Aobhcation Software' are referred to collectvely as 'Software' You pJrchasemantenance of the Products,and it is year intent'a use lire Products for the have no other hgnts and may not 11)distribute,copy modify,create donvatwes of, entire tern and to make al;payments required under Ih sAgteement if ii)'hfough no decompile, or reverse engineer Software (2) activate Software delivered with the action inl'ated by you, your legislative body does rot appropriate funds for the Equipment,n an insictmateJ stale or 13)allovi orders to engage it sar,e Tit e to,and continuation of this Agreement for any kscaf year after the first fiscal year and has no all intellectual protnaly fights in Sofivare will reside solely wth Xerox ari is funds to do so from Other sources one (2) you have made a reasonable but licensors(who v.11 to considered ti.rd party beneficiaries of th s Sechsr) Software unsuccessful e"o't to find a creditswar'hy assignee acceptable to Xerox in its sale may contain code capable of autorralva IV disabling the Eou€(anent Disabling code discretion wirer your gdrerai Osganizaticn who can corttnue this Agreement, this may be activated if (A Xerox is pen ad access to penodh airy reset such code,(yf you Agreement real be terminated To effect tins termination you mus',at least 30 days are notified of a default under this Agreement cr(z)your l€c=_nso is terminated or E prior to the begnd.ng of the fiscal year for which your legislative body does not exp res The Base Sa%vare license will lermnate,it)if you no longer use or possess appropriate funds notify Xerox In venting that your tegislatve body fated to appropriate the Equpmert,(ill you ate a lessor of the Equipment are your first lessee no longer fends and'flat you have made the required effort In Ind an assignee Your nowe must uses or possesses it,or jail undo idle expiration or ermrabori df this Agreement ( be accompanied by payment of all sums than Owed Inroagh trier current year under this unless you have exercised your option to purchase.he equipment Nether Xerox nor ' ) Agreement[and must certify that Use canceled EGwpmmnl is not being reo'aced by its licensors warrant Iffall Software will be free from errors or that its operaton All be equipment performing sxrrar functions d nrig the ens i,-9 fiscal year You will return uninterrupted The foregoing terms do rot app y to Diagnostic Sofhvare or to the Equipment at your expense,to a location designated by Xerox and,when returned, softwareteocumentatpn accompanied by a chc.iwrap or shnnxwrnp license agreement the Equ pment.ul be in good coridd on and Irate of all lens and encumbrances You or othenv se made subject to a separate I cease agreement will then be released from any further payment obligations beyond those payments due 10 SOFTWARE SUPPORT Xerox(or a designated servicer)will provide the software for the current f,scal year(.with Xerox rebunirg all sums paid to date) support set kith bakoy✓{'Software Support') Fa✓Base Software,Software Support will SOLUTIONISERVICES be provided during the imfiai Term aria any renewal period but in no evert longer than 5 5 PRODUCTS 'Products' means the equipment ('Eoutpment') Software and years after Xerox stops taking customer orders for the sub,ect model of Equ parent For P r e t r a I i n 1 1 I Y /s i Agreement o the [ for � i will v, are current supplies dent i t s gee r u agree a cd�c's are o your ousmess Application Software,Softvar.,Support vi!be provided d.d as wig as you a e..0 t in use(not resale)in the Urded S ates and its[err tones and possessions('U S')and vn8 the payment of all applicable software license and support fees Xerox cif I mamlan a rot be used for personal no„sail Or family purposes web based or toll-free hotline d,.rng Xerox s standard working hours to report Software 6 CARTRIDGES If Xerox is providing Maintenance Services for Equipment utilizing problems ano answer Software—la'ed questions Xerox, ertner directly or with [is 1 cannoges designated by Xerox as customer replaceab�e units nclud,r, copylpnfit vendors all make reasonatila efforts to jai assure that Software performs in ma[enal cartridges and xerographic modules or fuser modules i'Carmdges;,you agree to use conformity alh rs user docun entalion,(bi provide ava I&e viorkarounds or patties to, i lA VA.'S U09747 01,11,20f 013 37 31 Corkdent at-Copyr.ght)2008 XEROX CORPORATION AlI nghts raserved Page 2 of 5 t ( 1 resolve Software performance problems,and let resolve coding errors for fit tl-e current trademarks used by Xerox to Identify the Coded Font Programs and Typefaces only to I Release and (€€) the previous Release for a penod of 6 months after the current Identify printed output produced by the Coded Font Programs t Release is made avoided to you Xerox etch not be requaed to orcl SoYvrare 4 You may embed copies of file For)'Programs it to your electronic documents to,the ESupped it you have modified Ire Sothtare Nov'releases of Sof^rane that of manly purpose of prrfing ano viewing the document You are responsible for ensuring that rncomomtc comp,rank.rdates ni•d coding error,frxas are cosignataf as"1ahni iti you have;he right and are sutnor zec by a,y r,ecessary third parties in eirbad anv>ont Releases' or Updates' L+a•7tcnarce P,eleases ar Updates trial Xerox may make Programs of a•eclronlc doatmerts croateJ,t Ih trio FreeFlow Appixaton Soflviare If avatab e will be provided at no charge and must be imp erne^tell aft n six mortis the =ont Progrars are €cenefred as 'licensed tot eddat s embedding' at tloA noonsesofSo$.:are that€^.c aeeev,co,tcnlorfcncto^aity('Featurenepesos') w'rrnadcoeco;n•lypeibrowseelegatembendVaihtml,You may also embed copies dill be sub,ecl to addit o^al,icense lees at Xe•o s then-surreal or cing tot€,Amerce of de Pont Programs for the additions purpose of cc rang you•electronic documents. Releases,Jpdates and Feature Releases are collectively referred to as `Rc eases' No older e nbeo9ng rgnts are rot l ell o oerir fled under thus I cerise j Each Release cut I be considered So` care goverrad cy the Software Licerse and 5 If you I sense=reeFlowr Process Manager VIdio.t also licensing the 100-User PDF Saftware Support provisims of this Agreement iunhss oche tese noted), Corvers,onor the Max mum-User PDF Comasron option youtrayasehighresoraftoo Impietrentaton of a Release may require you to procure, it your expense,auddtonal Adobe ")°files resulting from the automated cones on of doci.Tenis only for your haroIiare armor soNvare from Xerox or another entry Uoen installat on of a Pelease, subseque+'t Fr riling purposes It you have also licensed the 100 User PDF Conversion I 1 you v l return or destroy all prior Releases option,vod may use Freaclav Process Manager to convert files into the Adobe PDF ' t 11.DIAGNOSTIC SOFTWARE Softa^aro used to evaluate or maintarn the Ecurpment format for a maximum of one hundrao(100)users 3 ('Diagnostic Salivate') is included with the Equipment Diallisi Sofirreare is a 6 If you license=fee-la'v>Veb Services you may use nigh resolution Adage PDF files ( valuable trade secret of Xerox Title to Diagnusr€c Software will rema,a vvi=h Xerox or its resuli€ng from Inc au'Oraki Corvesror of JOA me^ts Writ to,your subsequent ) licensors Xerox does no:grant you any right*a use D agnostic Software,and you twill printing purp+osas not zecess,use,reproduce a ribute or oisctose Dagnostic Sottware tot any o uposet D You wrl not,without the pnor wniten consent of Xerox and Its licensors (a)aPer the i (or allow third padres to do so) you will alo^a Xerox reasonable access to the digrtaiccnlagurationoitheFreaFfo4eSofi;vate orsc ito'herstocausethesame seas ` Equepment to remove or disable Diagnostic Sofviia'e I you are no longer receiving to change the vista appearance of an;of the FreeFlow Sofh.are output ii use the Maintenance Sear ces from Xerox FreaFovr Software in any may that is not author zoo of this Agreement,(c)use the 12 FREEFLOW LICENSE.The following terns apply to Xerox Freii Print Server embedded code with n'he FreeFiow Scftvare outside of ire equiprnent on vrhich n tvras fDocuSP solavil that is Baso Sritwarc t'FreeFlow Base Softararo') and'or instal red in a stand alone lime-share or service bu•eau model,(of disaoser the results Appi-ahon Soy ware identt ed as Xerox FreeFlow software i€ncludng but not 6miled of any performance:car b richmarr,tests of the FreeFlow: Software, (to cL hl sh the to, Priori Makeready FreieForr Process Manager Frei Output N'anager, results of any benchmark les's of dalaease saftvare licensed Iran Oracle Corporaton Free"-low Aleb Serr€ces FreeFiow Cocument L,bRmy, FreeFo,v Preoress Suds,Print that is incorporated in FreeFlow App'ica ein Sot:verte ,ff use the FreeFlow So#ovaro for Shop PDF Ccnvers on Tool Free�lor, Print Vanager-Advanced Pat^ Punt,and any purpose other Ilan to carry out ids purposes or this Agreement,or{g)disclose or Dig,pa'h to"rrneFew Sothvare Up^,raae)('FreeFlow Appi,cation So`T,vare;and will be otherwise permit any olne person or entry access to he object code of the FreaPlow adartve to those found e;se'r,,ere n'his Agreement FreeFlow Base Software and So(Avare FreeFVosv Application Soltw ire are ca°sanely referred to as"Frxxx9Q.v Scfhxior E Upon not less than forty-frve (45) days prior written notice, Xerox and+ear its A FreeFa;.Scfd•.are may cortar•i..avn lechn-logy licensed from Si,r V crosystems, licensors may,at lher expense,directly or throi.gh an independent auditor,auditvour Inc t'Suri You may not create addhoral classes to,or mou•9whaos of Ire Java use of FreeFlow Process Manager one a! relevant records not more :her once technology, except under eompat.bdity requirements tnrougn a separate agreement annually Any sucn aunt will he conducted at a mutually agree.-tocaton and ,it I not d available at^s ,,t fava net Sun supports and flanks'ha global corri mly of open unreasonably intonate with four business aclivi'rex You agree to cooperate with the ! source develorers`or its mportant cordribut,ons Sun beret fol this community audit and provide reasanap e assistance and access to mfo•ination mcluarug but not , ' mror.gh•,ro open slardards based technology from which many of Suns pmuricts were limr'sel to, ralevan' records ag cements +toikslat,dns, serves and technical j develci=ell Please note that ponsurts of FreeFiow Sotware may oe provided with personnel If an audit rovea s that you have underpaid fees in excess of five percent I j notices and licenses from open source developers ano oiner'hird portals that govern (S'o) then you xwll pay Xerox`s andfor its licerital reasonable costs of conducting the the use of those portions Any Ycenses grantee hereunder do not a ter ary rights and audit obhgalions you may have under such open source I senses how ,ver the d,sciarmer of F in the event Frill cw Process Manager is sub ecl to a landing or leasing warranty and limitation of liab by provisions in this Agreemerl wA apply to all FreeFlow arrangement entered into.vith a party other than Xerox ('Financing Arrangement`) i Software then for the shorter o'ten(10,,years from file date of such F nancang Arangement or B Freeptow Base Software may contain Intelfifont Software licensed from Mono" the specified tern Charon-,the party that pravdcs the Financing Arangement;vr'i not t Imaging Inc ('Moretype') You acknowledge that title 'o the mtef tort Software be prevented Tom enforcing a valid security merest by Ina nontrans(arabie nature of rema ns at all times u.rth Msro€ypa and agree rip'to disclose the Intelttcnt Satrware to the license granted-o you hereunder,provided that die righ's acoumd by such party any third part'vi,thourthe prier„r€fen consent of";forotype and Xerox will otnervisa be restricted in acco'dance W.IA the terns set forth in the Agreement C FreeFlow Software may inck de andtar incorporate certain software provided by goventmg Appoaton Software E Adobe Systems Iricorttoraled,345 Park Avenue San Jose CA 95110('Adobe') G If you license FreeFlow Makeready Copyright Management('FFCM`),the following 1 Adobe, Adobe Coniigwab e Pos;Scripl interpreter Adobe Nornific er, Adobe terms app;y 1 You wwiJ riot disclose the resu is of any benchmark lost ct Microsoft SOL Postscript and Adahe PD= Library tridmiot a y aria collectivity 'Adobe Licensed Server to any third party without fArcrosoR s error written approval 2 It you use the Sol wawa'} are e hoer rem Bred trademarks or trademarks of Acohe in the Urled Copyright Cleararce Caner,Ire ('CCC")copyright licensing sery ces feature of FFCM ' States aeolor aPer coun•r,es Any use by you of trademarks permitted herourder wil' i CCC Sere ce'),you.vid coma with any appitmue'arms and wrist ens coriained on be in accorda•ice with accepted trademarx practice, rrictudma idenhfcanon of the the CCC eaabsrte,anfiw copyright porn and anv other ngrtsholder leans governing use traders ark owners r Give of matanats,which are occessiole in FFCM 3 It CCC term notes Xerox's ngnt 10 offer 2 Adobe is a thud party banetattiary of this Agreement to the extent that this access to the CCC Seri cc through FFCM,Xerox may,upon written note and wtitoaf Agreement contains provisions which relate to your use of Adobe Licensed Software any oability to you terminate vcur nghl to access the CCC Sernoe through FFCM 4 I Such provisions are made expressly for the bereft of Adobe ana are enforceable by THE CCC SERV;CE IS PROVIDED 'AS IS', WiTH0i3' ANY WARRANTIES, I Adobe€oadditontoXerox WHETHER EXPRESS OR ItvfPLkED XEROX DISCLAMS AL'. IVPLIEC 3 Yed are graved toe right to use Q)the digitally-encoded mach ne-readable outline WARRANTIES I.NC_LDING WiTHOLP LiMITA-ION THE Il^iP_IED WARRANTIES OF data ,'front Picgrams'i encoded in the special format and in the encrypted term NONINFRINGEVENT, MERCHANTABILITY At,D FITiJESS FOR A PAftTICU_AR ('Cooed Font Frog'arrs`)to w-,duce^veignts styles and viols o ns or letters,numerals, PURPOSE 5 You will defend and tndernn,ti Xerox from anv,,and ail losses,claims, characters and symbc's Typefaces) on the urwt(s) or Equipment with wh ch the damages I nes,penalties,interest costs and expenses,v oluerng reasonable ahamey Ceded Font Programs were prov-ded of Xerox,or A you nslah FreeFlow App ication fees arising mom or relating to your use of 1"e CCC Service Sot;ware on a computer that you supply than only on such computer and ivy the H 1t you install FreeFlow Application Softp are on a computer that you supply,II WSU03747 C1-1'129'3133732 Confidential-Copytgnii2008 XEROX CORPORATa, Aingntsrese-feu Page3015 Y"'1"177, el a=a . Xerox fallowing terms apply,),You may only install and use FreeFlow Process Manager on a determined by Xerox,less any costs incurred by Xerox, computer having the ability to inn a maximum of tour processors 2 Xerox will only be GENERAL TERMS&CONDITIONS t obligated to support FreeFlow Application Software it it is installed on hardware and 21 NON-CANCELABLE AGREEMENT THIS AGREEMENT CANNOT BE ' software meeting Xerox's published specifcations ('Workstation') 3 If you use CANCELED OR TERMINATED EXCEPT AS EXPRESSLY PROVIDED HEREIN FreeFlow Application Software with any hardware or software other than a Workstation, YOUR OBLIGATION TO MAKE ALL PAYMENTS, ACID TO PAY ANY OTHER all representations and warranties accompanying such Free FlowApoli cation Software AMOUNTS DINE OR TO BECOME DUE IS ABSOLUTE AND UNCONDITIONAL AND will be void and any support/maintenance you contract for in coinection with such NOT SUBJECT TO DELAY,REDUCTION,SET-OFF,DEFENSE,COUNTERCLAIM FreeFlow Application Software vol,be voidable andior subject to additional charges 4 OR RECOUPMENT FOR ANY REASON WHATSOEVER, IRRESPECTIVE OF You are solely responsible for (I)the acquisition and support,including any and all XEROX'S PERFORMANCE OF ITS OBLIGATIONS HEREUNDER ANY CLAIM associated costs, charges and other fees, of any Workstation you supply, (u) AGAINST XEROX MAY BE ASSERTED ,N A SEPARATE ACTION AND SOLELY compfance with all terms governing such Workstation acquisition and si pport, AGAINST XEROX Including terms applicable to any non-Xerox software associated with such Workstation' 22 REPRESENTATIONS The individuals signing this Agreement are duty authorized - and(in)ensuring that such Workstation insets Xerox s pub'ished specifications Xerox to do so and all financial information you provide completely and accurately represents reserves the right to charge its then-current time amp materials rate for any time spent your financial cond.hon supporting a Workstation that does nor meet Xerox's pubushed specifications 23 LIMITATION OF LIABILITY. Except for liability under the indemnification PRICING PLAWGFFERING SELECTED obligations set forth in this Agreement,Xerox will no'be liable to you for any direct 13 TERM The Term for each unit of Equipment will commence Anon Ian delivery of damages m excess of$10 000 or the amounts pad hereunder,whichever is greater, customer-installable Equipment, or (b) installation of Xerox-installable Equipment and neither parry will be table to the other for any special, indirect, incidental, Unless either parry provides notice of termination at least thirty days before the consequential or punitive damages arising out of or relating to this Agreement,whether expiration of the initial Term,it will renew automatically on a month to month basis am the claim alleges tomous conduc-Including negligence)ant any other legal theory Any ! the same'erms and conditions During this renewal Denod,either parry may terminate action you take against Xerox must be commenced within 2 years after the event that the Equipment upon at "east 30 days notice Upon termination,you will make the caused it Products available for removal by Xerox At the time of removal,the Equipment will be 24 CREDIT REPORTS You authorize Xerox or its agent to obtain credit reports from in the same condition as when delivered(reasonable wear and tear excepted) commercial credit reporting agencies 14.PAYMENT.Payment including applicable Taxes)is cue within 30 days after the 25,FORCE MAJEURE Xerox will not be liable to you cluing any period in which its wo ce late with ail charges being billed in arrears This Agreement will not be performance is delayed or prevented,m whole arm p31,1y a circumstance beyond its I automatically renewed reasonable control Xerox will notify you A such a circumstance occurs I 15.LATE CHARGE. If a payment is not received by Xerox within 10 days after the due 26.PROTECTION OF XEROX'S RIGHTS You authorize Xerox or its agent to file,by date,Xerox may charge,and you will pay,a late charge of 5%of the amount due or any permissible means,financing statements necessary to project Xerox s rights as $25,whichever is greater lessor of the Equipment You will promptly nohly Xerox of a change in ownership,or it ! 16.PRICE INCREASES.Xerox may annually increase the maintenance component of you relocate your principal place or business or change the name of your business I the Minimum Payment and Print Charges,each such increase no to exceed 100% 27. WARRANTY & FINANCE LEASE DISCLAIMERS XEROX DISCLAIMS THE For Application Software,Xerox may annually increase Yoe software ncanse or support IMPLIED WARRANTIES OF NON INFRINGEMENT AND FITNESS FOR A i fees,each such increase not to exceed 10,. These adjustments will occur at the PARTICULAR PURPOSE This Agreement is a't nance lease'under Article 2A of the I 1 commencement of each annual contract cycle Uniform Commercial Code and,except to the extent expressly provided herein,and as i ' 17. DELIVERY, REMOVAL. & RELOCATION Equipment prices include standard permitted by applicable law,you ware all of your right: and remedies as a lessen delivery and removal charges Nortstardard delivery and Equipment relocation must under Article 2A i be arranged(orapprovec in advance)by Xerox and will be at vour expense 28 INTELLECTUAL PROPERTY INDEMNITY Xerox will defend and pay any 18 TAXES y ou will be responsible for all applicable taxes,fees or charges of any kind settlement agreed to by Xerox or any final judgment for,any claim that a Xerox brand S (including interest and penalties) assessed by any governmental onlrly on this Product infringes a third party's U S intellectual property rights You will promptly nobly Agreement or fine amounts payable under this Agreement ('Taxes'), which will be Xerox of any alleged infringement and permit Xerox to direct the defense Xerox is not included in Xerox is invoice unless you timely provide proof of your tax exempt status responsible for any non-Xerox litigation expenses or settlemems unless it pre-approves Taxes do not include personal property taxes in jurisdictions where Xerox is required 10 them in writing To avoid infringement,Xerox may moll or substitute an equivalent t t J pay personal property taxes and taxes on Xerox s income This Agreement is a lease Xerox brand Product, refund the price paid for the Xerox brand Product (less the for all income lax purposes and you will not claim any credit or deduction for reasonable rental value for the penod it was available to you) or obtain any necessary I depreciation of the Equipment,or take any other action Inoonsistent with your role as licenses Xerox is not liable for any infnngeiient based open a Xerox brand Product i lessee of the Equipment being modified to your specifications or being used or sold with products not provided i 19 PURCHASE OPTION If not in default you may purchase the Equdmonl,'AS IS, by Xerox i s WHERE lS'and WITHOUT ANY WARRANTY AS TO CONDITION OR VALUE,at the 29 TITLE & RISK OF LOSS Until you exercise your Purchase Option (a)title to i end of the initial Term for the'Purchase Option"indicaled on the face of this Agreement Equipment will remain with Xerox,(b)Equipment will remain personal property,(c)you (I e, either a set dollar amount or the fair market value of the Equipment at the will not attach the Equipment as a fixture to any real estate (d)you will not pledge sub- I expiration of the initial Term!,plus all applicable Taxes lease or pail with possession of it,or file or permit to be filed any ben against it,and,(a) j 20.DEFAULT&REMEDIES You will be in default under this Agreement it(1)Xerox you will not make any permanent alterations to It Risk of loss passes to you upon does not receive any payment.vlthm 15 days after the date 9 Is due,or(2)you breach delivery and remains with you until Xerox removes the Eauipnenb You w II seep the I any other obhgahon in llis or any other agreement with Xerox If you default,Xerox Products Insured against loss or damage and the policy,will name Xerox as a joss j may,in addition to its other remedies including cessation of Maintenance Services), payee l i remove the Equipment at your expense and require immediate payment,as liquidated 30 ASSIGNMENT Except for assignment by Xerox to a parent,subsidiary or affiliate damages for loss or bargain and not as a penalty,of (a)all amoants then due,plus of Xerox or to secrxitize this Agreement as part of a financing transaction(`Pernntled , interest from the due date until paid at the rate of 1 S%per month,(b)the Minimum Assignment') neither party will assign any of Its rights or obligations under this i Payments (less the Maintenance Seances and Consumable Suipphes components Agreement without the I written consent of the other party In the event of a thereof,as reflected on Xeroxs books and records)remaining m the Term,discounted Permitted Assignment (a)Xerox may,without your prior,written consent,release to the at 4%per annnm,to)the applicable Purchase Option ant(d)all applicable Taxes You proposed assignee riformalion it has about you related to this Agreement (b) the 1 I will pay all reasonable costs,Including attorneys'fees,incurred by Xerox to enforces assignee will have a I of the rights but none o1 the obhgatons of Xerox hereunder,(c) t Agreement 11 you make the Equipment available for removal by Xerox within 30 dlys you will continue to look to Xerox for performance of Xerox s obligations,including the after notice of default In the same condition as when delivered(reasonable wear and provision of Maintenance Servces,(d)you waive and release the assignee from any fear excepted),you will receive a credit for the fair market value of the Equipment s claim relating to or arising from the performance of Xeroxs obligations hereunder,(9); Section 20,_DefauIt&Remedies 'You wtH Irk any dispute arising from the parties'performance of thts�greamergt,each paItt WS U09747 0111112010 13 37 32 Confidential-CopyrglI2008 X 0 shall pay its own rea5onablecosts,including attorneys'fees, friturr0by (ef tgenfor�Ehrs eemeni_G�ofKent 2/a 2010 you shall not assert any defense, counterclaim or setoff you may have against an writing and signed by both parties Any terms on your ordering documents will be of no assignee, and (f) you will remit payments in accordance with instructions of the, force or effect The following four sentences control over every other part of INS assignee Agreement Bout parties will comply with applicable laws Xerox will not charge or 31,MISCELLANEOUS_Notices must be in writing and will be deemed given 5 days collect any amounts in excess of those allowed by applicab!e law Any part of this after mailing,or 2 days after sending by nationally recognized ovemght courier Notices Agreement that would,but for the last four sentences of this Section,be read under any will be sent to you at the'Bi I to'address identified in this Agreement and to Xerox at circumstances to allow for a charge higher than that allowed under any applicable legal I the inquiry address set forth on your most recent invoice,or to such other and ess as Imid,is modified by this Section to hm't Elie amounts chargeable under this Agreement either party may designate by wnren notice You authorize Xerox or is agents to to the maximum amount allowed under the legal limit It, in any circumstances,any communicate with you by any electronic means (including calfular phone, email amount In excess of that allowed by law is charged or received any such charge will be automatic dia!irg and recorded messages)using any phone numbe,(mciufing cellular) deemed limited by the amount legally allowed and any amount received by Xerox in ' or electronic address you provide to Xerox s Agreement consttules the entire excess of that legally allowed wil be applied by Xerox to the payment of amounts l agreement as to Its subject matter,sepersed II prior oral and wittten agreements, legally owed under this Agreement,or refunded to you and will be governed by time laws o`Cho State of�Vew York(wrthodt regard to conflict of- 32,REMOTE SERVICES Certain models of Equipment are supported and serviced law principles) In any action to enforce'nis Apzeament,the panes agree(a)to the using data that is automatically cotected by Xerox from the Equipment via electronic lunsd ation and venue of the lederal and state c4irts in Monroe County,New Yore,and transmission from the Equipment to a secure off-site location Examples of (tit to waive then right to a jury trial If a court finds any term of this Agreement automatically transmitted data include product registration,meter read,supply level unenforceable,the remaining terms will remain hi effect The failure by either party to Equipment configuration and settings,software version,and problem faUt code data exercise any right or remedy wid not coni a'waiver of such right or remedy Each All such data shall be transmitted in a secure manner specibed by Xerox The party may retain a reproduction(a g,electronic image,ehotocepy,fees"le)of this automatic data transmission capability will not allow Xerox to read,view or download I , Agreement which will be admissible in any acbonito enforce it,but only the Agreement the content of any Customer documents residing on or passing through the Equipment 11 held by Xerox will be considered an original Xer'bx may accept this Agreement either or Customer's information management systems I by signature or by commencing performance Changes to this Agreement must be in 3 t ! Section 31,Miscellaneous. "This Agreement constitutes the entire agreement as to its subject matter,supersedes all prior oral and written agreements,and will be governed by the laws of the State of New York Washington(without regard to conflict-of-law principles). In I any action to enforce this Agreement,the parties agree(a)to the I jurisdiction and venue of the federal and state courts in Monroe King County,Washington New York,and(b)to waive their right to a jury i trial. i City of Kent 2105/2010 71 I i i i I i f i I ' I ' I I I I � I 1 I ' I ( I j t[€ I f E I WS U09747 0111li2010 13 37 32 Confidential-Copyrghi@2008 XEROX CORPORATION All rights reserveo Page 5 of 5 x ro . _) Customer KENT,CITY OF PARKS&RECREATION BwTo CITY OF KENT Install CITY OF KENT PRINT SHOP LOCATION 2204th Ave S 220 4th Ave S Kent,WA 98032-5895 Kent,WA 98032-5895 ITax ID# Exempt State or Local Government greement Information Requested five Date 1 P120CP(SOT-120 COPIER/PTR) S/N KRC555237 Lease Term 12 months 4/15/2010 -30 Amp To 20 Amp Purchase Option FMV -Printeract-connect This agreement modifies the current Xerox -Operating System Sw Agreement 956668925 for P120CP S/N KRC555237 -Ethernet N/w Package as of payment 58 -Imposition License -Professional Mff 2.D242(SOT-DOCUCOLOR 242) S/N DIX270521 Lease Term 12 months 4/15/2010 -Advance Finisher Whole Punch Purchase Option FMV This agreement modifies the current Xerox Agreement 957233265 for D242 S/N DUX270528 as of payment 58 3 EXP252(SOT-FIERY DFE 242152) SIN EEA115875 Lease Term 12 months 4/15/2010 Xnte S2 Densitometr Purchase Option. FMV Ga Premium Kit Editn This agreement modifies the current Xerox ' Agreement 957233448 for EXP252 S/N EEA015875 as of payment 58 iii!iiiliii!;�""""i;Jlia�filiJil(i(i!; i k�!Ii1i{,IIIIIidGtlillllix ` li(It' , ;;'!;",(iIl(I(1(ii, rCustomer acknowledges receipt of the terms of this agreement Thank You for your businesst which consists of 6 pages including this face page -, This Agreement is proudly presented by Xerox and �i Signer Suzette Cooke Mayor Phone (253)856-4646 Howard Chiu j TTAA (425)780-0686 SA�ACT,i� For information on your Xerox Account,go to GUARANTEE! �J Signature Date www xeiox com,Accounttv1anzuenent i ti� .... .,- r ,i zr<s-rswrr-�wis.rs..ras�r+vrraeae»n ur.�.- .> _ -i r- - � ,irwa: s=.•tta�. + i �<^ti-ara -.v+' WS T75402 W l 1t 31 32 ifid,n ial CopynghP-)L?Od xt i,'x CJl F ;fJ N iigh w Irv, I ao 1 of 6 xerox � 1 P120CP $2,014 40 1 Total 1 -125,000 Included -Consumable Supplies Included for all prints I 125,001+ $0 0065 -Meters Reconciled Quarterly 2 D242 $1,238 80 1 Color 1 -15,000 Included Consumable Supplies Included for all prints 15,001+ $0 0590 -Meters Reconciled Quarterly 2 BW All Prints $00129 -T 3 EXP252 $2730 N;A N,A N-A -Full Service Maintenance Included -Meters Reconciled Quarterly Total $3,280 50 Minimum Payments(Excluding Applicable Taxes) 1 t 1 WST754V ?n10'43132 C ha Co , i ,'ORATION All rights reserved a 2of6 xerox {') INTRODUCTION. Supples') For full-color Equipment,Consumable Supplies will also ncude color toner 11. TOTAL SATISFACTION GUARANTEE. If you are not totally satisfied with any and developer For Phase, Oroaucts Consumable Supplies may also include, if 1 Xerox-brand Ecru prrert delivereu under this Agreemenl,Xerox will at your request, applicable,o ack so lit mti,color so to ink, maging trots,roast,cartridges 'rarsier roils, i replace d ,vTroul charge with an identical made] or,at Xerox's option, with Xerox transfer belts, transfer units, be.t cleaner,maintenance kris c,r' Cafhidges drum ' Equipment with comparabe females and capab lilies "nis Guaranles apolars only to Cabrmgas +,vasle trays and c=caning Ivts Caisi,mab:e Supplies pre Xerox's property Xerox-brand Equipment that has been conf ruoasiy mamia,red by Xerox under this until used by you and you Will use then only will the Equipment for voli � Agreement or a Xerox maintenance agreement For'Prevrous'y lnsta6ed'Equipment 'Consumable Suppl es is ider iLed in va,r3eaance Plan Features If Consumable this Guarantee w li be effective for 1 yea,after installation For all amer Equipment,this Supplies Includes Canndges trial are f mashed vain are Pad shipping labels,you will Guaranis,will be effective for 3 years after tWahahon unless the Equ pn ern is being return used Carnage,to Xerox lo'remanulac'urng Upon expiration of this Agreement financed under this Agreement for more than 3 years,in w uch event it mll expire at the you will return to Xerox any unused Consumable Supbdos that are furnished mun pre end of`ne imtral Term of Iris Agreement. paid shipping tabefs and destroy at oiler unused Consumable Supplies if your use of 2. MODIFICATION OF PRIOR AGREEMENT. This Agreement modifies a prior Consumable Supplies exceeds Xerox s pub,shed yield by were than 100G,Xerox will agreement be ween you and Xerox for the Products identified as "Moddres Prior Panty you it s,ich excess u sage If st ch excess usage does flat cease rial ii 30 days Agreemenr The prof agreement A0 remain in affect except that any terms in this after such nonce Xerox map charge you for such excess usage Upon request,you Agreement that confud wIn a,are addiime tote prior agreement will control You may will provide an nventi of Consumable Supplies in your pcssess.on i be charged a one-time a0m,r,slocivetprecessing fee for the modification of a prior 7.CARTRIDGES if Xerox is pier ding Mantenance Services for Equipment utilizing agreement cads ges designated by Xerox as customer replaceable units, including copylibml 3 GOVERNMENT TERMS: cadridyes and xerograph c modules a fuser medaies('Cadndge>),you agree to use 3.REPRESENTATIONS&WARRANTIES i representand warrant,as o'tre data only unmodified Cartridges purchased d Trt,y from Xerox or its authorized rasehers in of this Agreement,that (1)yea are a State or a fuCy eonstnu'ad pmmcai subdivision or the U S Cartrdges packed wi,h Equpmenr and rep€ecament Cartilages may be new, age`h y of the Slate n wh on yos are located and are author zed to enter into,and carry remanufactured or reprocessed Pemanufactured and reprocessed Carridges meet C out,you,obligations under this Agreement and any other docanterts requ,r(-d In be Xerox s new CaRndge performance standards and contain new or reprocessed delivered ih corneorl with the Agreement{oolleck iv tne'Documents') t21 the components To enhance printqueriry,Cartage(s)for many models of Equipment have Documents have been duly authorized,executed amid delmnad by you=n accordance been desigred to cease fanct,onrg at a predetermined point In addition, many with all applicable laws,rues,ordinances and regulations(oc'uding all applicable laws Equipment models are designed to function only w4h Cad,dges that are newly govern rig open meetings public lediing aria appmprahans required in connect on with rnanufav'ured ongirol Xerox Carinuges cr.vrh Garfndges,nerd for use in the U S this Agreerent and the acquisihor of the Products) and are valid, legal bnamg 0 MAINTENANCE SERVICES_ Except for Equipment idenhfiea as-NP Svc',Xerox agreements,enforceable in accordance with their terms,0 fre pe'scntsi signng the fora des gnated servicer)will keep ins Ecpiipanant in good-rorkmg order f'rvi ntenance I Documents have the authority to cc so are act ng with the lull authorization of your Services`) Ma nlenance Services yr I be pi dtrr rig Xerox's standard warring governing boot'and hold the offices indicated below their signatures each of wh ch are hours in are35 Open for repair service for the Equipment Maintenance Services genuine, Of tree Products are essential to the mmedare penormance of a excludes rep.nrs dde to (i)mrsdse,neglect or abuse,da IaE9ure of the;rs;allalon site or i govarrmertalor proprietary fum,lien by you:vithin the scope of your authony and or11 the PC or workstaho*n used ,.iln the Equpment to comply w.th Xerox's punished be used ar ring the Tenn only by yod and onfy to perform s ich IL nation,and(5)your specs ica ions lui€use of options arcesso,ies or products not sery ced by Xerox try) payment Obligations.order tuts Agreement constitute a airrer t expense and not a debt nor-Xerox aderations relocation Service or supplies or(vi farlwe to pinhorm operator under applicable state law and rro provision of this Agreement constitutes a Fledge of maintenance procedures itch tied to operator mannais Replacement parts may be your tax or genera,revenues,and any provision that is so construed by a court of new,reprocessed or recovered arc all replaced pails oecome Xerox's property Xerox competent jurisdiction is void from the inception of this Agreement wrl,, as your exclusive remedy for Xerox s failure to prey de Ma rienance Services. 4 FUNDING You represent and warrant that all payments due and to become due replace the Equipment with at,identical model or,at Xerox's opon,another model with durng your current fiscal year are wth n the fiscal budget of such year and are included comparable features and caoabi'ries There w1l be no additional charge for the wilhir an unrestricted and unencumbered appreprafron currently avai able for the replacement Equipment during the remander of the imhai Term t•meter reads are a purchase4mainter)arce of the Products,and a rs your rntert to use the Products lot the cornponem of your Maintenance flan,you will provide them using the method and !!!