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HomeMy WebLinkAboutResolutions - 2007.07.19 - 28435MISCELLANEOUS RESOLUTION #07167 MISCELLANEOUS ORDINANCE #29 July 19,2007 RESOLUTION #07XXX BY: Finance Committee, Mike Rogers, Chairperson IN RE: AN AMENDMENT TO ORDINANCE NO. 27, AN ORDINANCE TO CONFIRM AND RESTATE OAKLAND COUNTY'S EXISTING CONTRACTUAL OBLIGATIONS TO PROVIDE FOR MEDICAL BENEFITS FOR CERTAIN RETIRED COUNTY EMPLOYEES AND THEIR ELIGIBLE DEPENDENTS TO THE OAKLAND COUNTY BOARD OF COMMISSIONERS Chairperson, Ladies and Gentlemen: THE COUNTY OF OAKLAND ORDAINS: Section 1. Amendment to Section 4 of Ordinance No. 27. Section 4 of Ordinance No. 27, adopted by the Oakland County Board of Commissioners on June 14, 2007, is hereby amended to read in its entirety as follows: "Section 4. Confirming existing contractual obligations for retiree medical benefits. A. The County Board of Commissioners hereby confirms, reaffirms and restates the County's existing contractual obligations to provide retiree medical benefits to eligible retired and active County employees and their dependents, and acknowledges and agrees that these are binding contractual obligations of the County to eligible retired and active County employees and their dependents that future County Boards of Commissioners cannot repudiate. B. The retired and the currently active County employees who are eligible to receive County-provided retiree medical benefits are described in Exhibit B at the end (and hereby made a part) of this ordinance. They perform their side of the County's contractual commitments to provide retiree medical benefits to them and their dependents by providing their services to the County as its employees and by meeting the applicable age and length-of-service criteria described in Exhibit B. FINANCE COMMITTEE Motion carried unanimously on a roll call vote with Potter. - and Coulter absent. C. The scope of benefits currently included in the County's retiree medial benefits program ("RMB Program") is summarized in Exhibits C, D and E at the end (and hereby made a part) of this ordinance. In addition, the County is obligated to pay the Medicare Part B premiums for certain designated groups of retirees. Such scope of benefits shall continue to be the core package of retiree medical benefits in the RMB program that will be provided by the County for eligible current and future retirees in fulfillment of its existing, binding, contractual obligations which are confirmed, reaffirmed and restated in this ordinance; provided, that the County has the right, subject to and strictly limited to the extent of any conflicting collective bargaining agreement obligation, to reasonably modify from time to time the RMB program, taking into account then prevailing customs and standards for governmental employers reasonably comparable to the County: (1) with respect to the amounts retirees may have to contribute to the costs of their and their dependents' coverage (for example and without limitation, co-pays and deductibles) and the scope of coverage and range of benefits provided, as appropriate to comport with evolving changes in medical research, technology, drug development, the practice of medicine, health care delivery and the costs thereof (for example and without limitation, if developments in medical treatment and technology allow for replacing certain services and treatments that are currently provided with different services and treatments that are better suited to achieve the intended clinical results), but not modifications tantamount to providing less than an appropriate core package of retiree medical benefits, and (2) to introduce programs designed to help participants in the RMB program better maintain their health, encourage preventive care and better control and manage chronic conditions; and provided, further, that any modifications by the County to the RMB program's scope of coverage shall maintain a level of coverage after their implementation reasonably comparable to the level of coverage immediately prior to their implementation. (2) There is added as Exhibit E to (and hereby made a part of) Ordinance No. 27 the Blue Cross Blue Shield of Michigan booklet entitled "Vision Care Group Benefit Certificate Series A80" (identified on its back cover as "Bureau Approved 9/95") which is at the end (and hereby made a part) of this amendatory ordinance. 2 D. Notwithstanding anything to the contrary in this ordinance, in the event that any other health care benefits plan, program or arrangement becomes effective which, at no further expense to the County and with no lapse in coverage for any retirees or their dependents, incontrovertibly provides comparable or superior retiree medical benefits coverage in any respect to the persons then covered under the County's RMB program, the County's existing, binding, contractual obligations which are confirmed, reaffirmed and restated in this ordinance may be satisfied to that extent, in whole or in part, by such other retiree medical benefits provided by such other plan, program or arrangement." Section 2. Severability. If any provision of this ordinance is held invalid, the invalidity does not affect other provisions that can be given effect without the invalid provision. Section 3. Effective Date. This ordinance shall become effective upon adoption by the Board of Commissioners and approval by the County Executive. Chairperson, on behalf of the Finance Committee, I move the adoption of the foregoing Ordinance. FINANCE COMMITTEE *x/(4 lassl -oevb5a 3 A roll call vote on the foregoing Ordinance was then taken, and was as follows: YES: NO: ABSTAIN: The Ordinance was declared adopted. STATE OF MICHIGAN ) )ss. COUNTY OF OAKLAND ) CERTIFICATION The undersigned, being the Clerk of the County of Oakland, hereby certifies that the foregoing is a true and complete copy of an Ordinance duly adopted by the County of Oakland Board of Commissioners at its meeting held on the day of , 2007, at which meeting a quorum was present and remained throughout and that an original thereof is on file in the records of the County. I further certify that the meeting was conducted, and public notice thereof was given, pursuant to and in full compliance with Act No. 267, Public Acts of Michigan, 1976, as amended, and that minutes of such meeting were kept and will be or have been made available as required thereby. COUNTY CLERK DATED: , 2007 Lass11-ocvb5a 4 EXHIBIT B This Exhibit B describes the criteria for retired and currently active Oakland County employees (whether retired or active, each called "Employee" below) to be eligible to receive County-provided retiree medical benefits as of the effective date of the ordinance of which this exhibit is a part ("Effective Date"). 