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CITY COUNCIL AGENDA PACKET
November 23, 1993
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AGENDA
CITY OF DENTON CITY COUNCIL
November 23, 1993 0
Special Call Session of the City of Denton City Council on Tuesday,
November 23, 1993 at 5115 p.m. in the Civil Defense Room of City
Hail, 215 E. McKinney, Denton, Texas at which the following items
will be considered)
5115 P.M.
1. Executive Sessions
A. Legal Matters Under TEX. GOVT CODE Sec. 551.071
1. Consider claim against GTE relating to franchise
payments.
2. Consider action in the matter of the application of
Bolivar Water Supply Corporation for an amendment
to CCN No. 112571 Docket Nos. 9824-C and 9447-C of
the Public Utilities Commission.
3. Consider settlement in Roebuck V. City of Denton.
B. Real Estate Under TEX. GOVT CODE Sec. 551.072
C. Personnel/Board Appointments Under TEX. GOVT CODE
Sec. 551.074
1. Discussion regarding the hiring of a second
Assistant Municipal ,judge.
2. Consider adoption of an ordinance accepting competitive bids
and providing for the award of contracts for the purchase of
employee group health insurance to Harris Methodist Health
plan) providing for the administration of the contract; and
providing for the expenditure of funds therefor.
3. Consider adoption of an ordinance approving a letter of
understanding between the City of Denton and Harris Methodist
Health Plan relating to the award of Bid No. 15231 and
authorizing the City Manager to execute the letter.
4. Consider approval of a resolution adopting Policy No. 107.08
"Contribution Rate for City Employee Benefit Allowance".
5. Consider approval of a resolution est,tilishing the City's
contribution rate to the city employee nefit allowance; and
establishing payments that the City will make to employees.
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Agenda Oate_
6. Consider adoption of an ordinance authorizing the execution of
a change order to a contract between the C-Cy of Denton
Steele-Freemanj and providing for an increase in the contract
price.
7. Consider adoption of an ordinance retaining the lawfirm of
Wolfe, Clark & Henderson to represent the City of Denton in
litigation pending against the City; and authorizing the
expenditure of funds therefor.
S. Consider a motion to call the Cushman Addition escrow.
9. Consider appointments to the Keep Denton Beautiful Board, the
Electrical Code Board and the Juvenile Diversion Task Force.
10. Miscellaneous matters from the City Manager.
11. New Business
This item provides a section for Council Members to suggest
items for future agendas.
NOTE: THE CITY COUNCIL RESERVES THE RIGHT TO ADJOURN INTO
EXECUTIVE SESSION AT ANY TIME REGARDING ANY ITEM FOR WHICH IT IS
LEGALLY PERMISSIBLE.
C E R T I F I C A T E
I certify that the above notice of meeting was posted on the
bulletin board at the City Hall of the City of Denton, Texas, on
the day of , 1993 at o'clock (a.m.)
(P.M.)
CITY SECRETARY
NOTE: THE CITY OF DENTON CITY COUNCIL CHAMBERS IS ACCESSIBLE IN
ACCORDANCE WITH THE AMERICANS WITH DISABILITIES ACT. THE
CITY WILL PROVIDE SIGN LANGUAGE INTEP7RETERS FOR THE
HEARING IMPAIRED IF REQUESTED AT LEAST 48 HOURS IN
ADVANCE OF THE SCHEDULED MEETING. PLEASE CALL THE CITY
SECRETARY'S OFFICE AT 566-8309 OR USE TELECOMMUNICATIONS
DEVICES FOR THE DEAF (TDD) BY CALLING 1-800-RELAY-TX SO
THAT A SIGN LANGUAGE INTERPRETER CAN BE SCHEDULED THROUGH
THE CITY SECRETARY'S OFFICE.
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DATE: November 23, 1993 DO
C;1Y ~OUNC;L Bf YAO
SPECIAL C4LLEO SESSION
TO: Mayor and Members of the City Council
FROM: Lloyd V. Harrell, City Manager
SUBJECT: City Employee's Health Insurance Program - Effective
January 1, 1994
MQ ADWAT Ol!Cc_
It is the staff's recommendation that the City Council authorize
the City Manager to enter into contracts with Harris Methodist
Health Insurance Ccmpany (Harris Methodist) to provide health
insurance coverage for City of Denton employees, retirees; and
their dependents for the plan year January 1 to December 31, 1994,
SUMM98Y;.
On October 26, 1993, the City Council authorized staff to proceed
with:
o finalizing a service agreement with Harris Methodist Health
Plan to be brought to the Council for approval in November,
1993; and
o developing a transition plan for conducting open enrollment
and working out the necessary administrative issues to
implement the Harris Methodist Plan effective January 1,
1994 (if Council provided final approval).
The contracts and service agreements are shown in Exhibit I. City
Council stipulated that the agreement with Harris specify the
three year rate increase and renewal agreements. Council further
indicated that an agreement outlining the desire of staff and
Council to explore the addition of medical
providers in their ~
network, including efforts to add Denton Regional Medical Center,
be included.
It is the interpretation of Harris representatives that current
state insurance regulations specify that any contract amendments
must be filed with the state for their approval. In order to stay
on track for the planned December enrollment insurance meetings, a
letter of understanding has been developed specifying the rate
guarantee agreements, renewal agreements, and agreement concerning
network providers. Upon approval of City Council, Harris w1ll
file these with the state. Upon state approval, Harris and the
City have agreed to formally amend the contracts to incorporate
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Agenda Itemf.-~------
November 23, 1993 Dole LY~
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City Council Report on Employee Health Insurance oZ e
Page 2
the provisions desired. The letter of understanding is shown in
Exhibit 11.
Since the October 26th City Council meeting, it has been
determined that Harris and Denton Community HCA Hospital have an
exclusive contract with approximately 22 menths remaining. Mr.
Mike Clark, Senior Vice President of Managed Care Marketing with
Harris Methodist, has had preliminary discussions with HCA
officials on this matter. Their first issue in these discussions
was to determine if HCA will be motivated to provide some
flexibility in their contract with Harris. If so, it may
naturally take some time to work out the technical, legal, and
rate schedule agreements with various doctors. Therefore, as we
discussed with Council at the October 26th meeting, from a
practical standpoint, it would probably be the next plan year
(1995) before all components can be ironed out.
In the meantime, the proposed plan designs currently offered do
include the choice for both hospltels on the "Preferred Plus"
(non-HMO) portion of the new health insurance program.
Harris has additionally met its commitment of the October 26th
meeting by providing us with an update on their provider network
of physicians and other medical providers (Exhibit III). By the
time the contract becomes effective (January 1, 1994), there will
be 17 primary care physicians in Denton for employees and
dependents to chose as their primary doctor. These primary
doctors will be able to refer to 33 specialty doctors in Denton,
There are also primary care and specialty doctors in the other
Denton County cities. Further, Mr. Clark has notified us that
any primary care physician in Denton that meets the Harris
credentialing process and standards may be added to the network.
It must be stressed that an employee who chooses the Harris
Preferred Plus (higher level) program and pays an additional $6.00
to $8.00 per pay period in premium (above what was proposed by
PALICO), may receive care from any doctor or hospital in Denton or
elsewhere for covered benefits. This would include Denton
Regional Medical Center and doctors not on the Harris network
list. It is estimated that approximately 50% of the City's
employees will chose this option during open enrollment.
With City Council approval, the staff will proceed to finalize the
transition plan, conduct open enrollment meetings, conclude
necessary administrative issues and details, and implement the
Harris Methodist Health Insurance program effective January 1.
1994.
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Apendaltem
November 23, 1993
City Council Report on Emp'oyee Health Insurance . ~Jfo(0
Page 3
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On October 26, 1993, the City Council reviewed the staff
recommendation concerning health insurance program options for
City employees. Staff provided Council the results on an in-depth
analysis of two lowest insurance bids, Aetna and Harris Methodist,
and one renewal proposal with the current carrier, Philadelphia
Life Insurance Company (FA!.ICO) using the following criteria:
1) total plan cost us,ng monthly premiums quoted and projected
enrollment (City cc,st and empIoyse cost);
2) length of rate guaraitee;
3) schedule of benefits and plan design features, such as co-
payment, deductibles and out-of-pocket maximums;
4) Network providers (Doctors, hospitals, and other medical
providers)
5) ability to provide quality service for providers, employees
and dependents, and administering contract provisions.
While on the surface the Aetna proposed plan offers considerable
savings to the City over the budget amount, it has several
negative features:
1) Higher overall cost than the Harris bid
21' No second or subsequent rate increase guaran.ses
2) Limited access to pharmacies (Eckerd's only,
3) Concerns about the stability of the current provider
network
4) No in-Denton representative to assist employees,
dependents, and providers with problems and questions
5) No mental health coverage except through network providers;
no mental health providers listed for Denton
The renewal with PALICO was not recommended for the following
reasons:
1) Overall higher cost than the other plans considered,
2) Higher co-pays, deductibles, and out-of-pocket maxinums
3) Requirement that employees initiate and are responsible
for referral to specialty providers
4) Service and administration difficulties for both
employees, City staff, and providers
5) Uncertainty of rate increase beyond current year
Considering the combined relative importance of all evaluation
criteria, our analysis shows that the Harris Methodist Insurance
program will offer the City ani its employees and dependents:
1) low(5t overall total plan costs; lower cost to employees
and tower cost than budget for the City,
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Agenda Itek,_ ~9_______,_
Date
November 23, 1993
City Council Report on Employee Health Insurance
Page 4
2) an option for the employee to chose either:
o a Health Maintenance Ortily (HMO) Only
OR
o an HMO pl_+ Indemnity Plan
2) improved plan design and coverage (co-pays., deductibles,
out-of-pocket maximums, etc.) over the current carrier
3) ability of City to bi3tty, plan, budget, and manage
insurance coots for both employees and the City with a
guaranteed 3 year not; to enc.-d 15% rate increase
4) stable network of providers and %apitals for the size
g% up being insured; providers to -,ver rate estimated at
5) positive references of both employees and providers
concerning quality and service
Both the Employee Insurance Committee (El(;) and the Executive
Committee have reviewed the Harris rethodist Plan and agreed to
recommend it to the City Council.
Certainly, the Harris program is not without issues that concern
the staff in the delivery of health insurance to City employees
and their dependents. However, giwjn the options that developed
over the past six month, it represents an improved program over
what we were currently presented by the current carrier, PALICO,
or what was proposed by Aetna, The staff will closely monitor
Harris' performance over the 1994 Plan Year and will be prepared
to recommend to City Council a re-bid of the health insurance
program should expectations nDt meet our standard.
P_,WRAJM,_.DUP RIMORT$ _Q R_-99S E$_IfF f ME Q_-.
The employee Health Insurance Program co!ers all regular full-time
and part-time employees in all City departments.
FULL IM Pi I-4
If the Harris Methodist Plan is implemented on January 1, 19949
the City's cost for employee health insurance coverage would be
reduced substantially from the proposed PALICO plan of $220.32 per
employee per month to the Harris Methodist; Plan of $192.50
($188.50 + $4) per employee per month. The estimated savincis for
Date
November 23, 1993
City Council Report on Employee Health Insurance
Page 5
the City over what was budgeted in 1993/94 is $201,770 (and
$121,663 in General Fund).
Resp fully submitted:
Lloyd V. Harrell
City Manager
Prepared by:
Thomas W. Klinck, Directar of Human Resources
Approved:
ABetty McK n, Executive Director
Municipal Services and Economic Development
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Agenda No
12. COPAYMENT shall mean the fee as set forth in the Schedule of Benellts~ 1 ~tol covered by
di►eyblhei~r537t o'~~'a~ g~
premiums payabto hereunder, and which must be paid by Members
entity providing the service when the service as set forth in the Schedule lfleneLls is received -
13. COURSE OF TREATMENT shall mean that period of time represented by an inpatient hospital admission and related discharge during which time treatment has been received
by a Member or
that period of time authorized by a Participating Physician andlo( Harris Health as necessary to
complete a cycle of treatment and subsequently provide a medical release to the Member.
14. CRISIS STABILIZATION UNIT shall mean a twenty-four (24) hour residential program, licensed by
Texas Department of Menial Health and Mental Retardation, that is usually short-term in nature
and that provides intensive supervision and highly structurod activities to persons who are demon-
strating an acute demonstrable psychiatric crisis of moderate to severe proportions.
15. CUSTODIAL CARE shall mean 1) that care which is marked by or given to watching and protect.
ing rather than seeking to cure; or 124 MOO vhich is_nQLLWessary part of medical treatment or
recovery, or 3) care comprised of snargv~l~~jpdd supplies that are primarily provided to assist in the
activities of daily living
16. DEPENDENT shall mean an EligibIMpendent wfw has satisfied the eligibility and participation
requirements specified in this Agreement.
17. DOMICILIARY CARE shall mean that care provided for persons so disabled or infirm as to be
unable to live independently.
18. EFFECTIVE DATE shall mean the effective dale of coverage for Eligible Persons and Eligible
Dependents pursuant to the terms of this Agreement.
19. ELIGIBLE DEPENDENT shall mean an Individual as defined in Section 3.2 of this Agreement.
20. ELIGIBLE PERSON shall mean an individual as defined in Section 31 of this Agreement,
21. EMERGENCY CARE shall mean bona fido emergency services provided after the sudden onset of
a medical condition manifesting itself by acute symptoms of sufficient severity, including severe
pain, such that the absence of immediate medical attention could reasonably be expected to
result in placing the patient's health in serious jeopardy; serious impairment to bodily functions; or
serious dysfunction to any bodily organ or part
22. EVIDENCE OF INSURABILITY shall mean that an Eligible Person or Eligible Dependent verifies
that they were enrolled for the preueeding twelve (12) months in a group or individual plan provid-
ing benefits for medical, surgical and hospital expenses; and completes the Evidence of Insurabil-
ity form and provides timely any additional documentation of health status as required by Harris
Health. Such information shall be reviewed by Harris Health and the Eligible Person or Eligible
Dependent shall be notified regarding their eligibility for participation in Harris Health.
23. U(CLUSION shall mean those specific conditions or causes for which coverage by Harris Health
is entirety excluded.
24. FDA shall mean the Food and Drug Administration, an agency of the United States government.
2'. GROUP shall mean collectively 11,E contracting employer and all affiliated organizations of the
employer as set forth in Attachment A annexed hereto and made a part hereof, to which this
Agreement is Issued and through which as agent for Subscriber and not for Harris Health, Sub.
, scriber and Dependenis become entitled to the benclits as set forth in the Schedule of Benents.
26. GROUP 'FFECTIVE DATE shall mean the date specified as such in the Group Enrollment
? Agreenteut.
27. GROUP ENROLLMENT AGREEMENT shall mean that agreement which is executed between Har-
ris Health and Group for the purpose of making available to Eligible Persons arnf Eligible Depen-
dents of Group those benefits and services which are described in the Group Health Care
L, Agfee nenV Subscriber Certificate of Coverage. Such Group Enrollment Agreement shall idrintify
the Group, Group Effective Date, eligibility requirements, rates, and covered benefits.
28. HARRIS HEALTH shall mean Harris Health Plan, $no,, a Texas not-for-profit corporation organized
as a Health Maintenance Organization (HMO) and licensed by the Texas Department of
Insurance.
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29, 11EALi H PLAN Stoll mean It re Healih Maintenance Ofgaiiuatiai Opera k ~~Qarns fietdbha'-'
liarris Mcihodisl 1leallh Plan AgBtld3itllm
30. HOSPITAL shall mean an institution licensed t,y the Sldh PI Tuxas%V --77 -7A 31 -P
which is-(l)_prrcnarnly
engaged in providing diagnostic, medical and surgical laci6ties for the care and treatment of poly,
Injured or sick persons, (2) operated under the medical supervision of a staff of legally qualified Oil
and licensed physicians, (3) provides twenty-four (24) hour-a-day ruirsing service by or under the
direct supervisicn of a Registered Nurse (R.N.), (4) provides for overnight care of patients, (5)
maintains clerical and ancillary services necessary for the treatment of medical and surgical
patients including but, not limited to laboratory, X-ray, dietary and medical records library. In no
event shall the term "hospital" include a convalescent nursing home or any Institution or part
thereof which is used principally as a oonvalescnnt facility, rest facility, nursing facility, facility for
the aged, extended care facility, intermediate care facility, skilled nursing facility or facility primarily
for rehabilitative services; the term hospital shall, pursuant to Chapter 3, Texas Insurance Code,
Article 3.72 include treatment in a reggkdd~ential ireatme center for children and adolescents and
treatment provided by a cri;.is sfl 9rfF~f48n unk
31. INDIVIDUAL TREATMENT PLAh1{jfAl3R'i~ars aTre tma erd plan with specific attainable goals and
objectives appropriate to both thy~Ratient_gltdthaueatmenl modality of the program.
32. KIDNEY DIALYSIS CENTER shall mean any facility licensed by the Slate of Texas, approved by
Medicare to provide outpatient services and/or Instruction in home kidney d'ial'ysis treatments and
which has contracted with Harris Health to provide care to Members.
33. MEDICAL DIRECTOR shall mean the licensed Physician designated by Harris Health and/or such
other Physicians as the Medical Director may designate with the prior approval of Harris Health.
Such physician shall be responsible for supervising the delivery of medical serviwe. to Members
and for monitoring the quality of medical care rendered to Members.
34. MEDICAL EMERGENCY shall mean a medical condition so classified by the medical director acid
which manifests itself by acute symptoms of sufficient severity (including severe pain) such that
the absence of immediate medical attention could reasonably be expected to result In (a) placing
the patient's health in serious jeopardy; or (b) serious impairment to bodily functions; or (c) serious
dysfunction to any bodily organ or part. Examples of conditions which do not usually constitute
medical emergencies are colds, influenzas, ordinary sprains, children's ear Infections, or nausea
and headaches. Heart attacks, cardiovascular accidents, poisonings, fuss of consciousness or
respiration, convulsions, severe bleeding or broken bones are examples of true medical
emergencies.
35. MEDICALLY NECESSARY shall mean services or supplies which are (1) provided for the diagno-
cis or care and treatment of a medical condition: (2) appropriate and necessary for tfte symptoms,
diagnosis or treatment of a medical condition; (3) generally acceptable medical practice; (4) per.
formed in the most cost effective and efficient manner appropriate to treat the plan Member's
medical condition; and (5) provided in accordance with accepted medical standards and Harris
Health requirement3 as approved by the Health Plan's review committees for professional and
technical practices and the Health Plan Medical Director.
36. MEDICARE stall mean Part A and Part B of Title XVIII of the Social Security Act and any amend-
ments or regulations thereunder,
37. MEMBER shall mean any Subscriber and/or Dependent.
38, MEMBER HOSPITAL shall mean any Hospital which has contracted with Harris Health to provide
to Members the services as set forth in the Schedule of Benelds and described in this Agreement.
39. NOWMEMBER HOSPITAL shall mean any Hospital which has not contracted with Harris Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement.
40. MINOR EMERGENCY CENTER shall mean any licensed facility, not including a Hospital, which
provides Physician services for the immediate treatment only of an injury or disease. i
41, NON-PAHTICIPATiNG PHYSICIAN shall mean a Physician who is not a Participating Physician and
to whom a Member is referred for consultation or treatment by a Participating Physician only with
a
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HARRIS HEALTH PLAN, INC.
1300 Summit Avenue
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Fort Korth, TY 76102
agentla~ten~_,.
(817) 878-s830
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1-e00-633-859e
GRO'.P ENROLLMENT AGREEMENT'
Application is hereby made to Harris Health Plan, inc., hereinafter called "Harris
Health" by the Applicant named below, hereinafter called "Group" for the purpose of making
available to Eligible Persons and their Eligible Dependents under a Group Health Care
Agreement/Subscriber Certificate of Coverage, hereinafter called "Agreement" issued by Harris
Health, certain prepaid health care services and benefits. The arrangement of the provisions
of such services and benefits shall be the subject of the Agreement between Harris Health and
Group and shall be based on the statements and representations contained in this Group
Enrollment Agreement, a copy of which shall be incorporated by reference and made a part of
the Agreement.
1.0 GROUP
Group Names City of Denton
Address ` 324 Fast McKinney.
Citys Denton States _ Tx Zip codes _76201
2.0 GROUP EFFECTIVE DATE
This Group Enrollment Agreement shall be effective 12:01 A.M., central Time, on the
1st day of a u ty,,, 199A.
3.0 ELIGIBILITY
Any person or his/her dependents who meet the eligibility requirements for coverage
under the Group's Alternative Health Benefits Plan shall be eligible for coverage under
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Agreement an specified in Section 3.1 and Section 3.2 of Agreement.
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Rules of eligibility: Per the written ellolbili euidb'liner //JA _6 -9
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4.0 HEALTH CARE SERVICES (BENEFITS) AND COPAyMENTS
Eligible Persons and Eligible Dependents of Croup are entitled to Health Care Services
and Benefits as follows,
l.. Basic Health Care Services
X Covered - Basic Health Care Services as described in the
Schedule of Benefits.
9. Prescription Drugj
_ Accepted
Not Accepted
5.0 COVERAGE BASIS
x_ Contributory
Non-Contributory
6.0 SCHEDULE OF RATES
Total Monthly
Rate
ct
Employee Only $188.50
Employee + Spouse $292.98
Employee + Child(ren) $253.13
Employee + Family $318.45
Retirees nder~
Retiree Only $255.34
Retiree and Spouse $493.3S
i Retiree and Child(ren) $398,71
Retirea and Family $604.26
I
ROtireea 6 or over iM di are_servee asrvl
Retiree only $ 94.25
2 on Medicare $188.50
1 on, off $384.54
1 on, 1 off + Family $557.58
2 on + Family $368.00
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Group Enrollment AgreA•.,r•.c shall be automatically renewed at the end of each 'la Contract period ?P'.e terminated by Harris Health or Group as
provided in Agreement.
The fire: Con"tact period shall commence as of the Group Effective Date and will remain
in effiet for twelve (12) consecutive months unless terminated before this date by
s
Harris Healtt or Group.
IN WITMroS WHEREOF, the undersigned have caused the Group Enrollment Agreement to be
executed on the day of
clup~f Winton
G HARRIS HEALTH PLAN, INC.
Group
By, gys f 1_,r Lam' ! l_
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Authorised Representative
TitlesSenlor Vice Pr sidentlHanaaed Care
Titles
Address: j24 ast McXinrsv Market Va
Denton, T% 76201
Telephones
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Harris Methodist 1ER'----a
Health Plan
October 22, 1993
Mr. Thomas Klinck
Director of Human Resources
City of Denton
215 E. McKinney
Denton, Texas 76201
Re: City of Denton Health Plan Proposal
Dear Mr. Klinck:
Harris Methodist Health Plan is pleased to respond to the following issues as presented by
the City of Denton.
1) REQUEST FOR A MULTIYEAR RATE GUARANTEE.
HMHP is prepared to provide a rate guarantee tluough the second and third plan
year for the Preferred HMO plan only. Our conditions for the 1995 and 1996 rate
guarantee is that the City of Denton contribution to the employee rate for our
Preferred HMO plan must be 100`90 and we will be the only carrier offered by the
City of Denton.
The Preferred HMO plan guarantee will be as follows:
"The years 1995 and 1996 combined maximum rate guaramee will not exceed a total
of 15%. The year 1995 will not exceed 9.9% of our 1994 rate."
2) EXPANSION OF THE DENTON AREA PROVIDER NETWORK TO PROVIDE
FOR THE CITY OF DENTON EMPLOYEES.
As the City of Denton employees expand the needs for additional health care services
in the Denton area, the HMHP is conunitted to ongoing assessment of these needs
and expansion of our current network through the recruitment of appropriately
qualified providers to serve these need:.
A member or
HAff4 Mcthod4t HeAhk System
rY10 SummiLA~enue 1 Sui1e5001 F0. 001901051! Fort WotAb jeers 16106211541917 87tl SA(Wlfustomu Set•ce telephone Numtxl U11 878 5876
1 0
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Ten additional Denton providers have been approved recently and will be added to/ / Y,
the network as soon as contracts are executed. Your request for additional hospital !vim
services through Denton Regional Medical Center will be given consideration for
future needs. this ongoing effort will continue as a part of our partnership with
employer groups that we serve in the Denton area.
3) COVERAGE FOR EMPLOYEES NOT ACTIVELY AT WORK.
HMHP considers actively at work to include anyone the new employer group
considers to be actively at work. This would include those employees that are off on
approved medical leaves of absences, vacation, holiday, jury duty, or other similar
circumstances.
We would be very pleased to add the City of Denton to our family of satisfied clienrs. Please
feel free to call me at 878-5836 should you have any questions regarding the Harris
Methodist Health Plan proposal,
Kindest Regards, ,
I
Agenda No
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Director of ales Agandallem^
Managed Care Marketing [Cite
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Harris Methodist
Health Plan
GROUP HEALTH CARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
8171878.5826
1.800/633 8598
GA 992
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'We Health Plan, Inc.
L iealth Mallltellance organization
W Suinn6t Avenue, Suhe 300
tt Worth, Texas 76102
AV ISO IMPORT ANTE
INIpORTANT NOTICE Para someter Una
Para obtener information o p
To obtain information or make a complaint: queja:
Usted puede llamar al numero de telefono gratis de
.ou may call Harris Health Plan, Inc. 's toll tree
telephone one number for inf6rmation or to make a Harris Health plan, inc. Para information o Para
~ p at: someter Una queja al:
I.800.633-8598 1-800-633.8598
'ou may contact the Texas Department puede comuai`ar obtener informacnon acetcarde
insurance to obtain information on comp de Texas p al:
insurance, rights or complaints at: companias, coberturas, derechos 0 que1as
1.800-252.3439 1.800.252.3439
nt of urns de
You may write the Texas Departnte puede. escribir al Departmento de Seg
nsutance Texas
P.O. Box 147104
Austin, TX 78714.9104 P.O. Box 149104
FAX # (517) 475.1771 Austin, TX 78714.9104
FAX # (512) 415-1771
ATTACI Tills NO'FICE TO YOUR POLICY: UNA ISTR AVISO A SU POLIZA: Este aviso es
ice is for information only and d
ibis not oes not Para proposito de information y no se
ition of the attached p
Become a part or cond solo
document. convierte en parte, o condition del documento
adjunto.
ApendaND_ 9.3-D~Y
TABLE OF CONTENTS Agerdallem0 `'a
Page o .0 General Definitions 2 8.0 IttdepenCeni AgAW R usal laAC ~e~J
iQEBfiAr;ciP , 17-7../. Ef
2.0 Group and Affiliated Organizations 6
2.1 Organizations Included Under This 8:1e indepondent Agents •""""""""""•""'18
Agreement 6 8.2 Limitation on Liability ................19
8.3 Refusal to Accept Treatment/Excessive
2.2 Change of Affiliated Organizations 6
• Treatment .......................................19
3.0 Eligibility and Effective Date 6 9.0 Exclusions on Service Responsibilities ............19
3.1 Eligible Persons 6 9.1 Major Disaster or Epidemic 19
3.2 Eligible Dependents 6
,3 Change in Group Eligibility Criteria 7 9,2 9 .2 Circumstances Obtained Control ...............20
33.4 Effective Date for Eligible Persons 7 .4 Discontinuance Fraudulently Obtained Benefits ...............20
3.5 Effective Date for Eligible Dependents 7 9.4 20
3.6 Persons Not Eligible for Coverage • 8 10.0 Member Complaint Resolution Procedure ........20
3,7 Conditions of Eligibility 8
Notification of Ineligibility 10.1 Complaint Resolution Process ...............20
3.8 No 8 10.2 Complaint Resolution Appeal Process ......21
3.9 Clerical Error 8
4.0 Group and Member Termination, Continuation of 11.0 Health Care Services ...............................21
Benefits and Conversion 6 11.1 Benefits and Services ........................21
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4.1 Termination of Group 8 12.0 Term and Amendment of Agreement ..............22
4.2 Termination of Member - For Cause 9 12.1 Term .............22
4.3 Termination of Member - Other Than for
Cause 122 Amendment .........................................22
........................................10 12.3 Change of Rates I......... 22
4.4 Liability Upon Termination .....................10
4.5 Continuation o' Coverage .....................10 110 Miscellaneous Provisions 22
4.6 Conversion Privilege ...........................11 13.1 Use of Words
5.0 Payment Requirements • •.....11 132 Records and information ...................22
13.3 Information from Group ....................22
5.1 Premium Payments ..1 1 13,4 Assignment ..........23
5.2 Notification by Group 12
135 Authority . ..................................23
53 Cbpayments _ .......................12 136 Governing Law
.....23
6.0 Claim Provisions ....................................13 13.7 Incorporation by Reference ,...............23
6.1 Charges Paid by Members 13 13.8 Entire Agreement ...........................23
' 119 Information to Member .....23
62 Medical Emergency """""""'............13
13.10 Uniform Rules 23
63 Action on Claim .....13 1111 Calculation of Time 23
6.4 Examination o ember .......................13 13.12 Evidence .
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6.5 Limitation Provisions """"""""""""'..13 13 13 SeverabiGty . • • • • • • . • ..23
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7.0 Coordination and Subrogation of Benefits .......,14 13.14 Venue ........................................24
7,1 Definitions ...............14 13.15 Waiver of Not'ice............................. 24
7.2 Determination of Benefits ....14 13.16 Headings ...........,,.......................24
7.3 Order of Benefit Determination .........15 13.17 Notice of Cerlain Events ....................24
7.4 Medicare 16 13.18 Notice of Termination 1.11 . ...........24 7.5 Right to Receive and Release Information 17 13.19 Notice
24
7.6 racility of Payment .............................17 Allachmenl A Service Area Map and Description
7.7 Right of Recovery ..............................17
7.8 Disclosure ......................................18
7.9 Subrogation ....................................18
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section ..o a(aendaNo .__Q.'1.:11.~.
G[NERAt_ DEFINITIONS Agenda'lent.
L ACIIVILLY AT WORK shall mean that the eligible employee must be 'Awming aw-usuaLa d cus
tomary duties of his regular employment during his usual working hours on his effective date of
coverage; provided, however that if the eligible employee is absent from work due to vacation,
holiday, jury duty, or other similar circumstances, not caused by injury or illness, such ptoveP
shall be considered actively at work. Agenda No j~/yJ',~~ I~
2. ACUTE shall mean a condition of sudden onset or AgpedV1%WR omatofogy which mandates imme-
diate intervention. -
3. AGREEMENT shall mean this Group Health Care Agreement/Subscriber Certificate of Coverage,
Group Enrollment Agreement, Applications, all Attachments, Riders, Amendments herelo, if any.
4. ALLIED HEALTH PROFESSIONAL shall mean a dentist, nurse, audiologist, optometrist, physician's
assistant, clinical psychologist, pharmacist, nutritionist, physical therapist, speech language
pathologist, dietician, podiatrist, certified social worker (advanced clinical practitioner) and other
professionals engaged in the delivery of health services who are licensed, practice under an insti-
tulional license, are certified, or practice under the authority of a Physician or INally constituted
professional association, or other authority consistent with the laws of the Stale of Texas.
5. ALTERNATIVE HEALTH BENEFIT PLAN shall mean the plan which the Group designates as the
alternative to this Agreement.
6. APPLICATION shall mean the form prescribed by Harris Health which each Eligible Person shall
on his/her own behalf and or, behalf of his/er Eligible Dependents, be required to complete and
submit to Harris Health for the purpose of enrolling himself/herself and such dependents for cover.
age hereunder.
7. CHEMICAL DEPENDENCY, means the abuse of or psychological or physical dependence on'or
addiction to alcohol or a controlled substance.
8. CHEMICAL DEPENDENCE TREATMENT CENTER shall mean a facility which provides a program
for the treatment of chemical dependence pursuant to a written treatment plan approved and
monitored by a physician and which facility is also:
a, affiliated with o hospital under a contract agreement with an established system for patient
referral; or
b, accredited as such a facility by the Joint Commission on Accreditation of Health Care Organi-
zatioM or
a. licensed as a chemical dependency treatment program by the Texas Commission on Alcohol
and Drug Abuse; or
d. licensed, certified, or approved as a chemical dependency treatment program or center by
any other state agency having legal authority to so license, certify or approve.
9. COMPLICATIONS OF PREGNANCY shall mean those conditions, requiring hospital confinement
(when the pregnancy Is not terminated), whose diagnoses are distinct from pregnancy but are
adversely altected by pregnancy or caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of compa•
rable severity. Complications or pregnancy shall not include false tabor, occasional spotting, physi-
cian prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum,
pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not
constituting a nosologically distinct complication of pregnancy; non-elective cesarean section, ter-
mination of ectopic pregnancy, or spontaneous termination of pregnancy occurring during a
period of gestation in which a viable birth is not possible.
10. CONTRACT YEAR shall mean the period of tvrelve (12) months commencing on the Group Effect
live Date and each twelve (12) month period thereafter, unless otherwise terminated as hereinafter
provided.
11. CONTROLLED SUBSTANCE shall mean a toxic Inhalant or a substance designated as a con-
trolled substance in the Chapter 481, Health and Safely Code.
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55. SPEGIALISI PHYSICIAN shall mean any Physician Who has c(H)lracled wilt) HJ)riS l lealLl) lu pro-
vide specialist care to Members upon referral of a Primary Physician or upon referral of another
Specialist Physician wish the concurrence of the responsible Primary Physician
56. SKILLED NURSING FACILITY shall mean an institution or part [hereof, licensed by slate or local
law, that is accredited as an Extended Care Facility by the Joint Commission on Accreditation of
Health Care Organizations, or is recognized as a Skilled Nursing Facility by the Department of
Health and Human Services under Tole XVII104WS88W SewrVAct (Medicare), as amended.
57. SUBSCRIBER shall mean an Eligible Persorrl$d0410-zatisfied The eligibility and participation
requirements specified in this Agreement. Dale
58. TOXIC INHALANT means a volatile chemical under Chapter 484, Health and Safety Code, or
abusable glue or aerosol paint under Section 485.001, Health and Safety Code.
59. USUAL, CUSTOMARY, AND REASONABLE CHARGES shall mean the charge is (1) the fee
charged by a provider in normal practice for a given service; (2) within the range of usual charges
by providers for the same service in the geograph:; area where services are provided to a Mem-
ber; and (3) reasonable when taking into consideration any unusual circumstances or medical
complications requiring additional time, skill and experience in providing a specific trealment or
service,
agendaNo.
Section 2.0 A eadalte
GROUP AND AFFILIATED ORGANIZATi0f1A
2.1 ORGANIZATIONS INCLUDED UNDER THIS AGREEMENT 19 /~o?a
The Group and its affiliated organizations are included under this Agreement. Affilial~d organl•
zations include all those organizations which are subsidiary to or affiliated with the Group and located
within the Service Area of Harris Health.
2.2 CHANGE OF AFFILIATED ORGANIZATIONS
The Group shall notify Harris Health, in writing, when an affiliated organization ceases to be a
subsidiary of, or affiliated with, the Group. When an organization ceases to be a subsidiary of, or affili-
ated with, the Group, it shall cease to be an included organization. Therefore, this Agreement shall ter-
minate on the date of such cessation with respect to all Eligible Persons of that organization, except for
those persons who on the next day are employees of another affiliated organization and thus Eligible
Persons under this Agreement.
Section 3.0
ELIGIBILITY AND EFFECTIVE DATE
3.1 ELIGIBLE PERSONS
To be eligible to enroll as a Subscriber, a person must reside in the Service Area and be an Eli-
gible Person as follows;
a In the employment of the Group or a bona fide Member of the Group, and/or
• Eligible under the eligibility criteria established by the Group; and
• Entitled on his or her behalf to participate in the medical and hospital care benefits arranged
by the Group.
32 ELIGIBLE DEPENDENTS
l To be eligib!a to enroll as a Dependent, a person must reside in the Service Area and be:
• The legal spouse of a Subscriber;
• A dependent unmarried natural child, foster child, stepchild, legally adopted child or child
under Subscribers court appointed legal guardianship, residing with Subscriber or with Sub-
scriber's present or former spouse In the Service Area who is (a) under nineteen (19) years
of age, or (b) under twenty-five (25) years of age and primarily dependent on the Subscriber
for fmancial support and attending an accredited oolloge or unlver0y, trado or secondary
school on a full-time basis, whic'i has, in wrifini, verified said ar,endance or;
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• A dependent unmarried naluraf child, foster child, stepchild, legally adopted child, or child
under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub.
scriber's present or former spouse in the Service area who is nineteen (19) years of age or
older but incapable of self-sustaining employment becauseVi relardation °r hysical
handicap which commenced prior to age nineteen (19) (or prior to age twenty-
rive (25) it such child was attending a recognized college'tli`' F , fradeTts¢00ndary
school on a full-time basis when such incapacity occurrecfktgndrma dee ent upon
the Subscriber for support and maintenance.
Such dependent child must have been a Member either prior to attaining nineteen (19) years
of age or twenty-five (25) years of age under the conditions of the provious sentence. Sub-
scriber shall fumish Harris Health proof of such incapacity and dependency within thirty-one
(31) days before the dependent child's attainment of the limiting age and from time to time
thereafter as Harris Health deems appropriate, but not more frequently than annually,
• Maternity care benefits will be extended to an unmarried Dependent Child. II coverage is
provided to the Dependent of the Subscriber, upon payment of the premium, benefits must
be provided for any children of the Dependent if those children are Dependents of the Sub-
sc,iber for federal income lax purposes.
3.3 CHANGE IN GROUP ELIGIBILITY CRITERIA
Requirements as defined by the Group for determining the eligibility for participating in Harris
Health are material to the execution of this Agreement by Harris Health, l the term of this Agree-
ment no change in the Group definition of eligibility for participation shall be permitted to a'!ect eligibil-
ity or enrollment under this Agreement in any manner unless such change is approved in advance by
mutual written agreement between Group and Harris Health.
3.4 EFFECTIVE DATE FOR ELIGIBLE PERSONS agenda No.
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3.4.1 Open Enrollment Period Agendallem
Date _11 v~, 9
An Eligible Person who applies for coverage in Harris Health by submitting an Application dur-
ing an Open Enrollment Period shall become covered as a Subscriber on the Group Elleclive Date,or
such Effective Date specified as such for the Open Enrollment Period. Ae /
e /
3.4.2 On Acquirng E;igibility Status
An Eligible Person who first meets the eligibility requirements other than during the Open
Enrollment Period may enroll within thirty (30) days of meeting such requirements by submitting an
Application. Such person shall t cacome covered under Harris Health as a Subscriber on the first day
he became an Eligible Person provided that the premium applicable to the Subscriber has born
received in accordance with this Agreement.
3.5 EFFECTIVE DATE FOR ELIGIBLE DEPENDENTS
3.51 Open Enrollment Period
An Eligible Dependent for whom the Subscriber has applied for coverage in Harris Health by
submitting an Application during ran Open Enrollment Period shall become covered as a Dependent
on the Effective Date of the Subscriber.
35.2 On Acquiring Eligibility Status
A newly acquired Eligible Dependent, and an Eligible Dependent other than a newborn child
who first meets the eligibility requirements of Group on other than during an Open Enrollment Period,
may be enrolled by the Subscriber within thirty (30) days of meeting such requirements by submitting
an Application. Such Eligible Dependent shall become covered under Harris Health as a Dependent
on the day he became an Eligible Dependent provided that the premium applicable !o the Dependent
has been received in accordance with this Agreement described in Section 5.1.
Coverage for newly adopted children shall commence on the earlier of (a) the date upon which
such child commences residence with the Subscriber or (b) when the adoption becomes legal.
