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Home My WebLink AboutOrdinances - 2007.07.19 - 8536MISCELLANEOUS RESOLUTION 10 7 67 MISCELLANEOUS ORDINANCE 129 July 19, 2007 RESOLUTION #07XXX BY: Finance Committee, Mike Rogers, Chairperson IN RE: AN AMENDMENT TO ORDINANCE NO. 27, AN ORD/NANCE 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 arid 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 roil call vote with Potter and Coulter absent. • • C. The scope of benefits currently included in the County's retiree medial benefits program ("R,MB 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 R_MB 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. • • 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 INB 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 COMMIITEE lass] l-oevb5a 0 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 Las. r 1 I -co? b.Sa • 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). I. 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 withtheC t Care Coverage Direct Retirement Less than 8 years 8-14 years None Single Person, though retiree has option to pay the difference thr 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 • B-1 verage • Total Service with the County Less than 15 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years or more No coverage 60% paid coverage 64% paid coverage 68% paid coverage 72% paid coverage 76% paid coverage 80% paid coverage 84% paid coverage 88% paid coverage 92% paid coverage 96% paid coverage 100% paid 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: 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 arc 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). • 13-2 EXHIBIT C [See Attached Medical Chart} • • 7 90% wider MM after deductible 90% under MM after deductible 80% after deductible 3D% after deduetibk Covereri-$5 or 10% coep_ay 80% after deduct ibLe Covered-S5 or 10% co-pay 80% after deductible Covered-SS or 10% co-pay 80% after deductible Covered SCI% after deductible 90% under Mtvil_after deductible SO% after deductible _ Gene rat-unlimited 80% after deductible Mental health car-45 days Mental health care- - days 80% after deductible Covered 90% under letlel after deductilule 180% after deductible Not covered INat Covered $20 Co-par _. $20 Co-pay*** _ _ _ , Covered $20 Cia-pay" " S20 Co-Ray"! _j -6-.weeed ' Covered — S20 Co-pay 20 Col* Covered 820 Co-erty.* $20 Co-pay" Covered Covered Covered $20 Co-py Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered C.uv Ned Covered Covered Covered Covered Covered Covered Covered Cove1oci(120 davsilcar) - Covered Covered Covered $20 Co-pay "AU services perforated during one visit have a onc time $20 Co-pay. Covered Not Covered Covered if 13 LI- thoritedl Covered _ Covered - Covered - $20 Ca-pay- 1 •4- All servicas. ptifanind during one visit will have a one Cunt $20 Co-pay. It;SPitai hiaStei Medlin]. KM1911 EDI CA 1:4 AND suitpicii .tARE 2:5 -17FS' -Surgery J Voluntary second sutgkat o pirinn on certain Surgeries _inpatient Consultations _ Emergency Care; (Physician') • Accidental injuries • Medical Emergencies * Lite_threarening ernsgrneies Labonsilir/ Putholopr _ Diagnostic Services -Diagnostic and Therapeutic. ltediaiogy ADDITIONAL, 13BNEff rA Office Visits Well-Baby Care lmieruidention Allergy Testing AleeigLTherapy Arnbulanet Services - Prosthetic Appliances Durable Medical Fiquierrient puny Nursing _ Skilled Nursing Facility Vntuniary_Sterititation _Routine Pap Smear_ _ Routine Mammogram itoutine Physical • Technival Sorgical Assisi • Anesiliesia Matenute Care • Pc-livery • Pre- and Pusi-lilatel Care _ hipatient Medical Care Available to Retirees bil(Fd _ -prior - . 4541:1-01.,- . • Bhia CT9-1-11Pirig ble!il • nat.Ittional.gf n. • Covered Covered Not covered Nat Covered 90% under MM after deeturtible 80% after deductible. 90% under MM after deductible 80% alter deductible 90% under MM alter deductible ._ SO% after deductible -90% rimier MM after deductible 80% efies deductible 90% under MM after deductible 80% eller deductible ,75% under Mlei after -deductible 80% after _deductible Covered ' r.,ieer after deductible -.