1. On the Effective Date, the Employee must be eligible for a pension benefit under the Oakland County Retirement System upon his or her retirement or separation from service. 2. On the Effective Date, if Employee was hired by the County before September 21, 1985, the County pays the entire cost of Employee's retiree medical benefits coverage. 3. On the Effective Date, if Employee was hired by the County on or after September 21, 1985, but no later than December 31, 1994, Employee is eligible for the package of retiree medical benefits offered, but under the following payment scheme: Total Service with the County Paid Health Care Cnverar Direct Retirement Less than 8 years 8-14 years None Single Person, though retiree has option to pay the difference for family coverage. 15 years or more Family coverage Deferred Retirement Less than 15 years None 15-19 years Single Person, though retiree has option to pay the difference for family coverage. 20 years of more Family coverage 4. On the Effective Date, if Employee was hired on or after January 1, 1995, but not later than December 31, 2005 (though these dates may vary by bargaining unit), Employee is eligible for the package of retiree medical benefits offered, but under the following payment scheme: Total Service with the County Paid Less than 15 years No coverage 15 years 60% paid coverage 16 years 64% paid coverage 17 years 68% paid coverage 18 years 72% paid coverage 19 years 76% paid coverage 20 years 80% paid coverage 21 years 84°/0 paid coverage 22 years 88% paid coverage 23 years 92% paid coverage 24 years 96% paid coverage 25 years or more 100% paid coverage 5. On the Effective Date, any employee who was hired by the County on or after January 1, 2006, is not eligible for any retiree medical benefits under the County's contractual obligations which are confirmed, reaffirmed and restated in this ordinance (although he or she may be eligible for certain post-employment health care benefits under what is commonly called a "defined contribution" plan, which is outside the scope of this ordinance). EXHIBIT C [See Attached Medical Chart] 7 , MEDICAL OPTIONS COMPARISON RETIREE (NON-MEDICARE) Important Note: The information contained on this comparison is intended to be an easy-to-read summary to help you and your family make a choice among the different options available to you. Be sure to carefully study each option before making your choice. This comparison summarizes some of the provisions and certain features of each plan. It cannot modify or affect the coverage or benefits provided in any way. No right will accrue to you and/or your eligible dependents because of any statement, error, or omission from this comparison. Its provisions do not constitute amendments, modifications, or changes in any existing contract. . - vailablt to alt Retirett vallable tall AvailsOle M Retit06 liiritYnriot ' '--N,Kiallahleli) till tfiree -Alai to Ali REtiree.1% ' .0 irri97 - :., -- • . :,: h ealth ."44: 0 it 1124 1 - . , g BlIWCrOi§/1114 •,: ittO SS _re_ .01:re IWChfll e. ,. BENEFITS ' raditioifil a r •, „. .....„ . lei&-otn •Ohe,n5s .. ... — (Beill a ott,, 0 . s Hospital aritfMedical/Sirrggca w , e. erg WC 14,41a .1*. diei 1 ital 1/Y14541.1SI*41 Paipto Seryike Master MeciicaIiMJ1) Plan a-sieriAia ; - . . _ : INPATIENTIIOSPITAL.CARE - : .::: General Conditions 120 days, 60-day renewal ; 80% after deductible 120 days, 60-day renewal; Covered Covered • Semi-Private Room additional days under MM with additional days under MM with • Drugs not deductible, co-pays no deductible, co-pay 0 Intensive Care Unit # Meals • Hospital Equipment # Special Diets • Nursing Care OUTPATIENT HOSPITAL CARE . . ' •: . Emergency Room • Accidental Injuries Covered 80% after deductible Covered Covered, $25 Co-pay Covered; $25 Co-pay • Medical Emer encies Covered for approved dia. nosis 80% after deductible Covered Covered, $25 Co-pay Covered; $25 Co-pay Physical Therapy 60 consecutive days per 80% after deductible 60 consecutive days per Covered 60 visits per condition 60 Visits per condition condition; additional days under condition; additional days under Per life time MM; 90% after deductible MIVI 90% after the deductible ...r • MENTAU HEAL,TH CARE .. . .... r — Inpatient Mental Health Care 30 days, 60 day renewal; 80% after deductible 30 days, 60-day renewal; r—Covered up to 30 days per 45 days, 60-day renewal additional days under MM; 75% additional days under MM; 75% calendar year after deductible after deductible --I Inpatient Substance Abuse Unused mental health care days( 80% after deductible Unused mental health care days Covered up to 30 days per 45 days, 60-day renewal Care no MM benefits) Am MM benefits) calendar year Outpatient Mental Health Care 75% under MM after deductible 0% after deductible 75% under MM after deductible Covered; $20 Co-Pay, up to 50 20 visits/calendar year visits per calendar year. $20 Co-pay ,Outpatient Substance Abuse Covered up to the state Covered up to the state- Covered up to the state- Covered up to the state- 35 visits/calendar year or Cart mandated level mandated level mandated level mandated level; $20 Co-pay per state-mandated level; $20 co- visit Pay _ , SPECIAL HOSPITAL PROGRAMS .'.':' .-.; -_ . .::-_ “:-,!..5, gki:4?.-'i'il'-.!,q=: .ii.:::: ,,,,,:,;x;L';'.'...,.! .:. : ',i.,V::: hospice Care Covered up to a lifetime 80% up to a maximum that is Covered up to a lifetime Covered up to a lifetime Covered if authorized maximum that is adjusted that is adjusted annually maximum that is adjusted maximum annually annually Specified Human Organ Covered up to program 80% after deductible, in Covered up to program Covered up to program Covered if authorized Transplants maximums in approved facilities approved facilities maximums in approved facilities , maximum in approved facilities. , _ 11-YRDataIMAr rInrsilropntt\ FtwnFormelerwrrn Chart Rotirpec -70(17 — Available to Retirees hired eriot:. . Availibie,tii'lli-RitIrees ::Available.t641,1R _. Arashbeo all Retirees s --1Avaltabre to altRetireek. ... Hea lth /mace fa '- NO C-f40-011. 100-g!IP! Choice 0 - - -' ' I 9 01 p.,. 4,, rfferok ) , . .:13ENEFITS.- rad ittii44P[it ii, hi0 l " eitiy0, .1..2 . ,...,„ :., :.0 . s,. N.? ,o -..=:. . - . 