Loading...
HomeMy WebLinkAboutES04-169 - Original - Vision Service Plan (VSP) - Group Vision Care Plan Administrative Services Program - 01/01/2004 VISION SERVICE PLAN 3333 Quality Drive Rancho Cordova, California 95670 GROUP VISION CARE PLAN ADMINISTRATIVE SERVICES PROGRAM Group Name CITY OF KENT Plan Number 12229020 State of Delivery WASHINGTON Effective Date JANUARY 1,2004 Plan Term TWENTY-FOUR(24)MONTHS Administrative Fee Due Date FIRST DAY OF MONTH In consideration of the statements and agreements contained in the Group Application and in consideration of payment by Group of the administrative fees and other amounts due as herein provided, VISION SERVICE PLAN ("VSP") agrees to provide certain individuals under this Group Vision Care Plan("Plan")the benefits provided herein, subject to the exceptions, limitations and exclusions hereinafter set forth. This Plan is delivered in and governed by the laws of the State of Delivery and is subject to the terms and conditions recited on the subsequent pages hereof,which are a part of this Plan. Anoo� (34-4. Gary Brooks, enior Vice President, Operations Sue Viseth , Employee Services Director City of Kent i VSP-GVCP-ASP-6/99 DDM 08/04 04 7wl TABLE OF CONTENTS TITLE PAGE I. DEFINITIONS 1 II. TERM,TERMINATION,AND RENEWAL 4 III. OBLIGATIONS OF VSP 5 IV. OBLIGATIONS OF THE GROUP 8 V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN 10 VI. ELIGIBILITY FOR COVERAGE 14 VII. CONTINUATION OF COVERAGE 17 VIII. ARBITRATION OF DISPUTES 18 IX. NOTICES 19 X. MISCELLANEOUS 20 EXHIBIT A 22 SCHEDULE OF BENEFITS 22 EXHIBIT B 27 SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE 27 ii I. DEFINITIONS Key terms used in this Plan are defined and shall have the meaning set forth as follows, unless the context of a term's usage clearly requires otherwise. 1.01 ADMINISTRATIVE FEE: The payments made to VSP by or on behalf of Group in consideration of administrative services rendered. 1.02. ADMINISTRATIVE SERVICES PROGRAM: A group vision care plan whereby Group pays VSP for the Plan Benefits in addition to a monthly Administrative Fee. 1.03. ADVANCE PAYMENT: The amount paid in advance to VSP by or on behalf of Group to cover the estimated benefit costs of Group for one(1)month. 1.04. BENEFIT AUTHORIZATION: Authorization issued by VSP identifying the individual named as a Covered Person of VSP, and identifying those Plan Benefits to which Covered Person is entitled 1.05. CLAIMS AMOUNT: Total charges for benefits delivered, including the cost of professional services and ophthalmic materials, charges for VSP services related to materials purchased,and taxes. 1.06. CONFIDENTIAL MATTER: All confidential or personal information concerning the medical, personal, financial or business affairs of Covered Persons acquired in the course of providing Plan Benefits hereunder. 1.07. COPAYMENTS: Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully covered. 1.08. COVERED PERSON: An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and who is covered under this Plan. 1.09. ELIGIBLE DEPENDENT: Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and approved by VSP in Article VI of this Plan under which such Enrollee is covered. 1 1.10. EMERGENCY CONDITION: A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate,non-medical action. 1.11. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under VI. ELIGIBILITY FOR COVERAGE. 1.12. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or accepted by the vision care profession,as detemuned by VSP. 1.13. GROUP: An employer or other entity which contracts with VSP for coverage under this Plan in order to provide vision care coverage to its Enrollees and their Eligible Dependents. 1.14. GROUP APPLICATION: The form signed by an authorized representative of the Group to signify the Group's intention to have its Enrollees and their Eligible Dependents become Covered Persons of VSP. 1.15. GROUP VISION CARE PLAN (also, "THE PLAN"): The Plan provided by VSP in favor of a Group, under which its Enrollees, and their Eligible Dependents are entitled to become Covered Persons of VSP and receive Plan Benefits in accordance with the terms of such Plan. 1.16. MEMBER DOCTOR: An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care materials on behalf of Covered Persons of VSP. 1.17. NON-MEMBER PROVIDER Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP. 1.18. PLAN BENEFITS: The vision care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under this Plan, as defined in the Schedule of Benefits attached hereto as Exhibit A. 2 1.19. RENEWAL DATE: The date on which the Plan shall renew, or terminate if proper notice is given. 1.20. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A, which lists the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of this Plan. 1.21. SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE: The document,attached hereto as Exhibit B,which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him to Plan Benefits. 1.22. VISUALLY NECESSARY OR APPROPRIATE: Services and materials medically or visually necessary to restore or maintain a patient's visual acuity and health and for which there is no less expensive professionally acceptable alternative,as determined by VSP. 3 111. TERM.TERMINATION,AND RENEWAL 2.01. This Plan shall become effective on the Effective Date and shall remain in effect for the Plan Term. At the end of the Plan Term, it will renew on a month to month basis unless either party notifies the other in writing, at least sixty(60) days before the end of the Plan Term, that the party is unwilling to renew the Plan. If such notice is given, the Plan will terminate at 12:00 midnight on the last day of the Plan Term,unless the parties reach mutual agreement on its renewal. If the Plan continues on a month to month basis after the Plan Term, either Party may thereafter terminate the Plan upon thirty(30)days advance written notice to the other party. If VSP issues written renewal materials to Group at least sixty(60) days before the end of the Plan Term and Group fails to accept the new terms and/or rates in writing prior to the end of the Plan Term, this Plan shall terminate at 12:00 midnight on the last day of the Plan Term as noted above. 2.02. In the event of termination of this Plan by either party, Group agrees to provide funds for payment of the Claims Amount associated with Plan Benefits provided pursuant to Benefit Authorizations issued prior to the Plan termination date, provided claims for such Plan Benefits are filed with VSP within six(6)months after termination of this Plan. 4 III.OBLIGATIONS OF VSP 3.01. Coverate of Covered Persons: VSP will enroll each eligible Enrollee and his Eligible Dependents, if dependent coverage is provided, all of whom shall be referred to as "Covered Persons." To institute coverage, Group may be required to complete and sign a Group Application and forward such application to VSP, along with information regarding Enrollees and Eligible Dependents, and applicable amounts due. (Refer to VI. ELIGIBILITY FOR COVERAGE for further details.) Following enrollment, VSP will provide Group with Vision Care Brochures for Covered Persons. Such Brochures will summarize the terms and conditions of this Plan. 3.02. Provision of Plan Benefits: Through its Member Doctors (or through other licensed vision care providers in cases where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non-Member Provider)VSP shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, as may be Visually Necessary or Appropriate,subject to any limitations,exclusions,or Copayments therein stated. Benefit Authorization must be obtained prior to a Covered Person obtaining Plan Benefits from a Member Doctor. When a Covered Person desires to receive Plan Benefits from a Member Doctor, the Covered.Person must schedule an appointment and identify himself as a VSP Covered Person in order for the Member Doctor to obtain Benefit Authorization from VSP. VSP shall provide Benefit Authorization to the Member Doctor to authorize the provision of Plan Benefits to the Covered Person. Each Benefit Authorization will contain an expiration date,allowing a specific period of time for the Covered Person to obtain Plan Benefits. Benefit Authorization shall be issued by VSP in accordance with the latest eligibility information furnished by Group and the Covered Person's past service utilization, if any. Any Benefit Authorization so issued by VSP shall constitute a certification to the Member Doctor that payment will be made. VSP shall not be held liable to Group for any Benefit Authorization issued in error in reliance on the latest eligibility information available to VSP as provided by the Group. 