-F-erit Covered 80% after deductible , Covered _ RD% after deductible Covered 80% after deductible _ I Not covered Not covered SO% after deductible; voluntary second surgical opinion on certain surgeries au% after deductible 80% after deductible yaillbli taill Retire 1 -Avallatite to all Retirees Ng- Rotolo, ttipybi-t-„, • - - 'AJ.T14,"4=itafit • - Voluntary second surgical Opinion; $20 Co-pay 14-C over ed Covered Covered Covered I OW under basic- no co-eeey General -- unlimited Mental health care — 45 days Covered 100%under MM after deductible 100%under MM after deductible Covered Cover ed Cover ed tbroue I Ey (up through age fel Covered 90% under MIA after deductible 90% under MM after deductible 90% under MIVI after deductible 7% under MM after deductible Covered Covered Covered* C nve,red $20 co-pay. labs not covered* *if 'routine PAP smear end physical are performed separately, only one is CDYClad ily a12 tetanth period - not both. 03 '44 r „ 'r Covered Covered $20 Co-pay $21) Co-pay $20 Co:pay Covered 'milk Ailtanee Pian-1 ,. - 7-- fieaffh A415Ince - (11A-1') Voluntary second s-urgica opinion; $20 Co-pay Covered Coveted D:14DataVviy docurnents;BenForrns\Comp Chart Retirees 2007.dac 4111 • Avaitahle lir ell Relliterl - Available to all Re tir ries — Arailabls to All *Veil I AYAllable In all Itefircra ' MOiliggr,MErtlf.P1117 d‘.virciA-.124i it)toirOc,i1Parrvcrairdrth ..• 'pint of Stericg-- Ileallh Alliance Plan CRAP.) HMO Available lo Refit res hired prior to 1/1(97 Blase CrossilEl.l ae ble:11.11. None an Basic. $I million per member per coveted type of organ transplant. Maximum Si million per member per covered type of organ ti a nspl ant $5 million per member life time iher services. Maximum $1 Million per covered type of organ transplants. $5 million pc - member life time other services i -Oa- meat of Covered Services P.5.11.e.i.oUpg HOMAN'S: 100% of covered benefits, less applicable co-pays Nockputicipa Inpasicnt MC in acute-care hospital-570 a day, less applicable cu-pays. Enpanein critic in other hospi1.als-515 a day, less applicable co-pays. Mediau e Surgical: 100% of HC1-3ShYs approved amount, less applicable co pays. Pr Hoscriiair 100% of covered benefits, less applicable co-pay Em-1.1s1aorkikaspga. 8.5% of IICRSIvig approved payment amount. less applicable CO pays (refer to non-participating under TradiliOnill option) Prrlerted agelviitYsiatis 100% of PCBSM's scheduled paymEnt arammt, less applicable. co-pays. Liqn-netwoit 85% of 1210EISkr s scheduled payment amatiok less applicable WilOINWEEki 1111n• BENEFITS Tral4it1cingl - - liusp dal arid MedriatiSirrgieral with MagerMtjai Maxim= S1 million per member in network. SI million out of network. Covered serlices are paid in fulL except where noted, when performed at Health Alliance Plan facilities/others or authorized in advance by health All lance Plan providers • *lfyou choose an HMO under the Health Maintenance Organization Option, you awee to receive all of your health care services through the HMO's providers If you choose to gu to a non-H1s10 provider, in a non- emergency situation, services will not be covered. 6:15. DatAly docurrients\RenFonns\.Comp Chart Retirees 2007.doc • Covered Services - I Plan Pays You Pay Plaa Pays You Pay • A DELTA DENTAL DeltaPreferred Option point-of-service USA Summary of Dental Plan Benefits For Group#0009936-0004 OAKLAND COUNTY This Sunnuary of Dental Plats Benefits should be read in conjunct:4u 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 iiiitinkliOns. In the event that you a seek treatment from a dentist that does nat pakcipote ia any of Deka Dental 's programs, you way be responsibk for more than the percentage indicated below. Control Plan - Delta Dental Plan of Michigan Benefit Year - January I through December 31 DPCI Member DehaPremier or Dentist Nou-Partielpating Dentist • • Class I Benefits Dlagansti'e and Preventive Services - Used to diagnose aniVor prevent dental ' ,4:10% abnormalities or disease includes exams, cleanin -s and fluoride treatments 7,--.W-+ ' . -.,.. .. ,...0,0LL .Emergency Palliative Tresitxaent - Used to temporarily relieve pam , '...