1A-0- rtri" ' 1 and Me4hea1i4firgical with CcanprehCmsiv MajorMedwal with ouir of Sen we "5., 2 . Master MediCaC - e. 2: ' - - - - 14 7c4t1 .12 . :. . .. _MEDICAL AND SURGICAL CARE :.' -I. : - :. Surgery -r Voluntary second surgical 80% after deductible; Voluntary second surgical Covered Voluntary second surgical opinion on certain surgeries voluntary second surgical opinion; $20 Co-pay opinion; V0 Co-pay opinion on certain surgeries • Technical Surgical Assist. Covered 80% after deductible Covered Covered Covered • Anesthesia Covered 80% after deductible Covered Covered Covered -- — Maternity Care • Delivery Covered 80% after deductible Covered Covered Covered • Pre- and Post-Natal Care 90% under MM after deductible 80% after deductible ___, 100% under basic; no co-p' Covered $20 Co-pay Inpatient Medical Care General-unlimited 80% after deductible General — unlimited Covered Covered Mental health care-45 days Mental health care —45 Mental health care —45 days days Inpatient Consultations Covered 80% after deductible Covered Covered Covered Emergent)/ Care* (Physician) • Accidental Injuries 90% under MM after deductible 80% after deductible I00%under MM after deductible Covered Covered • Medical Emergencies 90% under MM after deductible 80% after deductible I00%under MM after deductible Covered Covered * Life threatening emergencies Laboratory & Pathology Covered-$5 or 10% co-pay 80% after deductible Covered Covered Covered Diagnostic Services Covered-$5 or 10% co-pay 80% after deductible Covered Covered Covered _ Diagnostic and Therapeutic Covered-$5 or 10% co-pay 80% after deductible Covered Covered Covered Radiology_ ' ADDITIONAL BENEFITS - - - .. .., Office Visits 90% under MM after deductible 80% after deductible $20 Co-pay $20 Co..p4y** $20 Co-pay*** -1 , Well-Baby Care Not covered Not Covered $20 Co2pay (up through I year) $20 Co-pay** $20 Co-pay*** Immunizations Not covered Not Covered $20 Co-pay (up through age 6) Covered Covered Allergy Testing 90% under MM after deductible 80% after deductible Covered $20 Co-pay** $20 Cop y*** Allergy Therapy 90% under MM after deductible 80% after deductible r-Covered $20 Co-pay** $20 Co-pay*** _ Ambulance Services , 90% under MM after deductible 80% after deductible 90% under MM after deductible Covered Covered Prosthetic Appliances 90% under Mivl after deductible 80% after deductible 90% under MM after deductible Covered Covered Durable Medical Equipment 90% under MM after deductible 80% after deductible 90% under MM after deductible Covered Covered Private Duty Nursing 75% under MM after deductible 80% after deductible 75% under MM after deductible Covered Net Covered Skilled Nursing Facility Covered 80% after deductible Covered Covered (120 days/year) Covered if authorized Voluntary Sterilization Not covered 80% after deductible Covered Covered Covered Routine Pap Smear Covered 80% after deductible Covered Covered Covered Routine Mammogram Covered 80% after deductible Covered Covered Covered Routine Physical Not covered Not covered $20 co-pay; labs not covered* $20 Co-pay $20 Co-pay ._. *If a routine PAP smear and physical *MI services performed during one *** All services performed during are performed separately, only one is visit have a one time $20 Co-pay. one visit will have a one time $20 covered in a 12 month period- not Co-pay. both. D:N$Dat-a\My documents\BenForms\Comp Chart Retirees 2007.doe Available to Retirees hired to 111,7 _ tillable to:all RitirieS .k!c],[3#01an1,46diç'.4.11S.,utji I Master PRESCRIPTION DRUG PROGRAX Participating /Network Pharmacies: Covered, co-pays $5 Generic; $10 Brand name; $25 Non-formulary. Non-participating/Non-net wot k Pharmacies: Paid at 75% of allowed cost, less $5, $10 or $25 Co-pay. Also, available is the mail order program for drugs taken on a long-term basis. A three—month supply can be ordered for a one- month co-pay. Participating /NetwOrk pharmacies: Covered, co- pays $5 Generic; $10 Brand name; $25 Non-formulary. Birth Control Pills covered Non-participating/Non- network Pharmacies: Paid at 75% of allowed cost, less $5, $10 or $25 Co-pay. Also, available is the mail order program for drugs taken on a long-term basis. A three —month supply can be ordered for a one-month co-pay. Participating /Network Pharmacies: Covered, co-pays $5 Generic; $10 Brand name; $25 Non-formulary. Birth Control Pills covered. Non-participatineNon-network Pharmacies: Paid at 75% of allowed cost, less $5, $10 or $25 Co-pay. Also, available is the mail order program for drugs taken on a long-term basis. A three —month supply can be ordered for a one- month co-pay. Participating /Network Pharmacies: Covered, co-pays $5 Generic; $10 Brand name; $25 Non-formulary. Birth Control Pills covered. Non-Participating/Non- Network Pharmacies; Covered, 30% Co-pay. Also, available is the mail order program for drugs taken on a long-term basis. A three — month supply can be ordered for a one-month co-pay. participating /Network Pharmacies: *Covered, co-pays $5 Generic; $10 Brand name; $25 Non-formulary. Birth Control Pills covered, *If a prescription is written DAW (Dispense as Written) by a physician for a brand name drug and a generic is available, you're responsible for the full cost of the brand and the co- pay of the generic drug, unless the physician has filed an approved medical exception. Non-Network Pharmacies: Not Covered. Also, available is the mail order program for drugs taken on a long-term basis. A three — month supply can be ordered and is discounted by $5 total. PROGRAM PROVISIONS: Deductibles, Co-payments and Dollar Limitations Basic: No deductible, Co-pays as noted: Master Medical: Deductible: $200 per person, $400 family per calendar year. Co-payments: 10% for general services ($1,000 out-of- pocket maximums); 25% for mental health care and private duty nursing. Deductible: $350 per person, $700 per family per calendar year. Co-pays as noted. Co-payments: 20% general services ($1000 per person max_ $2000 per family max.); 50% psychiatric care & substance abuse treatment; 20% private duty nursing. Pasic: No deductible, Co-pays as noted: Master Ivledical: Deductible; $200 per person, $400 per family per calendar year. Co-payments: 0%-10% for general services ($1,000 out-of-pocket maximums); 25% for mental health care and private duty nursing. In-network: No deductible; co-pays as noted. Out-of-network: $150 deductible per person; $300 deductible per family. Co-payments: 30% to a maximum of $1250 per person and $2,500 per family. Co-pays as noted. No deductibles. D: \NData\Mv documents\ FlenForms1Comn Chart 1 etirees 2007.doc Available to Retirees hired price ' : :Mailable to all Retirees, ..:, Available to allitedreeir. : Available to OR Retirees vallahle to all Retirees ', .. . : to 111/97 , Health Alliance Plan . . : :.. Blue Cros4/131:90 Shlel lugiCto ro rred.: I hie tlieffe-e OS) : MAP). ' BENEFITS'T , • , (11C1BS):' ': .t.d _i c a : • - — • 'Major- i.pito and ,04;60v8 ogito with corotooisl _9joi 40 c.ip , al FOlin of Service ,.: HMO Mister Medical (MM ' . ' tan ;01-&., 4t4.141/.51.1011.