HomeMy WebLinkAboutES04-321 - Original - First Choice Health Network - Employee Assistance Program - 01/01/2012 TO INITIATE EAP,MAP,OR PAP SERVICES PLEASE SIGN AND RETURN ONE COPY OF
THE FOLLOWING GROUP SERVICE AGREEMENT
First Choice Health Assistance Services
600 University Street,Suite 1400 • Seattle,WA 98101
Phone (800) 777-4114 • Fax 206-268-6120 • eap@fchn corn
GROUP SERVICE AGREEMENT
THIS AGREEMENT is entered by and between First Choice Health Assistance Services. a division of
First Choice Health Network, (hereinafter"First Choice Health Assistance Services" or"FCH AS'�,and City
of Kent(hereinafter"Company'
This Agreement will be effective on January 1, 2012, and will remain in effect until the first of the month
following 30 days advance written notice of cancellation by either party
WHEREAS, First Choice Health Assistance Services makes available to Company an Employee Assistance
Program(EAP),a Member Assistance Program(MAP),and/or a Physician Assistance Program(PAP),and
WHEREAS, Company desires to contract with First Choice Assistance Services for the purpose of providing
EAP/IvIAP/PAP services to covered Company employees and will be responsible for payment to FCH AS
for services provided to Company
NOW THEREFORE,the parties agree as follows:
I. FIRST CHOICE HEALTH ASSISTANCE SERVICES OBLIGATIONS
A. Services Included.
L Toll Free Phone Lines
The First Choice Health Assistance Services has toll free lines available to all employee families
24 hours a day seven days a week The lines are promptly answered and there is always a
counselor available to assist families in crisis or distress In emergency situations, the EAT will
utilize local resources such as police, fire or emergency mental health resource facilities to
stabilize the situation or provide ongoing emergent care
2. Typical Problems Addressed
The First Choice Assistance Services is a confidential resource located outside the workplace for
employees and their covered family members to utilize whenever they are experiencing a wide
range of concerns There is no charge to the employee or family member for any
EAP/MAP/PAP service The EAP/IvLAP/PAP is an employer-sponsored program. The
following list is representative of frequently-seen problems
Substance Abuse Marital Problems Parenting Issues Retirement
Work Conflict Anxiety&Stress Depression Financial Concerns
Gambling Issues Anger Control School Problems Eating Disorders
3. Assessment and Referral Service
a) Professional assessment and referral services will be provided to employees and their
nnmedtate family members (spouse,partner,children up to age 26) through the First Choice
Health Assistance Services Provider Network The goal of FCH AS will be to assess the
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presenting problem, solve that problem or conflict when possible, or develop a treatment
plan and assist the employee family in implementing that treatment plan in the community
Under the terms of this Agreement and based upon the specific program design purchased
by the Company and selected in Addendum A, each employee may utilize up to the number
of assessment and referral visits chosen by the Company with a licensed behavioral health
provider on a per condition basis every twelve months
b) Appointments will be offered in a geographic location that is near the employee family's
home or work and at a time of convenience to the employee Normally appointments are
available within 24-48 hours of the initial call requesting services In an emergent situation,
referral will be made immediately to community emergency services or other appropriate
care facility
c) Employees who do not show up for a scheduled appointment,or who cancel with less than
24-hours advance notice, Nvill have that appointment counted as one of their maximum
number of sessions allowed under this contract A cancellation that is cancelled by or
excused by the counselor will not be counted as one of the employee's allowable sessions
d) Exclusions Special evaluations such as those required by the Department of Transportation
and FAA with services provided by Substance Abuse Professionals (licensed providers who
specialize in chemical dependency evaluations and are required by the Department of
Transportation to conduct all assessments on employees in safety sensitive positions) are
usually paid by the employee and not covered by FCH AS In addition, the following
services are not covered unless pre-approved by FCH AS those required by court order or
as a condition of parole or probation, evaluation or diagnostic testing related to learning
disorders, developmental delays, and congenital and/or organic disorders, psychological or
IQ testing, services related to medication management or medication consultation with a
psychiatrist,fitness for duty evaluations, or services received from a non-network provider
4. Employee Orientation
Upon the request of the Company, First Choice Health Assistance Services will provide onsite
orientation classes lasting about 20 minutes for employees These presentations are normally
presented in parallel with the Supervisor Orientation Included will be a brief review of program
components and assurances of confidentiality A contracted number of Employee Orientations
are included at the primary Company location at no fee, as described in Addendum A Webinar
Orientations can be substituted for these onsite orientations Additional orientations or onsite
orientations provided at other locations would be provided at an additional hourly fee, portal to a
portal, in accordance with Addendum A Company may elect to utilize the free online Employee
Orientation on the First Choice Health EAP Internet site on an unlimited basis
5. Supervisor/Manager Orientation
It is recommended that a Supervisor/Manager Orientation be held in conjunction with the
Employee Orientation classes and be attended by all managers and supervisors A Supervisor
Manual will be distributed to all staff in a leadership position, a review of the EAP/MAP/PAP
program will be presented, and the referral process reviewed Methods of identifying and
approaching troubled employee will be discussed, as well as making mandatory referrals,
encouraging employees, and a variety of other topics A contracted number of Supervisor
Trainings are included at the primary Company location at no fee, as described in Addendum A
Additional orientations or onsite orientations provided at other locations would be provided at
an additional hourly fee, portal to portal, in accordance with Addendum A Company may elect
to utilize the free online Supervisor Orientation on the FCH AS Internet site on an unlimited
basis.