Adopted children and newborn children shall be covered under Harris Health for an Initial period of
thirty-one (31) days and shall continue to be so covered after that time only if, prior to the expiration of
such Thirty-one day period, an Application has been submitted and the premium applicable to the
Dependent has been received in accordance with this Agreement described in Section 5.1.
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3.G PLHSor4S rJOT LLIGIULL 1-011 COVERAGE 4gerdafVe
Notwithstanding Ilia foregoing provisions of this Section, persoRgEralls iblo for cover--'6a2
age m I larris health shall be a; follows _
~8r ddfd0. DltB ~ ~ o~4
• Coverage Previously Terminated: No person sha11 be n„e ' ? become a Member whol,
had coverage terminated by Harris Health for cause!, 'd estribed In Section 4.2 of this
Agreement. iti;10 - _
• Indebtedness No person shall be eligible to become a Member if such person has unpaid
financial obligations arising from prior coverage in Harris Health.
3.7 CONDITIONS OF ELIGIBILfTY
No Eligible Person or Eligible Dependent shall be refused enrollment by Harris Health because
of health slates, requirements for health services, or the existence of a Pre-Existing Condition on the
Group Effective Date. In addition, no Member's coverage shall be terminated by Harris Health due to
his health status or his healthcare needs. If an Eligible Person or Eligible Dependent applies for cover-
age on a date other than Open Enrollment Period or more than thirty (30) days after becoming an Eligi-
ble Person or Eligible Dependent, then such Eligible Person'or Eligible Dependent shall have to
dncument Evidence of Insurability as required by Harris Health.
3.8 NOTIFICATION OF INELIGIBILITY
A condition of participation in Harris Health Is Subscriber's agreement to notify Harris Health of
any changes In status that affect Subscriber or the ability of the Subscriber's Dependents to meet the
eligibility criteria set forth in this Section,
39 CLERICAL ERROR
Eligibility under this Agreement shall In no event be invalidated by failure of the Group, due to
clerical error, to record or report an Eligible Person or Eligible Dependent to Harris Health if an Appli.
j cation had been completed and submitted to Group as required under the terms of this Agreement by
or on behalf of such Eligible Person or Eligible Dependent and that the premium applicable to such
coverage had been received by Harris Health,
Section 4.0
GROUP AND MEMBER TERMINATION, CONTINUATION OF
BENEFITS AND CONVERSION
4.1 TERMINATION OF GROUP
4,11,11 Default In Payment of Premium
If Group fails to pay to Harris Health the premium payable hereunder on or before the thirty-first
(31) calendar day aher such payment is due, this Agreement may be terminated by Harris Health and
all benelits and services shall cease at the end of such thirty-one (31) day grace period. Group may
be held liable for the cost of all benefits and services provided to Member by Harris Health during the
grace period. Group shall remain liable for all premiums (and any Interest accrued thereon) not paid
prior to termination. Interest on We payments from the dale such premiums were due may be charged
at a rate equal to eighteen percent (18%) per year. Unpald interest shall be due and payable upon
notice theteof to Group from Harris Health.
If Group remits its dolinquent payments to Harris Health within fifteen (15) days of a termination
date, Harris Health may reinstate Group without requiring a new Group Enrollment Agreement. 11ow•
ever, Harris Health reserves She right to refuse to reinstate by refunding within five (5) business days all
l payments made by Group alter the date of termination.
4.12. Upon Notification
This Agreement may be terminated by either Harris Health or Group upon written notice to lf>o
other party at least sixty (60) days prior to the end of the Contract Year. Such termination shall oocur at
midnight on the day proceeding the end of the Contract Year, In the event that Harris Health terminates
this Agreement, any Member who Is a registered bod patient In a Hospital on the date of lormination
shall receive coverage for all hosplfat services for that hospital confinement or until a determir>.ation Is
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made by the medical Director that inpatient care is no lorxjer medically nxLcated, Whicylll "ver occurs
first vrdafdo.- 193- if
TERMINAT ION OF MEMBER FOR CAUSE
42
4.2.1 Default in Payment of Copayments
It any required Copayment is not paid timely by or on behalf of Member, pursuanlio tno terms
of this Agreement, such Member's entitlement to benefits may be terminated not less than sixty-one
(61) days written notice after the date such Copayment was due.
4.2.2 Default In Payment of Premium
if any premium contributuxis due from Member are net paid timely by or on behalf of Member,
such member's entitlement to henefts may be terminated not less than thirty-one (31) days after the
date such premium was due.
4.2.3 Misrepresenlatlon
if any Subscriber should make a fraudulent statement or provide any material misrepresenia.
lion of tact by or on behall of such Subscriber or Dependent on an Application or Evidence of Insura-
bility form, Harris Health shall have the right to terminate the Member's coverage under this Agreement
vrthout any further liability or obligation to such Member. Such Subscriber's entitlement to boneGls may
be terminated not less than sixty-one (61) days written notice after such misrepresentation. If a Mem-
ber corrects inaccurate information furnished to Barris Health, and Harris Health has not relied upon
such incorrect information to its prejudice, the furnishing of incorrect information shall not constitute a
basis for termination of the Member's coverage. In the absence of fraud, all statements made by a
Subscriber are considered representations and not warranties. During the first two years, coverage
can be voided for material misrepresentation contained in a written Application or Evidence of Insura-
bility Form. After two years, coverage can be voided only in the event of a fraudulent mMtatemspt
contained in the written Application or Evidence of Insurabili y form. A copy of the written Application
must have been lurnished to the Subscriber if the terms of the Application or Evidence of Insurability,
form are to be applied.
4.2.4 Misuse of Identification Card
Possession of a Harris Health identification card in and of itself confers no rights to services or
other benefits. The holder of the card must be, in fact, a Member on whose behalf all applicable pre-
miums under this Agreement have actually been paid Any person receiving services of other benefits
to which he is not entitled pursuant to this Agreement "it be solely responsihle for the full payment of
any charges associated with the services received. If any Member permits the use of the Member
identification card by any other person, such card may be confiscated and Harris Health shall have
the right to terminate the Membor's coverage under this Agreement and, if a Subscriber, the coverage
of his Dependents. Such Member's entitlement to bonefils may be terminated not less than fifteen (15)
days written notice after such misuse of the Identification card.
4.2.5 Fraudulent Use of Benefits or Servloes
Fraudulent use by Member of services, benefits, providers, facilities, or coverage wili result in
cancellation of coverage after not less than a fifteen (15) day written notice to Subscriber.
4.2.6 Misconduct
Misconduct by a Member detrimental to sale Health Flan operations and the delivery of service
or treatment, or abuse of healthcare professlonals, facilities, or Health Plan personnel may result In
cancellalion of coverage etfeclivo Immediately.
1 4.2.7 Untenable PatfonluPhysician Relationship
If the Member aroJ the Participating Physician fail to establish a satisfactory patient-physician
retationshlp and if it !s shovrn that Harris Health has, in good faith, provided the Member with the
opportunity to sefert an altemative Participating Physician, the Member shall be notified in writing at
least thirty (30) days In advance that Harris Health considers the patient-physician relationship to be
unsatisfactory and specifies the changes that are necessary in order to avoid termination if Member
fails to make such changes, coverage may be cancelled at the end of thirty (30) days,
ror refusal by a Member to accept recommended proced,xes or treatment as described in
Section 5 3 of this Agreement, the Member's coverage may be cancelled alter not less than thirty (30)
days written notice.
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4.2.6 Termination Procedure
Any Member terminated for cause pursuant to this Section shall be given wfillen notice of ter.
mnatrorr p,ior to the elfective date of termination in accordance with notification requirernents of Soc•
lion 4.2. II Member receiving notice of termination Initiates the Member Complaint Resolution
Procedure described in Section 10 of this Agreement during the notification period to challenge the
grour>js for termination, the effective dale of termination shall be postponed until Member Complaint
Resolution Procedure is completed and a final decision regarding termination is provided. II the Mem-
ber, on his own behalf or on behalf of a minor child, fails to initiate the Member Complaint Resolution
Procedure within the notification period, such failure shall consul e a waiv ofSa~ ember's right to
challenge the termination. ;eo„d v _ QSf
4,3 TERMINATION OF MEMBER - OTHER TITAN FOf r~Xfjtt
4 3 1 Subscriber No Longer Eligible Person 2his If the Su
bscriber ceases to be an Eligible Person, coverage undke rrrr e t'' shall auto-
matically terminate at midnight of the day on which such Subscriber ceased to be an Eligible Person,
subject to continuation of coverage and conversion privitego provisions.
4.3.2 Dependent No Longer Eligible Dependent
If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall
automatically terminate at midnight of the day on which such Dependent ceased to be an Eligible
Dependent, subject to continuation of coverage and conversion privilege provisions.
4.3.3 Service Area Resident
If a Member ceases to be a resident of the Service Area as defined by Harris Health, eligibility
to participate in Harris Health shall automatically terminate as of the date on which the Member
ceased to be a resident of the Service Area, except as may be required by Slate and Federal reg.rta.
tions for COBRA participants. Such Member shall be eligible to convert to an individual Hospital and
Surgical Expense Policy as specified in Section 4.62.
4.4 LIABILITY UPON TERMIN.' 0 ON effe
ive date
of an
e under ments received ontaccou t of such`Memaber applicable orpedodsrafftter the efflecUve dat of the termiy-
nation of coverage, plus amounts due to such Member for clalms reimbursement, if any, less any
amount due to Harris Health or which must be paid by Harris Health on behalf of such Member, shall
be refurvded to the appropriate party within thirty-one (31) days. Harris Health and Group shall there-
after have no further liability or responsibility to such Member except as may be specifically provided
in Section 4.1.2 of this Agreement.
4.5 CONTINUATION OF COVERAGE
If a Member's coverage ends, such coverage may quality to be continued In one of the follow-
ing ways:
• it may be extended under the Extension of Medical Benefits provisions, if the Member Is Hos-
pilai Confined when this Agreement terminates; or
• it may be continued under the Optional Continuai un of Coverage provisions; or
• it may be converted to an individual plan of medical coverage as described in the Conver-
sion provisions.
i If, under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of
1985, Public Law 99.272 ("COBRA") , any Member Is granted the right to continuation of coverage
beyond the date his coverage would otherwise terminate, or, if COBRA Is inapplicable and the provi-
sions of an applicable slate statute grants such Member similar rights to continuation of coverage, this
Agreement shall be deemed to allow continuation of coverage to the extent neoes&ary to comply with
the provisions of the applicable statute. Contact the employer for verification of eligibility and prooe•
dures to follow.
4 5,1 Extension of Medical Benefits
Harris Health shall continuo to provide medical services if this Agreement lerminates under
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Section 4.1 2 white a Member is confined in a Ifospital or Skilled Nursing Facddy. Services will be pro-
vided only for the same injury or sickness which caused the Member to be confined
[his continued coverage will end on the earlier ol. (1) the date the conline,meni is no, longer
Medically Necessary; or (2) the date tto Member reaches any limits under to Group Contract for the
provisions of services; of (3) the date the Memtx r becomes eligible for similar coverage under another
plan.
4.6 CONVERSION PRIVILEGE c? Ier11
II a Membe- has been covered by this AgreeMnt kx al leastthmaj3) consecutive months or
covered as a newbc:n from the date of birth and meels th3 definition of a person eligible for conver-
sion, Member may enroll In an Individual plan wish a defined Schedule of Benefits available to conver-
sion Members only under the terms and conditions of this Agreement.
ELIGtBUTY 70 CONVERT
A Member whose coverage under this Agreement is terminated in accordance with the Termi-
nation provisions may convert if the coverage is net ending for one of the following reasons:
• Termination of this Agreement; ~ Q
• Falure to any required pay copayment amounts;
• Termination for cause;
• Coverage under another individual or rou health policy, plan or contract;
• Eligibility for Medicare;
• Eligibility or coverage for similar hospital, medical or surgical benefits under a state or federal
la N.
A covered Dependent whose coverage is terminated under this Agreement may also convert if
the termination is due to;
• Legal :,eparalion or divorce; or
• The Subscriber's death; or
• The Dependent reaching the maximum Dependent age.
HOW TO CONVERT
4.8.1 Residence In Service Area
The Member eligible for conversion may, without Evidence of Insurability, convert to an Individ-
ual Health Care Agreement Issued by Harris Health. To obtain an individual enrollment, the Eligible
Person roust continue to reside in the Service Area, must submit a ocimplial d application for toner.
sloe within thirty-one (31) days aftor termination of coverage under this Agroement, and must submit
the promium for such Individual Health Care Agreement as required from the effective date of termina-
tion of coverage under this Agreement.
4.6.2 Residence Out of Service Area
without It the Member
of Insurability, conert t ann Individual reside
poliicy issed try and Ara,
rer ewable at the eop on
of the indemnity insurer malting such conversion coverage available to Harris lieallh,
Section 5.0
PAYMENT REOUIRLMENTS
5.1 PREMIUM PAYMENTS
The Initial rates for the benefits and services under this Agreement shalt be duo and payable in
advance on or before the first (1) day of the month for which such payment Is made or Is to be made.
In accordance with the terms and provislons of Section 12,3 of this Agreement, Harris Health shall
have the eghl to change the rato payable under this Agreement at any time when the extent or nature
of this Agreement is changed by amendrront or termination of any provision, or by reason of any pro-
vision of law or any governmental program or regulation. No proraton of the rate shall be mado with
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prior written approval of Harris Health unless there is a Medical Emergency and a Participatiny
Physician is not available.
42. NON-PARTICIPATING PROVIDER shall mean any Physician, Hospital, Alle,S Health Prolessional,
Home Health Agency, Laboratory, Minor Emergency Center, Residential Treatment Facility, Chemi•
cal Dependency Treatment Center, or other licensed healthcare professional or other provider or
entity which has not contracted with Harris Health to provide to Members the services as set forth
in the Schedule of Benefits and described in this Agreement, ~76 -0 oy
43. OPEN ENROLLMENT PERIOD shall mean a period of at &VORy (30)~a~s daring each twelve
(12) consecutive months v,fien Eligible Persons may elekl110,, yWnge.(r+utFtihe_Ahernaiive Health
Benefit Plan to Harris Health or from Harris Health to the A``g alive f al y PI
44. PARTICIPATING PHYSICIAN shall mean any Physician who has contracted wR Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement.
45. PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional, Home
Health Agency, Laboratory, Manor Emergency Center, Chemical Dependency Treatment Center,
Psychiatric Day Treatmenl facility or other provider or entity which has contracted with Harris
Health to provide to Members the services as set forth in the Schedule of Benefits and described
in this Agreement,
46. PSYCHiATRiC DAY TREATMENT FACILITY shall mean a mental health facility which provides
treatment for individuals suffering from acute mental and nervous disorders in a structured psychi-
atric program utilizing individualized treatment plans with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program and that is clinically
supervised by a Physician who is certified in Psychiatry by the American Board of Psychiatry and
Neurology. The facility shall ho licensed by the State of Texas, accredited by the Program for Psy•
chiatr;c Facilities, or its successor, of the Joint Commission on Accreditation of Health Care Orga•
nizations, and shall have contracted with Harris to provide to Members the mental health services
as set forth in the Schedule of Benefits and described in this Agreement.
47. PHYSICIAN shall mean any individual (other than a hospital resident or intern) who is fully licensed
and qualified to practice within the scope of the license under the law of the jurisdiction in which
treatment is received.
48. PRIMARY PHYSICIAN shall mean, with respect to each Member, those Participating Physicians
who are designated by Harris Health and idant'd;ed in writing to Members as Physicians having
primary responsibility for coordinating such Member's medical care, providing initial and primary
care to Members, maintalnirw,T the continuity of such Member's care and Initiating referrals for spe-
cialist care.
49. RESIDENTIAL TREATMENT CENTER FOR CHILDRE14 AND ADOLESCENTS shall mean a child.
care instilution that provides residential care and treatment for emotionally disturbed children and
adolescents. licensed by Texas Department of Mental Health and Menial Retardation, and that Is
accredited as a residentiaMreatment center by the Council on Accreditation, the Joint Commission
on Accreditation of Health Care Organizations or the American Association of Psychiptric Services
for Children
50. RIDER ahall mean a Schedule provided with this Agreement, and made a part hereof, which Eels
forth additional benefits and services made available by Harris Health by amending this Schedule
of t3enerils,
51. SCHEDULE OF BENEFITS shall mean the schedule which sets forth the benefds and services that
Harris Health shall make available to Members.
52. SEMIPRIVATE shall mean the charge made by a Member Hospilal,lor a room containing two (2)
or more beds,
53. SERVICE AREA shall mean the geographic area as set forth and annexed hereto as Attachment
A.
54. SHORT TERM shall mean a course of treatment lasting thirty (30) days or less.
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Section 6.0 AgalidaNo
CLAIM PROVISIONS 4gendaffC7fi _
6.1 CHARGES PAID BY MEMBERS alte_
It is not anticipated that a Member shall make payments, other than the Copayrnents as h
forth In the Schedule of Benefits, for benefits and coverod services under this Ag'eenx nt. However, if
a payment is made by a Member then a written description of such services, accompanied by evi-
dence of payment by the Member must be provided to Harris Health within sixty (60) days after the
performance of the service. Failure to furnish such proof within the required timo shall not invalidate
nor reduce any claim, if it was not reasonably possible to give proof within such time, provided such
proof is furnished as sow as reasonably possible. It the Member provides evidence that he has made
such payment. payment shall be paid to the Member but without prejudice to Harris Health's right to
seek recovery of an
y any payment made by it before receipt of such evrdence.
Benefits under this Agreement will be paid directly to the provider unless Member requests
payment to be made to himself and submits to Harris Health prool of prior payment to the provider for
covered ser ices. Claims for such servicas will be processed
A. Fifteen (15) calendar days after receipt of claim, HarAg.%%pill`
1, Acknowledge receipt of claim;
2. Commence investigation of claim;
3. Request all information from claimant as deemed necessary by Harris Health. Subse-
quent additional requests may be necessary.
B. No later than fifteen (15) business days after receipt of all items required by Harris Health,
Harris Health will:
1. Notify claimant of acceptance or rejection of rlaim;
2, Notify claimant of the reason(s) Harris Health needs additional time.
Harris Health shall accept or reject the claim no later than lorly-five (45) calendar days
following receipt of additional information.
C. Upon notification from Harris Health that the claim will be paid, the claim will be paid no
later than five (5) business days after such notification was made
62 MEDICAL EMERGENCY
Medical Emergency services which are covered under this Agreement but are not received
tr(5m Participating Providers shall be reimbursed subject to the C:opaymenls in the Schedule of Bane-
fits. Harris Health reserves the right to deny a claim for reimtwfsement of services received from a
Hospital emergency Ceparimont or a Minor Emergency Center, if 0 Is determined by Harris Health that
such services were not obtained pursuant to ft terms of this Agreement or if a Medical Emergency
did not exist at the time services were roooived by the Member.
6.3 ACTION ON CLAIM
All claims for reimbursement shall be finalized by Harris Iiealth within sixty (60) days of receipt
of written documentation describing the occurrence, character and extent of lhs event for which the
claim is made, unless the Member Is notified of the need for a longer limo. If a claim is denied, written
notice to the Member will state the reason for the denial. Member may obtain a review of the denial
through the Mernber Complatnt Resolution Procedure as described In Section 10.0.
6A EXAMINATION OF MEMBER
Harris Healh, at its own expense, shall have the right to examine the Member whose trickrv)ss
or Injury is the basis of a claim when and so often as it may reasonably require, during the pendency of
i any claim
65 LIMITATION PROVISIONS
• No action at law or equity shall be brought under this Section against Harris Health prior to
the expiration of the sixty (60) day period Immediately following the dale on which written
proof of this charge or loss upon which the action Is brought, in accordance Willi the provi-
slons of this Section, has boon furnished to Harris Health; or later than three (3) years after
the expiration of the period of time in winch such prool of charge or loss is required under
this Section to ba furnished to I fa'ris Health.
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• No liability shall be imposed under Harris Health other llm~jfpe ben-„ el is acct etwces cov-
ered under this Agreement.
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Section 7.0
COORDINATION AND SUBROGATiON Of ` cNEhT6 a y ~4~
The Barris Health Coordination and Subrogation of Benefits provisions applies,, t all of the ben-
efits provided under this Agreement, The value of any benefits or services provided by Harris Health
shall be coordinated with any group insurance plan or coverage under governmental programs,
includingj Medicare, to assure that a Member receives coverage while avoiding double recovery. It is,
therefore, understood and agreed that should a Member be covered by or under a Coordinated Plan
in addition to coverage under this Agreement, the provisions and rules as described in this Section
shall determine whether Harris Health or the Coordinnied Plan is primarily responsible for paying the
costs of benefits and services provided to the Member.
• II a Member who has enrolled under this Health Plan is entitled to inpatient benefits under
another contract or policy of insurance doe to inpatient care which began while the Member
was enrolled under a previously heto policy, Harris Health will pay, subject to Copayments
under this plan, the dit!erence between entitlements under this Health Plan and entitlements
under the other contract or policy of insurance.
Benefits which are provided directly through a specified provider of an employer shall in all
cases be provided before the benefils of this Health Plan.
• Services and benefits for military service connected disabilities for which a Member is legally
entitled and for which facilities are reasonably available, shall in all cases be provided before
the benefits of this Health Plan.
• All sums payable for services provided pursuant to worker's compensation shall not be reim
bursab!e under this Agreement
7,1 DEFINITIONS
For purposes of this Section only, words and phrases shall have meanings as follows:
• ALLOWABLE EXPENSE shall mean any Usual and Customary expense of which at feast a
poton is covered under this Health Plan covering the Member for whom the claim is made.
When a Coordinated Plan provides bene its in the form of services rather than cash pay-
ments. the Usual and Customary cash value of each service provided shall be deemed to
be both an Allowable Expense and a benefit paid.
* CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any portion of a
calendar year occurring prior to the Effective Dato.
• COORDINATED PLAN shall mean any of the following that provides benefits or services for,
or by reason of, medical care or treatment.
- Coverage under governmental programs, including Medicare, required or provided by
any statute unless coordination of benefits Mth any such program is forbidden by law.
- Group coverage or any other arrangement of coverage for individuals In a group,
whether on an insured or uninsured basis, including any prepayment coverage, group
practice basis or individual practice coverage and any coverage for students which is
sponsored by, or provided through, a school or other educalional institution above the
high school level.
7.2 DETERMINATION OF BENEFITS
This provision shall apply in delermining the benefits payable for the Allowable Expenses
Incurred by a Member during a Claim Determination Period,
The term Coordinated Plan shall be construed separately with respect to each policy, ocxtitract,
or other arrangement for bonefits or services and separately with respect to that portion of any such
policy, contract, or other arrangement which reserves the right to take the benefits or services of other
Coordinated Plans into consideration in determining its benefits and that portion which does not.
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Whenever she sum of the be❑ofits that would be payable under this Agreement in the absence
of this provision, and the benefits that would be payable under all Coordinated Plans in the absence
thereof or amendments of similar purpose to This provision vroutd exceed the Allowable Ei'penses, then
the following shall apply: We I'
• The benefits that would be payable under this AgreemennalF mew lhaeklent
necessary so that the sum of such reduced benefits and aim riefrt ay ble fo~such
Allowable Expenses under all Coordinated Plans shall noF d bbable under
This Agreement Benefits payable under a Coordinated Plarl,V dude s that icy
y
have been payable had claim been duly made therefor. G o~Vbe~rerrts
• If a Coordinated Plan would, acmding to its rules, determine its benefils after payable under this agreement have been determined, and the rules as described
in Section
7.3 would require payment under this Agreement to be determined before the Coordinated
Plan, then the benefits of the Coordinated Plan shall no! be included for the purpose of deter-
mining the benefits under this Agreement.
7.3 ORDER OF BENEFIT DETERMINATION
The rules establishing the order of benefit determination shall be as foltows:
• The benefits of a Coordinated Plan without a coo4natien of benefits provision (or a non-
duplication provision of similar intent) shall be determined before the benefits of this
Agreement.
• The benefits of a Coordinated Plan which covers the Member other than as a dependent
shall be determined before the benefits of a Coordinated Plan which covers such person as
a dependent.
• The benefits of a Coordinated Plan which covers the Member as a dependent child of a par-
son whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be
determined before the benefits of a plan which covers such person as a dependent of a per-
son whose date of birth. excluding year of birth, occurs later In a calendar year. If a Coordi-
naled Plan does not have the provisions of this paragraph regarding dependents, which
results either in each Coordinated Plan determining its benefits before the other or lit each
Coordinated Plan determining its benefits after the other, the provisions of this paragraph
shall not apply, and the rule set forth in the Coordinated Plan which does not have the provi
sions of this paragraph shall determine the order of benefit determination unless Section
TV shall apply,
• It the rules provided above or Uto rules provided in Section 7,3,1 do not establish an order of
benefit determination, then the benefits of a Coordinated Plan wfilch has co'dered the Mem•
be( for whom the claim is rnado for the longer period of time shall be determined before the
benefits of a Coordinated Plan which has covered such Member for the shorter period of
time except as follows!
- The benefits of a Coordinated Plan covering the Member as a laid-off or retired employee
or as the dependent of such Member shall be determined after the benefits of a Coordi-
nated Plan covering such person as a Member other than as laid-oh or retired employee
or dependent of such person.
If a Coordinated Plan does not have a provision regarding laid-olf or retired employees,
and, as a result, such Coordinated Plan determines its benefits after the Coordinated
Plan with this provision, then the provisions of the immediately preceeding paragraph
shall not apply.
7.3A Legal Separation or Divorce
In the event of a legal separation or divorce, the following order of benefit determination shall
aPPbr
• H there is a court decree that establishes financial responsibility for the healthcare expenses
of the child, the benefits of a Coordinated Plan which covers the child as a dependent of the
parent with such financial responsibility shall be determined bofofe the uenelils of a Coordi-
nated Plan which covers the child as a dependent of the parent without such financial
responsibility
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• In the event of a legal separaiion or divorce in which Ilia court decruo dais not establish
financial responsibility for the healthcare expenses of the child [hen the following shah apply.
If tho parent with custody of the child has not remarried, the benel;ts of a Coordinated
Plan which covers the child as a dependent of the parent with custody of the child shall
be determined before the benerils of a Coordinated Plan which covers that child as a
dependent of the child without custody.
- if the parent with custody of the child has remarried, the benefits of a Coordinated Plan
which covers the child as a dependent of the parent with custody shall be determined
before the benefits of a Coordinated Plan which covers that ch;ld as a dependent of the
stepparent; and the benefits of a Coordinated Plan which covers that child as a depen-
dent of the stepparent shall be determined before the benefits of a Coordinated Plan
which covers that child as a dependent of the parent without custody.
Thus, in the event of a legal separalion or divorce, unless a court decree specifies otherwise,
the order of benefit determination described above may be summarized as follows:
Separated or Divorced and not Remarried Separated or Divorced and Remarried'
(1) Parent with custody (}~Q t with cu eftdaNo--
(2) Parent without custody ((Z~'ff pparent with custody~_.__-----
(8)'.f"a1~nFtinRtl,ocraost6tlq-~eRdattafn.~- g
7.4 MEDICARE Da1e_14' 9 ~?o
For purposes of determining benertc provided for a Member who is eligible to enroll for Medr
j care, but does not, Harris Health will assume the amount provided under Medicare to be the amount
j the Member would have received if he or she had enrolled for it.
A Member is considered to be eligible for Medicare on the earliest dale coverage under Meli.
care could become effective for the Member. Except as described under TEFRA in Section 7.4, Medi-
care shall be interpreted so as to be included in Section 71 for each Member as follows;
• Such Member must agree to enroll for both Parts A and B of Medicare and assign to Harris
Health any Medicare benefits for services covered by Harris Health. If such Member
receives benefits from Harris Health that would have been paid or reimbursed by Medicare,
but Member has tailed to enroll for Medicare coverage, then Harris Health shall be entitled to
receive from the Member the acluat costs of the services provided. the Member shall remain
liable for payment of the Copayments as set forth in the Schedule of Benefits.
• When Allowable Expenses are incurred by such Member during any Claim Determination
Period and Include expenses for wrAces, treatment, or supplies which are payable under
Medicare, such AllowaUe Expenses shall be reduced by an amount equal to the benefits
payable by Medicare before comuting the benefits payable under this Agreement.
7.4.1 TEFRA Options for Empooyees with 20 or More Employees
Actively waking covered Employees and their covered spouses who are eligible for Medicare
will be permitted to choose one of the following options if the Emptoyee is age 65 or older and eligible
for Medicare;
Option 1 - The service of the Group Agreement will be provided first and the benefits of
Medicare will be provided second.
Option 2 - Medicare benefits only. Subscriber and Dependents, if any, will not be covered by
the Group Agreement.
The employer will provide Subscriber with a choice to elect one of these options at least one
month before becoming age 65. All new Employees age 65 or older will be offered these options when
hired. II Option 1 Is chosen, Subscriber's rights under this Agreement will be subject to the same
requirements as for an Employee or Dependent who is under age 65,
There afe two categories of persons eligible for Medicare. The calculation and payment of ben-
efits by this Agreement differs for each category,
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Category 1 Medicare Eligibles are
AoendalfarrL
1. Actively working covered Employees age 65 or older wlro choose opl, 1; q~
2, The age 65 or older covered spouses of actively working ooveredlmployee aya Ui'af'
older who choose Option 1; .30 Yr
'O
3. Ago 65 or older covered spouses of actively working covered Employees who are and age 65;
_
4. Actively working covered Employees of employers with 100 or more Employees and their
Covered Dependents who are entitled to Medicare by reason of disability other than End
Stage Renal Disease (ESRD); and
5. Covered Individuals entitled to Medicare solely on the basis of ESRD during a
Y ng period of u
to 12 months after the individual has bee ned p
%kgfr,~' ~lig~te-f«3r-E3itD benefits.
Category 2 Medicare Eligibles are: a4~~q,liem~
1. Retired employees and their spouses;
2. Covered Employees of employers with less than 100 Employees and their covered Depen-
dents who are entitled to Medicare by reason of a disability other than ESRD; and
3. Covered Individuals entitled to Medicare solely on the basls of ESRD for more than 12
months after the individual has been determined eligible for ESERD benefits.
Calculation and Provision of Services;
For Members in Category 1, services are provied by this Agreement without regard to
any benefits provided by Medicare. Medicare will then determine its benefits
For Members In Category 2, services are provided by the Group Agreement. Harris
_ Health shall then have the right to recover the lull amount of all Medicare benefits the Member
is entitled to receive, whether or not the Member is actually enrolled for them. The Member
should authorize payment of Medicare benefils directly to Harris Health for services rendered,
II the Member does not authorize direct payment, he or she is responsible for Harris Health for
the reasonable value of the services rendered. The Member Is also responsible to Harris
Health for the reasonable value of all Group Agreement services reimbursable by Medicare if
the Member is not enrolled for all benefits he or she Is entitled to receive.
7.5 RIGHT TO RECEIVE AND RELEASE INFORMATION '
For purposes of administering the provisions of this section, Harris Health may, without further
consent of, or notice to any Member, release to or obtain from any healthcare plan, Insurance com-
pany or other person or organization, any information with respect to any Member which it deems to
be reasonably necessary for such purposes, as permitted by law, Any Member receiving services or
claiming benefits under this Agreement shall furnish to Harris Health all information deemed necessary
by Harris Health to Implement this Section 7.0.
7.6 FACILITY OF PAYMENT
Whenever payments which should have been made by Harris Health in accordance with this
Section have been made by a Coordinated Plan, Harris Health shall have the right, exercisable alone
and in its sole d+'scretion, to authorize payment to the Coordinated Plan making such payments any
amounts Harris Health shall determine to be warranted in order to satisfy the intent of this Section, and
amounts when so paid shall be deemed to be benefits under this Agreement, and, to the extern 0
such payments, Harris Health shall be fully discharged from liability under this Agreement.
• 7.7 RIGHT OF RECOVERY
Whenever payments have been made by Harris Health with respect to Allowable Expenses in a
total amount which is, at any time, in excess of the maximu n amount of payment neocessary at that
time to satisfy the Intent of this Section, Harris Health shall have the right to recover such payments, to
the extent of such excess, from one or more of the following, as Harris Health shall determine: any per-
son or persons to, or for, or wilts respect to whom such payments were made, any Insurance company
or companies, and any other organization or organizalions which provided services, or to which such
payments were made.
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7.8 DISCLOSURE 93 -0 5/~
Each Member agrees to disclose to Iiarris Heallh at the lime of er1FA~iFi~R(at, at the lime of
receipt of services and benefits, and from time to time as requested by I larri; eat If'i~Zk t L~ ofd'
other health plan coverage, the identity of the carrier, and the group 1hrough4waligiXhcouciageit~'2'
provided.
7.9 SUBROGATION
UU i
Subrogation seeks to shift the expense for injuries suffered by Plan Members to those responsi-
ble for causing them.
In return for Harris Health providing benefits for injuries, ailments, or diseases caused as a
result of the negligence, omission or willful act of a third party, each Member agrees to execute any
Instrument which may be needed in order for the right of subrogation to be effective, Each Member
also agrees to assign to Harris Health the right of recovery against such third party to the extent of
benefits received from or through Harris Health plus costs of legal suit including attorney fees. At the
time such benefits are provided or thereafter as Harris Health may request, Member agrees to compty
with the following provisions,
• Execute a format written injury report and assignment to Harris Health of right to recover the
reasonable value of any benefits provided directly by Harris Health and the actual costs paid
by Harris Health under this Agreement for Injuries, ailments and diseases caused by a third
party together with the costs of legal suit Including attorney fees.
• Reimburse Barris Health for the reasonable value of any benefits and services provided by
Harris Health and in an amount equal to the charges therefor together with the costs of legal
suit, including allorney fees, but not in excess of monetary damages collected, Immediately
upon receipt of any monies paid by or on behalf of a third party in settlement of any claim
arising out of Injuries, ailments and diseases covered by such third party. In determing the
reasonable value of benefits and services provided by Harris Health, Harris Health shall con-
" Sider charges for,similar services being made by providers in the community which possess
similar training or capability as well as unusual circumstances, or a medical complication
requiring addition•sl time, skill experience and/or facilities in connection with a particular ser•
vice. Harris Health shall have a lien on any recovery from such third party whether by judg-
ment, settlement, compromise or reimbursement.
• Execute and deliver such papers and provide such reasonable help (including authorizing
bringing suit against such third party in Member's name and making court appearances) as
may be necessary to enable Harris Health to recover the reasonable value of benefits and
services provided by Harris Health, together with costs of legal suit, including attorney fees.
Section 8.0
INDEPENDENT AGENT&REFUSAL TO ACCEPT TREATMENT
81 INDEPENDENT AGENTS
The relationships between Harris Health and contracting entities may be defined as follows:
• The relationship between Harris Health and Member Hospitals is that of Independently oon-
Iracling entities. Member Hospitals are not agents or employees of Harris Health nor is Harris
Health an agent of any Member Hospital, Member Hospitals shall malnlain the hospital-
patient relationship with Members and shall be the only parties responsible to Members for
the Hospital services that they provide
• The relationship between Harris Health and Participating Providers is that of independent
contracting entities. Participating Providers are not agents or employees of Harris Health nor
Is Harris Health an employee of agent of any Participating Provider. Participating Providers
shall maintain the physician-patient or professional-patient relationship with Members and
shall be the only parties responsible to Members for the services provided. Neither Harris
Health nor any employee of Harris Health "I be deemed to too engaged in the practice of
modlcine. Harris Health shall in no way supervise the practice of medicine by any Participat-
ing Provider hereunder, not shall Harris Health In any manner supervise, regulate or Interfere
with the usual professional relationships between a Particlpaling Provider and a Member.
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• the relalonshO between Iiarus Iieallh, the Group and any M,,r1rtxr is that of independent
conlracling entities. Neither the Group Mr any Member is the agent or employee or Harris
110111h, and Harris Health is not the employee or agent of the G or any Member. Neither
the Group or any Member shati be fable for any acts or orrtisAroYti! 67-Aa•rfts fieaith, s agent s
or employees, any Physician, any Iiospital, or any other persp~}
ris Health has made, or hereafter shall make arrangements foP I e petor orrmance ur erv ces
under this Agreement. UD3te_
82 LIMITATION ON LIABILITY ~9endRO
Harris Health does not guarantee by this Agreement that any ParticipaAgr pal~tle Ala
form or properly perform such contracts; the only obligation of liarris Fieallh in tFib°Went of br acn-tt _ ~w
such contract by arty Participating Provider shall be, upon r uest
eq to use its best alerts to procure'3API
the needed services from another provides Harris Health shall not be liable to a Member for any act of
omission or commission on the part of any Participating Provider.
6.3 REFUSAL TO ACCEPT TREATIVIENT/EXCESSIVE TREATMENT
Members may, for reasons personal to themselves, refuse to accept services or complete a
Course or Treatment as recommended by a Participating Physician. Participating Physicians snail use
their best efforts to render all necessary and appropriate professional services in a manner compatible
with the Member's wishes, insofar as this can be done consistently with such Participating Physician's
judgment as to the requirements of proper medical practice. refuses Physiciaf nabel evesrthat no prof~ionally ace pt ble alternative a exists, s, such me ber shall
be licipating
advised. If upon being so advised, the Member still refuses to follow the recommended treatment or
procedure, Then the Member shall be given no further treatment for the condition, and neither the Par-
ticipating Physician nor Harris Health shall have any further responsibility to provide care for such con-
dition. A Member may appeal a withdrawal of treatment under this provision through the Member
Complaint Resolution Procedure as described in Section 10.0 of this Agreement.
If two (2) or more Participating Physicians who have rendered care to a Member inform Harris
Health that the Member is receiving health services or prescription medications in a manner or in a ntity
medicall Haarris alth tosselect a s ngle Pnecessary or articipating Primaryry Physic an (hereafter referred to as a "Coordinal-the Member Y be squired by
ing Ficahh Plan Physician") end a single Participating Pharmacy, it Pharrna
Member, for the provision and Coordination of all future health services. if the Me
benefit mber are a ailableato
iffy serf a Coordinating Hallh Plan Physician and a single Pdrticipati
days of wrinen notice by Harris lioalth of ttr3 need to do so, Harris Ifealtrh~shPalld sSg rate a thirty (30)
Ing Health Plan Physician and/or a participating Pharmacy for the Member
Following selection or designation of a Coordinating Halth Plan Physician for a Member, cov-
erage of health servlcos set forth on this Agreement shall be contingent upon each health service
being provided by or through written referral to the Coordinating Health Plan Physician for that
Member.
If, after sixty (60) days from Initial notification by Harris Health, the Member Is nG in ompliance,
with this Section, the Member may be terminated by Harris Health undor Section 421,
Section S.0
EXCLUSIONS ON SERVICE RESPONSIBILITIES
The rights of Members and obligations of Participating Providers under this Agreement are
I subject to the exclusions as specified below.
9.1 MAJOR DISASTER OR EPIDEMIC
In the event of any major disaster or epidemic that would severely limit the availab illy of Particl-
paling Providers to provide healthcare sorvlces on a timoly basis, Participating Providers shall, in good
• faith, use their best efforts to render the benefits and serv lcoo covered Insofar as practical according
to their best J Wgmonl and within Uv limltalion of such facl i fes and personnel as are then available, If
Harris health and Participating Providers shall, In good faint, have used their Bost efforts to provide or
19
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make arrangements for the lxu~nefds and services, they shall have no lurlher liability or obligation for
delay or failure to provide such benetts and services due to a shortage of available fact' i s r Fv-
sonnrl resufling from such disaster or epidemic Agenda No
9.2 CIRCUMSTANCES BEYOND CONTROL AyeOCallern//~
In the event that, due to circumstances riot reasonably within lhef~I troLo[_kiauic~fq h or
Participating Providers, such as the complete or partial destruction of facilities because of war, riot.3.9
civil insurrection, or the disability of a significant number of Participating Providers, the rendering of ~d0y
benefits and services covered hereunder is delayed or rendered impractical, neither Harris Health nor
any Participating Provider shall have any liability or oblryalion on account of such delay or such failure
to provide such benefits and services, if they shall, in good faith, have used their best efforts to pro-
vide or rrG%e arrangements for the benefits and services covered insofar as practical according to
their best judgment and within the limitations of such facilities and personnel as are then available. Pre-
mium paymer shall be suspended for the duration of such time period for the Group.
