HomeMy WebLinkAboutES11-097 - Original - Vision Service Plan - Group Vision Care Plan - 01/01/2011 1
y
® Records 1gema
Me
KENT Document
4ASNINGTON "
CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office. All portions are to be completed.
If you have questions, please contact City Clerk`s Office.
Vendor Name: �� lr S�pN S�,Q�_.�r�Tl.%fA,)
Vendor Number:
JD Edwards Number
Contract Number: eS ) ) -077
This is assigned by City Clerk's Office
Project Name: y S Y cx-� Cho
Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment Kcontract
❑ Other:
Contract Effective Date: Termination Date: >l •$� - r 3
Contract Renewal Notice (Days):
Number of days required notice for termination or renewal or amendment
Contract Manager: Department: E:h&p6W2=t
Detail: (i.e. address, location, parcel number, tax id, etc.):
S:Publlc\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08
t
VS
Vision Care for Life
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, 2011
Plan Term THIRTY-SIX(36) MONTHS
Premium Due Date FIRST DAY OF MONTH
In consideration of the statements and agreements contained in the Group Application and in consideration of
payment by Group of the administrative fees and other amounts due as herein provided, VISION SERVICE PLAN ("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.
By:
Ti �� f
Date* /2�7�0
Gary N. Brooks, Secretary
VSP-GVCP-ASP-5/07 11/06/10 Alw
TABLE OF CONTENTS
I. DEFINITIONS........................................... .. . ... ........................ . . ............. 1
II. TERM, TERMINATION, AND RENEWAL........... ......... . . ....... .. ............................. 3
III. OBLIGATIONS OF VSP..................... ........................................................... ........ 4
IV. OBLIGATIONS OF THE GROUP................................................................................ 6
V. OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN....................... 8
VI. ELIGIBILITY FOR COVERAGE........ ..................................................... ... ............ 11
VII. CONTINUATION OF COVERAGE.............................................................................. 14
VIII. ARBITRATION OF DISPUTES.................................................................................... 15
IX. NOTICES... .. ......................................................................................................... 16
X. MISCELLANEOUS......................................................................... ................. 17
EXHIBIT A
SCHEDULE OF BENEFITS..................................... . .... .. ........... 19
EXHIBIT B
SCHEDULE OF PREMIUMS ....................................................................... 24
ADDENDUM
DOMESTIC PARTNER COVERAGE............................... ... . ...................... 25
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.
1.10. EMERGENCY CONDITION: A condition, with sudden onset and acute symptoms, that requires the
Covered Person to obtain immediate medical care, or an unforeseen occurrence calling for immediate, non-medical action.
1.11. ENROLLEE: An employee or member of Group who meets the criteria for eligibility specified under VI.
ELIGIBILITY FOR COVERAGE.
1
1 12. EXPERIMENTAL NATURE: Procedure or lens that is not used universally or accepted by the vision care
profession, as determined by VSP.
1.13. GROUP: An employer or other entity which contracts with VSP for coverage under this Plan in order to
provide vision care coverage to its Enrollees and their Eligible Dependents
1.14. GROUP APPLICATION- The form signed by an authonzed 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"1• 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.
119. RENEWAL DATE: The date on which the Plan shall renew, or terminate if proper notice is given.
1.20. SCHEDULE OF BENEFITS: The document, attached hereto as Exhibit A, which lists the vision care
services and vision care materials which a Covered Person is entitled to receive by virtue of this Plan.
1.21. SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE- The document, attached hereto as
Exhibit B, which states the payments to be made to VSP by or on behalf of a Covered Person to entitle him to Plan Benefits.
2
II.
TERM, TERMINATION,AND RENEWAL
2.01. Plan Term: This Plan shall become effective on the Effective Date and shall remain in effect for the Plan
Term. At the end of the Plan Term, it will renew on a month to month basis unless either party notifies the other in writing,
at least sixty (60) days before the end of the Plan Term, that the party is unwilling to renew the Plan. If such notice is given,
the Plan will terminate at 12 00 midnight on the last day of the Plan Term, unless the parties reach mutual agreement on its
renewal. If the Plan continues on a month to month basis after the Plan Term, either Party may thereafter terminate the
Plan upon thirty (30) days advance written notice to the other party
If VSP issues written renewal materials to Group at least sixty(60) days before the end of the 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.