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6. Benefit/Wellness/Safety Fair Attendance
A contracted number of hours, as specified in Addendum A, may be included so that EAP can
attend an Open Enrollment meeting or a benefit/safety/wellness fair to increase visibility of the
EAP/MAP/PAP and distribute brochures and materials Additional hours are available at an
additional hourly fee,portal to portal,in accordance with Addendum A
7. Training
a) Online Premium Level Internet training is included under this contract The Company will
have unlimited access for supervisors and employees to Web site based training provided at
www firstchonceeap corn as part of services This training includes topics such as Harassment
Prevention,Workplace Diversity,Conflict Resolution,Drug Free Workplace and DOT level
supervisor and employee training
b) Onsite Training on a variety of subjects can be provided under this contract at an additional
hourly fee, portal to portal, in accordance with Addendum A The price of additional
trains ngs is negotiated in advance, and depends on the nature of the training and
customization requested by the Company A current list of available trainings is available on
the FCH AS website
S. Critical Incident Services
Debriefing, defusing, and educational services can be provided upon request to individuals,
teams, and company-wide related to workplace disruptions due to accidents, violence, criminal
activity, natural disasters, death, etc A contracted number of onsite Critical Incident/Trauma
Services are included each year, as specified in Addendum A The rate for additional hours is
$200 per hour,portal to portal
9. Promotional Materials
A variety of promotional materials will be provided to the Company for distribution to employee
families at the time of program initiation with additional supplies available on an annual basis
These materials will include
a) Letter of Introduction for each employee family.
b) EAP Referral Cards for each employee with a 20% additional supply for supervisors and
Human Resources to utilize in making referrals
e) Posters for each location,normally one per 50 employees
d) Program Pamphlets for each employee with 10%extra supply for Human Resources for use
with new employees
e) Web Site Promotion Handouts encouraging visits to the EAP website will be provided
f) Newsletters will be distributed electronically to the Company every month for distribution
to employees
10. Leadership Consultation
Managers, supervisors and Human Resources will be encouraged to contact the EAP for
consultation regarding any difficult work place problem or for assistance to identify and
approach troubled employees, discuss documentation, employee motivation and other concerns
that may be appropriate Unlimited telephonic management consultations are provided for
supervisors and managers in the Mandatory Referral process
11. Quality Assurance and Utilization Reporting
Utilization Reports will be prepared and sent to the Company on the following basis based on
Company size Quarterly for Companies with more than 100 employees, Semi-Annually for
Companies with 50 to 100 employees, and Annually for Companies with fewer than 50
employees Every employee who utilizes the EAP will be offered an opportunity to complete an
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Employee Evaluation of Service form This form will ask for their rating and comments regarding the
service they received from the EAT A summary of comments will be provided the company
12. Enhanced Services. (Optional)
If the Company selects the Enhanced Services plan, the WorlcLife Enhanced services will be
accessible to employees Thts includes
a) Web Content supplies content and including over 8,000 articles and fact sheets, personal
self-assessments, tools, and calculators 92 online training programs are offered offering
printable certificates of completion,monthly online seminars are delivered live and archived
for later listening, and a comprehensive Wellness Center and Relocation Center is available
There is a Spanish language site also available
b) Legal Consultation 24/7 access to assessment and referral services,providing a no-cost 30-
minute consultation with a legal professional by phone or in person,with a discounted rate
of 25% off their hourly rate for ongoing services Enhanced legal content includes over 100
legal forms Some exceptions apply,including no availability for work-related matters
c) Financial Services Consultation Financial counselors and educators to assist with budgeting,
debt management,bankruptcy prevention,credit issues,and similar financial issues
d) Eldercare Consultation and referral for assistance and referrals that assist employees and
their family members deal with the issues of supporting elderly parents or relatives
e) Childcare Consultation and referral for assistance and referrals that assist employees and
their family members with finding childcare and daycare and with issues such as adoption,
education(K-12,higher education,continuing education),and other parenting issues
f) ID Theft Prevention An interactive advocacy service that provides education, guidance,
support, and legal/financial assistance to victims of fraud related entries Toll-free,
telephonic,30-minute consultation with a Certified Consumer Credit Counselor is available
g) Work Life Program Promotion Posters and Handouts for the Enhanced EAP Services will j