9.3 FRAUDULENTLY OBTAINED BENEFITS
In the event a member fraudulently obtains healthcare services as a result of the improper or
unauthorized use of a Harris Health identification card, such Member agrees and is solely responsible
for the payment of all charges for services so obtained and for the payment of all reasonable costs of
collection thereof, including court costs, collection fees and attorney fees.
9.4 DISCONTINUANCE
It Harris Health or Group determines i. would be impractical to continue due to circumstances
beyond the control of Harris Health or Group, Harris Health and Group may endeavor to agree to
amerr;ments and adjustments to this Agreement which relate to services and benefits to be discontin-
ued. If parties cannot agree on amendments and adjustments, Harris Health or Group may terminate
this Agreement at the end of any month upon at least sixty (60) days written notice for Group, 1n.the
event of such termination, neither Harris Health nor Participating Providers shall have any further liabil-
ity or responsibility under this Agreement.
However, it any Participating Provider terminates their contract, then Harris Health shall be lia.
ble for the continuance of services and benefits described in this Agreement. Such services shall be
rendered to Members by other Participating Providers.
Section 10.0
MEMBER COMPLAINT RESOLUTION PROCEDURE
10.1 COMPLAINT RESOLUTION PROCESS
A Member may make an oral or written suggestion or indicate a complaint to any Harris Health
employee or to any Participating Provider. All oral suggestions and complaints shall be handled
promptly by Harris Health. II the Member is not satisfied with the response to an oral suggestion or
complaint, the Member may file a written complaint by calling Harris Health or, at the Member's option
the Member may file a written complaint by completing and forwarding a complaint form to Harris
Health at the latest address provided on the front of this Agreement. A Harris Health Member Service
Representative shall contact the Member by telephone to verity details and resolve the problem k me-
diately if possible Within fifteen (15) business days from the receipt of the oral or written complaint,
Harris Health shall respond in writing to inform the Member of the progress or decision on the corn-
plaint. In the event a decision cannot be reached within fifteen (15) business days, Harris Health shall
notify the Member that a decision shall be provided as soon as possible, but not later than sixty (60)
days after initial receipt of the complaint.
101.1 Ad Hoc Review Committee
If the Member is not satisfied with the resolution of the complaint by Harris Health, the Member
may request a review by riling such a request, in writing, within fifteen (15) business days of receiving
written notice of the resolution of the complaint. This request shall be sent to Harris Health. Upon
receipt of this written request, Harris Health shall forward the request and any and all memoranda and
notes made as a result of the uriginal investigation of the complaint to the Medical Director and to Har-
ris Health.
20
s
a
a
After reviewing the complaint records, Harris Health shalt convene an Ad Hoc Review Commit-
tee composed of Harris Health, the Medical Director, and at least two other individuals not involved in
the i6lial investigation of 1110 complaint. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other individuals on the Ad Hoc Review Committee shall
be Participating Physicians. Within fifteen (15) business days of r ipt of ra review,
Harris Health shall respond, in writing, to inform the Member d f the com
plaint by the Ad Hoc Review Committee. Acvdd
10.1.2 Notification By Review Committee -ale
It the original complaint involved a physician-patient relationship, the written fe of the Ad
Hoc Review Committee shall inform the Member that he has the option, at his discretion, to submit the
complaint to the mediation service maintained by the Tarrant County Medical Society, and that such
mediation shall usually be concluded within a thirty (30) day to sixty (60) day time period. The notice
shall inform the Member that participalion in the mediation process is voluntary and that mediation rec-
ommendalions are non-binding on both parties. As part of their contractual obligation to comply with
the Health Plan rules and regulations, Participating Physicians must cooperate vAh the Tarrant County
Medical Society mediation service.
10.2 COMPLAINT RESOLUTION APPEAL PROCESS
If a Member is not satisfied with the decision of the rid Hoc Review Committee, or the Tarrant
County Medical Society mediation service, the Member may request an additional review by Harris
Health. The Member must fee a request for review within fifteen (15) business days of receipt of the
decision of the Ad Hoc Review Committee or the mediation service. Upon receipt of a request for a
review, Harris Health shall forward the review request and a complete record of the complaint history
to the Medical Director and to Harris Health.
After reviewing the complaint records, Harris Health shall convene an Ad Hoc Appeal Commit-
tee composed of Harris Health, the Medica! Director and at least two other individuals not involved in
the initial investigation of the complaint. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other individuals on the Ad Hoc Appeal Committee shall
be Participating Physicians.
Within fifteen (15) business days of receipt of the request fcr a review, Harris Health shall
respond in writing, to inform the Member of the decision or resolution of the complaint by the Ad Hoc
Appeal Committee. 11 all parties Involved in the complaint agree, the complaint response of the Ad Hoc
Appeal Committee shall be final and binding on all parties.
Section 11.0
HEALTH CARE SERVICES
11.1 Benefits and Services
Harris Health agrees to arrange for the provision of the benefits and services in the Schedule of
Benefits and/or Riders, in accordance with the procedures and subject to the limitations and exclu-
sions specified in such Schedule of Benefits and/or Riders and in this Agreement.
Unless referred in writing by a Participating Primary Physician (or by a Participating Specialist
Physician), and except in cases of Med cal Emergency, benefits and services set forth in the Limita-
tions and Exclusions Section of the Schedule of Benefits or any Riders that are rendered by a Partici-
pating Physician oitr.r than a Par ticipating Primary Physician shall not be covered.
All hospital admissions must be authorized by Harris Health, and the Member's condition or
required services must be such that treatment can be rendered only in a hospital setting. Harris Health
and the Participating Physician may decide to provide Medically Necessary services on an outpatient
basis or in an ougeticnt surgery unit. The use of alternative levels of care, such as outpatient hospital
or home care, will be encouraged where possible based on Member randiGofr and treatment.
Unless previously authorized in writing by a Participating Physician and by the Medical Director
and except in ca :es of Medical Emergency, all benefits and services set forth in the Schedule of Ben-
efits and any Riders shall be available and covered only when provided by a Participating Physician.
Participating Hospital or by another Provider under contract with Harris Health to provide healthcare
services to Members.
e
s
a
r
a
All charges related 10 services and supplies incurred pr'ar to the Member's elleclive ale, pt
after the Member's termination dale of coverage under this Agreemgo~h- jif?ot I over V y
Section 12.0
TERM AND AMENDMENT OF AGREEKNT
~U
12.1 TERM
This Agreement shall remain in effect for the first Contract Year and thereafter for successive
Contract Years unless sooner terminated as provided in Section 4.0 of this Agreement.
12.2 AMENDMENT
• Harris Health and Group may mutually alter or revise the terms of this Agreement and/or
Schedule of Benefits and Riders attached hereto. In the event of such alteration or revision,
Harris Health shall provide Group with at least sixty (60) days written notice before effective
date of Amendment. Such notice shall be considered to have been provided when mailed to
the Group at the latest address shown on the records of Harris Health.
• This Agreement may be amended at any time, according to any provision of this Agreement
or by written agreement between Harris Health and Group, without the consent of the Mem-
bers, or any other person having a beneficial interest in it Any such amendment shall be
without prejudice to any claim arising prior to the effective date of such amendment.
12 3 CHANGE OF RATES
Harris Health shall have the right to change the rates and premiums payable hereunder (i) as
of any Anniversary Date (in which case th.a Group shall be notified at least sixty (60) days prior to a
change in rates) or (ii7 in accordance with Section 12.2 of ttris Agreement
Section 13.0
MISCELLANEOUS PROVISIONS
13.1 USE OF WORDS
Words used in the masculine shall apply to the feminine where applicable, and, wherever the
context of this Agreement dictates, the plural shall be read as the singular and the singular as the plu-
ral. The words "hereof," "herein" "hereunder" and other similar compounds of the word "here" shall
mean and refer to the entire Agreement and not to any particular Section or provison. All references to
Sections and provisions shall mean and refer to Sections and provisions contained in this Agreement
unless otherwise indicated.
13.2 RECORDS AND INFORMATION
Harris Health shall conduct a review program for the healthcare services it provides hereunder
and for that purpose may examine the records of each Member. Information from medical records of
Members and infonnation received from Physicians or Hospitals incident to the Physician-patient or
Hospital-patient relationship shall be kept confidential. This information, except as reasonably neces-
sary in connection with the administral'on of this Agreement or as required by law, shall not be dis-
closed without the consent of the Member.
Harris Health shall, to the extent legally allowable and without lurther consent of or notice to
any Member, release to or obtain from any insurance company or other organization or person any
information, with respect to any person, which Harris Health deems to be necessary for such pur-
poses. Any person claiming benefits shall furnish to Harris Health such information as may be neces-
sary to implement this Agreement.
13.3 INFORMATION FROM GROUP
Group shall periodically forward the information required by Harris Health in conjunction with
the administration of this Agreement. All records of Group which have a bearing on the Coverage shall
be open for inspection by Harris Health at any reasonable time. Harris Health shall not be fable for the
fulfillment of any obligation dependent upon such information prior to its receipt in a form satisfactory
to Harris Health. Incorrect information furnished may be corrected, if Harris Health shall not have acted
to its prejudice by relying on it. Harris Health shall have the right, at reasonable timas, to examine
Group's records, including payroll records of employers having employees covered through Group,
with respect to elrgibiliiiy and monthly premiums under this Agreement. i,~
13.4 ASSIGNMENT gereaNo %
nd are not
The benefits to a Member under this agreement ate raClii~°+a
assignable or otherwise transferable.
13.5 AUTHORITY
Any alterations or revisions to this Agreement shall not be valid unless a dented by a written
amendment which has been signed by Group and by an officer of Harris Health and attached to the
affected document. No other person has the authority to change this Agreement or to waive any of its
provisions.
13.6 GOVERNING LAW
This Agreement is executed and is to be performed in all respects in accordance with all fed-
eral and Texas state laws applicable to Health Maintenance Organizations and all other applicable
Texas state laws or regulators.
13.7 INCORPORATION BY REFERENCE
The Schedule of Beneras, Group Enrollment Agreement, Applications, any optional Riders, any
Attachments, and any amendments to any of the foregoing, form a part of this Agreement as if fully
incorporated herein. Any direct conflict or ambiguity of this Agreement shall be resolved under terms
most favorable to the Member.
13.8 ENTIRE AGREEMENT
This Agreement constitutes the entire understanding between Harris Health and Group.
13.9 INFORMATION TO MEMBER
Upon execution of this Agreement, Harris Health shall provide to each Subscriber a copy of
this Agreement and an Identification Card. Such delivery shall be accomplished by mailing postage
paid, to the latest address furnished to Harris Health or by delivery from a representative of Harris
Health or Group to Subscriber.
13.10 UNIFORM RULES
In the administration of Harris Health, this Agreement shall be applied uniformly to all Members
similarly situated.
13.11 CALCULATION OF TIME
In determining time periods within which an event or action is to take place for purposes of
Harris Health, no fraction of a day shall be considered, and any act, the performance of wi collwould
fall on a Saturday, Sunday, holiday or other non-business day, may be performed
business day.
13.12 EVIDENCE
Evidence required of any Member of Harris Health may be by certificate, affidavit, document,
or other information which the person acting on it considers pertinent and reliable, and signed, rnk,de
or presented by the proper party or parties.
13.13 SEVERABILITY
If any provision of this Agreement shall be held invalid or illegal, the rest of this Agreement shall
remain in full force and effect and shall be construed in accordance with the intentions of the parties
as manifested by alt provisions hereof including those which shall have been herd invalid and illegal.
Furthermore, in lieu of any provision hereof which is found to be illegal, invalid or unenforceable, there
shall be added hotel() a provision as similar in terms to such illegal, invalid or unniinfforceabl provisiw
as may be possible and be legal, valid and enforceaUe without materially changing T the purpose and
intent of this Agreement
I
13.14 VENUE
The parties hereby expressly agree 111,31 this Agreement is executed and shall 1x3 performable
in Tarrant County, Texas, and venue of any d apules, claimS, Or IaNSLAS arising hereunder shall be in
the said Tarrant County. -1ggndaMO._ -a--
13.15 WAIVER OF NOTICE AgE~d~llem„.___ Any person entitled to notice under this Agreement may wafvq notice. 13.16 HEADINGS
The titles and headings of Sections or provisk~ns are included for convenience of r ference
only and are not to be considered in construction of the :,ections or provisions hereof.
13.17 NOTICE OF CERTAIN EVENTS
If Group may be materially or adversely affected thereby, Harris Health shall, within a reasona•
ble time, provide written notice to Group of any termination or breach of contract, or inability of any
Participating Provider to provide the services and benefits as described in this Agreement.
13.18 NOTICE OF TERMINATION
All Harris Health notices of termination of this Agreement cf of a.ry Member's rights will be in
writing and shall state the cause of termination, with specific reference to the provision(s) of this Agree-
ment giving rise to the right of termination.
13.19 NOTICE
My notice under this Agreement shall be in writing, and shall be given by United Slates mail,
postage prepaid, addressed as follows:
Harris Health: 1300 Summit Avenue, Suite 300
Fort Worth, TX 76102
Group: The address specified on the executed Group Enrollment Agreement or the latest
address provided, in writing, to Harris Health.
Subscriber: The latest address provided by the Subscriber on Application form actually delivered
to Harris Health.
The effective date of notice is two (2) business days after the date of depo.;it with the United
States Post Office.
24
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>
~gendaNo _ C -
tale
HARRIS HEALTH SERVICE AREA
The Harris Health Service Area includes six-
n (16) counties and parts of four (4) win-
s in North Central Texas-
The following sixteen (16) counties are in-
rded in the Service Area:
ascue Hood Montague
wmmanche Johnson
Dallas Limestone
entoo Parker
rath Palo Pinto t
reestone Somervell Wise
Hamilton Tarrant Denlo,a
fill Wise
,n the following four (4) counties zip codes 1] 11 12
are included as specified in the Service Area. Parker Tamar Dallas _
4 217 5920
s 3
:OUNTY ZIP CODES
:oryell 16512 - 14 16
76525 - !food 21 -
76528 15 Johnson Ellis
76538
76566 a Erath S 01 76580 [ 9 ti
Ellis 76064 Iiosque Hdl Nanno r - F
76065 Comanche
Montague 76230
76239
76751 Efamilton Freestone
76270 Limestone
Navarro 75110 t9
76639
75153 Cor)el!
76679
76681
1. All Saints Cnyview Hospual 11, Yantis hlca130diA I I-E-f3
2. All Saints Episcopal Hospital 12. Harris Methodist HE13•Springwood
3. Arlington Memorial Hospital 13. Barris Methodist Northwest
4. Campbell Memorial Hospital 14. Harris Methodist Southwest
5. Cook-Fort Worth ClAdren's 15. Hood General Hospital
I Medical Center 16. Hugulcy Memorial Medical Center
6. Decatur Community Hospital 17. Medical Plaza Hospital
7. Denton Community Hospital 18. Osteopathic Medical Center of Texas
8. Harris Methodist Erath County 19. Parkview Regional Ilospital
9. Harris Methodist Fort Worth 20. St. Joseph Ilospital
10. Hams Methodist Glen Rose 21. Wails Regional Hospital
Agenda No .„L' ,-.Q./.`....
Agendalte A`°2
r cite a3 _q.~
SCHEDULE OF BENEFITS
PREFERRED PLAN
` HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
j Fort Worth, 7eaas 76102
1.800/633-0598
f (811) 8785826
1
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PREF•592
R
1gerda No
E L OBTAINING HEALTH CARE SERVICES
0 G
Each Subscriber and his Dependent Members are entitled to receive the services d benefits set
forth in this Schedule of Benefits which are Medically Necessary and obtained in accordance with the
provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage.
A. Upon enrollment, each Member shall choose (or the Subscriber shall choose on behalf of his
Dependents) a Primary Care Physician. If the Member fails to choose a Primary Care Physi-
cian, Harris Health shall assign a Primary Care Physician for the Member. The names and ad-
dresses of the Primary Care Physician from which the Member may choose shall be provided
to each Subscriber upon enrollment. Services are provided or coverage arrangements are avail-
able twenty four (24) hours per day, seven (7) days a week by calling the telephone number
provided for the Primary Care Physician.
B. A Member may change their Primary Care Physician by contacting the Harris Health Member
Services Department at the address or telephone number specified above. The change will be-
come effective on the lirst day of the month following the request.
C. All health care services, except those resulting from a Medical Emergency, are to be per-
formed, prescribed, arranged, directed or authorized by the Primary Care Physician selected by
the Member. When care by a Specialist Physician is necessary, the Primary Care Physician
shall coordinate the referral to a Participating Specialist Physician. No referral is necessary for
a female member to obtain obstetrical/gynecological services from a Harris Health participating
OBlGyn Specialist. If a required specialty is not represented in Harris Health, a referral may be
made to a Non-Participating Provider. All such non emergency referrals must be authorized by
the Harris Health before services are obtained. Any Member may obtain additional information
as to how medical services are obtained by contacting the Harris Health at the address specl-
lied above.
D. Except in cases of a Medical Emergency, or as a result of special prior approval by Harris
Health as specified above, only those services provided by a Participating Provider shall be
covered under this Schedule of Benefits.
E. All services and benefits are subject to any stated Copaymeot amounts, limitations, and exclu-
sions described in this Schedule of Benefits.
F. Any copayment expressed as a percentage of "Total Charges" shall mean the stated percent-
age of the medical provider's preferred rate which is the amount paid to the medical provider
by Harris Health,
0. This Schedule of Benefits may be supplemented by additional benefit Riders if Included with
this Group Health Care AgreemenUSubscriber Certificate of Coverage.
H. The relationship between Harris Health and Participating Providers is that of Independent con-
tracting entities. Participating Providers are not agents or employees of Harris Health nor is
Harris Health an employee or agent of any Participating Provider. Participating Providers shall
maintain the physician-patient or professional-patient. relationship with Members and shall be
the only parties responsible to Members for the services provided. Neither Harris Health nor
any employes of Harris Health shall be deemed to be engaged In the practice of medicine. Har-
ris Health shall in no way supervise the practice of medicine by any Participating Provider, nor
shall Harris Health in any manner supervise, regulate or interfere with the usual professional
relationships between a Participating Provider and a Member.
PI
PREP-592 t
Cie
II. PHYSICIAN SERVICES
Only one Copayment will be required for covered services performed or furnished on same date of
service by the same Provider. This Copayment will be the higher of all listed Copayments.
Benefits
Required Copayment
Physician office visits, adult health assessments routine
physical examinations, , well child care, and health education $15.OONisit Primary Care
for P
bydriagnoimarysisCare, care andPhysiciantreatment of illness or injury provided
Physician office visits from Specialist Physician
L $20.00Nisit•Speciatist
Annual well woman examination
$15.OOMsit•Primary Care
f $20.O0Nisit•Speclalfst
Physician office visits after hours
$25.00/Visit
Immunizations and Injections
No Copayment
Home visits $15.00Nisit
Hearing, vision, and speech screening provided by Primary $15,00Nisit
Care Physician to determine the need for correction
Allergy diagnosis and/or testing; serum is not covered $50.00Msit
Administered drugs, medications, dressings, splints, and
casts $15.00Msit•Primary Care
520.00Msit•Speciali st
Diagnostic services, laboratory tests, and x-rays No Copayment
Ultrasound, NlRI, CAT, and non-routine laboratory tests $50.00frest
Surgery and/or anesthesia performed In the physician's office
or outpatient setting $50,00/Procedure (Phys.)
All physician fees Including anesthesia while a member is 20% of Total Charges
hospitalized, except professional radiology and pathology fees
Professional radiology and pathology fees No Copayment
k' Physician fee In an emergency room or urgent care center
r 20% of Total Charges i
f l~
PREF•592
'I 2
AgendaNa._1~,3_~Q_~f -
Agendaltem >~`.~2
For maternity services within the Service Area, Member shall -9d
and hospital care from Participating Physicians and other Propiog e term otthe~pregnancy,
'
6 upon delivery, and during the postpartum period for normal Rt fkt riages; i
and for complications of pregnancy. Charges related to meQ' services connected with the home
delivery of a newborn and services of mid-wives, unless proUTtlc? 3>; Emergency Care Services, will
not be covered, Any normal delivery which occurs outside the Service Area within thirty (30) days of
the expected date of confinement as specified by a Participating Physician, will not qualify for
Emergency Care Services benefits, and will not be a covered benefit Benelits for the child of an
unmarried Dependent Member will be provided if the child is considered to be a dependent of the
Subscriber for Federal income tax purposes, and upon payment of the applicable p e~mlu I ?4 X Benefits a
Required Cop meni
eni
Physician services for maternity care including delivery, 20% of Total Charges
hospital visits, and anesthesia
Physician care In the hospital for care of Eligible Newborn 20% of Total Charges
F
III. HOSPITAL SERVICES
Member shall be entitled to receive Medica!Iy Necessary hospital services, subject to all definitions,
terms and conditions of this Agreement and Schedule of Benefits when performed, prescribed,
arranged for, directed or authorized by Participating Physicians and received at Participating
Hospitals. Members electing to remain in the hospital beyond the period which is Medically Necessary
will be responsible for direct payment to the hospital for any such time beyond the discharge time
authorized by the Participating Physician and/or the Harris Health Medical Director or his designee. E
Benefits Required Copayment #
INPATIENT HOSPITAL SERVICES! 20% of Total Charges
Semi-private room, private if Medically Necessary, and
all services end medical supplies related to Inpatient
treatment.
OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Facilities)
Surgery $100.00/Procedure (Facility)
Therapeutic radiation treatment 20% of Total Charges
Inhalation therapy 20% of Total Charges
Diagnostic testing, laboratory, and x-rays No Copayment
Ultrasound, MRI, CAT, and non-routine laboratory tests $50.00/Test
I PREF-592
3
b
i IV. EMERGENCY CARE SERVICES
In cases of a Medical Emergency, Member is entitled to the Wnefits and services set forth in this
Schedule of Benefits and in this Agreement even if the services are not received from Participating
Providers. Member is entitled to receive these bona fide emergency services provided after the
r sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity,
[ including severe pain, such that the absence of immediate medical attention could reasonably be
expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily
functions or serious dysfunction of any bodily organ or part.
All treatment for such services will be reviewed retrospectively by the Harris Health Medical Director
or his designee to determine whether an acute condition or situation indicated immediate emergency
[ care to be appropriate. If upon review, the Harris Health Medical Director or his designee determines
( that no need for emergency care existed, the Member will be responsible for payment of all charges
Incurred for such care.
WITHIN THE SERVICE AREA Emergency Care Services must be obtained or authorized through the
Primary Care Physician who provides the Member wish twenty-tour (24) hours a day, seven (7) days
a week access to call coverage to assist the Member in obtaining Emergency Care Services. At the
time of a Medical Emergency, the Member or someone acting on behalf of the Member, shall make
every reasonable effort to contact the Member's Primary Care Physician for advice. If it is not
reasonably possible to contact the Primary Care Physician at the time (such as that of a life or limb
threatening emergency), the Member shall seek care from a Participating Hospital or Participating
Emergency Center.
At the time of a Medical Emergency which results in a hospital admission, the Member or someone
acting on behalf of the Member, shall notify Harris Health within iwenly•four (24) hours or as soon as
reasonably possible, Upon notification, the Harris Health Medical Director or his designee may
coordinate transfer of the Member to the care of their Primary Care Physician or other designated
provider when medically prudent to do so.
Benefits (Within Service Area) Required Copayment
Physician office visits $15.OONisit-Primary Care
$20 , OONi s i t-S pe cia list
Physician office visits after hours $25.00Nisit
Hospital emergency room and urgent care center services, 20% of Total Charges
Including physician fees
Follow-up care Is covered from Primary Care Physician only, $15.DONisit•Pr' Care
or upon referral from the Primary Care Physician $20.00Nisil-Sp It
u
~j
IJ ~ I
1
1
Y
PREF•592 4
t
if
AgafldAo
Apsa~a+;orrr
Eve;a ' ~a
OUTSIDE THE SERVICE AREA coverage for Emergency Caro Services whi e o ode the Service Area
are available provided that such Emergency Care Services cannot be reasonably delayed without risk
to Member until the Member is able to return to the Service Area to obtain treatment from
ParticipatinC Providers.
At the time of a Medical Emergency which results in a hospital admission, the Member or someone
acting on behalf of the Member, shall notify Harris Health within twenty-four (24) hours or a! soon as
reasonably possible. Upon notification, the Harris Health Medical Director or his desitnee may
coordinate any transfer of management and ccnlrol of the care to a Participating Provider or other
designated provider in the Service Area as soon as medically prudcat to do so.
Continuing or follow-up treatment shall be provided within the Service Area. No claim for oat-of-area
emergency services shall be allowed when procedures in this section are not complied with by the
Member.
Benefits (Outside the Service Area) Required Copayment
Physician office visits for stabilization and emergency care $15.00/Visit-Primary Care
services only $20.00Nisit-Specialist
Physician office visits after hours $25.00Nisit
Hospital emergency roora and urgent care center services for 20% of Total Charges
stabilization only, including physician fees
Follow-up care is covered from Primary Care Physician only, $15.00)Visit-Primary Care
or upon referral from the Primary Care Physician $20.OONisit-Specialist
V. FAMILY PLANNING SERVICES
Family Planning Services will be available to Members on a voluntary basis Covered services are
limited to the use of Participating Providers and will include history, physical examination, related
laboratory tests; medical supervision in accordance with generally accepted medical practice;
information and counseling on contraception, including advice or prescription for a Contraceptive
method; education, in.U,ing education on the prevention of venereal disease; and voluntary
sterilization after approFri,'e counseling.
Benefits Required Copayment
Physician office visits, including related testing, education and $115.00Msit-Primary Care
counseling $20.OONisit- Specialist
Fitting and dispensing of IUD and diaphragms $15.OONisit-Primary Care
$20.00Nisit-Specialist
Tubal ligation $50.00/Procedure (Phys )
Vasectomy $50.00/Procedure (Phys,)
P
PREF-592 5
~ VI. INFERTILITY SERVICES
t Infertility services will be available to Members on a voluntary basis Artificial insemination and
t diagnostic services to determine the cause of infertility will be provided from Participating Providers
and Participating Facilities. Excluded from services to treat infertility are those services described In
"Exclusions," Section XIX, Number 23 of this Schedule of Benefits.
Benefits Required Copayment
Physician office visits for diagnosis, non-psychiatric $15.00Nisit-Primary Care
counseling, artificial insemination, and sperm count $20AOMsit-Specialist
" Administration of infertility medications; Infertility $15.OONisit•Primary Care
medications not covered $20.00Nisit-Specialist
n metrrial biopsy, hysterosatpingography and diagnostic 20% of Total Charges
aP py
i
Sonogram and/or ovulation kit $50.OO/fesl or Kit
VII. CHEMICAL DEPENDENCY SERVICES
Member shall be entitled to all necessary care and treatment for chemical dependency on the same
basis as that provided for any physical illness to a lifetime maximum of three (3) separate series of
treatments for the member. Diagnosis and treatment for chemical dependency shall include
detoxification and/or rehabilitao.ion on either an inpatient or outpatient basis as determined to be
Medically Necessary by Participating Physicians. All treatment is subject to the same limitations,
exclusions, and copayments as applied to covered services of any other physical illness,
A series of treatments is considered to be a planned, structured, and organized program to promote
chemical free status which may Include different facilities or modalities and is complete when:
The member is discharged on medical advice from inpatient detoxification, inpatient
rehabilitation treatment, partial hospitalization or intensive outpatient; or
The member has received a series of these levels of treatments without a lapse in treatment; or
The member tails to materially comply with th3 treatment program for a period of thirty (30)
r days,
Benefits Required Copayment
Office visits $IS.OONisit-Primary Care
$20.10ONis it•Specialist
Necessary care and treatment for detoxification and/or $15.00Nisit•Primary Care
rehabililation from chemical dependency $20.00Nisif-Specialist
j 20% Total Inpatient Charges
l Intensive outpatient or partial uspitalization 201/6 Total Inpatient Charges
M I~
PREP-592 6
r
,;~cowu _ 13~a~~ ,
VIII. MENTAL HEALTH SERVICES i
OUTPATIENT MENTAL HEALTH SERVICES: 4
Member shall be entitled to receive up to twenty (20) or' a visits per Calendar Year for evaluation,
crisis intervention and stabilization, and for outpatient therapy In support of the evaluation or crisis
Intervention. Member must be referred by the Primary Care Physician or by the Harris Health
designee to Participating Specialist. Services must represent treatment for conditions which in the
judgment of Participating Providers can substantially benefit from short-term treatment. The twenty
(20) visits maximum may include individual treatment, couple, or family visits.
Benefits Required Copaymeni i
Outpatient office visits for crisis Intervention and treatment $20.00Nisit !
i
Psychological testing 20% of Total Charges
INPATIENT MENTAL HEALTH SERVICES:
When determined to be Medically Necessary by Participating Physician or by the Harris Health
designee, the Member shall be entitled to evaluation, crisis intervention, treatment or any
combination thereof for acute conditions at a Participating Facility. Services must represent treatment
for conditions which in the judgment of Participating Providers can substantially benefit Irom
treatment, and requires inpatient treatment.
Only treatment at the most appropriate level of care as determined by Participating Providers or by
the Harris Health designee will be authorized by Harris Health.
Chronic mental health conditions and long-term treatment are not covered.
Benefits Required Copayment
Inpatient hosp;Nizaticn for up to thirty (30) Inpatient days per 20% of Total Charges
Calendar Year.
Psychiatric Day Treatment Facility, Crisis Stabilization Unit or 20% of Total Charges
Residential Treatment Center for Children and Adolescents for
up to sixty (60) days per Calendar Year. Treatment In such
facilities will be limited to sixty (60) days of care such that one
(1) day of care shall be equal to one-half (112) day of inpatient
care,
PI
PREF•592 7
~gsrdaNo . -D ~1~1
AgenOaltem_ #O'7
-~5t 0
DL REHA8ILITATIDN SERVICES -
rehabilitation services
( Member shall be entitled to receive short-term physical or occupational therapy s are
from a llrHecessary,r subject to significant improvement th rough short-termgl eatment Sand
t Medically
authorized by Harris Health before services are obtained Short-term treatment Is defined as up to
da or
r, and pirovidedlon ane outrpat entsbas swonly,lSho t term (rehab i tationlserv eels on anlinp tient basissorlin a
skilled nursing facility will be authorized only it other non-rehabilitation medical services are required
by the Member.
Occupational therapy shall mean those services designed to prevent dysfunction, restore functional
ability and facilitate maximal adaptation to impairment.
Required Capayment
Benefits
Hospital, home health agency, or other provider for restorative $15.00ffisit•Primary Care
treatment subject to short-term clinical Improvement, and $220.OON (sit-Specialist
20, Total Inpatient Charges
Iperrtcondition, whiehevver is greater. Long tom orvmaintenance consecutive days or services are not covered.
X KIDNEY DIALYSIS SERVICES
Member shall be entitled to services and benefits provided within the Service Area for kidney dialysis
upon prior authorization from Harris health and by referral to Participating Providers, only it
and the tin Ph sician ewer to la that such sViceolnvolveden Coveeape wilrlebe ncoo~dlnated for any
Member eligible for available coverage under the Medicare provisions for ~ gated C Renal Disease,
Benefits
I
Inpatient or outpatient hospital, or outpatient kidney dialysis $20.00Nisit•Outpatlent
20% Total Inpatient Charges
• center
home dialysis (continuous ambulatory peritoneal dialysis) $20.90Nisit
Including equipment, training, solutions, coda, drug and
surgical supplies
)0. AMBULANCE SERVICES
Required Capayment
Benefits
20°/° of Total Charges
Member shall be entitled to both land and air ambulance
services for Medically Necessary Emergency Care Services
8
PREP-592
XiI. HOME HEALTH CARE SERVICES
Member shall be entiVed to receive home health care services from a Participating Provider according
to a treatment Plan approved by the Participating Physician, and with prior authorl'ation from Harris
Health. Treatment will be provided only for those medical conditions subject to clinical improvement
through short-term treatment; for recovery or rehabilitation of illness or injury; or for treatment of
terminal illness.
Benefits Required Copayment
Skilled nursing care; physical, occupational, or respiratory $15.OONisit
therapy; Intravenous solutions; and home health aid services
Hospice (home health service only) $15.OONisit
XIII. SKILLED NURSING FACILITY SERVICES
Member is entitled to receive services in i rarticlpating Skilled Nursing Facility for medical conditions j
which in the judgment of a Participating Physician is subject to significant clinical improvement and
which require services which can only be provldcd at that level of care. Services in a Skifled Nursing
Facility may be provided in lieu of hospitalization (either In lieu of admission or upon discharge from
inpatient care) as Medicaffy Necessary based on acuity of services and patient condition, are limited
to sixty (60) days per Calendar Year, and Include Participating Physician services only.
Benefits Required Copaymenl
Room, board, medications and supplies while confined in a 200% of Total Charges
Skilled Nursing Facility as part of a short-term recovery or
rehabilitation program
Participating physician visits while confined to Skilled Nursing 20% of Total Charges
Facility
XIV. PROSTHETIC MEDICAL APPLIANCES
Member shall be entitled to prosthetic medical services or medical appliances if Medically Necessary,
with authorization from Harris Health, and received from Participating Providers. While the Member Is
covered under this Agreement, initial prostheses are provided when required due to illness or injury. 1
Replacement Is provided only when marked physical changes occur which require replacement, and is
not provided for items which wear out due to normal usage,
Benefits Required Copayment
Internal prosthetic appliances Including internal cardiac 20% of Total Charges
pacemakers, and minor devices such as screws, wire mesh,
nails, and artificial joints. Supply of or replacement of internal
breast prothesis covered only if Initial surgery was result of
Injury or d cease,
PREF•592
9
( Benefits
External prosthetic appliances including artificial arms, legs, a.'1"red Capaymen!
above or below knee or elbow prostheses; eyes, lenses,
external cardiac pacemaker; terminal devices such as hand or 20'° of Tot rg~s
hook; rigid or semirigid Immobilizing devices such as arm,
leg, neck or back braces; and ordinary splints, and crutches
XV• DURABLE MED1CAl EQUIPMENT
Member shall be entitled to benefits received from a Participating Provider for certain durable medical
equipment, s ordered by a Participating Physician, and with prior authorization from Harris Health,
r Durable medical equipment must be able to withstand repeated use, customarily sere
• medical purpose, generally not be useful in primarily and the absence of illness or Injury, require a participating
Physician's order, and be appropriate for use in the home. At its option, Harris Health may rent or
purchase approved equipment. Harris Health retains the right of possession of equipment.
Harris Health shall have no liability or responsibility for repair or replacement of equipment lost or
dama ed. Equipment not considered durable medical equipment is described In ''Exclusions", XIX, Number 31 01 this Schedule of Benefits.
,
- ~ Benefits
Rental or purchase of medicol equipment Required Copayment
- ~ 204,~ of Total Charges
LIMITED DENTAL SERVICES
The Member shall be entitled to services
►
occupational injury to for the Initial stab lizatio
in Of acute`- ac idental, ron•
within thirty (30) days of the sound natural
I
accident ral on teeth an with outpatient prior basis only, authorization by Harris Health, when provided
J
l While Membe► is covered under this Agreement coverage is limited to treatment
dislocated Jaw, or to repair damage to sound natural teeth. Limitations and exclusions for dental
services are described In Section XVIR, Number 3 and Section XIX, Number 17 of this Schedule of
Benefits. Copayments will be the same as described for other illness or injury services.
r XVtt. COPAYMENT MAXIMUM
The maximum annual Copayments for covered benefits, under this Schedule of Benefits, shall not
I exceed the following In a CatenJar Year as described' n Section 5.3, of the Group Health Care
Agreernent/Subscriber Certificate of Coverage
Benefits
Maximum Annual Copayments
Per Member
r Per Family $2,000.00
` $4,000 00
PREF-592
r
10
.y r,~ E!3 Pr 0
XVIII. LIMITATIONS
The following services are limited as described below, r
1. Any service, supply, or treatment which is not provided, ordered, performed, prescribed,
directed, referred, arranged, authorized or approved by the Member's Primary Care Physician, r
or the Harris Health Medical Director or his designee, will not be covered; except for
Emergency Care Services as described in this Schedule of Benefits.
2, Services by physicians, facilities or other providers, who are not Participating Providers, will
not be covered; except for Eme gency Care Services as described in this Schedule of Benefits, 1
or those services authorized in advance In writing by the Harris Health Medical Director or his
designee.
3 Care and treatment of the teeth or gums, except for oral surgery for tumors or injuries to the
jaw bone or surrounding tissue, Is limited to the Initial stabilization of acute, accidental non-
occupational injury to sound, natural teeth when provided within thirty (30) days of the
accident on an outpatient basis only,
4. Coverage for vision examinations is limited to conditions which require examination to r
diagnose injury or illness, unless covered by Rider attached to this Agreement. L,
5. The benefit for durable medical equipment Is limited to either the total rental cost or the
purchase price of such equipment, whichever Is less, as determined and authorized In advance
by the Harris Health Medical Director or his designee. Harris Health shall have no liability or
responsibility for repair or replacement of equipment lost or damaged,
r
6, Care and treatment provided in nonparticipating hospital owned or operated by federal, state,
county or city government is limited to the care for the condition which the law requires to be
treated or provided in a public facility,
7. The purchase or fitting of eye glasses or contact lens or advice on their care Is limited to the
Initial set of eye glasses, contact lens, or lens implant required following cataract surgery,
repair of congenital defect or as required by an accidental Injury to the Member, G
8. Coverage for reconstructive surgery is limited to surgery necessary to repair a functional
disorder resulting from disease, injury, or congenital defect, Supply or replacement of internal
breast prothesis is covered only if Initial surgery was a result of Injury or disease,
9. Any normal delivery for the Member which occurs outside the Service Area, and is within thirty
(30) days of the expected date of confinement, as specified by a Participating Physician, will
not qualify as Emergency Care Services benefits described in this Schedule of Benefits.
10, Benefits for Dependents who are students temporarily residing outside the Service Area, are C
limited to Emergency Care Services only outside the Service Area. The Dependent must return
to the Service Area for all other services.
11. Coverage for treatment of the lemporomandibular (jaw or cranicmandibufar) joint Is limited to
Medically Necessary diagnostic services and/or surgical treatment as determined to be
Medically Necessary by the Harris Health Medical Director or his designee. All services must
be provided by a Participating Provider Charges related to dental services for this condition
are not covered. [
l
PREF•592 11
i
it-,Z3 _ i
12, If Medically Necessary and authorized by the Harris Health Medical Director or designee, Harris
Health will cover kidney transplants, corneal transplants, liver transplants for children with
congenital biliary atresia, and bone marrow transplants for Aplastic Anemia; Leukemla;
Lymphoma; Severe Combined Immunodeficiency Disease; or Wiskott-Aldrich Syndrome where
traditional modalities of traditional medical therapy have been exhausted. Medical costs for
organ procurement associated with the removal of an organ for a covered transplant when the
recipient is a Member are limited to a maximum benefit of $10,000, Charges related to organ,
tissue, or artificial organ transplants except as otherwise specified in this section are excluded.