202. Termination- Either party may terminate the agreement upon a sixty (60)day advance written notice.
Group agrees to pay all Claims Amount and Administrative Fees for Plan Benefits provided pursuant to Benefit
Authorizations issued prior to the Plan termination date, provided claims for such Plan Benefits are filed with VSP within six
(6) months after termination of this Plan.
3
' t
III.
OBLIGATIONS OF VSP
3.01. Coverage of Covered Persons: VSP will enroll each eligible Enrollee and his Eligible Dependents, if
dependent coverage is provided, all of whom shall be referred to as "Covered Persons." To institute coverage, Group may
be required to complete and sign a Group Application and forward such application to VSP, along with information regarding
Enrollees and Eligible Dependents, and applicable amounts due (Refer to VI ELIGIBILITY FOR COVERAGE for further
details.)
Following enrollment, VSP will provide Group with Member Benefit Summaries for Covered Persons. Such
Member Benefit Summaries will summarize the terms and conditions of this Plan.
302. Provision of Plan Benefits: Through its Member Doctors (or through other licensed vision care providers
in cases where a Covered Person is eligible for, and chooses to receive Plan Benefits from a Non-Member Provider) VSP
shall provide Covered Persons such Plan Benefits listed in the Schedule of Benefits, Exhibit A hereto, subject to any
I
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.
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. Provision of Information to Covered Persons: Upon request, VSP will make available to Covered
Persons necessary information describing Plan Benefits and procedures. A copy of this Plan will be placed with Group.
The Plan will also be available at the offices of VSP for copying or inspection by Covered Persons. VSP shall provide
4
Group with an updated list twice annually of Member Doctors' names, addresses, and telephone numbers for distribution to
Covered Persons Covered Persons may also obtain a copy of the latest Member Doctor list by contacting VSP's Customer
Service Department in writing or via the toll-free Customer Service telephone line, or by visiting VSP's Web site at
www vsp.com.
304. 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.
305 Emergency Vision Care: When vision care is necessary for Emergency Conditions, Covered Persons may
obtain Plan Benefits by contacting a Member Doctor or Out-of-Network Provider. No prior approval from VSP is required for
Covered Person to obtain vision care for Emergency 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.
5
Iv.
OBLIGATIONS OF THE GROUP
401. 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. in order to assure bmely 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 after receipt of VSP's statement. The Advance Payment amount
may be adjusted each Plan Term if the average of monthly Claims Amount increases or decreases. The parties agree that
such Advance Payment is reimbursable to the Group upon termination of this Plan, after the Group's indebtedness to VSP
and/or its benefit providers has been satisfied. However, amounts paid to VSP as Advance Payment shall not be
considered assets of the Group, and need not be held in trust by VSP.
4.03. Administrative Fee: Additionally, on or before the first day of each month, Group shall remit to VSP an
Administrative Fee as outlined on the attached Schedule of Advance Payment and Administrative Fee, Exhibit B. Change
will not be made to the Administrative Fee during any Plan Term unless there is a change in the Schedule of Benefits or a
material change in any other terms and conditions of the Plan, provided any such change is mutually agreed upon in writing
between VSP and Group.
Notwithstanding the above, VSP reserves the right to increase amounts due hereunder during a Plan Term by the
amount of any tax or assessment not now in effect which is subsequently levied by any taxing authority, which is attributable
to the amount due VSP from Group.
404. Grace Period: Group shall be allowed a grace period of thirty-one (31) days following the due date for
making any payment of amounts due under this Plan. During the grace period, this Plan will remain in full force and effect
I
for all Covered Persons. Late payments will be considered by VSP at the time of Plan renewal and may impact Group
6
Advance Payment and Administrative Fees in future Plan Terms.
If Group fails to make any payment of amounts due by the end of any grace period, VSP may notify Group that the
payment of amounts due has not been made, that coverage is canceled and that the Group is responsible for payment for
the Claims Amount associated with Plan Benefits provided to Covered Persons 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.
7
V.
OBLIGATIONS OF COVERED PERSONS UNDER THE PLAN
5.01. General: By this Plan, Group makes coverage available to its Enrollees and their Eligible Dependents, if
dependent coverage is provided This Plan may be amended or terminated by agreement between VSP and Group as
otherwise indicated herein Consent or concurrence of Covered Persons for any such amendment or termination is not
necessary. This Plan, and all Exhibits, attachments and amendments, constitute VSP's sole and entire undertaking to
Covered Persons underthis Plan.