be provided for distribution to all employees
14. Other Optional Services.
a) Wellness Coaching If Company purchases this package for a minimum one year
commitment, employees are eligible to receive wellness telephonic and internet coaching,
information, education, and referral services accessed through a toll-free number Wellness
coaches consult with employees on Weight Management, Smoking Cessation, Fitness and
Exercise, Nutrition, and Chronic Disease or conditions including asthma, diabetes,
cardiovascular disease,back pain,menopause,and pre-and post-natal issues Employees have
an intake and goal setting session followed by four 15-30 minute follow-up sessions, and
additional follow-up with personalized emails and coach-chosen materials Employees may
also choose online interactive programs for Weight Management (12 sessions), Smoking
Cessation (10 sessions),or Walking(90 days)
b) Health Risk Assessment If Company purchases this package for a minimum one year
commitment, employees may access an online confidential HRA tool that provides
statistically measurable, actionable information regarding the health status of the workplace
population as a whole This tool assists in developing an accurate assessment of Company's
employees' health and fitness, providing "before and after" data on wellness initiatives, and
can target particular health challenges within the workforce The HRA covers key health
issues including cancer risk, fitness, heart health, nutrition, safety, smoking, stress and
weight management
c) Nurse Line If Company purchases this package for a muvmum one year commitment,
employees may access a Registered Nurse through a toll-free number 24 hours a day, who
will provide clinical assessment of the callers' symptoms and provide health care
information, direct callers to the appropriate level of care or provide self-care instructions,
and provide general health education and care options
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B. Insurance.
First Choice Health Assistance Services will maintain liability insurance in the amount of
$1,000,000 00 In addition, First Choice Health Assistance Services requires that its Network
Providers (Licensed Mental Health Care Professionals) carry a minimum of $1,000,000 00 in
malpractice insurance with$3,000,000 00 Aggregate
C. Compliance.
First Choice Health Assistance Services, in carrying out its obligations under this Agreement, shall
comply with all applicable federal and state laws and regulations
D. Responsibility for ERISA Plan.
If you are offering the EAP benefits to your Employees under a Plan governed by the Employee
Retirement Income Security Act of 1974 as amended ("ERISA Plan', you have sole authority and
responsibility for the ERISA Plan and are solely responsible for complying with ERISA and any
related laws All final determinations as to a Participant's EAP eligibility and benefits are to be made
by you, including any determination upon appeal of a denied claim for EAP services Without
limiting your responsibilities,you have the sole duty and responsibility as to the ERISA Plan benefit
design, admanstenng the appeals process, the preparation and contents of any ERISA Plan,
Summary Plan Description,Trust Agreement, and any other documents required under ERISA and
related laws (collectively"ERISA Plan Documents"), and all amendments related theteto, including
the description of the EAP services in the ERISA Plan Documents You represent that the ERISA
Plan Documents are consistent with this Agreement You will provide us with all ERISA Plan
Documents prior to the commencement of services under this Agreement You shall be responsible
for printing, maintaining a supply of and distributing the Summary Plan Description and all other
information and forms necessary for Participants' enrollment and continued eligibility for services
under this Agreement and will provide us with copies of the ERISA Plan Documents and
Participant communications pertaining to the services provided under this Agreement prior to
distributing such materials to Participants or third parties You will amend ERISA Plan Documents
and Participant communications if we determine that references to us are not acceptable, or any
ERISA Plan or EAP provision is not consistent with this Agreement or the services that we are
providing We are not the Plan Admumtrator of the ERISA Plan
You will be solely responsible for ensuring compliance with COBRA, performing required
nondiscrimination testing, amending the ERISA Plan as required to ensure ongoing compliance
with applicable law and providing us copies of any such amendments prior to their adoption, filing
any required tax or governmental returns (including Form 5500 returns) relating to the ERISA Plan,
determining if and when a valid election change has occurred, executing and retaining required
ERISA Plan and claims documentation,and taking all other steps necessary to maintain and operate
the ERISA Plan in compliance with applicable provisions of the ERISA Plan, ERISA, and other