The donor's transportation costs are not covered, Services provided to any Member for the
donation of any organ or element of the body are not covered.
13. Benefits for the infant child of an unmarried Dependent will be provided if the Infant Is
considered to be a dependent of the Subscriber for Federal income tax purposes, and upon
payment of the applicable premlum.
r
~l
.r s
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i
PREF-592 12
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"yeti;? Iirrp~~,~
y,.9 _._11Aa3 - a
XIX, EXCLUSIONS
The following services and supplies, and the cost thereof, are excluded from coverage under this
Agreement, unless specifically added by Rider to this Schedule of Benefits.
1. Charges related to any service or treatment which a Member would not be legally required to
pay in the absence of this Agreement.
2, Charges related to personal, convenience, or comfort items such as personal kits provided on
admission to a hospital, television, telephone, newborn Infant photographs, guest
meals, birth
announcements, and other related articles which are not for the specific treatment of illness or
Injury.
1 Charges related to transportation, except charges related to land and air ambulance services
for Medically Necessary Emergency Care Services described in Section XI of this Agreement.
4. Charges related to private hospital room and/or private duty nursing.
5. Charges related to services rendered by a person who resides in a Member's home, or by an
immediate relative of the Member.
6. Charges related to services for military or service connected conditions for which the Member
Is legally entitled, and for which appropriate facilities are reasonably available to the Member.
7. Charges related to occupational Injury or Illness or conditions covered under Worker's
Compensation.
8. Charges related to hP "maker, chore or similar services; and health care services primarily for
rest, custodial, res- omiciliary, or convalescenl care.
9. Charges related to reports, evaluations, or physical examinations not required for health
reasons (not Medically Necessary). Excluded items are: reports for employment, Insurance,
camp, adoption, travel, or government licenses.
10. Charges related to drugs or medicines, prescription or non-prescription, provided to the
Member while he or she Is not an Inpatient, unless added by Rider to this Schedule of
Benefits.
11. Charges related to experimental drugs or substances not approved by the FDA for other than
FOA approved Indications; and drugs labeled "Cautlon • limited by Federal Law to
investigational use."
12. Charges related to formulas, dietary supplements, or special diets provided to the Member on
an oulpafient basis,
13. Charges related to vision care. Excluded services are: examination for eye glasses; retraction,
dispensing, or fitting of eye glass frames and lenses; all types of contact lens; eye exercise and
visual training; and orthoptics; except as otherwise specified in Section XVIII, Number 4 of this
Schedule of Benefits.
14. Charges related to radial keralotomy or other radial ke~atoplasties, and all costs associated
with such surgery,
PREF•592 13
r
yel
15. Charges related to hearing aids, batteries, and examinatiortsfortittln~fhe~eoTunless dried y
Rider to this Schedule of Benefits, .58 AV 96 ,q
JO' ~
16. Charges related to the care and treatment of the feet unless such services are Medically
Necessary, Exclusions include routine foot care, such as removal of corns, calluses, or the
splintstrimming of nails; treatment for flat feel: orthotics; arch supports; or custom fitted braces and
.
11. Charges related to dental care, except as otherwise specified In Section XVI of this Schedule of
Benefits, including services related to the care, fillings, removal, or replacement of teeth;
treatment of diseases of the teeth or gums; extraction of wisdom teeth; malocciusion or
malposition of the teeth and jaws (mandibular hyperplasla'hypoplasla); professional services or
anesthesia related to or required for the sole purpose to provide dental care; hospital care;
inpatient or outpatient surgery required for any dental care; prescription drugs for dental
treatment; dental x-rays; dentures; and dental appliances or prostheses.
18, Charges related to surgical procedures and other treatment associated with the treatment of
obesity, regardless of associated medical or psychological conditions, Including treatment of a
complication of surgical treatment for obesity. Excluded procedures are: intestinal or stomach
bypass surgery, gastric stapling, wiring of the jaw, insertion of gastric balloons, or similar
procedures.
19, Charges related to transsexual surgery, including medical or psychological counseling or
hormonal therapy, in preparation for or subsequent to any such surgery.
20. Charges related to services for cosmetic surgery or reconstructive surgery, except as
otherwise specified as covered in this Schedule or Benefits. Cosmetic surgery exclusions are: r
rhinoplasty; scar revisions; prosthetic penile implants; surgical revision or reformation of any
sagging skin on any part of the body, described as relating to the eye lids, face, neck,
abdomen, arms, legs or buttocks; liposuction procedures; any services performed In
connection with the enlargement, reduction, Implantation or appearance of a portion of the t
body described as the breast, face, iips, jaw, chin, nose, ears, or genitals; hair transplantation;
chemical face peels or abrasions of the skin; removal of tatoos; and electrolysis depilation.
Supply or replacement of inlernal breast prothesis is covered only if Initial surgery was a result
of injury or disease.
21. Charges related to reduction mammoplasty, unless determined to be Medicatiy Necessary by a
the Harris Health Medical Director or his designee.
22. Charges related to reversal of surgically performed sterilization or subseque+,1 resterilizalion
23. Charges related to surrogate parenting; in-vitro fertilization; GIFT procedures; and any costs e
associated with the collection or storage of sperm for artificial insemination Including doncr 9
fees; and infertility medications unless added by Rider to this Schedule of Benefits.
24, Charges related to amniocentesis, ultrasound, or any other procedure performed solely for sex
determination of the fetus,
25. Charges related to medical and hospital care for an infant of an unmarried Dependent Member,
unless the infant is considered to be a dependent of the Subscriber for Federal income tax y
purposes, and applicable premium payment has been made
26. Charges related to menial health services for psychiatric conditions which ara determined by
the Harris Health Medical Director or his designee, to be chronic or organic in nature, and
which will not substantially benefit from short-term evaluation, crisis Intervention and
stabilization, or short-term treatment
PREF•592
14
27. Charges related to court ordered testing, and s
treatment, pecjal reporly~l, d to medical
28. Charges related to services for the treatment of mental retardation ac
29• Charges related to employment, and men at"i deficiency
remedial education, including evaluationaandrtreatroent oluleaenling and developm
g behavioral i ning;
disabilities and minimal brain dysfunction; or attention deficit therapy, ental
36. Charges related to services for chronic intractable pain provided by '
acupuncture, naturopathy, and hypnotherapy; holistic or homeopathic care, Including drugs;
and ecological or environmental medicine. a Pain control center; '
31. Charges related to durable medical equipment, unless described In this Schedule of Benefits,
Excluded items are: (a) egJOrnent, such as motor driven wheel chairs and beds, possessing
features of an aesthetic nature or features of a
patient medical nature which are not required by the L'
's condition; {b) item s not primarily medical in nature or for the patient's comfort and
convenience, such as bed boards, bathtub lifts, over-bed tables, adlust•a•bed, and telephone
arms; (c) Physician's equipment such as stethoscope and sphygmomanometer; (d) exercise F
equipment such as exercycles and enrollment in health or athletic clubs; (e) self-help devices
not primarily medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (f)
corrective orthopedic shoes and arch supports r
household use, such as but not limited to, air purifiers), uppli central s or equipm nd water
for Common
Purifiers, items allergenic pillows or mattresses, and water beds; and (h) research equipment or
j
deemed to be experimental as determined by the Harris Health. Harris Health shall have
no liability or responsibility for repair or replacement of equipment lost or damaged.
32. Charges related to prosthetic medical appliances, except as specified In Section XIV of this
Schedule of Benefits. Excluded items include; (a) dentures, hearing aids unles by
Rider, and contact ►ens; (b) medical supplies such s provided
as elastic stockings, garter belts, arch
supports, corsets, and corrective orthopedic shoes; (c) research devices or items deemed to
be experimental as determined by Harris Health; nt
and (d) replacement, repair, and routine
required mainte due nance to Of
a marked covered appliances or braces unless surgically implanted, or replaceme
change in physical growth or physical requirements.
33. Charges related to medical supplies, aids, and ap pliances except as atherwisa specified as
covered In this Schedule of Benefits. Excluded items are: consumables, disposable supplies,
sheaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure ,
fraction apparatus, slings, TEN S or electrical nerve stimulation devices, wigs or hair pieceunitss,
dressings, testing supplies, syringes, home testing kits, disposable diapers or Incontinent
supplies, and over-the-counter medications.
34• Charges related to inpatient or outpatient lon
services or other rehabilitation service g -term neuromuscular, or occupational therapy
five (25) outpatient visits, whichever is greater. of sixty (r;o) days per condition or twenty
g eater,
35. Charges related to recreational or edurational there and an r
except as provided by the hospital as part of an approved lnpahent hospleali action ostic testing, `
38• Charges related to structural changes to a house or vehicle.
37. Charges related to any medical, surgical, or health care procedure or treatment held
experimental or Investigational at the lime the procedure or Ireatmant Is performed. Harris
Health will utilize findings and assessments of national medical associations, professional body federalegovernment for similar ent any 10 determine coverage
aind/or efectaenessby any state or
PREF•592
IN-VTTROFERTILIZATION RIDER
FOR USE ONLY WITH HARRIS HEALTHGROUP HEALTHCARE AGREE584 4d y
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health NTain(enance Organization
1300 Surruni1 Avenue,Sui11t 300
Fort Worth, Texas 76102
8001633.8598
1.0 Ef[ROD 1 "f1ON
In considentizri for the timelypaymentof pretdomis,and ell other terms and conditions of the Group
Healthcare Agreement'Subscriber I t o rice of coverage ('Agwalen0), it is agreed (hat the benertt
orthis Rider, together ailh the terns and conditions of this Rider, shall be added to Agreement ac
Issued if (his Rider is accepted by the Group,
2,0 @E_M FM
For the purpose of this Rider, outpatient expenses arising from ln•vitro fertilizatioa procedures for
the Subscriber or the Subscriber's spouse, the followingconditiorss shall apply:
• The fertilization or attempt at fertilization of the Member's oocytes is made only with
ATember's spowe's sperm.
• The Member and the Member's spouse have a history of infertility of al least rive
continuous years duratiun; or the infertility is associated with one cr more of IN
follouingmedical conditions:
a. endometriosis;
h. exposure In unto to die(bylstilbestrol (DES);
c. blockage or, or surgical removal of, one or both fallopian tubes (non-voluntar)); or
d. cligospcrmia.
0 The Member has been unable to attain a successful pregnancy through any less costly
applicable infertility trealments for %hich I-enefita are availahle under the Platt.
• The In-vitro fertilisation procedures are performed at a medical facility thrl conforms
to the American College of Obstetric and Gynecologyguidclines for in-vitro fertilization
clinics or to the American Fertility Society minimal standards for prograw of in-vitro
fertilization.
' Benefits for in-vitro fertilization procedures shall be, provided to the same extent as
the benefits for other pregnancy-nlaW procedures under the Plan.
rvKnt
1
Agenda No
AgWalle 'rrt,
D719 -5p'
3.0 ELIGIBILffI
Benue under this Rider are available to tlu Subscriber and the Subsoriber's spouse. Benefits
provide no conversion privileges or benefit continuity for Members when such persons are no
longer entitled to Group benefits as set forth in Agreement to which twit Rider is issued,
4.0 U.NWATION
Benefits shall be provided only if recommended by a Harris Health Primary or Barris Health
Specialty Physician and have received prior written approval from the Harris Medical Director of his
designee.
Venda No.
4gc~tQa Item
rvF1ss
2
E
IN•VITRO FERTILIZATION RUDER J "tl:PJO. - Y`~
FOR USE ONLY WMI IIARRJS IIEALTH GROUP HEALTHCARE AgRIjM~~JTf
SUBSCRIBER CERTIFICATE OF COVERAGE `Ll °aG
>EPTED: _ HARRIS HEALTH PLAN, INC. Senior' Vi Pnrident, Meruped Qn Muketinj
1300Sumnit Avenue, Suite 200
Fort Worth, TX 76102
(817) 878.5830
Dale:
REJECTED:
Group
By.
Authorized Repneerwive
Date:
SERIOUS MENTAL HEALTH RIDER ~iJf'1~ Ii0f11 ~ ~
FOR USE ONLY WIT If GROUP HEALTH CARE AGREENIENTISUBSCRIBER
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Mainlenance Organization
1300 Summit Ave, Suite 300
Fort %Vorth, Texas 76102
8001633-8598
1.0 INTRODUCTION
I
In consideration for the timely paymentof premiums, and all other terms and conditions of the Group
Health Care Agreement/Subscriber Certificate or Coverage ("Agreement"), it is agreed thal the
benefits of this Rider, together with the terns and conditions or this Rider, shall be added to
Agreement as issued if this Rider is accepted by the Group.
2.0 DEFINITIONS
Benefits for Serious Mental Health provided through this Rider shall be subject to the provisions and
definitions of the Agreement to which this Rider is a part.
Serious Mental Illness shall mean the following psychiatric illnesses as defined by the American
Psychiatric Association in the Diagnostic and Statistical Manual (DSM) Ill•Ro
I. Schizophrenia;
2. Paranoid and other psychotic disorders;
3. Bipolar disorders (mixed, manic, and depresshe);
4. Major depressive disorders (single episode or recurs nt); and
5. Schizo•afl'ectivediisorders (bipolar or depressive).
3.0 BENEFITS
For the purpose of this Rider, bencliU for Serious Mental illness care shall include only those
services obtained from Participating Provides.
Copaymenl by Mtmber:
Mental heal+h services prorided for Serious Mental Illness shall be provided
subject to the same limitations, exclusions, and copaymenls as applied to
covered services of any other physical illness.
SMI-792
4
4.0 44U-
Benefits under this Rider are available to the Subscriber and Dependents (M bers)
Agreement ein as Identified In
.
Benelila provide no conversion privileges or benefit continuity for Alembers when such persons are
no Ic iger entitled to Group benefits a, set forth in Agreement to which this Rider is attache.
S-0 EXCLUSION
Charges related to mental health services for Fsychlatriccnnditions determined by the Harris
Medical Director or his designee, as not qualirying for coverage under this Rider will be
subject to The same limitations, exclusions, and copayments as applied to mental health
services listed In the Schedule of Benefits or which this Rider is a part.
• Services must be obtained in accordance with 111"s Health ut$imtion review
guidelines.
i
SMI-292
2
gcadah'o Q-g•Q~--
SERIOUS MENTAL HEALTH RIDER Acf.,.1~,,If01 ra
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AG MSE`NT/
SUBSCRIBER CERTIFICATE OF COVERAGE
ACCEPTED:
Group HARRIS HEALTH PLAN, INC.
By:
By: g
Authorized Rcpreaenwivo Senior Vie Pee RidcnL L h1aoi/f-°ds/- Cad Marketing
Date: 1300Sumn it Avenue, Suite 200
Fort Worth, TX 76102
(817) 8785830
Data: +
REJECTED:
Group
By:
Amhodned Repreeenwive
Date:
i
i
+genda No. _ a-9 ~4
Agendaitem.~'~2
Dale 1/ ~_-L_.
Harris Methodist
Health Plan
r
Preferred Plus
Network
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a
SCC~'~~; i;Cm
YiA
"gendaNo ~
Agenda lte_
aAnR15 HEALTH PLAN, INC.
~ll-_ -
1300 Summit Avenue Date
Fort Worth, TI 76102
(817) 878-5830
1-800-633-8598
GROUP ENROLLMENT AGREEMENT
Application is hereby made to Harris Health Plan, Inc., hereinafter called "Harris
Health" by the Applicant named below, hereinafter called "Group" for the purpose of making
available to Eliglble Persons and their Eligible Dependents under a Group Health care
Agreement /subscriber Certificate of Coverage, hereinafter called "Agreement" issued by Harris
Health, certain prepaid health care services and benefits. The arrangement of the provisions
of such services and benefits shall be the subject of the Agreement between Harris Health and
Group and shall be based on the statements and representations contained in tli■ Group
Enrollment Agreement, a copy of which shall be incorporated by reference and made a part of
the Agreement.
1.0 GROUP
Group Names City of De
Address, 324 East MsK nney
Citys Denton States rS X Zip Codes 76201
2.0 GROUP EFFECTIVE DATE
This Group Enrollment Agreement shall be effective 12s01 A.H., Central Time, on the
^lot day of 7an9ary- 1929•
3.0 EGIOIBILITY
Any person or his/her dependents who meet the eligibility requirements for coverage
under the Group's Alternative Health Benefits Plan shall be eligible for coverage under
Agreement as specified in Section 3.1 and Section 3.2 of Agreement.
1 y
A
A. Rules of eligibllitys Per the written eligibility ayidelines provided by the City of
Dent
4.0 KE."TH CURE SERVICES (BENEFITS) AND COMMENTS
Eligible Persons and Eligible Dependents of Group are entitled to Health Care services
and Benefits as follcwss
A. e.sic Health Care Servicess
x covered - Basic Health Care Services as described in the
Schedule of Benefits.
B. Prescription Drugs
X_ Accepted /I
Not Accepted AR003N7._ t2j-,0
S.0 COVERAGE BASIS C!;S91Li.1_~~
_A_, contributory
Non-Contributory
6.0 SCHEDULE of RATES
Total Montbly
Rate
ctive $217.60
Employee Only
Employee + Spouse $331.59
Employee + Child(ren) $291.85
Employee + Family $366.08
Ratireec under 65 $295.0]
Retiree Only
Retiree and Spouse $568.47
Retiree and Child(ren) $459.69
xetiree and Family $698.
i
l Etgtirees L91-over H dd 0ryes as Primarvt
Retiree Only $108.90
2 on Medicare $217.80
1 ono off $444.31
1 on, 1 off + Family $644.15
2 on + Family .
Group Enrollment Agreement shall be automatically renewed at the end of each
Contract period unless terminated by Harris Health or Group as provided in Agreement.
The first Contract period shall commence as of the Croup Effective Date and will remain
in effect for twelve J12) consecutive months unless terminated before this d,te by
Hs:ris Health or Group.
IN WITNESS WHEREOF, the undersigned have cauved the Group Enrollment Agreement to be
executed on the day of , 19_.
City of Dentgd
Group HARRIS HEALTH PLAN, INC.
eys Sy,
Authorised Representative
Titles TitlesSenior Vice President/Hanaged Cara
Address 324 East McKinney Marketing
Denton, TX 76201
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Agenda No
Hams Methodist A1^ efi
Health Plan s d
October 22, 1993
Mr. Thomas Klinck
Director of Human Resources
City of Denton
215 E. McKinney
Denton, Texas 76201
Re: City of Denton Health Plan Proposal
Dear Mr, Klinck:
Harris Methodist Health Plan is pleased to respond to the following issues as presented by
the City of Denton.
1) REQUEST FOR. A MULTI-YEAR RATE GUARANTEE.
HMHP is prepared to provide a rate guarantee through the second and third plan
year for the Preferred HNIO plan only. Our conditions for the 1995 and 1996 rate
guarantee is that the City of Denton contribution to the employee rate for our
Preferred HMO plan must be 100` and we will be the only carrier offered by the
City of Denton.
The Preferred HMO plan guarantee will be as follows:
"The years 1995 and 1996 combined maximum rate guarantee will not exceed a total
of 15%. The year 1995 will not exceed 9.9% of our 1994 rate."
2) EXPANSION OF THE DENTON AREA PROVIDER NETWORK TO PROVIDE
FOR THE CITY OF DENTON EMPLOYEES.
As the City of Denton employees expand the needs for additional health care services
in the Denton area, the HMHP is committed to ongoing assessment of these needs
and expansion of our current network through the recruitment of appropriately
qualified providers to serve these needs.
A member of
Harris MedodiIt Hu1th System
t s'N a^~-'' v it "if nn nor wigS4 t fort Worth, Te,3t761QI.MSr t 917.819 SAM tf7uVomet Service Telephone Num bet 617 978-5926
v.y
Agenda No ._.._V-:QIY
Agendaitem &
Date
Ten additional Denton providers have been approved recently and will be added to
roe network as soon as contracts are executed. Your request for additional hospital
services through Denton Regional Medical Center will be given consideration for
future needs. this ongoing effort will continue as a part of our partnership with
employer groups that we serve in the Denton area. .
3) COVERAGE FOR EMPLOYEES NOT ACTIVELY AT WORK.
HMHP considers actively at work to include anyone the new employer group
considers to be actively at work. This would include those employees that are off on
approved medical leaves of absences, vacation, holiday, jury duty, or other similar
circumstances.
i
c We would be very pleased to add the City of Denton to our family of satisfied clients. Piuse
feel free to call me at 878-5836 should you have any questions regarding the Ilarris
Methodist Health Plan proposal.
Kindest Regards, .
AgendaNo.
Robe Ir~ oldaltem
Duector of ales ~le
Managed Care Marketing
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Harris Methodist
Health Plan
GROUP HEALTH CARE AGREEMENT/
SUBSCRIBER CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
1300 Summit Avenue, Suite 300
Fort Worth, Texas 76102
617/878-5826
1-800/633.8598
GA "2
,
D
lards Health Plan inc.
Health Maintenance Organization
'300 Summit Avenue, Suite 300
'ort Worth, Texas 76102
IMPORTANT NOTICE AVISO INIPORTANTE
To obtain information or make a complaint: Para obtener informacion o para someter una
queja:
You may call Harris Health Plan, Inc.'s toll-free
telephone number for information or to make a Usted puede llarnar at numero de telefono gratis de
complaint at: Harris Health Plan, Inc. para informacion o para
1.800.633.8598 someter una queja at.
You may contact the Texas Department of 1.800-633.8598
Insurance to obtain information on companies, Puede comunicarse con et Departmento de Seguros
coverages, rights or complaints at: de Texas para obtener informacion acerca de
1-800.252-3439 companias, coberturas, derechos o quejas at;
You may write the Texas Department of 1.800.2523439
Insurance Puede escribir at Departmento de Seguros de
P.O. Box 149104 Texas
Austin, TX 78714-9104
FAX # (512) 475.1771 P.O. Box 149104
ATTACK THIS NOTICE TO YOUR POLICY: Austin, TX 78714-9104
This notice is for information only and does not FAX # (512) 475-1771
become a part or condition of the attached UNA ESTE AVISO A SU POLIZA: Este aviso es
document. solo para proposito de informacion y no sc
convierte en parte o condicion del documento
adjunto.
("Perl to Members wtaso coveragr; unJur this Agreement Corrurie,x:us allof Iho fu :I (1) day of the
rnonlh A
rr race Period of thirty-one (31) days shall be ahlovved for each payment payable hereunder,
vrhglh r due Trwi GreuP or a Member except for the first payment due
The rite req ed for a newts acquired Elig+bte Dependent shall be payable ini!iaify when the ired
Harris
all Eligirble Depenldentt shall be made as therwise provided in this Ag eemenIts with respect to such new
Any payments required for newborn children who meet the requirements of Section 3.5.2 of this
Agreement shall be initially payable to Harris Health on cr before the first day of the next month follow-
ing the month in which the Application required under Section 3.5.2 is submitted to the Health Plan.
Thereafter, all payments with respect to such newborn cbr'I shale made as otherwise required
under this Agreement. efldaNO o
51.1 Non-Contributory Coverage AgeadalteN AR
It the coverage basis hereunder is "fSWSConiuuut°pO~
office of Harris Health, or to its authorized representative, one ea a p ag~~spay at the principal
Harris Health rate for tha coverage then provided under this Agreemerl~The Grou te, the sum of the
the
coverage provided by Harris Health under this Agreement shall be determined by the premium applicable rr t
o
then in effect and the number of Members at the monthly intervals established by Harris Health.
5. 12 Contributory Coverage
II the coverage basis hereunder is "Contributory," Group agrees to pay at the principal office of
Harris Health, or to its authorized representative, on each payment due dale, that part of the Harris
Health rate for the coverage then provided under this Agreement. Group shall permit Subscribers to
pay their contributory portion of such rate through payroll deduction. Procedures for implementing
payroll deductions for the Subscriber's portion of such rate shall be the same as those utilized for any
Alternative Health Benefit Plan. If the Group does not have an Alternative Health Benefit Plan, the pro-
cedures shall solely be those as agreed to, in writing, between Group and Harris Health. The Group
premiums for the coverage provided by Harris Health under this Agreement shall be determined by
the applicable rate then in effect and the number of Members at the monthly intervals established by
Hanis Health,
Group shall offer Harris Health to all Subscribers of Group on terns no less favorable with
respect to the Group contribution than those applicable to any Alternative Health Benefit Plan as may
be available through the Group. The Group contributions shall not be changed during the term of this
Agreement unless such change is prior approved, i.) writing, by Harris Health. If, however, Group con-
tribution to the Alternative Health Benefit Plan as may be available through the Group is increased dur-
ing lho term of this Agreement, Group agrees to also increase contribution to Harris Health effective
the first monthly payment due following such increase.
5.2 NOTIFICATION BY GROUP
Group shall forward completed Applications and any Evidence of Insurability form(s) to Harris
Health within ten (10) business days of their receipt from Eligible Persons. In the event Group fails to
notify Harris Health of the ineligibility of any person for whom the Group has made t1 to monthly prepay-
ment required pursuant to this Agreement, then, such prepayment shall be credited to Group only if
Harris Health has rK4 made arrangements for or paid benefits for the ineligible person but in no event
shall such prepayment be credited subsequent to thirty (30) days after the date such person became
ineligible
53 COPAYMENTS
All Copayments, as specified in the Schedule of Benefits, are due and payable at the time a
service is provided. The maximum amount of Copayment shall not exceed the maximum specified in
the Schedule of Benefits. It Is the Subscriber's responsibility to retain receipts and to notify Harris
Health upon attaining the Copayment limit so that additional services can be provided without a
Copayment charge.
1?
TABLE OF CONTENTS agpOaNo
.
Page Page
.0 General Definitions 2 8.0 Indepril Al t
Treatmenl__ 18
2.0 Group and Affiliated Organizations 6
2.1 Organizations Included Under This 8.1 Independent Agents .N ~'S O. ,18
Agreement 82 Limitation on Liability ................19
6 8.3 Refusal to Accept Treatment/Excessive
2.2 Change of Affiliated Organizations 6
Treatment .....................19
3.0 Eligibility and Effective Date 6 9.o Exclusions on Service Responsibilities ............19
3.1 Eligible Persons 6 9.1 Major Disaster or Epidemic ...................19
3.2 Eligible Dependents 6 9.2 Circumstances Beyond Control .....,.........20
3.3 Change in Group Eligibility Crilefia 7 9.3 Fraudulently Obtained Benefits ...............20
3.4 Effective Date for Eligible Persons 7
3.5 ENecCrve Date for Eligible Dependents 7 9.4 Disrontinuance •........20
3.6 Persons Not Eligible for Coverage 8 10,0 Member Complaint Resolution Procedure ,.......20
3.7 Conditions of Eligibility 8 10.1 Complaint Resolution Process ...............20
3.8 Notification of Ineligibility 8 10.2 Complaint Resolution Appeal Process ......21
3.9 Clerical Error 8
4.0 Group and Member Termination, Continuation of 11.0 Health Care Services. ..............................21
Benefits and Conversion 8 11.1 Benefits and Services ...........,..,.........21
4.1 Termination of Group 8 12.0 Term and Amendment of Agreement ....,,........22
4.2 Termination of Member - For Cause , , . , 9
4.3 Termination of Member - Other Than for 121 Term . .............................22
Cause 10 12.2 Amendment , .............................22
12.3 Change of Rates
4.4 Liability Upon Termination 10 """"""""""""""""""2
4.5 Continuation o' Coverage .....................10 13.0 Miscellaneous Provisions ..........................22
4.6 Conversion Privilege ...........................11 111 Use of Words
5.0 Payment Requirements .............................11 132 Records and Information ....,..............22
5.1 Premium Payments ............................11 133 Information from Group................-,... 22
5.2 Notification by Group 12 13.4 Assignment ..................................23
73.5 Authority
• 13.6 Governing Law w ..............................23
6.0 Claim Provisions ....................................13 13.7 Incorporation by Reference ................23
6.1 Charges Paid by Members 138 Entire Agreement ...........................23
....................13 13.9 Information to Member ...,.,,....,.,......,.23
6.2 Medical Emergency . . ................13
6.3 Action on Claim """"""..'"...............13 13 10 Uniform Rules . ...23 ' 6.4 Examination of Member ..13 1111 Calculation of rime ...•••••••.••.•••••.•••••23
6.5 Limitation Provisions ...........................13 1312 Evidence 23
13.13 Severability ..................................23
7.0 Coordination and Subrogation of Benefits .......,14 13.14 Venue .......................................24
7,1 Definitions 13.15 Waiver ol Notice .............................24
7.2 Determination of Benefits ....11d 4 1116 Headings 24
13.17 Notice of Certain Events ....................24
7.3 Order of Benefit Determination ................15 1318 Notice of Termination
7.4 Medicare 16 • • 24
1319 Notice
7.5 night to Receive and Release Information ...17 4
7.6 Facility of Payment .............................17 Attachment A Service Area Map and Description
7.7 Right of Recovery ,17
7.8 Disclosure ......................................18
7.9 Subrogation ...................................18
.SWKXI 1.0 GENERAL DEFINITION5.,J r :r~ Ate
1. ACTiVLLY Al WORK shall mean Ural the eligible employee must be nof- ll~o usual and cus
lomary duties of his regular employment during his usual v6 rid frours on his effective date of a
coverage; provided, however that if the eligible employee is absent from work due to vacation,,
holiday, jury duty, or other similar circumstances, not caused by injury or illness, such employee
shall be considered actively at work
2. ACUTE shall mean a condition of sudden onset or severe symplomalulogy which mandates imme-
diate intervention.
3. AGREEMENT shall mean this Group Health Care Agreement/Subscriber Certificate of Coverage,
Group Enrollment Agreement, Applications, all Attachments, Riders, Amendments hereto, if any.
4. ALLIED HEALTH PROFESSIONAL shall mean a dentist, nurse, audiologist, optometrist, physician's
assistant, clinical psychologist, pharmacist, nutritionist, physical therapist, speech language
pathologist, dietician, podiatrist, certified social worker (advanced clinical practitioner) and other
professionals engaged in the delivery of health services who are licensed, practice under an Insti-
tutional license, are certified, or practice under the authority of a Physician or legally constituted
professional association, or other authority consistent with the laws of the State of Texas.
5. ALTERNATIVE HEALTH BENEFIT PLAN shall mean the plan which the Group designates as the
alternative to this Agreement.
6. APPLICATION shall mean the form prescribed by Harris Health which each Eligible Person shall
on histher own behalf and or, behalf of hisftw Eligible Dependents, be required to complete and
submit to Harris Health for the purpose of enrolling himself/herself and such dependents for cover-
age hereunder.
7. CHEMICAL DEPENDENCY, means the abuse of or psychological or physical dependence on"or
addiction to alcohol or a controlled substance,
8. CHEMICAL DEPENDENCE TREATMENT CENTER shall mean a facility which provides a program
for the treatment of chemical dependence pursuant to a written treatment plan approved and
monitored by a physician and which facility is also:
a. alfiliated with a hospital under a contract agreement with an established system for patient
referral; or
b. accredited as such a facility by the Joint Commission on Accreditation of Health Care Organi-
zations; or
c. Ili as a chemical dependency treatment program by the Texas Commission on Alcohol
and Drug Abuse; or
d. licensed, certified, or approved as a chemical dependency treatment program or center by
any other state agency having legal authority to so license, certify or approve.
9. COMPLICATIONS OF PREGNANCY shall mean those conditions, requiring hospital confinement
(when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are
adversely affected by pregnancy or caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of compa-
rable severity, Complications or pregnancy shall not include false tabor, occasional spotting, physi•
cian prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidanum,
pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not
constituting a nosologically distinct complication of pregnancy; non-elective cesarean section, ler-
rnination of ectopic pregnancy, or spontaneous termination of pregnancy occurring during a
period of gestation in which a viable birth is not possible,
10. CONTRACT YEAR shall mean the period of twelve (12) months commencing on the Group Effec-
tive Date and each twelve (12) month period thereafter, unless otherwise terminated as hereinafter
provided.
11. CONTROLLED SUBSTANCE shall mean a toxic Inhalant or a substance designated as a con-
trolled substance in the Chapter 481, Health and Safety Code.
Ag~e~ndaNo.3
12 COPAYMENT shall mean the fee as set forth in the Schedule of Gene fit aPr;dfl~'.ror ~a
premium, payabte hereunder, and which must be paid by Membe S, or
entity providing the service when the service as set forth in Vie Schedu~ y L{
`(e1 Tzip. ?l
13. COURSE OF TREATMENT shall mean that period of time re of
admission and (elated discharge during which Vme treatment has beendr Q atrrtn rea ;tat D
that period of time authorized by a Participating Physician and/or Harris is Healaan necessary o
complete a cycle of treatment and subsequently provide a medical release to the Member.
14. CRISIS STABILIZATION UNIT shall mean a twenty-four (24) hour residential program, licensed
Texas Department of Mental Health and Menta' Retardation, that is usually short-tern in nature
and that provides intensive supervision and highly structured activities to persons who are denture
strafing an acute demonsVable psychiatric crisis of moderate to severe proportions.
15. CUSTODIAL CARE shall mean 1) that care which is marked by or given to watching and protect-
ing rather than seeking to cure; or 2) care which is not a necessary part of medical atreatment nd p of or
revovery or 3) care comprised of services and supplies that are p(((ity provided al assist in the
activities of daily living.
16. DEPENDENT shall mean an Eligible Dependent who has satisfied the eligibility and participation
requirements specified in this Agreement.
17. DOMICILIARY CARE shall mean that care provided for persons so disabled or infirm as to be
unable to live independently.
18. EFFECTIVE DATE shall mean the effective date of coverage for Eligible Persons and Eligible
Dependents pursuant to the terms of this Agreement.
19. ELIGIBLE DEPENDENT shall mean an individual as defined in Section 3,2 of this Agreement.
20. ELIGIBLE PERSON shall mean an Individual as defined in Section 3.1 of this Agreement.
21. EMERGENCY CARE shall mean bona fide emergency services provided after the sudden onset of
a medical condition manifesting itself by acute symptoms of sufficient severity, including severe n, such esrult in p acing the patient's h althorn serious
jeopardy; serious impairment to (bodily functions; or
serious dysfunction to arty bodily organ or part.
22. EVIDENCE OF INSURABILITY shall mean that an Eligible Person or Eligible Dependent verifies
that they were enrolled for the preceeding twelve (12) months in a group or individual plan
ing benefits for medical, surgioai and hospital expenses; and completes the livid p
ity forth and provides timely any additionat documentation of health status as required byy Haft
Health. Such information shall be reviewed by Harris lrealth and the Eligible Person or Eligible
Dependent shall be notified regarding their eligibility for participation in ft'arris Health.
23. EXCLUSION shall mean those specific conditions or causes for which coverage by Harris Health
is entirely excluded,
24. FDA shall mx:an the Food and Drug Administration, an agency of the United Stales government
25. GROUP shall mean collectively the contracting employer t
employer as set forth in Attachment A annexed hereto and made allpart hereof, to Iwh chf this
Agreement is issued and through which as agent for Subscriber and not for Harris Health, Sub-
scriber and Dependents become entitled to the benefits as set forth in the Schedule of Benerrts.
26. GROUP EFFECTIVE DATE shall mean the date specified as such In the Group Enrollment
Agreement
27. GROUP ENROLLMENT AGREEMENT shall mean that agreement which is executed between Hare
ris Health and Group for the purpose of making available to Eligible Persons and Eligible Depen-
dents of Group those benefits and services which are described in the Group Health Care
Agreement/ Subscriber Certificate of Coverage, Such Group Enrollment Agreement shall identify
the Group, Group Effective Dale, eligibility requirements, (ales, and covered benefits.
28. HARRIS HEALTH shall mean Harris Health Plan, Inc., a Texas notdor-profit corporation organized
as a Health Maintenance Organization (HMO) and licensed by the Texas Department of
Insurance.
Agenda No
29. HEALTH PLAN shall mean the health Maintenance Organization operated q
Barris Melladisl Health Plan. Date
Daate
30. HOSPITAL shall mean an institution licensed by the State of Texas and which is (1) prirnariiy~ e1
engaged in providing diagnostic, medical and surgical facilities for the care and treatment of
injured or sick persons, (2) operated under the medical supervision of a stall of legally Qualified
and licensed physicians. (3) provides twenty four (24) h¢_ - _y rrrxeing eerviec by or under the
direct supervision of a Registered Nurse (R.N.), (4) piipvid 9, r overni ht care oj patients, (5)
maintains clerical and ancillary services necessary fd? the ties ment o me rand surgical
patients including but not limited to laboratory, X-ray, d4tary_ard medieal- x(ds library. In no
event shall the term "hospital" include a convalescent nursing home or any institution or part
thereof which is used principally as a convalescent facility, rest facility, nursing facility, facility for
the aged, extended care facility, intermediate care facility, skilled nursing facility or facility primarily
for rehabilitative services-, the term hospital shall, pursuant to Chapter 3, Texas Insurance Code,
Article 3.72 include treatment in a residential treatment center for children and adolescents and
treatment provided by a crisis stabilization unit.
31. INDIVIDUAL TRFATMENT PLAN shall mean a treatment plan with specific attainable goals and
objectives appropriate to both the patient and the treatment modality of the program.
32. KIDNEY DIALYSIS CENTER shall mean any facility licensed by the State of Texas, approved by
Medicare to provide outpatient services and/or instruction in home kidney dialysis treatments and
which has contracted with Harris Health to provide care to Members.
33• MEDICAL DIRECTOR shall mean the licensed Physician designated by Harris Health and/or such
other Physicians as the Medical Director may designate with the prior approval of Harris Health.
Such physician shall be responsible for supervising the delivery of medical services to Members
and for monitoring the quality of medical care rendered to Members.
34. MEDICAL EMERGENCY shall mean a medical condition so classified by the medical director acid
which manifests itself by acute symptoms of sufficient severity (including severe pain) such that
the absence of immediate medical attention could reasonably be expected to result in (a) placing
the patient's health in serious jeopardy; or (b) serious impairment to bodily functions; or (c) serious
dysfunction to any bodily organ or part. Examples of conditions which do not usually constitute
medical emergencies are colds, influenzas, ordinary sprains, children's ear infections, or nausea
and headaches. Heart attacks, cardiovascular accidents, poisonings, loss of consciousness or
respiration, convulsions, severe bleeding or broken bones are examples of true medical
emergencies.
35. MEDICALLY NECESSARY shall rnean services or supplies which are (1) provided for the diagno-
sis or care and treatment of a medical oonciition, (2) appropriate and necessary for the symptoms,
diagnosis or treatment of a medical condition; (3) generally acceptable medical practice: (4) per-
formed in the most cost effective and efficient manner appropriate to treat the plan Member's
medical condition; and (5) provided in accordance with accepted medical standards and Harris
Health requirements as approved by the Health Plan's review committees for professional and
technical practices and the Health Plan Medical Director.
36. MEDICARE shall mean Part A and Part 8 of Title XVIII of the Social Security Act and any arlrnd-
menis of regulations thereunder.
37. MEMBER shall mean any Subscriber and/or Dependent
38. MEMBER HOSPITAL shall mean any Hospital which has contracted with Harris Health to provide
to Members the services as set forth in the Schedule of Benefits and described in this Agreement.
39. NON-MEMBER HOSPITAL shall mean any Hospital which has not contracted with Harris Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement
40. MINOR EMERGENCY CENTER shall mean any licensed facility, not including a Hospital, which
provides Physician services for the irrlrrled'+ate treatment only of an injury or disease.
