HomeMy WebLinkAboutCAG1995-0042 - Supplement - Group Health Cooperative - Group Medical Coverage Agreement - 04/27/1995 Grou441730 Minor Avenue
Ci00^pIV@ P.O.Box 34750
Of Puget Sound Seattle,Washington 98124 1750
April 27, 1995
MR DOUG EVANS
R L EVANS COMPANY INC
600 STEWART STREET SUITE 1210
SEATTLE WA 98101
Dear Mr.Evans:
Enclosed are two copies of the 1995 Group Health medical coverage agreement for City of Kent, #0369. One
copy is for your records, and the other copy is for City of Kent, #0369's records. Please note that we have in-
cluded an extra signature page that must be signed by the person who represents City of Kent, #0369 and
returned to us within three weeks.
The agreement includes changes we've made that reflect enhancements to the plan. Certain words,paragraphs,
and 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 ad-
ministrative or care delivery practices. These changes can be found on the attached CONTRACT REVISIONS.
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 medical coverage agreement.
The dues schedule,which is part of the medical coverage agreement, confirms the dues 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
Whatcom/Skagit County 647-7222 or toll free in WA 1-800-552-4330
We appreciate your business.
Sincerely,
Sharon Oliver
Contract Administration
cc: Marketing
Enclosure
CCN2
GROUP HEALTH COOPERATIVE OF PUGET SOUND
CONTRACT REVISIONS
Effective 1/1/95
CONTRACT
LANGUAGE/ EXPLANATION
BENEFIT CHANGE
Enrollee Definition The term"Enrollee" has been revised to"Member"throughout the Group
Medical Coverage Agreement and Certificate of Coverage. According to a
recent survey completed by GHC,persons receiving care from GHC prefer to
be called"Member" rather than"Enrollee" (see Section I.).
Health Evaluation This is a clarification in the basic contract because of Health Care Reform:
Definition Review of the applicant's or other eligible persons medical history to
determine whether such person is subject to a Pre-existing Condition
waiting period as defined under this Group Medical Coverage Agreement
see Section I.).
Pre-existing Condition The definition of"Pre-existing Condition"has been revised to replace the
Definition reference to"12 monthperiod" with"3 monthperiod" (see Section I.).
Service Area Definition The definition of Service Area has been revised to include Island,Lewis and
San Juan Counties see Section I.).
Fees This is a clarification in the basic contract:
Failure to cancel a scheduled appointment at least 24 hours prior to the
appointment may result in a billing for the value of the service(see Section
II.B.).
Termination on Notice In response to the Washington State Healthcare Reform Act,the following
provision has been replaced as follows:
"This is a guaranteed renewable contract and cannot be terminated without
the mutual approval of each of the parties except as set forth below
(Subsection 2.and 3.)." (see Section III.A.1.
Subrogation This is a clarification in the basic contract: GHC shall be subrogated to and
may enforce all rights of the injured person to the extent of its medical
expense. GHC's right of subrogation shall be limited to the excess of the
amount required to fully compensate the injured person for the loss
sustained. Full compensation shall be measured on an objective,case-
by-case basis,but is subject to a presumption that a settlement which
does not exhaust the third party's reachable assets is full compensation
to the injured person. If the Member fails to cooperate fully with GHC in
recovery of medical expenses as described above,the Member shall be
responsible for reimbursing GHC for such medical expenses(see Section
VI.).
Grievance Procedures/ This is a clarification in the basic contract due to the name change of the
Investigational or Consumer Relations Department. This department is now referred to as the
Experimental Treatment "Member Services De artment" (see Section VII.and XI.A.10.).
Miscellaneous Provisions This is a new provision in the basic contract: The medical coverage
agreement is entered into and governed by the laws of Washington State.
(See Section VIII.)
Comp
04/12/95
CONTRACT
LANGUAGE/ EXPLANATION
BENEFIT CHANGE
Enrollment and This is a clarification in the basic contract: "Enrollment may be extended
Eligibility Schedule past the limiting age...if the Dependent is totally incapable of self-sustaining
employment...Enrollment for such a dependent child may be continued for
the duration of continuous total incapacity..." (see Section IX.B.2.c.ii.).
Hospital Care The exclusion of"Personal comfort items, such as telephone and television"
has been deleted,as these services are now covered.
This is a revision to the basic contract requested by the Office of the
Insurance Commissioner:
"As-a cost-effective alternative to hospitalization or other institutional care
which is covered by this Agreement,skilled home health services or skilled
nursing facility services will be covered when a determination is made in
advance by a GHC physician that such care is appropriate based on the
patient's medical condition.See Section X.G.Skilled Home Health Care
Services and Section X.K.Hospice."(see Section X.A.)
Legend(Prescription) Coverage of off-label use of FDA-approved drugs provided they are
Drugs prescribed by GHC for conditions covered by the contract and are listed in
the Drug Formulary has been added as requested by the Office of the
Insurance Commissioner(See Section X.F.)
Certificate of Coverage This document now contains a more detailed description of the benefits
available to those Members that are Medicare-eligible and still covered under
a group contract(see benefit grid at end of Allowances,Deductibles,
Copayments,and Fees Schedule). We have also changed the name of
Customer Service to Business and Insurance Services.
Comp
04/12/95