� entire term and to make all payments required under his Agreement if(')thro gh ro frequency identified by Xerox It you do not provide a meter reading Xerox may action initiated by you, your ,egslanve body does not approprate funds for the estimate the reacing and bill you accordingly continuation of this Agreement for any Iscal year alter the bust f scat year and has no 9 EQUIPMENT STATUS Unless you are acquiring'Previously Installed'Equipment, funds to do so from other sources, and (21 you have made a reasonable bud Equipment vrdl be(1)"Nowlp Manufaciurec',ohich may contain sane reconditioned unsuccessful effort to Ind a creditworthy assignee accepmble, to Xerox in its sole components,(2) 'Factory Produced New:#dodos', vilicn ,s manufactured and newly discretion within your general organization who can conl,nue this Agreement, this serialized at a Xerox factory, adds tunchons and features to a uioduct previously Agreement may be terminated To effect this term nation you must at least 30 days disassemb`ed'o a Xerox predetermned standard and ccriairis new anc reconditioned 1 prior to Ito bag•mmng of the fiscal year for which year legislators body does not components, or(31 "Remanulaclured', when has been fach y podu,ed following I appropriate funds,notify Xerox in writing that your legislative body fa+'ed to appropriate disassembly to a Xerox predetermined standard and conains rev and reconditioned funds and that you have made the required effort to rrd an assignee Your notice must cornpc,ents be accompanied by payment of all sums then owed through the cunem year under this 10 SOFTWARE LICENSE Xerox grants you a non-exclusve non-transferable license Agreement and most notify that the canceled Ecapment is not being replaced by to use,n the U 5 ra)so iw ra one acaa van qrg d cumartaiior provided win Xerox- equpment performing similar functions during the er img fiscal year You vall return brand Equipiren','Base Sof wa e)only will the Xerox brand Equmrert wdn.which it the Equipment,at your expense to a location oesig•naled by Xerox ard,when returned, was delivered and(b)sothiirare and accompanying docu rnonla'ion idaN=f,ed=n this the Equipment will be in good cond.lon and free of al I ens arid encumbrances You Agreement as'App,caton Softvrate'only on any single and of eqa to tent for as long i will then be released from any further payment obhgahons Deyond those payments due as you are current in the paymart of all applicable software rams, tees 'Base for the current'iscal year ivrilh Xerox retaining all sums pa d to date` Software' and 'Application S.^,fC.aars'are referred to collective y as'SoR,vare' You SOLUTIONISERVICES. have no other lights arid may ror (1,d,strbule,copy modify,create derivatives of, t 5 PRODUCTS 'Products' means the equipment ('Equipment'), Software and decarmi or reverse engineer Software, (21 activate Software delivered with Use i supp.ss identified in this Agreement You agree the Products are for your bus less Equipment in an inaciwatea state,or(3;a low ofrers to engage in sane Tile to and i use(not rescue)in the Uri'ed States and its territories and possessions t`U'S't and will all Intellectual property, Pghts in, Softrare will, reside soi wnfi Xerox ardor its not be used for personal,household or family purposes licensors fwho evil be considered dnid-party beneficiaries of this Section) Sorhaare 16 CONSUMABLE SUPPLIES If'Consumable Supplies'is identified in Nantenance may contain code capable of automatically disabling the Equipment, Disabl rg code Plan Features,IvIa,menance Services wolf mdude black toner!excluding le,l hi color may be aehvaled,I off Xemx,s den el access to penclIcahy reset such cone (y)you ,toner), black developer Cartridges, and, if applicable fuser agent {'Consumable are notified of a default urder this Agreement, or rz)your license is terrerrated Of i 4tf6 F;ln[U2 61 it Zulu 13 vu 14 'c^sal-:,aF,i right ICCn X=ntiX GO-PO-IATIUV Ali nghfs rese•ved t aged of 6 :r'o " expires The Base Software license will terminate (if if you no longer use or possess C FreeFlow Sofwvare may include function Incorporate certain software provided by IN Equipment (if)you are a lessor of the Equipment and your first lessee no longer Adobe Systems Incorporated,345 Park Avenue,San Jose CA 95110('Adobe') , ices or possesses it or atilt upon the expirat.on o' termination cf this Agreement, I Adobe, Adobe Cori curable PostScript Interpreter, Adobe Normalize r, Adobe unless you have exercised yawcapon to rwcrase the equpinena Nerve'Xerox nor PostScrpl and Adobe PDF Library individually and collectively 'Adobe Licensed its€censors v tyrant that St;tvaro wit he[too from ersars or that is operatdn vall be Sof°rare') are simin registered traderrarxs or lowemarks of Adobe in the United , uninterrouted The forego rig terms do r•a, apply to (t agoost€ Sattware or to Sla'es ardor other corm iea Any use by you of tmdernarks permitted hereunder will sd1M,a,ernocumen1aton accompaned by a c€ckwrap a,sh€nkwom icense rrimzment be in accordance with aerospace trademark practice, includng tdentfication of the orother.vise made sub,eat-oaseparate canseagreement trade^aTkovmersnarre j 11.SOFTWARE SUPPORT.Xerox for a designated sere"car)will crovide,the software 2 Adobe is a guru party beneficiary of this Agreement to the extent that this support set forth below('Software Suppod'? For Base Sod.rare,Software Support will Agreemen coiitams provision s'Juch relate to your use of Adobe Licensed Software be provided during the initial Term and ary rehecial period but in no eeee€criget than 5 Such p-ov,sicns are made oxprassy to,the benef I of Adobe and are enforceable by years error Xerox stops taking customer orders for the subject model of Ent ipfrient For Adobe in ackta en to Xerox Application Software,Software S oporf vol be orov€ded as long as you are current in 3 Yoa are granted the right to use fit the digAilliv encoded mash'ne raadable out.ine 1 the paymen'a+it applicable sotbutre license and support fees Xerox coil ma earn a data I'Font Programs') encoder; in the special formal and in Ire encrypted form web based or tel-free hottne during Xeroxs stardard rsrorkirg hours to report Seltuare ('Coiled Font Programs)to produce weights,styles,and vers ons of loners,rirrerals, problems and answer Software-related questions Xerox, eitner cirecty or writ its chatacte s and symbols("Tppafasse') on the Untie) of cgwpinert v.,th wticn the vendors,wail make reasonable eForts to (at assure trat Somvare performs in material Coded Font Programs ve a provided by Xerox,or it you install FreeFlo",v Applicahcn corlorm4y with its user documentation (bi providis available arorkarourds o'parches to Sobware on a computer that you suppy then only on sudh computer and el, the resolve Software ueddrmance problems,ano(c)resolve coding errors for f)the current trademarks used try Xerox to identify the Coded Font Programs and Typefaces only to Release and (€r} the previous Pelease far a period of 6 months after the current Identify printed output produced by the Coded Font Programs Release is mace available to you Xerox wit not be root€fired to provide Sc`nwarer 4 You may embed copies of the Fort Programs into your electronic documents for tie ; Supcor I`you have modified the Software New releases of SofB,are that pnmanly purpose of printing and vie'.viig Inc easement You are responsible for ensuring that ,ncorperate comp)arcs updates and coring error fixes one designated as'Mallutenance you have the right and are authorized by any,necessity mud pad es to embed any Font Releases' or "Jpdates' klaintenarce Releases or Upcales Ina'Xerox may make Programs at electronic decal created with the FreeFlo v Applrca'ion Software It avai'atylb will be orovided at ro charge aid must be implerrented wit m six months the Font Prograis are idenb"ied as 'i censea for eddab e embedding" at Nei ralmasas of Software than include now content or functionality{'Feature,Releases') will adobe com'type,'brovrse,legat'embeddingeu a min 1,you may also embed copies ;rill be subject to audit coal icense fees at Xerox s Timi current pricing Maintenance of the Fon'Programs for Ire eii anal purpose of err fag your ti ecorma,dotumeols Releases,Updates and Feature releases are on lectr,ely referred to as 'Releases' No otherambedd ng rights are implied or pemntled under this license Each Release will be consrdered Sot^care govemeo by the Software License and 5 If you icense=reoPicw Process Manager wtntrit also lioansmg the 100-User PDF Softtsare Support orov sons of th s Agreement (unless othariv,se noted) Conversion cilia Maximum User PDFConversion option,yot may use high resoluton ; implementation of a Release may require you to procure at your expense,additional Adobe PDF files resuf€ng from the automated convens on of documents only'a,your hardware andtor sohvnare from Xerox or another entry Upon instal"alien o-a=elease, subsequem pnffiing purposes I-you haae also iwensad the too-User PDF Ccrversion j you•vdl return or destroy all prior Releases option you may use FreeFlow Process'darager ter convert files into the Adobe PDF i 12.DIAGNOSTIC SOFTWARE Software tundra evaluato or maintain tie Egarpmant format for a maximum of one hundred(100)users I'Diagnost e Sctrait re') is included with the Equipment Diagnostic Software is a 6 If you license FreeFlow'Nen Services,you may use high resolution Adobe PD;-files vat,ai'e Made secret of Xeroti Tie to Ciagndst c Softvare will re.^air faith Xerox or ifs resell from tine automated conversion of documents only for your subsequent licensors Xerox does not grant vcu any nghr to a<e D agnstc So';rare and you will print inl purposes not acres" use,reproduce d shibute or disclose Diagnostic Softtare to,any purpose D You:v-ll not without the prior eottao consent of Xerox ano is licensors raj alter the j (or a ov. third parties to ao so) You xul afo1,w Xerox reasonable access to the digital ecn4guration of ilia FreeFlow Software,or solicit others to cause the same,so as I Equ Diner;to remove of it sable Diagnostic Sobviare t you are no longer receiving to change the v suit appea'ance of any of the FreeFlow Sofh,vare output,(bi use tie Mainterance Services from Xermr FreeFlow Schwan in any wan that is.)at authorized by€pis Agreement,(of use the 1 13 FREEFLOW LICENSE The follow ng terms apply to Xerox F€eeFlow Print Sever embedded code within the FreeFlot Softvare outside of the egmpmem on which rtwas I rpocuSP software That is Base Software ('FreeFl(w., Base Sottvare'} ano=or installed in astand-alone,hrre-share or service Winer morel rd)d sc;ose the results Appication Software=denuied as Xerox FreeFbN software(including but not limited of any performance or bencnr)ark lasts of the °reeFlor; Sathvare, raj publish the to.FreeF000,Lfai.ereacy,FreeFlowv Process Manager,=reeFow Cali Manager results of any bencnmara'osts of dat2base sotMvarc'censad front Creole Corporalon , FreePlo^r ilNeb Sena€cos FreeF'av Document uibrary preeRow Prepri ss Su to,Pi that is incorpora'ed in--reeFlo:r Aup!uaUon Software,If)use the=reeFlo,u SnMrrare,for Shop PDF Conver coil Too' Gre(,Flow Pon, Manager -Arnvanced Palo Print, and any purpose other than to carry out toe purposes of this Agreement,or',gl disclose or Digipath to FreeFlow Sixtylare'Jpgrade)C reeFlosr Application So#Ir,are`)and will be otherwise permit any other person or ant ty access to the object code of the Free^"low additve to those fodnd e'srrwhere in this Agreement FreeFlow Base Softrrere and Software t FreeFlowr Application Software are oaae€bvehy referrea to as`FreoFloii Software" E Upon not less than forty-five (451 days prior written notice Xerox andor its A F1eeFlois So`ware may contain Java technology licensed from San Microsys•e,ms, licensors may,at their expense direc9y or through an ndspendent au.litor audit your Inc I'Sun`) You may not create additional classes to,or mddi#icatc is of the Java use of FreeFlow Process tfanager and al, re'evant records not more 'ban once technology except under comparbiity requremehts through a separate agreement annually Ary such audit is 8 be conducted at a mutually agreed•ocaucn and evil not 1 ' available at r.v.vr lava net Sur,supports and thanks the global community of open unreasonably interfere,wa'h your bpsiress activities You agree to coopera'e with the i source developers for its arreo0alit coninbu erns Sun nerel.ts from this commun€ty audit ano provda reasonable assistance one access to o formation nc L,d rg,but not Imougntheopenstandards-basedtecrmeegyfrom•whichmanyofSun'sproductsvere fimileo to, re' pant records, agreements, workstations servers, and leohn,cal i doreioped Please r,)w that oodrons of FreaFow Sclfware may be provided rrth personnel it an and=t reveals that you pave underpaid fees in excess ct f ve percent rotces and licenses from cash source de,c opers and other bra par,as Ina'govern (5°st,;nun you will pay Xerox s ardor as licensors'reasonable costs of conducting the the use of those portions Any I canes granted hereunder do rot a let any ngms and audit obkgat ons you may have under such open source licenses,however the cisclauner or F In the event FreeFktw Process kilanager is sub,ed 10 a lending or leasing warranty and i irdiban of 3 aBil€ty provisions m this AgreernerM ill apply to a I FreeFlow arrangement entered nto w Ili a party other than Xerox f`,:Inancmg Arrangeh;arl Saf wit e then,ter the shorter of on 001 years train Ina parent such Finene rig Arrangement or B F,PeFlow Base Soft€rare may contain intell•foni SoMuare licensed thorn tytonotype the speciheo form therac`,the party that provides the Financ,hg Arrangemert will not I Imaging Inc t" drusiype') You aclmowiedge that title to the Intelf lout Sofavare be pre entail from en`orcing a vaid security interest by the ricntransferable nature of evict 1s at al tines with P,cnah}pe and ag ee not to viscose the`rite€Mont Software to the aiceose granted to you hereunder,prove.led that the rights acquired by such party 1 any igtrd party wNhout the oror vntlenconsent of Morotype and Xerox will otnenyise be restricted in accordance with the terns set forth in the Agreement,t t _i.... ��a 4VST7� 02 01,`t=20t01340t4� Confidanlal- pyugir 8XEROXCORPORAT,CPt Al rgilsreseuec Pageadfc Secnon20,,Uefault&Remedies "You will ln any-dispute arising from the parties'performance of this Agreement,each party shall pay its own reasonable casts,including attorneys'-fees, FRI incurredbxXeroxtaenioFcetIAgseetmnt_GtyofKe�t2/OS/19}0 o -- --— -------Tons,ad CFnhilitiom ---' ---� governing Application Software, WHERE IS'and WITHOUT ANY WARRANTY AS TO CONDITON OR VALUE at the G,If you license FreeFlow Makeready Copyright Management('FFCMh,the following end of the initial Term for the'Purchase Opeot indicated on the face of:h s Agreement 1 1 terms apply 1 You ev,h not disclose the results of any benchmark last of Microsoft SOL It e, either a set dollar amount or the fair market value of to Equipment at the Server to any third party without Microsor s prior written approval 2 If you use the expiration of the imhal Term) plus all applicable Taxes Copyright Clearance Center,Inc I'0CC')copyright bcensmg services feature of FFCM 21 DEFAULT&REMEDIES You v:dl be in deault under this Agreement if it)Xerox ('CCC Service'),you will comply with any applicable terms and conditions contained on does not receve any payment within 15 days after the date it is due,of you breach the CCC website,www wpyrghtcom,and arty other rghtsholder farms governing use any other obligation in this or any other agreement with Xerox It you default,Xerox k of mane,ials,which are accessible in FFCM 3 11 CCC terminates Xerox is right to offer may,or addition to its other remedies(including cessation of Maintenance Services), I access to the CCC Service through FFCM,Xerox may,upon written rohce and without remove the EciLiprnent at your expense and require anmedate payment,asi'l quioated I any habit ly to you,terminate your right to access the CCC Se v,ce through FFCM 4 damages for loss of bargain and not as a penalty,of (a)all amouns then xi.e,plus THE CCC SERVICE IS PROVIDED 'AS IS', WITHOUT ANY WARRANTIES, interest from the due date until paid at the rate of 1 5%per month (b)the Nvmmum WHETHER EXPRESS OR IMPLIED XEROX DISCLAIMS ALL IMPLIED Payments Iless the Maintenance Services and Consumable Supplies components WARRANTIES,INCLUDING WITHOUT LIMITATION THE IMPLIEE WARRANTIESOF thereof,as reflected on Xerox s books and records)remadung in the Term disco4ted NONINFRINGEMENT, MERCHANTABILITY AND FITNESS FOR A PARTICULAR at 4%per annurn,lot the applicable Purchase Option,and(d)a I applicable Taxes You I PURPOSE 5 You wilt defend and indemnity Xerox from any and all losses,claims, will pay all reasonable costs,including abomeys'lees,incurred by Xerox to enforce this damages ices penalties,interest,costs and expenses including reasonable attorney Agreement It you make the Equipment available for removal by Xerox w,thin 30 days fees,apsing from or relating to your use of the CCC Service after notice of default in the same condition as when del voted treasonable wear and ' H It you install FreeFlow Application Software on a computer that you supply,the tear excepted),you will receive a credit for the fair markdl vents of the Equipment as following terms apply 1 You may only install and use FreeFlow Process Manager on a determined by Xerox,less any costs incurred by Xerox computer having the ability to run a maximum of four processors 2 Xerox will only be GENERAL TERMS&CONDITIONS. obligated to support FreeFlow Application Software it it is installed on hardware and 22 NON-CANCELABLE AGREEMENT. THIS AGREEMENT CANNOT BE software meeting Xerox is published specifications {'WorkstatxpY' 3 If you use CANCELED OR TERMINATED EXCEPT AS EXPRESSLY PROVIDED HEREIN , i FreeFlow Application Software with any hardware or sotivare oll-rourlhan a Workstation YOUR OBLIGATION TO MAKE ALL PAYMENTS, AND -0 PAY ANY OTHER I all representations and warrant es accompanying such FreeFlow Application Software AMOUNTS DUE OR TO BECOME DUE,IS ABSOLUTE AND UNCONDITIONAL AND ' { will be void and any support maintenance you contract for in connection with such NOT SUBJECT TO DELAY, REDUCTION,SET-OFF, DEFENSE, COON"ERCLAIM i FreeFlow:Application Soltvraro will be voidable andor subject to additional charges 4 OR RECOUPMENT FOR ANY REASON WHATSOEVER, IRRESPECTIVE OF I You are solely responsible for (q the acquisition and support,in.iud,ng any and all XEROX S PERFORMANCE OF ITS OBLIGATIONS HEREUNDER ANY CLAIM associated costs, charges and other fees, of any Workstation you supply, (i) AGAINST XEROX MAY BE ASSERTED IN A SEPARATE ACTION AND SOLELY compliance with all terms governing such Workstation acquisition and support, AGAINST XEROX including terms applicable to any non-Xerox software associated will such Workstation, 23 REPRESENTATIONS The individuals signing this Acreement are duly autonzed t and pit)ensuring that such Workstation meets Xerox's published specifications Xerox to do so and all financial information you provide completely and accurately represents reserves the right to charge its then-currenl time and materials rate for any time spent your financial condition support ng a Workstation that does not meet Xerox's published sperciticatans 24 LIMITATION OF LIABILITY. Except for liability under the indemnification PRICING PLANfOFFERING SELECTED obligations set lorth in this Agreement,Xerox will not be liable to you tar any direct 14,TERM The Tenn for each unit of Equipment will commence cpon (a)delivery of damages in excess of$10 000 or the amounts paid hereunder,whichever is greater customer-installable Equipment, or tb) installation of Xerox-installable Equipment and neither parry will be liable to the aher for any special, indirect, Incidental, Unless either party provides notice of termination at least thirty days before the consequential or punitive damages arising out of or relating to this Agreement whether expiration of the initial Term,it vAl renew automatically on a month to month basis on the claim alleges tortuous conduct(including negligence)cr any other legal teary Any u the same terms and conditions During this renewal period,either party may terminate action you take against Xerox must be commenced within 2 years after the event that the Equipment upon at least 30 days notice Upon termination,you will make the caused t Products available for removal by Xerox At the time of removal,the Equipment will be 25.CREDIT REPORTS.You authorize Xerox or its agent to obtain credit reports from I In the same condition as when delivered(reasonable wear and tear excepted) commercial credit reporting agencies 115,PAYMENT Payment(includmg applicable Taxes)is due within 30 days after the 26 FORCE MAJEURE Xerox will not be liable to you during any paned in which its invoice date, with all charges being billed in arrears This Agreement will not be performance is delayed or prevented,in whole or in part,by a circumstance beyond its automatically renewed reasonable coral Xerox will notify you if such a cecumsance occurs 15 LATE CHARGE. fl a payment is not received by Xerox within 10 days after the due 27 PROTECTION OF XEROX'S RIGHTS You authorize Xerox or its agent to file,by date,Xerox may charge,and you will pay,a late charge of 5%of the amount due or any permissible means,financing statements necessary ro protect Xerox's rights as I $25,whichever is greater lessor of the Equ pment You will promptly notify Xerox of a change in ownership,or if 1 17 PRICE INCREASES Xerox may annually increase the maintenance component of you relocate your principal place of business or change the name of your business the Minimum Payment and Print Charges,each such increase net to exceed 100%. 28. WARRANTY & FINANCE LEASE DISCLAIMERS XEROX DISCLAIMS THE For Application Software Xerox may annually increase the software license or support IMPLIED WARRANTIES OF NON INFRINGEMENT AND FITNESS FOR A , fees, each such increase not to exceed 100. These ad,ustmems will occur at the PARTICULAR PURPOSE This Agreement is a 'f.narce lease'under Article 2A of the commencement of each annual contract cycle Uniform Commercial Code and,except to the extent expressly provided herein,and as 18 DELIVERY, REMOVAL & RELOCATION. Equipment prices include standard permitted by applicable law, you waive all of your rights and remedies as a lessee i delivery and removal charges Non-standard delivery and Equipment relocation must under Article 2A be arranged(or approved in advance)by Xerox and will be at your expense 29 INTELLECTUAL PROPERTY INDEMNITY Xerox will defend, and pay any 19 TAXES You will be responsible for all applicable taxes,fees or charges of any kind settlement agreed to by Xerox or any teal judgment for,any claim that a Xerox brand (including interest and penalties) assessed by any goverrme9lai entity on this Product infringes a thud party s 1,S intellectual property rights You will promptly nerdy if Agreement or the amounts payable under this Agreement("Taxes'), which will be Xerox of any alleged n'rngement and permit Xerox to direct the defense Xerox is rot I included in Xerox s invoice unless you timely provide proof of your tax exempt status responsible for any non-Xerox litigation expenses or setlements unless it pre-approves Taxes do not include personal property taxes in jurisdictions where Xerox is required to them in writing To avoid mfrngement,Xerox may rnodifv or substitute an equivalent pay personal property taxes and taxes on Xerox's income This Agreement is a lease Xerox-brand Product, refund the price pad for the Xerox-brand Product (less the I for all income tax purposes and you will not claim any credit or deduction for reasonable rental value for the per ad it was available to vou),or obtain any necessary depreciation of the Equipment,or take any other action inconsistent with your role as licenses Xerox is not liable for any infringement based upon a Xerox-brand Product > lessee of the Equipment being modified to your specifications or being used or sod with products not provided 20 PURCHASE OPTION. If not in default,you may purchase the Equipment,'AS IS, by Xerox WS T7541 01,11i2010134015 Co0dent a,-Copyngnr.200b XEROx 009PORxTON All rights reserved Page 5 of 6 .-. . xernyra 1 ____ _-___ T"rift"�i>iu' ,.,, n� 30.TITLE &RISK OF LOSS Until you exercise your Pwchase Option (a)title to law phnciples) In any action to enforce this Agreement,the parties agree(a)to the j Equipment will remain w th Xerox lb)Equipment vnll remain personal property,to)you jurisdiction and venue of the federal and state courts in Monroe County,New York,and wilr not allach the Equipmeni as a fixture to any real estate,(d)you mll cot pledge,sub- (b) to waive Cher right to a jury trial It a court finds any term of this Agreement t lease or part with possession of t,of file or permit to be filed any lien against r;and,(e) unenforceable,the remaining terms will remain in effect The failure by either party to you will not make any permanent alterations to it Risk of loss[asses to you upon exercise any right or remedy will not constitute a wan,er of s,ch ngnt or remedy Each ' delivery and remains with you until Xerox removes the Equipment You will keep the party may retain a reproduction(e g, electronic image,photocopy,farsimife)of this Products insured against loss or damage and the policy will name Xerox as a loss Agreement which will be admissible to any acton to enforce r,but only the Agreement payee held by Xerox will be considered an ongrnal Xerox may accept this Agreement either 31.ASSIGNMENT Except for assignment by Xerox to a parent,subsidiary or aftiirata by signature or by commencing performance Changes 0 this Agreement must be in of Xerox or to securlize this Agreement as pad of a financing transact on('Permitted writing and signed by Coln Dart es Any terms on your croenng documents will be of no ; j Assignment'j, neither party wit assign any of its rghle or obligations under this force or effect The following four sentences control over every other part of this l Agreement without the prior written consent of the other party In the event of a Agreement Both parties will compty with aophcable lases Xerox will not charge or Permitted Assignment (a)Xerox fray,without your prior written consent release to the collect any amounts in excess of those allowed by appl.cable law Any can of this ; pr000sed assignee information it has about you related to this Agreemem, (b) Ine Agreement that would but for the last four sentences of dis Section,be read under any assignee will have all of the rights but none of the obligations of Xerox hereunder,It) circumstances to allow for a charge higher than that allowed under any appbcabla legal I you will continue to loot:to Xerox for performance of Xerox s obligations, nciudrng the ]anti,is modified by this Section to limit the amounts c4argeable under this Agreement E provision of Maintenance Services,(d)you waive and release the assignee from any to the maximum amount allowed under the legal limit 11 in any circumslances,any I claim retaking to or ani from the performance of Xerox's obligations hereunder (e) amount in excess of that allowed by law is charged or received,any such charge will be } you shall not assert any daferse, counterclaim or setoff you may have against an deemed limited by the amount legally allowed and any amount received by Xerox in assignee, and (f) you will remit payments in accordance with rnslruchons of the excess of that legally allowed roil be applied by Xerox to the payment of amounts assignee legally owed under this Agreement,or refunded to you 32 MISCELLANEOUS.Notices must be in wrrhng and will be deemed given 5 days 33 REMOTE SERVICES Conti models of Equ parent are supported and serviced after mailing or 2 days after sending by nationally recognized overnight courier Notices using data that is automatically collected by Xerox from he Equipment via electronic will be sent to you at the'Bill to'address identified In this Agreement,and to Xerox at transmission from the Equipment to a secure off-site location Examples of the inquiry address set forth on your most recent invoice,or to such Giber address as automatically transmitted data include product registration, meter read,supply level, either party may designate by wnhon notice You authorize Xerox or its agents to Equipment configuration and settings,software version,and probiem/fault code data I I communicate with you by any electronic means (including cellular phone, email, All such data shall be transmitted in a secure manner specified by Xerox The i automatic dialing and recorded messages)using any phone number(Including ceilular) automatic data transmission capability will not allow Xerox to read,view or download I or electronic address you provide to Xerox This Agreement constitutes the entire the content of any Customer documents residing on or passing through the Equipment i agreement as to its subject matter,supersedes,all prior oral and written agreements, or Customers information managemert systems and will be governed by the laws of the State of New York(without regard to conflict-Gf- ' I i i I Section 3l,Miscellaneous. "This Agreement constitutes the entire agreement as to its subject matter,supersedes all prior oral and t written agreements and wilt be governed b jhe laws of the State of New York Washington(without regard to conflict-of-law principles). In t any action to enforce this Agreement,the parties agree(a) the jurisdiction and venue of the federal and state courts in Monroe King Coin Washington New York ands to waive their right to a jug Etrial. � l0ty of Kent 2/05/2010 i f[ , i 1 E l , _ WS T7S4u1 ui 11, 0 10 1 a 4 15 Conti -Cup, R 200d XHOX CORPOAT101 AAd lights reserved J i p3ge 6 016 s From: White Tammy To: Drake Dea Cc: Brubaker,Tom Subject: Xerox Lease Agreement Date: Thursday,January 21,2010 3 36 51 PM 1 Dea, I reviewed the Xerox lease agreement with Tom and there are just 2 amendments he would like made. If Xerox will consent to these 2 minor amendments, Tom will approve the rest of the lease agreement's terms. These changes can easily be incorporated into the agreement. Section 20, Default & Remedies. Tom would like the 3rd sentence revised as follows: "You-wtF-In any dispute arising from the parties' performance of this Agreement, each party shall pay its ow reasonable ' costs, including attorneys' fees, incurred by XeFex to enfE),--.. Agreengent. Section 31, Miscellaneous. Tom would like the 4th and 5th sentences in this section revised as follows: "This Agreement constitutes the entire agreement as to its subject matter, supersedes all prior oral and written agreements, and will be governed by the laws of the State of New YE)rk Washington (without regard to conflict-of-law principles). In any action to enforce this Agreement, the parties agree (a) to the jurisdiction and venue of the federal and state courts in ME)nFee King County, Washington New York, and (b) to waive their right to a jury trial. Let us know if you have any questions. Thanks' 1 Tammy Larson-White, Legal analyst Civil Division I Law Department I City of Kent 220 Fourth Avenue South, Kent, WA 98032 1 Direct 253-856-5774 1 Fax 253-856-6770 wrww.choosekent.com `O?ONMENT BEFORE PRINTING THIS E-MAIL r 1 t - 1 1 r F ! Drake, Dea From: Chiu, Howard [Howard Chiu@xerox coin] Sent: Tuesday, February 16, 2010 3 01 PM ' To: Drake, Dea Subject: Re City of Kent Contract with Xerox I Perfect Thanks -Howard From: Drake, Dea <DDrake@ci.kent.wa.us> X7 . To: Chiu, Howard Sent: Tue Feb 16 14:53:13 2010 Subject: RE. City of Kent Contract with Xerox Dear Howard Attached is the modified contract I am presenting to the Mayor for signature. I have replaced all the signature pages with your latest version dated Feb. 9 2010. Please note that the contract details reflect the earlier version with the agreed upon changes. I am keeping the original version to avoid any concerns that the contract our legal department read is the same one we are using. I will send you the signed document and purchase order as soon as I have it. ' Sincerely, Dea Drake, Multimedia Manager Multimedia Services Division I Information Technology Dept. ?= 220 Fourth Avenue South, Kent, WA 98032 K E N T Phone 253-856-4646 1 Fax 253-856-4700 www.kenttv2l.com YLEASL LONSIDE2 IF-E ENVIRONMENT BEFORE PkI NTING THIS E-MAIL From: Chiu, Howard [mailto•Howard.Chiu@xerox.com] Sent: Tuesday, February 09, 2010 2:41 PM To: Drake, Dea Subject: RE: City of Kent Contract with Xerox ' Hi Dea, I put Suzette Cooke's name on the first two pages of the agreement Once again please combine the signature pages with the T&Cs that your legal department modified for a complete agreement Thank you and let me know if there are any questions. -Howard From: Drake, Dea [mai Ito-DDrake@ci.kent.wa.us] Sent: Monday, February 08, 2010 2:08 PM t i From: Chw Howard To: Drake.Dea Subject: RE City of Kent Contract with Xerox Date: Monday, February 08,2010 10 40 02 AM Attachments: Lease Exte�s�on Nuvera a'd 742 ' Lease Exte ision MakeReadv adf Hi Dea, I got the approvals We are good to go Please find attached the updated agreements. I updated Mike Carrington's name as the signer and updated the date to reflect February You will also see a lower total monthly because you are one more month into your lease What I need to finish this transaction. • Please substitute the front two pages of old agreement with these new ones. (Both Contracts) • We will use the modified T&C's pages that you sent me that your legal department modified • We'll need a signature and a PO. If there are any questions please don't hesitate to contact me Thank you -Howard From: Drake, Dea [mailto DDrake@ci kent wa.us] Sent: Friday, February 05, 2010 3.37 PM To: Chiu, Howard Subject: RE: City of Kent Contract with Xerox Thank you Dea Drake, Multimedia Manager ' Multimedia Services Division I Information Technology „_ Dept , 220 Fourth Avenue South, Kent, WA 98032 IENT Phone 253-856-4646 1 Fax 253-856-4700 www.kenttv2l.com Fk1-4iT , wan? From: Chw, Howard [madto Howard.Chiu@xerox.com] Sent: Friday, February 05, 2010 3-36 PM To: Drake, Dea Subject: RE City of Kent Contract with Xerox Hi Dea, I will send it up my chain for approval. i From: Drake, Dea [mailto:DDrake@ci kent wa us] Sent: Friday, February 05, 2010 3.12 PM To: Chu, Howard Subject: FW. City of Kent Contract with Xerox For your convenience, the changes are as follows: Section 20, Default & Remedies. 3rd sentence revised as follows: "Yeti vvt14-In any dispute arising from the parties' performance of this Agreement, each arty shall pay its own --costs, including attorneys' fees, InEUFFed by Xerox to enforce this AgFeengent. Section 31, Miscellaneous. 4th and 5th sentences in this section revised as follows. "This Agreement constitutes the entire agreement as to its subject matter, supersedes all prior oral and written agreements, and will be governed by the laws of the State of New York Washington (without regard to conflict-of-law principles). In any action to enforce this Agreement, the parties agree (a) to the jurisdiction and venue of the federal and state courts in Monroe !Sung County, Washington New YeFk, and (b) to waive their right to a jury trial. Dea Drake, Multimedia Manager Multimedia Services Division I Information Technology Dept 220 Fourth Avenue South, Kent, WA 98032 !CENT Phone 253-856-4646 1 Fax 253-856-4700 www.kenttv2l.com �5 co's511,1 Wt ,• 'NMENT aLPORE PRINTING THIS E-MAIL From: Drake, Dea Sent: Friday, February 05, 2010 3:11 PM To: 'Chiu, Howard' Subject: City of Kent Contract with Xerox ' Howard Attached is a copy of your Xerox Standard agreement, and proposal. The City of Kent can agree to enter into this contract, and I can get you a Purchase Order signed by the Mayor if you are willing to accept the minor changes indicated in the contract attached ' These changes are required in all City contracts, are approved by our City Attorney and the contract is recommended by our attorney with those changes Changes are Indicated on Pages 4 of ' 5 and 5 of 5 in the contract I look forward to your expedient response so I can get a purchase order signed by the Mayor. rSincerely, 1 Dea Drake, Multimedia Manager Multimedia Services Division I Information Technology # Dept 220 Fourth Avenue South, Kent, WA 98032 ENT K Phone 253-856-4646 1 Fax 253-856-4700 www.kenttv2l.com I _ TkTS T-4'AY' r r r r r f 1 t t 1 1 r r 1 r 4339 E$ifi pg�� E339 x5 F B F F 8 F $a�F y tl St �� 433g 3 =Zc�t" �tggs� r^3 �F1, s=§ ass F qq;;�i G( � F3R �qq3^ L�S�i Gpp34 PKlx Spi4g3 SE� SA=fip� Spd� SC= n Bd�C S �3 iC s SA3 Sy� 5;�¢ S�=5p rp=� £ a £�£ @ a £ a g�a £�a �=a s3£ £•a =�a spa £•£� �1" £g a£ ag rrh nr Is Is ' _ sax aaa saa «ggoo sgqBggggg gxgr@Tg P nNo -xa xggso spax s Cpx wi rig tat ra � �YI 4 Qs y &Pet �•�v 9e£C �£"ex aeWgy �W�r st'�s s5m�g »w alG � agar � EGeG Hv,J .-vE aG w� a cIn ~xri six �" p � nag g �g, :na -rg Mg nnx Y w e ar calm SP�b =ezx €c�aa c�ee Mt YOBS YGNW «"«o - era. "sp N� STCy V. r sxi " 's�. kh_ Cg` 1: t s V J agG a�IDID �a'< g�IDek -IDo � a s&�> mgox g a'5 4laa= aae� �mm „5s "g fi x�als� o as 9 _ aa:e ae ua ys _ u»ems o_u . Nr « - z ge 9 9a � 8 '��•� eewa k�Wa Ge: �"9 It :age k ..G W57a e5 r"r"a �eaa ua„' aGg'a s�EA oiW�4 :it '� .m� �eHe 9'E ReIn ^eG ; ZIg 'e_„E su sea"_�bG3 �� iN�a Pae gs� do„x M l "y» r hl L' CAl G 8Y YG aLY',anb �Plje iY,�rV' iPx" ..u. g NWav W1 m aw Nt clan S tl� � Mcs��a _ "a ^rMs arG krNG k5 arcs Nv» W�v. Wa} sNNv vpF AHP5 SW"5s GP W� ar ara5 a"es� srxa �d: '��� ^�En xE'ak� 4.G_rT � prID€ T:^ Tg fp&' IDLE GIDy� NIT IDID »!4 ME -�['5t 4rhE gn� G T, PM'N'E Wg_N4 Ya�b Y$s61d 'd 2 C:3lz `f « _ YGGGP «mC» YG"�f� u, vY"W C NW �biF «KCC g#CY Cie«» «IC i..G »KC. ago _"gaK trysGa rS�TT Otb �ws E"sPs - rep k ac aYr a. 9 :GW 8 ^C G C Ya u �r«" NNACS •_7.IDr irw` EM`•V S'T»' TV-- r «xC IDIDGJ aeW n » Ca�e " 4 ' to 'a «s, yx�- ;�' ~aur'; Mree � I "g »g »g» g J yelp ✓gu $ «»2- 5"mc :? _ V$p. Bg9 gm a T lh 1vn;_ s z.p 6m � r 'a z -aa$f �mmex appa %m ;as? buv xa�; ^a= see s ew am '«xaw�' Hams aNv sc » x«n «rr az e x W V>¢ k Ck5 pCpa yCye aeea � E_ _ - yOGG Bk pC$ re sgs 8c k es LCY 8 3 i i atlL AtlS M o _ g4& } al RU7M 9Y C p Kent City Council Meeting t Date March 16, 2010 Category Consent Calendar - 6H 1. SUBJECT: WASHINGTON TRAFFIC SAFETY COMMISSION GRANT - AUTHORIZE AND ACCEPT 2. SUMMARY STATEMENT: Authorize the Kent Police Chief to accept a grant in the amount of $5,500 from the Washington Traffic Safety Commission, authorize the Kent Police Chief to sign all necessary documents, amend the budget and authorize expenditure of the funds. ' Accept a grant award in the amount of $5,500 to fund officer overtime for speed enforcement. Highly visible enforcement will be used to reduce the number of fatalities and serious injury collisions caused by exceeding the posted speed limits or driving too fast for conditions. The speed enforcement will be conducted statewide by law enforcement agencies April 9 through May 1, 2010, and July 9 through August 1, 2010. Funding is on a reimbursement basis. 