(46.4)0 . lvii!)..,:y _:, ., .. .. . .. Maximum: Maximum: Maximum: Maximum: None on Basic. $1 mill ion per $1 million per member per $1 million per covered type of $1 million per member in , member per covered type of covered type of organ organ transplants. $5 million per network. $I million out of organ transplant. transplant. $5 million per member life time other services, network. member life time other services. _ - - . f ' Preferred (Network) Hospitals:, ) Covered services are paid in fill, Payment of Covered Services ParticipatingHosoitais: 7r.' . - 100% of covered benefits, less 100% of covered benefits, less except where noted, when applicable co-pays applicable co pays performed at I [with Alliance ..,. Plan facilities/offices or ' Non-particicating Ilospitals: Non-Network Hospitals: authorized in advance by Health Inpatient care in acute care 85% of BCBSMS approved Alliance Plan providers hospital $70 a day, less applicable --'',' payment amount, less applicable t' cc pays co-pays (refer to non-participating ** If you choose an HMO under under Traditional option). the Health Maintenance Inpatient care in other hospitals $15 Organization Option, you agree a day, less applicable co pays Preferred (Network) Physicians; to receive all of your health care 100°A of BCBSM's scheduled services through the HMO's Medicare Surgical: - payment amount, less applicable . providers. If you choose to go to 100% of BCBSM's approved co-pays ' a non-HMO provider, in a non- amount, less applicable co-pays emergency situation, services Non network Physicians: ...; will not be covered. 85% of BCBSM's scheduled payment amount, less applicable co-.as, EXHIBIT D [See Attached Dental Chart] 12 401 1111:1 DELTA DENTAL' DeltaPreferred Option point-of-service USA Summary of Dental Plan Benefits For Group#0009936-0904 OAKLAND COITNTY This Summary of Dental Plan Benefits should be read in conjunction with your Dental Care Certificate. Your Dental Care Certificate will provide you with additional information about your Delta Dental plan, including information about plan exclusions and limitations. In the event that you seek treatment from a dentist that does not participate in any of Delta Dental's programs, you may be responsible for more than the percentage indicated below. Control Plan - Delta Dental Plan of Michigan Benefit Year - January I through December 31 DPO Member DeltaPremier or Dentist Non-Participating Dentist Covered Services - Plan Pays You Pay Plan Pays You Pay Class I Benefits Diagnostic and Preventive Services - Used to diagnose and/or prevent dental 100% abnormalities or disease (includes exams, cleanin .4. and fluoride treatments Emergency Palliative Treatment - Used to temporarily relieve pain v. 76 !(, . Class II Benefits Radiographs - X-rays Vd ' t rLw"...1.1,..N.S...4 , Oral Surgery Services - Extractions and dental surgery, including preoperative and 0 `.5-177/..,; 1 , to. . ;ve care Endodontie Services - Used to treat teeth with diseased or damaged nerves (for '' . 5%1. ` ,, ,. -1. exam .1e, root canals) ,LLIY. , Periodontic Services - 'Used to treat diseases of the gums and supporting structures .17---77.9' 7,71 of the teeth . ., _ Relines and Repairs - Relines and repairs to bridges and dentures ... 85%. ,. ,;*-41v45.,44 Minor Restorative Services - Used to repair teeth damaged by disease or injury (for ''' ')/i. eximi. le, Min 1 s) Major Restorative Services - Used when teeth can't be restored with another filling' 85%: 1 7717.7g71 material for example, crowns) Class 111 Benefits Prosthodontic Services - Used to replace missing natural teeth (for example, bridges 50% ,..n.' I and dentures) Class IV Benefits Orthodontic Services (to age 19) - Used to correct malposed teeth arid/or facial 50%. it).* 500.6 .1 - • , .,i. 4. I% bones (for exiun.le, braces) 4. , Benefits for prophylaxes, fluoride treatment, oral examinations and bitewing X-rays are payable twice per calendar year. Benefits for full mouth X-rays (which include bitewing X-rays) are payable once in any three-year period. If you're planning on traveling outside the United Stares, you can receive emergency dental treatment through a worldwide dental network of English-speaking dentists. English-speaking customer service is available 24 hours a day, seven days a week, to help you find a dentist. Contact your benefits representative to obtain our international dental emergency brochure before you travel. Maximum Payment - $1,000 per person total per benefit year on Class I, Class II and Class III Benefits. Delta Denial's payment for Class IV Benefits will not exceed a lifetime maximum of $1,000 per eligible person. September 1, 2004 13 EXHIBIT E [See Attached Vision Chart] 14 , Approved 9/95 Drrri No. 4770 jj 1111111111111111111111110 wo44.....—L...._ Vision Care Group Benefit I Certificate Series A80 • 1 . . • ...1'-:::,z.,,,:,....1,-.P'.:,. ?*"...:,,1--''-:...1:...-.1.::,,,i; -',.;:.,. "1-4 ,k,-,.....- ,.. --,,t- ' - ----.-- ,,,-J ,:.. . :.. .. .. 4... -. -:.. - -,' -. , .- - -- • , I :: '.14::'!'v',:iii.1:11i --..°4-1.4iX ' 1:0;;.::-.r,;".i.- '..,k4A.7,-., • . '.."'--':.".:_:.-1,F.,.,,_„4-1; -,;..,',i.:74-4:17.-i'l"'f'=-L_ ,.,-;;' F..-7.` .1,.. .-,=-.. '.7....-4;,,,....:41. ....., '. -....... ;-.::: : ..... ,-,,-..-et.t....,.....-:,,C;Y::: 7.7.:-.--; - .. -.r.- ,',..: rti t.tika"•:4.-4..,.e-‘4:;':,t....,-..,.',-q.. .-.,' ,:•.....'.,....:1 !;,:. :..;_..,..,.-: : .:: F.:..-:., r.f.,...j=3,....ti-,,- ......,...'...-.÷...;,,,..4..,„....---. -.1...Fz:V.4_,7- . '...k- I.,.....- ..41r.1=',..--wfii:.?;,;:'.._-.:?; .: - ,I7T'.,.'•'.:.*:..-"-',.%-.-.'-'!,'--";'Y'-'77-.4.:.'• t4re*IT - - - • - - --- ' - -- .4 ,.".*'-'%-; ' -,'::- •,•-•''''-r-i-74'-'.'f,KIV;;A:4;-.0;''64.4.F.41-,t-t".