HomeMy WebLinkAboutCAG1994-0041 - Other - Group Health Cooperative - Revisions to Group Medical Coverage Agreement - 06/02/1994 p
Health 1730 Minor Avenue
*G'ou
4750
Coo erative SeaP.O Box ashin i7 Seattle,Washington 98124-1750
of Puget Sound
June 2, 1994
MR DOUG EVANS
R L EVANS COMPANY INC
600 STEWART STREET SUITE 1210
SEATTLE WA 98101
Dear Mr. Evans:
Enclosed are three copies of the 1994 Group Health medical coverage agreement for City of Kent, #0369.
One copy must be signed by the person who represents City of Kent,#0369 and returned to us within three weeks.
The second copy is for your records, and the third copy is for City of Kent, #0369's records.
The agreement includes changes we've made that reflect enhancements to the plan. Certain words,paragraphs or
sections of this contract have been bolded and italicized. This identifies changes Group Health Cooperative has
made to the plan. We've also corrected or clarified language so it more accurately reflects our current administrative
or care delivery practices. The following changes have been made and can be found in the referenced sections:
• Re-rating of Group and failure to cancel Section II.
appointments
• Termination provisions Section III.B.3.
• Coordination of Benefits provisions Section V.
• Miscellaneous provisions Section VIII.E.
• Medical and Surgical Care- Optical Section X.B.3.
• Temporomandibular Joint (TMJ) Section X.B.12.
services
• Prescription Drug clarification Section X.F.
• Mental Health Care services Section X.H.
• Pre-Existing Conditions Section XI.A.12.
• Insurance Coverage Exclusion Section XI.A.18.
• Medical and Surgical Care See Copayments and Allowances Schedule
• Smoking Cessation See Copayments and Allowances Schedule
In addition, other benefit or contract provisions that you or Group Health might have requested or negotiated
during the contract renewal process are included in the enclosed contract.
The dues schedule, which is part of the medical coverage agreement, confirms the dues increases specified in a
previous letter which the group has accepted.
If you have any questions about this information or your new contract,please call your Marketing account executive:
Seattle 448-4140 or toll free in WA 1-800-542-6312
Tacoma 383-6226
Kitsap County 479-6241
Whatcom/Skagit County 647-7222 or toll free in WA 1-800-552-4330
We appreciate your business.
Sincerely,
Sharon Loveless
Contract Administration
cc: Marketing
Enclosure
CCN3
GROUP HEALTH COOPERATIVE OF PUGET SOUND
CONTRACT REVISIONS
Effective 1/1/94
CONTRACT
LANGUAGE/ EXPLANATION
BENEFIT CHANGE
Table of Contents The Dues&Fees Schedule(as it pertains to the Schedule of allowances
considered part of the contract)has been renamed the Allowances,
Deductibles,Copayments,and Fees Schedule. All applicable references to
the Dues&Fees Schedule have been changed in the group medical coverage
agreement to the Allowances,Deductibles,Co a ments,and Fees Schedule.
Acquisition/Merger This is a new provision in the basic contract regarding group mergers and
acquisitions which may cause an increase in enrollment. The provision states
that:
In the event the group increases enrollment at least twenty-five percent(25%)
or more through acquisition or merger,GHC reserves the right to require re-
rating of the group. (see Section II.A.)
Billing Fee This is a clarification in the basic contract:
Failure to pay for services at the time of service may result in a billing
fee. Failure to cancel a scheduled appointment at least 24 hours prior to
the appointment may result in a billing fee or the value of the service.
(see Section II.B.)
Misrepresentation This is a clarification in the basic contract. The provision states that:
Misrepresentation to Obtain Insurance. Group Heai�_z Cooperative may
rescind or terminate this Agreement upon written notice in the event of
material misrepresentation,fraud,or omission of information in order to
obtain group coverage. (see Section III.A.3.)