All Covered Persons under this Plan shall have the following obligations as a condition of their coverage.
5.02. Coeavments 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.
504. 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.
505. 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.
8
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.
506 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.
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
Denied Claims for Services Rendered: within thirty (30) calendar days after receipt of a request for an
appeal from the Covered Person.
b) Second Level Appeal: If the Covered Person disagrees with the response to the initial appeal of
the claim, the Covered Person has a right to a second level appeal Within sixty (60) calendar days after receipt of VSP's
response to the initial appeal, the Covered Person may submit a second appeal to VSP along with any pertinent
documentation. VSP shall communicate its final determination to the Covered Person in compliance with all applicable
state and federal laws and regulations and shall include the specific reasons for the determination.
c) Other Remedies. When Covered Person has completed the appeals process stated herein,
additional voluntary alternative dispute resolution options may be available, including mediation, or Group should advise
Covered Person to contact the U S Department of Labor or the state insurance regulatory agency for details Additionally,
under the provisions of ERISA(Section 502(a)(1)(13)) [29 U.S.C. 1132(a)(1)(13)], Covered Person has the right to bring a civil
action when all available levels of review of denied claims, including the appeals process, have been completed, the claims
were not approved in whole or in part, and Covered Person disagrees with the outcome.
5.07. Time of Action: No action in law or in equity shall be brought to recover on the Plan prior to the Covered
9
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
i
the expiration of six (6) years from the last date that the claim and any applicable invoices may be submitted to VSP, in
i
accordance with the terms of this Plan.
10
VI.
ELIGIBILITY FOR COVERAGE
6.01. Eligibility Criteria: Individuals will be accepted for coverage hereunder only upon meeting all the
applicable requirements set forth below.
(a) Enrollees. To be eligible for coverage, a person must,
(1) currently be an employee or member of the Group, and
(2) meet the criteria established in the coverage criteria mutually agreed upon by Group and VSP.
(b) Eligible Dependents: If dependent coverage is provided, the persons eligible 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. Such dependent children shall
be eligible until the end of the month in which they attain the age of 25years.
(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.
602 Documentation of Eligibility: Persons satisfying the requirements for coverage under either of the above
classes shall be eligible f:
(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.
11
6 03. Retroactive Eligibility Changes: Retroactive eligibility changes are limited to sixty (60) days prior to the
date notice of any such requested change is received by VSP. If coverage is retroactively terminated for an individual,
I
Group shall remain responsible for the Claims Amount associated with any Plan Benefits provided to that individual
I
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.
604. Change of Participation Requirements. Contribution of Fees. and Eligibility Rules: Composition of
the Group, percentage of Enrollees covered under the Plan, and Group's contribution and Group's eligibility requirements
are all material to VSP's obligations under this Plan. During the term of this Plan, Group must provide VSP 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 Nth the terms of
this Plan.
6.05. Change in Family Status: In the event Group is notified of any change in a Covered Person's family
status (by marriage, the addition (e g., newborn or adopted child) or deletion of dependent children, etc.) Group shall
provide 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.
12
6.06. Family and Medical Leave Act; The federal Family and Medical Leave Act of 1993 (FMLA), requires that
under certain circumstances health plan benefits available to an eligible Enrollee and his or her Eligible 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.
13
Yll.
CONTINUATION OF COVERAGE
7.01. COBRA. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that, under
certain circumstances, health plan benefits available to an Enrollee and his or her Eligible Dependents be made available
for purchase by said persons upon the occurrence of a COBRA-qualifying event. If, and only to the extent, COBRA applies,
VSP shall make the statutorily-required continuation coverage available for purchase in accordance with COBRA.
14
Mill.
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.
803 Choice of Law: Question(s) and dispute(s) hereunder are to be resolved by arbitration However, if there
are any matters arising in connection with this Plan which do become the subject of legal process, the applicable law shall
be that of the State of delivery of this Plan.
15
Ix.
NOTICES
9.01. Required Notices: Any notices to be given under this Plan to either the Group or VSP shall be in writing
and delivered by United States First Class Mail. Notices sent to the Group will be mailed to the address shown on the
Group Application. Notices sent to VSP shall be sent to the address shown on this Plan. Any notices 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.
16
X.