5 VSP shall pay or deny claims for Plan Benefits provided to Covered Persons, less any applicable Copayment, within a reasonable time but not more than thirty (30) calendar days after VSP has received a completed claim,unless special circumstances require additional time. In such cases, VSP may obtain an extension of fifteen (15) calendar days of this time limit by providing notice to the claimant of the reasons for the extension. 3.03. Determination of Visual Necessity: Plan Benefits are covered only when they are deemed Visually Necessary or Appropriate for the proper treatment of a Covered Person's condition. Questions involving necessity or appropriateness of treatment shall be decided by the doctor responsible for the Covered Person's care and are subject to review and final determination by VSP. Any objections of a Covered Person regarding such decisions may be made to VSP in accordance with VSP's grievance procedures(See Paragraphs 5.05 and 5.06). 3.04. Provision of Information to Covered Persons: Upon request, VSP will make available to Covered Persons necessary information describing Plan Benefits and procedures. A copy of this Plan will be placed with Group. The Plan will also be available at the offices of VSP for copying or inspection by Covered Persons. VSP shall provide Group with an updated list twice annually of Member Doctors' names, addresses, and telephone numbers for distribution to Covered Persons. Covered Persons may also obtain a copy of the latest Member Doctor list by contacting VSP's Customer Service Department in writing or via the toll-free Customer Service telephone line, or by visiting VSP's Web site at www.vsp.com. 3.05. Preservation of Confidentiality: VSP will hold in strict confidence all Confidential Matters. VSP will also exercise its best efforts to prevent any of its employees, Member Doctors, or agents, from disclosing any Confidential Matter. An exception would be if disclosure is necessary to enable any of the above to perform their obligations under this Plan, including but not limited to sharing information with medical information bureaus, or as may otherwise be required by law. Covered Persons and/or Groups that want more information on VSP's Confidentiality Policy may obtain a copy of the policy by contacting VSP's Customer Service Department or by visiting VSP's Web site at www.vsp.com. 6 3.06 Emer¢e cy Vision Care: When vision care is necessary ryfor Emergency y Conditions, Covered Persons may obtain Plan Benefits by contacting a Member Doctor or Out-of- Network Provider. No prior approval from VSP is required for Covered Person to obtain vision care for Emergency Conditions of a medical nature. However, services for medical conditions, including emergencies, are covered by VSP only under the Acute EyeCare and Supplemental Primary EyeCare Plans. If Group has not purchased one of these plans, Covered Persons are not covered by VSP for medical services and should contact a physician under Covered Persons' medical insurance plans for care. For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, the Covered Person should contact VSP's Customer Service Department for assistance. Reimbursement and eligibility are subject to the terms of this Plan. 7 r IV. OBLIGATIONS OF THE GROUP 4.01. Identification of Eligible Enrollees: An Enrollee is eligible for coverage under this Plan, if he satisfies the enrollment criteria specified in Paragraph 6.01(a) and/or as mutually agreed to by VSP and Group. Group shall provide monthly eligibility information to VSP in a mutually agreed upon format and medium to identify all Enrollees who are eligible for coverage under this Plan. Group will supply to VSP, on or before the last day of each month, eligibility information sufficient to identify all Enrollees to be added to or deleted from VSP's coverage rosters for the coming month The eligibility information shall include designation of family status for each such Enrollee,if dependent coverage is provided. Group shall,when requested,make available for inspection by VSP records having a bearing on the coverage of Covered Persons under this Plan. 4.02. Claims Amounts and Advance of Payment: Group shall provide all funds necessary to pay the Claims Amount associated with Covered Persons pursuant to this Plan. hi order to assure timely and adequate payment, Group agrees to make an Advance Payment as outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. This Advance Payment is an estimate of the Claims Amount for one(1)month. Group agrees to pay the actual Claims Amounts on a monthly basis within ten (10) days receipt t of VSP's statement. P The Advance Payment amount may be adjusted each Plan Term if the average of monthly Claims Amount increases or decreases. The parties agree that such Advance Payment is reimbursable to the Group upon termination of this Plan, after the Group's indebtedness to VSP and/or its benefit providers has been satisfied. However, amounts paid to VSP as Advance Payment shall not be considered assets of the Group,and need not be held in trust by VSP. 8 4.03. Administrative Fee: Additionally, on or before the first day of each month,Group shall remit to VSP an Administrative Fee as outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. Change will not be made to the Administrative Fee during any Plan Term unless there is a change in the Schedule of Benefits or a material change in any other terms and conditions of the Plan, provided any such change is mutually agreed upon in writing between VSP and Group. Notwithstanding the above, VSP reserves the right to increase amounts due hereunder during a Plan Term by the amount of any tax or assessment not now in effect which is subsequently levied by any taxing authority,which is attributable to the amount due VSP from Group. 4.04. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the due date for making any payment of amounts due under this Plan. During the grace period,this Plan will remain in firll force and effect for all Covered Persons. Late payments will be considered by VSP at the time of Plan renewal and may impact Group's Advance Payment and Administrative Fees in future Plan Terms. If Group fails to make any payment of amounts due by the end of any grace period, VSP may notify Group that the payment of amounts due has not been made, that coverage is canceled and that the Group is responsible for payment for the Claims Amount associated with Plan Benefits provided to Covered Persons after the last period for which amounts due were fully paid, including the grace period and through the effective date of the termination. Group shall also remain responsible for payment,in accordance with Paragraph 2.02,of any Claims Amount associated with Benefit Authorizations outstanding at the time of termination, and for any legal and/or collection fees incurred by VSP in collecting amounts due under this Plan. 4.05. Distribution of Required Documents: Group agrees to distribute to Enrollees any disclosure forms, plan summaries or other materials that may be required to be given to plan subscribers by any regulatory authority. Such materials shall be distributed by Group no later than thirty(30)days after receipt or as otherwise required under state law. 9 V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN 5.01. General: By this Plan, Group makes coverage available to its Enrollees and their Eligible Dependents, if dependent coverage is provided. This Plan may be amended or terminated by agreement between VSP and Group as otherwise indicated herein. Consent or concurrence of Covered Persons for any such amendment or termination is not necessary. This Plan, and all Exhibits, attachments and amendments, constitute VSP's sole and entire undertaking to Covered Persons under this Plan. All Covered Persons under this Plan shall have the following obligations as a condition of their coverage. 5.02. Copayments for Services Received: Where, as indicated on the Schedule of Benefits, Exhibit A hereto, Copayments are required for certain Plan Benefits, these Copayments shall be the personal responsibility of the Covered Person receiving the care and must be paid to the Member Doctor (or Non-Member Doctor if Non-Member Provider benefits are indicated on the attached Schedule of Benefits at Exhibit A)on the date the services are rendered. 