Termination of Specific In response to the Washington State Healthcare Reform Act,the following
Enrollees provision has been added:
In no event will an Enrollee be terminated solely on the basis of their
physical or mental condition provided they meet all other eligibility
requirements set forth in this Agreement (see Section III.B.3.)
Comp wo mh/pec
02/07/94
COBRA There are several clarifications to the basic contract. These provisions state
that:
In the event the group has retirees,the Subscriber who is a retiree or the
spouse or Dependent of a retiree,may continue coverage hereunder if the
Subscriber and/or Family Dependent would otherwise lose coverage
hereunder within one year of the date a proceeding under Title 11 of the
United States Code is commenced with respect to the Group. (see Section
IV.A.4.).
Where the Subscriber becomes entitled to Medicare,the period of
continuation coverage for Family Dependents as a result of the Subscriber's
Medicare entitlement or any later event...shall extend up to a maximum of
thirty-six(36)months from the date the Subscriber becomes entitled to
Medicare. This provision did read: Where the Subscriber becomes entitled
to Medicare, the period of continuation coverage...shall extend up to a
maximum of thirty-six(36)months from the earlier of the date the Subscriber
becomes entitled to Medicare or the initial qualifying event as set forth(in
subsection 2)above. (see Section IV.A.S.)
Coordination of Benefits In response to the Washington State Healthcare Reform Act,the following
clarification has been added:
"...GHC may recover the reasonable cash value of services provided under
this Agreement so that benefits and services under all plans do not exceed
100%of allowable expenses(except copayments,coinsurances and
deductibles)as fully set forth in this section." (see Section V.)
In determining liability under this section,the Plan is not required and
will not take into consideration,deductibles,copayments,or other cost-
sharing rovisions. see Section V.H.2.,last sentence)
Miscellaneous Provisions This is a new provision in the basic contract:
No oral statement of any person shall modify or otherwise affect the benefits,
limitations and exclusions of this Agreement,convey or void any coverage,
increase or reduce any benefits under this Agreement or be used in the
prosecution or defense of a claim under this Agreement. (see Section
VIII.E., last paragraph)
Optical Care This is a clarification ir,the 5asic contract:
Evaluations and surgical procedures to correct refractions which are not
related to eye pathology are not covered. Complications related to such
surgery is also excluded. (see Section X.B.3.).
Transplants This is a clarification in the basic contract:
Donor costs for a covered organ recipient are covered,limited to
procurement center fees,travel costs for a surgical team,excision fees,and
matching tests. (see Section X.B.,third paragraph)
Except for children who have been continuously enrolled at GHC since birth,
coverage for all transplants and any related services...shall be excluded until
such time as the Enrollee has been continuously enrolled under this
Agreement,or any prior GHC Medical Coverage Agreement,for twelve(12)
consecutive months without any lapse in coverage,unless the Enrollee
requires a transplant as the result of a condition which had a sudden
unexpected onset after the Enrollee's effective date of coverage. (see
Section X.B.,fourth paragraph)
Comp wo mh/pec
02/07/94
Temp oromandibular This is a clarification in the basic contract:
Joint(TMJ)Care Medical and surgical services and related hospital charges,including
orthognathic(jaw)surgery for the treatment of temporomandibular joint
(TMJ)disorders,are covered as set forth in the Allowances,Deductibles,
Copayments,and Fees Schedule when determined to be Medically
Necessary and referred in advance by GHC...Orthognathic(jaw)surgery,
radiology services and TMJ specialist services,including
fittingladjustment of splints,is subject to the benefit limit set forth in the
Allowances,Deductibles,Copayments and Fees Schedule.
The following services,including related hospitalizations,are excluded
regardless of origin or cause: orthognathic(jaw)surgery in the absence
of a TMJ diagnosis,treatment for cosmetic purposes,and all dental
services(except as noted above),including orthodontic therapy. (see
Section X.B.)