3. EXHIBITS: Memorandum of Understanding 4. RECOMMENDED BY: Public Safety Committee 3/9/10 (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? Y Revenue? Y Currently in the Budget? Yes No X 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds ' DISCUSSION: ' ACTION: �g VA? o � 0 ay Jv MEMORANDUM OF UNDERSTANDING WASHINGTON TRAFFIC SAFETY COMMISSION THIS AGREEMENT, pursuant to Chapter 39.34 RCW, is made and entered into ' by and between the KENT POLICE DEPARTMENT and the Washington Traffic Safety Commission (WTSC). IT IS THE PURPOSE OF THIS AGREEMENT to: use highly visible enforcement to reduce the number of fatalities and serious injury collisions caused by exceeding the posted speed or driving too fast for conditions. TERMS: April 9 through May 1, 2010 and July 9 through August 1, 2010 AMOUNT: NOT TO EXCEED $5,500.00 CFDA # 20.600 IT IS, THEREFORE, MUTUALLY AGREED THAT: 1. GOAL: to reduce the number of fatal and serious injury crashes caused by ' speeding, defined as exceeding the posted speed limit or driving too fast for conditions, by using highly visible enforcement during set hours and days in April 2010 and in July 2010 in high fatality and serious injury ' crash areas. 2. SCOPE OF WORK: April Statewide Speeding Campaign: (Agency) will provide highly visible patrols on high crash areas for all or part of the following hours: Friday April 9, 2010 from 11.00am until 7:OOpm Saturday April 10 from noon until 8:OOpm Sunday April 11 from noon until 8:OOpm Friday April 16 from 11:OOam until 7:OOpm ' Saturday April 17 from noon until 8:OOpm Sunday April 18 from noon until 8:00 pm Friday April 23 from 11:00am until 7:OOpm Saturday April 24 from noon until 8 OOpm Sunday April 25 from noon until 8:OOpm Friday April 30 from 11:OOam until 7:OOpm Saturday May 1 from noon until 8:OOpm July Statewide Speeding Campaign: (Agency) will provide highly visible patrols on high crash areas for all or part of these hours: Starting on Friday July 9, 2010 through Sunday August 1 , following the same day and hourly schedule as above. 3. CONDITIONS: (Agency) will work with their Target Zero Manager to determine the best strategy for providing highly visible patrols on high , crash roads on the days and times outlined above. a. (Agency)'s patrols may remain within their own jurisdiction, work with one or more neighboring agencies, or all agencies may , group together to work one or more high fatality and serious injury collision areas. The locations of these patrols, and distribution of agencies will be made locally based on fatality and serious injury collision data. b. Agencies that have a high crash location on a rural road with low traffic volume will be reimbursed for officer time on that road even , should that officer not be able to obtain 3 contacts per hour. c. In addition to speeding drivers, motorcycle riders should also be targeted for dangerous behavior during the July campaign. Patrols , may be shifted to high motorcycle crash locations for the July campaign. 4. PAYMENT FOR LAW ENFORCEMENT: (Agency) will provide commissioned , law enforcement with appropriate equipment (vehicle, radar, etc.) to participate in these emphasis patrols. (Agency) may use one of the following three options for payment: a. overtime only (not to exceed 1.5 times normal salary and benefits); , b. straight time law enforcement (including reserves) for $20/hour credit toward traffic equipment purchases for participation on the days/times of the project; or , c. hybrid, some agency officers on overtime and some on straight time for the $20/hour equipment credit. Use of this model requires permission of the Target Zero Manger and coordination with the ' WTSC program manager. NOTE: Law enforcement on straight time will earn $20/hour of participation. April funds can be merged with July funds. Funds can , only be used to purchase traffic equipment. Equipment must be purchased and received by September 30, 2010 in order to receive reimbursement. If equipment is purchased prior to July 1, 2010, ' reimbursement must be submitted no later than August 15, 2010. S. RESERVE OFFICERS: I certify that any reserve officer for whom reimbursement is claimed has exceeded his/her normal monthly working hours when participating in this emphasis patrol and is authorized to be paid the amount requested. I understand that reserve officers are not eligible for overtime for this project. However any reserve officer who is allowed to take part in these emphasis patrols will be allowed to claim the $20/hour equipment credit for his/her agency. ' 6. DISPATCH: WTSC will reimburse communications officers/dispatch ' personnel for work on this project providing (Agency) has received prior approval from the WTSC Program Manager. 1 7. GRANT AMOUNT: WTSC will reimburse (Agency) for overtime salary and benefits. WTSC will also keep a tally of the amount accrued by (Agency) officers working straight time for the $20/hour equipment credit. However, the total cost of overtime, benefits, and equipment credit under this project shall not exceed dollars ($ .00 I. 8. PERFORMANCE STANDARDS: a. All participating law enforcement are required to have 3 self- initiated contacts per hour of enforcement. However, law enforcement working a high crash, rural road may be exempted from this requirement providing they have permission from their Agency and provided this is stated on their activity log. b. Some violator contacts may result in related, time-consuming activity. This activity is reimbursable. c. Other activities such as collision investigation or emergency response that are not initiated through emphasis patrol contact WILL NOT be reimbursed. 9. REIMBURSEMENT OF CLAIMS: Claims for reimbursement must include: a. Invoice Voucher (A19-1A Form). ' 1) (Agency) identified as the "Claimant"; 2) a Federal Tax ID #; and, 3) original signature of the agency head, command officer or ' contracting officer. b. Payroll support documents (signed overtime slips or lists, payroll documents, etc.). ' c. Officer activity logs showing 3 or more self-initiated contacts per hour, unless officer is visibly present on a high crash, low traffic rural road. 10.DEADLINES FOR CLAIMS: a. First Deadline: All claims for reimbursement for emphases conducted prior to June 30 must be received by WTSC no later than August 15, 2010. b. Second Deadline: All claims for reimbursement for emphases conducted between July 1 and September 30 must be received by WTSC no later than November 15, 2010. ' c. Any equipment purchased with funds obtained by officers working straight time for the $20/hour equipment credit must be received by ' (Agency) by September 30, 2010 in order to receive reimbursement. i That reimbursement request must also be received by WTSC no later ' than November 15, 2010. d. WTSC will NOT pay faxed copies of any claims unless previously , approved by the WTSC program manager. 11. DISPUTES: Disputes arising under this Memorandum shall be resolved ' by a panel consisting of one representative of the WTSC, one representative from (Agency), and a mutually agreed upon third party. The dispute panel , shall decide the dispute by majority vote. 12. TERMINATION: Either party may terminate this agreement upon 30 days , written notice to the other party. In the event of termination of this Agreement, the terminating party shall be liable for the performance rendered prior to the effective date of termination. , 13. SUPPLANTING DISCLAIMER: I certify that none of the funds for this project supplant the normally budgeted funds of this agency nor do these ' funds pay for routine traffic enforcement normally provided by this agency. IN WITNESS THEREOF, THE PARTIES HAVE EXECUTED THIS AGREEMENT. (Agency) (Washington Traffic Safety ' Commission) (Date) (Date) , Return to: , Penny Nerup Speeding Program Manager WTSC , 621 - 81h Avenue SW, Suite 409 PO Box 40944 Olympia, WA 98504-0944 , 360.725.9890 pnerup2wtsc.wa.gov; i Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6I ' 1. SUBJECT: EDWARD BYRNE MEMORIAL GRANT AWARD - ACCEPT, - AUTHORIZE AND ESTABLISH BUDGET 2. SUMMARY STATEMENT: Accept the Edward Byrne Memorial Competitive Grant in the amount of $82,869, authorize the Mayor to sign an interagency agreement with the Seattle Police Department as Fiscal Agent, amend the budget, and authorize expenditure of the funds. ' The Kent Police Department submitted a joint application with 14 other jurisdictions in King County to share in a total grant amount of $1,161,026, The grant was awarded to these Jurisdictions and the City of Seattle was appointed as the fiscal agent for this grant award. The City of Kent's allocation for FY 2009 Edward Byrne Memorial grant program is $82,869, and the grant period is 8/28/09 through 9/30/12. No city matching funds are required. ' 3. EXHIBITS: Interagency Agreement, Dept of Justice Award Letter, and KPD Narrative and Budget 4. RECOMMENDED BY: Public Safety Committee 3/9/10 (Committee, Staff, Examiner, Commission, etc.) ' S. FISCAL IMPACT Expenditure? Y Revenue? Y Currently in the Budget? Yes No X 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds DISCUSSION: ' ACTION: _ ' Interagency Agreement Edward Byrne Memorial ' Justice Assistance Grant (JAG) Program FY 2009 Local Solicitation Executed by Seattle Police Department (SPD), a department of the ' City of Seattle, hereinafter referred to as"SPD", Department Authorized Representative: Nancy Tuck 610 5"'Avenue ' PO Box 34986 Seattle,NVA 98124-4986 and ' City of Kent, hereinafter referred to as "Recipient", Department Authorized Representative- Debra LeRoy 220 4th Ave S Kent,WA 98032 ' IN WITNESS WHEREOF, the parties have executed this Agreement by having their representatives affix their signatures below. ' CITY OF KENT SEATTLE POLICE DEPARTMENT Suzette Cooke,Mayor John Diaz, Interun Clitef of Police Date: ' Authorized by: Grant Program: Edward Byrne Memorial Justice Assistance Grant UAG)Program FY 09 JAG Interagency Agreement,Page 1 of 7 WHEREAS, the Justice Assistance Grant (JAG) Program is the primary provider of federal criminal justice ' funding to state and local jurisdictions; and WHEREAS,the JAG Program supports all components of the criminal justice system, from multi- ' jurisdictional drug and gang task forces to crime prevention and domestic violence programs,courts, corrections,treatment, and justice information sharing initiatives, and , WHEREAS,the United States Congress authorized$8,929,860 in the Justice Assistance Grant GAG) Program for jurisdictions in Washington State;and , WHEREAS, 14 jurisdictions in King County were required to apply for a JAG Program award with a single, joint application; and ' WHEREAS, the City, as the identified Fiscal Agent, submitted the joint application to the Bureau of Justice Assistance on July 9, 2009 to request JAG Program funds;and , WHEREAS,based on the City's successful application, the Bureau of Justice Assistance has awarded $1,161,026 to the City from these JAG Program funds;and ' WHEREAS, pursuant to the terms of the grant whereby the City, as the identified Fiscal Agent for this award,is to distribute grant funds to co-apphcants, the City intends to transfer some of the JAG funds it receives to those co-applicants;and WHEREAS, the City is not obligated to continue or maintain grant funding levels for the JAG Program once grant funds have lapsed;and WHEREAS, recipients of JAG funds from the City should not anticipate the City will assume responsibility ' for any program costs funded by JAG once JAG funds are spent; NOW THEREFORE, the parries hereto agree as follows: This Interagency Agreement contains six Articles ' ARTICLE I: TERM OF AGREEMENT: The term of this Interagency Agreement shall be in effect from the date it is executed by the SPD Chief of ' Police, or designee,until September 30, 2012 unless terminated earlier pursuant to the provisions hereof. ARTICLE II: DESCRIPTION OF SERVICES ' The services to be performed under this Agreement shall be conducted for the stated purposes of the Byrne Memorial Justice Assistance Grant JAG) Program (42 U.S.0 3751(a.) The Edward Byrne Memorial Justice Assistance Grant GAG) Program is the primary provider of federal criminal justice funding to state and local jurisdictions.JAG funds support all components of the criminal justice system, from multijunsdictional drug and gang task forces to crime prevention and domestic violence programs, courts, corrections, treatment,and justice information sharing initiatives.JAG funded projects may address crime , through the provision of services directly to individuals and/or communities and by improving the effectiveness and efficiency of criminal justice systems,processes, and procedures. FY 09 JAG Interagency Agreement,Page 2 of 7 ' i ' ARTICLE III: SPECIAL CONDITIONS • Funds are provided by the U S. Department of Justice, Office of Justice Programs,Bureau of Justice Assistance solely for the purpose of furthering the stated objectives of the Edward Byrne Memorial Justice Assistance Grant GAG) Program. The Recipient shall use the funds to perform tasks as ' described in the Scope of Work portion of this Agreement. • The Recipient acknowledges that because this Agreement involves federal funding, the period of ' performance described herein will likely begin prior to the availability of appropriated federal fiends. The Recipient agrees that it will not hold the Seattle Police Department, the City of Seattle, or the Department of Justice liable for any damages, claim for reimbursement, or any type of payment ' whatsoever for services performed under this Agreement prior to the distribution and availability of federal funds. ' • The Recipient shall comply with all conditions and limitations set forth in the FY 2009 Justice Assistance Grant Program Award# 2009-DJ-BX-0336. The FY 2009 Justice Assistance Grant Program Award Report #: 2009-DJ-BX-0336 is attached to and made part of this agreement, as Attachment A.Allocation and use of grant funding must be in accordance with all special conditions included in the Award Report.All Recipients are assumed to ' have read,understood, and accepted the Award Report as binding • The Recipient acknowledges that all allocations and use of funds under this agreement will be in ' accordance with the Edward Byrne Memorial Justice Assistance Grant GAG) Formula Program- Local Sohcitaauon Allocation and use of grant funding must be coordinated with the goals and objectives included in the Local Solicitation. All Recipients are assumed to have read, understood, and accepted the Local Solicitation as binding. • Recipient agrees to obtain a valid DUNS profile and create an active registration with the Central ' Contractor Registration (CCR) database no later than the due date of the Recipient's first quarterly report after a subaward is made. • The Recipient shall comply with all applicable laws, regulations,and program guidance. A non- exhaustive list of regulations commonly applicable to BJA grants are listed below,including the guidance: ' (A) Administrative Requirements: OMB Circular A-102, State and Local Governments (10/7/94, amended 8/29/07) (44CFR Part 13) (B) Cost Principles: OMB Circular A-87,State and Local Governments (5/10/04) (C) Audit Requirements: OMC Circular A-133,Audits of State,Local Governments, and Non- Profit Organizations (6/24/97, includes revisions in the Federal Register 6/27/03) ' (D) The Recipient must comply with the most recent version of the Administrative Requirements, Cost Principals, and Audit Requirements ' PY 09 JAG Interagency Agreement,Page 3 of 7 1) Non-Federal entities that expend$500,000 or more in one fiscal year in Federal awards ' shall have a single or program-specific audit conducted for that year in accordance with the Office of Management and Budget (OMB) Circular A-133-Audits of States,Local Governments, and non-Profit Organizations Non-federal entities that spend less than $500,000 a year in federal awards are exempt from federal audit requirements for that year, except as noted in Circular No.A-133,but records must be available for review or audit by appropriate officials of the Federal agency,pass-through entity, and General Accounting Office (GAO). 2) Recipients required to have an audit must ensure the audit is performed in accordance , with Generally Accepted Auditing Standards (GARS), as found in the Government Auditing Standards (the Revised Yellow Book) developed by the Comptroller General and the OMB Compliance Supplement. The Recipient has the responsibility of notifying the Washington State Auditors Office and requesting an audit. ' 3) The Recipient shall maintain auditable records and accounts so as to facilitate the audit requirement and shall ensure that any sub recipients also maintain auditable records. , 4) The Recipient is responsible for any audit exceptions incurred by its own organization or that of its subcontractors. Responses to any unresolved management findings and disallowed or questioned costs shall be included with the audit report submitted to the Seattle Police Department. The Recipient must respond to requests for information or corrective action concerning audit issues or findings within 30 days of the date of request.The City reserves the right to recover from the Recipient all disallowed costs resulting from the audit 5) If applicable, once any single audit has been completed,the Recipient must send a full copy of the audit to the City and a letter stating there were no findings, or if there were findings, the letter should provide a list of the findings. The Recipient must send the ' audit and the letter no later than nine months after the end of the Recipient's fiscal year(s) to Nancy Tuck,JAG Program Manager Seattle Police Department 610 5th Avenue PO Box 34986 ' Seattle,WA 98124-4986 206-386-1996 6) In addition to sending a copy of the audit,the Recipient must include a corrective ' action plan for any audit findings and a copy of the management letter if one was received. 7) The Recipient shall include the above audit requirements in any subcontracts. • The Recipient agrees to cooperate with any assessments, national evaluation efforts, or information or data collection requirements,including, but not limited to, the provision of any information FY 091AG Interagency Agreement,Page 4 of 7 ' required for assessment or evaluation of activities within this agreement, and for compliance BJA reporting requirements. I • When implementing funded activities,the Recipient must comply with all applicable federal, state, tribal government, and local laws,regulations, and policies.The Recipient is entirely responsible for determmmg the Recipient's compliance with applicable laws,regulations and policies,which include, but are not limited to: (A) City of Seattle regulations including,but not limited to: (1) Equal Benefits Program Rules (SMC Ch.20.45 http•//cityofseatte.net/contract/equalbenefits/) (2) Women and Minority Owned Affirmative Effort If a Recipient intends to subcontract out any part of a contract instead of performing the work itself, then the following requirement applies- Consultant shall use affirmauve efforts to promote and encourage participation by women and minority businesses on subcontracting opportumttes within the contract scope of work. Consultant agrees to make such efforts as a condition of this Agreement. a. Outreach efforts may include the use of solicitation lists, advertisements in publications directed to minority communities,breaking down total requirements into smaller tasks or quantities where economically feasible,making other useful schedule or requirements modifications that are likely to assist small or ti`(WBE businesses to compete, targeted recruitment efforts, and using the services of available minority community and public organizations to perform outreach. b. Record-Keeping The Consultant shall maintain, for at least 24 months after the expiration or earlier termination of this Agreement,relevant records and information necessary to document all Consultant solicitations to subconsultants and suppliers,all subconsultant and supplier proposals received, and all subconsultants and suppliers actually utilized under this Agreement. The City shall have the right to inspect and copy such records. (3) Licenses and Similar Authorizations: The Consultant,at no expense to the City, shall secure and maintain in full force and effect during the term of this Agreement all required licenses, permits, and similar legal authorizations, and comply with all requirements thereof. (4) Use of Recycled Content Paper: Whenever practicable, Consultant shall use reusable products including recycled content paper on all documents submitted to die City. Consultant is to duplex all documents that are prepared for the City under this Contract, whether such materials are printed or copied, except when impracticable to do so due to the ' nature of the product being produced. Consultants are to use 100%post consumer recycled content, chlorine-free paper in any documents that are produced for the City,whenever practicable,and to use other paper-saving and recycling measures in performance of the contract with and for the City. (5) Americans with Disabilities Act: The Consultant shall comply with all applicable provisions of the Americans with Disabilities Act of 1990 as amended (ADA) in performing its obligations under this Agreement. failure to comply with the provisions of the ADA shall be a material breach of,and grounds for the immediate termination of, tlus Agreement. FY 09 JAG Interagency Agreement,Page 5 of (6) Fair Contracting Practices Ordinance: The Consultant shall comply with the Fair Contracting Practices Ordinance of The City of Seattle (Chapter 14.10 SMC), as amended. (7) Suspension and Debarment:The Recipient certifies that neither it nor its principals are presently debarred, suspended,proposed for debarment, declared meligible, or voluntarily excluded from participating in transactions by any Federal department or agency By signing and submitting this Agreement, the Recipient is providing the signed certification set out below. The certification this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the Recipient rendered an erroneous certification, the Federal Government and City may pursue available remedies,including termination and/or debarment. The Recipient shall provide uninediate written notice to the City if at any time the Recipient learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. The Recipient agrees by signing this Agreement that it shall not enter into any coveted transaction with a person or subcontractor who is debarred, suspended,proposed for debarment, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized in writing by the City The Recipient shall include the requirement in this section in any subcontracts. (8) In the event of the Recipient's or subcontractor's noncompliance or refusal to comply with any applicable law,regulation or policy, the City may rescind, cancel, or terminate the Agreement in whole or in part. The Recipient is responsible for any and all costs or liability , arising from the Recipient's failure to comply with applicable law, regulation, or policy. ARTICLE IV: SCOPE OF WORK The Scope of Work of tins Agreement and the time schedule for completion of such work is as described in Attachment B: Edward Byrne Memorial Justice Assistance JAG) Grant Formula Program King County Joint Application,Project Narrative and Attachment C:JAG Budget Worksheet, as approved by BJA. Attachment B and Attachment C are attached to and made part of this agreement. The work shall,at all tines, be subject to the City's general review and approval.The Recipient shall confer with the City periodically during the progress of the Work, and shall prepare and present such information and materials (e.g. a detailed outline of completed work) as may be pertinent,necessary, or requested by the City or BJA to determine the adequacy of the Work or Recipient's progress. ' ARTICLE V: PAYMENT (A) Compensation The Recipient shall be reimbursed on an actual cost basis. Total compensation under this Agreement is $82,869. The Recipient shall incur authorized allowable expenses in accordance with the Program Narrative and Project Budget, as detailed in Attachments B and C. FY 09 JAG Interagency Agreement,Page 6 of 7 The Recipient may request additional reimbursement up to the amount of interest accrued on their portion of the grant award. The City will provide quarterly statements to the Recipient, once the interest balance accrued equals at least$1,000. Reimbursements will not be made for interest accrued that is less than$1,000. Reimbursements can be requested,up to the total amount of interest accrued, after the initial quarterly statement has been sent, to perform tasks in accordance with the Program Narrative and Project Budget, as detailed in Exhibits B and C. The Recipient shall submit invoices not more than monthly, and at least quarterly. After the first quarter, monthly submission is preferred. Invoices are due no later than 30 days after the end of the period in which the work was performed. No travel or subsistence costs,including lodging and meals, reimbursed with federal funds may exceed federal maximum rates,which can be found at. http://-,vw-,v gsa.gov. (B) Manner of Payment The Recipient shall submit reimbursement requests not more than monthly,and at least quarterly.After the first quarter, monthly submmssion is preferred. Requests are due no later than 30 days after the end of the period in which the work was performed. Reimbursement request forms are provided. Substitute forms are acceptable. With each reiimbursement request, the Recipient shall submit- Detailed spreadsheet of expenditures by task and related financial documents (timesheets,invoices) ■ Project status report ■ These documents and invoices must be kept on file by the Recipient and be made available upon request by the City or to state or federal auditors Reimbursement will not be processed without accompanying documentation for the corresponding time period. Once the above conditions are met,payment shall be made by the City to the Recipient. tSubmit invoicing and documentation to. Nancy Tuck,JAG Program Manager Seattle Police Department 610 5th Avenue PO Box 34986 Seattle,WA 98124-4986 206-386-9885 ARTICLE VI: AMENDMENTS No modification or amendment of the provisions hereof shall be effective unless in writing and signed by authorized representatives of the parties hereto. The parties hereto expressly reserve the right to modify this Agreement,by mutual agreement. FY 09 JAG Interagency Agreement,Page 7 of 7 i t ---Department ofJustice I Office of Juatlee Programs ay Bureau of Justice Assistance Grant PAGE i of s I I RECIPIENT NAME AND ADDRESS(lncludmg Zip Code) '4 AWARD NUMBER 2009-137-BX-0336 i Cny eTSeatdo v i j 600 Fourth 4veme 7th FI"P 0 Box 94749 5 PROJECTPERIOD FROM 10Y01=8 TO 09/30POI2 Seattle,WA 981244749 BUDGET PERIOD FROM 101012oo8 TO 09J3012012 I 6 AWARD DATE 05128•'2009 7.ACTION IA GRANTEE TRSNENDOR NO. -_- li g SUPPI-FMHNTNUMBER 916091303 00 i 9 PREVIOUS AWARD AMOUNT so ` - 1 3 PROTECT TITLE 10 luM0iJM OF THIS AWARD 51,161,026 � FY 2009 Justice Assistance Count Progistn 11 TOTAL AWARD $1,161,026 ' � I 12.SPECIAL ClR♦DI11ON8 I I THEABOVE GRANTPROJECTIS APPROVED SUBJECTTO SUCH CONDITIONS OR LIMITATIONS AS ARE SET FORTE ON THE ATTACHED PAGE(S). ; 13 STATUTORY AUTHORITY FOR GRANT �-- - -- - - i This project is supported under 42 US C 3751(a)(BIA-JAG Fmmuh) t t 15 METFIOD OF PAYMENT I PAPRS ._ AGENCY AP?ROVAL _— _ GRANTEEACCEPTANCE 16 TYPED NAME AND TITLE OF APPROVING OFFICIAL ; 18 TYPED NAME AND TITLE OF AUTHORIZED GRANTEE OFFICIAL JanueslLBtnchll i Greg ory Nickels Amng Dcenim i Mayor i � II ' I 4 17 SIGNATURE OF APPROVING OMCW, 19 TURE • A[JTHOA7 ORE P FFSC 19A DA J� AGE24CYUSEONkyI 20 ACCOUNTING CLASSIFICATION CODES 21 IDJUGT3793 i ! FISCAL FUND BUD D14 I i YEAR CODE ACT OFC. REG. SUB POMS AMOUNT X B DJ 80 00 00 II61026 OJP FORM 4000n(REV 5-87)PREVIOUS EDITIONS ARE OBSOLETE OUP FORM 40U M(REV.4-M i i Department of Justice Office of Justice Programs AWARD CONTLNuATION a� Bureau of Justice Assistance SHEET PA(�F 2 of 5 Grant PROJECTNUMBBR 2009-DJ-BX-0336 AWARD DATE 98282009 — — l SPECIAL CONDITIONS t The recipient agrees to comply with the financial and administrative requirements set forth in the current edition of the j Office of Justice Programs(OJP)Financial Guide { 1 2. The recipient acknowledges that failure to submit an acceptable Equal Employment Opportunity Plan(if recipient is required to submit one pursuant to 28 C F R.Section 42302),that is approved by the Office for Civil Rights,is a violation of its Certified Assurances and may result in suspension or termination of funding,until such time as the I recipient is in compliance. 3. The recipient agrees to comply with the organizational audit requirements of OMB Circular A-133,Audits of States, Local Governments,and Non-Profit Organizations,and further understands and agrees that funds may be withheld,or f other related requirements maybe imposed,if outstanding audit issues(if any)from OMB Circular A-133 audits(and ` any other audits of OJP grant funds)are not satisfactorily and promptly addressed,as further described in the current edition of the OR Financial Guide,Chapter 19. 4 Recipient understands and agrees that it cannot use any federal fiirids,either directly of indirectly,in support of the i enactment,repeal,modification or adoption of any law,regulation or policy, at any level of government,without the express pnor written approval of OJP" 5 The recipient must promptly refer to the DOJ 010 any credible evidence that a principal,employee,agenr,contractors i subgrantee,subwntractor,or other person has either 1)submitted a false claim for grant finds under the False Claims Act,or 2)committed a criminal or civil violation of laws pertaining to fraud,conflict of interest,bribery,gratuity,or �? similar misconduct involving grant funds This condition also applies to any subreciptems Potential fraud,waste, I abuse,or misconduct should be reported to the OiG by- I mail �I- I Office of the Inspector General US Department of Justice Investigations Division 950 Pannsytvanu Avenue,N.W Room 4706 Washington,DC 20530 e-marl.oighothnaQusdoJ goy hotline (contact Information in English and Spanish) (800)869-4499 or hotline fax:(202)616-9881 Additional information is available from the DOJ OIG websrte at wwty usdoJ govloig. ! �L i OJPFORM 4000fL(REV 4-88) i �i 1 ; I ! i Department of Justice A Office of Justice Programs j AWARD CONTINUATION 3 Bureau of Justice Assistance SHEET PAGE 3 or s Grant I f i iPILMECT11 MUR 2M-At-M-0336 AWARDDAIE omsR009 6. The grantee agrees to assist BJA in complying with the National Envimnmental Policy Act(NEPA),the National t His`orie Preservation Act,and other related federal environmental impact analyses requirements in the use of these i E grant funds,either directly by the grantee or by a subgramee Accordingly,the grantee agrees to first determine if airy I of the following activities will be funded by the grant,prior to obligating funds for any of these purposes. If it is determined that any of the following activities will be funded by toe grant,the grantee agrees to contact BJA. The grantee understands that this special condition applies to its following new activities whether or not they are being specifically fumed with these grant funds That is,as long as the activity is being conducted by the grantee,a ' I subgrantee,or any third party and the activity needs to be undertaken in order to use these grant funds,this special I condition must first be met The activities covered by this special condition are New construction, b Minor renovation or remodeling of a property located in an environmentally or historically sensitive area,including I properties located within a 100-year flood plain,a wetland,or habitat for endangered species,or a property libted on or eligible for listing on the National RegisterofHistonc Places, c A renovation,lease,or any proposed use of a building or facility that will either(a)result in a change in its basic prior use or(b)significantly change its size; d, implementation of a new program involving the use of chemicals other than chemicals that are(a)purebased as an incidental component of a funded activity and(b)traditionally used,for example,in office,household,recreational,or i education environments;and ' e implementation of a program relating to clandestine trethamphetamme laboratory operations,including the identification,seizure,or closure of clandestine methamphetamine laboratories The grantee understands and agrees that complying withNEPA may require the preparation of an Environmental 1 Assessment and/or an Environmental Impact Statement,as directed by BJA The grantee further understands and agrees to the requirements for implementation of a Mitigation Plan,as detailed at j http_//www oJp usdoj.gov/BJA/resource/nepa html,for programs relating to methainphetamine laboratory operations. Application of This Special Condition to Grantee's Existing Programs or Activities For any of the grantee's or its j subgrantees'exishng programs or activities that will be funded by these grant funds,the grantee,upon specific request ! from BJA,agrees to cooperate with BJA in any preparation by BJA of a national or program environmental assessment e f that funded program or activity i 7. To avoid duplicating existing networks or lT systems in any initiatives funded by BJA for law enforcement information sharing systems which involve interstate connectivity between jurisdiction,such systems shall employ,to the extent j passible,existing networks as the communication backbone to achieve interstate connectivity,unless the grantee can ' demonstrate to the satisfaction of BJA that this requirement would not be cost effective or would impair the functionality of an existing or proposed IT system j I 8. To support public safety and justice information sharing,OJP requires the grantee to use the National Information Exchange Model(N1EM)specifications and guidelines for this particular grant Grantee shall publish and make available without restriction all schemas generated as a result of this grant to the component registry as specified in the guidelines For more information on compliance with this special condition,visit i httpJ/www mem.gov/implementationguide.php j9 The recipient is required to establish a trust fund account.Ube trust fund may or may not be an interest-beating i account)The find including any interest,may not be used to pay debts or expenses incurred by other activities beyond the scope of the Edward Byrne Memorial Justice Assistance Grant Program(JAG) The recipient also agrees to obligate and expend the grant funds in the trust fund(including any interest earned)during the period of the grant Grant funds I (including any interest earned)not cxponded by the end of the grant perned must be returned to the Bureau of slice I i Assistance no later than 90 days after the end of the grant period,along with'he final submission of the Fina ct Status Report(SF-269) ; I I WP FORIN14000l2(REV 4-88) f 1 I Department of Justice a� Office of Justice Programs AWARDCONTINUA"ON s s Bureau of Justice Assistance SHEET PAGE 4 of s Grant I PRO]ECI't4TJMBER 2009-DJ-13X-0336 AWARD DATE 082812009 SPECIAL COADMONS 10, The grantee agrees to comply with all reporting,data collection and evaltiation requimmeats,as prescribed by law and detailed by the BJA in program guidance for the Justice Assistance Grant(JAG)Program Compliance with these requirements will be monitored by BJA I 11 The recipient agrees that any information technology system funded or supported by OJP funds wilt comply With 28 C.FR.Part 23,Criminal Intelligence Systems Operating Policies,if OJP deter times thus regulation to be applicable Should OR determine 28 C FR Part 23 to be applicable,OR may,at its discretion,perform audits of the system,as per the regulation. Should any violation of 28 C.F.R.Part 23 occur,the recipient maybe fined as per 42 US C ! 3789g(c)-(d). Recipient may not satisfy such a fine with federal funds. 