&7",t.7 ,. . .,..:- I Your Cor -irrac:t volt -) U.,, Blue Cross Blue Shield of Michigan An inoepencient Licensee of the Slue Cros and Blue Shield Association Ul Dear Subscriber: We are pleased you have selected Blue Cross and Blue Shield of Michigan for your vision care coverage. Your benefits are described in this book, which is your Certificate. Your Certificate, application and BCBSM identification card are your contract with us. You may also have riders. These riders amend your Certificate and are an important part of your coverage. When you receive riders, be sure to keep them with this book. This Certificate will help you understand your benefits and your financial responsibilities before you require vision services. Please read It carefully. If you have any questions about your coverage, call us at the customer service telephone numbers in the "How to Reach Us" section of this book. Every Blue Cross and Blue Shield employee is dedicated to giving you the finest service. We look forward to serving you for many years. Richard E. Whitmer President and Chief Executive Officer Blue Cross and Blue Shield of Michigan About Your Crtiticate This Certificate is arranged to help you locate information easily. You will find: id Table of Contents for quick reference How to Reach Us - your customer service center telephone numbers and addresses The Language of Vision Care - explanations of the terms used in your Certificate di information About Your Contract si General Conditions of Your Contract Coverage for Vision Care Services ill Vision Care Services Not Covered is How Vision Expense Benefits Are Paid This Certificate refers to you as the subscriber because the contract is in your name. The term patient refers to either you or one of your eligible dependents when you receive vision care. Your eligible dependents are those who are listed on your application. This Certificate provides you with the information you need to get the most from your BCI3SM vision care coverage. Please call us if you have any questions. Tcibk of Contents Page ,cut Your Certificate 1 Your Local Customer Service Centers 1 To Call Us 1 To Visit Us 1 Sectk-dn 2: The Language of Vision Care 4 Acquisition Cost .4 Approved Amount . 4 BCBSM 4 Certificate 4 Contact Lenses 4 Contract 4 Copayment 4 Dispensing Fee 4 Effective Date 5 Exclusions 5 Experimental and Investigational 5 Frame 5 Group 5 Lenses 5 Lien 5 Medically Necessary 5 Member 6 Non-participating Provider 6 Optician 6 Optometrist 6 Participating Provider 6 Physician 6 Provider 7 Remitting Agent 7 Rider 7 Subrogation 7 Subscriber 7 We, Us, Our 7 You and Your 7 Section 3: Inforrnc.ilion About Your Contruc.-,t 8 Eligibility 9 Who is Eligible to Receive Benefits', 9 Cancellation 10 How to Cancel Coverage. 10 Automatic Cancellation 10 Consolidated Omnibus Budget Reconciliation Act (COBRA) 11 Section 4: General Conditions of Your Contract 12 Changes in Your Family 12 Changes to Your Certificate 12 Notification 12 Other Coverage. 12 Coordination of Benefits (COB) 13 Release of information 13 Unlicensed Provider 13 Experimental Services 13 Time Limit for Legal Action 14 Improper Use of Contract '14 Assignment 14 Section 5: Coverage for V151011 Cure Services 15 Frequency 15 Participating Providers 15 Sfecltoo 1: How 10 itach 03 Non-Participating Providers Vision Examinations Eyeglass Lenses Special Lenses Lens Insertion Fee Eyeglass Frames Contact Lenses. Non-Participating Providers. 19 Suction 6: What 'Y'OU Must Pay 20 Vision Testing Examination 20 Eyeglasses. .20 20 sctiori 7: Vision Services Not Covered. 21 Section 6: How Vision benefits Are Paid. 22 Paying a Participating Provider 22 Paying a Non-Participating Provider. 22 SECTION 1: How To Reach Us Your Local Customer Service Centers This section gives phone numbers and lists addresses to help you get information quickly. You may call us or visit our centers. To Call Us Most of our customer service lines are open for calls between the hours of 8:30 am and noon and between 1 pm and 5 pm, Monday Through Friday. Please have your ID card with your group and contract numbers ready when you call. (The contract number is usually the subscriber's nine-digit social security number). Area Code 313/810 Detroit 225-8100 Southeast Michigan Toll -free 1 -800-637-2227 Area Code 616 Western Michigan Toll -free 1 -800-972-9797 Area Code 517 Central Michigan Toll-tree 1-800-258-8000 Area Code 906 Upper Peninsula Toll-free 1-800-562-7884 NOTE: You may have been given a special number to call instead of the above numbers. Please use the special number when you need assistance. Page 15 16 16 17 17 18 Contacts. SECTION 1: How To Reach Us ( continued) To Visit US BCBSM Customer Service Centers are located throughout the state of Michigan. Check the following list to find the center nearest you. Alpena 135 W. Chisholm Street, Alpena 49707 Located on the main street in downtown Alpena. Open from 8:30 am to 5 pm. Detroit 600 Lafayette East, Detroit 48226 Located downtown three blocks north of Jefferson at 1-375. Open from 8:30 am to 4:30 pm. Flint G 3346 Beecher Road, Suite B, Flint 48504 Open from 8:30 am to 5 pm. Grand Rapids 5540 Glenwood Hills Parkway, S.E„ Grand Rapids 49512 and 122 Lyon St. N.W., Grand Rapids 49503 Open from 8:30 am to 5 pm. Jackson 817 West Ganson, Jackson 49201 Open from 8:30 am to noon and from 1 pm to 5 pm. Kalamazoo 3624 S. Westnedge, Kalamazoo 49008 Open from 8:30 am to noon and from 1 pm to 5 pm. 2 Lansing 1405 S. Creyts Road, Lansing 48917 Open from 8:30 am to 5 pm. Marquette 415 S. McClellan Ave., Marquette 49855 Open from 8:30 am to 4:55 pm. Mt. Pleasant 1620 South Mission, Mt. Pleasant 48858 Open from 8:30 am to 5 pm, Muskegon 3375 Merriam Rood, Randers Professional Bldg., Muskegon 49444 Located in Muskegon Heights with the Blue Care Network offices, behind the Holiday Inn. Open from 8:30 am to 5 pm. Port Huron 1924 Pine Grove Ave., Port Huron 48060 Open from 8;30 am to 5 pm. Saginaw 3150 Enterprise Drive, Saginaw 48603 Located off Bay Road near Sullivan's Restaurant. Open from 8:30 am to 5 pm. Traverse City 1769 S. Garfield, Traverse City 49684 Located across from Cherryland Mall, with the Blue Care Network offices. Open from 8:30 am to 5 pm. Utica 6100 Auburn Road, Utica 48487; located across from the AAA building. Open from 8:30 am to 5 pm. 3 4 5 SECTION 2: The Language Of Vision Care This section explains the terms used in your Certificate. The terms are listed in alphabetical order. Acquisition Cost The actual cost of lenses and frames to the provider. Approved Amount For vision examinations by a participating provider, the lower of the billed charge or our maximum payment level for the examination. For lenses, the participating provider's net acquisition cost plus a dispensing fee. Copayments are subtracted from the approved amount before we make our payment. Amounts we pay for nonparticipating provider's services are shown at the end of Section 5. BOBS IM Blue Cross and Blue Shield of Michigan. Certificate This book, which describes your benefit plan and any riders that amend the Certificate. Contact Lenses Glass or plastic lenses prescribed by a physician or optometrist to correct or improve vision. They are fitted directly to the patient's eye. Contract This Certificate and any related riders, your signed application for coverage and your BCBSM ID card. Copayrnent The portion of the approved amount that you must pay for a covered service. Dispensing Fee The