5.03. Obtaining Services from Member Doctors: Benefit Authorization must be obtained prior to receiving Plan Benefits from a Member Doctor. When a Covered Person desires to receive Plan Benefits from a Member Doctor,the Covered Person must select a Member Doctor, schedule an appointment, and identify himself as a Covered Person in order for the Member Doctor to obtain Benefit Authorization from VSP. Should the Covered Person receive Plan Benefits from a Member Doctor without such Benefit Authorization, then for the purposes of those Plan Benefits provided to the Covered Person, the provider will be considered a Non-Member Provider and the benefits available will be limited to those for a Non-Member Provider,if any. 10 r Y 5.04. Submission of Non-Member Provider Claims: All claims for services received from Non-Member Providers (if Non-Member Provider coverage is indicated on the attached Schedule of Benefits at Exhibit A) shall be submitted by Covered Persons to VSP within one hundred eighty(180)days of the date of service. VSP reserves the right to reject such claims which are filed more than one hundred eighty (180) days after the date of service. Failure to submit a claim within one hundred eighty(180) days, however, shall not invalidate or reduce the claim if it was not reasonably possible to submit the claim within such time period, provided the claim was submitted as soon as was reasonably possible and in no event, except in absence of legal capacity, later than one year from the required date. 5.05. Complaints and Grievances: Covered Persons shall report any complaints and/or grievances to VSP at the address given herein. Complaints and grievances are disagreements regarding access to care, quality of care, treatment or service. Complaints and grievances may be submitted to VSP verbally or in writing. A Covered Person may submit written comments or supporting documentation concerning his/her complaint or grievance to assist in VSP's review. VSP will resolve the complaint or grievance within thirty (30) days after receipt, unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but not later than one hundred twenty(120) days after VSP's receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thirty(30) days, VSP will notify the Covered Person of the expected resolution date. Upon final resolution, VSP will notify the Covered Person of the outcome in writing. 5.06. Claim Denial Appeals: If,under the terms of this Plan,a claim is denied in whole or in part, a request may be submitted to VSP by Covered Person or Covered Person's authorized representative for a full review of the denial. Covered Person may designate any person, including his/her provider, as his/her authorized representative. References in this section to "Covered Person"include Covered Person's authorized representative,where applicable. 11 a) Initial Appeal: The request must be made within one hundred eighty(180) days following denial of a claim and should contain sufficient information to identify the Covered Person for whom the claim was denied, including the VSP Enrollee's name, the VSP Enrollee's Member Identification Number, the Covered Person's name and date of birth, the provider of services and the claim number. The Covered Person may review, during normal working hours, any documents held by VSP pertinent to the denial. The Covered Person may also submit written comments or supporting documentation concerning the claim to assist in VSP's review. VSP's response to the initial appeal, including specific reasons for the decision, shall be provided and communicated to the Covered Person as follows: 1. Prior Authorization for Visually Necessary or Appropriate Services: within thirty(30)calendar days after receipt of a request for an appeal from the Covered Person. 2. Denied Claims for Services Rendered: within thirty (30) calendar days after receipt of a request for an appeal from the Covered Person. b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of the claim,the Covered Person has a right to a second level appeal. Within sixty (60) calendar days after receipt of VSrs, response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable state and federal laws and regulations and shall include the specific reasons for the determination. c) Other Remedies: When Covered Person has completed the appeals process stated herein,additional voluntary alternative dispute resolution options may be available,including mediation, or Group should advise Covered Person to contact the U.S. Department of Labor or the state insurance regulatory agency for details. Additionally,under the provisions of ERISA Section 502(a)(1xB), Covered Person has the right to bring a civil action when all available levels of review of denied claims,including the appeals process,have been completed,the claims were not approved in whole or in part,and Covered Person disagrees with the outcome. 12 5.07. Time of Action: No action in law or in equity shall be brought to recover on the Plan prior to the Covered Person exhausting his grievance rights as described in Paragraphs 5.05 and 5.06 above and/or prior to the expiration of sixty (60) days after the claim and any applicable invoices have been filed with VSP. No such action shall be brought after the expiration of six (6) years from the last date that the claim and any applicable invoices may be submitted to VSP, in accordance with the terms of this Plan. 13 VI. ELIGIBILITY FOR COVERAGE 6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all the applicable requirements set forth below. (a) Enrollees: To be eligible for coverage,a person must: (1)currently be an employee or member of the Group, and (2) meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP. (b) Eligible Dependents: If dependent coverage is provided, the persons eligible for coverage as dependents shall include: (1)the legal spouse of any Enrollee,and (2) any unmarried child of an Enrollee, including any natural child from the moment of birth, or legally adopted child from the moment of placement for adoption with the Enrollee,or other child for whom a court holds the Enrollee responsible;and (A) for whose support the Enrollee is legally responsible and who has not yet attained the age of 23 years. (3) as further defined by Group. If a dependent unmarried child, prior to attainment of the prescribed age for termination of eligibility,becomes and continues to be,incapable of self-sustaining employment because of mental or physical disability, that Eligible Dependent's coverage shall not terminate. Coverage will continue as long as he remains chiefly dependent on the Enrollee for support and the Enrollee's coverage remains in force; PROVIDED satisfactory proof of the dependent's incapacity can be furnished to VSP within thirty-one(31)days of the date the Eligible Dependent's coverage would have otherwise terminated, and at such other times as VSP may request proof, but not more frequently than annually. 6.02. Documentation of Eligibility: Persons satisfying the requirements for coverage under either of the above classes shall be eligible if: 14 (a) in the case of an Enrollee, the individual's name and Social Security Number have been reported by the Group to VSP in the manner provided hereunder,and (b) in the case of changes to an Eligible Dependent's status, the change has been reported by the Group to VSP in the manner provided herein. As indicated in Paragraph 4.01 above, VSP may elect to inspect the Group's records in order to verify eligibility of Enrollees and dependents. Plan Benefits will be available only to persons on whose behalf applicable amounts due have been paid for the current period, or Grace Periods outlined above in Paragraph 4.04. If a clerical error is made, it will not affect the coverage to which the Covered Person is entitled under the Plan. 6.03. Retroactive Elisbdity Chanees: Retroactive eligibility changes are limited to sixty (60) days prior to the date notice of any such requested change is received by VSP. If coverage is retroactively terminated for an individual, Group shall remain responsible for the Claims Amount associated with any Plan Benefits provided to that individual pursuant to the Benefit Authorization issued by VSP in reliance on the latest eligibility information available to VSP at the time of such Benefit Authorization. 