12 The recipient agrees to ensure that the State fitformanon Technology Point of Contact receives written notification regarding any information technology project funded by this grant during the obligation and expenditure period This is , ! to facthtate communication among local and slate governmental entities regarding various information technology , projects being conducted with these grant finds.In addition,the recipient agrees to maintain an administrative file documenting the meeting of tlas requirement For a list of State information Technology Points of Contact,go to ! bttp//www.itolpgov/default aspx9area=polrcyAndPractice&page--1046_ 13. The grantee agrees ro comply with the applicable requirements of 28 C F R.Part 38,the Department of Justice regulation governing"Equal Treatment for Faith Based Organizations"(the"Equal Treatment Regulation") The Equal I l ! Treatment Regulation provides in part that Department of Justice grant awards of direct funding may not be used to fund any inherently religious activities,such as worship,religious instruction,or proselyhzation.Recipients of direct grants may still engage in mhemntly religious aenviues,but such activities must be separate in time or place from the ; Department of Justice funded program,and participation in such activities by individuals receiving services from the grantee or a sub-grantee must be voluntary The Equal Treatment Regulation also makes clear that organizations k I participating in programs directly funded by the Department of Justice are not permitted to discriminate in the provision i of services on the basis of a beneficiary's religion. Notwithstanding any other special condition ofthis award,faith- " based organizations may,in some circumstances,consider rehgion as a basis for employment See hitp//www.cjp.gov/aboudocr/equal_fbo him i 14. The recipient acknowledges that all programs funded through subawards,whether at the state or local levels,must• conform to the grant program requirements as stated in BJA program guidance 15 Grantee agrees to comply with the requirements of 28 C F.R Part 46 and all Office of Justice Programs policies and procedures regarding the protection of human research subjects,including obtainment of Institutional Review Board approval,if appropriate,and subject informed consent 16 Grantee agrees to comply with all confidentiality requirements of 42 U S C.section 3789g and 28 C F.R Part 22 that j are applicable to collection,use,and revelation of data or information.Grantee further agrees,as a condition of grant ! approval,to submit a Privacy Certificate that is in accord with requirements of 28 C F R Part 22 and,in particular, section 22.23• 17, The recipient agrees that funds received under this award will not be used to supplant State or local funds,but will be � used to increase the amounts of such funds that would,in the absence of Federal funds,be made available for law ' ienforcement activities. i 03P FORM 40002(REV,4-88) i Department of Justice Office of Justice Programs AWARD CONTINUATION r Bureau of Justice Assistance SHEET PAGE s of s Grant ' I E ' PROJECT NIJMBER 2009-DJ-BX-0336 AWARD DATE_ -08120069 ' I SPECIRL CONDITIONS I l8- The grantee agrees that withm 120 days of award,for any law enforeement task force funded with these funds,the task force commander,agency executive,task force officers,and other task force members of equtvalent rank,will complete 1 required online(intemet-based)task force training to be provided free of charge through BJA's Center for Task Force Integrity and Leadership.This training will address task force effectiveness as well as other key issues including privacy and civil liberues/aghts,task force performance measurement,personnel selection,and task force oversight and accountability Additi anal information will be provided by BJA regarding the required training and access methods via BJA's web site and the Center for Task Force Integrity and Leadership(www etlli org) � 19 Recipient may not obltgale,expend or drawdown funds until the Bureau of justice Assistance,Office of Suetice I Programs has received and approved the signed bfemora:idum of Understanding(MOM between the disparate Jurisdictions and has issued a Grant Adjustment Notice(GAN)releasing this special condition- ! 20 Recipient may not obligate,expend or drawdown funds until the Bureau of Justice Assistance,Office of Justice ! f Programs has received documentation demonstrating the.the state or local governing body review and/or community notification requirements have been met and has issued a Grant Adjustment Notice(GAIN releasing this special condition. i i i ] . i i : i I � i ' � I r i - i OJP FORM 4000)2(REV+-sa) i FY 109 Edward Byrne Memorial Justice Assistance (JAG) Grant Formula Program King County Joint Application Program Narrative City of Kent Project Name: Targeted Law Enforcement Projects ' Project Cost: $82,969 1 Project Description: ■ Part Time Evidence Custodian Position: $32,535 ■ Officer Overtime Targeting Identified Hot Spot Areas: $16,223 ■ Purchase & Deployment of Surveillance Cameras in Identified Hot Spot Areas: $20,000 ■ Upgrade of Computer Forensic & Cellular Phone Forensic Investigation Equipment& Regional Computer Forensic Training: $10,826 ■ Purchase of Graffiti Clean-Up Kits. $3,285 Program Need: The City of Kent is located in King County, Washington. The estimated King County population in 2008 was 1.8 million. (Puget Sound Regional Council, 2008) Kent is the ninth largest city in Washington and second largest city in South King County. Located midway between Seattle and Tacoma, Kent is located along the Interstate 5 corridor. Kent encompasses 29 square miles with an estimated population of 87,600. The city plans to annex an unincorporated area in the next year that would increase the population to over 100,000. t Part Time Evidence Custodian Position: Kent's growing population and crime rate require additional staffing for the city's criminal justice system to ensure public safety. We propose to add staffing to manage the police evidence as our city population continues to grow. The Kent City Council voted in June 2009 to proceed with the Panther Lake annexation vote in the fall of 2009. This annexation will add approximately 24,000 residents to the City of Kent. The volume of evidence continues to increase in Kent. This is driven by effective investigations by officers and detectives. Technological advances in computers, PDA's and cell phones also add to this volume of evidence. The number of evidence items processed increased 11% from 2007 through 2008 (9,217 to 10,216 respectively). Tlus volume increased 31% over the past five years. We expect this volume to increase further with the Panther Lake annexation in 2010. ' The City of Kent plans to add staffing for this annexation, however the current economic climate and the lag time in receiving tax revenue from the annexed area will delay hiring for these positions. The police department will focus the 2010 budget plans on hiring police officers. These additional police officers will need civilian support staff to ensure that the chain of custody on evidence is maintained to support ongoing successful prosecution for serious crimes. Officer Overtime Targeting Identified Hot Spot Areas: The Kent Police Department uses crime analysis to allocate resources. Crime trends in the city are reviewed on a daily basis and weekly meetings are held to coordinate available resources to address these crime trends Bicycle officers are assigned to patrol areas experiencing street crimes, however bicycle staffing is limited. Patrol officers are briefed on areas to concentrate their patrol efforts while on routine patrol. We also coordinate law enforcement activities with other local and federal law enforcement agencies. Gang activity continues to increase in Kent. Tacoma and Seattle law enforcement agencies report that gang members are traveling back and forth between these two major cities. Kent's location along the I-5 corridor is a convenient stop for gang members traveling between Seattle and Tacoma. Kent police officers and citizens are reporting increases in gang members wearing gang colors hanging around the Kent Transit station. Gang members from throughout King County have easy access to Kent riding King County Metro transit primarily arriving at the Kent Transit station near Kent's major retail and restaurant area. Kent police officers' gang related contacts totaled 244 in 2008 and 2009 contacts already reached 248 as of June 10, 2009. Officer education on gangs is one reason for the increase in gang contacts. Another reason is the attraction that suburban cities in South King County have for gang members. Seattle property development of low-income areas such as the Central District is moving well-established Seattle gang members to cities throughout South King County. Kent officers report that gang members also advise them they moved here from Yakima, Washington and California. Gang members have told Kent officers that one reason they moved was to protect their families and children from gang related violence. Gang activity is also demonstrated by the prevalence of graffiti throughout Kent. Kent is home to and a popular city to visit for many different King County gangs. Kent officers report that Surenos and their affiliated gangs are the most prevalent gangs in Kent. Gang members migrating from Seattle are primarily Bloods, Crips and Gangster Disciples affiliated gangs. Kent officers report fewer contacts with Asian gangs, however these gang members are associated with a high volume of property crimes in Kent. A 17-year-old boy was shot and killed outside of an Arby's restaurant in Kent on July 12, 2008. The suspect in this case was subsequently shot,just a couple of hours later in the adjacent city of Renton after getting off the bus he caught in Kent. The Kent Police detectives have determined through investigation that this was a gang related shooting. , This funding will provide additional officer overtime for emphasis activities in hotspots identified through weekly crime analysis. We will deploy bicycle officers on overtime whenever possible. Bicycle patrol officers can get into more locations than officers patrolling in squad cars. They also are able to interact with community members more readily to gain intelligence information. Purchase & Deployment of Surveillance Cameras in Identified Hot Spot Areas: We will ' purchase and deploy pole mounted surveillance cameras in crime hotspots. The initial cameras will be deployed in the King County Metro Transit Station near the Kent downtown retail and restaurant businesses. This is an ongoing area of concern for street crimes and general public disorder incidents. This equipment will provide video of crime suspects and promote successful crime investigations and prosecution. Upgrade of Computer Forensic & Cellular Phone Forensic Investigation Equipment & r Regional Computer Forensic Training: One Kent Police Department Detective is assigned to computer forensic investigations. Other South King County municipal law enforcement agencies turn to Kent for assistance with these investigations. Technological advances require constant computer forensic software and hardware upgrades to enable the department to examine computer evidence. The Kent Police Department equipment is updated periodically,but currently requires an entire system upgrade. Cellular telephone evidence is developing into a very valuable crime investigation tool. Different types of cellular telephones require specialized equipment to extract data to use in criminal investigations. The Kent Police Department Detectives have received training and currently do Inot have the equipment necessary to conduct this type of investigation. The technological advances also require ongoing training for Detectives. This project includes a training class for two Detectives to prepare for succession on this type of criminal investigation. Purchase of Graffiti Cleanup Kits: Community Service opportunities for juvenile justice involved youth are limited in Kent. The number of youth needing community service hours (court appointed) overwhelms the current opportunities. Each month, Kent Police provides community service hours to youth needing court ordered hours. These youth participate in graffiti cleanup activities We are only able to accommodate 10 youth per month. There is a much greater need for community service opportunities in Kent as others are sent outside of Kent to get community service hours. This eliminates the opportunity for these youth to give back to and connect with their own community. This project will provide additional graffiti cleanup kits to support additional youth participating in community service opportunities in Kent. Identification of types of gang activity/violence in Kent: ' Over 200 incidents of graffiti occurred in 2008. ■ Currently 100 incidents of graffiti have been reported as of June 15, 2009. ■ Twelve "hot spots"have been identified as targets for gang related graffiti (based on repeated incidents). ■ Gangs are using graffiti to communicate, including holding "roll calls" and declaration of violence towards other gangs. I Program Activities for 4-Year Grant Period: Evidence Custodian Part-time position: The Kent Police Department Evidence Unit is staffed by one Evidence Technician Supervisor, one Evidence Technician and one Evidence Custodian. The supervisor and Evidence Technician respond to major crime scenes, write supplemental case reports, process evidence and analyze marijuana. The evidence custodian processes all evidence submitted by police officers and manages evidence storage and records. jThe police department is prepared to facilitate the hiring process for the Evidence Custodian immediately upon notification of this funding award This funding will support a part-time ' evidence custodian working 21 hours per week over eight months. This additional evidence custodian will allow the police department to maintain the evidence chain of custody as we add the estimated 24,000 additional people through the Panther Lake annexation in 2010. This will ensure adequate support for police officers and detectives' crime prosecution cases. The City Administration Officer and Mayor support increasing this position to full-time and sustaining it beyond the eight months of funding under this grant program. Police officer emphasis overtime: This funding will support 204 hours of patrol officer overtime for crime trend directed emphasis activities This overtime funding will be expended by the end of 2010. Law enforcement equipment: This project funding will allow the Kent Police Department to purchase and install pole surveillance cameras initially at the Kent Transit Station This equipment consists of Video surveillance cameras, power supplies, software and servers to provide video monitoring and surveillance by Police. These cameras and supporting monitoring equipment will be installed by the first quarter of 2010. The crime reduction outcomes from these cameras will determine future camera acquisition and deployment in other hotspots in the city. Computer and cellular telephone forensic investigation equipment and software will be ' purchased by the end of the first half of 2010. This project funding will support a two-year software upgrade for the universal forensic extraction device. The budgeted training will be ' completed by the end of 2010. Prevention and education: This funding will provide an additional 6 graffiti kits for youth diversion work crews and community graffiti cleanup events. These kits will ensure adequate graffiti removal tools for the quarterly community clean up events where we reach out to businesses, neighborhoods, service clubs, and church groups four times a year. This funding will purchase supplies to staff 50 volunteers at each of these cleanup events. The funding will be expended by the end of 2010. Anticipated Coordination Efforts Involving JAG and Related Justice Funds: The FY 2009 JAG funding will be coordinated with existing city and grant justice funds currently allocated to law enforcement, crime investigation and crime prevention and education activities. Department of Justice, Weed and Seed Program funding provides officer overtime for emphasis activities in the designated Kent East Hill Corridor Weed and Seed community. The Kent Police Department participates on the Special Gang Enforcement Taskforce managed by the Seattle Police Department. This task force is developing a gang intelligence network with other justice agencies. The Kent Police Department participates through this taskforce with other local law enforcement and immigration agencies on gang emphasis events. Project Objectives: 1. Provide adequate staffing and equipment to ensure timely evidence processing and support successful prosecution of crimes. This funding will allow the Kent Police Department to hire a part-time evidence custodian to keep up with the increased volume of evidence submitted to the police department. This position will transition to a full-time evidence custodian beyond the grant-funding period of eight months. ' Baseline data of evidence volumes and processing times will be captured prior to hiring this position. This data will be compared with the same measures at the end of this new employee's eight months with the City of Kent. We expect to see increased volumes of evidence and at least maintain the process time for all evidence. We will track the number of successful prosecutions using computer and cellular phone ' forensic investigation. Other local law enforcement agencies already turn to our computer forensic investigators for assistance with this type of investigation. We will also provide , anecdotal evidence of other regional agencies' supported by our computer and cellular phone forensic investigators. 2. 20% Decrease crime activity in crime hotspots. We already track crime trend data on a weekly basis. We have already documented successful crime reduction through patrol officer overtime emphasis activities funding primarily by other justice grants. Areas targeted with patrol officer overtime or with pole surveillance cameras will experience a 20% decrease in crime activity through 2010. We will track the number of arrests as a result of pole camera surveillance and resulting successful piosecutions. This funding will support additional graffiti cleanup events for both juvenile diversion work crews and community partner events. We will report the number of and type of graffiti cleanup events supported with the six additional graffiti cleanup kits from this funding. We expect increased graffiti cleanups to discourage ongoing gang graffiti and subsequently decrease crime 1 activity in these areas of the city. Performance Measures: f. Amount of award expended on training. 2. Percent of criminal justice staff who completed training. 3. Number of overtime hours paid with JAG funds. 4. Amount of funds expended on equipment and/or supplies. 5. Types of equipment and/or supplies purchased with JAG funds. 6. Number of units to directly benefit from equipment and/or supplies purchased with JAG funds. 1 7. Percent of Criminal Justice staff who reported a desired change in job performance as a result of equipment or supplies purchased by JAG funds. 8. Percent of Criminal Justice staff who reported a desired change in program quality as a result of equipment or supplies purchased with JAG funds. Personnel Name/Position Computation Cost Part-time Evidence Custodian(2010) $24.10/hr x 21 hrs/wk x 34 $17,205 Police Officer Overtime(2009) $66.75/hr x 80 hours S5,340 Police Officer Overtime(2010) $68.42/hr x 124 hours $8,484 TOTAL: $31,029 B Fringe Benefits Name/Position Computation Cost Part-tune Evidence Custodian(2010) ' FICA $17,204 x 7.65% $1,315 Retirement $17,204 x 5.29% $910 Medical Insurance $1,500/month x 8 months $12,000 Medical Aid $1.2583/hour x 714 hours $898 Life Insurance S13.50/month x 8 months $108 Unemployment S12 40/month x 8 months $99 Police Officer Overtime FICA $13,825 x 076 $1,058 Retirement $13,825 x 097 $1,341 TOTAL: $17,729 C Travel/Training Purpose Location Computation Cost Regional Computer Forensics Traming Western WA Meals $35/day x 3 days x 2 detectives $210 Tuition- $375 x 2 detectives $750 TOTAL: $960 . E mpment Item Computation Cost Surveillance camera System(mounting and power, control/monitoring software system) 2 x$7,500 $15,000 Server(index, store,provide video images/snapshots) 1 x$5,000 $5,000 Computer forensic workstation upgrade $6,600+9.5%sales tax $7,227 TOTAL: $27,227 D. Supplies Item Computation Cost Computer forensic device software upgrades ($1000/yr x 2 yrs)+9.5%tax $2,190 Cellular phone forensic imaging device $410+9 5% $449 Graffiti Removal Kits $500 each x 6 kits+9.5%sales tax $3,285 TOTAL: $5,924 IKENTT• :69 Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 61 1. SUBJECT: WASHINGTON AUTO THEFT PREVENTION AUTHORITY GRANT AWARD - ACCEPT AND ESTABLISH BUDGET 2. SUMMARY STATEMENT: Authorize the Kent Police Department, as Fiscal Agent of the P.A.T.R.O.L. Task Force, to accept a grant in the amount of $800,000 from the Washington Auto Theft Prevention Authority, amend the budget, authorize expenditure of the funds in accordance with the task force procedures, and authorize the Mayor, or her designee, to sign all documents related to the grant as may be required of Kent. The Kent Police Department will serve as the fiscal manager for the WATPA grant in the amount of $800,000. The grant was awarded to the Preventing Auto Theft through Regional Operational Links (PATROL) Task Force. The grant was submitted by the Federal Way Police Department on behalf of the PATROL Task j Force which is comprised of many South King County law enforcement agencies, King County Prosecutor's Office and two North Pierce County police agencies. The grant will fund personnel and equipment for the PATROL Task Force. The award is for a one- year period and is funded by $10 of every traffic citation from across the state, which has been directed to WATPA. 3. EXHIBITS: Award notification from WATPA 6/6/09 1 4. RECOMMENDED BY: Public Safety Committee 3/9/10 (Committee, Staff, Examiner, Commission, etc.) i5. FISCAL IMPACT Expenditure? Y Revenue? Y Currently in the Budget? Yes _ No X 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds DISCUSSION: ACTION: WAtSHINGITON AUTO THEFT PREVENTION AUTHORITY WASHINGTON ASSOCIATION OF SHERIFFS AND POLICE CHIEFS 3060 Willamette Dnve NE,Suite 101—Lacey,WA 98516—Phone (360)292-7900—Fax (360)292-7269—Welislte http t/watpa waspcmg preventing and reducing motor vehicle thefts and other associated crime in the State of Washington " June 6,2009 Chief Brian Wilson Federal Way Police Department PO Box 9718 Federal Way WA 98063-9718 Dear Chief Wilson: We are in receipt of your revised budget proposal, which has been approved. The grant award is effective July 1, 2009 and expires on June 30, 2010. Enclosed is an award agreement, This agreement is to be signed and returned to the WATPA. No funds will be reimbursed until the signed agreement is received. Expenditures prior to the award effective date or after the grant expiration date are not authorized and will not be reimbursed. In addition, the grant award is subject to all Grant Awards General Terms and Conditions, and Special Conditions of the Washington Auto Theft Prevention Authority(copies enclosed). Costs will be paid on a reimbursement basis. Appropriate invoices and receipts are to be submitted no more than once each month. You will be reimbursed for actual expenses only up to the limit of the award. Congratulations on your grant award approval. We look forward to seeing positive outcomes from your efforts toward improving the motor vehicle theft problem in Washington State. If you have any questions, please contact me at 360-292-7900 or via e-mail at I lam unyonAwaspe,org. Sincerely, Im unyon, Executive Director W ington Auto Theft Prevention Authority Warhingion Aura Theft PYtmmd" Authunly JOHN BATISTE EMIL DAMMEL HARVEY CJESDAL KEN HORENNERO JOHN LOVICK Chief-WA Slate Palml lntvmnce ladmlry Shall—iMaglat Coupe• Chief—KenneMlch Sh"if-Snoham6h Cowry MERLE PFIEFER DON PIFRCE DANSATI ERRERO STEVESTRACHAN MICIIAEI WEST General PUNK LrerurWe Ovaror WASPC FWSecuring Av ey-KmgrAWaly Chief—Kent Automobile lndwvy JIM LAMIINYON EreaRee Dveclae WAWA 1 AGREEMENT BETWEEN AND WASHINGTON AUTO THEFT PREVENTION AUTHORITY WASHINGTON AUTO THEFT AUTO THEFT PREVENTION PREVENTION AUTHORITY GRANT PROGRAM AWARD SHEET 1. Award Recipient Name and Address: 6. Contact: Brian Wilson Federal Way Police Department Title: Chief 2. Project Title Telephone: 253-835-6701 PATROL Task Force 7. Award Period: 3. Tax Identification No: 07/01/09-06/30/10 8. Funding Authority: WASHINGTON AUTO THEFT 4. Grant No: PREVENTION AUTHORITY 09-GG-WATPA-001 9. Service Area: 5. Amt. Approved $800,000.00 10. Requests for reimbursement under this agreement are subject to the following Budget: A. Personnel 570,540.00 B. Employee Benefits 187,960.00 C. Consultants/Contracts 7,500.00 D. Travel/Trainings 5,000.00 E. Other Expenses 29,000 00 11. Total: $800,000.00 IN WITNESS WHEREOF, the WATPA and RECIPIENT acknowledge and accept the terms of this AGREEMENT and attachments hereto,and to witness whereof have executed this AGREEMENT as of the date and year last written below. The rights and obligations of both parties to this AGREEMENT are governed by the information on this Award Sheet and other documents incorporated herein by reference- Agreement Specific Terms and Conditions,and Agreement General Terms and Conditions. R THE V TPA: FOR THE RECIPIENT: J' unyon, Executive Director Name r �lL,/lS�, -%lrr�+ G� � iCl„daf�(w TPA Title: Date: 'aO Dater 27 Special Conditions Washington Auto Theft Prevention Authority Grant Award 1. The funding under this project is for the payment of salaries,overtime, and approved benefits for sworn law enforcement officers and support personnel; equipment and technology, and training and/or travel as approved in advance by the WATPA. The particular areas for which your grant has been approved are listed in the budget section of the grant face sheet which is included in your award packet. 2. Travel costs for transportation,lodging and subsistence, and related items are allowable as specified in your approved budget. Costs are to be governed by your junsd►ction's travel policies or by those of the State of Washington. Invoices for travel expenses shall indicate which travel policies are used as a method of reimbursement. 3. In order to assist the WATPA in the monitoring of the award, your agency will be responsible for submitting quarterly Program Progress Reports and quarterly Financial Status Reports. 4. The WATPA may conduct periodic reviews or audits(program and financial)of the Auto Theft Grant Program. The grantee agrees to cooperate with the auditors. 5. The grantee agrees to abide by the terms, conditions and regulations as found in the Washington Auto Theft Prevention Authority Grant Policies and Procedures. 6. The grantee agrees that no WATPA funding for grant activities will be used to supplant funding from other sources. 28 WASHINGTON AUTO THEFT PREVENTION AUTHORITY INTERAGENCY AGREEMENT AUTO THEFT PREVENTION GRANT AWARDS GENERAL TERMS AND CONDITIONS DEFINITIONS ' As used throughout this AGREEMENT, the following terms shall have the meanings set forth below: 1. "WATPA"shall mean the Washington Auto Theft Prevention Authority, any division, section,office,unit or other entity of the WATPA, or any of the officers or other officials lawfully representing the WATPA. 2. "RECIPIENT"shall mean the agency, firm, provider, organization, individual,or other entity receiving financial assistance under this AGREEMENT. It shall include any SUBRECIPIENT as designated by the RECIPIENT and permitted under the terms of this AGREEMENT. 3. A"SUBRECfPIENf"shall mean a person or entity who is not an employee of the RECIPIENT, who is an individual or other entity performing all or dart of the services under this AGREEMENT,under a separate written AGREEMENT with the RECIPIENT. It shall include any SUBRECIPIENT retained by the prime RECIPIENT as permitted under the terms of tins AGREEMENT. The terms"SUBRECIPIENT"and"SUBRECIPIENTS"mean SUBRECIPIENT(S)in any tier. GOVERNING LAW AND VENUE This AGREEMENT shall be construed and enforced in accordance with, and the validity and performance hereof shall be governed by, the laws of the state of Washington. Venue of any suit between the parties ansing out of this AGREEMENT shall be the Superior Court of Thurston County, Washington RECIPIENT NOT EMPLOYEE OFFICER OR AGENT OF AGENCY The RECIPIENT and his/her employees or agents performing under this AGREEMENT are not deemed to be employees,officers, or agents of the WATPA in any manner whatsoever.The RECIPIENT will not hold himself/herself out as, nor claim to be an officer, employee,or agent of the WATPA by any reason hereof and will not make any such applicable claim,demand, or application to or for any right or privilege. AGREEMENT MODIFICATIONS The WATPA and the RECIPIENT may request changes in services to be performed with the funds, or in the amount of funds to be reimbursed to the RECIPIENT Any such changes that are mutually agreed upon by the WATPA and the RECIPIENT shalt be incorporated herein by i l of 7 29 written amendment to this AGREEMENT. It is mutually agreed and understood that no alteration or variation of the terms of this AGREEMENT shall be valid unless made in writing and signed by the parties hereto,and that any oral understanding or agreements not incorporated herein, unless made in writing and signed by the parties hereto, shall not be binding. DUPLICATION OF COSTS/SUPPLANTING The RECIPIENT certifies that work to be performed under this AGREEMENT does not duplicate any work to be charged against any other AGREEMENT, SUBAGREEMENT, or other funding.The RECIPIENT shall include the provisions of this clause in any SUBAGREEMENT. NONDISCRIMINATION During the performance of this AGREEMENT, the RECIPIENT shall comply with the WATPA'S nondiscrimination plan and the federal and state laws upon which it is based. Requirements of the nondiscrimination plan are hereby incorporated by reference, and include, but are not limited to: 1. Nondiscrimination in employment:The RECIPIENT shall not discriminate against any employee or applicant for employment because of race, color, sex, religion, national origin, creed, marital status, age, Vietnam era or disabled veterans status, or the presence of any sensory,mental,or physical handicap. The RECIPIENT shall take affirmative action to ensure that employees are employed and treated during employment without discrimination because of their race, color, religion, sex, national origin, creed, marital status, age, Vietnam era or disabled veterans status, or the presence of sensory,mental,or physical handicap. Such action shall include, but not limited to, the following• employment upgrading, demotion, or transfer, and recruitment or selection for training, including apprenticeships and volunteers. 2. Nondiscrimination in services: The RECIPIENT shall not discriminate against any person eligible lot services or participation in the program because of race, color, sex, religion, national origin, creed, marital status, age, Vietnam Era or disabled veterans status, or the presence of any sensory, mental or physical handicap. 3. Religious Activity: The RECIPIENT shall not use any curricula or materials, which have any religious orientation. The RECIPIENT shall not require participants under this AGREEMENT to participate in any religious activity. NONCOMPLIANCE WITH NONDISCRIMINATION PLAN In the event of the RECIPIENT'S noncompliance or refusal to comply with the above tion- discrimination plan, this AGREEMENT may be rescinded, canceled, or terminated in whole or in part, and the RECIPIENT may be declared ineligible for further grant awards from the WATPA The RECIPIENT shall,however, be given a reasonable time, in no event to exceed thirty(30)days, in which to correct this noncompliance Any dispute may be resolved in accordance with the"Disputes"procedure set forth herein 30 2 of 7 COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT OF 1990 i The RECIPIENT shall comply with the Americans with Disabilities Act of 1990(ADA),42 U.S.C. Section 12101 et seq. and its implementing regulations.This act provides comprehensive civil rights protection to individuals with disabilities in the areas of employment,public accommodations,state and local government services, and telecommunications. USE OF MINORITY AND WOMEN BUSINESS ENTERPRISES The RECIPIENT shall provide the maximum opportunity to Minority and Women Owned Business Enterprises to participate in the performance of this AGREEMENT.This condition shall be included in all SUBAGREEMENTS under this AGREEMENT. INDEMNIFICATION The RECIPIENT agrees that he or she is financially responsible (liable) for any audit exception or other financial loss to the WATPA which occurs due to the negligence, intentional acts,or failure for any reason,to comply with the terms of this AGREEMENT by the RECIPIENT and/or its agents, employees, SUBRECIP[ENTS or representatives. The RECIPIENT further agrees to protect, defend, and save the WATPA, its appointed officials, agents, and employees, while acting within the scope of their duties as such,harmless from and against all claims,demands, and causes of action of any kind or character, including the cast of defense thereof, arising in favor of the RECIPIENT'S employees or third parties on account of bodily or personal injuries, death, or damage to property or any other liability arising out of services performed or omissions of services or in any way resulting from the acts or omissions of the RECIPIENT and/or its agents, employees, SUBRECIPIENTS, or representatives under this AGREEMENT. The RECIPIENT is responsible for ensuring that any SUBRECIPIENT(S) includes a comprehensive indemnification clause holding harmless the RECIPIENT, and the WATPA. The RECIPIENT waives his or her immunity under Title S 1 RCW to the extent required by this clause. PROGRAM INCOME Program income generated by interest-bearing accounts or otherwise under this AGREEMENT shall be used for operational expenses directly related to motor vehicle theft activities not included in the total budget. 3 oF731 TREATMENT OF ASSETS The RECIPIENT shall take the following actions to secure the financial interest of the WATPA in items purchased under this AGREEMENT: 1. Title to all property purchased by the RECIPIENT,the cost of which the RECIPIENT is entitled to be reimbursed as a direct item of cost under this AGREEMENT, shall remain with the RECIPIENT provided the RECIPIENT uses the property for the same funded program purposes. 2. The RECIPIENT shall be responsible for any loss or damage to property purchased or procured with WATPA grant funding. 3. The RECIPIENT shall maintain records, perform inventories, and maintain control systems to prevent loss,damage, or theft of equipment, materials,and supplies. 4. The RECIP[ENT shall maintain a non-expendable equipment inventory on file The WATPA'S interest in equipment purchased under this AGREEMENT and prior AGREEMENTS from the same funding source is automatically transferred forward to the next AGREEMENT year at the close of the AGREEMENT period. 5. The RECIPIENT shall surrender to the WATPA all property of the WATPA prior to settlement upon completion, termination, or cancellation of this AGREEMENT. PROCUREMENT STANDARDS The RECIPIENT shall comply with the procurement policies and procedures established for their agency by their local governing body. RECIPIENTS and SUBRECIMENTS shall be required to receive prior approval from the WATPA for using funds from this AGREEMENT to enter into a sole source agreement or contract with a value exceeding$5,000 where only one bid or proposal is received Prior approval requests shall include: a copy of the proposed agreement or contract, any related procurement documents, and justification for noncompetitive procurement, if applicable. NONASSIGNABILITY Neither this AGREEMENT,nor any claim arising under this AGREEMENT, shall be transferred or assigned by the RECIPIENT. RIGHTS OF DATA All finished or unfinished documents,data, studies, surveys,drawings, models, photographs, films, duplicating plates, computer disks, and reports prepared by the RECIPIENT under this AGREEMENT shall be for the common use of both the RECIPIENT and the WATPA.The 4of12 WATPA may duplicate, use, and disclose in any manner,and for any purpose whatsoever, all material prepared under this AGREEMENT. The RECIPIENT shall be required to obtain prior approval of the WATPA to produce patents, patent rights, inventions, original books, manuals, films,or other patentable or copyrightable materials, in whole or in part, with funds received under this AGREEMENT. The WATPA reserves the right to determine whether protection of inventions or discoveries shall be disposed of and administered in order to protect the public interest. Before the RECIPIENT copyrights any materials produced with funds under this AGREEMENT, the WATPA reserves the tight to negotiate a reasonable royalty fee and agreement. RECAPTURE PROVISION In the event the RECIPIENT fails to expend funds in accordance with state law or the provisions of this AGREEMENT, the WATPA reserves the right to recapture funds in an amount equivalent to the extent of the noncompliance. Such right of recapture shall exist for a period not to exceed six(6) years following termination of this AGREEMENT. Repayment by the RECIPIENT of funds under this recapture shall occur within thirty(30)days of demand. WRITTEN POLICIES AND PROCEDURES Written policies and procedures consistent with federal and state regulations,as applicable, shall be kept on file in the office of the RECIPIENT or its local programs and available for review. Such policies and procedures shall include, but not be linuted to. personnel regulations;job descriptions;organizational charts; travel regulations, fiscal management regulations; and affirmative action policies and plans RECORDS AND DOCUMENTS The RECIPIENT shall maintain books, records,documents, and other evidence that properly reflect financial procedures and practices, participant records, statistical records, property and materials records and supporting documentation. These records shall be subject at all reasonable hours to review and audit by the WATPA, the Office of the State Auditor, and state and federal officials so authorized by law. The RECIPIENT shall retain all such records for a period of six (6) years fiom termination of the AGREEMENT. If any litigation or audit is begun in the period during which records must be retained, or if a claim is initiated involving the AGREEMENT or any related agreement, the RECIPIENT must retain the related records until the litigation, audit, or claim has been finally resolved. DOCUMENTS ON FILE Documents consistent with federal and state regulations, as applicable, shall be kept on file and available for review in the office of the RECIPIENT or its local programs. Such documents shall include, but not be limited to; Articles of Incorporation/Tribal Charter; by-laws; IRS Nonprofit Status Certification, and latest agency audit. 