-wlocrie-7 - ''.7,7'7' - ' - r..:- '''. - • • '' . : !--. •A , --- .. --.• 0 L, • ` t . Class II Benefits Radiographs - X-rays Eriiiii2E-,77.j.i'M ffiffrifffar,j4.1' • ' i Oral Surgery Senaces - Extractions and dental surgery, including preoperative wad ..,,411, 85n ' —.T.- r-7,?,7':,'; •4,-,,,,-,:pc----..,- .,;-•,:-.--:-..---,, VC care . 's -........ Eadedoutic Services - Used to treat teeth with diseased or damaged nerves (for +=mile, rout canals ,-. ...e--'• --41.1.....,:.11....._ 2, Periodontie Services - Used to n-eat diseases of the gums and supporting structures r,..„-.,-,8 4..'k --- - - ' 111,53r. of the teeth t•:57-k.ti1;1 , ... . . rz- '0'' ' - ; Relines amid Repairs - Refines and repairs to bridges and dentures 1,-----7-77---„ ..,. Trdeme,.. ez ,...",-- ' • - ' Z.E...F4'....:,-.-',.I.Le.-"'',........ Minor Restorative Services - Used m repair teeth damaged by disease or injury (for -,,..'t:?';15° '. 7, 7', exam . le fillin. a ' '',,;.;',/:' L._„' Lm., j is% OA r‘,. 'L-„.ILL--1 Major Reetorative Services - Used when teeth can't be restored with another fining ....e:. : / ...: ,., ,tro, material (for example, crowns) ..... ':,.1; Clam DI Benefits Prosthodoritic Services - Used to replace missing natural teeth (for example, bridges . • . - . l n IEhi - •...4-50,6 ' ...Lip- , . E - -.- -1 :, .. - and dentures) . . Class IV Benefits Orthodontic Services (to age 19) - Used to correct inaiposed teeth and/or facial . , ,,,;,,,-, t....,, .. . y.,..r.", _,'1 - • ,,..3.-_-,- t bones (for example, braces) •-7:- : -.1. .. 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 1:skewing X.rays) are payable ones 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 availab:e 24 hours a day, seven days a week, to help yini find a dentist. Contact your benefits representative to obtain our international dental emergency brochure before you travel. iftlinium Payment - $1,090 per person total per benefit year on Class I, Class El and Class IILBeztafitsiDeita_Dental's payment for Class IV Benefits will not exceed a lifetime maximum ofS 1,000 per eligible person. September I. 2004 13 Blue Cross Blue Shield of Michigan Drm No 4770 —9- . - povou Vision Care Group Benefit Certificate Series A80 1 1 ...{:, „..z.„:„.—i:r --4.,;t:'1,14_ ' t 'V-:,:et:....1 z,7- .-.. . -..., - !:- .-",•;-27.: : :-..:(Ati..,:.•,•0. r . - •Fori•-• .1..,-S, • Lk...4.'70r • ,1 - ,;.........j.:1:14 V '..-:2 1. AZ.4.1=.14.*-...,.......r ' i'''' .:2'"?•r'. < . '..1, A. -,'-- .:4::"71 ' tt-• :: ,..+-• r 11,4%-9..5L- ' w.el - i., n 2,, .:., ...- j+. ,' An incloperuCiant licensee of Ire BJue und Blue AA-Kik-lotion monNIn14.11=111n1111.11n11.11111110 immom.•nnnn. - - - - . 1 M•111111n11M11111111n11111•1n1111Mmin AbCait YOU!' CeititiC01 This Certificate is arranged to help you locate information easity. You will find: Table of Conients for quick referet How lo Reach Us - your customer service cen1er telephone numbers and addresses lki The Language of Vision Care - explanations of the terms used in your Certificate IN information About Your Contract sr General Conditions of Your Contract rir Coverage for Vision Care Services Id Vision Cate Services Not Covered or How Vision Expense Benefits Are Paici 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 e4igible dependents NA..rhen you receive ViSi00 cote. YOUf eliqible dependents are those who ace listed on your application, This Certificate provides you with the information you need to get the most from your EICBSIVI vibiori cure coverage. Please call us if you have any questions. AbCait YOU!' CeititiC01 This Certificate is arranged to help you locate information easity. You will find: Table of Conients for quick referet How lo Reach Us - your customer service cen1er teiephone numbers and addresses lki The Language of Vision Care - explunutions of the terms used in your Certificate IN information About Your