6.04. Chanee of Participation Reauirements, Contribution of Fees, and Elie;bility Rules: Composition of the Group, percentage of Enrollees covered under the Plan, and Group's contribution and Group's eligibility requirements are all material to VSP's obligations under this Plan. During the term of this Plan, Group must provide VSP with written notice of changes to its composition, percentage of Enrollees covered, contribution or eligibility requirements. Any such change which materially affects VSP's obligations hereunder must be mutually agreed upon in writing between VSP and Group and may constitute a material change to the terms and conditions of this Plan for purposes of Paragraph 4.03. Nothing in this section shall limit Group's ability to add Enrollees and/or Eligible Dependents in accordance with the terms of this Plan. 15 6.05. Chanee in Family Status: In the event Group is notified of any change in a Covered Person's family status (by marriage, the addition (e.g., newborn or adopted child) or deletion of dependent children, etc.) Group shall provide notice of such change to VSP via the next eligibility listing required under Paragraph 4.01. If such notice is given, the change in the Covered Person's status will be effective on the first day of the month following the request for change, or at a requested later date. Notwithstanding any other provision in this section, a newborn child will be covered for thirty-one(31)days after birth and an adopted child will be covered for thirty-one (31) days after the date the Enrollee or Enrollee's spouse acquires the right to control the health care of the child. To continue coverage for a newborn or adopted child beyond the initial thirty-one (31) day period, the Group must be properly notified of the Enrollee's change in family status and applicable amounts due must be paid to VSP on behalf of the child. 6.05. Famftv and Medical Leave Act: The federal Family and Medical Leave Act of 1993 (FMLA),requires that under certain circumstances health plan benefits available to an eligible Enrollee and his or her Eligible Dependents be made available during certain periods of leave. Benefits will be available at the level and under the conditions coverage would have been provided if the eligible Enrollee had not gone on leave. If, and only to the extent, FMLA applies to the parties to this Plan, VSP shall make the statutorily-required continuation coverage available based on the eligibility information provided by the Group. 16 VII. CONTINUATION OF COVERAGE 7.01. COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that under certain circumstances health plan benefits available to an eligible Enrollee and his or her Eligible Dependents be made available to said persons upon the termination of employment of said Enrollee,or the termination of the relationship between said Enrollee and his or her dependents. If, and only to the extent, COBRA applies to the parties to this Plan, VSP shall make the statutorily-required continuation coverage available in accordance with COBRA. 17 VIII. ARBITRATION OF DISPUTES 8.01. Dispute Resolution: Any dispute or question arising between VSP and Group or any Covered Person involving the application, interpretation, or performance under this Plan shall be settled, if possible,by amicable and informal negotiations. This will allow such opportunity as may be appropriate under the circumstances for fact-finding and mediation. If any issue cannot be resolved in this fashion,it shall be submitted to arbitration. 8.02. Procedure: The procedure for arbitration hereunder shall be conducted pursuant to the Rules of the American Arbitration Association in effect at the time of the dispute. 8.03. Choice of Law: Question(s) and dispute(s) hereunder are to be resolved by arbitration. However,if there are any matters arising in connection with this Plan which do become the subject of legal process,the applicable law shall be that of the State of delivery of this Plan. 18 IX. NOTICES 9.01. Any notices to be given under this Plan to either the Group or VSP shall be in writing and delivered by United States First Class Mail. Notices sent to the Group will be mailed to the address shown on the Group Application. Notices sent to VSP shall be sent to the address shown on this Plan. Any notices may be hand-delivered by either party to an appropriate representative of the party, with the burden being on the party effecting such hand-delivery, to prove,if questioned,that such delivery was made. 19 X. MISCELLANEOUS 10.01. Entire Plan: This Plan,the Group Application, and all Exhibits and attachments, and any amendments hereto, constitute the entire understanding between the parties and supersedes any prior understandings and agreements between them, either written or oral. Any change or amendment to the Plan must be approved by an officer of VSP and attached to be valid. No agent has the authority to change this Plan or waive any of its provisions. Communication materials prepared by Group for distribution to Enrollees do not constitute a part of this Plan. 10.02. Indemnity: VSP ages to indemnify, defend and hold harmless Group, its shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and expense (including defense costs and legal fees)of any nature whatsoever arising from the failure of VSP,its officers, agents or employees,to perform any of the activities,duties or responsibilities specified herein. Group agrees to indemnify, defend and hold harmless VSP, its members, shareholders, directors, officers, agents, employees, successors and assigns from and against any and all liability, claim,loss,injury, cause of action and expense(including defense costs and legal fees) of any nature whatsoever arising or resulting from the failure of Group, its officers or employees to perform any of the duties or responsibilities specified herein. 10.03. Liability: VSP arranges for the provision of vision care services and materials through agreements with Member Doctors, who are independent contractors responsible for exercising independent judgement. VSP does not itself directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be liable for the negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization performing services or supplying materials in connection with this Plan. 10.04. Assignment: Neither this Plan nor any of the rights or obligations of either of the parties may be assigned or transferred, except as noted herein, without the prior written consent of both parties. 20 10.05. Severability: Should any provision of this Plan be declared invalid,the remaining provisions shall remain in full force and effect. 10.06. Governing Law: This Plan shall be governed by and construed in accordance with applicable federal and state law. Any provision that is in conflict with, or not in compliance with, applicable federal or state statutes or regulations is hereby amended to conform with the requirements of such statutes or regulations,now or hereafter existing. 10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine, neuter,singular,or plural,as the identity(ies)of the person(s)may require. 10.08. Communication Materials: All Communication materials created by Group which relate to this vision care Plan must adhere to VSP's Member Communication Guidelines, distributed to Group by VSP. Such communication materials may be sent to VSP for review and approval in advance of mailing to Enrollees. VSP's review of such materials shall be limited to approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group's materials meet any applicable legal or regulatory requirements, including, but not limited to,ERISA requirements. 