33 5 of 7 APPLICABLE LAWS AND REGULATIONS The RECIPIENT shall comply with all applicable laws, ordinances,codes, regulations, and policies of state and federal governments, as now or hereafter amended. POLITICAL ACTIVITIES PROHIBITED No award funds may be used in working for or against ballot measures or for or against the candidacy of any person for public office. DISPUTES Except as otherwise provided in this AGREEMENT, when a bona fide dispute arises between the parties and it cannot be resolved through discussion and negotiation, either party may request a dispute hearing. The parties shall select a dispute resolution team to resolve the dispute The team shall consist of a representative appointed by the WATPA,a representative appointed by the RECIPIENT, and third party mutually agreed upon by both parties.The team shall attempt, by majority vote, to resolve the dispute. The parties agree that this dispute process shall precede any action in a judicial or quasi-judicial tribunal. LEGAL PROCEEDINGS In the event the WATPA is required to institute legal proceedings to enforce any provision of this AGREEMENT,and is the prevailing party, the WATPA shall be entitled to its costs thereof, including reasonable attorneys' fees. TERMINATION OF AGREEMENT I. If, through any cause, the RECIPIENT shall fail to fulfill in a timely and proper manner its obligations under this AGREEMENT,or if the RECIPIENT shall violate any of the covenants, agreements, or stipulations of this AGREEMENT, the WATPA shall thereupon have the right to terminate this AGREEMENT and withhold the remaining allocation if such default or violation is not corrected within thirty(30) days after submitting written notice to the RECIPIENT describing such default or violation. 2. Notwithstanding any provisions of this AGREEMENT,either party may terminate this AGREEMENT by providing written notice of such termination, specifying the effective date thereof,at least thirty(30)days pnor to such date. 3 Reimbursement for RECIPIENT services performed, and not otherwise paid for by the WATPA prior to the effective date of such termination, shall be as the WATPA reasonably determines. 4. The WATPA may immediately and unilaterally terminate all or part of this AGREEMENT, or may reduce its scope of work and budget, if there is a reduction in funds by the source of 34 6of7 those funds,and if such funds are the basis for this AGREEMENT. Such termination shall be effective when the WATPA sends written notice of termination to the RECIPIENT. SEVERABILITY In the event any term or condition of this AGREEMENT or application thereof to any person or circumstances is held invalid, such invalidity shall not affect other terms,conditions or applications of this AGREEMENT that can be given effect without the invalid term,condition, or application. To the end the terms and conditions of this AGREEMENT are declared severable. AUDIT REQUIREMENTS 1. State Funds Audit Requirements This AGREEMENT includes state funds. RECIPIENTS expending$75,000 or more in total state funds in a fiscal year must have a financial audit as defined by Government Auditing Standards,(The Revised Yellow Book) and according to Generally Accepted Accounting Standards(GAAS). If RECIPIENT has an OMB Circular A-133 audit, it meets these requirements. The RECIPIENT shall include the above audit requirements in any SUBAGREEMENTS granting state funds to sub recipients. 2. The RECIPIENT must send a copy of the audit report no later than nine months after the end of the RECIPIENT'S fiscal year(s)to: Washington Auto Theft Prevention Authority 3060 Willamette Drive NE Lacey WA 98516 ATTN. Grant Services Coordinator 3. Responses to any unresolved management findings and disallowed or questioned costs shall be included with the audit report.The RECIPIENT must respond to WATPA requests for information or corrective action concerning audit issues within 30 days of the date of request. SPECIAL PROVISION The WATPA'S failure to insist upon strict performance of any provision of this AGREEMENT or to exercise any right based upon breach thereof or the acceptance of any performance during such breach shall not constitute a waiver of any rights under this AGREEMENT. 7 of 15 1 Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6K 1. SUBJECT: PURCHASE OF SPERIAN PERSONAL PROTECTIVE EQUIPMENT - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign the Goods and Services Agreement with Santiam Emergency Equipment, Inc. for the purchase of Sperian personal protective equipment in an amount not to exceed $150,000, sub]ect to final terms and conditions acceptable to the City Attorney. The Fire Department requested and received from the Mayor a waiver, pursuant to KCC 3.70.080, of the City's procurement ordinance for the purchase of personal protective equipment for the year of 2010. Santiam is the sole distributor for Sperian personal protective equipment. The City has had a strong working relationship with Santiam for well over a decade. Firefighting clothing needs to be replaced on an ongoing basis due to normal wear and tear, to meet new safety standards, and to utilize improved technology. The cost for 2010 of the replacement for aged or damaged bunker gear will not exceed $150,000. As standard practice, equipment is evaluated by the Fire Department to insure this criterion is met and that the City purchases the most effective product for the tax dollars spent. After an extensive evaluation process, the Fire Department has found that the Sperian brand continues to meet these criteria. 3. EXHIBITS: Sole Source Authorization and Goods & Services Agreement 4. RECOMMENDED BY: Public Safety Committee 3/9/10 (Committee, Staff, Examiner, Commission, etc.) S. FISCAL IMPACT Expenditure? Yes Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: ' Councilmember moves, Councilmember seconds ' DISCUSSION: 1 ACTION: i CITY OF KENT FIRE ADMINISTRATION • Jim Schneider rgency Management KEN T Fire Chief/D€rector of Eme24611 116'h Ave. SE WAS MINOrOH Kent, WA 96030 Fax: 253-856-6300 Meo PHONE: 253-856-4300 ' To: Suzette Cooke, Mayor From: Jim Schneider, Fire Chief N Date: January 27, 2010 !, Re: Single Source Procurement for PPE The Fire Department is requesting a waiver, pursuant to KCC 3.70.080, of the City's procurement ordinance as negotiation with a particular supplier is appropriate due to the specialized needs of the Fire Department. The Kent Fire Department has been extremely diligent in purchasing Personal Protective Equipment (PPE) at the lowest possible price. Protective clothing needs to be replaced on an ongoing basis due to normal wear, to meet new safety standards and to utilize improved technology. The cost of replacement exceeds $50,000 each year, and often exceeds $100,000. Over the last decade the Department has had sole vendor authorization contracts with Santiam Emergency Equipment, Inc., the sole distributor for Sperian, the manufacturer of our current protective clothing. As a standard practice, bunker gear is evaluated by the Kent Fire Department to ensure that safety criteria are met and that the best product is purchased for the tax dollars spent. After six months of field-testing several new styles of unke ear in 2006, the recommendation was made to continue our Tong-standing relationship with he Sperian gear is superior in the areas of abrasion resistance and flame impingement. Also, the gear has an ergonomic cut for more flexibility and range of motion. The Fire Department would like to contract with Santiam Emergency Equipment for the purchase of 1 Sperian protective clothing. It is advantageous for the Department to purchase one brand of bunker gear which creates standardization and uniformity, and is better for firefighters who know the abilities and limitations of the gear they wear. This brand of bunker gear also presents a professional visual appearance to the public. In addition, it is much easier to make changes or have supplemental work done when working with one vendor. By this memo, the Fire Department requests that you authorize the department to enter into direct negotiations with Santiam Emergency Equipment for the purchase of Personal Protective clothing. If you approve of the Fire Department's request for a waiver of the City's procurement policies, please note your approval by signing below. Thank yo S zette ooke, Mayor Date t 1 KENT WAS HIN GTON GOODS & SERVICES AGREEMENT ' between the City of Kent and Santiam Emergency Equipment, Inc. ' THIS AGREEMENT is made by and between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and Santiam Emergency Equipment, Inc. organized under the laws of the State of Washington, located and doing business at PO Box 13585, Salem, Oregon 97309 (hereinafter the "Vendor"). AGREEMENT tI. DESCRIPTION OF WORK. Vendor shall provide the following goods and materials and/or perform the following services for the City: ` During the term of this Agreement, and in accordance with Vendor's quote attached and incorporated as Exhibit A, the City will order bunker gear on an as-needed basis, which includes Vendor's Securitex/Spenan UltraMotion Coat, identified by item number S250VZ8, and Vendor's Securitex/Sperian UltraMotion Pant, identified by item number S350VZ8. The cost charged to the City for each Securitex UltraMotion Coat purchased shall be $1,230.13. The cost charged to the City for each Securitex UltraMotion Pant purchased shall be $840.56. Vendor acknowledges and understands that it is not the City's exclusive provider of these goods, materials, or services and that the City maintains its unqualified right to obtain these goods, materials, and services through other sources. ' II. TIME OF COMPLETION. Upon the effective date of this Agreement, Vendor shall complete the work and provide all goods, materials, and services within 2010. 1 III. COMPENSATION. The City shall pay the Vendor an amount not to exceed $150,000, including applicable Washington State Sales Tax, for the goods, materials, and services contemplated in this Agreement. The City shall pay the Vendor the following amounts according to the following schedule: GOODS & SERVICES AGREEMENT - 1 (Over$10,000.00, including WSST) The City shall pay the Vendor an amount not to exceed $150,000 for the term of , this Agreement, including Washington State Sales Tax, for the goods, materials, and services contemplated in this Agreement. This "not to exceed" amount is provided as an estimate only and is in no way a guarantee of the payment the Vendor can expect to receive during the term of this Agreement. This estimate is based on the number and type of bunker gear that the City reasonably expects it needs to purchase and rent from the Vendor during the term of this Agreement. However, because the City's needs depends on the number of employees it has on staff, this amount may fluctuate up or down. The City shall pay the Vendor the following amounts according to the following schedule: The City shall remit payment to Vendor within thirty (30) days of the City's receipt of the ordered bunker gear and a proper invoice. If the City objects to all or any portion of an invoice, it shall notify Vendor and reserves the option to only pay that portion of the invoice not in dispute. Vendor shall submit invoices to Kent Fire Department, Attn: Elizabeth Kingery, 24611 116th Ave SE, Kent, WA 98030. 1 If the City objects to all or any portion of an invoice, it shall notify Vendor and reserves the option to only pay that portion of the invoice not in dispute. In that event, the parties will immediately make every effort to settle the disputed portion. A. Defective or Unauthorized Work. The City reserves its right to withhold payment from Vendor for any defective or unauthorized goods, materials or services. If Vendor is unable, for any reason, to complete any part of this Agreement, the City may obtain the goods, materials or services from other sources, and Vendor shall be liable to the City for any additional costs incurred by the City. "Additional costs" shall mean all reasonable costs, including legal costs and attorney fees, incurred by the City beyond the maximum Agreement price specified above. The City further reserves its right to deduct these additional costs incurred to complete this Agreement with other sources, from any and all amounts due or to become due the Vendor. B. Final Payment: Waiver of Claims. VENDOR'S ACCEPTANCE OF FINAL PAYMENT SHALL CONSTITUTE A WAIVER OF CLAIMS, EXCEPT THOSE PREVIOUSLY AND PROPERLY MADE AND IDENTIFIED BY VENDOR AS UNSETTLED AT THE TIME REQUEST FOR FINAL PAYMENT IS MADE. IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent , Contractor-Employer Relationship will be created by this Agreement. By their execution of this Agreement, and in accordance with Ch. 51.08 RCW, the parties make the following , representations: A. The Vendor has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. GOODS & SERVICES AGREEMENT - 2 (Over$10,000.00, including WSST) B. The Vendor maintains and pays for its own place of business from which Vendor's services under this Agreement will be performed. C. The Vendor has an established and independent business that is eligible for a business deduction for federal income tax purposes that existed before the City retained Vendor's services, or the Vendor is engaged in an independently established trade, occupation, profession, or business of the same nature as that involved under this Agreement. D. The Vendor is responsible for filing as they become due all necessary tax ' documents with appropriate federal and state agencies, including the Internal Revenue Service and the state Department of Revenue. E. The Vendor has registered its business and established an account with the state Department of Revenue and other state agencies as may be required by Vendor's business, and has obtained a Unified Business Identifier (UBI) number from the State of Washington. F. The Vendor maintains a set of books dedicated to the expenses and earnings of its business. V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party thirty (30) days written notice at its address set forth on the signature block of this Agreement. VI. CHANGES. The City may issue a written amendment for any change in the goods, materials or services to be provided during the performance of this Agreement. If the Vendor determines, for any reason, that an amendment is necessary, Vendor must submit a written amendment request to the person listed in the notice provision section of this Agreement, ' section XIV(D), within fourteen (14) calendar days of the date Vendor knew or should have known of the facts and events giving rise to the requested change. If the City determines that the change increases or decreases the Vendor's costs or time for performance, the City will make an equitable adjustment. The City will attempt, in good faith, to reach agreement with the Vendor on all equitable adjustments. However, if the parties are unable to agree, the City will determine the equitable adjustment as it deems appropriate. The Vendor shall proceed with the amended work upon receiving either a written amendment from the City or an oral order from the City before actually receiving the written amendment. If the Vendor fails to require an amendment within the time allowed, the Vendor waives its right to make any claim or submit subsequent amendment requests for that portion of the contract work. If the Vendor disagrees with the equitable adjustment, the Vendor must complete the amended work; however, the Vendor may elect to protest the adjustment as provided in subsections A through E of Section VII, Claims, below. The Vendor accepts all requirements of an amendment by: (1) endorsing it, (2) writing a separate acceptance, or (3) not protesting in the way this section provides. An amendment that is accepted by Vendor as provided in this section shall constitute full payment and final settlement of all claims for contract time and for direct, indirect and consequential costs, including costs of delays related to any work, either covered or affected by the change. VII. CLAIMS. If the Vendor disagrees with anything required by an amendment, another written order, or an oral order from the City, including any direction, instruction, interpretation, or determination by the City, the Vendor may file a claim as provided in this GOODS & SERVICES AGREEMENT - 3 (Over$10,000.00, including WSST) section. The Vendor shall give written notice to the City of all claims within fourteen (14) calendar days of the occurrence of the events giving rise to the claims, or within fourteen (14) calendar days of the date the Vendor knew or should have known of the facts or events giving rise to the claim, whichever occurs first . Any claim for damages, additional payment for any reason, or extension of time, whether under this Agreement or otherwise, shall be conclusively deemed to have been waived by the Vendor unless a timely written claim is made in strict , accordance with the applicable provisions of this Agreement. At a minimum, a Vendor's written claim shall include the information set forth in subsections A, items 1 through 5 below. FAILURE TO PROVIDE A COMPLETE, WRITTEN NOTIFICATION OF CLAIM , WITHIN THE TIME ALLOWED SHALL BE AN ABSOLUTE WAIVER OF ANY CLAIMS ARISING IN ANY WAY FROM THE FACTS OR EVENTS SURROUNDING THAT CLAIM OR CAUSED BY THAT DELAY. A. Notice of Claim. Provide a signed written notice of claim that provides the following information: ' 1. The date of the Vendor's claim; 2. The nature and circumstances that caused the claim; 3. The provisions in this Agreement that support the claim; 4. The estimated dollar cost, if any, of the claimed work and how that estimate was determined; and 5. An analysis of the progress schedule showing the schedule change or disruption if the Vendor is asserting a schedule change or disruption. B. Records. The Vendor shall keep complete records of extra costs and time incurred ' as a result of the asserted events giving rise to the claim. The City shall have access to any of the Vendor's records needed for evaluating the protest. The City will evaluate all claims, provided the procedures in this section are followed. If the City determines that a claim is valid, the City will adjust payment for work or time by an equitable adjustment. No adjustment will be made for an invalid protest. C. Vendor's Duty to Complete Protested Work. In spite of any claim, the Vendor shall , proceed promptly to provide the goods, materials and services required by the City under this Agreement. D. Failure to Protest Constitutes Waiver. By not protesting as this section provides, the Vendor also waives any additional entitlement and accepts from the City any written or oral order (including directions, instructions, interpretations, and determination). E. Failure to Follow Procedures Constitutes Waiver. By failing to follow the procedures , of this section, the Vendor completely waives any claims for protested work and accepts from the City any written or oral order (including directions, instructions, interpretations, and determination). VIII. LIMITATION OF ACTIONS. VENDOR MUST, IN ANY EVENT, FILE ANY LAWSUIT ARISING FROM OR CONNECTED WITH THIS AGREEMENT WITHIN 120 CALENDAR DAYS FROM GOODS & SERVICES AGREEMENT - 4 (Over$10,000 00, includrng WSST) THE DATE THE CONTRACT WORK IS COMPLETE OR VENDOR'S ABILITY TO FILE THAT SUIT SHALL BE FOREVER BARRED. THIS SECTION FURTHER LIMITS ANY APPLICABLE STATUTORY LIMITATIONS PERIOD. IX. WARRANTY. This Agreement is subject to all warranty provisions established under the Uniform Commercial Code, Title 62A, Revised Code of Washington. Vendor warrants goods are merchantable, are fit for the particular purpose for which they were obtained, and will perform in accordance with their specifications and Vendor's representations to City. The Vendor shall correct all defects in workmanship and materials within one (1) year from the date of the City's acceptance of the Contract work. In the event any part of the goods are repaired, only original replacement parts shall be used—rebuilt or used parts will not be acceptable. When defects are corrected, the warranty for that portion of the work shall extend for one (1) year from the date such correction is completed and accepted by the City. The Vendor shall begin to correct any defects within seven (7) calendar days of its receipt of notice from the City of the defect. If the Vendor does not accomplish the corrections within a reasonable time as determined by the City, the City may complete the corrections and the Vendor shall pay all costs incurred by the City in order to accomplish the correction. X. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any sub-contract, the Vendor, its sub-contractors, or any person acting on behalf of the Vendor or sub-contractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is qualified and available to perform the work to which the employment relates. Vendor shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement. ' XI. INDEMNIFICATION. Vendor shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or in connection with the Vendor's performance of this Agreement, except for that portion of the injuries and damages caused by the City's negligence. 1 The City's inspection or acceptance of any of Vendor's work when completed shall not be grounds to avoid any of these covenants of indemnification. IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE VENDOR'S WAIVER OF IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER. The provisions of this section shall survive the expiration or termination of this Agreement. ' XII. INSURANCE. The Vendor shall procure and maintain for the duration of the Agreement, insurance of the types and in the amounts described in Exhibit B attached and incorporated by this reference. 1 GOODS & SERVICES AGREEMENT - 5 (Over$10,000.00, including WSST) XIII. WORK PERFORMED AT VENDOR'S RISK. Vendor shall take all necessary precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be done at Vendor's own risk, and Vendor shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. XIV. MISCELLANEOUS PROVISIONS. A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its contractors and consultants to use recycled and recyclable products whenever , practicable. A price preference may be available for any designated recycled product. B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute, difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending or , bringing such claim or lawsuit, including all appeals, in addition to any other recovery or award provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section XI of this Agreement. D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. E. Assignment. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment, the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent. , F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding unless in writing and signed by a duly authorized representative of the City and Vendor. G. Entire Agreement. The written provisions and terms of this Agreement, together with any Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the City, and such statements shall not be effective or be construed as entering into or forming a part of or altering in any manner this Agreement. All of the above documents are hereby made a part of this Agreement. However, should any language in any of GOODS & SERVICES AGREEMENT - 6 (Over$10,000.00, including WSST) the Exhibits to this Agreement conflict with any language contained in this Agreement, the terms of this Agreement shall prevail. H. Compliance with Laws. The Vendor agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable to Vendor's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those operations. jI. Counterparts. This Agreement may be executed in any number of counterparts, each of which shall constitute an original, and all of which will together constitute this one ' Agreement. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. VENDOR: CITY OF KENT: By: By: (signature) (signature) ' Print Name: Print Name: Suzette Cooke Its Its Mayor (title) DATE: DATE: NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: IVENDOR: CITY OF KENT: Santiam Emergency Equipment, Inc Ken Weatherill, Deputy Chief PO Box 13585 Kent Fire Department Salem, OR 97309 24611 116`h Avenue SE Kent, WA 98030 (253) 951-3283 (telephone) (253) 856-4300 (telephone) (253) 344-1923 (facsimile) (253) 856-6300 (facsimile) APPROVED AS TO FORM: ' Kent Law Department [In this field,You may enter the electronic filepath where the contract has been saved] ' GOODS & SERVICES AGREEMENT - 7 (Over $10,000.00, including WSST) DECLARATION ' CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. , As such all contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically identify the requirements the City deems necessary for any , contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the , directives outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the Agreement; , The questions are as follows: 1. I have read the attached City of Kent administrative policy number 1.2. , 2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability. 3. During the time of this Agreement the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 4. During the time of the Agreement I, the prime contractor, will actively consider hiring and promotion of women and minorities. 5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above. By signing below, I agree to fulfill the five requirements referenced above. Dated this day of , 20_. By: For: , Title: Date: ' EEO COMPLIANCE DOCUMENTS - 1 of 3 CITY OF KENT ADMINISTRATIVE POLICY 1 NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998 ' SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996 CONTRACTORS APPROVED BY Jim White, Mayor POLICY: Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding Agreements with the City amounting to $10,000 or more within any given year, must take the following affirmative steps: 1. Provide a written statement to all new employees and subcontractors indicating 1 commitment as an equal opportunity employer. 2. Actively consider for promotion and advancement available minorities and women. 1 Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and equal opportunity requirements shall be considered in breach of contract 1 and subject to suspension or termination for all or part of the Agreement. Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments. 1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City's equal employment opportunity policy. 2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines. I 1 1 1 1 1 EEO COMPLIANCE DOCUMENTS - 2 of 3 CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. I, the undersigned, a duly represented agent of ' Company, hereby acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement known as that was entered into on the (date), between the firm I represent and the City of Kent. I declare that I complied fully with all of the requirements and obligations as outlined in the City ' of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. , Dated this day of , 20 ' By: For: , Title: Date: i i 1 EEO COMPLIANCE DOCUMENTS - 3 of 3 , SANTIAM EMERGENCY EQUIPMENT, INC. PRICE QUOTATION EXHIBIT A ' Client: Kent Fire February 1, 2010 Tracy Staggers 24611 116th Ave. S.E. Kent, Wa 98030 Item# Description Qty Price Ext. Price SE-S25ObVZ8 S25 Spenan UltraMotion Coat- Kent spec $1,230 13 $1,230 13 SE-S35ObVZ8 S35 Sperian UltaMotion Pant- Kent spec $840 56 $840 56 1 Subtotal $2,070 69 Shipping $30 00 1 Prepared by Dave Lindenmuth Tax 19 50% $199 57 Date February 1, 2010 TOTAL: $2,300.26 Prices valid 30 days, thereafter subject to change without notice FOB Origin, shipping est 6- 8 weeks Main Office 7905 State St Dave Lindenmuth, Sales Rep Salem, OR 97317 Phone 253-951-3283 Phone 503-540-8717 Fax; 253-344-1923 020110-Kent-Spenan EXHIBIT B INSURANCE REQUIREMENTS FOR CONSULTANT SERVICES AGREEMENTS ' Insurance The Contractor shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder , by the Contractor, their agents, representatives, employees or subcontractors. A. Minimum Scope of Insurance ' Contractor shall obtain insurance of the types described below: ' 1. Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01 and shall cover liability arising from premises, operations, independent contractors, ' products-completed operations, personal injury and advertising injury, and liability assumed under an insured contract. The Commercial General Liability insurance shall be , endorsed to provide the Aggregate Per Project Endorsement ISO form CG 25 03 11 85. There shall be no endorsement or modification of the Commercial General Liability insurance for liability arising from explosion, collapse or ' underground property damage. The City shall be named as an insured under the Contractor's Commercial General Liability insurance policy with respect to the work performed ' for the City using ISO additional insured endorsement CG 20 10 11 85 or a substitute endorsement providing equivalent coverage. B. Minimum Amounts of Insurance Contractor shall maintain the following insurance limits: ' 1. Commercial General Liability insurance shall be written with , limits no less than $1,000,000 each occurrence, $1,000,000 general aggregate and a $1,000,000 products-completed operations aggregate limit. C. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions for Automobile Liability and Commercial General Liability insurance: 1. The Contractor's insurance coverage shall be primary insurance as respect the City. Any Insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Contractor's insurance and shall not contribute with it. 2. The Contractor's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior ' written notice by certified mail, return receipt requested, has been given to the City. ' EXHIBIT A (Continued) 3. The City of Kent shall be named as an additional insured on all policies (except Professional Liability) as respects work performed by or on behalf of the contractor and a copy of the endorsement naming the City as additional insured shall be attached to the Certificate of Insurance. The City reserves the right to receive a certified copy of all required insurance policies. The Contractor's Commercial General Liability insurance shall also contain a clause stating that coverage shall apply separately to each insured against whom claim is made or suit is brought, except with respects to the limits of the insurer's liability. D. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best rating of not less than ANII. ' E. Verification of Coverage Contractor shall furnish the City with original certificates and a copy of the amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Contractor before commencement of the work. F. Subcontractors Contractor shall include all subcontractors as insureds under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the same insurance requirements as stated herein for the Contractor. 2010-01-26 15:17 MADISON & DAVIS INS 5037594379 >> P 211 ' PHAA2D D,w CERTIFICATE OF LIABILITY_INSURANCE rT`I MadisonD8V)S II1S. FIQQticy, THIS CERTIFICATE IS ISSUED AS A MATTER OF INI-011MATIO1N ' , Inc. ONLY AND CONFERS NO RIGHTS UPON THL CF.tTTtFICATE P,O, 89X 16O HOLDER, THIS CERTIFICATE DOES NOT AIAL'ND, CX I'8ND OH $t8}rton, OR 97383 ALTER THE CpVERAC3G AFFORDED THE POLK'WS BELOW i (503) 769-6311 ;INGUREHS AFFORDING COVERAGE NAICd tuxUHED __ _ IINbLIPWA Mutual of Enumclaw ' SANTIAM EMERGENCY EQUIPMENT, INC NBVHkHII Ohio Casual't'y Co. 7905 STATE ST NyURl'HC , SALEM, OR 97317 IlNsunrno _ �INSURLIt_E „•• I I lb )'Ut 1CI1 Lf Oh INSURANCE LISTED BELOW HAVE BEF,N ISSUED TO THE fNSLIRED NAMED AtACM f OR fHE YOLI(lY VI-HIOD INUILATFI) Nu rYYI I t1.11 ANOIN(, ANY AFOUIREMENT.%RM OR CONDITION OF ANY CONTRACt OH OTHER 00OUt4CN I WITH RESPECT I C)WI TICK I h11" C[RIIt I4,A1 L' AIAY lu 1"'(4 0 NAY PCHiAIN,THE IN$UPANCL•AFFORDED BY THE POLICIL-S DESCRIBED HEHL'N IS SUBJECI )U AL, rl IC 1 ERMS EXC;LU•,IONS ANU CUNIU)CIUN_)Of b1,k,I1 P01 IUES ACUHGGATC LIMITS SHOWN MAY HAVE BEEN RECUCFO BY PAID CLAIMS IN,R ADV L PGlICY L'FPtCT1YE POLICY eurIHATION, , LTRJHalw _—_- TYPROFINS RAN. - FOLICYNUAIOEH I ❑ATEjpr�1IMY$1 -. LJIAMp _ GLNLNAL1_AbIUTT + I ItA.:HinLVHfirr,tl• �7l0001000 X II 1 rfApiA0J 10 MKISIIID I t. MI&HUALuhNEHA_LIABILITY 1 I I PIII'MIr.hRIt„4, ,,.,1• 1 ti 300,000 LLAINVIMAUF [XIOccuR NC52629 i 9-2-09 9-2-201OG•.Icuehpla�ly,I�I.1..,�.,,,1 ti10 !000 , A X 1 i i.H'Wt,Al S UVINJV it I 1 t 000, 000 ULN01AL 140Hk GAR 1t2, 000, 000 y .:LNI.Ai,nRGOATF UrA1T AYYI IfSYtH I ' PIICICYVc.T] li)htP UY,.hu LBXC U t~(] .� _ YJlibl I I PC T I LOC �, . I •--AUTOMOBILE UABIUYY --T---���—_.••„.•.~_----' —"T' I I I (741,101NP051NC,LE LNO 6 5�� Q�� ANY AtJH) 1 . iLd n.4lJnnl) $ ALL LWINC D AV10!1 tlVUILfINJVIIY X ;.u,tonv)Au1o;. BAO54238464 9-22-09 ;9-22-10 }Fdit'.IUR IT r11Ht0 AVTOu i 60CIL Y 114111Hl I NUN JWNED AUTOS I lfVt e.uJm al y 1 . ...�...... CHOP'Ii l n)AMAOt y OAHAUt LIABILITY I I AV IV UNIT tA?.CCIOLIII j I ' iNI AIITQ ' I I IUIMH 1,IAN I 'AUTOONLY Adl, r _ ~E%CE59A1MbRELLA LIABILITY ^�„ LACN OCOVIINFNGI• ! Jti U.t I I t:IAIMS hUOIt Al„_HLCiAIL i 1 1 3 , ' l7lblR:Ill{lE I I t I ' ••�•— W45'1 rl�lJ j ii1N—^—•• YNBNcvh COMPENbATION AND "I EMPLOYEIlb LIABILITY .Rl khvPN,l WHYAHfhI ttk%k LTIIIVk , C L l4AU,AQ),UfiNI y 0"i.rh Wk LIHYNhLUUI`kIH I LL OdLASt L'AtMI'1VIL•ttS I,,,VgJ'.6V0.RI I ' _ ,PL(Al✓uJws[l1NS Ueun F I nlSt�dL YJLICI'-d.11r VTNER I , pESCRIpT10N Of OYEHATIDNSlLOCA7)OHSl VENIOLEB(E7ICLVEIONS ADDEp EYENDORS1IL18NT15P1:CtAt PROVISIONS �'--�„ •' •� Distributor of emergency equipment. ' CERTIFICATE HOLDER _ _ CANCELLATION CITY OF KENT/KENT FIRE DEFT. SHOULPANY OF,THI:AUOYL tj"CIIJOBO YOOCIZ4 BE OANCELLtV ULtOHt Olt chl'WAIIUN 24611 1 1 6 th Ave LSE DAIC lllAHw)�, Irlk I49UING INSURLIL WILL hNUtAV,HI 10 AIAU 30 PAYS Wt4FTtN NOTICE TO THE CERTIFICATE HOWER NAMED TO ME LEFT,BUT PAIU1111:10 OU SO A,IA7t Kent, WA, 98030 IMPOSE NO OULIOANON OR LIAVILRY of ANY KIND UPON VIE INSURtH US hGtNIL 01 neFrtes�Nrarlvcs --• -- - -- •_—•- �__—• „ .. ' AUIIt0HI[ HbPHk41:Nf flyk ACOR D 25(2001108) O ACORD COAPOHA LION 10ilb 2010-lit-26 15:17 MADISON & DAVIS INS 5037694379 >> P 3/3 POLICY NUMBER: NC52629 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 1 ADDITIONAL INSURED- DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART, SCHEDULE: ' Name of person or Organization: CITY OF KENT FIRE DEPARTMENT 24611 116t:h Ave sr. Kent, Wa. 98030 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations ' as applicable to this endorsement.) WHO IS AN INSURED(Section II) is amended to Include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or ' rented to you. CG 20 2611 85 Copyright, Insurance Services Office, Inc., 1984 r Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6L 1. SUBJECT: DEMONSTRATION COTTAGE HOUSING AMENDMENT ORDINANCE - ADOPT 2. SUMMARY STATEMENT: Adopt Ordinance No. which amends ' Ordinance No. 3895, the City's Cottage Housing Demonstration Ordinance, to allow flexibility in the maximum allowable number of cottage housing units. The Cottage Housing Demonstration Ordinance No. 3895 was passed by the City Council on November 18, 2008. The Ordinance establishes goals, a process for cottage housing selection and permitting, and development and design standards for up to two Cottage Housing projects. This amendment to the Ordinance allows for an increase in the maximum number of cottage housing units above 24 if a superior cottage housing development is proposed. One of the development standards in the Ordinance limits the size of the cottage housing development to a maximum of 24 units. This number of units was established based on a staff review of similar ordinances in other cities. After review of two projects, however, the Cottage Housing Committee supports flexibility in this maximum number if that flexibility allows a better cottage housing development. After a public hearing, the Land Use and Planning Board concurs and also recommends greater flexibility in the allowable number of cottage housing units if it results in a better cottage housing development. 