Contract sr General Conditions of Your Contract rir Coverage for Vision Care Services Id Vision Cate Services Not Covered or How Vision Expense Benefits Are Paici 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 e4igible dependents NA..rhen you receive ViSi00 care. YOUf eliqible dependents are those who ace listed on your application, This Certificate provides you with the information you need to get tile most from your EICBSIVI vibiori cure coverage. Please call us if you have any questions. ir•pimmrsomomMI IIMINININNINE1 • mriminingismimfirimmissimmillim Eyeglass Lenses 16 This section gives phone numbers and lists addresses Special Lenses 17 to help you get information quickly. You may call Eyeglass Frames 17 • Suction 6: Wii,:51 )(co Must Pay 20 between the hours of 8:30 am a.nd noon ancl between 1 pm Vision Testing Examination 20 and 5 pm, Monday throu h Friday. Please have your ID card Eyeglasses. 20 with your group and contract numbers ready when you call. Si'acriun 6: How Vision fienelits Are Puid. 22 Detroit 225-810C Paying a Participerting Provider 22 Southeast Michigan Tc.)Il .free 1-800-637-2227 11•111n11=11n1=11.111n11n1111M111M11n1 MINIIIMIIMIMIMn•n•nn•n Non-Pctrticipating Providers VisiDn Examinations 16 YOU( LOCO CUSiOffier SeiViCe Lens Insertion Fee 17 us or visit our centers. Contact Lenses , . 18 To Cali Us Non-Participating Providers. 19 Page Non-Pctrticipating Providers Visi EXCIMinCitiOnS 16 Eyeglass Lenses Special Lenses 17 Lens Insertion Fee 17 Eyeglass Frarnes 17 Contact Lenses , . 18 Non-Participating Providers. 19 Page SECTiON 1: HOW To Recich Us SECTION 1: How To Reoch Us YOU( LOCO CUSiOffier SeiVICe This section gives phone numbers and lists addresses to help you get information quickly. You may call us or visit our centers. To Cali Us Contacts. 20 social security r lumber). Suction á: Wii,:51 11,1ust Pay 20 Vision Testing Examination 20 Eyeglasses. 20 Contacts. 20 lvlost of our customer service lines are open fcr calls (The contract number is usually the subscriber's nino-digit Most of our customer service lines are open fcr calls between the hours of 8:30 am and noon ancl between 1 pm and 5 pm, Monday throu h Friday. Please have your ID card with your group and contract numbers ready when you call. (The contract number is usually the subscriber's nno-digit social security r lumber). s,v4:.tion 7: Vision Services Not Covered. 21 s,u4:.tion 7: Vision Services Not Covered. 21 Paying a Non-Participating Provider. 22 6: How Vision fienelits Are Puid. 22 Paying a Participerting Provider 22 Paying a Non-Participating Provider. 22 Area Code 313/810 Area Code 313/810 Detroit 225-810C Southeast Michigan Toll free 1-800-637-2227 Area Code 616 West rn Michigan Toll -froe 1 -800-972-Y79/ Area Coda 517 Central Michigan Toll-free 1-800-25B-8000 Area Code 906 Upper Penirisula Toll-free 1-800-562-'7884 Area Code 616 West rn Michigan Toll-froe 1 -800-972-Y79/ Area Coda 517 Central Michigan Toll-free 1-800-25B-8000 Area Code 906 Upper Peninsula Toll-free 1-800-562-'7884 NO1E: You rnay have been given a special number to call instead at the above numbers. Please use the special number when you need assistance. NO1E: You rnay have been given a special number to call instead at the above numbers. Please use the special number when you need assistance. 1 1 MiMMIIMIIIIIINMNIn11111•111•MIINSIMININIMINI111n1•11=1 CD • ....n••=mairmirwmommisimn1111111nM SkCi ION 2: The Language Oi Vision Core This section explains the terms used in your Certificate, The tams are listed in alphabetical order. Acquibition COsi 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 BCbSM Blue Cross and Blue Shield of Michigan. Cenificare This book, which describes your benefit plan and any riders that amend the Certificate, Contact Lenses Glass or plastic lenses prescribed by a physician (Di 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 cord. Copayment 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. 