21 EXHIBIT A VISION SERVICE PLAN SCHEDULE OF BENEFITS ENHANCED PLAN B GENERAL This Schedule lists the vision care services and vision care materials to which Covered Persons of VISION SERVICE PLAN ("VSP") are entitled, subject to any Copayments and other conditions, limitations and/or exclusions stated herein. If Plan Benefits are available for Non- Member Provider services, as indicated by the reimbursement provisions below, vision care services and vision care materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician, whether Member Doctors or Non-Member Providers. This Schedule forms a part of the Plan or Certificate to which it is attached. When Plan Benefits are received from Member Doctors, benefits appearing in the first column below are applicable subject to any Copayments as stated below. When Plan Benefits are available and received from Non-Member Providers, the Covered Person is reimbursed for such benefits according to the schedule in the second column below less any applicable Copayments. COPAYMENT The benefits described herein are available to each Covered Person subject only to payment of the applicable Copayment by the Covered Person. Copayments are required for Plan Benefits received from Member Doctors and Non-Member Providers. Covered Persons must also follow the proper procedures for obtaining Benefit Authorization. The applicable Copayment for Covered Persons under this Plan is: There shall be no copayment for the examination. If materials(lenses and flames)are provided, there shall be a$25.00 copayment payable at the time the materials are ordered. However, the copayment for materials shall not apply to elective contact lenses. PLAN BENEFITS MEMBER DOCTOR NON-MEMBER BENEFIT PROVIDER BENEFIT VISION CARE SERVICES Eye Examination Covered in Full* Up to$ 45.00* Complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated. Subsequent regular vision examinations every plan year beginning in January. *Less any applicable Copayment. 22 VISION CARE MATERIALS MEMBER DOCTOR NON-MEMBER BENEFTT PROVIDER BENEFIT Lenses Single Vision Covered in Full* Up to $ 42.00* Bifocal Covered in Full* Up to $ 72.00* Trifocal Covered in Full* Up to $ 82.00* Lenticular Covered in Full* Up to $ 122.00* Available every plan year beginning in January. Frames Covered up to Plan Up to $ 45.00* Allowance* Available every other plan year beginning in January. *Less any applicable Copayment. Lenses and frames include such professional services as are necessary,which shall include: • Prescribing and ordering proper lenses; • Assisting in the selection of frames; • Verifying the accuracy of the finished lenses; • Proper fitting and adjustment of frames; • Subsequent adjustments to frames to maintain comfort and efficiency; • Progress or follow-up work as necessary. 23 Contact Lenses Contact lenses are available once every 12 months in lieu of all other lens and frame benefits available herein. When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for 12 months. Visually Necessary — When Visually Necessary contact lenses are obtained from a Member Doctor, they will be covered in full with prior authorization from VSP. When Visually Necessary contact lenses are obtained from a Non-Member Provider, VSP will provide an allowance toward the cost as outlined below. Coverage for Visually Necessary contact lenses regardless of whether they are obtained from a Member Doctor or Non-Member Provider are subject to review and authorization from VSP's Optometric Consultants. MEMBER DOCTOR NON-MEMBER BENEFIT PROVIDER BENEFIT Professional Fees and Professional Fees and Materials—Covered in Full* Materials—Up to $210.00* Elective-Contact lenses for other than Visually Necessary circumstances: MEMBER DOCTOR NON-MEMBER BENEFIT PROVIDER BENEFIT Professional Fees** and Professional Fees and Materials—Covered up to $200.00 Materials—Up to $125.00 *Less any applicable Copayment **Additional discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation and fitting(see section on Additional Discounts below) 24 ADDITIONAL DISCOUNT Each Covered Person shall be entitled to receive a discount of twenty percent (20%) toward the purchase of additional complete pairs of prescription glasses (lenses, lens options, and frames) from a Member Doctor. Additional pair means any complete pair of prescription glasses purchased beyond the benefit frequency allowed under this Plan. Additionally,Covered Persons shall be entitled to receive a discount of fifteen percent(IS%) off Member Doctor professional fees for elective contact lens evaluations and fittings. Discounts are applied to the Member Dodoes usual and customary fees for such services and are available within twelve (12) months of the covered eye examination from the Member Doctor who provided the covered eye examination. Contact lens materials are provided at the doctor's usual and customary charges. Additional discounts noted on this schedule are subject to change as deemed appropriate by VSP with prior notification to the Group. LOW VISION BENEFIT The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with regular lenses and is subject to prior approval by VSP Consultants. MEMBER DOCTOR NON-MEMBER BENEFIT BENEFIT Supplementary Testing Covered in Full Up to $125.00 Complete low vision analysis and diagnosis which includes a comprehensive examination of visual functions, including the prescription of corrective eyewear or vision aids where indicated. Supplemental Care Aids 75%of Cost 75%of Cost Subsequent low vision aids as Visually Necessary or Appropriate. Copayment for Supplemental Aids: 25%payable by Covered Person. Benefit Maximum The maximum benefit available is$1000.00(excluding Copayment) every two years. NON-MEMBER PROVIDER BENEFIT Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements as described above for a Member Doctor. The Covered Person should pay the Non-Member Provider his full fee. The Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in similar circumstances. NOTE: There is no assurance that this amount will be within the 25% Copayment feature. 25 EXCLUSIONS AND LEMTATIONS OF BENEFITS PATIENT OPTIONS This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the following extras, the Plan will pay the basic cost of the allowed lenses, and the Covered Person will pay the additional costs for the options. • Blended lenses. • Oversize lenses. • Cosmetic lenses. • Optional cosmetic processes. • Progressive multifocal lenses. • UV(ultraviolet)protected lenses. • The coating of the lens or lenses. • The laminating of the lens or lenses. • Certain limitations on low vision care. • A frame that costs more than the Plan allowance. • Contact lenses(except as noted elsewhere herein). • Photochromic lenses;tinted lenses except Pink#1 and Pink#2. NOT COVERED There is no benefit for professional services or materials connected with: • Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a t.38 diopter power);or two pair of glasses in lieu of bifocals; • Replacement of lenses and frames famished under this Plan which are lost or broken, except at the normal intervals when services are otherwise available; • Medical or surgical treatment of the eyes; • Corrective vision treatment of an Experimental Nature; • Costs for services and/or materials above Plan Benefit allowances; • Services and/or materials not indicated on this Schedule as covered Plan Benefits. VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP'S OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON. 26 EXHIBIT B VISION SERVICE PLAN SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE ENHANCED PLAN B VSP shall be entitled to receive amounts due for each month on behalf of each Enrollee and his/her Eligible Dependents,if any in the amounts specified below: ADVANCE PAYMENT: $1630.68 ADMINISTRATIVE FEE: $2.14 PER ELIGIBLE ENROLLEE NOTICE: The amount due under this Plan is subject to change upon renewal (after the end of the Plan Tenn or any subsequent Plan Term) or upon change of the Schedule of Benefits or a material change in any other terms or conditions of the Plan. 27 • • Group Care Plan } Group Name: CITY OF KENT Group Number: 12229020 Effective Date: JANUARY 1,2004 EVIDENCE OF COVERAGE Provided by: VISION SERVICE PLAN 3333 Quality Drive, Rancho Cordova,CA 95670 (916)851-5000 (800) 877-7195 REGASP-M98 WA 004104 Al --now To be filled in by employer in the event this document is used to develop a Summary Plan Description: NAME OF EMPLOYER' NAME OF PLAN' PRINCIPAL ADDRESS. EMPLOYER I.D.