3. EXHIBITS: Ordinance 4. RECOMMENDED BY: Economic & Community Development 2/8/10 (Committee, Staff, Examiner, Commission, etc.) S. FISCAL IMPACT Expenditure? N/A Revenue? N/A Currently in the Budget? Yes No ' 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds DISCUSSION: ACTION: ORDINANCE NO. AN ORDINANCE of the City Council of the ' City of Kent, Washington, to allow flexibility in the maximum allowable number of cottage housing units under the City's Demonstration Cottage Housing Ordinance. RECITALS A. The Cottage Housing Demonstration Ordinance No. 3895 was passed by the City Council on November 18, 2008, and allows for up to two cottage housing pro]ects. The Ordinance established goals, a process for selection and permitting, development and design standards. One of the development standards limits the size of the cottage housing development to a maximum of 24 units. This number of units was established based on a staff review of similar ordinances in other cities. B. Applicants for the proposed Blueberry Cottages development submitted to the Cottage Housing Committee information summarizing research regarding the size of cottage housing developments and ' supporting a maximum number of units larger than 24. Having considered the issue, the Cottage Housing Committee supports flexibility in the ' allowable number of cottage housing units if that flexibility allows a better cottage housing development. 1 ' Cottage Housing Demonstration - Amendment C. The SEPA Responsible Official determined that the proposed ' revisions are procedural in nature and no further environmental review is required. D. The City's Economic and Community Development Committee ' discussed the Cottage Housing Demonstration Ordinance amendment at ' its meetings on January 11, 2010 and February 8, 2010. The Land Use and Planning Board held a public hearing and made a recommendation on ' February 22, 2010. The Committee considered the issue again on March 8, 2010, and recommended approval. The City Council voted to adopt the ' amendment to the Cottage Housing Demonstration Ordinance on March 16, 2010. ' ORDINANCE SECTION 1, — Amendment. Section 5 of the City of Kent Demonstration Cottage Housing Ordinance (Ordinance No. 3895) is ' amended as follows: Section 5. - Development and Design Standards for Cottage Housing Demonstration Proiects. Parameters identified in this section will ' apply to cottage housing demonstration projects only and will prevail if they conflict with the regulations specified in Chapters 12 and 15 KCC. ' A. Development Standards. Cottage Carriage' ' Max Unit Size 1,500 square feet 968 square feet 2 ' Cottage Housing Demonstration - Amendment Cottage Carriage' ' For single family zones- allowable density is the same as the underlying zone, unless the Low Impact Development (LID) techniques listed in subsection B.10 of this section are ' incorporated, then 1 5 times the maximum number of dwelling Density3,4 units allowed in the underlying zone shall be permitted, up to 12 units per acre. For multifamily zones- allowable density is the same as the underlying zone and LID techniques listed in subsection B 10 of this section are required for cottage housing developments ' Minimum Lot None Size per unit Max Floor 35 Area Ratio (FAR) Min. 6 units Max 24 units Allowed when included in Development Sizes a Minimum cluster 6 units cottage project. Maximum cluster 12 units Parking Requirements' 1 8 spaces per unit if on-street parking is provided, 2 if there is (See subsection B.8 of' this section) no on-street parking Minimum Development Front- 20' Perimeter Setbackse Other, 10' Maximum Impervious 50% Surfaces' ' Maximum Height 25', where minimum roof slope of 6.12 for all parts of the roof above 18' are provided Otherwise, 18'. Tree Retention Standards contained in KCC 15.08.240 for Tree Retention shall apply Cottages shall be designed around significant trees Accessory Dwelling Not permitted as part of a cottage development. Units (ADUs) ' This housing type is only allowed where it Is included In a cottage project and Is counted towards the development density. ' 2 Any additions or increases in unit sizes after initial construction shall be subject to the cottage housing development standards. Cottages may not be more than one thousand (1,000) square feet on the main floor. 3 Cottage Housing Demonstration - Amendment i 3 Existing detached dwelling units may remain on the subject property and ' will be counted towards the density. Existing dwelling units shall be ' remodeled to be consistent with the exterior architectural design elements of the development. The dwelling unit may not exceed the existing square , footage or the maximum square footage allowed for a new cottage, whichever is greater. ' 4 When determining the maximum allowed number of units for a cottage housing development, the entire site area may be included in the ' calculation. If calculations result in a fraction, the fraction shall be rounded to the nearest whole number as follows: fractions above one-half (1/2) shall be rounded up, fractions of one-half (1/2) and below shall be rounded down. ' 5 Carriage units may be included within a cottage housing proposal, , provided that the number of carriage units do not exceed twenty-five percent (25%) of the total number of units in the project. The Cottage Housing Committee may select and staff may approve a demonstration project with a greater percentage of carriage units or a greater maximum number of cottage housing units if the pro]ect demonstrates a superior level of unique site design, architectural design, building materials, open ' space, landscaping, or sustainable development. 6 Cluster size is intended to encourage a sense of community among ' residents and the homes within a cluster generally orient toward each ' other, community open space, or pathways and are not separated by roads or critical areas. A development site may contain more than one cluster, with a clear separation between clusters. Furthermore, clusters ' shall be connected via pedestrian pathway(s). 4 Cottage Housing Demonstration - Amendment Garages may count towards the parking count if, through a covenant, ' they are reserved only for the parking of vehicles. 8 Perimeter setback areas are to be designated for landscaping, in accordance with subsection B.9 of this section. ' 9 Maximum impervious surface is calculated using the entire development site. Lot coverage for individual lots may vary. ' B. Design Standards. 1. Orientation of Dwelling Units. Dwellings within a cottage ' housing development shall be clustered and homes within the clusters shall be oriented to promote a sense of community within the development. The planning manager shall have the authority to waive or modify specific requirements for dwelling unit orientation to insure this tintent is met and to allow for flexibility and innovation in design. a. Each dwelling unit shall have a primary entry and/or covered porch oriented to the common open space or pathway connecting to the common open space. ' b. Each dwelling unit abutting a public right-of-way (not including alleys) shall incorporate fagade modulation, windows, and roofline variations to avoid blank walls that orient to the public right-of- way. 2. Variation in Unit Sizes. Building, and Site Design. Cottage projects shall establish building and site design that promote variety and ' visual interest. a. Projects shall include a variety of unit sizes within a single development. b. Proposals shall provide a variety of building styles, features, colors, and site design elements within cottage housing communities. Dwellings with the same combination of features and t 5 - Cottage Housing Demonstration - Amendment 1 i treatments shall not be located adjacent to each other. Identical elements t shall not be repeated in more than twenty-five percent (25%) of the cottages in the development. , C. Design of carriage units shall be of similar character with that of the cottages included in the project. d. Cottages may not be more than one thousand (1,000) square feet on the main floor. ' 3. Community Buildings. Community buildings are required in cottage developments. ' a. Community buildings shall be at least five hundred (500) square feet on the main floor and shall be of similar architectural character to the dwelling units. b. Building height for community buildings shall be the same standard as for cottages. C. Community buildings must be located on the same site as the cottage housing development, and be commonly owned by the residents. 4. Storage Space. If garages are reserved only for the parking of vehicles through a covenant, alternative storage space onsite shall be ' provided. The development shall include thirty (30) square feet of storage space per dwelling unit. The storage space shall be in one or more of the following forms: a. Detached sheds, designed in similar character of that of the dwelling units. May be individual or shared sheds. b. Storage space within the detached parking structures (additional rooms, area for shelving, etc.) that does not conflict with the parking of vehicles in the garages. C. Storage space within the dwelling unit, accessible only through an external door. 6 ' Cottage Housing Demonstration - Amendment r rd. Designated storage space attached to the community building that is not counted towards the five hundred (500) square foot minimum. e. Other storage space options approved in writing by rPlanning Services. 5. Required Common Open Space. Common open space shall provide visual relief and a sense of community for cottage developments. It must be located outside of critical areas and their buffers. The common open space shall be of a general character similar to single family residential yard areas and provide similar opportunities for use. Elements of the single family residential yard areas that may be included in the common open space are lawns, community garden space, patio/seating, and cooking areas, etc. a. A minimum of 400 square feet of common open space per dwelling unit shall be provided. b. Each area of common open space in each cluster shall be in one contiguous and usable piece with a minimum dimension of twenty (20) feet on all sides. tj C. Required common open space may be divided into no more than one (1) separate area per cluster of dwelling units. d. Common open space shall be located in a centrally located area and be easily accessible physically and visually to all dwellings within rthe development. e. Fences may not be located within or around required common open space areas. f. Landscaping located in common open space areas shall be tdesigned to allow for easy access and use of the space by all residents, to accommodate principles of Crime Prevention through Environmental Design (CPTED), and to facilitate maintenance needs. Existing mature trees shall be retained in this area, as appropriate for site design. r Cottage Housing Demonstration - Amendment r g. Unless the shape or topography of the site precludes the r ability to locate units adjacent to the common open space, the following standards must be met: (1) The open space shall be located so that it will be surrounded by cottages or common buildings on at least three (3) sides; (2) At least fifty percent (50%) of the units in the development shall abut a common open space. A cottage is considered to "abut" an area of open space if there is no structure, road, or critical area between the unit and the open space. 6. Private Open Space. , (1) Each cottage unit must have a covered porch with a minimum area of sixty-four (64) square feet per unit and a minimum dimension of seven (7) feet on all sides. Porches shall be associated with primary point of entry. (2) Each carriage unit shall have a deck or balcony, oriented toward the common open space. (3) In addition to porches, at least three hundred (300) square feet of private, contiguous, usable open space adjacent to each individual dwelling unit shall be provided to contribute positively to the visual appearance of the development, promote diversity in planting materials, and utilize generally accepted good landscape design. The private open space shall be oriented toward the common open space as much as possible and shall have no dimension less than ten (10) feet. The private open space shall define private residences from common areas, trails, and parking areas. Fences surrounding these spaces shall be a maximum height of three feet and shall be wrought iron, cedar split rail, picket, or similar fencing material. 7. Pedestrian Flow through Development. Pedestrian connections shall link all buildings to the: a. Public right-of-way; 8 Cottage Housing Demonstration - Amendment r b. Common open space; C. Parking areas; and d. Other cottage clusters in the development. The pedestrian walkways shall meet International Building Code requirements for accessibility. 8. Shared Detached Garages and Surface Parking Design. Parking areas shall be located so their visual presence and associated noise are minimized, both within and outside the development. These areas shall also maintain the single-family character along public streets. a. Shared detached garage structures may not exceed four (4) single-car garage doors per building. Carriage units are preferred above these garage structures. b. For shared detached garages, the design of the structure must be of similar character to that of the dwelling units within the development. C. Shared detached garage structures and surface parking areas must be screened from streets outside the development and adjacent residential uses by landscaping or architectural screening. d. If garage structures are counted toward the required number of parking stalls, these structures shall be reserved through a i, covenant for the parking of vehicles owned by the residents of the development. Storage of items which preclude the use of the parking tspaces for vehicles is prohibited. e. Surface parking areas may not be located in rows of more than six (6) spaces. Parking rows must be separated by a distance of at least twenty (20) feet. 9. Landscaping. The intent of these landscaping requirements is to enhance to overall appearance of the cottage housing development and �I to give the development an appearance of establishment. 9 Cottage Housing Demonstration - Amendment a. Cottage housing developments shall incorporate a landscape master plan, designed and stamped by a professional landscape architect, and include the following elements: (1) All landscaped areas (except that which is in private open spaces) shall be densely planted with a variety of decorative trees, shrubs, groundcovers, and other plants. (2) Landscaping shall be located adjacent to all pathways and common open spaces and shall screen parking areas. (3) Perimeter setback areas shall be landscaped in a manner that results in a dense landscape screen. (4) Perimeter trees shall be maintained and incorporated in the master landscape plan. (5) Landscaping shall be included within private open space, which shall be consistent with the overall landscape concept. (6) The landscape design shall exhibit sensitivity to principles of Crime Prevention through Environmental Design (CPTED). (7) Maintenance of landscaping (except that which is in private open spaces) shall be the responsibility of the Homeowners' Association. b. Standards contained in KCC 15.08.240 for Tree Retention shall apply. Cottages shall be designed around significant trees. Within perimeter setbacks, all significant trees which do not constitute a safety hazard shall be retained. , 10. Low Impact Development. a. For single family zones, density bonuses will only be granted if all of the following low impact development (LID) techniques are met. LID techniques are not required if the proposal does not include a ' density bonus. LID techniques are required for cottage housing developments in multifamily zones. LID design standards shall be according to the 2005 Puget Sound Action Team LID Manual. 10 Cottage Housing Demonstration - Amendment b. When the density bonus is applied or the project is located in a multifamily zone, the proposed site design shall incorporate the use of LID strategies to meet stormwater management standards. C. LID is a set of techniques that mimic natural watershed hydrology by slowing, evaporating/transpiring, and filtering water, which allows water to soak into the ground closer to its source. The design shall implement the following ob)ectives: (1) Grading disturbance limited to roadway and building pad preparation. Removal and compaction of topsoils shall be 1 minimized and soils may be amended to facilitate LID techniques. The replacement of topsoils on all pervious areas disturbed by construction shall be replaced. (2) Use of pervious materials for a fifty percent (50%) of non-public driving and walking surfaces if soil type allows for infiltration. (3) Treatment of stormwater in numerous small, decentralized structures, which include the use of multifunctional open 1 drainage systems such as vegetated swales or filter strips which also help to fulfill landscaping and open space requirements. (4) Other options meeting the intent of this section and approved in writing by Planning Services and Public Works. 11. Stormwater Regulations. a. The proposed site design shall meet all applicable criteria from the 2002 City of Kent Surface Water Design Manual or current manual adopted by the City of Kent. b. Some sites, due to size or steeply sloping topography, may have special difficulty including a stormwater detention pond in the proposed site design. Vaults will be considered on a site by site basis for istormwater detention and water quality with the following conditions. it Cottage Housing Demonstration - Amendment (1) The vault access point(s) must be located in an area that will already be planned for impervious surface. (2) Water quality improvement and infiltration are desired characteristics of stormwater detention facilities. Because vaults eliminate infiltration and potentially degrade water quality, the vault design must be shown to not have a detrimental impact on water quality, and that an infiltration facility would not be feasible. (3) The proposal must include an analysis of low impact design techniques that will facilitate infiltration outside the vault, as included in the 2005 Puget Sound Action Team LID Manual. (4) The stormwater system will be required to be maintained by a homeowner's association. C. The special allowances for vaults in lieu of open water facilities for cottage housing demonstration projects do not nullify the requirements of the 2002 City of Kent Surface Water Design Manual or current manual adopted by the City of Kent for other developments. SECTION 2. — 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 portion of this ordinance and the same shall remain in full force and effect. ' SECTION 3. — Corrections by City Clerk or Code Reviser. Upon ' approval of the City Attorney, the City Clerk and the code reviser are authorized to make necessary corrections to this ordinance, including the i correction of clerical errors; references to other local, state or federal laws, codes, rules, or regulations; or ordinance numbering and section/subsection numbering. 12 Cottage Housing Demonstration - Amendment SECTION 4. - Effective Date. This ordinance shall take effect and be in force thirty (30) days from and after its passage as provided by law. SUZETTE COOKE, MAYOR ATTEST: BRENDA JACOBER, CITY CLERK 1 APPROVED AS TO FORM: TOM BRUBAKER, CITY ATTORNEY I 13 Cottage Housing Demonstration - Amendment PASSED: day of , 2010. APPROVED: day of , 2010. PUBLISHED: day of , 2010. 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\Civil\Ordinance\CottageHousingDemonstmtlonAmendment docx I 1 14 Cottage Housing Demonstration Amendment Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6M 1. SUBJECT: VAN NESS CONTRACT FOR FEDERAL LOBBYIST SERVICES - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign a one-year agree- ment with Van Ness Feldman, in the amount of $90,000, for federal lobbyist Lservices, and ratify all acts consistent with the terms of the agreement. Van Ness Feldman will provide the City of Kent with federal lobbyist repre- sentation, with a particular emphasis on the Washington State congressional delegation. This contract with Van Ness Feldman will not exceed $90,000 during 2010. 3. EXHIBITS: Consultant Agreement and memo from Ben Wolters 4. RECOMMENDED BY: Economic and Community Development Committee (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds DISCUSSION: ACTION: ECONOMIC & COMMUNITY DEVELOPMENT Ben Wolters, Director K EN T Phone 253-856-5703 W A s H I N G T 0 N Fax 253-856-6454 Address 220 - 4th Avenue S Kent, WA 98032-5895 March 3, 2010 TO: Chair Jamie Perry and Economic & Community Development Committee Members FROM: Ben Wolters, Economic & Community Development Director SUBJ: Van Ness Feldman, Attorneys at law, Federal Lobbyist Agreement Staff report for the March 8, 2010 ECDC Meeting MOTION: Recommendation for Council to authorize the Mayor to sign the Consultant Services Agreement with Van Ness Feldman, Attorneys at Law representing the City of Kent as our Federal Lobbyist, not to exceed $90,000, '`subject to final terms and conditions acceptable to the City Attorney. SUMMARY: This agreement with Van Ness Feldman, Attorneys at law will provide the City of Kent, Federal representation with a particular emphasis on the Washington State Congressional Delegation. This contract will not exceed $90,000. The expense incurred will come from the budgets of the Economic & Community Development and Public Works Departments. Van Ness will provide representation for funding for the next years reauthorization of the Federal Transportation Reauthorization Bill and the yearly discretionary appropriations bills for key grade separation and other transportation projects for Kent. Van Ness will also continue policy support for replacing the Green River levee system and a reasonable Interim flood zone and flood insurance program along with Federal funding and regulatory policy support for the Green/Duwamish Rivers Ecosystem Restoration. With this contract Van Ness will work to restore Human Service and Community Development block grant funding and other federal opportunities and issues as they arise. If you have any questions prior to the meeting, please call Ben Wolters, 856-5703. BUDGET IMPACT: Yes BW/IP/pm P\Planning\ECDC\2010\03-08-10\van Ness_Memo dm Attach Signed Consultant Services Agreement(4 pg) City of Kent Declaration (1 pg) City of Kent Administrative Policy (1 pg) City of Kent Compliance Statement(1 pg) Work Program (3 pg) cc Ben Wolters, ECD Director Kurt Hanson, ECD Manager Fred Satterstrom, AICP, Planning Director Charlene Anderson,AICP, Planning Manager • KENT - WPSMINGTON CONSULTANT SERVICES AGREEMENT Between the City of Kent and i Van Ness Feldman, a Professional Corporation THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and Van Ness, a Professional Corporation, organized under the laws of the State of Washington DC, located and doing business at 1050 Thomas Jefferson Street N.W., Washington D.C., 20007-3877, (202) 298-1956 (hereinafter the "Consultant"). I. DESCRIPTION OF WORK. Consultant shall perform the following services for the City in accordance with the following described plans and/or specifications: Provide federal legislative representation to the City of Kent, with particular emphasis on the Washington State congressional delegation, as further described in Consultant's work program attached and incorporated as Exhibit A. Consultant further represents that the services furnished under this Agreement will be performed in accordance with generally accepted professional practices within the Puget Sound region in effect at the time those services are performed. II. TIME OF COMPLETION. The parties agree that work will begin on the tasks described in Section I above immediately upon the effective date of this Agreement. Upon the effective date of this Agreement, Consultant shall complete the work described in Section I beginning on January 1, 2010 and ending on December 31, 2010. III. COMPENSATION. ' A. The City shall pay the Consultant, based on time and materials, an amount not to exceed Ninety Thousand Dollars and no/100 ($90,000.00) for the services described in this Agreement. This is the maximum amount to be paid under this Agreement for the work described in Section I above, and shall not be exceeded without the prior written authorization of the City in the form of a negotiated and 1 executed amendment to this agreement. The Consultant agrees that the hourly or flat rate charged by it for its services contracted for herein shall remain locked at the negotiated rate(s) for a period of one (1) year from the effective date of this Agreement. The Consultant's billing rates shall be as delineated in Exhibit A. B. The Consultant shall submit monthly payment invoices to the City for work performed, and a final bill upon completion of all services described in this Agreement. The City shall provide payment within forty-five (45) days of receipt of an invoice. If the City objects to all or any portion of an invoice, it shall notify the Consultant and reserves the option to only pay that portion of the invoice not in CONSULTANT SERVICES AGREEMENT - 1 (Over$10,000) dispute. In that event, the parties will immediately make every effort to,settle the disputed portion. IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor-Employer Relationship will be created by this Agreement and that the Consultant has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party thirty (30) days written notice at its address set forth on the signature block of this Agreement. After termination, the City may take possession of all j records and data within the Consultant's possession pertaining to this project, which may be used by the City without restriction. If the City's use of Consultant's records or data is not related to this project, it shall be without liability or legal exposure to the Consultant. VI. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any subcontract, the Consultant, its subcontractors, or any person acting on behalf of the Consultant or subcontractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is qualified and available to perform the work to which the employment relates. Consultant shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement. I VII. INDEMNIFICATION. Consultant shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or inj connection with the Consultant's performance of this Agreement, except for that portion of the injuries and damages caused by the City's negligence. The City's inspection or acceptance of any of Consultant's work when completed shall not be grounds to avoid any of these covenants of indemnification. Should a court of competent jurisdiction determine that this Agreement is subject to RCW1 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of the Consultant and the City, its officers, officials, employees, agents and volunteers, the Consultant's liability hereunder shall be only to the extent of the Consultant's negligence. IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE, INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OFIg THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER. The provisions of this section shall survive the expiration or termination of this Agreement. VIII. INSURANCE. The Consultant shall procure and maintain for the duration of thel Agreement, insurance of the types and in the amounts described in Exhibit B attached and incorporated by this reference. IX. EXCHANGE OF INFORMATION. The City will provide its best efforts to provide reasonable accuracy of any information supplied by it to Consultant for the purpose of completion of the work under this Agreement. CONSULTANT SERVICES AGREEMENT - 2 (Over$10,000) X. OWNERSHIP AND USE OF RECORDS AND DOCUMENTS. Original documents, drawings, designs, reports, or any other records developed or created under this,Agreement shall belong to and become the property of the City. All records submitted by the City' to the Consultant will be safeguarded by the Consultant. Consultant shall make such data, documents, j and files available to the City upon the City's request. The City's use or reuse of any of the documents, data and files created by Consultant for this project by anyone other than Consultant on any other project shall be without liability or legal exposure to Consultant. XI. CITY'S RIGHT OF INSPECTION. Even though Consultant is an independent contractor with the authority to control and direct the performance and details of the work authorized under this Agreement, the work must meet the approval of the City and shall be subject to the City's general right of inspection to secure satisfactory comn►ot;or. XII. WORK PERFORMED AT CONSULTANT'S RISK. Consultant shall take all necessary precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be done at Consultant's own risk, and Consultant shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. XIII. MISCELLANEOUS PROVISIONS. A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its contractors and consultants to use recycled and recyclable products whenever practicable. A price preference may be available for any designated recycled product. B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. C. Resolution of Dilutes and Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute, difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or award provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section VII of this Agreement. D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. E. Assignment. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. If the non-assigning party gives its consent to CONSULTANT SERVICES AGREEMENT - 3 (Over$10,000) any assignment, the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent. F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding unless in writing and signed by a duly authorized representative of the City and Consultant. G. Entire Agreement. The written provisions and terms of this Agreement, together with any Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the City, and such statements shall not be effective or be construed as entering into or forming a part of or altering in any manner this Agreement. All of the above documents are hereby made a part of this Agreement. However, should any language in any of rhP Exhibits to this Agreement conflict with any language contained in this Agreement, the terms of this Agreement shall prevail. H. Compliance with Laws. The Consultant agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable) to Consultant's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those operations. I. Counterparts. This Agreement may be executed in any number of counterparts, each of which shall constitute an original, and all of which will together constitute this one Agreement. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. CONSWT1� � � CITY OF KENT: BY: �9� By: (signature) (signature) Print Name: mte *Al^ Print Name: Suzette Cooke Its AVk^E% P0,l. VNF7 Its Mayor If DATE: �- �-� DATE: NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: CONSULTANT: CITY OF KENT: Ben McMakin Ben Wolters, Economic Development Director VanNess Feldman City of Kent 1050 Thomas Jefferson St., N.W. 220 Fourth Avenue South Washington, D.C. 20007-3877 Kent, WA 98032 (202) 298-1800 (telephone) (253) 856-5703 (telephone) (202) 338-2716 (facsimile) (253) 856-6700 (facsimile) APPROVED AS TO FORM: Kent Law Department CONSULTANT SERVICES AGREEMENT - 4 (Over$10,000) a DECLARATION CITY,OF-KENT-EQUUAL EM-iiWYM ENT iOPPORTUNITY:POLICY'-',- 1 The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all contractors, subcontractors and suppliers who perform work with relation to this l Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically identify the requirements the City deems necessary for any contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the Agreement; The questions are as follows: 1. I have read the attached City of Kent administrative policy number 1.2. 2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability. 3. During the time of this Agreement the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 4. During the time of the Agreement I, the prime contractor, will actively consider hiring and promotion of women and minorities. 5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above. By signing below, I agree to fulfill the five requirements referenced above. iDated this � ^day of �"^��'`� , 204 b . IBy: W For: �P^ Nccs l 1jvrs�d► Title:_ Pori,nWt P&( iDate: IP`a` f to EEO COMPLIANCE DOCUMENTS - 1 CITY OF KENT ADMINISTRATIVE POLICY NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998 SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996 CONTRACTORS APPROVED BY Jim White, Mayor POLICY: Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding Agreements with the City amounting to $10,000 or more within any given year, must take the following affirmative steps: 1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 2. Actively consider for promotion and advancement available minorities and women. Any contractor, subcontractor, consultant or supplier who willfully disregards the City' nondiscrimination and equal opportunity requirements shall be considered in breach of contract and subject to suspension or termination for all or part of the Agreement. I Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments. I 1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City's equal employment opportunit'l policy. 2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines. EEO COMPLIANCE DOCUMENTS - 2 CITY OF KENT EQUAL EMPLOYMEWr'OPPOPi'Ul4ITY COMPLIANCE STATEMENT--" {-tjt; This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the IAgreement. I. the undersigned, a duly represented agent of Company, hereby acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement known as that was entered into on the_ (date) , between the firm I represent and the City of Kent. I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. Dated this day of 1200_. 1 By. For: Title: 1 Date: EEO COMPLIANCE DOCUMENTS - 3 iExhibit A d Work Program Van Ness Feldman (Firm) agrees to provide federal representation to the City of Kent (City), beginning on January 1, 2010 to December 315`, 2010 Van Ness Feldman will provide the City with comprehensive federal representation and will work with the Mayor, City Council and City departments to develop and implement both a short term and long range federal relations strategy in support of City projects, policies, and programs that are influenced or supported by federal policies and funding. Toward this end, Van i Ness Feldman will implement the following work plan on behalf of the City of Kent: • Work with the City's federal relations manager, city departments,mayor, and city council on developing and implementing a strategy to secure federal funding and policy support for the following key federal relations priorities in 2010 and beyond: 1. Fiuiding and policy support for replacing the Green River levee system in Kent, adoption of a reasonable interim flood zone and flood insurance program until the levee system is replaced, repaired and recertified, and support for recertification of the levee system by the federal government once repairs and replacement have been completed. 2. Federal funding support to permanent repair of the Howard Hanson Dam, encourage congressional action to speed work at Howard Hanson to restore the Dam to its full flood protection capacity as soon as possible. 3. Funding from the reauthorization of the Federal Highway Reauthorization Bill and through the yearly discretionary appropriations bills for key grade separations and other significant transportation project priorities for Kent 4. Continued federal funding and regulatory policy support for the Green/Duwamish Rivers Ecosystem Restoration projects and program. 5. Continued federal support for local law enforcement and crime prevention. 6. Restoring Human Service and Community Development block grant funding 1 in support of growing human service needs in the Kent community. 7. Identify federal policies, regulatory programs and grants that can support the ICity of Kent's strategic goals. 