External Breast This is a clarification and benefit change in the basic contract:
Prostheses For women who have not undergone breast reconstruction,external
breast prostheses following mastectomy and post-mastectomy bras limited to
one external breast prosthesis per diseased breast every two years,and two
post-mastectomy bras every six months,up to four in any twelve consecutive
month period. Coverage for post-mastectomy bras is subject to the
Coinsurance as set forth in the Allowances,Deductibles,Copayments and
Fees Schedule. (see Section X.D.3.)
See level of coverage change under"Allowances,Deductibles,
Copayments and Fees Schedule".
Drugs and Medicines for This is a clarification in the basic contract:
Outpatient Use The Enrollee will be charged for mailing drugs,medicines or devices,and
replacing lost or stolen drugs, medicines or devices. (see Section X.F.)
Comp wo mh/pec
02/07/94
First Party Coverage This is a clarification in the basic contract:
Exclusion Any services to the extent benefits are available to the Enrollee under the
terms of any vehicle,homeowner's,property or other insurance policy,
except for individual or group health insurance, whether the Enrollee asserts
a claim or not,pursuant to:(1)medical coverage, medical "no fault"
coverage,Personal Injury Protection coverage,or similar medical coverage
contained in said policy;and/or(2)uninsured motorist or underinsured
motorist coverage contianed in said policy. For the purpose of this
exclusion,benefits shall be deemed to be"available"to the Enrollee if the
Enrollee is a named insured,comes within the policy definition of insured,is
a third-party donee beneficiary under the terms of the policy,or otherwise
has the right to receive benefits under the policy.
The Enrollee and his or her agent smust cooperative fully with GHC in its
efforts to enforce this exclusion. This cooperation shall include supplying
GHC with information about any available insurance coverage. The
Enrollee and his or her agents shall permit GHC,at GHC's option,to
associated with the Enrollee or to intervene in any action filed against any
party related to the injury. The Enrollee and his or her agents shall do
nothing to prejudice GHC's right to enforce this exclusion.
GHC shall not enforce this exclusion as to coverage available under
uninsured motorist or underinsured motorist coverage until the Enrollee has
been made whole,unless the Enrollee fails to cooperate fully with GHC as
described above. In the event the Enrollee fails to cooperate fully,the
Enrollee shall be responsible for reimbursing GHC for such medical
expenses.
GHC shall not pay any attorneys'fees or collection costs to attorneys
representing the injured person where it has retained its own legal counsel or
acts on its own behalf to represent its interests and unless there is a written
fee agreement signed by GHC prior to any collection efforts. (see Section
M.A.).
Allowances,Deductibles,
Copayments and Fees
Schedule
• Post Mastectomy Post-mastectomy bras remain covered at a 50%coinsurance;however,
Bras external breast prostheses are now covered at 100%.
Comp wo mh/pec
02/07/94
Enrollment and This schedule has been modified to to include the following:
Eligibility Schedule
Subscribers and Family Dependents must reside in the GHC Service
Area(as defined in Section I.)in order to be eligible for enrollment
under this Agreement,except for temporary residency outside the
Service Area for purposes of attending school,court-ordered coverage
for Dependents,or when approved in advance by GHC,other unique
family arrangements. All non-urgent/emergent care must be provided
at GHC Facilities or GHC Designated Facilities. (see Section IX.B.
heading).
"Children" means the children of the Subscriber including adopted children,
stepchildren,foster children,children for whom the Subscriber has a
court order to provide coverage,and any other children for whom the
Subscriber is the legal guardian. (see Section IX.B.2.).
While on a group approved leave of absence the Subscriber and listed
Dependents can continue to be covered under this Agreement provided they
remain eligible for coverage,such leave is in compliance with the
employer's established leave of absence policy consistently applied to all
employees,the employer's leave policy is in compliance with the Family
and Medical Leave Act when applicable,and the employer or Group
continues to remit dues for the Subscriber and Dependents to the
Cooperative. see Section IX.C.).
Miscellaneous All standard contract revisions for 1994 will be bolded and italicized in both
Information the Group Medical Coverage Agreement and the Certificate of Coverage.
Comp wo mh/pec
02/07/94