41. NON-PARTICIPATING PHYSICIAN shall mean a Physician who is not a Participating Physician and
to whom a Member is referred for consultation or treatment by a Participating Physician only with
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prior written approval of Harris Health unless there is a Medical Emergen%e W.parti
Physician is not available. Date __L/- ~'1 3
42. NONPARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professiona, p
Home Health Agency, Laboratory, Minor Emergeny:y Center, Residential Treatment Facility, Chemi-
cat Dependency Treatment Center, or other licensed health-p9, g professional or ?th provider or
entity which has not contracted with Harris Heath to proi~9 01Ie mbt37S tf1>3'~e~vices as set forth
in the Schedule of Benefits and described in this Agreerrtprtt,; , I,r;,tf-------
41 OPEN ENROLLMENT PERIOD shall mean a period of at least JhirJy (3%rlays during each twelve
(12) consecutive months when Eligible Persons may elect to change from the Alternative Health
Benefit Plan to Harris Health or from Harris Health to the Alternative Health Benefit Plan.
44. PARTICIPATING PHYSICIAN shall mean any Physician who has contracted with Harris Health to
provide to Members the services as set forth in the Schedule of Benefits and described in this
Agreement.
45. PARTICIPATING PROVIDER shall mean any Physician, Hospital, Allied Health Professional, Home
Health Agency, Laboratory, Minor Emergency Center, Chemical Dependency Treatment Center,
Psychiatric Day Treatment facility or other provider or entity which has contracted with Harris
Health to provide to Members the services as set forth in the Schedule of Benefits and described
in this Agreement.
46. PSYCHIATRIC DAY TREATMENT FACILITY shall mean a mental health facility which provides
treatment for individuals suffering from acute mental and nervous disorders in a structured psychi-
atric program utilizing individualized treatment plans with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program and that is clinically
supervised by a Physician wino is certified in Psychiatry by the American Board of Psychiatry and
Neurology. The facility shall be licensed by the State of Texas, accredited by the Program for Psy-
chiatric Facilities, or its successor, of the Joint Commission on Accreditation of Health Care Orga-
nizations, and shall have contracted with Harris to provide to Members the mental health services
as set forth in the Schedule of Benefits and described in this Agreement.
47, PHYSICIAN shall mean any individual (other than a hospital resident or intern) who in fully licensed
and qualified to practice within the scope of the license under the law of the jurisdiction In which
treatment is received.
48. PRIMARY PHYSICIAN shall mean, with respect to each Member, those Participating Physicians
who are designated by Barris Health and identified in writing to Members as Physicians having
primary responsibility for coordinating such Member's medical care, providing Initial and primary
care to Members, maintaining the oontinu'rty of such Members care and initiating referrals for spe-
cialist care.
49. RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS shall mean a child-
care institution that provides residential care and treatment for emotionally disturbed children and
adolescents, licensed by Texas Department of Mental Health and Mental Retardation, and that Is
accredited as a resfdentW treatment center by the Council on Aocreditatx n, the Joint Commission
on Accreditation of Health Care Organizations or the American Association of Psychiatric Services
for Children
50 RIDER shall mean a Schedule provided with this Agreement, and made a part hereof, which sets
forth additional benefits and services made available by Harris Health by amending this Schedule
of Benefits.
51. SCHEDULE OF BENEFITS shall mean the schedule which sets lorth the benefits and services that
Harris Health shall make available to Members.
52. SEMI-PRIVATE shall mean the charge made by a Member Hospital for a room containing two (2)
or more beds,
53. SERVICE AREA shall mean the geographic area as set forth and annexed hereto as Attachment
A
54. SHORT TERM shall mean a course of treatment lasting thirty (30) days or less.
55. SPECIALIST PHYSICIAN shalt mean any Physician who has A9ertdaNo.~ y -4A
vide specialist care to Members contracted w,'rardrea4h to P,0-1
upon rele«al of a Primary Physician or u'(~b"n ~f}af
Specialist Pirysician with the concurrence of the responsible Primary Physic
56. SKILLED NURSING FACILITY shall mean an institution or ~p
law, that is accredited as an Extended Care Facility , licensed by rA
Health Care Organizations, or is recognized as Skilled Nu *;W4 Ys on on ACCred nant of
of
Health and Human Services under Title Will of the Social I rPL
~Q~ Act (Medicare 8s s Wnendnl
amended.
57. SUBSCRIBER shall mean an Eligible Person who has satisfied the eligibility and participation
requirements specified in this Agreement.
58. TOXIC INHALANT means a volatile chemical under Chapter 4134, Health and Safety Code, or
abusable glue or aerosol paint under Section 485.001, Health and Safety Code.
59. USUAL, CUSTOMARY, AND REASONABLE CHARGES shall mean the charge is (1) the fee
charged by a provider in normal practice for a give service; (2) within the range of usual charges
by providers for the same service in the geographic area where services are provided to a Mem-
ber; and (3) reasonable when taking inlo consideration any unusual circumstances or medical
complications requiring additional time, skill and experience in providing a specific treatment or
service.
Section 2.0
GROUP AND AFFILIATED ORGANIZATIONS
2.1 ORGAN17ATIONS INCLUDED UNDER THIS AGREEMENT
The Group and its affiliated organizations are included under this Agreement. ,+,ffilialecl organi-
zations include all those organizations which are subsidiary to or affiliated wiln the Group and located
within the Service Area of Harris Health.
22 CHANGE OF AFFILIATED ORGANIZATIONS
The Group shall notify Harris Health, in writing, when an affiliated organization ceases to be a
subsidiary of, or affiliated with, the Group. When an organization ceases to be a subsidiary of, or affili-
ated with, the Group, it shall cease to be an included organization. Therefore, this Agreement shall ter-
minate on the date of such cessation with respect to all Eligible Persons of that organization, except for
those persons who on the next day are employees of another affiliated organization and thus Eligible
Persons under this Agreement,
Section 3.0
ELIGIBILITY AND EFFECTIVE DATE
3.1 ELIGIBLE PERSONS
To be eligible to enroll as a Subscriber, a person must reside in the Service Area and be an Eli-
gible Person as fotlows:
e In the emntoyment of the Group or a bona fide Member of the Group, and/or
o Eligible under the eligibility criteria established by the Group; and
6 Entitfed on his or her behalf to participate in the medical and hospital care benefits arranged
by the Group.
3.2 ELIGIBLE DEPENDENTS
To be eligible to enroll as a Dependent, a person must reside in the Service Area and be:
a The legal spouse of a Subscriber;
is A dependent unmarried natural child, foster child, stepchild, legally adopted child or child
under Subscriber's court appointed legal guardianship, residing with Subscriber or with Sub-
scriber's present or fomter spouse In the Service Area who Is (a) undei nineteen (19) years
of age, or (b) under twenty-five (25) years of age and primarily dependent on the Subscrlber
for financial support and attending an accredited college or university, trade or secondary
school on a full-time basis, which has, in writing, verified said aftendance or;
ti
4genda No 96 29 f z
• A dependent unmarried natural child, foster child, stepchild, legally A child, or child -23
under Subscriber's court appointed legal guardianship, resic"hilitsubscn r or wit i b•
scriber's present or loaner spouse in the Service area who . nipr;}e 1 s-
4 ear/' y3
Oder W incapable of self-sustaining employment because~trt rSt"a`~selardatioo*v( physical 7Ly~~ay
handicap which commenced prior to age nineteen (19) (or Opqmencedprior to ale twenty-
five (25) if such child was attending a recognized college or university, trade of secondary
school on a full-time basis when such incapacity occurred), and primarily dependent upon
the Subscriber for support and maintenance.
Such dependent child must have been a'Member either prior to attaining nineteen (19) years
of age or twenty-five (25) years of age under the conditions of the previous sentence. Sub-
scriber shall furnish Harris Health proof of such incapacity and dependency within thirty-one
(31) days before the dependent child's attainment or the limiting age and from time to time
thereafter as Harris Health deems appropriate, but not more frequently than annually.
• Maternity care benefits wilt be extended to an unmarried Dependent Child. If coverage is
provided to the Dependent of the Subscriber, upon payinenl of the premium, benefits must
be provided for any children of the Dependent if those children are Dependents of the Sub.
scriber for federal income tax purposes.
33 CHANGE IN GROUP ELIGIBILITY CRITERIA
Requirements as defined by the Group for determining the eligibility for participating in Harris
Health are material to the execution of this Agreement by Harris Health. During the term of this Agree-
meet no change in the Group definition of eligibility for participation shall be permitted to affect eligibil-
ity or enrollment under this Agreement in any manner unless such change is approved in advance by
mutual written agreement between Group and Harris Health.
3.4 EFFECTIVE DATE FOR ELIGIBLE PERSONS
3.4.1 Open Enrollment Period
An Eligible Person who applies for coverage in Harris Health by submitting an Application dur-
ing an Open Enrollment Period shall become covered as a Subscriber on the Group EflecUve Date or
such Effective Date specified as such for the Open Enrollment Period.
3.42 On Acquiring Eligibility Status
An Eligible Person who first meets the eligibility requirements other than during the Open
Enrollment Period may enroll within thirty (30) days of meeting such requirements by submitting an
Application. Such person shall become covered under Harris Health as a Subscriber on the first day
he became an Eligible Person provided that the premium applicable to the Subscriber has been
received in accordance with this Agreement.
35 EFFECTIVE DATE FOR ELIGIBLE DEPENDENTS
35.1 Open Enrollment Period
An Eligible Dependent for whom the Subscriber has applied for coverage In Harris Health by
submitting an Application during an Open Enrollment Period shail become covered as a Dependent
on the Effective Date of the Subscriber,
3.52 On Acquiring Eligibility Status
A newly acquired Eligible Dependent, and an Eligible Dependent other than a newborn child
who first meets the eligibility requirements of Group on other than during an Open Enrollment Period,
may be enrolled by the Subscriber within thirty (30) days of meeting such requirements by submitting
an Application. Such Etigibte Dependent shall become covered under Harris Health as a Dependent
on the day he became an Eligible Dependent provided that the premium applicable to the Dependent
has been received in accordance with this Agreement described in Section 5.1,
Coverage for newly adopted children shall continence o t the earlier of (a) the date upon which
such child commences residence with the Subscriber or (b) when the adoption becomes legal.
Adopted children and newborn children shall be covered under Harris Health for an Initial period of
thirty-one (31) days and shall continue to be so covered after that time only if, prior to the expiration of
such thirty-one day period, an Application has been submitted and the premium applicable to the
Dependent has been received in accordance with this Agreement described in Section 5.1.
3.6 PERSONS NOT ELIGIBLE 17011 COVEttAGE
Notwithstanding the foregoing Provisions of this Section, Fr , r1o
p~isdnot Clig b1e for cover. aye in Hares health shall be as follows, 1., t `,r) n~ -
• Coverage Previously Terminated: No person shall be eligible to tiecorra a Member wno
had coverage terminated by Harris Health for cause, as described in Section 4.2 of is
Agreement.
• Indebtedness; No person shall be eligible to become a Member if such person has unpaid
financial obrgalions arising from prior coverage in Harris Health.
3.7 CONDITIONS OF ELIGIBILITY
No Eligible Person or Eligible Dependent shall be refused enrollment by Harris Health because
of health status, requirements for health services, or the existence of a Pre-Existing Condition on the
Group Effective Date, In addition, no Member's coverage shall be terminated by Harris Health due to
his health status or his healthcare needs. If an Eligible Person or Eligible Dependent applies for cover-
age on a date other than Open Enrollment Pe(K)d or more than thirty (30) days after becoming an Eligi-
l to Person or Eligible Dependent, then such Eligible Person "or Eligible Dependent shall have to
document Evidence of Insurability as required by Harris Health,
3.8 NOTIFICATION OF INELIGIBILITY
A condition of participation In Harris Health is Subscriber's agreement to i • .Ai y Harris Health of
any changes in status that affect Subscriber or the ability of the Subscribers Depeoidents to meet the
eligibility criteria set forth in this Section.
3.9 CLERICAL ERROR
Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due to
clerical error, to record or report an Eligible Person or Eligible Deperxient to Harris Health if an Appli-
cation had been completed and submitted to Group as required under the terms of this Agreement by
or on behalf of such Eligible Person or Eligible Dependent and that the premium applicable to such
coverage had been received by Harris Health.
Section 4.0
GROUP AND MEMBER TERMINATION, CONTINUATION OF
BENEFITS AND CONVERSION
4.1 TERMINATION OF GROUP
4.11 Default In Payment of Premium
If Group fails to pay to Harris Health the premium payable hereunder on or before the thirty-first
(31) calendar day after such payment is due, this Agreement may be terminated by Harris Health and
all benefits and services shall cease at the end of such thirty-one (31) day grace period, Group may
be held liable for ft cost of all benefits and services provided to Member by Harris Health during the
grans period. Group shat! remain liable for all premiums (and any Interest accrued thereon) not paid
prior to termination. Interest on late payments from the date such premiums were due may be charged
at a rale equal to eighteen percent (18%) per year. Unpaid Interest shv" ho due and payable upon
notice thereof to Group from Harris Health.
If Group remits its delinquent payments to Harris Health within fifteen (15) days of a termination
date, Harris Health may reinstate Group without requiring a new Group Enrollment Agreement. How-
ever, Harris Health reserves the right to refuse to reinstate by refunding within five (5) business days all
payments made by Group after the date of termination.
4,1.2. Upon Nobfication
This Agreement may be terminated by either Harris Health or Group upon written notice to the
other party at least sixty (60) days prior to the end of the Contract Year. Such termination shall occur at
midnight on the day proceeding the end of the Contract Year. In the event that Harris Health terminates
this Agreement, any Member who is a registered bed patient in a Hospital on the date of teoinaron
shall receive coverage for all hospital services for that hospital confinement or until a determination Is
13
made by the Medical Director that inpatient care is W longer medically utd+cated, whichever occurs Tr
first iggri;4J),_~_7.
4.2 TERMINATION OF MEMBER - FOR CAUSE
4.2.1 Delaull in Payment of Copaymenls
It any required Copayment is not paid timely by or on behalf of Member, pursuant to the te.rrrt$ pt~
terminated not less sWY
of this Agreement, such Member's entitlement to be te was due.
(61) days written notice after the date such Copayme
4.2.2 Default in Payment of Premium
If any premium contributions due from Member are not paid timely by or on behalf of Member,
such Members entitlement to benefits may be terminated not less than thirty-one (31) days after the
date such premium was due.
4.2.3 Misrepresentation material misre reserda-
lf any Subscriber should make a fraudulent stalement or provide anon or Evidence of insure
lion of fact by or on behatf of such Subscriber or Dependent on an App
bility form, Harris Health shall have the right to terminate the Member's coverage under this Agreement
without any lurther liability or obligation to such Member, Such Subscriber's entitlement to benefits may
be terminated not less than sixty-one (6i) days written notice after such misrepresentation. It a Mem-
ber corrects inaccurate information furnished to Harris Health, and Harris Health has not retied upon
such inco^ect information foils prejudice, the furnishing of incorrecl information shall not constitute a
basis for termination of the Member's coverage. In the absence of fraud, all statements made by a
Subscriber are considered representations and not warranties. During the first two years, coverage
can be voided for material misrepresentation contained in a written Application or Evidence of Insura-
bility Form. After two years, coverage can be voided only in the event of afraudulent
written Aptatir eon
contained in the written Application or Evidence of insurability form. A copy of the
must have been furnished to the Subscriber it the terms of the Application or Evidence of Insurability
form are to be applied.
4.2.4 Misuse of Identification Card
Possession of a Harris Health identification card in and of itself confers no rights to services or
other benefits. The holder of the card must be, in fact, a Member on whose behalf all applicable pre-
miums under this Agreement have actua;ly been paid. Any person receiving rs e ic ~1so ofull thP~ fits
to which he is not entitled pursuant to this Agreement shall be -solely ,esporu 11
the u
Member any charges associated otther peece card m y be pscatedermits
and Har s~Health shall have
the Identification tn card any
the fight to terminate te the Member's coverage under this Agreement and, if a Subscriber, the coverage
of his Dependents. Such Member's entitlement to benefits may be terminated not less than fifteen (15)
days written notice after such misuse of the identification card.
4.2.5 Fraudulent Use of Benefits or Services
notice to Subssccriber.e will result in
(15) day providers,
ion of Faudulent after not w less than a enefits,
cancellat
4.2.6 Misconduct
Misconduct by a Member detrimental to safe Health Plan operations and the delivery of service
or treatment, or abuse of healthcare professionals, facilities, or Health Plan personnel may result in
cancellation of coverage effective immediately.
4.2.7 Untenable Patient/Physician Relationship
'
It the Member and the Participating Physician fail to establish a satisfactory patent-physrcian
relationship and it it is shown that Harris Health has, in good faith, provided the Member with the
opportunity to select an allernative Participating Physician, the Member shall bey i writing amt
least thirty (30) days In advance that Harris at are wry in ord to avoid termination if Member
unsatisfactory and specifies the charrQ
fails to make such changes, coverage may be cancelled at the end of thirty (30) days.
For relusal by a Member to accept recommended procedures or treatment as described in
Section 6 3 of this Agreement, thn Member's coverage may be cancelled after not less than thirty (30)
days wrillen notice
t
4.2.6 Termination Procedure
Any Member terminated for cause pursuant to this Section shall be given written notice of far.
mination prior to the effective date of termination in accordarv;e with not f caliuri requirements of Sec•
tion 4.2. If Member receiving notice of termination initiates the Member Complaint Resolution
Procedure described in Section 10 of this Agreement during ft notification period to challenge the
grounds for termination, the effective date of termination shall be postponed until Member Complaint
Resolution Procedure Is completed and a final decis'cn regarding termination is provided, if the mem-
ber, on his own behalf or on behalf of a minor child, fails to initiate the Member Complaint Resolution
Procedure within the notification period, such failure shall constitute a waiver of said Member's right to
challenge the termination.
4.3 TERMINATION OF MEMBER OTHER THAN FOR CAUBErdaflo 93 6
4.3.1 Subscriber No Longer Eligible Person a^ ;rf1 1i
Fi1. - -O~'
If the Subscriber ceases to be an Eligible Person, ccJeragolx3derthiT-A t shall au~~qq /
matically terminate at midnight of the day on which such Subscriber ceased to be an Eligible Persol'i,9 i
subject to continuation of coverage and conversion privilege provisions. ~a o y'
4.3.2 Dependent No Longer Eligible Dependent
If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall
autematicafly terminate at midnight of the day on which such Dependent ceased to be an Eligible
Dependent, subject to continuation of coverage and conversion privilege provisions.
4.3.3 Service Area Resident
If a Member ceases to be a resident of the Service Area as defined by Harris Health, eligibility
to participate in Ha4is Health shall automatically terminate as of the date on which the Member
ceased to be a resident of the Service Area, except as may be required by State and Federal regula-
tions for COBRA participants. Such Member shall be eligible to convert to an Individual Hospital and
Surgical Expense Policy as specified in &--ction 4.6.2.
4.4 LIABILITY UPON TERMINATION
At the effective date of any termination of a Member's coverage under this Agreement any pay-
ments receved on account of such Member applicable to periods after the effective date of the termi-
nation of coverage, plus amounts due to such Member for claims reimbursement, if any, less any
amount due to Harris Health or which must be paid by Harris Health on behalf of such Member, shall
be refunded to the appropriate party within thirty-one (31) days. Harris Health and Group shall there-
after have no further liability or responsibility to such Member except as may be specifically provided
in Section 4.1.2 of this Agreement.
4.5 CONTINUATION OF COVERAGE
If a Member's coverage ends, such coverage may quality to be continued in one of the follow-
ing ways:
• it may be extended under the Extension of Medical Benefits provisions, if the Member Is Hos-
pital Confined when this Agreement terminates; or
• it may be continued under the Optional Coetinuatior of Coverage provisions; or
• it may be converted to an Individual plan of medical coverage as described in the Conver-
sion provisions.
If, under the provisions of Title X cf the Consolidated Omnibus Budget Reconciliation Act of
1985, Public Law 99-272 ("COBRA"), any Member is granted the right to continuation of coverage
beyond the date his coverage would otherwise terminate, or, if COBRA is inapplicable and the proA-
sions of an applicable state statute grants such Member similar rights to continuation of coverage, this
Agreement shall be deemed to allow continuation of coverage to the extent necessary to comply with
the provisions of the applicable statute. Contact the employer for verification of eligibility and proce-
dures to follow.
4.5.1 Extension of Medical Benefits
Harris Health shall continue to provide medical services if this Agreement terminates under
Section 4.1.2 while a Member is confined in a Hospital or Skilled Nursing Facility. Services will be pro-
vided only for the same injury or sickness which caused the Member to be confined.
This continued coverage will end on the earlier ol: (t) the dale the confinement is 0 longer
Medically Necessary, or (2) the dale the Member reaches any limits under the Group Contract for the
provisions of services; or (3) the date the Member becomes eligible for sii ry age under another
i~
Plan V. +J ~
4.6 CONVERSION PRIVILEGE
It a Member has been covered by this Agreement tot at least three (3aonsocutive months or
covered as a newborn from the date of birth and meets the definition of a person eligible for corner
lion, Member may enroll in an individual plan with a defined Schedule of Benefits available to calver•
sion Members only under the terms and conditions of this Agreement.
ELIGIBILITY TO CONVERT
A Member whose coverage under this Agreement is terminated in accordance with the Termi-
nation provisions may convert it the coverage is not ending for one of the following reasons:
• Termination of this Agreement;
• Failure to pay any required copayment amounts;
• Termination for cause;
• Coverage under another individual or group health policy, plan or contract.
• Eligibility for Medicare;
• Eligibility or coverage for similar hospital, medical or surgical benefits under a state or federal
taw.
A covered Dependent whose coverage is terminated under this Agreement may also convert if
the termination is due to;
• Legal separation or divorce; or
• The Subscriber's death; or
• The Dependent reaching the maximum Dependent age.
HOW TO CONVERT
4.6.1 Residence in Service Area
The Member eligible for conversion may, without Evidence of Insurability, convert to an Individ-
ual Health Care Agreement issued by Harris Health. To obtain an individual enrollment, the Eligible
Person must continue to reside in the Service Area, must submit a completed application for conver-
6Ion within thirty-one (31) days after termination of coverage under this Agreement, and must submit
the premium for such Individual Health Care Agreement as required from the effective date of termina-
tion of coverage under this Agreement
4.6.2 Residence Out of Service Area
If the Member eligible for conversion does not reside in the Service Area, the Member may,
withw, Evidence of Insurability, convert to an individual policy issued by and renewable at the option
of the Indemnity insurer making such conversion coverage available to Harris Health.
Section 5.0
PAYMENT REQUIREMENTS
5.1 PREMIUM PAYMENTS
The initial rates for the benefits and services under this Agreement shall be due and payable in
advance on or before the first (1) day of the month for which such payment is rnaua or is to be made.
In accordance with lh3 terms and provisions of Section 123 of this Agreement, Harris Health shad
have the right to change the fate payable under this Agreement at any time when the extent or nature
of this Agreement is changed by amendment or termination of any provision, or by reason of any pro-
vision of law or any governmental program or regulation. No proration of the rate shall be made with
L.
r
respect to Members wliose coverage under this Agreement coiurwiices alter ttru hrsl (t) day of the
month. A grace period of thirlyone (31) days shall be allowed for each payment payable hereunder,
wholher due from Group or a Member except for the first payment due.
The rate required for a newly acquired Eligible Dependent shall be payable initially when the
required Application is submitted to Harris Health. Thereafter, all payments with respect to such new
Eligible Dependent shall be made as otherwise provided in this Agreement.
Any payments required (or newbom children who meet the requirements of Section 3.5.2 of this
Agreement shall be Initially payable to Harris Health on or before the first day of the next month follow-
ing the month in which the Application required under Section 3.5.2 is submitted to the Health Plan.
Thereafter, all payments with respect to such newborn child shall be made atAth_eryy'se required
~,rJo
under this Agreement.
.~,'t
5.1.1 Non -Contributory Coverage
33
If the coverage basis hereunder is "Non-Contributory;" the Group agrees to pay.at the principal
office of Harris Health, or to its authorized representative, on each payment due date, the sum of the1F/0y
Harris Health rate for the coverago then provided under this Agreement. The Group premium for the o
coverage provided by Harris Health under this Agreement shall be determined by the applicable rate
then in effect and the number of Members at the monthly intervals established by Harris Health.
5.12 Contributory Coverage
It the coverage basis hereunder is "Contributory;' Group agrees to pay at the principal office of
Harris Health, or to its authorized representative, on each payment due date, that part of the Harris
Health rate for the coverage then provided under this Agreement. Group shall permit Subscribers to
pay their contributory portion of such rate through payroll deduction. Procedures for implementing
payroll deductions for the Subscriber's portion of such rate shall be the same as those utilized for any
Alternative Health Benefit Plan. If the Group does not have an Alternative Health Benefit Plan, the pro-
cedures shall solely be those as agreed to, in writing, between Graup and Harris Health. The Group
premiums for the coverage pror;ded by Harris Health under this Agreement shall be determined by
the applicable rate then in effect and the number of Members at the monthly intervals established by
Harris Health.
Group shall offer Harris Health to all Subscribers of Group on terms no less favorable with
respect to the Group contrilr,ition than those applicable to any Alternative Health Benefit Plan as may
be available through the Group. The Group contributions shall not be changed dudrrg the term of this
Agreement unless such change is prior approved, in writing; by Harris Health. If, however, Group con-
triMlion to the Alternative Health Benefit Plan as may be available through the Group is increased dur-
Ing tho term of this Agreement, Group agrees to also Increase contribution to Harris Health effective
the first monthly payment due following such increase.
5.2 NOTIFICATION BY GROUP
Group shah forward completed Applications and any Evidence of insurabliq form(s) to Harris
Health wilhin ten (10) business days of their receipt from Eligible Persons. In the event Group fails to
notify Harris Health of the ineligibility of any person for whom the Group has made the monthly prepay-
ment required pursuant to this Agreement, then, such prepayment shall be credited to Group only if
Harris Health has not made arrangements for or paid benefits for the ineligible person but in no event
shall such prepayment be credited subsequent to thirty (30) days after the date such person became
ineligible.
53 COPAYMENTS
All Copaymenls, as specified in the Schedule of Benefits, are due and payable at the time a
service is provided. The maximum amount of Copayment shall not exceed the maximum specified in
the Schedule of Benefits. It Is the Subscriber's responsibility to retain receipts and to notify Harris
Health upon attaining the Copayment limit so that additional services can be provided without a
Copayment charge.
I
5
Section 6.0
,CRQ.3PJ0 ___J
CLAIM PROVtS10NS
6.1 CHARGES PAID BY MEMBERS
It is not anticipated that a Member shall make payments, other than the opayfffrtts as set
forth in the Schedule of Benefits, for benefits and covered services under this Agreement. However, ilk,
a payment is made by a Member then a written description of such services, accompanied by evi. y
dente of payment by the Member crust be provided to Harris Health within sixty (60) days after the
performance of the service. Failure to furnish such proof within the required time shalt not invalidate
nor reduce any claim, if it was not reasonably possible to give proof within such time, provided such
proof is furnished as soon as reasonably possible. If the Member provides evidence that he has made
such payment, payment shall be paid to the Member but without prejudice to Harris Health's right to
seek recovery of any payment made by it before receipt of such evidence.
Benefit; under this Agreement will be paid direcliy to the provider unless Member requests
payment to be made to himself and submits to Harris Health proof of prior payment to the provider for
covered services. Claims for such services will be processed as follows:
A. Fifteen (15) calendar days after receipt of claim. Harris Health will:
1. Acknowledge receipt of claim;
2. Commence investigation of claim;
3. Request all information from claimant as deemed necessary by Harris Health. Subse-
quent additional requests may be necessary.
B. No later than fifteen (15) business days after receipt of all items required by Harris Health,
Harris Health will
1. Notify claimant of acceptance or rejection of claim;
2. Notify claimant of the reason(s) Harris Health needs additional time.
Harris Health shall accept or reject the claim no later than forty-five (45) calendar days
following receipt of additional information.
C. Upon notification from Harris Health that the claim will be paid, the claim will be paid no
later than five (5) business days after such notification was made.
6.2 MEDICAL EMERGENCY
Medical Emergency services which are covered under this Agreement but are not received
from Participating Providers shall be reimbursed subject to the Copayments in the Schedule of Bene-
fits. Harris Health reserves the right to deny a claim for r5imtwrsement of services received from a
Hospital emergency department or a Minor Emergency Center, if it is determined by Harris Health that
such services wore not obtalned pursuant to ft terms of this Agreement or N a Medical Emergency
did not exist at the time services were received by the Member.
6.3 ACTION ON CLAIM
All claims for reimbursement shall be finalized by Harris Health within sixty (60) days of receipt
of written documentation describing the occurrence, character and extent of the event for which the
claim is made, unless the Member Is notified of the need for a longer timo. If a ciatrn Is denied, written
notice to the Member will state the reason for the denial. Member may obtain a review of the denial
through the Member Complaint Resolution Procedure as described in Section 10.0
6A EXAMINATION OF MEMBER
Harris Health, at its own expense, shall have the right to examine the Member whose sickness
or injury is the basis of a claim when and so often as it may reasonably require during the pendency of
any claim
6.5 LIMITATION PROVISIONS
No action at law or equity shall be brought under this Section against Harris Health prior to
the expiration of the sixty (60) day period immediately following the date on which written
proof of this charge or foss upon which the action is brought, in accordance with the provi-
stns of this Section, has been furnished to Harris Health; or later than three (3) years after
the expiration of the period of time in which such proof of charge or loss Is required under
this Section to bo furnished to Harris Health,
• No liability shall be imposed under Hams Heahh other than for tl•,e benelts and services cov-
ered under this Agreement. +)nr ,1 Vv 9~
Section 7.0
COORDINATION AND SUBROGATION OF tjENEFffS
The Harris Health Coordination and Subrogation of Benefits provisions applies to all otpl~a O~
efits provided under this Agreement. The value of any benefits or services provided by Barris Health
shall be coordinated with any group insurance plan or coverage under governmental programs,
including Medicare, to assure that a Member receives coverage while avoiding double recovery. It is,
therefore, understood and agreed that should a Member be covered by or under a Coordinated Plan
in addition to coverage under this Agreement, the provisions and rules as described In this Section
shall determine whether Harris Health or the Coordinated Plan Is primarily responsible for paying the
costs of benefits and services provided to the Member.
• If a Member who has enrolled under this Health Plan is entitled to inpatient benefits under
another contract or policy of insurance due to inpatient care which began while the Member
was enrolled under a previously held policy, Harris Health will pay, subject to Copaymenis
under this plan, the difference between entitlements under this Health Plan and entitlements
under the other contract or policy of Insurance
• Benefits which are provided directly through a specified provider of an employer shall In all
cases be provided before the benefits of this Health Plan.
• Services and benefits lot military service connected disabilities for which a Member is legally
entitled and for which facilities are reasonably available, shall in all cases be provided before
the benefits of this Health Plan.
• All sums payable for services provided pursuant to worker's compensation shall not be reim-.
burnable under this Agreement.
7.1 DEFINITIONS
For purposes of this Section only, words and phrases shall have meanings as follows-.
• ALLOWABLE EXPENSE shall mean any Usual and Customary expense of which at least a
'When Coordinated Plan provides s blenefittss Inntghe the form of fsservices rfor w ather t an cash pay-
ments, the Usual and Customary cash value of each service provided shall be deemed to
be both an Allowable Expense and a benefit paid.
• CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding any portion of a
calendar year occurring prior to the Effective Date,
• COORDINATED PLAN shall mean any of the following that provides benefits or services for,
or by reason of, medical care or treatment.
- Coverage under governmental programs, including Medicare, required or provided by
any statute unless coordination of benefits with any such program is forbidden by law.
- Group coverage or any other arrangement of coverage for individuals to a group,
whether on an insured or uninsured basis, including any prepayment coverage, group
practice basis or individual practice coverage and any coverage for students which Is
sponsored by, or provided through, a school or other educational institution above the
high school level.
7.2 DETERMINATION OF BENEFITS
This provision shall apply In determining the benefits payable for the Allowable Expense
Incurred by a Member during a Claim Determination Period.
The term Coordinated Plan shall be construed separately with respect to each policy, contract,
or other arrangement for benefits or services and separately with respect to that portion of any such
policy, rontract, or other arrangement which reserves the right to take the benefits or services of other
Coordinated Plans Into consideration in determining Its benefits and that portion which does not,
i
~I
p~
ti i
S
a
whenever the sum of the benefits that would be payable under this Agreement in the absence
of this provision, and the benefits that would be payable under all Coordinated Plans in the absence
thereof or amendments of similar purpose to this provision would $ the Allowable Eros, then
the following shall apply:'
• The benefits that would be payable under this Agreerrten't'i~'atf a uo the extent
necessary so that the sum of such reduced benefits and._all the benefits payable for such
Allowable Expenses under all Coordinated Plans shall not exceed the total payable under
this Agreement. Benefits payable under a Coordinated Plan include the benefits that would
have been payable had claim been duly made therefor.
• If a Coordinated Plan would, according to its rules, determine its benefits after the benefits
payable under this agreement have been determined, and the rules as described in Sectiot%
7.3 would require payment under this Agreement to be determined before the Coordinated
Plan, then the benefits of the Coordinated Plan shall not be included for the purpose of deter-
mining the benefits under this Agreement. N__ 9-'e
7.3 ORDER OF BENEFIT DETERMINATION AgA9nfle enda..0 #
31r1
The rules establishing the order of benefit determination shall be as f flows:
• The benefits of a Coordinated Plan without a coordination of bene its rowsron (or a
duplication provision of similar intent) shall be determined before the benefits of this
Agreement.
+ The benefits of a Coordinated Plan which covers the Member other than as a dependent
shall be determined before the benefits of a Coordinatt,d Plan which covers such person as
a dependent.
• The benefits of a Coordinated Pfan which covers the Member as a dependent child of a per-
son whose date of birth, excluding year of birth, occurs earlier in a calendar year, shall be
determined before the benefits of a plan which covers such person as a dependent of a per-
son whose date of birth, excluding year of birth, occurs later in a calendar year. If a Coordi-
nated Plan does not have the provisions of this paragraph regarding dependents, which
results either in each Coordinated Plan determining its benefits before the other or in each
Coordinated Plan determining its benefits after the other, the provisions of this paragraph
shall not apply, and the rule set lorth In the Coordinated Plan which does not have the provi-
sions of this paragraph shall determine the order of benefit determination unless Section
73.1 shall apply.
• If the rules provided above or the rules provided in Section 7.3.1 do not establish an order of
benefit determination, then the benefits of a Coordinated Plan which has covered the Mem-
ber for whom the claim Is made for the longer period of time shall be determined before the
benefits of a Coordinated Plan which has covered such Member for the shorter period of
time except as follows:
- The benefits of a Coordinated Plan covering the Member as a laid-off or retired employee
or as the dependent of such Member shall be determined after the benefits of a Coordi-
nated Plan covering such person as a Member other than as IaidoN or retired employee
or dependent of such person.
- It a Coordinated Plan does not have a provision regarding laidofl or retired employees,
and. as a result, such Coordinated Plan determines its benefits after the Coordinated
Plan with this provision, then the provisions of the immediately proceeding paragraph
shall not apply.
7.3.1 Legal Separation or Divorce
in the event of a legal separation or divorce, the following order of benefit determination shall
apply:
+ If there is a court decree that establishes financial responsibility for "healthcare expenses
of the child, the benefits of a Coordinated Plan which covers the child as a dependent of the
parent with such financial responsibility shall be determined before the benefits of a Coordi-
nated Plan which covers the child as a dependent of the parent without such financial
responsibility
ri
Y
• In the event of a legal separalion or divorce in which the court decree daa not establish
financial responsibility for the healthcare expenses of the child then the following shati apply:
- II Itre parent with custody of the child has not remarried, the benefits of a Coordinated
Plan which covers the child as a dependent of the parent with custody of line child shall
be determined before the benefits of a Coordinated Plan which covers that child as a
dependent of the child without custody.
If the parent with custody of the child has remarried, the benefits of a Coordinated flan
which covers the child as a dependent of the parent with custody shall be determined
before the benefits of a Coordinated Plan which covers that child as a dependent of the
stepparent; and the benerrtz of a Coordinated Plan which covers that child as a depen-
dent of the stepparent shall be determined before the benefits of a Coordinated Plan
which covers that child as a dependent of the parent without custody.
Thus, in the event of a legal separalion or divorce, unless a court decree specifies otherwise,
the order of benefit determination described above may be summarized as follows:
Separated or Divorced and not Remarried: Separated or Divorced and Remarried:
(1) Parent with custody (1) Parent wit ~~~tpp~~
(2) Parent without custody (2) Stepparenl`Wtth'&t~sT,
(3) Parent without Wstady
7.4 MEDICARE
For purposes of determining benefits provided for a Member who is eligible to enrK edi-7
cr:re, but does not, Harris Health will assume the amount provided under Medicare to be the amount
tl r6 Vernber would have received if he or she had enrolled for it.
A Member is considered to be eligible for Medicare on the earliest dale coverage under Me&
care could become effective for the Member. Except as described under TEFRA in Section 7A, Medi-
care shall be interpreted so as to be included in Section 7.1 for each Member as follows:
• Such Member must agree to enroll for both Parts A and B of Medicare and assign to Harris
Health any Medicare benefits for services covered by Harris Health. It such Member
receives benefits from Harris Health that would have been paid or reimbursed by Medicare,
but Member has failed to enroll for Medicare coverage, then Harris Health shall be entitled to
receive from the Member the actual costs of the services provided. The Member shall remain
liable for payment of the Copayrnonts as set forth in the Schedule of Benefits.
• When Allowable Expenses are incurred by such Member during any Claim Determination
Period and Include expenses for eervices, treatment, or supplies which are payable under
Medicare, such Allowable Expenses shall be reduced by an amount equal to the benefits
payable by Medicare before cornuting the benefits payable under this Agreement.
7.4.1 TEFRA Options for Employers with 20 or More Employees
Actively vrofWng covered Employees and their covered spouses who are eligible for Medicare
will be permitted to choose one of the following options it the Employee is age 65 or older and eligible
(or Medicar
Option 1 The service of the Group Agreement will be provided fast and the benefits of
Medicare will be provided second.
Option 2 - Medicare benefits only. Subscriber and Dependents, it any, will not be covered by
the Group Agreement,
The employer will provide Subscriber with a choice to elect one of these options at least one
month before becoming age 65. All new Employees age 65 or older will be offered these options when
hired. If Option 1 Is chosen, Subscriber's rights under this Agreement will be subject to the same
requirements as for an Employee or Dependent who is under age 65.
There are two categories of persons eligible for Medicare. The calculation and payment of ben-
efits by this Agreement differs for each category.
t r,
s
Category 1 Medicare Eligibles are:
1. Actively working covered Employees age 65 or older who choose Option 1;
2. The age 65 or older covered spouses of actively wokng covered Employees age 65 or
older who chooso Option 1;
3. Age 65 or older covered spouses of actively working covered Employees who are under
age 65;
4. Actively working covered Employees of employers with 100 or more Employees and their
Covered Dependents who are entitled to Medicare by reason of disability other than End
Stage Renal Disease (ESRD); and
5. Covered individuals entitled to Medicare solely on the basis of ESRD during a period of up
to 12 months after the individual has been delermined eligible for ESRD benefits.