amount we pay a participating provider for dispensing lenses and frames. Elective Date The date your coverage begins under your contract. This date is established by BCBSM. Exclusions Situations, conditions, or services that are not covered by your contract. Experimental and Investigational A service or supply that has not been scientifically demonstrated to be as safe and effective for treatment of the patient's condition as conventional or standard treatment. Frame Standard eyeglass frames into which two covered lenses may be fitted. Group A collection of subscribers under one contract. Generally, all members of a group are employed by the same employer. One employer, however, may have several groups (different contract benefits available for segments of personnel under the same employe). A group can also include members who are associated with the same organization. Lenses Glass or plastic lenses prescribed by a physician or optometrist to correct or improve vision. They are fitted into frames. Lien A first priority security interest in any money or in any action to recover money for treatment of injuries for which we paid benefits. Medically Necessary We pay for lenses that are medically necessary. Medical necessity is the determination by physicians or optometrists acting for BCBSM, based on criteria and guidelines developed by physicians and optometrists for BCBSM, that the service is appropriate and necessary for the condition. NOTE: In the absence of established criteria, medical necessity will be determined by physicians or optometrists according to accepted standards and practices. Member Any person eligible for health care services under this Certificate. This means the subscriber and any eligible dependent listed on the application. The member is the "patient" when receiving covered services. Non-participating Provider A physician, optometrist or optician who has not signed an agreement with BCBSM to participate in our vision care plan. Optician A person or organization that makes corrective lenses prescribed by a physician or optometrist. The optician must be licensed in the state where the service is performed. Optometrist A person licensed to practice optometry in the state the service is provided. Participating Provider A physician, optometrist or optician who has a signed agreement with BCBSM to participate in our vision care plan. The provider accepts direct payment from BCBSM and accepts our payment plus your copayment as payment in full for covered services. Physician A licensed doctor of medicine (M.D.) or osteopathy (D.O.) who, within the scope of his or her license, performs vision testing examinations and prescribes corrective lenses. An ophthalmologist is a physician. Provider A physician, optometrist or optician that provides services related to vision care. Remitting Agent Any individual or organization which has agreed, on behalf of the subscriber to: • collect or deduct from wages or other sums owed by the subscriber; and • pay the subscriber's BCBSM bill, Rider A document which amends this Certificate by adding, limiting, deleting or clarifying benefits. Subrogation The assumption by BCBSM of your right, or the right of your beneficiaries, to receive money from another person, insurance company, or organization. Subrogation does not apply to money received from insurance issued in your name or the names of your beneficiaries. Subscriber The person who signed and submitted the application for coverage. We, Us, Our Used when referring to Blue Cross and Blue Shield of Michigan. You and Your Used when referring to any person covered by the subscriber's contract. SECTION 3: Information About Your Contract This section provides answers to general questions you may have about your contract. Topics include: Eligibility II Who is Eligible to Receive Benefits Cancellation a How to Cancel Coverage Automatic Cancellation id Consolidated Omnibus Budget Reconciliation Act (COBRA) ELIGIBILITY Who is eligible to receive benefits? You, your spouse and your unmarried children listed on your contract are eligible. a Unmarried children are covered through the end of the year in which they turn age 19. They must be your dependents as defined by the United States Internal Revenue Code and claimed as an exemption on your tax return. Ml If these children do not live with you, they are eligible under your contract only if their health care is your, or your spouse's, legal responsibility. a Disabled, unmarried children may remain covered on your contract beyond the end of the year in which they turn age 19. These children must be: NI diagnosed as permanently disabled due to a physical or mental condition. • disabled before the age of 19. II dependent on you for all or most of their support. (The disability must prevent the person from supporting him or herself.) a eligible members on your contract before they became 19. If there is a change in your family such as birth, divorce, death, etc., we must be notified within 30 days of the change so that any contract changes take effect as of the date of the event. Any changes in rates resulting from contract changes will take effect with the billing cycle following the event. If notice is not received within bq days, we determine the effective date of the change. IMINIMMINEMEMEINEINI CANCELLATION How to Cancel Coverage You must send a written request to cancel coverage to your employer. We must receive it at least 30 days before your renewal date. IN Your coverage will then be canceled as of your next billing period. Automatic Cancellation We will automatically cancel your coverage if: lid You misuse your coverage. Misuse includes any illegal or improper use of your coverage such as: allowing an ineligible person to use your coverage. Ai requesting payment for services you did not receive. a your group does not qualify for coverage under this Certificate. IA you no longer qualify to be a member of your group. is your group does not pay its bill. IN you are serving a criminal sentence for defrauding BCBSM. NI you are paying a civil judgment to BCBSIV1, hi you are paying BCBSM back (funds you received illegally) under a voluntary agreement between you and BCBSM. NI you no longer qualify as a dependent. kr you do not repay BCBSM for payments made for services not a benefit under this Certificate. Your coverage will end on the last day covered by your last payment. Consolidated Omnibus Budget Reconciliation Act (COBRA) COBRA is a federal law which affects all employers with 20 or more employees. It extends the opportunity for group coverage to members who no longer qualify as members of a group. This Group