4 41110 EffeCtive Date the dale 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 condon as conventional or standard treatment, Frame Standard eyeglass frames into which two covered lenses may he 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 employer). 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. 5 _ . . mnEirimixime hom. SkCTION 3: Information About Your Contract This section provides answers to general questions you may have about your contract. Topics include: Id Who is Eligible to RecNve Benefits Cancellation How to Cancel Coverage ki Automatic Cancellation Consolidated Omnibus Budget Reconciliation Act (COBRA) 8 0 ELIGIBILITY ... . Who is eligible to receive benefits? You. your spouse and your unmarried children listed on your contract are eligible. • 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 dr-timed as an exemption on your tax return. • if these children do not live with you, they are eligible under your contrac only if their heallti care is your. or your spouse's, legal responsibility. at Disabled, unmarried children may remain covered on your contract_baygna the end of the year in which they turn age 19. These children must be lil diagnosed as permanently disabled due to a physical or mental condition. X disabled before the oge of 19. • dependent on you for all or most of their support. (The disability must prevent the person from supporting him or herself.) • 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 daYLc2f the CtiOncla SO that any coniraCt 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. It notice is not received within 60 days, we determine the effective dote of the change. 9 mworrom... • . tk...11‘..)i‘l 4: Gfoi Conchlions Of Your COTAMC" Certain general conditions apply to your contract. These conditions may make a difference in how, where ond when benefits are available to you. This section lists and explains these conditions. Churigeb in Your r:cirniry We must be notified within 30 da ys of any chc:ingos 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. Criein9eb to Yeur' Coertereiele BCBSIV employees, agents or representatives cannot agree to change or add to the benefits described in this Certificate. Any changes must be In writing and approved by BCSSM and the Michigan Insurance Commissioner. NI We may add or delete benefits by issuing a rider. For your convenience, keep any riders you receive with this book. ieeiiie:;01100 When we need to notify you, we mail the notice to your remitting agent. Ihis fulfills our obligation to notify you. C'Uc COVetiCeje In certain cases, we may hove poid for vision Services under your Certificate for which another person. insurance company or organization should have paid. In these cases You grant us your right to recover our payments from them. You grant us a lien on all money, specifically Identified as medical costs. Mut 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 lion 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. You are required to do whatever is n9C95sciry to help us enforce our right of recovery. si It you receive money through a lawsuit, settlement or other means for services paid under this Certificate, you must reimburse us lor This does not apply if the funds you receive ore from additional coverage you purchased in your name from on 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 at 1954. To the extent that the services covered under this Certificate are also covered and payable under another group vision core pion, we will combine our payment with that of the other pion 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 ore not legally qualified or licensed to provide such services are not payable. Experimental Services Services which we dotermine to be experirnentai or investigational are not covered by this Certificate Please see the definition in The Language of Vision Care" in this book. 13 • If an optometrist recommends on examination by a physician, we pay for this examination. II The examination by the physician must be within 60 days following the optometrist's examination. Eyeglass Lenses We pay for eyegrioss lenses when prescribed