MISCELLANEOUS
10 01. Entire Plan: This Plan, the Group Application, and all Exhibits and attachments, and any amendments
hereto, constitute the entire understanding between the parties and supersedes any prior understandings and agreements
between them, either written or oral Any change or amendment to the Plan must be approved by an officer of VSP and
attached to be valid No agent has the authority to change this Plan or waive any of its provisions. Communication
materials prepared by Group for distribution to Enrollees do not constitute a part of this Plan.
10.02. Indemni : VSP agrees to indemnify, defend and hold harmless Group, its shareholders, directors, officers,
agents, employees, successors and assigns from and against any and all liability, claim, loss, injury, cause of action and
expense (including defense costs and legal fees) of any nature whatsoever arising from the failure of VSP, its officers,
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 judgment. VSP does not itself
directly furnish vision care services or supply materials. Under no circumstances shall VSP or Group be liable for the
negligence, wrongful acts or omissions of any doctor, laboratory, or any other person or organization performing services or
supplying materials in connection with this Plan.
10.04 Assignment: Neither this Plan nor any of the rights or obligations of either of the parties may be assigned
or transferred, except as noted herein, without the prior written consent of both parties.
10.05. Severabili : Should any provision of this Plan be declared invalid, the remaining provisions shall remain
in full force and effect.
10.06. Governing Law This Plan shall be governed by and construed in accordance with applicable federal and
state law Any provision that is in conflict with, or not in compliance with, applicable federal or state statutes or regulations
is hereby amended to conform with the requirements of such statutes or regulations, now or hereafter existing.
10.07. Gender: All pronouns used herein are deemed to refer to the masculine, feminine, neuter, singular, or
plural, as the identity(ies) of the person(s)may require.
17
i
10.08. Communication Materials: Al Communication materials created by Group which relate to this vision care
Plan must adhere to VSP's Member Communication Guidelines, distributed to Group by VSP. Such communication
materials may be sent to VSP for review and approval in advance of mailing to Enrollees. VSP's review of such materials
shall be limited to approving the accuracy of Plan Benefits and shall not encompass or constitute certification that Group's
materials meet any applicable legal or regulatory requirements, including, but not limited to, ERISA requirements.
18
EXHIBIT A
VISION SERVICE PLAN
SCHEDULE OF BENEFITS
Signature Plan
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.
There shall be no Copayment for the examination. If materials (lenses and frames) are provided, there shall be a
Copayment of$25.00 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 eye examinations once every plan year beginning on January 1st.
*Less any applicable Copayment.
19
VISION CARE MATERIALS
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Lenses
Single Vision Covered in full* Up to $ 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 once every plan year beginning on January 1st.
Frames Covered up to Plan Up to$ 45.00*
Allowance*
Available once every other plan year beginning on January 1st.
*Less any applicable Copayment.
Frame allowance may be applied towards non-prescription sunglasses for post PRK, LASIK, or Custom LASIK patients.
Lenses and frames include such professional services as are necessary, which shall include:
• Prescribing and ordering proper lenses;
• Assisting in the selection of frames;
• Verifying the accuracy of the finished lenses,
• Proper fitting and adjustment of frames;
• Subsequent adjustments to frames to maintain comfort and efficiency;
• Progress or follow-up work as necessary.
20
CONTACT LENSES
Contact lenses are available once every plan year in lieu of all other lens and frame benefits available herein When contact
lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for one plan year.
Necessary-
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered
Person's Member Doctor or Non-Member Provider. Prior review and approval by VSP are not required for Covered Person
to be eligible for Necessary Contact Lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees and Materials Professional Fees and Materials
Covered in full* Up to$210.00*
Elective-
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Professional Fees**and Materials Professional Fees and Materials
Up to $200 00 Up to$125.00
*Subject to Copayment
**15% discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation
and fitting.
21
LOW VISION BENEFIT
The Low Vision benefit is available to Covered Persons who have severe visual problems that are not correctable with
regular lenses.
MEMBER DOCTOR NON-MEMBER
BENEFIT PROVIDER BENEFIT
Supplementary Testing Covered in Full Up to$125.00
Complete low vision analysis/diagnosis, which includes a comprehensive examination of visual functions, including the -
prescription of corrective eyewear or vision aids where indicated.
Supplemental Care Aids 75%of Cost 75%of Cost
Subsequent low vision aids.
Copayment for Supplemental Aids: 25%payable by Covered Person.
Benefit Maximum
The maximum benefit available is $1000.00 (excluding Copayment) every two years.