Continuation Option provides, at the coverage member's expense: • 18 months of continued group coverage for an employee who leaves the job other than because of gross misconduct or whose hours are reduced; and • 36 months of continued group coverage for eligible dependents. Eligible dependents are: • divorced or legally separated spouses; N surviving spouses and/or children; III children who will lose their coverage because they reach an age that does not qualify them for dependent coverage. • children of an employee who will lose their coverage when the employee becomes eligible for Medicare. NOTE: When members become eligible for Medicare they are no longer eligible to continue coverage under COBRA. To qualify for this coverage, you must select the Group Continuation Option within the first 60 days from the time that you or your eligible dependents no longer qualify for group coverage. Please contact your employer for more details about the COBRA. StiCii014 4: Gi-ietai Condilions Of Your Contract Certain general conditions apply to your contract. These conditions may make a difference in how, where and when benefits are available to you. This section lists and explains these conditions. Criunges in Your foi-niiy We must be notified within 30 days of any changes in your family. This requires you to complete a membership and record change form, Your coverage changes will then take effect as of the date of the event. Changes include marriage, divorce, death, birth, adoption, address changes or the start of military service. lo Your Cvrtiticate BCBSM employees, agents or representatives cannot agree to change or add to the benefits described in this Certificate. low Any changes must be In writing and approved by BCBSM and the Michigan Insurance Commissioner. We may add or delete benefits by issuing a rider. For your convenience, keep any riders you receive with this book. When we need to notify you, we mail the notice to your remitting agent. This fulfills our obligation to notify you. Ohi COVerOcie In certain cases, we may have paid for vision services under your Certificate for which another person, insurance company or organization should have paid. In these cases: ft You grant us your right to recover our payments from them. iht You grant us a lien on all money, specifically identified as medical costs, that you or your beneficiaries recover through settlement, verdict or judgment. Any part of the recovery that is used to pay attorneys' fees will not be subject to our lien or recovery. 12 You agree to inform us when you hire an attorney to represent you, and to inform your attorney of our rights under this Certificate. mi You are required to do whatever is necessary to help us enforce our right of recovery. III If you receive money through a lawsuit, settlement or other means for services paid under this Certificate, you must reimburse us. a This does not apply if the funds you receive are from additional coverage you purchased in your name from an insurance company. Coordination of Benefits (COB) We will coordinate the benefits payable under this Certificate pursuant to the Coordination of Benefits Act, Public Act No. 64 of 1984. To the extent that the services covered under this Certificate are also covered and payable under another group vision care plan, we will combine our payment with that of the other plan to pay the maximum amount we would routinely pay for the covered services. Release of Information You agree to permit providers to release information to us. This can include vision records related to services you may receive. We agree to keep this information confidential. The information will be used to determine eligibility and rights under this Certificate. Unlicensed Provider Vision care services provided by persons who are not legally qualified or licensed to provide such services are not payable. Experimental Services Services which we determine to be experimental or investigational are not covered by this Certificate. Please see the definition in "The Language of Vision Care" in this book. 13 s Time Limit for Legal Action Legal action against us may not begin later than two years after we have received a complete claim for services. Improper Use of Contract If you allow any ineligible person to receive benefits (or try to receive benefits) under your contract, we may: id refuse to pay benefits; mi cancel your contract; Id begin legal action against you; or refuse to cover your vision care services at a later date. Assignment The services provided under this Certificate are for your personal benefit and cannot be transferred or assigned. Any attempt to assign this contract will automatically terminate all your rights under it. No right to payment from us, claim or cause of action against us may be assigned by you to any provider. We will not pay any provider except under the terms of this contract. 14 SECTION 5: Coverage For Vision Care Services This section describes covered vision services to detect, improve or correct vision problems. Frequency We pay for the following once in any period of 24 consecutive months: a One vision testing examination a One pair of eyeglass lenses with or without frames; or contact lenses. Participating Providers We pay participating providers the approved amount minus your copayment. Your copayments are shown in Section 6: What You Must Pay. Non -Participating Providers We pay fixed dollar amounts for lenses and frames obtained from non-participating providers. These amounts are listed at the end of this section. The amounts are less than we pay for services of participating providers. The following pages describe your covered services. Vision Examinations We pay for vision examinations by a physician or optometrist to determine the need for lenses to correct or improve eyesight. The examination must include the following: 1111 History MI Testing of visual acuity a External examination of the eye a Binocular measure ▪ Opt halmoscopic examinations ▪ Tonometry (test for glaucoma) when indicated a Medication for dilating the pupils and desensitizing the eyes for tonometry, if necessary a Summary of findings 15 If an optometrist recommends an examination by a physician, we pay for this examination. • The examination by the physician must be within 60 days following the optometrist's examination. Eyeglass Lenses We pay for eyeglass lenses when prescribed or dispensed by a physician, optometrist or optician. a Lenses may be molded or ground, glass or plastic. Lenses must be equal in quality to the first-quality lens series made by American Optical, Bausch & Lomb, or Tillyer and Unlvis. • The lens blank must