applicable state and federal laws
II. COMPANY'S OBLIGATIONS
A. Payment for Services.
The Company will make payments to First Choice Health Assistance Services in accordance with
Addendum A,attached to thus Contract
B. Group Enrollment Form.
The Company will provide to First Choice Health Assistance Services for each group enrolled a
completed Group Enrollment Form as set forth in Addendum B
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C. EAP Liaison.
The Company will assist First Choice Health Assistance Services in group implementation as
needed, and will act as a liaison between the EAP and all groups enrolled pursuant to this
Agreement
D. Compliance.
The Company,in carrying out its obligations under this Agreement, shall comply with all applicable
federal and state laws and regulations,provided that nothing in this Agreement shall be construed as
providing a type of medical benefit or service subject to the requirements of the Employee
Retirement Income Security Act of 1974(Pub L 93-406,Sept 2, 1974)
III. CONFIDENTIALITY OF HEALTH INFORMATION
The parties acknowledge that as a result of this agreement, either party may have access to and receive
from the other pasty individually identifiable health information ("Health Information's as that term is
defined under the Health Insurance Portability and Accountability Act of 1996, Section 1171 of Public
Law 104-191 ("HIPAA"), and Chapter 70 02 RCXV, the Washmgton State health Care Information
Access and Disclosure of 1991 Both parties agree to maintain the confidentiality of such Health
Information and to not use or disclose such Health Information other than as may be permitted or
required by federal or state law or regulations currently in effect,or becoming effective during the term
of this Agreement,including,but not lmuted to,the federal I IIPAA Privacy regulations
To the extent either party, in carrying out its responsibilities under this Agreement, conducts Standard
Transaction(s) as that term is defined under HIPAA, that party shall, without limitation, comply with
the HIPAA regulations, "Adna istratrve Requirements for Transactions,"45 CFR 162 200 et seq
IV. TERM AND TERMINATION
This Agreement will be effective on the date set forth on page one and will remain in effect until the
first of the month following 30 days advance written notice of cancellation by either party Upon
cancellation by either party,First Choice Health Assistance Services will continue to provide services to
the termination date of this agreement
V. INDEPENDENT CONTRACTOR STATUS
First Choice Health Assistance Services is an independent contractor and in no way should this
contract be construed to create an employer-employee relationship All payments made hereunder for
services performed shall be made to the First Choice Health Assistance Services as an independent
contractor
VI. ASSIGNABILITY
First Choice Health Assistance Services will not assign or transfer any interest in this contract without
written notice to the Company, PROVIDED HOWEVER that claims for money due or to become
due to First Choice Health Assistance Services under this contract may be assigned to a bank, trust
company or other financial institution without such approval
VII. DISPUTE RESOLUTION
In entering this agreement, it is assumed that a relationslp of cooperation and understanding will be
maintained between the parties However, in the event of any dispute, or disagreement over the terms
and conditions contained herein, such dispute will be settled through binding arbitration in accordance
with the rules of the American Arbitration Association,and judgment upon the award rendered by the
arbitrator(s) may be entered in any court having jurisdiction thereof Such arbitration shall occur within t
King County, Washington, unless the parties mutually agree to have such proceedings in some other
FCHFAP201 Itemplate 6
locale The arbitrator(s) may in any such proceeding award attorney's fees and costs to the prevailing
party
VIII.AMENDMENTS
Tlus agreement contains the full understanding of the parties and supersedes and cancels all prior
negotiations, correspondence or communication between the parties No oral modification to this
Agreement shall be effective however, this Agreement may be modified or amended by a written
signed agreement by both parties
IX. NOTICES
Any notice by the Company to First Choice Health Assistance Services, may be delivered by certified
or registered mail postage prepaid addressed to
First Choice Health Assistance Services
600 University Street,Suite 1400
Seattle,WA 98101
Notice by First Choice Health Assistance Services to the Company may be delivered by certified or
registered mail postage pre-paid, addressed to the group at the address designated by the Company via
written notice
X. GOVERNING LAW
This agreement is made pursuant to and shall be construed in accordance with the laws of the State of
Washington
IN WITNESS WHEREOF,the parties hereto have executed this agreement on the date indicated above.