NON-MEMBER PROVIDER BENEFIT
Low Vision benefits secured from a Non-Member Provider are subject to the same time limits and Copayment arrangements
as described above for a Member Doctor. The Covered Person should pay the Non-Member Provider his full fee The
Covered Person will be reimbursed in accordance with an amount not to exceed what VSP would pay a Member Doctor in
similar circumstances. NOTE There is no assurance that this amount will be within the 25%Copayment feature
I
22
EXCLUSIONS AND LIMITATIONS OF BENEFITS
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits, or may be subject to additional
limitations. Covered Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by
calling VSP's Customer Care Division at(800)877-7195.
PATIENT OPTIONS
This Plan is designed to cover visual needs rather than cosmetic materials. When the Covered Person selects any of the
following extras, the Plan will pay the basic cost of the allowed lenses or frames, and the Covered Person will pay the
additional costs for the options.
• Optional cosmetic processes.
Anti-reflective coating.
Color coating.
Mirror coating.
Scratch coating.
Blended lenses.
Cosmetic lenses
Laminated lenses.
• Oversize lenses.
Polycarbonate lenses.
Photochromic lenses,tinted lenses except Pink#1 and Pink#2.
Progressive multifocal lenses.
UV(ultraviolet)protected lenses.
Certain limitations on low vision care.
A frame that costs more than the Plan allowance.
Contact lenses (except as noted elsewhere herein).
NOT COVERED
There is no benefit for professional services or materials connected with.
Orthoptics or vision training and any associated supplemental testing; plano lenses (less than a± .50 diopter power); or
two pair of glasses in lieu of bifocals,
• Replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals
when services are otherwise available;
• Medical or surgical treatment of the eyes;
• Corrective vision treatment of an Experimental Nature;
• Costs for services and/or materials above Plan Benefit allowances;
• Services and/or materials not indicated on this Schedule as covered Plan Benefits.
VSP MAY, AT ITS DISCRETION, WAIVE ANY OF THE PLAN LIMITATIONS IF, IN THE OPINION OF VSP's
OPTOMETRIC CONSULTANTS, IT IS NECESSARY FOR THE VISUAL WELFARE OF THE COVERED PERSON.
23
EXHIBIT B
VISION SERVICE PLAN
SCHEDULE OF ADVANCE PAYMENT AND ADMINISTRATIVE FEE
Signature Plan
VSP shall be entitled to receive amounts due for each month on behalf of each Enrollee and his/her Eligible Dependents, if
any in the amounts specified below.
ADVANCE PAYMENT: $9860.68
ADMINISTRATIVE FEE: $2 05 PER ELIGIBLE ENROLLEE
(INCLUDES COVERAGE FOR ELIGIBLE DEPENDENTS)
NOTICE- The amount due under this Plan is subject to change upon renewal (after the end of the Plan Term or any
subsequent Plan Term) or upon change of the Schedule of Benefits or a material change in any other terms or conditions of
the Plan.
' I
i
24
ADDENDUM
VISION SERVICE PLAN
DOMESTIC PARTNER COVERAGE
VI. ELIGIBILITY FOR COVERAGE
6.01 (b) Eligible Dependents, Add the Following:
(1 a)The domestic partner of the same gender as Enrollee, pursuant to the Group's eligibility rules which
are applicable to the Group's general medical benefits, and
(2b) any unmarried children of the domestic partner provided they depend upon the Enrollee for support
and maintenance.
25
Group Vision Care Plan
VSP.
Vision Care for Life
Group Name: CITY OF KENT
Group Number: 12229020
Effective Date: JANUARY 1,2011
Evidence of Coverage
Provided by:
VISION SERVICE PLAN
3333 Quality Dnve, Rancho Cordova, CA 95670
(916) 851-5000 (800) 877-7195
I
I
REGASP-00898 WA
11A6/10 AM
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 ID#
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 provisions 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 furnished upon request
DEFINITIONS.
ADDITIONAL BENEFIT The document attached to this Evidence of Coverage„ when purchased by Group, which lists selected
RIDER vision care services and vision care materials that a Covered Person is entitled to receive by virtue of the
Plan.