meet Z80.1 or Z80.2 standards of the American National Standards Institute. a The lenses must be colorless. a Tinted lenses equal to Rose tints #1 and #2 are covered if they are necessary for therapeutic purposes. hi The provider may bill you for the difference in cost between clear and non-therapeutic tinted lenses. a The lens blank of a standard lens must not exceed 65 mm in diameter. a The provider may charge you for the difference in cost between standard and oversize lenses. Special Lenses We pay for the following special lenses: a Myodisc a Lenticular myodisc a Lenticular aspheric myodisc • Aphakic a Lenticular aphakic a Lenticular aspheric aphakic We do not pay for aphakic lenses for aphakia (lack of natural lens). These may be covered by your BCBSM hospital-medical-surgical plan. 16 We pay for prism, slab-off prism and special base curve lenses when medically necessary. Lens insertion Fee If you do not receive new frames, we pay to have new lenses inserted in your old frames. Eyeglass Frames We pay the provider's acquisition cost up to $14.75, plus a dispensing fee for standard eyeglass frames. • If you select more expensive frames, the provider may charge you the difference between the usual retail charge for covered frames and the more expensive frames. Contact Lenses a Suitability Exam A contact lens suitability examination determines whether you can wear contact lenses. The exam may include: ▪ Biomicroscopic evaluation is Lid evaluation ▪ Ophthcilmoscopy • Tear test II Pupil evaluation IIII Fluorescein evaluation ▪ Cornea evaluation IN Lens tolerance tests The fee for the examination is included in our dispensing fee if you get contact lenses. If it is determined that contact lenses would not be suitable, we pay for the examination. 17 am Contact Lenses We pay the approved amount minus your copayment for medically necessary contact lenses. Contact lenses are considered medically necessary if: • They are the only way to correct vision to 20/70 in the better eye; or • They are the only effective treatment to correct keratocanus. irregular astigmatism or irregular corned curvature. If prescription contact lenses are not needed for the above reasons, we pay up to $35 per pair. in-Pcirticipatirig Providers If you receive services from a non-participating provider, we pay the following: Vision testing examination ii 75 percent of the approved amount, after It has been reduced by your $5 copayment. Eyeglass Frames Provider's charge up to $14 mi Contact Lenses Medically Necessary $96 per pair Not Medically Necessary $35 per pair If only one lens Is needed, we pay one half of the amount per pair. ris Eyeglass Lenses Single Vision Bifocal Trifocal Special Lenses $13 per pair $20 per pair $24 per pair 50 percent of the provider's charge or 75 percent of the average amount paid to participating providers, whichever is less. im Additional Charges Plastic Lenses Rose Tints #1 and tt2 Prism Lenses $3 per pair $3 per pair $2 per pair 18 19 SECliON 6: What You Must Pay This section explains the copayment you pay for covered vision services. Von Testing Examination lid Your copayment is $5.00 No copciyment for a second examination by a physician when recommended by optometrist. Eyeglasses id Your copayment is $7,50 di One copuyment amount for both lenses and frames id No copayment for eyeglasses obtained from a non-participating provider, but you are responsible for charges in excess of our payment. CCAIICICES II Your copayment is $7.50 for medically necessary contact lenses di No copayment for cosmetic contact lenses but you are responsible for charges in excess of our payment. 20 SECTION 7: Vision Services Not Covered We do not pay for: • Additional charges for N Lenses tinted darker than Rose Tint #2 • Anti-reflective and photosensitive lenses is Oversize lenses • Sunglasses II Medical-surgical treatment • Medications administered during any service except a vision exam Services or materials ordered before coverage began N Services not prescribed by the attending physician or optometrist • Special services, such as orthoptics, vision training, low (subnormal) vision aids, aniseikonic lenses and tonography • Replacement of broken or lost lenses or frames • Services covered by Workers"Compensation Laws • Services received at a medical clinic provided or maintained by an employer • Services covered by government-approved health care programs such as Medicare or CHAMPUS • Services received as a result of an eye disease, defect or injury due to an act of war, declared or undeclared • Services available at no cost to you or for which no charge would be made in the absence of BCBSM coverage • Charges for lenses or frames ordered while you were eligible for benefits but delivered more than 60 days after coverage ends N Charges for completing insurance forms • Aphakic lenses when the patient lacks a natural lens • Charges for experimental or poor quality services 21 SECTION 8: How Vision Benefits Are Paid Paying a Participating Provider hi The participating provider submits a claim to us for the services you receive. id We pay the provider directly for the covered services. A participating provider may bill you when: tia you receive a service not covered by your contract II we deny a claim from a participating provider that was submitted more than 180 days after the service because you did not furnish needed information. Paying a Non -participating Provider You should expect to pay charges to a non-participating provider at the time you receive the services. You should then submit a claim to us. is If we approve the claim, we will send payment to you. You are responsible for non-participating providers' charges in excess of the fees listed in Section 5. 22 n••• Resolution #07167 — (Ordinance #29) July 19, 2007 Moved by Rogers supported by Kowar the resolution be adopted. AYES: Crawford, Douglas, Gershenson, Gingell, Gosselin, Gregory, Greimel, Hatchett, Jacobsen, KowaII, Long, Middleton, Nash, Potter, Potts, Rogers, Scott, Spector, Suarez, Zack, Bullard, Burns. (22) NAYS: None. (0) A sufficient majority having voted in favor, the resolution was adopted. I MY APPROVE THE FORME RESOLUTION STATE OF MICHIGAN) COUNTY OF OAKLAND) 1, Ruth Johnson, Clerk of the County of Oakland, do hereby certify that the foregoing resolution is a true and accurate copy of a resolution adopted by the Oakland County Board of Commissioners on July 19, 2007, with the original record thereof now remaining in my office. In Testimony Whereof, I have hereunto set my hand and affixed the seal of the County of Oakland at Pontiac, Michigan this 19th day of July, 2007. Ruth Sbirrnii, County Clerk