or dispensed by a physician. optometrist or optician. Lenses may be molded or ground. glass or plastic. Ili Lenses must be equal in quality to the first-quality lens series made by American Optical, Bausch & tomb, or Tillyer and Unlvis. Id The ler is blank must meet 280.1 or Z80.2 standards of the American National Standards Institute. ha The lenses must be coioriess. or Tinted lenses equal to Rose tints #1 and #2 are covered if they are necessary for therapeutic purposes. ▪ The provider may bill you for the difference in cost between clear and non-therapeutic tinted lenses. po The lens blank of a standard lens must not exceed 65 mm in diameter. hi The provider may charge you for the difference in cost between standard and oversize lenses. Spcicit Lenses We pay for the following special lenses: Myodisc Lenticular myodisc Lenticular aspheric myodisc Aphakic IN Lenticular aphakic: 31 Lenticular °Spheric ophokic We do not pay for aphokic lenses for aphakia (lack of natural lens). These may be covered by your BCBSM hospital-medical-surgiccil 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 S14.75, plus a dispensing fee for standard eyeglass frames. • It 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 • Suitability Exam A contact lens suitability examination determines whether you con wear contact lenses. The exam may include: 1111 Biomicroscopic evaluation • Lid evaluation • Ophthalmoscopy • Tear test • Pupil evaluation • Fluorescein evaluation • Cornea evaluation • 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 SECIION 6: Whot You Must Pay This section explains the copaymeni you pay for covered vision SerVIC04. Vion Tvstilkg EACialiflatiOn hi Your copayment is 55.00 irk No copayment for a second examination by a physician when recommended by optometrist. ky ,gicisses is Your copayment is S7.50 or One copayment amount for both lenses and trarries No copayrnent for eyeglasses obtained from a non-participating provider, but you are responsible for charges in excess of our payment. fit Your copayment is $7.50 for medically necessary contact lenses ha No copoyment for cosmetic contact lenses but you are responsible for charges in excess of our payment. • 20 SECTION 7: Vision Services Not Coverci We do not pay for: is Additional charges for MI Lenses tinted darker than kose Tint #2 • Anti-reflective and photosensitive lenses • Oversize lenses III Sunglasses ▪ Medical-surgical treatment ▪ Medications administered during any service except a vision exam NI Services or materials ordered before Coverage began MI Services not prescribed by the attending physician or optometrist its Special services, such as orthoptics, vision training. low (subnormal) vision aids aniseikonic lenses and tonography • Replacement of broken or lost lenses of frames •-• 11 Services covered by Workers'Compensation Laws • Services received at a medical clinic provided or maintained by on employer • Services covered by government approved health care programs such as Medicare or CHAMPLIS • Services received as a result of on 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 hi Charges for completing insurance forms • Aphcikio lenses when the patient lacks a natural lens • Charges for experimental or poor quality services 21 soommimimmx• • Resolution #0717 — (Ordinance #29) July 19, 2007 Moved by Rogers suppo -tecl by Kowal: toe resoiution be adopted_ AYES: Crawford, Douglas, Gershenson, Gingell, Gossek, Gregory, Greimel, Hatchetl, Jacobser,, Kowali, Long, Middleton, Nash. Potter, Potts, Rogers, Scott, Spector, Suarez. Zack, Bollard, Burns. (22) NAYS: None. P) A sufficiert majority having voted in favor, trio resolution was adopted. • AM. I IBM PROVE THE FOREGOING IISOLVION STATE OF MICHIGAN) COUNTY OF OAKLANO) I, Ruth Johnston, 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 cn ,,iuly1G, 2307. with the original retorci thereof now remaining in my office. In Testimony Whereof, I have hereunto set my hand and affixed tne seal of the County of Oakland at Pontiac. Michigan this 19th day of July, 2007. •