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, non-medical action
ENROLLEE An employee or member of Group who meets the critena 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
1
MEMBER DOCTOR An optometrist or ophthalmologist licensed and otherwise qualified to practice vision care and/or provide
pq P
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 aridlor vision care materials to Covered Persons of VSP
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 on the enclosed insert or in the Schedule of Benefits attached as
Exhibit A to the Group Plan document maintained by your Group Administrator.
r
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 terminate if 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
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, unmanned child over the limiting age as shown on the enclosed insert may continue to be eligible as a dependent rf 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
Your 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 geographic 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 Authorization 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 Authorization 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
2
4 You pay only the Copayment(if any)to a Member Doctor for services covered by the Plan VSP wi11 pay the Member Doctor directly according
to its agreement vnth the doctor
Note. If you are eligible for and obtain Plan Benefits from a Non-Member Provider, you should pay the provider his/her 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-of-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 Acute
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 Doctor's membership in VSP,VSP wall 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 eligibility information furnished to VSP by Covered Person's Group and the level of coverage
(i a service frequencies, 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 coverage Please refer to the attached
Schedule of Benefits for a summary of the level of coverage provided to Covered Person by Group
BENEFITS AND COVERAGES
Through its Member Doctors, VSP provides Plan Benefits to Covered Persons, 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, propedy 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
Necessary contact lenses, together with professional services,wall be provided as indicated on the enclosed insert
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 Doctor's usual and customary professional
fees for contact lens evaluation and fitting Contact lens matenals are provided at the Member Doctor's usual and customary charges.
3
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 toward plan benefit frequencies.
6 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 non-optical aids,subject to the frequency and benefit
limitabons 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
Some brands of spectacle frames may be unavailable for purchase as Plan Benefits,or may be subject to additional limitations. Covered
Persons may obtain details regarding frame brand availability from their VSP Member Doctor or by calling VSP's Customer Care Division
at(800) 877-7195.
This vision service Plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following options, the
Plan will pay the basic cost of the allowed lenses or frames, 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-reflective coating
• Color coating.
• Mirror coating
• Scratch coating
• Blended lenses
• Cosmetic lenses
• Laminated lenses
• Oversize lenses.
• Polycarbonate lenses
• Photochromic lenses, tinted lenses except Pink#1 and Pink#2.
• Progressive mulhfocal lenses
• UV(ultraviolet)protected lenses.
• Certain limitations on low vision care
5
NOT COVERED
There is no benefit for professional services or materials connected with:
• Orthoptics or vision training and any associated supplemental testing, piano lenses(less than t.50 diopter power);or two pairof glasses in lieu
of bifocals
• Replacement of lenses and frames furnished under this plan which are lost or broken except at the normal intervals when services are
otherwise available
• Medical or surgical treatment of the eyes
• Corrective vision treatment of an Experimental Nature.
• Costs for services and/or materials above Plan Benefit allowances indicated on the enclosed insert
• Services/matenals 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 wnting by using the complaint
form that may be obtained upon request from the Customer Service Department Complaints and gnevances include disagreements regarding
access to care, or the quality of care, treatment or service Covered Persons also have the right to submit wntten 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 VSPs expected resolution date Upon final resolution, the Covered Person will be
notified of the outcome in writing
I
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
B. Request for Appeals If a Covered Person's claim for benefits is denied by VSP in whale 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 written 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 services 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 authonzed
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 Covered 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 ("ERISK), additional
6
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)) [29 U S C.
1132(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.
INDIVIDUAL CONTINUATION OF BENEFITS
This program is available to groups of a minimum of ten (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 Enrollee and his or her Eligible Dependents be made available for purchase by said persons upon the occurrence of a COBRA-qualifying
event If,and only to the extent COBRA applies, VSP shall make the statutonly-required continuation coverage available for purchase in accordance
with COBRA
7
i
VISION SERVICE PLAN
3333 Quality Drive
Rancho Cordova, CA 95670
Group Name: CITY OF KENT
Plan Number. 12229020
Effective Date: JANUARY 1, 2011
Plan Term: THIRTY-SIX(36)MONTHS
VISION CARE PLAN
DISCLOSURE FORM AND EVIDENCE OF COVERAGE
PLAN ADMINISTRATOR: Becky Fowler
(Name)
220 4th Ave S
(Address)
Kent, WA 98032-5838
(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, 1F ANY, BY YOUR
GROUP
ELIGIBILITY. ENROLLEES & ELIGIBLE DEPENDENTS. UNMARRIED DEPENDENT
CHILDREN ARE COVERED TO THE END OF THE MONTH IN WHICH THEY
TURN AGE 25 THE WAITING PERIOD IS THE SAME AS YOUR OTHER
HEALTH BENEFITS
PLAN AND SCHEDULE: SIGNATURE PLAN
EXAMINATION. ONCE EVERY PLAN YEAR*
LENSES ONCE EVERY PLAN YEAR*
FRAMES: ONCE EVERY TWO PLAN YEARS*
*PLAN YEAR BEGINS JANUARY 1ST
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 OF ADMINISTRATION: 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
8
SCHEDULE OF BENEFITS
GENERAL
This Schedule and any Additional Benefit Rider(s), when purchased by Group, attached hereto list the vision care services and vision care materials
to which Covered Persons of VSP are enbUed, subject to any Copayments and other conditions, bmitabons 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
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 Full* Up to$ 82 00*
Lenticular Covered in Full* Up to$ 122 00*
Frames Covered up to Plan Allowance* Up to$ 45 00*
Frame allowance maybe applied towards non-prescription sunglasses for post PRK LASIK or Custom LASIK patients.