FIRST CHOICE HEALTH City of Kent
ASSISTANCE
��SERVICES
B �^"`( B
Y Y
David Mitche
Director,EAP Services
Date a`V /o--
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ADDENDUM A
PRICING
GROUP RATE QUOTE FOR EAP SERVICES—Please Select one option.
Rates are Guaranteed for 24 Months First Choice EAP
Basic EAP Services
Includes- Up to Three Visit Model
• 24/7 toll-free phone coverage
• Employee and family assessment and referral
services
• Internet Training services
• Promotional Materials Up to Six Visit Model
• Leadership Consultation and Mandatory Referrals
Enhanced EAP Services
Includes all Basic Services plus: Up to Three Visit Model X $1.96 pepm
• Elder Care Consultation
• Child Care/Daycare Consultation
• Financial Services
• ID Theft Prevention o Up to Six Visit Model
• Legal Consultation and 25/a Discount in attorney's
normal hourly fees
Utilization Reports Included
Critical Incident Debriefing 6 Hours Included each year, $200/hr after
Employee Orientations—Onsite or Webinar 10 20-minute orientations Included each
year, $1501hr after
Supervisor/Manager Orientation and 4 60-minute orientations Included each year,
Included Services: Leadership Training—Onsite or Webmar $150/hr after
Unlimited Online Harassment,Violence
Other Trainings Prevention, Diversity, Conflict Resolution,
and Drug Free Workplace Trainings
Onsite trainin s$175-$350/hr
Optional Services:
Wellness Coaching $1 25 pepm with a 12 month commitment
HRA Appraisal $0 20 pepm with a 12 month commitment
Nurse Line $0 80 pepm with a 12 month commitment
This quote is based upon approximately 831 employees
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ADDENDUM B
GROUP ENROLLMENT FORM
Please provide the following information at the time of contract signing:
Group Name
or Company Name 1'T`T b F
Contact Name. t4C k EOLQL
Contact Title I.,-rrzk
Telephone Number: as _ S5LP Ga90
Fax Number.
E-mail Address
Web Address: V{tt4T-UJPr-
Mailing Address: Qo
c 4 t BOA
Billing Address
d different
Broker Name -�6u S (�L tU faiA:`b ! IV C,,rf applicable)
Broker Contact Info. (if
applicable)
Does your company have an Intranet? Yes-ly No ❑
If so,would you like us to develop a Splash Page Yes)CNo ❑
to link your employees to our Web Site,at no additional cost?
May we list your company as a new group in our Newsletter? Yes ❑ No pC
Would you like us to send you a co-branded newsletter with your logo? Yes )C No ❑
(if so,please email us a current version of your logo with permission to use it to promote EAP services)
Our goal at First Choice Health EAP is to always"Make the Right Referral the First Time" Please assist us in this effort by
providing the name of your specific Insurance Plans or Carriers for Mental Health Services,your limits for outpatient services,
and any other information that will assist us in arranging the best care for your employee families Please, be as specific as
possible (PPO, HMO, Access, Advantage Choice, etc) We will use this information to select a community provider who is
covered under your health benefit plan,and will not release this information other than to a Network Treatment Provider
Name of specific Insurance Plan(s) PiR'E l Eit u�, LRDSS ILLP P�
Is a special Yes)4 Name
network used No fj
Is your plan Yes ❑ By whom(please add the
managed? No V telephone number used for the
approval of authorizations
You will be assigned a Username and Password for your employees to use for access to all areas of our
website If you have specific Username and Password you would like to have used simply contact our office and
we will arrange for a change in those previously assigned
Thank you very much.
This information will be of great help in initiating your EAP Service and in serving your employees.
FCHEAP2011 template 9
Addendum to First Choice Health EAP Contract
Responsibility for ERISA Plan. If you are offering the EAP benefits to your
Employees under a Plan governed by the Employee Retirement Income Security Act of
1974 as amended ("ERISA Plan"), you have sole authority and responsibility for the
ERISA Plan and are solely responsible for complying with ERISA and any related laws.