#: PLAN#: PLAN ADMINISTRATOR: ADDRESS: PHONE NUMBER REGISTERED AGENT FOR SERVICE OF LEGAL PROCESS,IF DIFFERENT FROM PLAN ADMINISTRATOR' ADDRESS: This form is a summary of the Plan provisioris and is presented as a matter of general information only. The contents are not to be accepted or construed as a substitute for the provisions of the Plan itself. A specimen copy of the Plan will be fumished upon request. DEFINITIONS: ANISOMETROPIA A condition of unequal refractive state for the two eyes, one eye requiring a different lens correction than the other. BENEFIT AUTHORIZATION Authorization issued by VSP identifying the individual named as a Covered Person of VSP,and identifying those Plan Benefits to which a Covered Person is entitled. COPAYMENTS Any amounts required to be paid by or on behalf of a Covered Person for Plan Benefits which are not fully covered. COVERED PERSON An Enrollee or Eligible Dependent who meets VSP's eligibility criteria and on whose behalf Premiums have been paid to VSP,and who is covered under this plan. ELIGIBLE DEPENDENT Any legal dependent of an Enrollee of Group who meets the criteria for eligibility established by Group and approved by VSP under section VI. ELIGIBILITY FOR COVERAGE of the Group Plan document maintained by your Group Administrator under which such Enrollee is covered. EMERGENCY CONDITION A condition, with sudden onset and acute symptoms, that requires the Covered Person to obtain immediate medical care,or an unforeseen occurrence requiring immediate,nonmedical action. ENROLLEE An employee or member of Group who meets the criteria for eligibility specified under section VI ELIGIBILITY FOR COVERAGE of the Group Plan document maintained by your Group Administrator. EXPERIMENTAL NATURE Procedure or lens that is not used universally or accepted by the vision care profession,as determined by VSP. GROUP An employer or other entity which contracts with VSP for coverage under this plan in order to provide vision care coverage to its Enrollees and their Eligible Dependents. KERATOCONUS A development or dystrophic deformity of the comea in which it becomes coneshaped due to a thinning and stretching of the tissue in its central area. MEMBER DOCTOR An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide vision care materials who has contracted with VSP to provide vision care services and/or vision care materials on behalf of Covered Persons of VSP. NON-MEMBER PROVIDER Any optometrist, optician, ophthalmologist, or other licensed and qualified vision care provider who has not contracted with VSP to provide vision care services and/or vision care materials to Covered Persons of VSP PLAN BENEFITS The visor care services and vision care materials which a Covered Person is entitled to receive by virtue of coverage under this plan, as defined on the enclosed insert or in the Schedule of Benefits attached as Exhibit A to the Group Plan document maintained by your Group Administrator. PREMIUMS The payments made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits, as stated in the Schedule of Premiums attached as Exhibit B to the Group Plan document maintained by your Group Administrator. RENEWAL DATE The date on which this plan shall renew or terminated proper notice is given. SCHEDULE OF BENEFITS The document,attached as Exhibit A to the Group Plan document maintained by your Group Administrator,which lists the vision care services and vision care materials which a Covered Person is entitled to receive by virtue of this plan. SCHEDULE OF PREMIUMS The document attached as Exhibit B to the Group Plan document maintained by your Group Administrator,which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him/her to Plan Benefits. VISUALLY NECESSARY Services and materials medically or visually necessary to restore or maintain a patients visual acuity and health OR APPROPRIATE and for which there is no less expensive professionally acceptable alternative. ELIGIBILITY FOR COVERAGE Enrollees To be eligible for coverage,a person must currently be an employee or member of the Group, and meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP. Eligible Dependents: If dependent coverage is provided, the persons eligible for coverage as dependents shall include the legal spouse of any Enrollee,and any unmarried child of an Enrollee who has not obtained the limiting age as shown on the enclosed insert including any natural child from the moment of birth, legally adopted child from the moment of placement for adoption with the Enrollee, or other child for whom a court or administrative agency holds the Enrollee responsible. A dependent unmarried child over the limiting age as shown on the enclosed insert may continue to be eligible as a dependent if the child is incapable of self-sustaining employment because of mental or physical disability, and chiefly dependent upon the enrollee for support and maintenance PREMIUMS You Group is responsible for payments to VSP of the periodic charges for your coverage.You will be notified of your share of the charges,if any,by your Group The entire cost of the program is paid to VSP by your Group. PROCEDURE FOR USING THE PLAN 1. When you desire to receive Plan Benefits from a Member Doctor, contact VSP or a Member Doctor. A list of names, addresses, and phone numbers of Member Doctors in your geographic location can be obtained from your Group, Plan Administrator,or VSP. If this list does not cover the geographical area in which you desire to seek services,you may call or write the VSP office nearest you to obtain one that does 2 If you are eligible for Plan Benefits,VSP will provide Benefit Authonzatign directly to the Member Doctor If you contact a Member Doctor directly,you must identify yourself as a VSP member so the doctor knows to obtain Benefit Authorizabon from VSP 3. When such Benefit Authorization is provided by VSP,and services are performed prior to the expiration date of the Benefit Authorization, this will constitute a claim against the Plan in spite of your termination of coverage or the termination of the Plan Should you receive services from a Member Doctor without such Benefit Authorization or obtain services from a provider who is not a Member Doctor,you are responsible for payment in full to the provider. 4. You pay only the Copaymuent(if any) to a Member Doctor for services covered by the Plan. VSP will pay the Member Doctor directly according to its agreement with the doctor. -2- Note: If you are eligible for and obtain Plan Benefits from a Non-Member Provider,you should pay the provider histher full fee. You will be reimbursed by VSP in accordance with the Non-Member Provider reimbursement schedule shown on the enclosed insert, less any applicable Copayments. 5. In emergency conditions, when immediate vision care of a medical nature such as for bodily trauma or disease is necessary, Covered Person can obtain covered services by contacting a Member Doctor (or Out-ol-Network Provider if the attached Schedule of Benefits indicates Covered Person's Plan includes such coverage). No prior approval from VSP is required for Covered Person to obtain vision care for Emergency Conditions of a medical nature.However,services for medical conditions,including emergencies,are covered by VSP only under the Agate EyeCare and Primary EyeCare Plans. If coverage for one of these plans is not indicated on the attached Schedule of Benefits or Addendum, Covered Person is not covered by VSP for medical services and should contact a physician under Covered Person's medical insurance plan for care. For emergency conditions of a non-medical nature,such as lost, broken or stolen glasses,the Covered Person should contact VSP's Customer Service Department for assistance. Emergency vision care is subject to the same benefit frequencies, plan allowances, Copayments and exclusions stated herein. Reimbursement to Member Doctors will be made in accordance with their agreement with VSP. 6. In the event of termination of a Member Doctors membership in VSP,VSP will remain liable to the Member Doctor for services rendered to you at the time of termination and permit the Member Doctor to continue to provide you with Plan Benefits until the services are completed or until VSP makes reasonable and appropriate arrangements for the provision of such services by another authorized doctor. BENEFIT AUTHORIZATION PROCESS VSP authorizes Plan Benefits according to the latest eAoNty information furnished to VSP by Covered Person's Group and the level of coverage (i.e.service frequenciees,covered materials,reimbursement amounts,limitations,and exclusions)purchased for Covered Person by Group under this Plan. When Covered Person requests services under this Plan, Covered Person's prior utilization of Plan Benefits will be reviewed by VSP to determine if Covered Person is eligible for new services based upon Covered Person's Plan's level of ooverage. Please refer to the attached Schedule of Benefits for a summary of the level of coverage provided to Covered Person by Group. Prior Authorirat[on Certain Plan Benefits require VSP's prior authorization before such Plan Benefits are covered. VSP's prior authorization determinations are based upon criteria developed by optometric and ophthalmic consultants and approved by VSP's Utilization Management Committee and Board of Directors. A. Initial Determination: VSP will approve or deny requests for prior