CONTACTLENSES
Necessary
Professional Fees and Materials Covered in Full* Up to$ 210.00*
Elective
Professional Fees*"and Materials Up to$200,00 Up to$ 12500
Necessary Contact Lenses are a Plan Benefit when specific benefit criteria are satisfied and when prescribed by Covered Person's Member Doctor
or Non-Member Provider Prior review and approval by VSP are not required for Covered Person to be eligible for Necessary Contact Lenses
When contact lenses are obtained, the Covered Person shall not be eligible for lenses and frames again for one plan year.
*Subject to Copayment;if any.
**15%discount applies to Member Doctor's usual and customary professional fees for contact lens evaluation and fitBng.
9
COPAYMENT
There shall be no Copayment for the examination If materials(lenses and frames) are provided, there shall be a Copayment of$25 00 payable by
the Covered Person to the Member Doctor at the time the materials are ordered The Copayment shall not apply to Elective Contact Lenses,
LOW VISION
Professional services for severe visual problems not corrected with regular lenses, including:
Supplemental Testing Covered in Full Up to$125 00
(includes evaluation, diagnosis and prescription of vision aids where indicated)
Supplemental Aids 75%of cost 75%of cost
Mawmum allowable for all Low Vision benefits of$1000.00 every two(2)years.
THIS EVIDENCE OF COVERAGE CONSTITUTES ONLY A SUMMARY OF THE VISION PLAN. THE VISION PLAN DOCUMENT MUST BE
CONSULTED TO DETERMINE THE EXACT TERMS AND CONDITIONS OF COVERAGE.
10
� r
ADDENDUM
EVIDENCE OF COVERAGE&DISCLOSURE FORM
Please note the following revisions to your Evidence of Coverage and Disclosure Form Keep this document with your Evidence of Coverage and
Disclosure Form for a complete and accurate description of your benefits
1 The following provision is added to the section titled DEPENDENT ELIGIBILITY
Domestic Partners Domestic partners of the same gender as the Enrollee shall be covered pursuant to the Group's eligibility rules which are
applicable to the Group's general medical benefits The domestic partner's unmarried dependent children are also covered provided they
depend upon the Enrollee for support and maintenance
11
I
REQUEST FOR MAYOR'S SIGNATURE
KENT Please FIII in All Applicable Boxes
WASHINGTON
is Routing Information (ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT)
Originator: \j GIriLSbacl-N Phone (Originator): 2-S3 95(o 52-10
Date Sent: QZ 2U• to Date Required: ClS0.
Return Signed Document to. 13, Fowl e>^ CONTRACT TERMINATION DATE: (2 31 2014
VENDOR NAME: \J. �j, f? DATE OF COUNCIL APPROVAL: kL�. �p
Brief Explanation of Document:
V S. P Cbh-AYA-C�+
All Contracts Must Be Routed Through the Law Department
I- Z Ll (J (This Area to be Completed By the Law Department)
Received: ,
Approval of City Attorn
City Attorney Comme
Date Forwarded to Mayor:
W Shaded Areas to Be Completed by Administration Staff
Rede�ved _ £ex
des' " �nJRo'" �' e a,.=. �` > ���4 �.k` s' � cgr'�.s g$''- �x g� � �yl� r a- ,
Recommendations &,Comments:
r
Disposition:}2, t � ?fZ -- - a =
UTY C r
Cate Returned:
Iage5870 2/04