All final determinations as to a Participant's EAP eligibility and benefits are to be made
by you, including any determination upon appeal of a denied claim for EAP services
Without limiting your responsibilities, you have the sole duty and responsibility as to the
ERISA Plan benefit design, administering the appeals process, the preparation and
contents of any ERISA Plan, Summary Plan Description, Trust Agreement, and any
other documents required under ERISA and related laws (collectively "ERISA Plan
Documents"), and all amendments related thereto, including the description of the EAP
services in the ERISA Plan Documents You represent that the ERISA Plan Documents
are consistent with this Agreement You will provide us with all ERISA Plan Documents
prior to the commencement of services under this Agreement You shall be responsible
for printing, maintaining a supply of and distributing the Summary Plan Description and
all other information and forms necessary for Participants' enrollment and continued
eligibility for services under this Agreement and will provide us with copies of the ERISA
Plan Documents and Participant communications pertaining to the services provided
under this Agreement prior to distributing such materials to Participants or third parties
You will amend ERISA Plan Documents and Participant communications if we determine
that references to us are not acceptable, or any ERISA Plan or EAP provision is not
consistent with this Agreement or the services that we are providing We are not the
Plan Administrator of the ERISA Plan
You will be solely responsible for ensuring compliance with COBRA, performing
required nondiscrimination testing, amending the ERISA Plan as required to ensure
ongoing compliance with applicable law and providing us copies of any such
amendments prior to their adoption, filing any required tax or governmental returns
(including Form 5500 returns) relating to the ERISA Plan, determining if and when a
valid election change has occurred, executing and retaining required ERISA Plan and
claims documentation, and taking all other steps necessary to maintain and operate the
ERISA Plan in compliance with applicable provisions of the ERISA Plan, ERISA, and
other applicable state and federal laws
r ,
GROUP HEALTH COOPERATIVE
ANNUAL DEDUCTIBLE
CONTRACT REVISIONS
Effective January 1, 2012
(Created 04/29/11)
This is the most current list of revisions, but this list is subject to change at any time.
CONTRACT
LANGUAGE/BENEFIT CHANGE EXPLANATION
Accessing Care A clarification has been made throughout the document to replace references
to"referral"with"authorization"for consistency in terminology Terms such
as self-referral and preauthorization have either been removed or replaced as
well
A clarification has been added to enhance the description of a second opinion.
t
Allowances Schedule A new provision has been added to state that newborn services are covered the
same as for any other condition Any applicable cost share for newborn
services is separate from that of the mother
The optical services provision has been revised to state that eye examinations
for eye pathology,including contact lens exams are covered Lenses for eye
pathology are now covered.
A clarification has been added to the tobacco cessation provision to state that
individual/group counseling is covered.
Enrollment and Eligibility The special enrollment provision for eligibility for medical assistance has been
re),ised in accordance with state regulations to reflect that the request for
enrollment must be made within 60 days An additional provision was added
to address termination of coverage under Medicaid or CHIP,and the
requirement for application within 60 days 4
Medical and Surgical Care Benefit provisions in Section IV have been clarified to include pertinent
exclusions from Section V
The optical services provision has been revised to state that eye examinations
for eye pathology,including contact lens exams are covered Lenses for eye
pathology are now covered.
Exclusions Exclusion provisions in Section V have been moved to the pertinent benefit
provisions in Section IV,and the remaining exclusions listed in Section V.
have been re-arranged
Miscellaneous Provisions A provision on utilization management of covered services has been added for
clarification purposes
Definitions A definition for authorization has been added to replace the definition for
referral
GHC AD(04/29111) 1
400 REQUEST FOR MAYOR'S SIGNATURE
KENT Please Fill In All Applicable Boxes
WASHINGTON
Routing Information (ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT)
Originator: L Phone (Originator): X a( jQ
Date Sent: Date Required. A-as-la,
Return Signed Document to: CONTRACT TERMINATION DATE: N
VENDOR NAME: ( tTC�p1en DATE OF COUNCIL APPROVAL:
Brief Explanation of Document:
a v I a F t.(zcT C-4,401 Cx We-P-UTH O-a N7?E-A C74
All Contracts Must Be Routed Through the Law Department
(This Area to be Completed By the Law Department)
Received: RECENED r
Approval of City Attorney: FEB
City Attorney Comments:
Date Forwarded to Mayor: .s 240)
Shaded Areas to Be Completed by Administration Staff1iF`D �f
Received: - 4
Recommendations & Comments:
<L
'Disposition_ s 12 --
-Date Returneda
Iage5870 • 2/04