Category 2 Medicare Eligibles are: AgerdaNO.-_-J44
I . Retired employees and their spouses; Abe l` ep1 yD~-- 8~O ~D~
2. Covered Employees of employers with "than 1Mloyaes and their coven Au pen-
dentswho are entitled to Medicare by nasal ofof a disability other than ESRD; and
3. Covered individuals entitled to Medicare solely on the basis of ESRD for more than 12
months after the individual has been delermined eligible for ESERD benefits.
Calculation and Provision of Services:
For Members in Category 1, services are provted by this Agreement without regard to
any benefits provided by Medicare. Medicare will then determine its benefits.
For Members in Category 2, services are provided by the Group Agreement. Harris
Health shall then have the right to recover the full amount of all Medicare benefits the Member
is entitled to receive, whether or not the Member is actually enrolled for them. The Member
should authorize payment of Medicare benefits directly to Barris Health for services rendered.
If the Member does not authorize direct payment, he or she is responsible for Harris Health for
the reasonable value of the services rendered, The Member is also responsible to Harris
Health for the reasonable value of all Group Agreement services reimbursable by Medicare if
the Member is not enrotled for all benefits he or she is entitled to receive.
7.5 SIG14T TO RECEIVE AND RELEASE INFORMATION
For purposes of administering the provisions of this section, Harris Health may, withatrt further
consent of, or notice to any Member, release to or obtain from any healthcare plan, insurance oom-
pany or other person or organization, any information with respect to any Member which it deems to
be reasonably necessary for such purposes, as permitted by law. Any Member receiving services or
claiming benefits under this Agreement shall fumish to Harris Health all information deemed necessary
by Harris Health to implement this Section 7.0.
7,6 FACILITY OF PAYMENT
Whenever payments which should have been made by Harris health in accordance wish this
Section have been made by a Coordinated Plan, Harris Health shall have the right, exercisable awe
and in its sole discretion, to authorize payment to the Coordinated Plan making such payments any
amounts Harris Health shall determine to be warranted in order to satisfy the Intent of this Section, and
amounts when so paid shall be deemed to be benefits under this Agreement, and, to the extent of
such payr, ents, Harris Health shall be fully discharged from liability under Ihi;; Agreement.
T.7 RIGHT OF RECOVERY
Whenever payments have been made by Harris Health with respect to Allowable Expenses In a
total amount which is, at any time, in excess of the maximum amount of payment neccessary at that
time to satisfy the intent of this Section, Harris Health shall have the right to recover such payments, to
the extent of such excess, from one or more of the following, as Harris Health shall determine: any per-
son or persons to, or for, or wim respect to wham such payments were made, any insurar" company
or companies, and any other organization or organizations which provided services, or to which such
payments were made.
1
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7.8 UISCLOSUiriE Agendallem~
Each Member agrees to disclose to Harris Health at the time qq1 C Imeni, a t e i of
receipt of services and benefits, and from time to time as requested bjr'F(3~ 1&-aIRP" )PI, rSMof~~
other health plan coverage, the identity of the carrier, and the group througq,sf ~4S.11co'J" is ~rirGf~
provided.
7.9 SUBROGATION
Subrogatan seeks to shift the expense for injuries suffered by Plan Members to those responsi-
ble for causing them.
In return for Harris Health providing benefits for injuries, ailments, or diseases caused as a
result of the negligence, omission or willful act of a third party, each Member agrees to execute any
instrument which may be needed in order for the right of subrogation to be effective. Each Member
also agrees to assign to Harris Health the right of recovery against such third party to the extent of
benefits received from or through Harris Health plus costs of legal suit including attorney lees. At the
time such benefits are provided or thereafter as Harris Health may request, Member agrees to comply
with the following provisions:
• Execute a formal written injury report and assignment to Harris Health of right to recover the
reasonable value of any benefits provided directly by Harris Health and the actual costs paid
by Harris Health under this Agreement for injuries, ailments and diseases caused by a third
party together with the costs of legal suit Including attorney fees.
• Reimburse Harris Health for the reasonable value of any benefits and services provided by
Harris Health and in an amount equal to the charges therefor together with the costs of legal
suit, including attorney fees, but not in excess of monetary damages collected, Irnmedialely
upon receipt of any monies paid by or on behalf of a third party in settlement of any claim
arising out of injuries, ailments and diseases covered by such third party. In detemiing"
reasonable value of benefits and services provided by Harris Health, Harris Health shall con-
sider charges for similar services being made by providers in the community which possess
similar training or capability as well as unusual circumstances, or a medical complication
requiring additional time, skill experience and/or facilities in connection with a particular ser-
vice. Harris Health shall have a lien on any recovery from such third party whether by judg-
ment, settlement, compromise or reimbursement.
• Execute and deliver such papers and provide such reasonable help (including authorizing
bringing suit against such third party in Member's name and making court appearances) as
may be necessary to enable Harris Health to recover the reasonable value of benefits and
services provided by Harris Health, together with casts of legal suit, including attorney fees.
Section 8.0
INDEPENDENT AGENTSIREFUSAL TO ACCEPT TREATMENT
8.1 INDEPENDENT AGENTS
The relationships between Harris Health and contracting entities may be definod as follows:
. The relationship between Harris Health and Member Hospitals is that of independently con-
tracting entities, Member Hospitals are not agents or employees of Harris Health nor is Harris
Health an agent of any Member Hospital, Member Hospitals shall maintain the hospital-
patient relationship with Members and shall be the only parties responsible to Members la
the Hospital services that they provide
The relationship between Harris Health and Participating Providers is that of independent
contracting entities. Participating Providers are not agents or employees of Harris Health nor
is Harris Health an employee or agent of any Participating Provider. Participating Providers
shall maintain the physic tan•patient or professionat-patient relationship with Members and
shall be the only parties responsible to Members for the services provided. Naither Harris
Health nor Any employee of Harris Health shall be deemod to be engaged In the practrce of
medicine. Bards Health shall in r10 way supervise the practice of medicine by any Partiaipat-
Ing Provider hereunder, nor shall Harris Health in any manner supervise, regulate or Interfere
with the usual professional relationships between a Participating Provider and a Member.
In
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• Ilia relalionstup between Ilarns Health, itre Group and any Mcmbes is that of independent
contracting entities. Neither the Group nor any Member is the agent or employee of Harris
Heahh..and Harris Health is not the employee or agent of the Group or any Member. Neither
the Group or any Member shall be liable for any acts or omissions of Barris Health, its agents
or employees, any Physician, any Hospital, or any other person or organization in which Har-
ris Health has made, or hereafter shall make arrangements for the perf nca of services
under this Agreement. :C^'l1 o .___y,~
8.2 LIMITATION ON LIABILITY rl
Harris Health dons not guarantee by this Agreement that anji ParlicipatrngEcs2dder.shail per•
form or property perform such contracts; the only obligation of Harris Health in the event of breacfi o~
such contract by any Participating Provider shall be, upon request, to use its best efforts to procure `
the needed services from another provider. Harris Health shall not be liable to a Member for any act of
omission or commission on the part of any Participating Provider.
8.3 REFUSAL TO ACCEPT TREATMENT/EXCESSIVE TREATMENT
Members may, for reasons personal to themselves, refuse to a;cept services or complete a
Course of Treatment as recommended by a Participating Physician. Participating Physicians shall use
their best efforts to render all necessary and appropriate professional services in a manner compatible
with the Member's wishes, insofar as this can be done consistently with such Participating P'hysician's
judgment as to the requirements of proper medical practice.
If a Member refuses to complete a recommended Course of Treatment, and the Participating
Physician believes that no professionally acceptable alternative exists, such member shall be so
advised. It upon being so advised, the Member still refuses to follow the recommended treatment or
procedure, then the Member shall be given no further treatment for the condition, and neither the Par-
ticipating Physician nor Harris Health shall have any further responsibility to provide care for such con-
dition. A Member may appeal a withdrawal of treatment under this provision through the Member
Complaint Resolution Procedure as described in Section 10.0 of this Agreement.
It two (2) or more Participating Physicians who have rendered care to a Member inform Harris
Health that the Member is receiving health services or prescription m-:dicalions in a manner or in a
quantity which is not medically necessary or not medically beneficial, the Member may be required by
Harris Health to select a single Participating Primary Physician (hereafer referred to as a "Coordhat-
ing Health Plan Physician'l and a single Participating Pharmacy, it Pharmacy benerds are available to
Member, for the provision and coordination of all future health services. If the Member fails to voluntar-
ily select a Coordinating Health Plan Physician and a single Participating Pharmacy within thirty (30)
days of written notice by Harris Health of the need to do so, Harris Health shall designate a Coordinat-
Ing Health Plan Physician and/or a Participating Pharmacy for the Member.
Following selection or designation of a Coordinating Health Plan Physician for a Member, cov-
erage of health services set forth on this Agreement shall be contingent upon each health service
being provided by or through written referral to the Coordinating Health Plan Physician for that
Member.
It, after sixty (60) days from initial ratification by Harris Health, the Member Is not In compliance
with this Section, the Member may be terminated by Harris Health under Section 4.2.7.
Section 9.0
EXCLUSIONS ON SERVICE RESPONSIBILITIES
The rights of Members and obligations of Participating Providers under this Agreement are
subject to the exclusions as specified below
9.1 MAJOR DISASTER OR EPIDEMIC
In the event of any major disaster or epidemic that would severely limit the availability of Partici-
pating Providers to praride healthcare services on a timely basis, Participating Providers shall, in good
faith, use their best efforts to render the benefits and services covered Insofar as practical according
to their best judgment and wiWn the limitation of such facilities and personnel as are then available. If
Harris Health and ParticipatiN Providers shall, In good faith, have used their best efforts to provide or
i
i
make arrangements 1101' the benefits and services, they Utall have fao further liability or obligation for
delay or lailure to provide such benefits and services due to a shortise of ilab cilities or per.
sonncl resultinrq from such disaster or epidemic
9.2 CIRCUMSTANCES BEYOND CONTROL `n .Z
In the event that, due to circumstances not reasmably'ithi /-,23
n t~M Harris Health org?41
Participating Providers, such as the complete or partial destruction of faciliUos because of war, riot,
civil Insurrection, or the disability of a significant number of Participating Providers, the rendering of `f
benefits and services covered hereunder Is delayed or rendered impractical, neither Harris Health nor
anyParticipnting Provider shall have any liability or obligation on account of such delay or such failure
to provide such benefits and services, if they shall, in good faith, have used their best efforts to pro-
vide or make arrangements for the benefits and services covered Insofar as practical according to
their best judgment and within the limitations of such facilities and personnel as are then available. Pre-
mium payment shall be suspended for the duration or such time period for the Group.
9.3 FRAUDULENTLY OBTAINED BENEFITS
In the event a member fraudulently obtains healthcare services as a result of the improper or
unauthorized use of a Harris Health identification card, such Member agrees and is solely resp 4sibie
for the payment of all charges for services so obtained and for the payment of all reasonable costs of
collection thereof, including court costs, collection fees and anorney fees.
9.4 DISCONTINUANCE
If Harris Health or Group determines it would be impractical to continue due to circumstances
beyond the control of Harris Health or Group, Harris Health and Group may endeavor to agree to
amendments and adjustments to this Agreement which relate to services and benefits to be discontin.
ued. if parties cannot agree on amendments and adjustments, Harris Health or Group may terminate
this Agreement at the end of any month upon at least sixty (60) days wfinen notice for Group, fn-the
event of such termination, neither Harris Health nor Participating Providers shall have any further liabil-
ity or responsibility under this Agreement.
However, it any Participating Provider terminates their contract, then Harris Health shall be lia-
ble for the continuance of services and benefits described in this Agreement. Such services shall be
rendered to Members by other Participating Providers.
Section 10.0
MEMBER COMPLAINT RESOLUTION PROCEDURE
10.1 COMPLAINT RESOLUTION PROCESS
A Member may make an oral or written suggestion or indicate a complaint to any Harris Health
employee or to any Participating Provider. All oral suggestions and complaints shall be handled
promptly by Harris Health. If the Member is not satisfied with the response to an oral suggestion or
complaint, the Member may file a written complaint by calling Harris Health or, at the Member's option
the Member may file a written complaint by completing and forwarding a complaint form to Harris
Health at lho latest address provided on the front of this Agreement A Harris Health Member Service
Representative shall contact the Member by telephone to verify details and resolve the problem limmei-
diatety it possible. Within fifteen (15) business days from the rerelpi of the oral or written complaint,
Harris Health shall respond In writing to inform the Member of the progress or decision on the com-
plaint. In the event a decision cannot be reached within ftheen (IS) business days, Harris Health shall
notify the Member that a decision shall be provided as soon as possible, but not later than sixty (60)
days after initial receipt of the complaint.
10.1.1 Ad Hoc Review Committee
If the Member is not satisfied with the resolution of the complaint by Harris 143alth, the Member
may request a review by filing such a request, in writing, within fifteen (15) business days of receiving
written notice of the resolution of the complaint. This request shall be sent to Harris Health. Upon
receipt of this written request, Harris Health shall forward the request and any and all memoranda and
notes made as a result of the original investigatiort of the complaint to the Medical Director and to Har-
ris Heallh.
I
Ice composed of liarris HealUmi tho ivledreai t)ir
After reviewing the ornptaint records, Hectarrisor,Healthandat shall least two convene other an Ad indivHociduals not Review involved in
Cornmil.
lire Initial investigation of the cornplainl. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other Individuals on the Ad Hoc Review
be Participating Physicians Within fifteen (15) business days of r Co
eceipt shall
Harris Health shall respond, in writing, to Inform the Member f the,'-: of the request for a review.
by the Ad Hoc Review Committee. or~ _ut' If the_
10,112 Notification By Review Committee
if the original complaint inv olved a physician-patient relationship, tho writtens 9
Hoo Review Committee shall Inform the Member that he has the option, at his discretion, to sufbets t "
complaint to the mediation service maintained by the the
mediation shalt usually be concluded within a thirty Tarrant County Medical Societyand that such
shall inform the Member that participation in the mediation tiproces is (60)day time
commendations are non-binding parties As part of y i9 period. The notice
that mediation rec
the Health Plan rules and regulations, ti a
Medical Society mediation service. rticipating Physicianse musttooopeaateNith he Tarrant comply with
County
102 COMPLAINT RESOLUTION APPEAL PROCESS
If a Member is not satisfied with ft decision of the Ad Hoc Review Committee or the Tarrant
County Medical Society mediation service, the Member may request Health. The Member must file a request for review within fiftee5)businesstdayys of rIPI oahe
decision of the Ad Hoc Review Committee or the mediation service. Upon receipt of a request for a
review, Harris Health shall forward the review request and a complete record of the oompUnt history
to the Medical Director and to Harris Health.
After reviewing the complaint records, Harris Health shall convene an Ad Hoc
Appeal composed of Harris Health, the Medical Director and at least two other individuals otinohiCommed in
the initial investigation of the complaint. In the case of a complaint concerning medical treatment or
services, medical personnel or facilities, such other individuals on the Ad Hoc Appeal Committee shall
be Participating Physicians.
respond Within fifteen (5) business days of receipt of the request lot a review, Harris Health shall
,
Appeal in writing, to Inform the Member of the decision or resolution of the complaint by the Ad Hoc
Committee. If all parties involved in the complaint agree, the omplaint response of the Ad Hoc
Appeal Committee shall be final and binding on all parties.
HEALTH CARE SERVICES
11.1 Benefits and Services
Harris Health agrees to a;: ange for the provision of the benefits and services in the Schedule of
BeBenofils and/or Riders, in accordance w th the procedures and subject to thg limitations and exclu-
sions specif ed in such Schedule of Bene(ls and/; • ,~i +r•n and in this Agreement,
Physici n)leandrefl ept in case ofyMed~calcEmerge cynabcr 'ysrand serbcessettlforlhllin the Li tali t
tions and Exclusions Section of the Schedule of Benefits or any Riders that are rendered by aParticl-
paling Physician other than a Participating Primary Physician shall not be covered.
All hospital admissions must be authorized by Harris Health, and the Member's condition or
required services must be such that treatment can be rendered only in a hospital setting. Harris Health
and the Participating Physician may decide to provide Medically Necessary services on an outpatient
basis or in an outpatient surgery unit. The use of aliernative levels of cafe, such as outpatient hospital
or home care, will be encouraged where possible based on Member condition and Ireatment.
Unless previously authorized in writing by a Participating Physician and by the Medical Director
and except In cases of Medical Emergency, all benefits and services set forth in the Schedule of Ben-
Parsicipal ng Hosspi al or by anotherbProvideroundeer contract with Harms Health Participating ~d p althea ician,
services to Members.
~I
r
All charges related to services and supplies incurred prior to the Member's elleclivo date, or
alter the Member's termination date of coverage under this Agreement shalt not be covered.
Section 12.0 o r IN, g
TERM AND AMENDMENT OF AGRE&M fFa
12.1 TERM ,'o~~Z=- ~?0
This Agreement shall remain in effect for ft first Contract Year and thereafter for is live
Contract Years unless sooner terminated as provided in Section 4.0 of this Agreement.
12.2 AMENDMENT
• Harris Health and Group may mutually alter or revise the terms of this Agreement and/or
Schedule of Benefits and Riders attached hereto. in the event of such alteration or revision,
Harris Health shall provide Group with at least sixty (60) days written notice before effective
date of Amendment. Such notice shall be considered to have been provided when mailed to
the Group at the latest address shown on the records of Harris Health.
* This Agreement may be amended at any time, according to any provision of this Agreement
or by written agreement between Harris Health and Group, without the consent of the Mem-
bers, or any other person having a beneficial interest in iL Any such amendment shall be
without prejudice to any claim adsing prior to the effective date of such amendment.
12.3 CHANGE OF RATES
Harris Health shall have the right to change the rates and premiums payable hereunder (i) as
of any Anniversary Date (in which case the Group shall be notified at least sixty (60) days prior to a
change in rates) or (u) in accordance with Section 12.2 of this Agreement
Section 110
I
PROVISIONS
MISCELLANEOUS
13.1 USE OF WORDS
Words used in the masculine shall apply to the lcminine where applicable, and, wherever the
context of this Agreement dictates, the plural shall be read as the singular and the singular as the plu-
ral. The words "hereof," "herein" "hereunder" and other similar corpounds of the word "here" shall
mean and refer to the entire Agreement and not to any particular Section or provison. All references to
Sections and provisions "I mean and refer to Sections and provisions contained in this Agreement
L' ass otherwise indicated.
132 RECORDS AND INFORMATION
Harris Health shall conduct a review program for the healthcare services it provides hereunder
and for that purpose may examine the records of each Member. Information from modical records of
Members and Information received from Physicians or Hospitals incident to the Physician-patient or
Hosp toI•patient relationship shall be kept conficloNial, This information, except as reasonably neces-
sary in connection with the adminlstration of this Agreement or as required bY law, s hall not be dis-
closed without the consent of the Member.
Harris Health shall, to the extent legally allowable and without lurther consent of or notice to
any Memt,er, release to or obtain from any insurance company or other organization or person any
information, with respect to any person, which Harris Health deems to be necessary for such pur-
poses. Any person claiming benefits shall furnish to Harris Health such informaton as may be neces-
sary to implement this Agreement.
13 3 INFORMATION FROM GROUP
Group shall periodically forward the Information required by Harris Health in conjunction with
the administration of this Agreement. All records of Group which have a bearing on the coverage shall
be open for Inspection by Harris Health at any reasonable time. Harris Health shall not be liable for the
fulfillment of any obligation dependent upon such Information prior to its receipt in a form satisfactory
to Harris Health. Incorrect information furnished may be corrected, if Harris Health shall not have acted
to its prejudice by relying on it. Harris Health shall have the right, at reasonable times, to examine
Y
r
Group's records, including payroll records of employers having employees covered through Group;
with respect to eligibilrity and monlhly premiums under this Agreemornl.
13.4 ASSIGNMENT y-:5 -•o'eO
The benefits to a Member under this agreement are splg06ejv 1t px2iei~'are not
assignable or otherwise transferable.
13.5 AUTHORITY r a fa, Xe Any al terations or revisions to this Agreement shall not be valid unless videnced by a wn
amendment which has been signed by Group and by an officer of Harris Heand attached e
affected document. No other person has the authority to change this Agreement or to waive any of its
provisions.
13.6 GOVERNING LAW
This Agreement is executed and is to be performed in all respects in accordance with all fed-
eral and Texas state laws applicable to Health Maintenance Organizations and all other applicable
Texas state laws or regulations.
13.7 INCORPORATION BY REFERENCE
The Schedule of Benefits, Group Enrollment Agreement, Applications, any optional Riders, any
Attachments, and any amendments to any of the foregoing, form a part of this Agreement as if fully
incorporated herein. Any direct conflict or ambiguity of this Agreement shall be resolved under terms
most favorable to the Member.
13.8 ENTIRE AGREEMENT
This Agreement constitutes the entire understanding between Harris Health and Group.
13.9 INFORMATION TO MEMBER
Upon execution of this Agreement, Harris Health shall provide to each Subscriber a copy of
this Agreement and an Identification Card. Such delivery shall be accomplished by mailing postage
paid, to the latest address furnished to Harris Health or by delivery from a representative of Harris
Health or Group to Subscriber.
13.10 UNIFORM RULES
In the administration of Harris Health. this Agreement shall be applied uniformly to all Members
similarly situated.
13.11 CALCULATION OF TIME
In determining time paws within which an event or action is to lake place for purposes of
Harris Health, no fraction of a day shall be considered, and any act, the performance of which would
fall on a Saturday, Sunday, holiday or other nom-business day, may be performed on the next following
business day.
13.12 EVIDENCE
Evidence required of any Member of Harris Health may be by certificate, affidavit, document,
or other intormalion which the person acting on it considers pertinent and rekaoie, and signed, made
or presented by the proper party or parties.
1313 SEVERABlUTY
It any provision of this Agrecrnent shall be held invalid or illegal, the rest of this Agreement shall
remain in full force and effect and shall be construed in accordance with the intentions of the parties
as manifested by all provisions hereof Including those which shall have been held Invalid and illegal.
Furthermore, in lieu of any provision hereof which is found to be illegal, invalid or unenforceable, there
shall be added hereto a provision as similar in terms to such illegal, invalid or uninforceable provision
as may be possible and be legal, valid and enlorceahle without materially changing the purpose and
intent of this Agreement.
k
13.14 VENUE
The parties hereby expressly agree that this Agreement is executed and shall be performable
in Tarrant County, Texas, and venue of any disputes, claims, or lawsuils arising hereunder shall be in
the said Tarrant County,
13.15 YJAIVEROF NOTICE AQ9AdaNo 9~Dyl~
pp~~C , „ th d /
Any person entitled to notice under this Agreement may waive lfi~l a aQ y
13.16 HEADINGS 3
The titles and headings of Sections or provisions are included for convenience of re rence
only and are not to be considered in owstructlon of the Sections or provisions hereof.
13.17 NOTICE OF CERTAIN EVENTS
II Group may be materially or adversely affected thereby, Harris Health shall, within a reasona-
ble time, provide written notice to Group of any termination or breach of contract, or inability of any
Participating Provider to provide the services and benefits as described in this Agreement
13.18 NOTICE OF TERMINATION
All Harris Health notices of termination of this Agreement or of any Member's rights will be in
writing and shall state the cause of termination, with specific reference to the provision(s) of this Agree-
ment giving rise to the right of termination.
13.19 NOTICE
Any notice under this Agreement shall be in writing, and shall be given by United States mail,
poatsoe prepaid, addressed as follows:
Barris Health: 1300 Summit Avenue, Suite 300
Fort Worth, TX 76102
Group: The address specified on the executed Group Enrollment Agreement or the latest
address provided, in writing, to Harris Health.
Subscriber: The latest address provided by the Subscriber on Application form actually delivered
to Harris Health,
The effective date of notice is two (2) business days after the date of deposit with the United
States Post Office
24
p
a
HARRIS HEALTH SERVICE AR~A
tine Harris Hcalth Service Area includes six.
n (16) counties and parts of tour (4) cot
in North Central Texas.
The following sixteen (16) counties are in-
ided is the Service Area:
moue flood Montague
wmmanche Johnson.
Dallas limestone
colors Parker
rath Palo Pinto 6
A reestone Somervell Wise
Hamilton Tarrant Demon
ill Wise 7
.d the following four (4) counties zip codes 13 1a 11
are included as specified in the Service Area. Paler Tr t 12 Dallas
2 17 5 9 20
.OLWTY ZIP CODES ` 1 7
bryell 76512 14 t5
76525 140'A
21
76528 is a .r
r Johnson
765M Ellis
Eralh wes
76566
76580 tom' a S°~\\t
Ellis 76064 Bosque Hill Navarro
76065 Comanche
Montague 76230
76239
76251 Hamilton Fretsione
76270 Limestone
Navarro 75110 19
76639
75153 Corydi
76679 Y
76681 Y'.
E All Saints layvtew Hospnai ii. liatrts 1wlclitudut 11-L 11
T All Saints Episcopal FiospitaT 12. Harris Methodist IiEB-Sprinew'ood
3. Arlington Memorial Hospital 13, Barris Methodist Northwest
4, Campbell Memorial Hospital 14. Harris Methodist Southwest
5 Cook-Fort Worth Children's 15. Hood General I lospdal
Medical Center 16 1toguley Memorial Medical Ccnur
6 Decatur Community Hospital 17, Medical Plaza hospital
7. Denton Community Hospital 18. Osteopathic Mcdlcal Cer,er of'retas
8. Harris Methodist Erath County 19. Parkview Regional Hospital
9. llarris Methodist Fort Worth 20. St. Joseph Hospital
10. Harris Methodist Glen Rose 21, Walls Regional Hospital
u.
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SCHEDULE OF BENEFITS
Preferred PLUS
NETWORK
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summa Avenue Suae 300
Fort Worth, Texas 76102
1.800633 8598
817 8785826
i
PREF•592
4
2
1. OBTAINING HEALTH CARE SERVICES 9 p D
TV-
2
Each Subscriber and his Dependent Members are entitled to receive the services and benefits set
2 forth in this Schedule of Benefits which are Medically Necessary and obtained in accordance with the
provisions of the Group Health Care Agreement/Subscriber Certificate of Coverage.
` A. Upon enrollment, each Member shall choose (or the Subscriber shall choose on behalf of his
Dependents) a Primary Care Physician. If the Member fails to choose a Primary Care Physi-
cian, Harris Health shall assign a Primary Care Physician for the Member. The names and ad-
dresses of the Primary Care Physician from which the Member may choose shall be provided
to each Subscriber upon enrollment. Services are provided or coverage arrangements are avail-
able twenty-four (24) hours per day, seven (7) days a week by calling the telephone number
provided for the Primary Care Physician.
B. A Member may change their Primary Care Physician by contacting the Harris Health Member
Services Department at the address or telephone number specified above. The change will be-
come effective on the first day of the month following the request.
C. All health care services, except those resulting from a Medical Emergency, are to be per-
formed, prescribed, arranged, directed or authorized by the Primary Care Physician selected by
the Member. When care by a Specialist Physician is necessary, the Primary Care Physician
shall coordinate the referral to a Participating Specialist Physician. No referral is necessary for
a female member to obtain obstetrical/gynecological services from a Harris Health participating
CB'Gyn Specialist. If a required specialty is not represented in Harris Health, a referral may be
made to a Non-Participating Provider. All such non-emergency referrals must be authorized by
the Harris Health before services are oblained. Any Member may obtain additional information
as to how medical services are obtained by contacting the Harris Health at the address speci-
fied above
D. Except in cases of a Medical Emergency, or as a result of special prior approval by Harris
Health as specified above, only those services provided by a Participating Provider shall be
covered under this Schedule of Benefits.
E. All services and benefits are subject to any stated Copayment amounts, limitations, and exclu-
sions describer) in this Schedule of Benefits.
F. Any copayment expressed as a percentage of "Total Charges" shall mean the stated percent-
age of the medical provider's preferred rate which is the amount paid to the medical provider
by Harris Health.
0. This Schedule of Benefits may be supplemented by additional benefit Riders if Included with
this Group Health Care Agreement/Subscriber Certificate of Coverage.
H. The relationship between Harris Health and Participating Providers is that of Independent con II
tracting entities. Participating Providers are not agents or employees of Harris Health nor is f
Harris Health an employee or agent of any Participating Provider, Participating Providers shall I
maintain the physician-patient or professional-patient relationship with Ma :cu,s and shall be
the only parties responsible to Members for the services provided. Neither Harris Health nor
any employee of Harris Health shall be deemed to be engaged in the practice of medicine, Har-
ris Health shall in no way supervise the practice of medicine by any Participating Provider, nor I
shall Harris Health in any manner supervise, regulate or interfere with the usual professional 1I
relationships between a Participating Provider and a Member,
PREP-592 1
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II. PHYSICIAN SERVICES
f Only one Copayment will be required for covered services performed or lurnished on same date of
service by the same Provider. This Copaymenl will be the higher of all listed Copayments.
Benefits Required Copayment
Physician office visits, adult health assessments, routine $15.OONisit•Primary Care
I physical examinations, well child care, and health education
for diagnosis, care and treatment of illness or injury provided
by Primary Care Physician
Physician office visits from Specialist Physician $20,00Msit-Specialist
i ' Annual well woman examination $15.OONisil.Primary Care
I $20.OONisit-Specialist
Physician office visits after hours $25.00Nisit
Immunizations and Injections No Copayment
' Home visits i15.00Nisit
Hearing, vision, and speech screening provided by Primary $15.OONisit
Care Physician to determine the need for correction
Allergy diagnosis and/or testing; serum Is not covered S50.00Nisit
I ' Administered drugs, medications, dressings, splints, and $15.OONisit-Primary Care
casts S20.00Nisit-Specialist
I Diagnostic services, laboratory tests, and x-rays No Copayment
Ultrasound, MRI, CAT, and non-routine laboratory tests $50,004est
i ' Surgery and/or anesthesia performed in the physician's office $50.00/Procedure (Phys.)
or outpatient setting
' All physician fees including anesthesia while a member Is 20% of Total Charges
hospitalized, except professional radiology and pathology fees
' Professional radiology and pathology fees No Copayment
Physician fee in an emergency room or urgent care center 20% of Total Charges
ll
II
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PREP-592 2
agendaNo r.~'~" Ilk
Agendalterr
r.d:rlo. _--11`)3__.x'
For maternity services within the Service Area, Mebefspa4 be cn r ,:l t%, re;ei, medical, su gi~ict
and hospital care from Participating Physicians and'6tfi'er P48~kfrr ~1 r,r 7 ,y Corm of the preg rnir
upon delivery, and during the postpartum period for_pormal d;jly Y -I"- ,fxion and miscarriages;
and for complications of pregnancy. Charges related t~o medic;,/ ;crv r,V, r,0nnected with the home
delivery of a newborn and services of mid-wives, unless providwi as Ernr;rraency Care Services, will
not be covered. Any normal delivery which occurs outside the Service Arr;a within thirty (30) days of
the expected date of confinement as specified by a Participabrng Fhy•,iwan, will not qualify for
Emergency Care Services benefits, and will not be a covered henchl CenOils for the child of an
unmarried Dependent Member will be provided if the child is cunsirlarrr} to be a dependent of the
Subscriber for Federal income tax purposes, and upon payment of the applicable premium.
Benefits Required Copaymenl
Physician services for maternity care including delivery, 20% of Total Charges
hospital visits, and anesthesia
Physician care in the hospital for care of Eligible Newborn 20% of Total Charges
III. HOSPITAL SERVICES -
Member shall be entitled to receive Medically Necessary hospil,il services, subject to all definitions,
terms and conditions of this Agreement and Schedule of Benolits when performed, prescribed,
arranged for, directed or authorized by Participating Physicians and received at Participating
Hospitals. Members electing to remain in the hospital beyond the Period which is Medically Necessary
will be responsible for direct payment to the hospital for any such time beyond the discharge time
authorized by the Participating Physician and/or the Harris Health Medical Director or his designee.
Benefits Required Copaymenl
INPATIENT HOSPITAL SERVICES: 20% of Total Charges
Semi-private room, private if Medically Necessary, and
all services and medical supp!ies related to inpatient
treatment.
OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Facilities)
Surgery $100.OO/Procedure (Facility)
Therapeutic radiation treatment 20% of Total Charges
Inhalation therapy 20% of Total Charges
Diagnostic testing, laboratory, and x-rays No Copaymenl
Ultrasound, MAI, CAT, and non-routine laboratory tests $50 OO/Test
i
PREF-542 3
"'147
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IV. EMERGENCY CARE SERVICES
1 In cases of a Medical Emergency, Member is entitled to the benefits and services set forth in this
Schedule of Benefits and in this Agreement even if the services are not received from Participating
Providers. Member is entitled to receive these bona fide emergency services provided after the
' sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that the absence of Immediate medical attention could reasonably be
expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily
1 functions or serious dysfunction of any bodily organ or part.
All treatment for such services will be reviewed retrospectively by the Harris Health Medical Director
or his designee to determine whether an acute condition or situation indicated Immediate emergency
1 care to be appropriate. If upon review, the Harris Health Medical Director or his designee determines
that no need for emergency care existed, the Member will be responsible for payment of all charges
1 incurred for such care.
WITHIN THE SERVICE AREA Emergency Care Services must be obtained or authorized through the
Primary Care Physician who provides the Member with twenty-four (24) hours a day, seven (7) days
a week access to call coverage to assist the Member in obtaining Emergency Care Services. At the
time of a Medical Emergency, the Member or someone acting on behalf of the Member, shall rnake
every reasonable effort to contact the Member's Primary Care Physician for advice. If it is not
reasonably possible to contact the Primary Care Physician at the time (such as that of a life or limb
threatening emergency), the Member shall seek care from a Participating Hospital or Participating
Emergency Center.
j 1 At the time of a Medical Emergency which results in a hospital admission, the Member or someone
acting on behalf of the Member, shall notify Harris Health within twenty-four (24) hours or as soon as
reasonably possible. Upon notification, the Harris Health Medical Director or his designee may
1 coordinate transfer of the Member to the care of their Primary Care Physician or other designated
provider when medically prudent to do so.
Benefits (Within Service Area) Required Copayment
1 Physician office visits $15.OONisit-Primary Care
$20.OONi s it-Specialist
1 Physician office visits after hours $25.00Nisit
1 Hospital emergency room and urgent car, center services, 20% of Total Charges
Including physician fees
Follow-up care is covered from Primary Care Physician only, $15.OONisit-Primary Care
1 1 or upon referral from the Primary Care Physician $20.OONisit-Specialist
ll
11
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I PREF-592 4
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Y
v
OUTSIDE THE SERVICE AREA coverage for Emergency Care Service"fo'fe ~ ice Area
it:
are available provided that such Emergency Care Services cannot be reaso
without risk
luEW
to Member until the Member Is able to return to the Service Area to obtain treatment I
Participating Providers. pp Y, _'94 7
• At the time of a Medical Emergency which results in a hospital admission, the Member or someone
acting on behalf of the Member, shall notify Harris Health within twenty-four (24) hours or as soon as
reasonably possible. Upon notification, the Harris Health Medical Director or hfs designee may
coordinate any transfer of management and control of the care to a Participating Provider or other
designated provider In the Service Area as soon as medically prudent to do so.
Continuing or follow-up treatment shall be provided within the Service Area. No claim for out-of-area
emergency services shall be allowed when procedures in this section are not complied with by the
Member.
Benefits (Outside the Service Area) Required Copayment
Physician office visits for stabilization and emergency care $15.00Nisit-Primary Care
services only $20.OONisit-Specialist
Physician office visits after hours $25.00Nisit
Hospital emergency room and urgent care center services for 20% of Total Charges
stabilization only, including physician fees
Follow-up care is covered from Primary Care Physician only, S15.OONisit-Primary Care
or upon referral from the Primary Care Physician $20.00Nisit-Specialist
V. FAMILY PLANNING SERVICES
Family Planning Services will be available to Members on a voluntary basis. Covered services are
limited to the use of Participating Providers and will include history, physical examination, related
laboratory tests; medical supervision In accordance with generally accepted medical practice;
Information and counseling on contraception, including advice or prescription for a contraceptive
method; education, including education on the prevention of venereal disease; and voluntary
sterilization after appropriate counseling.
Benefits Required Copaymeni
Physician office visits, including related testing, education and $15.00Nisit-Primary Care
counseling $20.00Nisit-Specialist
Fitting and dispensing of IUD and diaphragms $15,0ONisit-Primary Care
$20.OONi s it-Specialist
Tuba[ ligation $50.00/Procedure (Phys.)
Vasectomy $50.00/Procedure (Phys.)
PREF-592 5
1
VI. INFERTILITY SERVICES _ - %Q vZ4
Infertility services will be available to Members on a voluntary basis. Artificial inseminator ion and
diagnostic services to determine the cause of infertility will be provided from Participating Providers
and Participating Facilities. Excluded from services to treat infertility are those services described In
"Exclusions," Section XIX, Number 23 of this Schedule of Benefits.
1 Benefits Required Copiyment
Physician office visits for diagnosis, non-psychiatric $15.OONisit-Primary Care
counseling, artificial insemination, and sperm count $20.OONisit•Specialist
' Administration of infertility medications; Infertility $15.00Nisil•Primary Care
medications not covered $20.00Nisit-Specialist
1 Endometrial biopsy, hysterosalpingography and diagnostic 20% of Total Charges
laparoscopy
] Sonogram and/or ovulation kit $50.00/Test or Kit
VII. CHEMICAL DEPENDENCY SERVICES
Member shall be entitled to all necessary care and treatment for chemical dependency on the same
basis as that provided for any physical illness to a lifetime maximum of three (3) separate series of
treatments for the member. Diagnosis and treatment for chemical dependency shall include
detoxification and/or rehabilitation on either an inpatient or outpatient basis as determined to be
Medically Necessary by Participating Physicians. All treatment is subject to the same limitations,
exclusions, and copayments as applied to covered services of any other physical illness.
A series of treatments Is considered to be a planned, structured, and organized program to promote
1 chemical free status which may Include different facilities or modalities and is complete when,
The member Is discharged on medical advice from inpatient deloxification, inpatient
1 ' rehabilitation treatment, partial hospitalization or intensive outpatient; or
J The member has received a series of these levels of treatments without a lapse in treatment; or
The member fails to materially comply with the treatment program for a period of thirty (30)
days.
' Benefits Required Copayment
Office visits $15.00Nisit-Primary Care
1 $20,00Nisit-Specialist
Necessary care and treatment for detoxification and/or $15.OONisit-Primary Care
rehabilitation from chemical dependency $20.OONisit-Specialist
20% Total Inpatient Charges
Intensive outpatient of partial hospitalization 20% Total Inpatient Charges
I PAEF-592 6
Vill. MENTAL HEALTH SERVICES Air
OUTPATIENT MENTAL HEALTH SERVICES: e/
Member shall be entitled to receive up to twenty (20) office visits per Calendar Year for evaluation,
crisis intervention and stabilization, and for outpatient therapy in support of the evaluation or crisis
Intervention. Member must be referred by the Primary Care Physician or by the Harris Health
designee to Participating Specialist. Services must represent treatment for conditions which in the
judgment of Participating Providers can substantially benefit from short-term treatment. The twenty
(20) visits maximum may include individual treatment, couple, or family visits.
Benefits Required Copayment
Outpatient office visits for crisis intervention and treatment S20.001visit
Psychological testing 20% of Total Charges
INPATIENT MENTAL HEALTH SERVICES:
When determined to be Medically Necessary by Participating Physician or by the Harris Health
designee, tha Member shall be entitled to evaluation, crisis intervention, treatment or any
combination thereof for acute conditions at a Participating Facility Services must represent treatment
for conditions which in the judgment of Participating Providers can substantially benefit from
treatment, and requires inpatient treatment
Only treatment a! the most appropriate level of care as determined by Participating Providers or by
the Harris Health designee will be authorized by Harris Health.