authorization of services within fifteen(15)calendar days of receipt of the request from the Covered Person's doctor. In the event that a prior authorization cannot be resolved within the time indicated, VSP may,if necessary,extend the time for decision by no more than fifteen(15)calendar days. B. Appeak: If VSP denies the doctor's request for prior authonzaton, the doctor, Covered Person or the Covered Person's authorized representative may request an appeal of the denial. Please refer to the section on Claim Appeals,below,for details on how to request an appeal. VSP shall provide the requestor with a final review determination within thirty(30) calendar days from the date the request is received. A second level appeal, and other remedies as described below, is also available VSP shall resolve any second level appeal within thirty (30) calendar days. Covered Person may designate any person, including the provider, as Covered Person's authorized representative For more information regarding VSP's criteria for authorizing or denying Plan Benefits,please contact VSP's Customer Service Department -3- BENEFITS AND COVERAGES Through its Member Doctors, VSP provides Plan Benefits to Covered Persons as may be Visually Necessary or Appropriate, subject to the limitations,exclusions,and Copayment(s)described herein. When you wish to obtain Plan Benefits from a Member Doctor,you should contact the Member Doctor of your choice, identify yourself as a VSP member, and schedule an appointment. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization for you directly to the Member Doctor prior to your appointment IMPORTANT: The benefits described below are typical services and materials available under most VSP Plans.However,the actual Plan Benefits provided to you by your Group may be different.Refer to the attached Schedule of Benefits and/or Disclosure to determine your specific Plan Benefits. 1 Eye Examination A complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated. 2. Lenses: The Member Doctor will order the proper lenses necessary for your visual welfare. The doctor shall verify the accuracy of the finished lenses. 3. Frames: The Member Doctor will assist in the selection of frames,properly fit and adjust the frames, and provide subsequent adjustments to frames to maintain comfort and efficiency. 4. Contact lenses: Unless otherwise indicated on the enclosed insert, contact lenses are available under this Plan in lieu of all other lens and frame benefits described herein for the current eligibility period. Visually Necessary contact lenses, together with necessary professional services, will be provided as indicated on the enclosed insert. Coverage for Visually Necessary contact lenses-regardless of whether they are obtained from a Member Doctor or Non-Member Provider-is subject to review and authorization from VSP's optometric consultants. If you select contact lenses for other than Visually Necessary circumstances, they will be considered Elective contact lenses. When Elective contact lenses are obtained from a Member Doctor,VSP will provide an allowance toward the cost of professional fees and materials as shown on the enclosed insert A 15%discount shall also be applied to the Member Doctors usual and customary professional fees for contact lens evaluation and fitting. Contact lens materials are provided at the Member Doctor's usual and customary charges. 5. If you elect to receive vision care services from a Member Doctor, Plan Benefits are provided subject only to your payment of any applicable Copayment. If your Plan includes Non-Member Provider coverage,and you choose to obtain Plan Benefits from a Non-Member Provider, you should pay the Non-Member Provider his/her full fee. VSP will reimburse you in accordance with the reimbursement schedule shown on the enclosed insert, less any applicable Copayment. THERE IS NO ASSURANCE THAT THE SCHEDULE WILL BE SUFFICIENT TO PAY FOR THE EXAMINATION OR THE MATERIALS. Availability of services under the Non-Member Provider reimbursement schedule is subject to the same time limits and Copayments as those described for Member Doctor services. Services obtained from a Non-Member Provider are in lieu of obtaining services from a Member Doctor and count loward plan benefit frequencies. 6. Additional Discount Each Covered Person shall be entitled to receive a 20% discount toward the purchase of additional complete pairs of prescription glasses(lenses,lens options,and frames)from a Member Doctor. Additional pair means any complete pair of prescription glasses purchased beyond the benefit frequency allowed by your Plan,as indicated on the enclosed insert Additionally,each Covered Person shall be entitled to receive a 15%discount off the Member Doctor's professional fees for contact lens evaluations and fittings. Contact lens materials are provided at the doctors usual and customary charges. Discounts are applied to the Member Doctor's usual and customary fees for such services and are available within twelve(12)months of the covered eye examination from the Member Doctor who provided the covered eye examination. 7. Low Vision Services and Materials(applicable only If included in your Plan Benefits outlined on the enclosed insert): The Low Vision Benefit provides special aid for people who have acuity or visual field loss that cannot be corrected with regular lenses. If a Covered Person falls within this category, he or she will be entitled to professional services as well as ophthalmic materials, including but not limited to, supplemental testing, evaluations, visual training, low vision prescription services, plus optical and ran-optical aids, subject to the frequency and benefit limitations as outlined on the enclosed insert. Consult your Member Doctor for details COPAYMENT The benefits described herein are available to you subject only to your payment of any applicable Copayment(s)as described in this booklet and on the enclosed insert.ANY ADDITIONAL CARE,SERVICE AND/OR MATERIALS NOT COVERED BY THIS PLAN MAY BE ARRANGED BETWEEN YOU AND THE DOCTOR. -4- EXCLUSIONS AND LIMITATIONS OF BENEFITS This vision service Plan is designed to cover visual needs rather than cosmetie materials. If you select any of the following options,the Plan will pay the basic cost of the allowed lenses,and you will be responsible for the options extra cost, unless it is defined as a Plan Benefit in the Schedule of Benefits attached as Exhibit A to the Group Plan maintained by your Group Administrator. • Optional cosmetic processes. • Anti-retiective coating. • Color coating. • Mirror coating. • Scratch coaling. • Blended lenses. • Cosmetic lenses. • Laminated lenses. • Oversize lenses. • Photochromic lenses,finted lenses except Pink#1 and Pink#2. • Progressive muitifocel lenses. • UV(ultraviolet)protected lenses. • Certain limitations on low vision care. NOT COVERED There is no benefit for professional services or materials connected with- 1 Orthoptics or vision training and any associated supplemental testing,piano lenses(less than t.38 dnopter power);or two pair of glasses in lieu of bifocals. 2. Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are otherwise available. 3. Medical or surgical treatment of the eyes. 4. Corrective vision treatment of an Experimental Nature. 