8. Other federal opportunities and issues as they arise. • Coordinate and advocate for the City of Kent's appropriations requests to the Washington Congressional delegation on behalf of levee repair, transportation, habitat restoration, and other municipal priorities identified by the City. • Manage relationships with key staff in the Washington congressional delegation. # • Coordinate with the City of Kent visits to Washington, D C. by City officials working on Kent's priority projects and other municipal interests. • Design and implement an outreach plan to bring Members of Congress and congressional staff to the City of Kent for further discussion and education on the needs and opportunities for federal support of the Kent communities' priorities. • Monitor legislative initiatives of interest to the City of Kent. • Assist City Departments with tracking, identifying, and securing grant opportunities in support of City priorities and initiatives, including human services, open space, law enforcement, environmental and energy conservation, and others • Provide updates, strategy development and coordination via monthly conference calls with the City of Kent staff on the progress of the work, next steps, and assignment of tasks between the lobbyist and City staff in support of the ongoing work program. These monthly calls will be supplemented by meetings and e-mail reports as needed. Ben McMakin for VanNess Feldman and Ben Wolters for the City of Kent will develop the agenda for these monthly calls in consultation with the leads of the City departments involved with the federal issues to be discussed and who will participate in those calls and meetings. Funding for Public Works' grade separation and levee replacement projects will be leading issues for the monthly calls. Ben McMakin will have primary responsibility for this representation. If necessary, he may request assistance from other professionals in the firm to provide the City with the most effective, efficient, and timely representation. Rick Agnew will provide additional support for Kent from the Finn's Seattle office. The City of Kent will pay the Firm a monthly retainer of $7,500. The retainer includes all associated costs, such as travel, printing,phone, etc, including all costs for one in person visit to Kent requiring air travel by up to two members of the Van Ness Feldman team. Additional air travel requested and required by Kent will be supplemental to the retainer and charged, without markup, as incurred. Van Ness Feldman understands that cities often work with significant budget constraints for this type of work and will work with the City on a work schedule that fits within the City's budget parameters and still accomplishes the ' work needed Van Ness Feldman will include in its billing statements all charges and disbursements for expenses incurred specifically for its representation of the City of Kent. A detailed statement of amounts due for professional services and expenses will be provided to the City of Kent on a monthly basis. The contract will not exceed a total amount of$90,000 The City agrees to provide monthly payment within 45 days of receipt. The City of Kent consents to being listed as a Firm client on firm promotional materials. This consent includes to permitting the firm to generally describe the matters on which we have or are representing you to the extent that those matters are public knowledge. The City of Kent has the right to terminate this engagement by written notice at any time. It is further agreed that after the conclusion of this contract, Van Ness Feldman will offer to return the files to the City of Kent. If Van Ness Feldman does not receive instructions as to the disposition of these files within 60 days after said offer, it is agreed that Van Ness Feldman need not retain such files for more than three (3) years, after which it may destroy all such materials that do not have intrinsic value. The City of Kent further agrees that Van Ness Feldman may Iretain a copy of materials in such files, at its own expense. I I t 1 i 1 ' Kent City Council Meeting Date March 16, 2010 Category Consent Calendar - 6N 1. SUBJECT: KENT DOWNTOWN PARTNERSHIP ANNUAL CONTRACT - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign an agreement with the Kent Downtown Partnership, in the amount of $33,600, for economic development services. Kent Downtown Partnership provides services to the City of Kent in an effort to increase economic development of Kent's downtown core, and to assist the City in developing an improvement plan for downtown sidewalks, trees, and light posts. The Kent Downtown Partnership works to encourage developers and businesses to locate in downtown Kent, funds downtown store front renovations, and publishes advertisements inviting consumers to visit downtown Kent. 1 I 3. EXHIBITS: Consultant Agreement and memo from Ben Wolters ! 4. RECOMMENDED BY: Economic and Community Development Committee (Committee, Staff, Examiner, Commission, etc.) ! 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: ! Councilmember moves, Councilmember seconds ! DISCUSSION: ACTION: i i ECONOMIC & COMMUNITY DEVELOPMENT Ben Wolters, Director K E N T Phone 253-856-5703 WASHINGTON Fax 253-856-6454 tAddress* 220 -4ch Avenue S Kent, WA. 98032-5895 March 3, 2010 TO: Chair Jamie Perry and Economic & Community Development Committee Members FROM: Ben Wolters, Economic & Community Development Director REF: Kent Downtown, DBA Kent Downtown Partnership -Agreement Staff report for the March 8, 2010 ECDC Meeting MOTION: I move to recommend approval of the 2010 yearly agreement with Kent Downtown Partnership (KDP). SUMMARY: This years' annual contract with Kent Downtown is the same as in 2009 (DBA Kent Downtown Partnership) in the amount of $33, 600.00. KDP provides direct services to increase economic development of the Kent I downtown core. Services under this agreement include but are not limited to; hosting events, marketing downtown properties, facade improvements program, developing an improvement plan for downtown sidewalks, street trees, light posts, and to encourage businesses and developers to locate in downtown Kent. If you have any questions prior to the meeting, please call Kurt Hanson at 1 856-5706. BUDGET IMPACT: Yes BW/7P/pm P\Planning\ECDC\2010\03-08-10\KDP_Memo doc I Attach, Signed Consultant Services Agreement(S pg) Signed Declaration City of Kent Equal Employment Opportunity Policy (1 pg) Signed City of Kent Equal Employment Opportunity Compliance Statement(1 pg) City of Kent Administrative Policy (1 pg) Exhibit B Insurance Requirements for Consultant Services Agreement (2 pg) Safeco Insurance Liability plus Endorsement (4 pg) Kent Downtown Partnership's 2010 Work Plan (3 pg) Certificate of Liability Insurance (2 pg) cc: Ben Wolters, ECD Director Kurt Hanson, ECD Manager Fred Satterstrom, AICP, Planning Director Charlene Anderson, AICP, Planning Manager i ' KENT CONSULTANT SERVICES AGREEMENT i between the City of Kent and tKent Downtown THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and Kent Downtown DBA Kent Downtown Partnership organized under the laws of the State of Washington, located and doing business at 202 W. Gowe St., Suite A, Kent, WA 98032, (253) 813-6976 (hereinafter the "Consultant"). I. DESCRIPTION OF WORK. Consultant shall perform the following services for the City in accordance with the following described plans and/or specifications: i Provides services in accordance with Consultant's 2010 Work Plan attached and i incorporated as Exhibit A, which seeks to increase economic development of Kent's downtown core. Consultant's services include, assisting the City in developing an improvement plan for downtown sidewalks, trees, and light posts; encouraging developers and businesses to locate in downtown Kent; and publishing advertisements inviting consumers to visit downtown Kent." Consultant further represents that the services furnished under this Agreement will be performed in accordance with generally accepted professional practices within the Puget Sound region in effect at the time those services are performed. II. TIME OF COMPLETION. The parties agree that work will begin on the tasks described in Section I above immediately upon the effective date of this Agreement. Upon the effective date of this Agreement, Consultant shall complete the work described in Section I by December 31, 2010. III. COMPENSATION. A. The City shall pay the Consultant, based on time and materials, an amount not to exceed $33,600.00 for the services described in this Agreement. This is the maximum amount to be paid under this Agreement for the work described in Section I above, and shall not be exceeded without the prior written authorization of the City in the form of a negotiated and executed amendment to this agreement. The Consultant agrees that the hourly or flat rate charged by it for its services contracted for herein shall remain locked at the negotiated rate(s) for a period of i one (1) year from the effective date of this Agreement. The Consultant's billing rates shall be as delineated in Exhibit A. 1 B. The Consultant shall submit monthly payment invoices to the City for work performed, and a final bill upon completion of all services described in this CONSULTANT SERVICES AGREEMENT - 1 (Over $10,000) Agreement. The City shall provide payment within forty-five (45) days of receipt of an invoice. If the City objects to all or any portion of an invoice, it shall notify the Consultant and reserves the option to only pay that portion of the invoice not in dispute. In that event, the parties will immediately make every effort to settle the disputed portion. IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor-Employer Relationship will be created by this Agreement. By their execution of this Agreement, and in accordance with Ch. 51.08 RCW, the parties make the following representations: A. The Consultant has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. B. The Consultant maintains and pays for its own place of business from which Consultant's services under this Agreement will be performed. C. The Consultant has an established and independent business that is eligible for a business deduction for federal income tax purposes that existed before the City retained Consultant's services, or the Consultant is engaged in an independently established trade, occupation, profession, or business of the same nature as that involved under this Agreement. D. The Consultant is responsible for filing as they become due all necessary tax documents with appropriate federal and state agencies, including the Internal Revenue Service and the state Department of Revenue. E. The Consultant has registered its business and established an account with the state Department of Revenue and other state agencies as may be required by Consultant's business, and has obtained a Unified Business Identifier (UBI) number from the State of Washington. F. The Consultant maintains a set of books dedicated to the expenses and earnings of its business. V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party thirty (30) days written notice at its address set forth on the signature block of this Agreement. After termination, the City may take possession of all records and data within the Consultant's possession pertaining to this project, which may be used by the City without restriction. If the City's use of Consultant's records or data is not related to this project, it shall be without liability or legal exposure to the Consultant. , VI. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any subcontract, the Consultant, its subcontractors, or any person acting on behalf of the Consultant or subcontractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is qualified and available to perform the work to which the employment relates. Consultant shall execute the attached City of Kent Equal Employment Opportunity Policy Declaration, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement. CONSULTANT SERVICES AGREEMENT - 2 (Over$10,000) VII. INDEMNIFICATION. Consultant shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or in connection with the Consultant's performance of this Agreement, except for that portion of the Iinjuries and damages caused by the City's negligence. The City's inspection or acceptance of any of Consultant's work when completed shall not be grounds to avoid any of these covenants of indemnification. Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of the Consultant and the City, its officers, officials, employees, agents and volunteers, the Consultant's liability hereunder shall be only to the extent of the Consultant's negligence. IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF IMMUNITY UNDER INDUSTRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER. The provisions of this section shall survive the expiration or termination of this Agreement. VIII. INSURANCE. The Consultant shall procure and maintain for the duration of the 1 Agreement, insurance of the types and in the amounts described in Exhibit B attached and incorporated by this reference. IX. EXCHANGE OF INFORMATION. The City will provide its best efforts to provide reasonable accuracy of any information supplied by it to Consultant for the purpose of completion of the work under this Agreement. X. OWNERSHIP AND USE OF RECORDS AND DOCUMENTS. Original documents, drawings, designs, reports, or any other records developed or created under this Agreement shall belong to and become the property of the City. All records submitted by the City to the ' Consultant will be safeguarded by the Consultant. Consultant shall make such data, documents, and files available to the City upon the City's request. The City's use or reuse of any of the documents, data and files created by Consultant for this project by anyone other than Consultant on any other project shall be without liability or legal exposure to Consultant. XI. CITY'S RIGHT OF INSPECTION. Even though Consultant is an independent contractor with the authority to control and direct the performance and details of the work authorized under this Agreement, the work must meet the approval of the City and shall be subject to the City's general right of inspection to secure satisfactory completion. XII. WORK PERFORMED AT CONSULTANT'S RISK. Consultant shall take all necessary precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be done at Consultant's own risk, and Consultant shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. CONSULTANT SERVICES AGREEMENT - 3 (Over$10,000) XIII. MISCELLANEOUS PROVISIONS. A. Recyclable Materials. Pursuant to Chapter 3.80 of the Kent City Code, the City requires its contractors and consultants to use recycled and recyclable products whenever practicable. A price preference may be available for any designated recycled product. B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement in one or more instances shall not be construed to be a waiver or , relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. C. Resolution of Disputes and Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute, difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute resolution , process. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending or bringing such claim or lawsuit, including all appeals, in addition to any other recovery or award 1 provided by law; provided, however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section VII of this Agreement. D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. E. Assignment. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment, the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent. F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding unless in writing and signed by a duly authorized representative of the City and Consultant. G. Entire Agreement. The written provisions and terms of this Agreement, together with any Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the City, and such statements shall not be effective or be construed as entering into or forming a part of or altering in any manner this Agreement. All of the above documents are hereby made a part of this Agreement. However, should any language in any of the Exhibits to this Agreement conflict with any language contained in this Agreement, the terms of this Agreement shall prevail. H. Compliance with Laws. The Consultant agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable to Consultant's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those operations. CONSULTANT SERVICES AGREEMENT - 4 (Over $10,000) ' I. Counterparts. This Agreement may be executed in any number of counterparts, each of which shall constitute an original, and all of which will together constitute this one Agreement. IIN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. CONSULTANT: CITY OF KENT: ' By: rdfy Ltd" � � By: (sin ure) , (signature) Print Name: `J �t, Print Name: Suzette Cooke ' Its Its Mayor (title) DATE: DATE: NOTICES TO BE SENT TO: NOTICES TO BE SENT TO: tCONSULTANT: CITY OF KENT: Barbara Smith Executive Director Kurt Hanson, Manager Kent Downtown Economic & Community Development Dept. 202 W. Gowe St., Suite A City of Kent Kent, WA 98032 220 Fourth Avenue South Kent, WA 98032 (253) 813-6976 (telephone) I (253) 520-0206 (facsimile) (253) 856-5706 (telephone) (253) 856-6454 (facsimile) IAPPROVED AS TO FORM: Kent Law Department [In this field,you may enter the eledtronh:flkgwAh where the wwmct has hen saved] CONSULTANT SERVICES AGREEMENT - 5 (Over$10,000) DECLARATION CITY OF !CENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically identify the requirements the City deems necessary for any contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative I response is required on all of the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the Agreement; The questions are as follows: 1. I have read the attached City of Kent administrative policy number 1.2. ' 2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability. 1 3. During the time of this Agreement the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 4. During the time of the Agreement I, the prime contractor, will actively consider hiring and promotion of women and minorities. 5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth ' above. By signing below, I agree to fulfill the five requirements referenced above. 1 Dated this S day of , 20 ©. IFor: Ke. Title: 4PAti��2 6�1L Qom " Date: — d�— Olo EEO COMPLIANCE DOCUMENTS - 1 i CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT t This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. I, the undersigned, a duly represented agent of ' Company, hereby acknowledge and declare that the before-mentioned company was the prime contractor for the Agreement known as that was entered ' into on the (date), between the firm I represent and the City of Kent. ' I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 1.2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. ` Dated this day of , 20 L 6 By: For: 11 ����/ Title: Date: EEO COMPLIANCE DOCUMENTS - 3 ! CITY OF KENT ' ADMINISTRATIVE POLICY NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998 SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996 CONTRACTORS APPROVED BY Jim White, Mayor POLICY: Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding Agreements with the City amounting to $10,000 or more within any given year, must take the following affirmative steps: 1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. I2. Actively consider for promotion and advancement available minorities and women. Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and equal opportunity requirements shall be considered in breach of contract and subject to suspension or termination for all or part of the Agreement. Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments. 1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City's equal employment opportunity policy. 2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines. i ! EEO COMPLIANCE DOCUMENTS - 2 EXHIBIT B INSURANCE REQUIREMENTS FOR CONSULTANT SERVICES AGREEMENTS , Insurance The Contractor shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which ' may arise from or in connection with the performance of the work hereunder by the Contractor, their agents, representatives, employees or subcontractors. A. Minimum Scope of Insurance i Contractor shall obtain insurance of the types described below: 1. Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01 and shall cover liability arising from premises, operations, independent contractors, products-completed operations, personal injury and advertising injury, and liability assumed under an insured contract. The Commercial General Liability insurance shall be endorsed to provide the Aggregate Per Project Endorsement ISO form CG 25 03 11 85. There shall be no endorsement or modification of the Commercial General Liability insurance for liability arising from explosion, collapse or underground property damage. The City shall be named as an insured under the Contractor's Commercial General Liability insurance policy with respect to the work performed for the City using ISO additional insured endorsement CG 20 10 11 85 or a substitute endorsement providing equivalent coverage. B. Minimum Amounts of Insurance Contractor shall maintain the following insurance limits: ' 1. Commercial General Liability insurance shall be written with limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate and a $1,000,000 products-completed operations aggregate limit. C. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following t provisions for Automobile Liability and Commercial General Liability insurance: , 1. The Contractor's insurance coverage shall be primary insurance as respect the City. Any Insurance, self-insurance, or insurance pool coverage 1 1 EXHIBIT B (Continued) 2. maintained by the City shall be excess of the Contractor's insurance and shall not contribute with it. 3. The Contractor's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given Lto the City. 4. The City of Kent shall be named as an additional insured on all policies ' (except Professional Liability) as respects work performed by or on behalf of the contractor and a copy of the endorsement naming the City as additional insured shall be attached to the Certificate of Insurance The City reserves the right to receive a certified copy of all required insurance policies. The Contractor's Commercial General Liability insurance shall also contain a clause stating that coverage shall apply separately to each insured against whom claim is made or suit is brought, except with ' respects to the limits of the insurer's liability. D. Acceptability of Insurers Insurance is to be placed with insurers with a current A.M. Best rating of not less than ANII. E. Verification of Coverage Contractor shall furnish the City with original certificates and a copy of the I amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Contractor before commencement of the work. 1 F. Subcontractors Contractor shall include all subcontractors as insureds under its policies or shall furnish separate certificates and endorsements for each subcontractor. All coverages for subcontractors shall be subject to all of the same insurance 1 requirements as stated herein for the Contractor. 01 CH62738330 • 1 n su re nce COMMERCIAL GENERAL LIABILITY ' e CG 76 35 02 07 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ' LIABILITY PLUS ENDORSEMENT , This endorsement modifies insurance provided under the following; COMMERCtAL GENERAL LIABILITY COVERAGE PART , SCHEDULE Name of Person or Organizallon: , City of Kent 220 4th Ave S Kent, WA 98032 ADDITIONAL INSURED — BY WRITTEN lease or occupy, subject to the following CONTRACT, AGREEMENT OR PERMIT, OR additional provisions: , SCHEDULE (a) This insurance does not apply to is added to WHO IS AN any "occurrence" wtvch takes place The following paragraph after you cease to be a tenant in INSURED (Section ll): any premises teased to or rented to 4. Any person or organization shown in the Sched- you; ule or for whom you are required by written con- (b) Ths insurance does not apply to tract, agreement or permit to provide insurance any structural alterations, new con- is an insured, subject to the following additional struction or demolition operations provisions. performed by or on behalf of the a. The contract, agreement or permit must be person or organization added as an ; in effect during the policy period shown in insured, the Declarations, and must have been exe- (2) Your ongoing operations for that in- cited prior to the "bodily injury", "property sured, whether the work is performed damage", or "personal and advertising by you or for you; injury". (3) The maintenance, operation or use by b. The person or organization added as an in- you of equipment leased to you by such sured by this endorsement is an insured only person or organization, subject to the to the extent you are held liable due to: following additional provisions: (1) The ownership, maintenance or use of (a) This insurance does not apply to that part of premises you own, rent, any "occurrence" which takes place after the equipment lease expires: Includes Copyrighted Material of Insurance Services Office, Inc., with its permission. , Copyright, Insurance Services, 2001 satew end the Swfeeo logo en reghteed Iradem ,i al safew Ompaatlon CG 70 35 02 07 Page 1 of 4 FP GAG•P3iRINT001•�i99m26d (b) This insurance does not apply to This exclusion apoies even d the claims "bodily injury" or "property dam- against any insured allege negligence or age" arising out of the sole negli- other wrongdoing in the supervision, hiring, genre of such person or employment, training or monitoring of pliers organization; by that insured, if the "occurrence" which caused the "bodily injury" or "property (4) Permits issued by any state or political damage" involved the ownership, mainte- subdivision with respect to operations nance, use or entrustment to others of any performed by you or on your behalf, aircraft, "auto" or watercraft that is owned subject to the following additional pro- or operated by or rented or loaned to any en- vision: sured This insurance does not apply to "bodily This exclusion does not apply to: injury", "property damage", or (1) A watercraft while ashore on premises "personal and advertising injury" arising you own or rent; out of operations performed for the state ' or municipality. (2) A watercraft you do not own that is: 6. The insurance with respect to any architect, (a) Less than 52 feet long; and engineer, or surveyor added as an insured (b) Not being used to carry persons or ' by this endorsement does not apply to property for a charge; "bodily injury", property damage", or `per- sonal and advertising injury" arising out of (3) Parking an "auto" on, or on the ways the rendering of or the failure to render any next to, premises you own or rent, pro- professional services by or for you, in<lud- vided the "auto" is not owned by or Ing: rented or loaned to you or the insured, (1) The preparing, approving, or failing to (4) Liability assumed under any "insured 1 prepare or approve maps, drawings, contract" for the ownership, mainte- opinions, reports, surveys, change or- nance or use of aircraft or watercraft;or ders, designs or specifications, and (6) "Bodily injury" or "property damage" (2) Supervisory, inspection w engineering arising out of services. (a) the operation of machinery or I to "bodily equipment that is attached to, or d. This insurance does not apply y y part of, a land vehicle that would injury" or "property damage" included within qualify wirer the definition of the "products-completed operations haz- "mobile equipment" if it were not and". subject to a compulsory or financial responsill jaw or other motor ve- I A pwson's or organization's status as an insured un- hicle insurance jaw in the state der this endorsement ends when your operations for where it r licensed or principally that insured are completed. garaged; or A ` (b) the operation of any of the machin- No coverage wilt be provided if, in the absence of this ery or equipment listed in Paragraph endorsement, no liability would be imposed by law on f.(2) or f.('l) of the definition of you Coverage shall be limited to the extent of your "mobile equipment" w negligence or fault according to the applicable pr nci- ples of comparative fault. (6) An aircraft you do not own provided it is not operated by any insured. NON-OWNED WATERCRAFT AND NON-OWNED AIRCRAFT LIABILITY TENANTS' PROPERTY DAMAGE LIABILITY Exclusion g. of COVERAGE A (Section 1) is replaced When a Damage To Premises Rented To You Limit is by the following. shown in the Declarations, Exclusion 1. of Coverage A, Section I is replaced by the following g. "Bodily injury" or "property damage" arising out of the ownership, maintenance, use or 1• Damage To Property entrustment to others of any aircraft, "auto" "property damage" to: or watercraft owned or operated by or rented or loaned to any insured. Use includes oper- (1) Property you own, rent, or occupy, including ation and "loading or unloading". any costs or expenses incurred by you, or Page 2of4 C.AQ23PfllNfON•�ll90lRIJ i any other person, 4organ17ation or entity, for WHO IS AN INSURED — MANAGERS repair, replacement, enhancement, restora- tion or maintenance of such property for any The following is added to Paragraph 2.a. of WHO IS reason, including prevention of injury to a AN INSURED (Section 11): person or damage to anther's property; (2) Premises you sell, give away or abandon, if Paragraph (1) does not apply to executive officers, or the "property damage"arises out of any part to managers at the supervisory level or above. of those premises; SUPPLEMENTARY PAYMENTS — COVERAGES A ' (3) Property loaned to you; AND B — BAIL BONDS -- TIME OFF FROM (4) Personal property in the care, custody or WORK control of the insured; ' Paragraph 1.b. of SUPPLEMENTARY PAYMENTS — (5) That particular part of real property on which COVERAGES A AND B is replaced by the following: you or any contractors or subcontractors working directly or nndnrectly on your behalf b. Up to $3,000 for cost of bail bonds required are performing operations, it the "property because of accidents or traffic law violations , damage" arises out of those operations, or arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. (6) That particular part of any property that must We do not have to furnish these bonds. be restored, repaired or replaced because "your work" was incorrectly performed on it. Paragraph 1.d. of SUPPLEMENTARY PAYMENTS — Paragraphs (1), (3) and (4) of this exclusion do COVERAGES A AND B is replaced by the following, not apply to "property damage" (other than d. All reasonable expenses incurred by the in- damage by fire) to premises, including the con- sured at our request to assist us in the in- tents of such premises, rented to you.A separate vestigation or defense of the claim or "suit", limit of insurance applies to Damage To Prom- including actual loss of earnings up to $500 ises Rented To You as described in Section III a day because of time off from work. — Limits Of Insurance. Paragraph (2) of this exclusion does not apply if EMPLOYEES AS INSUREDS — HEALTH CARE the premises are "your work" and were never SERVICES occupied, rented or held for rental by you. Provision 2a.(1}(d} of WHO IS AN INSURED{Section Paragraphs (3), (4), (5) and (6) of this exclusion II) is deleted, unless excluded by separate endorse- ' do not apply to liability assumed under a side- ment. track agreement Paragraph (6) of this exclusion does not apply to EXTENDED COVERAGE FOR NEWLY ACQUIRED "property damage" included in the "products- ORGANIZATIONS completed operations hazard". Provision 3.a. of WHO IS AN IIVSURED (Section II) is � Paragraph 6. of LIMITS OF INSURANCE (Section 111) replaced by the foltowmg. fs replaced by the following: a. Coverage under this provision is afforded 6. Subject to 5. above, the Damage To Premises only until the end of the policy period. Rented To You Limit is the most we will pay un- EXTENDED "PROPERTY DAMAGE" der Coverage A for damages because of "property damage" to any one premises, while Exclusion a. of COVERAGE A (Section I) is replaced rented to you, or in the case of damage by fire, while reed to you or temporarily occupied by by the following: rented you with permission of the owner. a. "Bodily injury" or "property damage" expected or intended from the standpoint of the insured. The Damage To Premises Rented To You limit is the This exclusion does not apply to `bodily injury" higher of the Each Occurrence Linxt shown in the or "property damage" resulting from the use of Declarations or the amount shown in the Declarations reasonable force to protect persons or property as Damage To Premises Rented To You Limit CIS 76 35 02 07 Paga 3 of 4 EP GA11,M OM-4194ODT2J ' EXTENDED DEFINITION OF BODILY INJURY interrupted only by a street, roadway, waterway, or right-of•way of a railroad. Paragraph 3. of DEFINITIONS (Section V) is replaced by the following, INCREASED MEDICAL EXPENSE LIMIT ' 3. "Bodily irHury" means bodily injury, sickness or The Medical Expense Lima is amended to $10,000. disease sustained by a person, including mental anguish or death resulting from any of these at KNOWLEDGE OF OCCURRENCE 1 any time. The following is added to Paragraph 2 Duties In The TRANSFER OF RIGHTS OF RECOVERY Event Of Occurrence, Offense, Claim Or Suit of COMMERCIAL GENERAL LIABILITY CONDITIONS The following is added to Paragraph 8. Transfer Of (Section IV): Rights Of Recovery Against Others To Us of COM- MERCIAL GENERAL LIABILITY CONDITIONS (Sec- Knowledge of an 'occurrence", claim or "suit" by ' tion IV): your agent, servant or employee shall not in itself constitute knowledge of the named insured unless an We waive any rights of recovery we may have against officer of the named insured has received such notice any person or organization because of payments we from the agent, servant or employee. make for injury or damage arising out of your ongoing operations or "your work" done under a contract with UNINTENTIONAL FAILURE TO DISCLOSE ALL that person or organization and included in the HAZARDS "products-completed operations hazard". This waiver applies only to a person or organization for whom you The fallowing is added to Paragraph 6. Representa- are required by written contract, agreement or permit tions of COMMERCIAL GENERAL LIABILITY CONDI- to waive these rights of recovery. TIONS (Section IV): iAGGREGATE LIMITS OF INSURANCE — PER If you unintentionally fail to cisclose any hazards ex- LOCATION isting at the inception date of your policy, we will not deny coverage under this Coverage Form because of For all sums wtuch the insured becomes legally obli- such failure However, this provision does not affect gated to pay as damages caused by "Occurrences" cur right to collect additional oiemium or exercise our under COVERAGE A (Section I), and for all medical rignt of cancellation or non-renewal expenses caused by accidents under COVERAGE C (Section 1), which can be attributed only to operations LIBERALIZATION CLAUSE at a single "location": The following paragraph is added to COMMERCIAL Paragraphs 2.a, and 2.b. of Limits of Insurance (Sec- GENERAL LIABILITY CONDITIONS (Section IV) tion III) apply separately to each of your `locations" owned by or rented to you 10. It a revision to this Coverage Part, which would provide more coverage with no additional pre- "Location" means premises involving the same or mium, becomes effective during the policy period connecting lots, or premises whose connection is in the state shown in the Declarations, your pol- icy will automatically provide this additional cov- erage on the effective date of the revision. Page 4 0l 4 ' Y•iWZL7flINi00i•�19P�73J i Exhibit A ' KENT DOWNTOWN PARTNERSHIP'S ' 2010 Work Plan Billing Requirements: Kent Downtown Partnership will bill on a monthly t basis for $2,800; total annual contract is $33,600.00. Executive Director: Barbara J. Smith ' Organizational ' 1. Build open communications and cooperation between KDP and Kent service clubs, including Kent Lions, Rotary and Kiwanis. 2. Increase our Business I* Occupation Tax Incentive contributions 3. Take an active role in advocating for downtown concerns with the City of Kent 4. Increase ethnic and retail representation on the KDP Board of , Directors 5. Lobby City of Kent for downtown projects by attending committee and council meetings; including more 1-on-1 meetings with Economic Development department head 6. Continue with educational programs for our businesses 7. Increase interactive participation of our membership ' 8. Develop positive spins on negative news; such as, potential flooding 9. Develop a consistent "brand" for KDP, including logo, fonts, , colors, etc 10. Continue providing information and proactive assistance for , potential flooding in downtown Kent Economic Development ' 1. Encourage property owners to become more involved in KDP; host a property owner's reception in February 2. Host a real estate broker's open house in April 3. Continue work with the City to find a developer for the "fire property" at 2"d and Meeker Street. 