Chronic mental health conditions and long-term treatment are not covered,
Benefits Required Copayment
Inpatient hospitalization for up to thirty (30) inpatient days per 20% of Total Charges
Calendar Year.
Psychiatric Day Treatment Facility, Crisis Stabilization Unit or 20% of Total Charges
Residential Treatment Center for Children and Adolescents for
up to sixty (60) days per Calendar Year. Treatment in such
facilities will be limited to sixty (60) days of care such that one
(1) day of care shall be equal to one-half (112) day of inpatient
care.
PREF-592 7
AgendaNo
AgendallerrU.....
rote
IX. REHABILITATION SERVICES
Member shall be entitled to receive short-term physical or occupational therapy rehabilitation services
from a Participating Provider for conditions which in the judgment of Participating Physicians are
Medically Necessary, subject to significant improvement through short-term treatment, and
authorized by Harris Health before services are obtained. Short-term treatment is defined as up to
sixty (60) consecutive days or twenty-five (25) visits per condition, whichever is greater, and shall be
provided on an outpatient basis only. Short-term rehabilitation services on an inpatient basis or in a
skilled nursing facility will be authorized only if other non-rehabilitation med'+cal services are required
by the Member,
Occupational therapy shall mean those services designed to prevent dysfunction, restore functional
ability and facilitate maximal adaptation to impairment.
Benefits Required Copayment
Hospital, home health agency, or other provider for restorative $15.OONisit-Primary Care
treatment subject to short-term clinical improvement, and $20.OONisit-Specialist
limited to sixty (60) consecutive days or twenty-five (25) visits 20% Total Inpatient Charges
per condition, whichever is greater. Long-term or maintenance
services are not covered.
)L KIDNEY DIALYSIS SERVICES
Member shall be entitled to services and benefits provided within the Service Area for kidney dialysis
upon prior authorization from Harris Health and by referral to Participating Providers, only if
Participating Physician determines that such service represents the preferred method of treatment,
and the Member satisfies criteria for the service involved, Coverage will be coordinated for any
Member eligible for available coverage under the Medicare provisions for End Stage Renal Disease,
Benefits Required Copayment
Inpatient or outpatient hospital, or outpatient kidney dialysis $20.OONisit-Outpatient
center 20% Total inpatient Charges
Home dialysis (continuous ambulatory peritoneal dialysis) S20.00/Visit
including equipment, training, solutions, coils, drug and
surgical supplies
t0. AMBULANCE SERVICES
Benefits Required Copayment
Member shall be entitled to both land and air ambulance 20% of Total Charges
services for Medically Necessary Emergency Care Services
8
PREP-592
e:
9
XII. HOME HEALTH CARE SERVICES
/e
Member shall be entitled to receive home health care services from a Participating P vider according
to a treatment Plan approved by the Participating Physician, and with prior authorization from Harris
Health. Treatment will be provided only for those medical conditions subject to clinical Improvement
through short-term treatment; for recovery or rehabilitation of illness or injury; n, for treatment of
terminal illness.
Benefits Required Capayment
Skilled nursing care; physical, occupational, or respiratory S15.OONisit
therapy; intravenous solutions; and home health aid services
Hospice (home health service only) S15.OONisit
i
XIII. SKILLED NURSING FACILITY SERVICES
Member is entitled to receive services in a Participating Skilled Nursing facility for medical conditions
which in the judgment of a Participating Physician is subject to significant clinical improvement and
which require services which can only be provided at that level of care, Services in a Skilled Nursing
Facility may be provided in lieu of hospitalization (either in lieu of admission or upon discharge from
inpatient care) as Medically Necessary based on acuity of services and patient condition, are limited
to sixty (60) days per Calendar Year, and include Participating Physician services only.
~ i
Benefits Required Capayment l
Room, board, rnedicationc and supplies while confined in a 20% of Total Charges
Skilled Nursing Facility as part of a short-term recovery or
rehabilitation program
Participating physician visits while confined to Skilled Nursing 20119 of Total Charges
Facility
XIV. PROSTHETIC MEDICAL APPLIANCES
Member shall be entitled to prosthetic medical services or medical appliances 11 Medically Necessary,
with authorization from Harris health, and received from Participating Providers. While the Member Is
covered under this Agreement, initial prostheses are provided when required due to illness or injury.
Replacement is provided only when marked physical changes occur which require replacement, and is
not provided for items which wear out due to normal usage.
Benefits Required C^payment
Internal prosthetic appliances including internal cardiac 20% of 10, I Charges
pacemakers, and minor devices such as screws, wire mesh,
nails, and artificial joints. Supply of or replacement of internal
breast prolhesis covered only if initial surgery was result of
injury or disease.
PREF•592 9
Benefits Required Copayment - l/
/GJ~~~SDY
External prosthetic appliances including artificial arms, legs 26 of Total s
above or below knee or elbow prostheses; eyes, lenses,
external cardiac pacemaker; terminal devices such as hand or
hook; rigid or semi-rigid immobilizing devices such as arm.
leg, neck or back braces; and ordinary splints, and crutches
XV. DURABLE MEDICAL EQUIPMENT
Member shall be entitled to benefits received from a Participating Provider for certain durable medical
equipment, as ordered by a Participating Physician, and with prior authorization from Barris Health.
Durable medical equipment must be able to withstand repeated use, primarily and customarily serve a
medical purpose, generally not be useful in the absence of illness or injury, require a Participating
Physician's order, and be appropriate for use In the home, At its option, Harris Health may rent or
purchase approved equipment. Harris Health retains the right of possession of equipment.
Harris Health shall have no liability or responsibility for repair or replacement of equipment lost or
damaged. Equipment not considered durable medical equipment is described in "Exclusions",
SecliGn XIX, Number 31 of this Schedule of Benefits.
Benefits Required Copayment
Rental or purchase of medical equipment 20% of Total Charges
XVI. LIMITED DENTAL SERVICES ^
The Member shall be entitled to services for the initial stabilization of acute accidental, non-
occupational injury, to sound natural teeth with prior authorization by Harris Health, when provided
within thirty (30) days of the accident on an outpatient basis only.
While Member is covered under this Agreement coverage Is limited to treatment of fractured or
dislocated jaw, or to repair damage to sound natural teeth. Limitations and exclusions for dental
services are described in Section XVIII, Number 3 and Section XIX, Number 17 of this Schedule of
Benefits. Copayments will be the same as described for other illness or injury services.
XVII. COPAYMENT MAXIMUM
The maximum annual Copayments for covered benefits, under this Schedule of Benefits, shall not
exceed the following in a Calendar Year as described In Section 5.3, of the Group Health Care
AgreemenUSubscriber Certificate of Coverage.
Benefits Maximum Annual Copayments
Per Member $2,000.00
Per Family $4,000.00
PREF-592 10
X4'III. LIMITATIONS
The following services are limited as described below:
1. Any service, supply, or treatment which is not provided, ordered. performed, prescribed,
directed, referred, arranged, authorized or approved by the Member's Primary Care Physician,
or the Harris Health Medical Director or his designee, will not be covered, except for
Emergency Care Services as described in this Schedule of Benefits.
2. Services by physicians, facilities or other providers, who are not Participating Providers, will
not be covered; except for Emergency Care Services as described in this Schedule of Benefits,
or those services authorized in advance in writing by the Harris Health Medical Director or his
designee.
3. Care and treatment of the teeth or gums, except for oral surgery for tumors or injuries to the
jaw bone or surrounding tissue, is limited to the initial stabilization of acute, accidental non-
occupational injury to sound, natural teeth when provided within thirty (30) days of the
accident on an outpatient basis only,
4. Coverage for vision examinations is limited to conditions which require examination to
diagnose injury or illness, unless covered by Rider attached to this Agreement.
5. The benefit for durable medical equipment is limited to either the total rental cost or the t
purchase price of such equipment, whichever Is less, as determined and authorized in advance
by the Harris Health Medical Director or his designee. Harris Health shall have no liability or
responsibility for repair or replacement of equipment lost or damaged.
6. Care and treatment provided in nonparticipating hospital owned or operated by federal, state,
county or city government is limited to the care for the condition which the law requires to be
treated or provided in a public facility.
7. The purchase or fitting of eye glasses or contact lens or advice on their care is limited to the
initial set of eye glasses, contact lens, or lens implant required fallowing cataract surgery,
repair of congenital defect or as required by an accidental injury to the Member.
8. Coverage for reconstructive surgery is limited to surgery necessary to repair a functional
disorder resulting from disease, injury, or congenital defect Supply or replacement of Internal
breast prothesis Is covered only it initial surgery was a result of injury or disease.
9. Any normal delivery for the Member which occurs outside the Service Area, and is within thirty
(30) days of the expected date of confinement, as specified by a Participating Physician, will
ncl qualify as Emergency Care Services benefits described In this Schedule of Benefits. r
10. Benefits for Dependents who are students temporarily residing outside the Service Area, are [
limited to Emergency Care Services only outside the Service Area. The Dependent must return
to the Service Area for all other services.
11, Coverage for treatment of the tempo romandibular (jaw or craniomandibular) joint is limited to
Medically Necessary diagnostic services and/or surgical treatment as determined to be
Medically Necessary by the Harris Health Medical Director or his designee. All services must
be provided by a Participating Provider. Charges related to dental services for this condition
are not covered.
I
PR Ef •592 11
I
12, It Medically Necessary and authorized by the Harris Health Medical Director or designee, Harris
Health will cover kidney transplants, corneal transplants, liver transplants for children with
congenital biliary atresla, and bone marrow transplants for Aplastic Anemia; Leukemia;
Lymphoma; Severe Combined Immunodeficiency Disease; or Wiskon-Aldrich Syndrome where
traditional modalities of traditional medical therapy have been exhausted. Medical costs for
organ procurement associated with the removal of an organ for a covered transplant when the
recipient is a Member are limited to a maximum benefit of $10,000. Charges related to organ,
tissue, or artificial organ transplants except as otherwise specified in this section are excluded,
The donor's transportation costs are not covered. Services provided to any Member for the
donation of any organ or element of the body are not covered.
13. Benefits for the infant child of an unmarried Dependent will be provided if the infant is
considered to be a dependent of the Subscriber for Federal income tax purposes, and upon
payment of the applicable premium.
it
:cm
~a7~aoy
PAEF•592 12
XIX, EXCILUS10NS
The following
Agreement Services and supplies, and the cost thereof, are excluded from cove age under this
, unless specifically added by Rider to this Schedule of BeneftkS,;6 _ ✓S~J~
1. Charges related to any service or treatment which a Memi b pay in the absence of this Agreement. id
be legally required to t i
2. Charges related to personal, convenience, or comfort items such fi
~
admission to a hospital, television, telephone, newborn infant photographs, guest meals, birth r
announcements, and other related articles which are not for the specific treatment of illness or
injury, r
3, Charges related to transportation, except charges related to land and air ambulance services }
for Medically Necessary Emergency Care Services described in Section Xi of this Agreement.
4. Charges related to private hospital room and/or private duty nursing.
5. Charges related to services rendered by a person who resides in a Member's home, or by an
immediate relative of the Member.
6. Charges related to services for military or service connected conditions for which tha Member
is legally entitled, and for which appropriate facilities are reasonably available to the Member, i
1. Charges related to occupational injury or illness or conditions covered under Worker's
Compensation.
B, Charges related to homemaker, chore or similar services; and health care services primarily for
rest, custodial, respite, domiciliary, or convalescent care.
9• Charges related to reports, evaluations, or physical examinations not required for health
reasons (not Medically Necessary), Excluded items area reports for employment, insurance,
camp, adoption, travel, or government licenses.
10. Charges related to drugs ur medicines, prescription or non-prescription, provided to the
Member while he or she is not an inpatient, unless added by Rider to this Schedule of
Benefits.
11. Charges related to experimental drugs or Scbslances not approved by the FDA for other than re
FDA approved indications; and drugs labeled "Caution - limited by Federal taw to
Investigational use." r
12. Charges related to formulas, dietary supplements, or special diets provided to the Member on o +
an outpatient basis.
13. Charges related to vision care. Excluded services are: examination for eye glasses; refraction, i mes
and lenses; virsualntraining; enttin d orthoptics: except as otherwise specified in s of Section cX4111S Number exercise 4 of this ( r
Schedule of Benefits. L
14. Charges related to radial keratotomy or other radial keratoplasties, and all costs associated
with such surgery,
PQEF•592
13
Zl .1 Oman
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e
1gendaNo
15. Charges related to hearing aids, batteries, and examinationsAlg idlihp thereof unless added by
Rider to this Schedule of Benefits. 5119
16, Charges related to the care and treatment of the feet unless such services ale a cally
Necessary. Exclusions include routine foot care, such as removal of corns, calluses, or the
trimming of nails: treatment for flat feet, orthotics;,vrch sW orts; or custom fitted braces and
splints
17. Charges related to dental care, except as otherwise, specified in Section XVI of this Schedule of
Benefits, Including services related to the care, rillings; removal, or replacLment of teeth;
treatment of diseases of the teeth or gums; extraction of wisdom teeth; malocclusion or
malposition of the teeth and jaws (mandibular hyperplasia'hypoplasia); professional services or
anesthesia related to or required for the sole purpose to provide dental care; hospital care;
inpatient or outpatient surgery required for any dental care; prescription drugs for dental
treatment; dental x-rays; dintures; and dental appliances or prostheses,
18. Charges related to surgical procedures and other treatment associated with the treatment of
obesity, regardless of associated medical or psychological conditions, including treatment of a
complication of surgical treatment for obesity. Excluded procedures are: intestinal or stomach
bypass surgery, gastric Stapling, wiring of the jaw, Insertion of gastric balloons, or similar
procedures.
19. Charges related to transsexual surgery, including medical or psychological counseling or
hormonal therapy, in preparation for or subsequent to any such surgery.
20. Charges related to services for cosmetic surgery or reconstructive surgery, except as
otherwise specified as covered in this Schedule of Benefits. Cosmetic surgery exclusions are:
rhinoplasty; scar revisions; prosthetic penile implants; surgical revision or reformation of any
sagging skin on any part of the body, described as relating to the eye lids, face, neck, j
abdomen, arms, legs or buttocks; liposuction procedures; any services performed in
connection with the enlargement, reduction, implantation or appearance of a portion of the
body described as the breast, face, lips, jaw, chin, nose, ears. or genitals; hair transplantation;
chemical face peels or abrasions of the skin; removal of tatoos; and electrolysis depilation.
Supply or rrptacemenl of internal breast prothesis is covered only if initial surgery was a result
of Injury or disease.
21. Charges related to reduction mammoplasty, unless determined to be Medically Necessary by
the Harris Health Medical Director or his designee.
22. Charges related to reversal of surgically performed sterilization or subsequent resterilization.
23, Charges related to surrogate parenting; in-vitro fertilization; GIFT procedures; and any costs
associated with the collection or storage of sperm for artificial insemination including donor
fees; and infertility medications unless added by Rider to this Schedule of Benefits.
24. Charges related to amniocentesis, ultrasound, or any other procedure performed solely for sex
determination of the fetus.
25. Charges related to medical and hospital care for an infant of an unmarried Dependent Member,
unless the infant is considered to be a dependent of the Subscriber for Federal income tax
purposes, and applicable premium payment has been made.
26. Charges related to mental health services for psychiatric conditions which are determined by
the Harris Health Medical Director or his designee, to be chronic or organic in nature, and
which will not substantially benefit from short-term evaluation, crisis intervention and
stabilization, or short-term treatment.
PREF-592 14
k
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27. Charges related to court ordered testing, and special repor d;
treatment, ~ L _ WTted to medical
28. Charges related to services for the treatment of mental retardation and m1fita deficiency,
29. Charges related to employment, vocational, or marriage counseling; behavioral training;
disabilities remedial education,
and ucation, minimal brain including e dysfunction; valuation and treatment of learning and developmental
or attention deficit therapy.
30. Charges related to services for chronic Intractable pain provided by a paln control center;
acupunctureand ,ecologicalnaturopathyor , andenvironmentalhypnotherapy;,
medicine holistic or homeopathic care. Including drugs;
I
31. Charges related to durable medical equipment, unless described In this Schedule of Benefits. r
Excluded items are; (a) equipment, suet as motor driven wheel chairs and beds, possessing
features of an aesthetic nature or features of a medical nature which are not required by the
patient's condition; (b) items not primarily medical in nature or for the patient's comfort and
convenience, such as bed boards, bathtub tiffs, over-bed tables, adjust-a-bed,and telephone
arms; (c) physician's equipment such as stethoscope and sphygmomanometer, (d) exercise
equipment such as exercycles and enrollment in heath or athletic clubs; (e? self-help devices
not primarily medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (f)
corrective orthopedic shoes and arch supports; (g) supplies or equipment for common
household use, such as but not limited to, air purifiers, central or unit air conditioners, water '
purifiers, allergenic pillows or matbesses, and water beds; and (h) research equipment or
items deemed to be experimental as determined by the Harris Health. Harris Health shall have
no liability or responsibility for repair or replacement of equipment lost or damaged
32. Charges related to prosthetic medical appliances, except as specified In Section XIV of this
Schedule of Benefits. Excluded items include; (a) dentures, bearing aids unless provided by
Rider, and contact lens; (b) medical supplies such as elastic stockings, garter belts, arch
supports, corsets, and corrective orthopedic shoes; (c) research devices or items deemed to
be experimental as determined by Harris Health; and (d) replacement, repair, and routine
maintenance of covered appliances or braces unless surgically implanted, or replacement
required due to a marked change In physical growth or physical requirements,
33. Charges related to medical supplies, aids, and appliances except as otherwise specified as l
covered in this Schedule of Benefits. Excluded items are; consumables, disposable supplies,
s
traction heaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure units,
dre sings, esting supplies, yri syringes, home testing ktsidisp sable diapers or incontinent
supplies, and over-the-counter medications. r
34. Charges related to Inpatienl or outpatient long-term neuromuscular, or occupational therapy `
services or other rehabilitation services in excess of sixty (60) days per condition or twenty-
five (25) outpatient visits, whichever is greater,
35. Charges related to recreational or educational therapy, and any related diagnostic testing,
except as provided by the hospital as part of an approved inpatient hospitalization.
38. Charges related to structural changes to a house or vehicle.
37. Charges related to any medical, surgical, or health care procedure or treatment held to be It
experimental or investigational at the time the procedure or treatment is performed. Harris LI
Health will utilize findings and assessments of national medical associations, professional
societies and organizations, and any appropriate technological body established by any state or
federal government or similar entities to determine coverage and/or effectiveness,
PREP-592
15
r _
x
a
PRESCRIPTION DRUG RIDER ~
FOR USE ONLY WITH GROUP HEALTH CARE AGREEMENT/SJBSCR1 R
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Avenue, Suite 300
Fort 1lorth, Texas 76102
800/633-8598
t
1.0 INTRODUCTION
In consideration for thus timely payment of premiums, and all other terms
and conditions of the Group Health Care Agreement/Subscriber Certificate
of Coverage ('Agreement'), it is agreed that the benefits of this Rider,
together with the terms and conditions of this Rider, shall be added to
Agreement as issued if this Rider is accepted by the Group.
2.0 DEFINITIONS
Benefits for outpatient prescription drugs provided through this Rider
shall be subject to the provisions and definitions of Agreement to which
this Rider is a part.
Prescription Drugs shall mean only those drugs and medicines which are
prescribed by a Participating Physician, and legally require the written
prescription of a Physician before they can be obtained by the Member.
Heritable disease shall mean an inherited disease that may result to
C mental or physical retardation or death.
Phenylketonuria (PKU) shall mean an inherited condition that may cause
severe mental retardation if not treated.
3.0 BENEFITS
For the purpose of this Rider, benefits for covered outpatient
prescription drugs shall include only those drugs and medicines which are
written by Participating Physician, and obtained from a Participating
Pharmacy.
Benefits limitations and Member cost shall be as follows:
' Cooayment by Memo
0 510.00 per new prescription or refill for each thirty-four (34) day
' supply or fraction thereof.
o $240.00 per Morplant device.
' POMIO-892
1
x
a.tti~~MtOala
3.0 BENEFITS (Continued) r~.a3 13
COVERED ITEMS //02 o`;~ `f
When rescribed by a Participating Physician and dispensed at a
Participating Pharmacy, coverage will include:
o Any Federal Legend Drugs
o Any medicinal substance which includes the legend 'Caution, federal
law prohibits dispensing without p.&escription.'
o Any medicinal substance which may be dispensed by prescription only
according to state law.
0 Any medicinal substance which has at least one ingredient that is
Federal legend or State restricted in a therapeutic amount.
0 Oral contraceptives.
0 injectable insulin, insulin syringes and miscellaneous diabetic !
supplies, including urine and blood glucose strips.
o PKU and other heritable diseases supplements.
0 Nicorette gum and nicotine patches limited to one (I) course of
treatment per lifetime. i
COVERED QUANTITIES r
As prescribed, up to a maximum of a thirty-four (34) day supply for each
new covered prescription or refill. Prescriptions shall not be refilled
until approximately 75% of the previously dispensed quantity has been
consumed, based on dosage instructions of the physician. Members must pay
in full for any amounts exceeding covered quantities, including lost or
misplaced medications.
COVERED REFILLS
A maximum of five (5) refills per prescription shall be covered if allowed
by law and authcrited by Physician, provided such refills are dispensed '
within six (b) months of the initial prescription date.
USE OF GENERIC DRUGS
Whenever possible, Participating Physicians will write prescriptions which
permit substitutions of a generic product. If generic product is
prescribed or permitted, only the generic cost will be covered.
4.0 MAIL ORDER PHARMACY BENEFITS
For the purpose of this Rider, benefits for mail order outpatient
maintenance prescription drugs shall include only those maintenance drugs
and medicines which are obtained from a Participating Mail Order Pharmacy
Provider.
Benefit limitations and Member cost shall be as follows:
0 Copayment by Member - $10.00 per new prescription or refill for each '
ninety (90) day supply or fraction thereof.
POMIO-692 2 r
P
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_ 4.0 MAIL ORDER PHARMACY BENEFITS (Continued)
COVER LQ ITEMS/EXCEPTIONS
Same as described under Section 3.0 08enefits' with the following
exceptions:
o Anorexic drugs
o Fluorides
o Drugs requiring refrigeration
COVERED QUANTITIES
As prescribed, up to a maximum of a ninety (90) day supply for each
covered maintenance drug prescription or refill. Prescriptions shall not
► be refilled until approximately 75% of the previously dispensed quantity
has been consumed, based on dosage instructions of the physician. Members
must pay in full for any amounts exceeding covered quantities, including
lost or misplaced medications.
COVERED REFILLS
A maximum of four (4) refills shall be covered if allowed by law and
authorized by Physician, provided such refills are dispensed within twelve
(12) months of the initial prescription date, and the Member remains
eligible for such benefit.
EXCLUS ON
Same as described under Section 6.0 'Exclusions', and including exceptions
listed above under 'Covered Items/Exceptions' in this Section.
5.0 ELIGIBILITY
f
j Benefits under this Rider are available to the Subscriber and Dependents
(Members) as identified in Agreement.
r Benefits provide no conversion privileges or benefit continuity for
+ Members when such persons are no longer entitled to Group benefits as set
forth in Agreement to which this Rider is attached.
6.0 EXCLUSION
o IUD Devices
a Therapeutic or Prosthetic devices
o Appliances, Supports or other non-medical products
o Medical Supplies except those listed as covered items
o Injectable Medications, other than insulin
o Prescription drugs produced from blood, blood plasma and blood
products
o Experimental Drugs
o Immunization Agents
o Fertility Medications
PDMIO-892 3
I
3
AgendaNo
Agendaltem
Date ~11.r~1 3
6.0 EXCLUSIONS (Continued) Q
o Drugs not requiring a prescription (DTC, Vitamins, Cough Syrup,
etc.), except PKU and other heritable diseases supplements
o Drugs to be consumed in an inpatient or other institutional care
setting
o Drugs requiring parenteral use or subcutaneous use
o Charges for cost difference in a brand name product when generic
drugs are prescribed or permitted by physician
o Nutritional or dietary supplement, or formulas other than
prescription required vitamins
o Prescription written by nonparticipating physicians
o Medications dispense by physician offices
o Prescriptions Drugs for cosmetic conditions not covered in the
Schedule of Benefits (such as Retin-A, Minoxidil, etc.)
Agenda No. -
Ags i"Um
^1!-1 ni 1i J
1
PDMIO-892 4
e
SERIOUS MENTALREALTH RIDER
FOR USE ONLY WITH GROUP HEALTH CARE AGREEhfENTISUBSCRIBER//~ Aj(
CERTIFICATE OF COVERAGE
HARRIS HEALTH PLAN, INC.
Health Maintenance Organization
1300 Summit Ave, Suite 300
Fort Worth, Texas 16102
8001633-8598
1.0 INTRODUCTION
In eonsi3eralion for the timely pa)rnentof premiums, and all other terms and conditions of the Group
Health Care AgreemenVSubscriber Certificate of Coverage ("Agreement"), it is agreed that the
benefits of this Rider, together with the terms and conditions of this Rider, shall be added to
Agreement as issued if this Rider Is accepled by the Group.
2,0 DEFINITIONS
Benefits for Serious Mental Health provided through this Rider shall be subject to the provisions and
definitions of the Agreement to which this Rider is a part.
Serious Mental Illness shall man the following psychiatric illnesses as defined by the American
Psychiatric Association in the Diagnostic and Statistical Manual (DSM) III-R:
L Schizophrenia;
I
2. Paranoid and ocher psychotic disorders;
3. Bipolar disorders (mixed, manic, and depressive);
4. Major depressive disorders (single episode or recurrent); and
51 Schizo-afrective disorders (bipolar or depressive),
3.0 SE E
For the purpose of this Rider, benefits for Serious Mental Illness care shall Include only those
services obtained from Participating Providers.
Copayment by Member:
Mental health services provided for Scrious Mental illness shall be provided
subject to the same limhalinns, exclusions, and copa)menLs as applied to
covered services of any other physic.) illness.
SM1292 l
E
;gendaNo __1.121L_
Agenda: 4.0 ]ELIGIBILITY
Benefits under this Rider are avail AItto the Subscriber and Dependents (Members) as identified in
Agreement.
Benefits provide no conversion privileges or henefil continuity for Members when such persons are
no longer entitled to Group benefits as set forth in Agreement to which this Rider is attached.
5.0 EXCLUSIONS
• Charges related lomental health services for psychiatric conditions determined by the Barris
Medical Director or his designee, as not qualifying for coverage under this Rider will be
subject to the same limitations, exclusions, and copayments as applied to mental health
services listed in the Schedule of Benefits of which this Rider is a part.
• Services must be obtained in accordance with Harris Health utilization review
guidelines.
saltavy 2
E
~gendatVo.._~~.~--agendaue
Date
SERIOUS MENTAL HEALTH RIDER
FOR USE ONLY WITH HARRW HEALTH GROUP HEALTHCARE AGREEMENT/
SUBSCR1BIiR CERTIFICATE OF COVERAGE
ACCEPTED:
HARRIS HEALTH PLAN, INC.
Group
By:
By.
Amhorited Rrpruemetive eniot i-# ~trmjm 1~na~ed Can Mu4riina
Date: 13DO Sumn it Avenue, Suite 200
Fan Worth, TX 76102
Dale: 878.38)0
Dale:
REJECTED:
Group
By: _
Author4cd Reprerenu irr
Date.
t
e
INNITROFERTILIZATION RIDER
FOR USE ONLY 11TyII IIARRIS IIEALTIIGRO17P HEALTHCARE AGREEMENT/
SUBSCRIBER CERTIFICATE GF COVERAGE
HARRIS HEALTH PLAN, INC.
Ilealth Maintenance Organization
1300 Summit Avenue,Suite 300
Fort Worth, Texas 76102
60016334598
1.0 1NTROl)UCT[ON
In consideration for the timely paymentof premiums, and all other terms and conditions orthe Group
Healthcare AgreementlSubstriber CertificateorCovernge ("Agreement'),it is agreed that the benefits
of this Rider, together with the terms and conditions of this Rider, shall be added to Agreement as
Issued if this Rider Is accepted by the Group.
2.0 BENEFITS
For the purpose of this Rider, outpatient expenses arising from in-vitro fertilization procedures for
the Subscriber or the Subseribcr's spouse, the following conditions shall apply:
The fertilization or attempt at fertilization of the Member's oocytes Is made only with
Member's spouse's sperm.
The Member and the Member's spouse have a history of infertility of at least five
continuous years duration; or the infertility is associated with one or more of the
following medial conditions:
a. endometriosts;
b. exposure in utero to diethylstilbestrol (DES);
a blockage of, or surgical removal of, one or both falloplan tubes (non-voluntary); or
d. oligospermia.
The Member has been unable to attain a successful pregnancy throuv,L any less costly
applicable lnrertility Ireatmcnts for which benefits are available under the Man,
• The In-vitro fertilization procedures are performed at a medical facility that conforms
to the American College or Obstetric and Gynecology guidelines for in-vitro fertilization
clinics or to the American Fertility Society minimal standards for programs of in-vitro
fertilization.
• Benefits for In-vitro fertilization procedures shall be provided to the same extent as
the benefits for other pregnancy •rtlaled procedures under the Plan.
MISS 1
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3.0 ELIGIBH.ITY J
Benefits under this Rider arc available to the Subscriber and the Subscriber's spouse. Benefits
provide no conversion privileges or benefit continuity for Members when such person an no
longer entitled to Group benefits as set forth in Agreement to which this Rider is issued.
4.0 ( BUTEATION
Benefits shall be provided only if recommended by a Harris Health Primary or Harris Health
Specialty Physician and have received prior written approval from the Harris Medical Diredor of his
designee.
Writs 2
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IN-VITRO FERTILIZATION RIDER
FOR USE ONLY WITH HARRIS HEALTH GROUP HEALTHCARE AGREEMENT
SUBSCRIBER CERTIFICATE OF COVERAGE lr-
' CEPTEI): /off ~ "?0
I li
HARRIS HEALTH PLAN, INC.
Group
By:
ILA,
A d Rcprcaenutive Senior Vici Prulded, Managed Can Marketinj
• \ {SOOSusr[nit Avenue, Suite 200
Fort Worth, TX 76102
Date:
8T
(817) '5
Dote: ~ n
REJECTED:
Group
By,
Aurhoriud Reprcxourive
Date:
Harris Methodist
Health Insurance
Preferred Plus
Non-network
'I
HARRIS METHODIST HEALTH INSURANCE COMPANY ~3: o~
' _ 1,1`.A .__e8....,._
GROUP ENROLLMENT APPLICATION——//
.
The Harris Methodist Health Insurance Company, and City of Denton (Croup), agree to be bound by the provisions for heal
care service in accordance with this Group Enrollment Application, the Coverage Agreement, the Listing of Benefits, and any
amendmtnts and riders. Coverage will be for eligible members of Croup and their Dependents who enroll in Harris Meth( dist
Health Insurance Company. Eligible members of the Group are those persons who are exempt employees and work at least
(30) hours pee week and who comply with the provisions of this agreement.
The Group street that, after the original enrollment period under the Coverage Agreement, each new employee will be given
the opportunity to elect membership as procedure of employment.
i
Effective dates of Harris Methodist Health Insurance Company Coverage of new Subscribcta and of termination of Coverage
offered by Group wi11 be (check appropriate box):
Coverage Effective Date Termination Effective Date
XX Date of hire x_ Date Employment ends
First of month from date of hire End of munih in which employment ends
Other (specify) Other (specify)
On the first day of etch month, Premiums for that month are payable as follows:
[n full for the complete month in which coverage begins or ends.
XX _ In full it -overage begins on or before Oth of month or ends on or after the 16th of the month.
Prorated according Ie the actual number of days covered.
Other (specify)
The benefits selected by Group are as follows. (Circle o
in vitro rc tilibtion Yea No _
Preferred Plus
Pmer.Minn Rider
This agreement wW Become effective ja Mry I 19A. The contract term Is _a months. This agreement will
automatically renew fir successive twelve (12) month period unless terminated by Harris Methodist Heahh IftsurancoCompany
or the Group in accordance with the provisions for the Coverage Agreement.
This Agreement will be governed by the laws of the Stale of Texas.
All notices should be sent to these administrative addresses:
HARRIS METHODIST HEALTH 1 URANCE GROUP: City of Denton
COMPANY t 6y._
Accepted by: Title:
Title: e ' e id t nsu race Address: 321 East McKinney
k Mmaeed Care Inkiatives Denton TX 76201
Address:1300Summit Avenue. Suite IP0
For• Worth, TX 76102
a.
The 1Ltrris Methodist Health Insurance Company and the Croup agree that This ageccrncnl will nct beevme effective unless at
least NIA ernploycu initially enroll in Harris Methodist Health Insurance Company.
FYrs-~A.7r7m9]
i
it
HARRIS METHODIST HEALTH INSURANCE COMPANY
PREMIU:A RATES
1994 The City of Denton
Total Monthly Rates
ACTIVE EMPLOYEE
Point of Service
Employee $_217.80
Employee _ $337.59
Employee d{ren ` `$291.85 i
Employee + Family $368.08
RETIREES UNDER 65 _
E Point of Service
Retiree Only $295.03
Retiree and Spouse $568.47
Retiree + Child(ren) $459.69
Retiree and Family_ - $698.43
RETIREES UNDER 65 OR OVER
MEOICARE SERVES AS PRIMARY
Point of Service
Retiree Only $108.90
2 on Medicare $217.80
1 on, off $444.31
1 on, 1 off + Family $644.25
12 on + Family $425.21
CERTIFICATE. OF INSURANCE
INSURANCE BOOKLET
A",,', w-.----
;~;3 -
v20
for Employees oft ~0W
CITY OF DENTON
(Called the Group)
Insured by:
Harris Methodist Health Insurance Company
(Called HMHIC)
Fort Worth, Texas 76102
The Harris Methodist Health Insurance Company has Issued Group Policy No. POS-GA-0019
covering Employees of the Group.
This booklet is your certificate of insurance when a sticker is attached to the inside front cover.
The sticker will show your name and the effective date of your insurance.
The benefits of the group policy are described in this booklet. Final interpretation is governed
by this Policy.
11iE GROUP AGREEMENT UNDER WHICH THIS CERTIFICATE. IS ISSUED IS NOT
A POLICY OF WORKERS' COMPENSATION INSURANCE. YOU SHOULD CONSULT
YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A
SUBSCRIBER TO THE WORKERS COMPENSATION EM.
This booklet is your certificate of insurance only when you are insured under the Policy.
Thts certificate describes the benefit under the Plan In effect as of January 1+ 1994 for ail
Employees.
1
1
p05-CER9-92
..maZ._ -
IMPORTANT NOTICE AVISO IMPORTANTE l~
To obtain information or make a complaint: Para obtener information o pars someter
una queja:
You may call Harris Methodist Health Usted puede Ilamar al numero de telefono
Insurance Company's toll-free telephone gratis de Harris Methodist Health Insurance
number for information or to make a Company's para informacion o para. someter
complaint at una queja al
1-800-633-8598 1-800-633-8598
You may contact the Texas Department of Puede comunicarse con el Departamento de
Insurance to obtain information on Seguros de Texas para obtener informacion
companies, coverages, rights or complaints acerea de companies, coberturas, derechos
at o quejas al
1-800-252-3439 1-800-252-3439
You may write the Texas Department of Puede escribir al Departamento de Seguros
Insurance de Texas
P.O. Box 149104 P.O. Box 149104
Austin,'TX 78714-9104 Austin, TX 787149-9104
FAX M (512) 475.1771 FAX p (512) 475.1771
PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS 0
Should you have a dispute concerning your RECLAMOS: Si tiene una disputa
premium or about a claim you should concemiente a su prima o a un reclamo,
contact the company first. If the dispute is debe comunicarse con la compania primero.
noti resolved, you may contact the Texas Si no se resuelve la disputa, puede entonces
Department of Insurance. comunicarse con el departamento (TDI).
ATTACH THIS NOTICE TO YOUR UNA ESTE AVISO A SU POLIZA: Este
POLICY: This notice is for information aviso es solo para proposito de informacion
only and does not become part or condition y no se convierte en pane o condition del
of the attached document. documento edjunto.
4
t~OS-CBR9-9Z 2
S
Yn..T'...µw~
TABLE OF CONTENTS-
BENEFIT DESCRIPTION • .
..Y...4
GROUP AND AFFILIATED OROANIZA71ON . . . . . Y . S
ELIGIBILITY AND EFFECTIVE DATE • 6
i
TERMINATION, CONTINUATION OF BENEFITS, AND CONVERSION I i
PAYMENT REQUIREMENT ....................................16
CLAIMS INFORMATION ......................................18
COORDINATION OF BENEFITS ..................................20
INDEPENDENT AGENTS ..Y ..................................27
GLOSSARY OF TERMS .............................28
TERM AND AMENDMENT OF AGREEMENv i . Y . 42
MISCELLANEOUS PROVISIONS .................................43
Poo-CM 9-92 3
a
BE.NE.FIT, DESCRIPTION
The benefits and, provisions of this Plan are described in the attached Schedule-of Benefits
provided by Harris Methodist Health Insurance Company (HMH1C). This clan is in ef`fgct as
of January 1, 1994. /,21 ~ .za
This policyis an additional benefit plan to the Harris Methodist Health Plan, Inc. HMO Product.
Any services which are provided under the Harris HMO will not be covered benefits under this
HMHIC Agreement. The patient has a choice to choose benefits under HMH1C or Harris
HMO, there are no coordination of benefits between the two plans.
Validity of the policy shall not be contested except for nonpayment of premiums after it has been
in force for two (2) years from its date of issue and that in the absence of fraud no statement
made by any person covered by the policy relating to his or her insurability shall be used in
contesting the validity of the Insurance with respect to which such statement was made after such
insurance has been In force prior to the contest for a period of two (2) years during such
person's lifetime nor unless it is contained in a written instrument signed by him or her;
provided, however, that no such provision shall preclude the assertion at any time of defenses
based upon: (a) provisions in the policy which relate to eligibility for coverage; (b) provision
in group accident and health insurance or disability insurance policies which relate to
overinsurance; (c) provision of disability policies which relate to the relation of earnings to
insurance; or (d) other similar provisions in such policies that limit the amounts of nrovery
from all sources to no more than one hundred (100%) percent of the total actual losses or
expenses incurred;
The certificate of coverage, application, schedule of benefits, and group contract attached shall
constitute the entire contract between the parties and that in the absence of fraud all statements
made by the policyholder or person Insured shalt be deemed representations and not warranties,
and that no such statement shall be used in any contest under the policy, unless a copy of the
written instrument containing the statement is or has been furnished to such person or in the
event of death or incapacity of the insured person to the individual's beneficiary or personal
representative;
Please see the attached Schedule of Benefits for Deductibles, Maximum Out-of-Pocket Limit,
Exclusions, Limitations, and Covered Services.
t
POS-CER9-92 4
k
s
e
QROUP AND-AFFILIATED OR
Organizations included under this A reem nt lag e
The Group and its affiliated organizations are included under this Agreement. Affiliated
organizations include all organizations which are a subsidiary to or affiliated with the Group.
Change of Affiliated Orgaaizatim
The Group shall notify lIMHIC, in writing, when an affiliated organization ceases ta be a
subsidiary of, or affiliated with, the Group. When an organization ceases to be a subsidiary of,
or affiliated with, the Group, it shall cease to be an included organization. Therefore, ':pis
Agreement shall terminate on the date of such cessation with respect to all Eligible Persons of
that organization, except for those persons who on the next day are employees of another
affiliated organization and thus Eligible Persons under this Agreement.