5. Costs for services and/or materials above Plan Benefit allowances indicated on the enclosed insert 6 Services/materials not indicated as covered Plan Benefits on the enclosed insert LIABILITY IN EVENT OF NON-PAYMENT IN THE EVENT COMPANY FAILS TO PAY THE PROVIDER,YOU SHALL NOT BE LIABLE TO THE PROVIDER FOR ANY SUMS OWED BY THE VISION PLAN OTHER THAN THOSE NOT COVERED BY THE PLAN. COMPLAINTS AND GRIEVANCES If Covered Person ever has a question or problem,Covered Person's first step is to call VSP's Customer Service Department The Customer Service Department will make every effort to answer Covered Person's question and/or resolve the matter informally. If a matter is not initially resolved to the satisfaction of a Covered Person,the Covered Person may communicate a complaint or grievance to VSP orally or in writing by using the complaint form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding access to care, or the quality of care, treatment or service. Covered Persons also have the right to submit written comments or supporting documentation concerning a complaint or grievance to assist in VSP's review.VSP will resolve the complaint or grievance within thirty(30)days after receipt,unless special circumstances require an extension of time. In that case, resolution shall be achieved as soon as possible, but no later than one hundred twenty(120)days after VSP's receipt of the complaint or grievance. If VSP determines that resolution cannot be achieved within thirty (30)days,a letter will be sent to the Covered Person to indicate VSP's expected resolution date. Upon final resolution,the Covered Person will be notified of the outcome in writing Claim Payments and Denials A. Initial Determination- VSP will pay or deny claims within thirty(30)calendar days of the receipt of the claim from the Covered Person or Covered Person's authorized representative. In the event that a claim cannot be resolved within the time indicated VSP may, if necessary, extend the time for decision by no more than fifteen(15)calendar days. -5- B. Request for Appeals: If a Covered Person's claim for benefits is denied by VSP in whole or in part,VSP will notify the Covered Person in writing of the reason or reasons for the denial.Within one hundred eighty(180)days after receipt of such notice of denial of a claim, Covered Person may make a verbal or wntten request to VSP for a full review of such denial The request should contain sufficient information to identify the Covered Person for whom a claim for benefits was denied, including the name of the VSP-Enrollee, Member Identification Number of the VSP Enrollee,the Covered Person's name and date of birth,the name of the provider of seances and the claim number.The Covered Person may state the reasons the Covered Person believes that the claim denial was in error. The Covered Person may also provide any pertinent documents to be reviewed. VSP will review the claim and give the Covered Person the opportunity to review pertinent documents,submit any statements,documents,or written arguments in support of the claim, and appear personally to present materials or arguments Covered Person or Covered Person's authorized representative should submit all requests for appeals to: VSP Member Appeals 3333 Quality Drive Rancho Cordova,CA 95670 (800)877-7195 VSP's determination, including specific reasons for the decision, shall be provided and communicated to the Covered Person within thirty (30) calendar days after receipt of a request for appeal from the Coed Person or Covered Person's authorized representative. If Covered Person disagrees with VSP's determination, he/she may request a second level appeal within sixty(60)calendar days from the date of the determination.VSP shall resolve any second level appeal within thirty(30)calendar days. When Covered Person has completed all appeals mandated by the Employee Retirement Income Security Act of 1974 ("ERISA"), additional voluntary alternative dispute resolution options may be available, including mediation and arbitration Covered Person should contact the U. S. Department of Labor or the State insurance regulatory agency for details.Additionally, under ERISA Section 502(a)(1)(B), Covered Person has the right to bring a civil (court)action when all available levels of reviews of denied claims, including the appeal process, have been completed, the claims were not approved in whole or in part,and Covered Person disagrees with the outcome. TERMINATION OF BENEFITS Terms and cancellation conditions of your vision care plan are shown on the enclosed insert Plan Benefits will cease on the date of cancellation of this Plan whether the cancellation is by Group or by VSP due to nonpayment of Premium. If service is being rendered to you as of the termination date of the Plan,such service shall be continued to completion but in no event beyond six(6) months after the termination date of the Plan. INDMDUAL CONTINUATION OF BENEFITS This program is available to groups of a minimum of ter► (10) employees and is, therefore, not available on an individual basis. When a Group terminates its coverage,individual coverage is not available for Enrollees of the Group who may desire to retain their coverage. THE CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985(COBRA) The Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA)requires that under certain circumstances health plan benefits available to an eligible participant and his or her dependents be made available to said persons upon the termination of employment of said participant,or the termination of the relationship between said participant and his or her dependents. If,and only to the extent, COBRA applies to your Group Plan, VSP shall make the statutorily-required continuation coverage available in accordance with COBRA. -6- VISION SERVICE PLAN 3333 Quality Drive Rancho Cordova, CA 95670 Group Name: CITY OF KENT Plan Number. 12229020 Effective Date: JANUARY 1, 2004 Plan Term: TWENTY-FOUR(24) MONTHS VISION CARE PLAN DISCLOSURE FORM AND EVIDENCE OF COVERAGE PLAN ADMINISTRATOR: BECKY FOWLER (NAME) 220 FOURTH AVENUE SOUTH (ADDRESS) KENT, WA 98032 (CITY, STATE,ZIP) MONTHLY PREMIUM: YOUR GROUP IS RESPONSIBLE FOR PAYMENT TO VISION SERVICE PLAN OF THE PERIODIC CHARGES FOR YOUR COVERAGE. YOU WILL BE NOTIFIED OF YOUR SHARE OF THE CHARGES, IF ANY, BY YOUR GROUP. ELIGIBILITY. ENROLLEES & ELIGIBLE DEPENDENTS. UNMARRIED DEPENDENT CHILDREN ARE COVERED TO AGE 23. THE WAITING PERIOD IS THE SAME AS YOUR OTHER HEALTH BENEFITS. PLAN AND SCHEDULE. ENHANCED PLAN B EXAMINA770N.AVAILABLE every PLAN YEAR BEGINNING IN JANUARY. LENSES. AVAILABLE every PLAN YEAR BEGINNING IN JANUARY FRAMES. AVAILABLE every other PLAN YEAR BEGINNING IN JANUARY. TERM, TERMINATION AND RENEWAL: AFTER THE PLAN TERM, THIS PLAN WILL CONTINUE ON A MONTH TO MONTH BASIS OR UNTIL TERMINATED BY EITHER PARTY GIVING THE OTHER SIXTY(60)DAYS PRIOR WRITTEN NOTICE. TYPE OFADMINISTRATION. VSP WILL PROVIDE ADMINISTRATIVE SERVICES OF THE FOLLOWING NATURE: CLAIM AND BILLING ADMINISTRATION. BENEFITS PROVIDED UNDER THIS PLAN ARE SELF-INSURED BY THE EMPLOYER. VSP'S ADDRESS IS: VISION SERVICE PLAN 3333 QUALITY DRIVE RANCHO CORDOVA, CA 95670 REGASP-008W 7 SCHEDULE OF BENEFITS GENERAL This Schedule lists the vision care services and vision care materials to which Covered Persons of VSP are entitled,subject to any Copayments and other conditions, limitations and/or exclusions stated herein If Plan Benefts are available for Non-Member Prowder services as indicated by the reimbursement provisions below, vision care services and vision,care materials may be received from any licensed optometrist, ophthalmologist, or dispensing opi can,whether Member Doctors or Non-Member Providers. When Plan Benefits are received from Member Doctors,benefits appearing in the first column below are applicable subject to any Copayment(s)as stated below. When Plan Benefits are available and received from Non-Member Providers,you are reimbursed for such benefits according to the schedule in the second column below less any applicable Copayment PLAN BENEFITS MEMBER DOCTOR BENEFIT NON-MEMBER PROVIDER BENEFIT VISION CARE SERVICES Vision Examination Covered in Full* Up to$45.00* VISION CARE MATERIALS Lenses Single Vision Covered in Full* Up to$42 00* Bifocal Covered in Full* Up to$72 00* Trifocal Covered in Fur Up to$82.00* Lenticular Covered in Fur Up to$122.00* Frames Covered up to Plan Allowance* Up to$45.00* CONTACTLENSES Visually Necessary Professional Fees and Materials Covered in Fu#* Up to$210.00* Elective Professional Fees"and Maleriac Up to$200.00* Up to$125.00* Man contact lenses are obtained,the Covered Person she#not be eligible for lenses and frames again for 12 months. *Subject to Copsyment Many. **Additional discount applies to Member Docto►W usual and customary professional fees for contact lens evaluation and fitting. _a. COPAYMENT There shall be no copayment for the examination. If materials(lenses and frames)are provided,there shall be a$25.00 oopayment payable at the time the materials are ordered. However,the copayment for materials shall not apply to elective contact lenses. LOW VlS/ON Professional seances,as necessary,for severe visual problems not corrected with regular lenses,including. Supplemental Testing Covered in Full Up to$125.00 (includes evaluation,diagnosis and preschiphon of vision aids where indicated) Supplemental Aids Covered up to 75%of cost Covered up to 75%of cost Maximum allowable for ad Low Vi*n benefits of$1000.00 every two(2)years. THIS EVIDENCE OF COVERAGE CONSTITUTES ONLY A SUMMARY OF THE VISION PLAN. THE VISION PLAN DOCUMENT MUST BE CONSULTED TO DETERMNE THE EXACT TERMS AND CONDITIONS OF COVERAGE. -9-