4. Continue work with Bruce Anderson in filling his property space ' 5. Continue work in adding more lighting in downtown 6. More emphasis with our businesses to cross promote the T-Birds, Kent Predators, and events at ShoWare Event Center , 7. Promote social media communication for KDP 8. Host a property owner's open house 9. Research putting art displays in vacant storefronts , 10.Continue partnership in Find It in Kent shop local campaigns 11.Reinstate "Juror's gift certificate" program with Regional Justice Center ' 12.Work with Design Committee on more banners in downtown 13.Award one restaurant and one business as business of the year at annual dinner/auction ' Design Committee 1. Continue KDP Clean-up Day (6/5/10); continue graffiti removal program 2. Organize a Mill Creek Clean-up Day ' 3. Work and partner with city to clean-up area around Willis Street and Hiway 167 off ramp Et 4th Avenue Fs Willis Street 4. Work with Burlington Northern Railroad to develop a "quiet zone" in downtown Kent 5. Work with KDP Economic Development Committee to develop banners at gateways 6. Metal sculptures at key intersections to promote local events 7. Continue with "fagade improvement" grants 8. Continue with "design awards" for 2010 ' 9. Complete "Design Et Maintenance booklet" in coordination with City 10.Implement Storefront program Safety and Security Committee; sub-committee of Design 1. Work with city to install lights in Kaibara Park 2. Identify and list light fixtures not working in downtown Kent to Puget Sound Energy and City 3. Meet with police department monthly to identify downtown safety concerns 4. Promote expedited removal of graffiti to business owners and continue graffiti clean-up program ' Downtown Breakfast Hour; sub-committee of Design Committee 1. Host three downtown breakfast hours 2. Schedule three planning meetings prior to downtown breakfasts Promotions Committee 1. Plan, promote and deliver a. Wine Women l* Wow b. First Avenue Block Party c. Holiday Open House d. Winterfest ' e. New Year's Eve Celebration f. Annual dinner/auction 2. Participate in International Festival sponsored by City 3. Have two micro-events , 4. Increase business participation for help; hours and financial 5. Create a tool for tracking event results ' 6. Add three committee members Membership Committee ' 1. Develop policy and procedure for retaining members , 2. Grow membership by 25% 3. Host annual membership picnic in August 4. Revisit giving new and renewing members a photo or should it be a plaque Kent Downtown Partnership ' 202 W. Gowe Street, Suite A Kent, WA 98032 253-813-6976 barbaras@kentdowntown.org Client#• 10586 KENTDOW ACORD-. CERTIFICATE OF LIABILITY INSURANCE DATE 112 0 1 0 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Bell-Anderson Ins-SBU ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO Box 887 HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW 724 West Smith Street Kent,WA 98032 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA American States Insurance Compa Kent Downtown Partnership Corporation INSURER B 202 W Gowe St A INSURER C Kent,WA 98032 INSURER D INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MMIDD/YYYV DATE MM/DDIYYYY A GENERAL LIABILITY 01 CH62738330 10116/2009 10/16/2010 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1 000 000 PREMISES Ea ccurr n CLAIMS MADE �OCCUR MED EXP(Any one person) $1 Q 000 PERSONAL B ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PRCPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANYAUTO OTHER THAN EAACC $ AUTO ONLY AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ 0 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATULIIWT- OTH- ER EMPLOYERS'LIABILITY ANY PROPRIETOR(PARTNERIEXECUTIVE EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS The certificate holder is additional insured for general liability, but only if required by written contract or written agreement, ongoing operations of the named insured only, per the attached endorsement #CG76350207. CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City of Kent DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL may_ DAYS WRITTEN 220 4th Ave S. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Kent,WA 98032 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES A(UTTH�ORIZ.E-D REPRESENTATIVE ® '""7 ACORD 25(2009101) 1 of 2 #S249906/M249905 © 1988-2009 ACORD CORPORATION All rights reserved. The ACORD name and logo are registered marks of ACORD KLP IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s) DISCLAIMER The Certificate of Insurance does not constitute a contract between the issuing insurer(s),authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon 1 i i 1 1 1 ACORD 25(2009101) 2 of 2 #S249906/M249905 ' Kent City Council Meeting Date March 16, 2010 ' Category Consent Calendar - 60 1 1. SUBJECT: 2008 DOWNTOWN SIDEWALKS SCHEDULE A - ACCEPT AS COMPLETE ' 2. SUMMARY STATEMENT: Accept the 2008 Downtown Sidewalks/Schedule A Project as complete and release retainage to Construct Company LLC, upon ' receipt of standard releases from the State and release of any liens. The original contract amount was $794,622.93. The final contract amount was $754,862.12. 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 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds iDISCUSSION: ACTION: Kent City Council Meeting ' Date March 16, 2010 Category Consent Calendar - 6P ' 1. SUBJECT: LITTLE PROPERTY ACQUISITION - AUTHORIZE 2. SUMMARY STATEMENT: Authorize the Mayor to sign all documents necessary to purchase the Little property for $420,000, execute closing documents subject to terms and conditions approved by the City Attorney, and ratify all acts consistent with this action. The property has been in probate for over thirty years, is not vested to any use. Acquisition of this property is identified in the City of Kent Drainage Master Plan for projects in Lower Mill Creek. The purchase price was negotiated based on professional appraisals prepared for the City and the Owner. The Superior Court, sitting in probate, has approved the sale to the City. The parties entered into a Purchase and Sale Agreement for the City's purchase of the Little property. However, consistent with past practice, the Purchase and Sale Agreement provides that any sale is conditioned upon Council approval and if the Council fails to authorize the purchase, the City is not bound. 3. EXHIBITS: Public Works Memorandum 3/1/2010 4. RECOMMENDED BY: Public Works Committee (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds 1 ' DISCUSSION: ACTION: PUBLIC WORKS DEPARTMENT ' Timothy J LaPorte P.E., Public Works Director Phone 253-856-5500 KENT Fax- 253-856-6500 Address: 220 Fourth Avenue S Kent, WA 98032-5895 Date: March 1, 2010 To: Chair Debbie Raplee and Public Works Committee Members PW Committee Meeting Date: March 1, 2010 ' From: Mike Mactutis, P.E., Environmental Engineering Manager Kelly Peterson, AICP, Environmental Conservation Supervisor Through: Timothy J. LaPorte, P.E., Public Works Director Subject: Little Property Acquisition Motion: Recommend that Council ratify the mayor's execution of the purchase and sale agreement, authorize purchase of the subject property for $420,000.00 and authorize the mayor to execute closing documents subject to terms and conditions approved by the City Attorney. tSummary: The Little property is two vacant parcels consisting of 18.47 acres located on the east side of Lower Mill Creek north of James Street. The property is encumbered with wetlands, streams, steep slopes and their associated buffers. Acquisition of this property is identified in the City of Kent Drainage Master Plan for projects in Lower Mill Creek. The James Street area is one of the first to flood following heavy rains and the Drainage Master Plan identifies these Lower Mill Creek projects as a high priority. The property has been in probate for over thirty years, is not vested to any use, and is currently owned by approximately twenty-five heirs of Verla Little. The Personal ' Representative for the estate offered the property for sale. The purchase price was negotiated based on professional appraisals prepared for the City and the Owner. The price includes reimbursement of some of the Owner's legal costs. The Superior ' Court, sitting in Probate, has approved the sale to the City. Budget Impact: No Budget Impact Kent City Council Meeting Date March 16, 2010 Category Bids - 8A 1. SUBJECT: TURNKEY PARK IMPROVEMENTS 2. SUMMARY STATEMENT: The bid opening for this project was held on March 9, 2010, with seven bids received. The low bid was submitted by Clement Bros. Inc. in the amount of $179,471, excluding Washington State Sales Tax (WSST). The Engineer's estimate is $224,788.45, excluding WSST. j f 3. EXHIBITS: Bid tab 4. RECOMMENDED BY: Parks Director Jeff Watling (Committee, Staff, Examiner, Commission, etc.) 5. FISCAL IMPACT Expenditure? X Revenue? Currently in the Budget? Yes X No 6. CITY COUNCIL ACTION: Councilmember moves, Councilmember seconds I to authorize the Mayor to enter into an agreement with Clement Bros. Inc. for the amount of $179,471, plus Washington State Sales Tax to complete the Turnkey Park Improvements Project. DISCUSSION: ACTION: i • j KENT WASH INGTON BID TABULATION FORM KENT PARKS, RECREATION &COMMUNITY SERVICES CITY OF KENT, WASHINGTON PROJECT: PR 03 10 NAME: Turnkey Park Expansion Base Bid A — Pervious Asphalt DATE: March 9, 2010 DUE: 10:00 a.m. OPENED: 10:15 a.m. Bidder: Total Lump Sum Bid: Addendum #1: in dollars I1. Clements Bros, Inc. $ 179,471.00 Yes 2. MVG, LLC $ 190,500.00 Yes 3. TF Sahli Construction $ 215,400.00 Yes ` 4. LW Sundstrom $ 219,500.00 Yes 5. RN Falk, LLC $ 229,910.00 Yes i6. Buckley Nursery $ 231,792.00 Yes 7. Premier Field Development $ 236,479.00 Yes CONSULTANT ESTIMATE: $224,788.45 (with pervious asphalt) 7 bids were received for this project and opened. The apparent low bidder is Clements Brothers. Inc. for $ 179,471.00 plus applicable Washington State sales tax. Staff will review the bid documents and verify references. Kent City Council is expected to award the bid on Tuesday March 16th Questions may be directed to Brian Levenhagen, project manager, at (253) 856-5116. REPORTS FROM STANDING COMMITTEES AND STAFF A. COUNCIL PRESIDENT B. MAYOR C. OPERATIONS COMMITTEE D. PARKS AND HUMAN SERVICES COMMITTEE E. ECONOMIC AND COMMUNITY DEVELOPMENT COMMITTEE F. PUBLIC SAFETY COMMITTEE G. PUBLIC WORKS COMMITTEE iH. ADMINISTRATION REPORTS FROM SPECIAL COMMITTEES i KENO W A S H I N O T O N OPERATIONS COMMITTEE MINUTES FEBRUARY 16, 2010 Committee Members Present: Jamie Perry Ron Harmon, and Elizabeth Albertson The meeting was called to order by Jamie Perry at 4:02 p.m. Ron Harmon and Elizabeth Albertson represented Debbie Raplee and Les Thomas in their absence. 1. APPROVAL OF MINUTES DATED FEBRUARY 2, 2010 Albertson moved to approve the minutes of the February 2, 2010 Operations Committee meeting, as amended. Harmon seconded the motion, which passed 3-0. 2. RECOMMEND COUNCIL ADOPT JOINT RESOLUTION REQUESTING THE PUBLICATION AND DISTRIBUTION OF A LOCAL VOTER'S PAMPHLET IN ACCORDANCE WITH CHAPTER 29A.32 RCW. Chief Schneider presented. The City of Kent and King County Fire Protection District 37 have adopted a Joint Resolution providing for the submission to qualified electors of the City and Fire District for a special election to be held on April 27, 2010 of a Ballot Proposition. The Ballot Proposition is pursuant to Chapter 52.26 of the Revised Code of Washington, approves a plan to form a Regional Fire Protection Service Authority, within the boundaries of the City and Fire District, effective July 1, 2010, to be funded by a property tax levy and a new six-year benefit charge ("Ballot Measure"). Because the ballot measure is anticipated to be the only ballot measure before the ' voters in the Jurisdiction of the City and Fire District, the Kent City Council and the Fire District's Board of Commissioners believe it is in the best interest of the voters of each Jurisdiction that the ballot measure be presented to the voters through the publication and distribution of a local Voter's Pamphlet in accordance with CH.29A.32 RCW. The Fire District approved the Joint Resolution at their 2/15/10 meeting. The cost will be split between the City and the District. Albertson inquired about the estimated cost, which Schneider explained would be between $3600 and $4300 for the City and between $2500 and $3100 for the District based on number of voters. Harmon moved to recommend Council adopt Joint Resolution requesting the publication and distribution of a local Voter's Pamphlet in accordance with Chapter 29A.32 RCW. Albertson seconded the motion, which passed 3-0. Operations Committee Minutes February 16 2010 Page: 2 3. MOVE TO RECOMMEND COUNCIL ADOPT THE PROPOSED RESOLUTION AUTHORIZING THE MAYOR TO ENTER INTO AN AGREEMENT WITH OTHER WASHINGTON MUNICIPALITIES FOR THE SHARING OF FIBER OPTIC INSTALLATION PROJECTS. Presented by Mike Carrington. Approval of this agreement to join the Consortium of Northern Cities/constituents (Bellevue, Kirkland, Renton, UW, Lake WA School District, etc.) together with the Consortium of Valley Cities/constituents (Kent, Auburn, Tukwila, Federal Way and Puyallup) will provide for the planning and completion of fiber optic installation projects. The project, which would interconnect all of the Valley Cities, would enhance interagency, law enforcement capabilities communications and emergency response, and support further expansion of wireless broadband. Carrington clarified for perry that the resolution allows us to enter into an agreement outside of the consortium as well if it is considered more beneficial as related to the project. Additional organizations will be added to the consortium throughout time. In review of the Resolution with the legal department, Harmon proposed an amendment in the language as follows: Recital, Section A, add Federal Way to the list of cities; Resolution, Section 1, add Federal Way to the list of cities and last paragraph after legislation; "however, this authorization is not intended to allow the Mayor to expend funds to carry out the directives of this legislation except through approved state and local bid and procurement processes". Perry confirmed that Council received an email with the proposed changes. Copies of the amended Resolution were not presented at the meeting but the language was changed and is in the final Resolution. There is no direct budget impact for the City to enter into this agreement. Funding for FOPAs under this agreement will be matched by in-kind contributions, grants, or private funding secured by the City of Kent and its participating partners. Albertson moved to recommend Council adopt the proposed resolution authorizing the Mayor to enter into an agreement with other Washington municipalities for the sharing of fiber optic installation projects, inserting the language under Section 1 at the end of the paragraph to read, "however, this authorization is not intended to allow the Mayor to expend funds to carry out the directives of this legislation except through approved state and local bid and procurement processes". Harmon seconded the motion, which passed 3-0. 3 Operations Committee Minutes February 16 2010 ' Page: 3 i 4. MOVE TO RECOMMEND THAT THE OPERATIONS COMMITTEE AUTHORIZE 1 THE ORDINANCE AMENDING THE 2010 BUDGET FOR THE POST ANNEXATION COSTS ESTIMATED AT $4,778,230 FOR THE PERIOD JULY 11 2010 THROUGH DECEMBER 31, 2010 AND FORWARD IT TO THE CITY COUNCIL MEETING OF MARCH 2, 2010. INFORMATION ONLY. Presented by Bob Nachlinger and John Hodgson. Hodgson opened discussion by noting that the City has been working on the budget for over a year and are responding with a budget that meets the needs of the city as well as the new annexation area. If we hired employees for the annexation area and current ' staffing level, proportionally it would equal 210 employees. We are taking advantage of existing resources and complimenting with staff we think we need to meet the needs of the Panther Lake area. The estimate for the costs associated with providing services to the Panther Lake area for the period July 1 through December 31, 2010 are anticipated to be $4,778,230 more fully detailed in attachment "A" to the ordinance. The costs are primarily associated with Police staffing and Public Works staffing. It continues the employees covered in the pre-annexation budget for the balance of the City's fiscal year. Nachlinger reiterated that the post annexation budget for 7/1-12/31 of 2010 carries forward the 15 positions authorized in the pre annexation budget, primarily all public safety, and carries them for the next six months and adds an additional six employees to be hired during that six month time period. Hodgson added that hire dates begin in July and go throughout the year as the departments determine when they will need that staffing. Nachlinger confirmed to Perry that the $4.7 million we receive annualy thru the state that is available for next 10 years will have to be requested annually as well. Nachlinger feels that amount will grow in relation to increased sales tax generated from the city and annexation area. The funding may also be removed by legislature although security is added in the fact that many cities have annexed and continue to. A total of 57 employees are being hired for annexation. Fifteen were already pre- authorized to hire ahead in public safety. In order to move forward, Albertson requested to see the full year of benefits and salaries for new positions as only six months is shown in the budget. Positions for 2011 were included on a separate page and were not included in the budget. Hodgson clarified to Harmon that none of the positions will be filled until Council authorizes the budget. r L 1 Operations Committee Minutes February 16 2010 Page: 4 r S. MOVE TO RECOMMEND THAT THE OPERATIONS COMMITTEE AUTHORIZE THE ORDINANCE CERTIFYING TO THE DEPARTMENT OF REVENUE THE ' ANTICIPATED AMOUNT OF THE STATE'S ANNEXATION FUNDING OF $3,772,678 FOR THE STATE'S FISCAL YEAR BEGINNING JULY 1, 2010 THROUGH JUNE 30, 2011 AND FORWARD IT TO THE FEBRUARY 16, 2010 CITY COUNCIL AGENDA ON OTHER BUSINESS. The estimate for the costs associated with providing services to the Panther Lake area on the State's fiscal year ending June 30, 2011 are anticipated to be $11,023,095 more fully detailed in attachment to this memo. These expenditures are offset by an anticipated revenue from the area of $7,250,417. The net difference between revenues and expenditures is the amount eligible for funding by the State through its annexation sales tax credit. This amount is anticipated to be not more than $3,772,678 through June 30, 2011. Proposed budget is being walked on to the council meeting as certification must be received by the state Department of Revenue by March 1. Harmon moved to recommend that the Operations Committee authorize the ordinance certifying to the Department of Revenue the anticipated amount of the State's annexation funding of $3,772,678 for the State's fiscal year beginning July 1, 2010 through June 30, 2011 and forward it to the February 16, 2010 City Council agenda on Other Business. Albertson seconded the motion, which passed 3-0. i The meeting adjourned at 4:36 p.m. by Perry. r Pamela Clark Operations Committee Secretary r r 1 I �-/ KENT WASHINGT01 ECONOMIC & COMMUNITY DEVELOPMENT COMMITTEE MINUTES February 8, 2010 Committee Members Chair 3amie Perry, Elizabeth Albertson, Deborah Ranniger Les Thomas attended in Ranniger's absence. Chair Perry called the meeting to order at 5:00 I p.m. 1. APPROVAL OF MINUTES Thomas MOVED and Albertson SECONDED to approve the Minutes of January 11, 2010. Motion PASSED 3-0. 2. SCA-2009-1 SUBDIVISION CODE AMENDMENT — TRACT DEFINITIONS Planner Matt Gilbert stated that 'tracts' as currently defined are not developable. Tracts are areas within residential subdivisions created for many purposes other than for building purposes; such as roadways, streams, wetlands, storm ponds or future development. Gilbert stated that the amendment adds language to clarify the purpose of Future Development Tracts. He stated that if an application is submitted to the city on a future development tract which shows that roads and utilities are provided and that the application meets the City's development standards, that future development tracts may become a buildable site. Assistant City Attorney Kim Adams Pratt addressed the Committee's concerns with respect to the protection of recreational, open space and sensitive areas tracts from future development. This amendment makes it clear that the amended language in the definition specifically applies to only future development tracts Albertson MOVED to approve the definition of tract as recommended by the LUPB. Thomas SECONDED the Motion. Motion PASSED 3-0. 3. TRANSPORTATION 2040 — PUGET SOUND REGIONAL COUNCIL (PSRC) PSRC staff Robin Mayhew stated that Transportation 2040 is a four-county Regional Plan with a 30 year focus to 2040. She presented information regarding the key drivers for the Plan with regard to regional growth, environmental constraints, and funding strategies. She spoke about the Planning Strategies with respect to congestion and mobility, the environment and the financial picture. Mayhew spoke about the Plan performance, South King County projects and programs. She stated that a Draft Environmental Impact Statement (EIS) is located on the PSRC's website and that a final EIS report is scheduled to be published on March 19th. The plan is currently open for comments. The intended date for adoption of the plan is late May when the General Assembly meets. This report was for informational purposes only. 4. COTTAGE HOUSING DEMONSTRATION ORDINANCE AMENDMENT - MAXIMUM NUMBER OF DWELLING UNITS AND DENSITY Planning Manager Charlene Anderson stated that two projects were proposed before the Cottage Housing Committee. One of the proposals relies on an amendment to the Cottage Housing Demonstration Ordinance regarding maximum allowable number of dwelling units. I The Land Use and Planning Board will hold a public hearing on February 22nd to address the maximum number of dwelling units; proposing options to drop the maximum unit requirement, retain maximum of 24 units, but offering flexibility in that regard if the proposal includes superior design elements. i Anderson stated that one of the projects proposes to keep two duplexes in the proposed development. Staff believes the duplexes can be kept, provided that the applicant brings those duplexes architecturally into consistency with the cottage housing. Language could be amended to provide more clarity in this regard. This amended language could be presented before the Land Use and Planning Board at the February 22"d Hearing. Anderson questioned if the Cottage Housing Committee opts to move only one proposal forward, would this Council Committee wish to accept another round of proposal submittals. , The Committee debated this issue concluding that they would not desire another round of submittals and would not be receptive to considering amending the ordinance other than to allow an increase in the number of units. This report was for informational purposes only. S. ECONOMIC DEVELOPMENT REPORT Economic & Community Development Director Ben Wolters along with Economic & Community Development Manager Kurt Hanson reported on the status of development projects. Wolters stated that approximately 15 to 18 acres of the Kent Highlands Land Fill located on the West Hill near Hwy 516 and I-5 will be available for development in the near future. Wolters stated that a new Asian Buffet restaurant will be built on the East Hill that will help to anchor the Kent Event Center currently under development. He stated that in the downtown area, Valley Cities applied to expand their facility into the empty portion of the Ben Franklin along Meeker Street Wolters stated that the City anticipates some positive activity for the Springboard property, as an appraisal by the lien-holders for that site is underway on the garage. Wolters stated the General Service Administration (GSA), landlord and developer for the Federal Government has issued a request for 500,000 square feet of office space that would serve as the new regional consolidated headquarters for the Federal Aviation Administration (FAA). The GSA has identified five or six South King County communities where they would like to locate this facility, with Kent being a contender. Wolters stated that Economic and Community Development is working hard to position Kent for this competition. Initial submittals for proposed sites are due March 1't. This would mean an increase of 2000 employees. Hanson stated that the City and Green River Small Business Development Center assisted an East Hill owner and proprietor with marketing his restaurant business through Facebook and Twitter resulting in a substantial increase in revenue. This report was for informational purposes only. 6. PANTHER LAKE ANNEXATION ZONING HEARINGS i Planning Director Fred Satterstrom asked the Committee to consider a Motion endorsing the notion that the Economic and Community Development Committee (ECDC) hold the annexation comprehensive plan and zoning hearings on behalf of the Council. He stated that it is a less formal venue, and could be less intimidating for those participants desiring to follow this through to the Council. At the conclusion of the hearings, the ECDC recommendations would move forward to Full Council. The ECDC concurred with this request. ' Thomas MOVED that due to the complexity of the issues, the large size of the annexation area, and the relatively short deadline for adoption, the City Council delegate to the ECDC the responsibility of holding the public hearings regarding the comprehensive plan and zoning designations for the Panther Lake annexation area. Albertson SECONDED the Motion. Motion PASSED 3-0. ECDC Minutes February 8, 2010 Page 2 of 3 3 Satterstrom stated that the Motion to keep the hearings before the ECDC will go to City Council on the consent calendar on the February 16th City Council Agenda. 7. PANTHER LAKE ANNEXATION LAND USE PLANNING & ZONING MAP ALTERNATIVES Satterstrom stated that the Land Use and Planning Board at their January 25th hearing recommended land use planning and zoning map designations as indicated by the Alternative 2 Maps. Satterstrom stated that he was presenting the Committee with the Alternative 2 maps for their information in preparation for the first hearing scheduled to be held before the ECDC on March 8th, with a second hearing to be held April 12th This report was for informational purposes only. Adiournment Perry Adjourned the Meeting at 6:20 p.m. Pamela Mottram Economic & Community Development Committee Secretary P\Planning\ECDC\2010\Minutes\01-11-10_Min doc 1 1 1 1 1 i i ECDC Minutes February 8, 2010 Page 3 of 3 t � i� �� KENT CITY OF KENT PUBLIC SAFETY COMMITTEE MEETING MINUTES February 9, 2010 COMMITTEE MEMBERS: Les Thomas, Dennis Higgins, and Ron Harmon, Chair • The meeting was called to order by Chair Harmon at 5.04 PM. • Chair Harmon called for additions to the agenda, there were none. 1. Approval of Minutes L. Thomas moved to approve the minutes of the January 12, 2010 meeting. The motion was seconded by D. Higgins and passed 3-0. 2. Washinoton Traffic Safety Commission arant - ACCEPT Deputy Chief of Police Mike Painter stated the funds will be used for officer overtime for the Night Time Seat Belt Enforcement program from May 24-June 6, 2010. L. Thomas moved to recommend Council authorize the Kent Police Department to accept the Washington Traffic Safety Commission grant in an amount not to exceed $1,800. The motion was seconded by D. Higgins and passed 3-0. 3. MetLife Foundation Award application - AUTHORIZE Deputy Chief Painter explained that, if awarded, the funds would be used to prevent youth gang initiation and enhance youth safety by providing community service opportunities to youth who have committed low level crimes. D. Higgins moved to authorize the Kent Police Department to apply for the MetLife Foundation Community-Police Partnership Award in an amount not to exceed $15, 000. The motion was seconded by L. Thomas and passed 3-0. 4. Agreement to Transfer Vehicles - APPROVE Deputy Chief Painter stated the vehicles will supply the two police officers serving as School Resource Officers with marked police vehicles for their assignments. L. Thomas moved to recommend that Council approve the Kent School District donation of two vehicles to the Kent Police Department and authorize the Chief of Police to sign the Agreement to Transfer Vehicles. The motion was seconded by D. Higgins and passed 3-0. S. Police Accreditation Coordinator — INFO ONLY Deputy Chief Painter explained the process to use one commissioned officer position to form one civilian position that will manage both the police (CALEA) and city Jail (ACA) accreditation in the future. r 6. Purchase of Fire Command Vehicle - AUTHORIZE Fire Chief Jim Schneider explained the purpose of the replacement and reserve command vehicles. He also explained that Fire District 37 and the City of Kent rotate the purchase of this type of apparatus The dealer selection is by state bid process. D. Higgins moved to recommend that Council authorize the Fire Department to enter into a contract, utilizing the Washington State Bid, to purchase and equip a new command vehicle not to exceed $74,477. ' The motion was seconded by L. Thomas and passed 3-0. 7. 2010 Fire Department Work Plan - INFO ONLY Chief Schneider distributed copies of the Work Plan 2010 and reviewed portions of the document. The meeting adjourned at 5:40 PM. i Jo Thompson, Public Safety Committee Secretary 1 1 t 1 Public Safety Committee Minutes 2 February 9, 2010 1 V PUBLIC WORKS COMMITTEE MINUTES Monday, February 22, 2010 COMMITTEE MEMBERS PRESENT: Committee Chair Debbie Raplee and committee member Dennis Higgins were present. Counalmember Thomas filled in for Harmon who was absent. The meeting was called to order at 4:00 p.m. I ITEM 1 — Approval of Minutes Dated February 1, 2010: Committee Member Thomas moved to approve the minutes of February 1, 2010. The motion was seconded by Higgins and passed 3-0. ITEM 2 — Information Only/Transit Issues: Cathy Mooney, Senior Transportation Planner noted that she has been working on transit 1 issues for the past 13 years She said that there are residents in Kent and elsewhere that do it on their own time and for free. She then introduced Mr. Ed Miller who lives on the East Hill in Kent. Miller commutes between Kent and Seattle and has been a volunteer for several years on the King County Transit-Advisory Committee (TAC). TAC members are appointed by the King County Executive and approved by the King county Council. Appointments are for two years. The TAC meets monthly from 6 to 8.30 p.m. on the second Tuesday of each month to help Metro improve transit services and programs. He spoke before the committee explaining what TAC is all about and his experiences representing the concerns of riders from South King County. He noted his personal key issues a few of which include accessibility, make it easy, funding, security in transit areas and integration with all transit. He asked for thoughts on how he might be more effective at representing the interests of Kent bus riders in the future. No Motion Required/Information Only ITEM 3 — Clark Lake Estates-Reauest from Clark Lake Estates Homeowners Association: Tim LaPorte,.Public Works Director introduced Dave Brock, Utilities Engineer and Mike ' Gillespie, Economic Development Engineering Manager. There were several Clark Lake Estates Homeowners at the meeting as well LaPorte noted that the Clark Lake Homeowners Association (HOA) has met with staff on several occasions and that this item was brought to committee back in September of 2009. Gillespie gave a brief history of the Clark Lake Estates neighborhood which is located at approximately 120t" & SE 2401h. Prestige Homes began construction of the homes in 2005. In 2008 the developer, Prestige Homes, notified the City that they were going bankrupt due to the economy. There were several lots that needed to be completed and sold. The City worked with them to complete the few items in the development that needed to be done, obtained their bond, which was reduced from $150,000 once they had reach a certain completeness to $50,000. In 2008 City staff went out and did the final lift and completed other items that were needed to meet the intent of the requirements. There are still a few items remaining to be completed, the survey monuments and the repair of approximately 10 feet of cracked sidewalk. This work is scheduled to be completed in the spring of 2010. Dave Brock gave an informative PowerPoint presentation highlighting the neighborhood and the issues still remaining. 2 PUBLIC WORKS COMMITTEE MINUTES Monday, February 22, 2010 HOA members, Denise Benezra, Thah Ksor and Biswajst Chaltopudhy voiced their concerns about a number of items in the neighborhood including the turnaround area, cracks in the sidewalks, and a pole in one of the driveways among other things. It was asked if property ' owners are allowed to park in the temporary turn-around. LaPorte asked that this question be deferred to a later date, so that he could do some checking Staff including our Law Department concur that the best course of action is for Council to adopt the work as complete and begin enforcement for parking issues. Higgins moved to accept the Improvements to Clark Lake Estates as Complete and cause the transfer of said infrastructure to the City, subject to terms and conditions acceptable to the City Attorney and the Public Works Director. The motion was seconded by Harmon and passed 3-0. ITEM 4 — Addendum to Cambridge Tower Site Lease with Valley Communications: Tim LaPorte, Public Works Director stated that the Water Utility leases ground space to Valley Communications at the Cambridge Site for a structure and tower for radio communications. Valley Communications wishes to sublease a portion of the property to the Washington State Department of Transportation. Thomas moved to recommend ratification of the Mayor's execution of an addendum to Cambridge Tower Site Lease with Valley Communications, subject to terms and conditions acceptable to the City Attorney and the Public Works Director. The motion was seconded by Higgins and passed 3-0. ITEM 5 — LLC Telecommunications License w/Goldfinch Communications: Tim LaPorte, Public Works Director stated that Goldfinch Communications, LLC has formally , completed the application process for a telecommunications license within Kent, WA. This is a housekeeping issue. Higgins moved to recommend Council authorize the Mayor to sign a non-exclusive License Agreement with Goldfinch Communications, LLC for it to construct, install maintain, repair, and operate a telecommunications system using the City's Rights-Of-Way as provided for in an agreement substantially similar to that presented to the Committee, subject to terms and conditions acceptable to the City Attorney and the Public Works Director. The motion was seconded by Thomas and passed 3-0. ITEM 6 — Contract w/Cascade Columbia Distribution for Supply of Water Treatment Chemical: , Brad Lake, Water Superintendent explained that the City annually advertises for water treatment supply chemicals. The use of these chemicals is required to obtain drinking water quality that meets State and Federal Regulations for drinking water standards. He asked committee to approve the contract with Cascade Columbia Distribution. Thomas moved to recommend Council authorize the Mayor to sign the 2010 Water Treatment Chemical Supply Agreement between the City of Kent and Cascade I3 PUBLIC WORKS COMMITTEE MINUTES Monday, February 22, 2010 Columbia Distribution for Sodium Fluoride, subject to terms and conditions acceptable to the City Attorney and the Public Works Director. The motion was seconded by Higgins and passed 3-0, Item 7 — Public Works Board Urban Vitality Grant for James St. at UPRR Non- Motorized Improvements: Tim LaPorte, Public Works Director introduced Mark Howlett, Design Engineering Manager and Ken Langholz, Engineering Supervisor. Langholz shared that the Public Works 1 Department was successful in obtaining a $235,000 grant from the Washington State Public Works Board. The estimated cost of the project is $470,000. Langholz explained that a SEPA requirement of the ShoWare Center is to provide pedestrian improvements along James Street between the Kent/James Street Park and Ride lot west of the Union Pacific Railroad (UPRR) tracks and the ShoWare Center. The City is required to provide $235,000 in matching funds as a condition of the grant. The City is working with the railroad to install Flashing lights, all cost are included in the $470,000. The City has to come up with the other half of the cost which is $235,000. The money must be in the budget in 2011. Mel Roberts, Kent resident would like to see the bike lane extended along the south side of James Street between the Interurban Trail and the Park and Ride. Staff stated that it would ' cost a substantial amount of money to do what he requested and that curb and gutters would need to be installed and that the area is in a wetland buffer area. Higgins asked if we can put a footnote in plans and look into Roberts request, seeing as we have a year to complete the project. Staff said they would do that, Higgins moved to recommend authorization for the Mayor to sign the agreement with the Washington State Public Works Board for an Urban Vitality Grant in the amount of $235,000 for the James Street at UPRR Non-Motorized Improvements Project, subject to the terms and conditions acceptable to the City Attorney and the Public Works Director. IFurther move to recommend that a capital line item be included in the 2011 budget in the amount of $235,000 for City matching funds. The motion was seconded by Thomas and passed 3-0. 1 Information Only/Contract w/The Frause Group, Inc. for Natural Yard Care Neighborhoods Program: Mike Mactutis, Environmental Engineering Manager explained what the Natural Yard Care (NYC) Education Program is. He further explained that they break the workshops to five different neighborhoods throughout the City. Six total hours of education over three nights have been presented to each neighborhood. A total of 15 workshops have been presented and well attended with an average of 71 participants per workshop. The purpose of the workshops is to educate and inform participants about the environmental effects of yard care, and to teach them how to create a beautiful, low- maintenance, environmentally "friendly" yard. 4 , PUBLIC WORKS COMMITTEE MINUTES Monday, February 22, 2010 Mactutis stated that his section plans to enact a contract with The Frause Group to assist them in recruiting and conduct six NYC workshops jointly develop No Motion Required/Information Only ' Adiourned: ' The meeting was adjourned at 5:41 p.m. Cheryl Viseth, Public Works Committee Secretary CONTINUED COMMUNICATIONS A. i 1 1 t t t t I 1 1 1 EXECUTIVE SESSION t ACTION AFTER EXECUTIVE SESSION 1 I t 1 t i t ! 1 I