Replacement of Former Policy
If an individual is disabled on the effective date the former policy is liable only to the extent of
its accrued liabilities and extensions of benefits. Regardless of whether the group policyholder
or other entity responsible for making payments to the carrier's plan of benefits, in respect of
classes eligible and actively at work and non-confinement rules and who elect such coverage
shall be covered under the succeeding provisions of the subsection but for the actively at work
or non-confinement rules shall become covered under the succeeding carrier plan when such
person satisfies st•ch actively at work and non-confinement rules. When replacing a prior
carrier's plan, the succeeding carrier's plan, in the case of a type of coverage for which
Extension of Coverage requires an extension of benefits for a person who is totally disabled shall
provide the lesser of (1) the extension of benefits which would have been required by the former
policy, or (2) the extension of benefits required for the succeeding former plan; provided, any
such benefits may be reduced by any benefits actually payable under the former policy.
If there is a preexisting condition limitation, other than a waitir d period, irncluded in the former
plan, the level of benefits applicable to preexisting conditions of -+ersons becoming covered in
accordance with this section by the succeeding carrier's plan and who are covered under the
prior plan during the period of time the limitation applies under the succeeding carrier's plan
shall be the less of. (l) the benefits of the succeeding carrier's plan determined without
application of the preexisting conditions limitations' or (2) the benefits of the prior plan.
The succeeding plan, in applying any waiting period in its pl^n, shall give credit for the
satisfaction or partial satisfaction of same or similar provision under the prig plan providing
j similar benefits. If a determination of benefits of rho prior plan is required by the succeeding
carrier, the prior carrier shall, at the succeeding carrier's request, furnish a statement of the
benefits available or pertinent information sufficient either to permit certification of the benefits
available under the prior plan are determined In =ordance with all of the definitions,
conditions, and covered expenses provisions of the former plan and not the succeeding carrier's
plan. The benefit determination is made as if the prior plan had not been replaced by the
succeeding carrier.
Pos-CEA9-92 5
PJAGIBILITY An'D EFFECTIVE Dn 't '
E. fiIBt F P>RM lav pSlv~~
To be eligible to enroll as an Employee, you must be c-,vered under Harris HMO as the
Employee.
ELIGIBLE DbPENDENIF
To be eligible to enroll as a Dependent, you must be covered under Harris HMO as a
Dependent, by satisfying the following:
• The legal spouse of a Employee;
• Determining the dependents or the beneficiaries of an insured, or both, prohibits a
distinction on the basis of the marital status or the lack of marital status between the
insured and the other parent.
• (a) A dependent unmarried natural child, and legally adopted child regardless of
residence; or (b) foster child,'step child, or child under Employee's court appointed legal
guardianship, residing with Employee or with Employee's present or former spouse: (1)
under nineteen (19) years of age, or (2) under twenty-five (25) years of age and primarily
dependent on the Employee for financial support and attending an accredited college or
university, trade or secondary school on a full-time basis, which has, in writing, verified
said attendpnce or;
• (a) A dependent unmarried natural child, or legally adopted child regardless of residence;
or ;b) foster child, stepchild, or child under Employee's court appointed legal
guardianship, residing with Employee or with Employee's present or former spouse:
who is nineteen (19) years of age or older but incapable of self-sustaining employment
because of mental retardation or physical handicap which commenced prior to age
nineteen (19) (or commenced prior to age twenty-five (25) if such child was attending
a recognized college or university, trade or secondary school on a full-time basis when
such incapacity occurred), and primarily dependent upon the Employee for support and
maintenance.
Such dependent child must have been a participant either prior to attaining nineteen (19)
years of age or twenty-five (25) years of age under the conditions of the previous
sentence. Employee shall furnish HMHIC proof of such incapacity and dependency
within thirty-one (31) days after the dependent child's attainment of the limiting age and
• from time to time thereafter as HMHIC deems appropriate, but not more frequently than
annually,
Pos-cER4-42 6
igenoa
• Grandchildren will be eligible for coverage if the child is considered a VOSOf the
Employees for federal income tax purposes. ate '
13D
• Managing Conservator: Coverage for a minor child who otherwise qualifies as a
dependent of a person who is a member of the group may pay benefits on behalf of the
child to the person who is not a member of the group if a court order providing for the
managing conservator of the child has been issued by a court of competent jurisdiction
in this or any other state. HMHIC is required to pay benefits pursuant to the terms of
the policy and as provided by this article on compliance by the person who is not a
member of the group with requirements of this Agreement. However, any requirements
imposed on the managing conservator of the child shall not apply in the case of any
unpaid medical bill for which a valid assignment of benefits has been exercised in
accordance with policy provisions or otherwise, nor to claims submitted by the group
member where the group member has paid any portion of a medical bill that would be
covered under the terms of the policy.
Before a person who is not a member of a group is entitled to be paid benefits under the
above mentioned paragraph, the person must submit to HMHIC with the claims
application written notice that the person:
(1) is the managing conservator of the child on whose behalf the claims is made; and
(2) submit a certified copy of a court order establishing the person as managing
conservator or other evidence designated by rule of the Texas Department of
Insurance that the person qualifies to be paid the benefits as provided by this
section.
CHANGE IN GROUP ELIGIBILITY CRITERIA
Requirements as defined by the Group for determining the eligibility for participating in HMHIC
are material to the execution of this Agreement by HMHIC. During the term of this Agreement
no change in the Group definition of eligibility participation shall be permitted to affect
eligibility or enrollment under this Agreement in any manner unless such change is approved in
advance by mutual written agreement between the Group and HMHIC.
POS•CEA9-92 7
atst10dNU Z-~"6'~~
EFFECTIVE DATG FOR 1'011 aenoailem -s2
OPEN ENROLLMENT
Harris HMO's Open Enrollment Period, and election of this rider, you shall become covered
on the Group Effective Date or the Effective Date specified as such for the Open Enrollment
Period.
ON ACQUIRING ELIGIBILITY STATUS
If you first meet the eligibility requirements other than during Harris HMO's Open Enrollment
Period you may enroll within thirty (30) days of meeting such requirements by submitting an
Application. You will become covered under HMHIC on the first day you become an Eligible
Person provided that the premium applicable to you has been received in accordance with this
Agreement.
EFFECTIVE DATE FOk YOUR D .PENDENTS
OPEN ENROLLMENT
Your Dependents, for whom you have applied for coverage in HMHIC by submitting an
AppCrcadon during Harris HMO's Open Enrollment Period, shall be covered as a Dependent on
your Effective Date.
ON ACQUIRING ELIGIBILITY STATUS
A newly acquired Eligible Dependent, other than a newborn child, and an Eligible Dependent
who first meets the eligibility requirements of the Group, other than during Harris HMO's Open
Enrollment Period, may be enrolled by the Employee within thirty (30) days of meeting such
requirements by submitting an Application to Harris HMO and election of this Ride:. Such
Eligible Dependent shall be covered under HMHIC as a Dependent on the day he became an
f Eligible Dependent provided that the premium applicable to the Dependent has been received
in accordance with this Agreement described in the PAYMENT REQUIREMENTS Section
Wow. Newborn children shall be covered for a period of thirty-one (31) days from the date
of birth and shall continue to be covered after that time only if, prior to the expiration of such
thirty-one day period, Notification has been submitted to Harris HMO for such newborn child
and the premium applicable to the Dependent has been received in accordance with this
Agreement described in the PAYMENT REQUIREMENTS Section.
Newly adopted children shall be covered as if they were newborn children. The thirty-one (31)
days grace period for submission of Notification to Harris HMO shall commence on the earlier
of the date upon which such child commences residence with you or when the adoption becomes
legal.
~oS-CEA4-92 8
I
gndaNo ~
PERSONS NOT ELIGIBLE, FOR OVERAGE agendallem
Notwithstanding the foregoing provisions of this Section, yo6VR-not be-ell3glble7o_ r, cove e
in HMHIC if: ~rff
4 Coverage Previously Terminated: You shall not be eligible for
coverage if you have had previous coverage terminated by HMHIC
or Harris HMO for cause, as described in Section
TERMINATION, CONTINUATION OF BENEFITS AND
CONVERSION of this Agreement.
0 Indebtedness: You shall not be eligible for coverage if you have
unpaid financial obligations arising from prior coverage in HMHIC
or Harris HMO.
CONDITIONS OF ELIGIBILITY
You or your Eligible Dependent shall not be refused enrollment by Harris HMO or HMHIC
because of health status, requirements for health services, or the existence of a Pre-Existing
condition on the Group Effective Date. In addition, your coverage shall not be terminated due
to your health status or health care needs. If you or your eligible Dependents apply for coverage
on a date other than Open Enrollment Period or more than thirty (30) days after becoming an
eligible person or eligible Dependent, then you or your eligible Dependent shall be required to
submit Evidence of Insurability as required by HMHIC.
NOTIFICATION OF INELIGIBILITY
i
A condition of participation in HMHIC is your Agreement to notify Harris HMO and HMHIC
of any changes in status that affect you or the ability of the your dependents to meet the
eligibility criteria set forth in this Section.
CLERICAL ERRORS
Eligibility under this Agreement shall in no event be invalidated by failure of the Group, due
to clerical error, to record or report you or your eligible Dependent to Harris HMO or HMHIC.
You shall be eligible if an Application has been completed and submitted to the Group as
required under the terms of the Harris HMO Agreement by or on behalf of you or your eligible
Dependent and the premium applicable to such coverage had been received by Harris HMO and
I forwarded to HMHIC for payment of this Rider.
POS_CEA9-92 9
17
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PRE EXISTING CON DrrtnNC genulBm
qtr
"Pre-existing Conditions" means any medical condition which diagnosis was made or treatment
received within the six (6) months immediately preceding your effective date of coverage under
this Agreement. A medical condition has been "diagnosed" if its existence has been identified
or recognized by a Physician or other Health Professional. A medical condition has been
"treated" if any services of a Physician or other Health Professional have been received with
respect thereto, including but not limited to office visits or consultations, hospital treatment,
laboratory services, X-rays or the dispensing of prescription medication or refills.
In no event shall the limitation of 50% additional Copayment apply to cost of treatment (which
shall include all applicable Copayment as specified in the Schedule of Benefits) following the
earlier of; (a) the end of a continuous period of twelve (12) months commencing on or after the
effective date of the person's coverage during all of which the person has received no medical
advice or treatment in connection with such disease or physical condition; and (b) the end of the
two (2) year period commencing on the effective date of the person's coverage.
The maximum amount of additional Copayment for a Pre-existing Condition during a Calendar
year will not exceed $2,000.00 for any such Covered Person or Dependent, or $4,000.00 total
for such Covered Person and his Dependents.
If benefits are received under the Barris HMO policy, no benefits are available under HMH1C,
therefore the Pre-existing condition clause does not apply to your coverage.
I
POS-CER9-92 10
I
Aur a tem p?
TERMINATION. CONTINUATION OF BENEFITS
1CIYD,// 0?~-9~
CONVERSION ~91/f ~?D
TERMINATION OF GROUP
i
DEFAULT IN PAYMENT OF PREMIUM
If the Group fails to pay to Harris HMO, on behalf of HMHIC, the premium payable for this
coverage, hereunder on or before the thirty-first (31) calendar day after such payment is due,
Ns Agreement may be terminated by IIMHIC and a,! benefits shall cease at the end of such
thirty-one (31) day grace period. Group may be held liable for the cost of all benefits provided
to you by HMHIC during the grace period. Group shall remain liable for all premiums (and any
interest accrued thereon) not paid prior to termination. Interest on late payments from the date
such premiums were due may oe charged at a rate NJ31 to eighteen percent (18%) per year.
Unpaid interest shall be due and payable upon notice thereof to the Group from HMHIC.
If Group remits its delinquent payments to Harris HMO for HMHIC within fifteen (15) days of
termination date, HMHIC may reinstate Group without requiring a new Group Enrollment
Agreement. However, HMHIC reserves the right to refuse to reinstate by refunding within five
(5) business days all payments made by Group after the date of termination.
UPON NOTIFICATION
This Agreement may be terminated by either HMHIC or the Group upon written notice to the
other party at least sixty (60) days prior to the end of the Contract Year. Such termination shall
occur at midnight on the day preceding the end of the Contract Year. In the event that HMHIC
terminates this Agreement, if you are Totally Disabled at the date of discontinuance of the group
policy or contact, expenses for treatment will continue at least for the period of such total
disability or for 90 days, whichever is less. For the purposes of this section, the terms "total
disability" and "totally disabled" mean (1) with respect to an employee or other primary insured
under the policy, the complete inability of the person to perform all of the substantial and
material duties and functions of his or her occupation and any other gainful occupation In which
such person earns substantially the same compensation earned prior to disability, and (b) with
respect to any other person under the policy, confinement as a bed patient in a hospital.
TERMINATION - FOR CAUSE
DEFAULT IN PAYMENT OF PREMIUM
If any premium contributions due from you are not paid timely by or on behalf of you, your
entitlement to benefits maybe terminated not less than thirty-one (3l) days after the date such
premium was due.
POs-CER9-92 11
~oenoa~lern '~°2
MISREPRESENTATION
If you should make a fraudulent statement or provide any material misrepresentation of f by
or on behalf of you or your Dependent on a Application for Harris HMO or Evidence of
Insurability form, HMHIC shall have the right to terminate your coverage under this Agreement
without any further liability or obligation to you. Your entitlement to benefits may be
terminated not less then sixty-one (61) days after such misrepresentation. If you correct
inaccurate information furnished to Harris HMO, and HMHIC has not relied upon such incorrect
information to its prejudice, the furnishing of incorrect information shall not constitute a basis
for termination of your coverage. In the absence of fraud, all statements made by you are
considered representations and not warranties and such statements shall not void the coverage
or reduce the benefits under this Agreement two (2) years after your Effective Date.
MISUSE OF IDENTIFICATION CARD
Possession of a HMHIC identification card is and of itself confers no rights to services or other
benefits. The holder of the card must be, in fact, you or an eligible person on whose behalf all
applicable premiums under this Agreement have actually been paid. When receiving services
or other benefits to which you are not entitled pursuant to this Agreement you shall be solely
responsible for the full payment of any charges associated with the services received. If you
permit the use of the your identification card by any other person, such card may be confiscated .
and HMHIC shall have the right '.o terminate your coverage under this Agreement and the
coverage of your Dependents. Your entitlement to benefits may be terminated not less than
fifteen (15) days written notice after such misuse of the identification card.
FRAUDULENT USE OF BENEFITS OR SERVICES
Fraudulent use by you of services, benefits, providers, facilities, or coverage will result in
cancellation of coverage after not less than fifteen (15) day written notice to you.
TERMINATION OF COVERAGE
EMPLOYEE NO LONGER ELIGIBLE PERSON
If you cease to be eligible, coverage under this Agreement shall automatically terminate at
midnight of that day on which you cease to be eligible.
DEPENDENT NO LONGER ELIGIBLE DEPENDENT
If a Dependent ceases to be an Eligible Dependent, coverage under this Agreement shall
( automatically terminate at midnight of the day on which the Dependent ceases to be an Eligible
Dependent.
POs-CE99-92 12
w
~lenoaroo _ ~%~-os~
LIABILITY UPON UgMINATI,(ON agendatlen,
cro
At the effective date of any termination of your coverage under this Agreem payments
received on your account, applicable to periods after the effective date of the termination of
coverage, plus amounts due to you for claims reimbursement, if any, less airy amount due to
HMHIC or which must be paid by HMHIC on your behalf, shall be refunded to the appropriate
party within thirty-one (31) days. HMHIC and the Group shall thereaficr have no further
liability or responsibility to you except as may be specifically provided in Section UPON
NOTIFICATION of this Agreement.
CONTINUATION OF OVERAG
COBRA
If, under the provisions of Title X of the Consolidated Omnibus Budget Reconciliation Act of
1985, Public Law 99-272 ("COBRA"), you are granted the right to continuation of coverage
beyond the date your coverage would otherwise terminate, or, if COBRA is inapplicable and the
provision of an applicable state statute grants you similar rights to continuation of coverage, this
Agreement shall be deemed to allow continuations of coverage to the extent necessary to comply
with the provisions of the applicable statute. No evidence of insurability is required. If you .
are eligible for continuation under COBRA you must inform HMHIC of eligibility within 3
months of the effective date.
CONTINUATION OF COVERAGE
Any employee, covered person, or dependent whose insurance under the group policy has been
terminated for any reason except involuntary termination for cause, including discontinuance of
the group policy in its entirety or with respect to an Insured class, and who has been
continuously insured under the group policy and under any group policy providing similar
benefit which it replaces for at least three consecutive months immediately prior to termination
shall be entitled to such continuation privileges. Involuntary termination for cause does not
include termination for any health related cause. HMHIC shall not be required to issue a
converted policy covering any person if: (a) such person Is or could be covered by Medicare;
(b) such person is covered for similar benefits by another hospital, surgical, medical, or major
medical expense insurance policy or hospital or medical service subscriber contract or medical
practice or other prepayment plan or by any other plan or program; such person is eligible
for similar benefits whether or not covered therefor under any arrangement of coverage for
individuals in a group, whether on an insured or uninsured basis; (d) similar benefits are
provided for or available to such person, pursuant to or in accordance with the requirements of
any state or federal law; or (e) the benefits provided under the sources herein enumerated,
together with the benefits provided by the continued policy, would result in overinsurance
according to HMHIC's standards. HMHIC's standards are the reasonable relationship between
the actual health care costs in the area in which the covered person lives at the time of the
continuation and must be filed with the commissioner of insurance prior to their use in denying
coverage. Continuation of group coverage for employees or covered persons ',nd their eligible
dependents subject to the eligibility provisions. Continuation of group coverage will not include
dental, vision care, or prescription drug benefits and must be requested in writing within twenty-
20S-C£R9-92 13
+gendaNo
Agendaltem_ _
%tp /7T-O-Po _
one (21) days following the later of (a) the date the group coverage would otherwise ter
or (b) the date the employee is given notice of the right of continuation by either the employe
or the group policy holder. In not event may the employee or the covered person elect
continuation more than 31 days after the date of such termination. An employee or covered
person electing continuation must pay to the group policyholder or the employer, on a monthly
basis in advance, the amount of contribution required by the policyholder or employer, but not
more than the group rate for the insurance being continued under the group policy on th
e due
day of each payment. The employee's or the covered person's written election of continuation,
!ogether with the first contribution required to establish contributions on a monthly basis in
advance, must be given to the policyholder or employer within thirty-one (31) days of the date
coverage would otherwise terminate. Continuation may not terminate until the earlier of. (a) six
months after the date the election is made; (b) failure to make timely payments; (c) the date on
which the group coverage terminated in its entirety; (d) or one of conditions specified in items
listed above regarding ineligible person's is met by the individual.
SEVERANCE OF FAMILY RELATIONSHIP
If coverage ends due to severance of family relationship, by virtue of family or dependent
relationship to a person who is a member or eligible for the group for which the health insurance
policy, is provided to continue coverage with the group if:
(1) Previous eligibility for coverage under the health insurance policy ceases because of the
severance of the family relationship or the retirement or death of the member of the
group, and
(2) The family member or dependent has been a member of the group for a period of at least
one year or is an infant under one year of age.
(3) A person who exercises this option, may not be required to take and pass a physical
examination as a condition for continuing coverage.
(4) A person who exercises this option is entitled to coverage under the policy, and
exclusions that were not included in the policy may not be included in the group
continuation coverage. However, if the group policyholder replaces the health insurance
policy within the one-year provided, the person may obtain coverage identical in scope
to the coverage under the replacement group policy as provided by this article.
(5) A person covered under group continuation coverage shall pay premiums for the
coverage directly to the group policyholder, and the coverage shall provide the persop
with the option of paying the premiums in monthly installments. The group policyholder
may require the person to pay a fee of not more than $5 a month for administrative
coso.
PQS-CEA9-92 14
-93
(6) Upon initial severance of fa,nily relationship, you must inform (IM141C o~ltin d-severan
upon receipt of the notification 1-114HIC will send the application to the-seve~~~h~""l
member immediately.
(7) Within sixty (60) days from the severance of tho. family relationship or retirement or
death of the member of the group, the dependent must give written notice to the group
policyholder of the desire to exercise the option under item (1) of this section or the
option expires. Coverage under the health insurance policy remains in effect during this
sixty (60) day period provided the policy premiums are paid.
(8) Any period of previous coverage under the health insurance policy is to be used in full
or partially satisfaction of any required probationary or waiting periods provided In the
contract for dependent coverage.
(9) If a health insurance policy provides to a group member continuation rights to cover the
period between the time that the member retires and the time of eligibility for coverage
by Medicare, those same continuation rights shall be made available to the group
member's dependents.
(10) If a person exercises the continuation option under item (1) of this section, coverage of
that person continues without interruption and may not be canceled or otherwise
terminated until:
(a) the insured fails to make a premium payment in the time required to make that
payment;
(b) the insured becomes eligible for substantially similar coverage under another
bealth insurance policy, hospital, or medical service subscriber contract, medical
practice or other prepayment plan, or by any other plan or program; or
(c) a period of three years has elapsed since the severance of the family relationship
or the retirement or death of the member of the group.
EXTENSION OF MEDICAL BENEFITS
HMHIC shall continue to provide medical services if this Agreement terminates while you are
Totally Disabled at the date of discontinuance of the group policy or contact at least for the
period of such tots! disability or for 90 days, whichever is less, for expense for treatment of the
condition causing such local disability. For the purposes of this section, the terms "total
disability" and "totally disabled" mean (l) with respect to an employee or other primary insured
under the policy, the. complete inability of the person to perform all of the substantial and
toaterial duties and functions of his or her occupation and any other gainful occupation in which
such person earns substantially the same compensation earned prior to disability, and (b) with
respect to any other person under the policy, confinement as a bed patient in a hospital.
This continued coverage will end on the earlier of. (1) the period of "total disability" is no
longer meets the above defined statement; or 90 days from the termination date; or (3) the
date you become eligible for similar coveraga ,rAcr another plan.
POS-CF'8223 1 S
N
AgenaaNu
Agendaltem
PAYMENT REOU1REM .NTS role
PREMIUM PAYMENTS UU
The initial rates for the benefits and services under this Agreement shall be due and payable in
advance on or before the first (1st) day of the meth for which such payment is made or is to
be made. In accordance with the terms and provisions of the TERM AND AMENDMENT OF
AGREEMENT Section of this Agreement, HMHIC shall have the right to change the rate
payable under this Agreement at any time when the extent or nature of this Agreement is
changed by Amendment or termination of any provision, or by reason of any provision of law
or governmental program or regulation. Premiums do not vary by age. No pro•3tion of the rate
shall be made with respect to your coverage under this Agreement commencing after the first
(Ist) day of the month. A grace period of thirty-one (31) days shall be allowed for each
payment payable hereunder, whether due from Group or you.
The rate required for a newly acquired Eligible Dependent shall be payable initially when the
required Notification is submitted to Harris HMO for coverage under HMHIC. Thereafter, all
pl.yments with respect to such new Eligible Dependent shall be made as otherwise provided in
this Agreement.
Any payments required for newborn children who meet the requirement of the Section.
ELIGIBILITY AND EFFECTIVE DATE of this Agreement shall be initially payable to Harris
HMO on behalf of HMHIC on or before the first day of the next month following the month in
which the Notification required under the above mentioned section is submitted to Harris HMO
for coverage under HMHIC. Thereafter, all payments with respect to such newborn child shall
be made as otherwise required under this Agreement.
NON-CONTRIBUTORY COVERAGE
If the coverage basis hereunder is "Non-Contributory", the Group agrees to pay at the principal
office of Harris HMO on behalf of HMHIC, or to its authorized representative, on each payment
due date, the sum of the HMHIC rate for the coverage under this Agreement. The Group
premium for the coverage provided by HMHIC under this Agreement shall be determine by the
applicable rate then in effect and the number of Members at the monthly intervals established
by HMHIC.
CONTRIBUTORY COVERAGE
If the coverage basis hereunder is "Contributory", the Group agrees to pay at the principal office
of Harris HMO on behalf of HMHIC, or to its authorized representative, on each payment due
date, the sum of the HMHIC rate for the coverage under this Agreement. Group shall permit
you to pay your contributory portion of such rate through payroll deduction. Procedures for
r implementing payroll deduction for your portion of such rate shall be the same as those utilized
for any Alternative Health Benefit Plan. If the Group does not have an Alternative Health
Benefit Plan, the procedures shall solely be those as agreed to, in writing, between Group and
HMHIC. The Group premiums for the coverage provided by HMHIC under this Agreement
os-c x9-92 16
AAe{idaNo q<D51`~ .
shall be detenuincd by the applicable rate than in effect and the number iPW;A ~eMs
monthly intervals established by HMHIC. This
- lee Group shall offer HMHIC to all Employees of Group on terms no less favorable with res '
to the Group contribution than those applicable to any Alternative Health Benefit Plan as may
be available through the Group. The Group contributions shall not be changed during the term
of this Agreement unless such change is prior approved, in writing,, by HMHIC. If, however,
the Group contributions to the Altemative Health Benefit Plan, as may be available through the
Group, is increased during the term of this Agreement, the Group agrees to also increase
contributions to HMI11C effective the first monthly payment due following such increase.
NOTIFICATION BY GROUP
Group shall forward completed Applications and any Evidence of Insurability form(s) to Harris
HMO for coverage under HMHIC within ten (10) business days of their receipt from Eligible
Persons. In the event Group fails to notify HMHIC of the ineligibility of any person for whom
the Group has made the monthly prepayment required pursuant to this Agreement, then, such
prepayment shall be credited to Group only if Hh1H1C h is not made arrangements for or paid
benefits for the ineligible person but in no event will prepayment be credited subsequent to thirty
(30) days after the date such person became ineligible.
P4S-C6A9-92 17
t
,endaNo
Cenoaiteml°?
CLAIMS INFORMATION
HOW TO FILE A CLAIM
You must send your medical bills to HMHIC. The claim office address can be found on the
back of your I.D. card. When you send your medical bills be sure to include your name,
address, and social security number.
Written notice of claim must be given to the insured within twenty (20) days after the occurrence
or commencement of any loss covered by the policy. Failure to give notice within such time
shall not invalidate or reduce any claim if it shall be shown not to have been reasonably possible
to give such notice and that notice was given as soon as was reasonably possible;
IIMHIC will furnish to the person making claim or to be policyholder for delivery to such
person such forms as are usually furnished by it for filing proof of loss. If such forms are not
furnished before the expiration of fifteen (15) days after the insurer received notice of any claim
under he policy, the person making such claims shall be deemed to have complied with the
requirements of the policy as to proof of loss upon submitting within the time frame fixed in the
policy for filing proof of loss, written proof covering the occurrence, character, and extent of
the loss for which claims is made.
No benefits will be paid for services rendered under the Harris HMO policy.
)IOW AND WHEN ARE CLAIMS PAID2
In the case of claim for loss, writtc % proof of such loss must be furnished to the insurer within
the ninety (90) days after the commencement of the period for which the insurer is liable.
Failure to furnish such proof within such time shall not invalidate or reduce any claim If it was
not reasonably possible to furnish such proof within such time, provided such proof is furnished
as soon as reasonably possible and in no event, except in the absence of legal capacity of the
claimant, later than one year form the time proof is otherwise required.
All benefits payable under the policy shall be payable not more than sixty (60) days after receipt
of proof.
HMHIC shall have the right and opportunity to examine the person of the individual for whom
claim Is made when and so often as it may reasonably require during the pendency of claim
under the policy and also the right and opportunity to make an autopsy in case of death where
I it is not prohibited by law.
a.
pos_ceR9-92 18
LM
A060a No_ 93 GS'f~
RAXYMNr To__ T Aged
MOO
The Group
policy shall provide payment to the Texas Department of Human Resources~or t
actual cost of medical expenses the department pays through medical assistance for a person
lnsired by the contract if the insured is entitled to payment for the medical expenses by the
insurance contract.
All benefits paid on behalf of the child or children under the policy must be paid to the Texas
Department of Human Services whenever:
• the Texas Department of Human Services is paying benefits under the Human Resources
Code, Chapter 3l, or Chapter 32, i.e., financial and medical assistance service programs
administered pursuant to the Human resources code; and
• the parent who is covered by the group policy has possession or access to the child
pursuant to a court order, or is not entitled to access or possession of the child and is
required by the court to pay child support.
QAL ACTION
No action at law or in equity shall be brought to recover on the policy prior to the expiration
of sixty (60) days after proof of loss has been filed in accordance with the requirements of the
policy and that no such action shall be brought at all unless brought within three years form the
expiration of the time within which proof of loss is required by the policy;
TIMir1.IMIT OF CERTAIN DFF Nct:S
Harris Methodist Health Insurance Company will not deny or reduce a claim because of a Pre.
Existing Condition If both of the following conditions are met:
• The claim is for a loss that happened or a disability str;ried after the insurance
coverage for that person has been In effect for the earlier of: (A) twelve (12)
months, with no treatment In connections with such pre-existing condition; or (8)
i vo (2) years, with any treatment for such pre-existing condition.
• The condition is not excluded from coverage by name or specific description.
POS-CER9-9T 19
agendahlo
Agendalletn~
COORDINA'CWN F~ItNF:HIfS hate
The Harris Methodist Health Insurance Company, Coordination of Benefit and Subrogation
Benefits provision applies to all of the benefits provided under this Agreement, excluding
services rendered under Harris HMO. The benefits provided by Harris Methodist Health
Insurance Company shall be coordinated with any group insurance plan or coverage under
governmental programs (excluding Medicaid), including Medicare, to assure that you receive
coverage while avoiding double recovery. It is, therefore, understood and agreed that should
you be covered by or under a Coordinated Plan in addition to coverage under this Agreement,
the provisions and rules as described in this Section shall determine whether HMHIC or the
Coordinated Plan is primarily responsible for paying the cost of benefits and services provided
to you.
• Services and benefits for military service connected disabilities for which you are
legally entitled and for which facilities are reasonably available, shall in all cases
be provided before the benefits of this Plan.
2EETIK 11 ONS
For purposes of this Section only, words and phrases shall have meaning as follows:
• ALLOWABLE EXPENSE shall mean any Usual and Customary expense of
which at least a portion is covered under this Plan covering you when a claim is
made. When a Coordinated Plan provided benefits in the form of services rather
than cash payments, the Usual and Customary cash value of each service provided
shall be deemed to bo both an Allowable Expense and a benefit paid.
• CLAIM DETERMINATION PERIOD shall mean a calendar year, but excluding
any portion of a calendar year occurring prior to the effective date.
• COORDINATED PLAN shall mean any of the following that provides benefits
or services for, or by reason of, medical care or treatment:
• Coverage under governmental programs, including Medicare
(excluding Medicaid), required or provided by any statute unless
coordination of benefits with any such program is forbidden by
law,
• Group coverage or any other arrangement of coverage for
individuals in a group, whether on an insured or uninsured basis,
Including any prepayment coverage, group practice basis or
Individual practice coverage and any coverage for students which
is sponsored by, or provided through, a school or other educational
Institution above the high school level, excluding Harris HMO.
E spy- BA9.92 20
s
4
vendaNo
DETERMINATION OF BENEFITS apendal3em ~a
.nte
This provision shall apply in determining the benefits payable for the Allowable Expenses
incurred by you during a Claim Determination Period. ~r1y~ ~41
The term Coordinated Plan shall be construes separately with respect to each policy, contract,
or other arrangement for benefits or services and separately with respect to that portion of any
such policy, contract, or other arrangement which reserves the right to take the benefits or
services of the other Coordinated Plans into consideration in determining its benefits and that
portion which does not.
Whenever the sum of the benefits that would be payable under this Agreement in the absence
of this provision, and the benefits that would be payable under all Coordinated Plans in the
absence thereof or amendments of similar purpose to this provision would exceed the Allowable
Expenses, then the following shall apply:
• The benefits that would be payable under this Agreement shall be reduced to the
extent necessary so that the sum of such reduced benefits and all the benefits
payable for such Allowable Expenses under e;l Coordinated Plan include the
benefits that would have been payable had claim been duly made therefor,
• If a Coordinated Plan would, according to its rules, determine its benefits after
the benefits payable under this Agreement have been determined, and the rules
as described below would require payment under this Agreement to be determined
before the Coordinated Plan, then the benefits of the Coordinated Plans shall not
be included for the purpose of determining the benefits under this Agreement.
ORDER OF BENEFIT DETERMINATIQN
The rules establishing the order of benefit determination shall be as follows.
• The benefits of a Coordinated Plan without a coordination of benefits provision
(or a non-duplication provision of similar intent) shall be determined before the
benefits of this Agreement.
• The benefits of a Coordinated Plan which covers you other than as a Dependent
shall be determined before the benefits of a Coordinated Plan which covers you
as a dependent.
• The benefits of a Coordinated Plan which covers you as a dependent child of a
person whose date of birth, excluding year of birth, occurs earlier in a calendar
year, shall be determined before the benefits of a Plan which covers you as a
dependent of a person whose date of birth, excluding year of birth, occurs later
in the calendar year. If a Coordinated Plan does not have the provisions of this
paragraph regarding dependents, which results either in each Coordinated Plan
determining its benefits before the other or in each Coordinated Plan determining
its benefits after the other, the provisions of this paragraph shall not apply, and
POS-CM-92 21
a
,9690 No
a~eo0allem `~°2
the rule set forth in the Coordinated Plan which does not have the 09#Avisions of_//~13
this paragraph shall determine the order of benefit determination unless the Legal
Separation or Divorce Section shall apply.
• If the rules provided above or the rules provided in the above section do not
establish an order of benefit determination, then the benefits of a Coordinated
Plan which covers you, when a claim is made, for the longest period of time shall
be determined before the benefits of a Coordinated Plan which covers you for the
shorter period of time except as follows:
• The benefits of a Coordinated Plan cover you as a laid-off part-
time or retired employee or as the dependent of such a person shall
be determined after the benefits of a Coordinated Plan covering
you as a covered member other than as a laid-off or retired
employee or dependent of such person.
• If a Coordinated Plan does not have a prowision regarding laid-off
or retired employees, and as a result, such Cwrdinated Plan
determines its benefits after the Coordinated Plan with this
provision, then the provision of the immediately preceding
paragraph shall not apply.
LEGAL SEPARATION OR DIVORCE
In the event of a legal separation or divorce, the following order of benefits determination shall
apply:
• If there is a court decree that establishes financial responsibility for the provision
of health insurance coverage for the child, the benefits of a Coordinated Plan
which covers the child as a dependent of the parent with such financial
responsibility shall be determined before the benefits or a Coordinated Plan which
covers the child as a dependent of the parent without such financial responsibility.
• In the event of a legal separation or divorce in which the court decree does not
establish financial responsibility for the health care expenses of the child then the
following shall apply:
• If the parent with custody of the child has not remarried, the
benefits of a Coordinated Plan which covers the child as a
dependent of the parent with custody of the child shall be
1 determined before the benefits of a Coordinated Plan which covers
that child as a dependent of the parent without custody.
• If the parent with custody of the child has remarried, the benefits
of a Coordinated Plan which covers the child as a dependent of the
paren! with custody shall be determined before the benefits of a
Coordinated Plan which covers that child as a dependent of the
M=CER9_9A 22
t
Agenda No.
Agendallem
stepparent; and the benefits of a Coordinated Plan whicafbovers
that child as a dependent of the stepparent shall be deterih '/7.77,
before the benefits of a Coordinatec Plan which covers that child Aye"?D
as a dependent of the parent without custody.
Thus, in the event of legal separation or divorce, unless a court decree specifies otherwise, the
order of benefit determination described above may be summarized as follows:
Separated or Divorced and not Remarried:
(1) Parent with Custody
(2) Parent without Custody
Separated or Divorced and Remarried
(1) Parent with custody
(2) Stepparent with custody
(3) Parent without custody
Medicare
For purposes of determining benefits provided for you, if you are eligible to enroll for
Medicare, but do not, HMHIC will assume the amount provided under Medicare to be the
amount you would have received if you had enrolled in it.
You are considered to be eligible for Medicare on the earliest date coverage under Medicare
could become effective for you. Except as described TEFRA, Medicare benefits will be
coordinated in accordance with the policy.
TEFRA Options for Groups with 20 or more Employees
If you are actively working, you and your covered spouse who are eligible for Medicare will
be permitted to choose one of the following options if you, the Employee are age 65 or older
and eligible for Medicare:
OPTION I - The service of the Group Agreement will be provided first and the
benefits of Medicare will be provided second.
OPTION 2 - Medicare benefits only. You and your Dependents, if any, will
not be covered by the Group Agreement.
The Group will provide you, the employee, with a choice to elect one of these options at least
one month before becoming age 65. All new Employees age 65 or older will be offered these
" options when hired. If Option 1 Is chosen, your rights under this Agreement will be subject to
the same requirements as for an Employee or Dependents who are under age 65.
POS-CER9-92 23
r
t
a
Agenda No There are two different categories of persons eligible for h1edicarAgegTTfengal ulat n ~
payment of benefits by this Agreement jirfers from each category, Wle.~_ -
Category I Medicare Eligible are:
1. Actively working covered Employees age 65 or older who choose
Option I:
2. Age 65 or older covered spouses of actively working employees
age 65 or older who choose Option 1;
3. Age 65 or older covered spouses of actively working covered
Employees who are under age 65;
4. Actively working covered Employees of groups with 100 or more
employees and their covered dependents who are entitled to
Medicare by reason of disability other than End Stage Renal
Disease (ESRD); and
5. Covered individuals entitled to Medicare solely on the basis of
ESRD during a period of up to IS months after the individual has
been determined eligible for ESRD benefits.
Category 2 Medicare Eligibly are:
1. Retired employees and their spouses;
2. Covered Employees of groups with less than 100 employees and
their covered Dependents who are entitled to Medicare by reason
of a disability other than ESRD; and
3. Covered individuals entitled to Medicare solely on the basis of
ESRD for more than 12 months after the Individual has been
determined eligible for ESRD benefits.
RIGHT TO RELEASE INFORMCM
For purposes of administering the provisions of this Section, HMHIC may, without further
consent of, or notice to you, release to or obtain from any health care plan, insurance company
or other person or organization, any Information with respect to you which it deems to be
reasonably necessary for such purposes, as to facilitate coordination of benefits, as permitted by
law. Wherk you receive services or claim benefits under this Agreement you shall furnish
14MHIC all Information deemed necessary by HMHIC to Implement this Section
(COOPDINATION AND SUBROGATION OF BENEFITS)
POS-CER9-92 24
sy
i
lgenda Mo 19 -e,' W
Agenda llem
FACILITY OF PAYMENT Idle/a3
i ao y
Whenever payment which should have been made by HMHIC in accordance with this s n
has been made by a Coordinated Plan, HMHIC shall have the right, exercisable alone and in
its sole discretion, to authorize payment to the Coordinated Plan making such payments any
amounts HMHIC shall determine to be warranted In order to satisfy the intent of this Section,
and amounts when so paid shall be deemed to be benefits under this Agreement, and, to the
extent of such payments, HMHIC shall be full discharged from liability
y under this Agreement.
BIGHT TO RECOVERY
Whenever payments have been made by HMHIC with respect to Allowable Expenses in total
amount which is, at any time, in excess of the maximum amount of payment necessary at the
dme to satisfy the intent of this CourtlinaVan of Benefits Section, HMHIC shall have the right
to recover such payments, to the extent of such excess, from one or more of the following, as
HMHIC shall determine: any person or persons to, or for, or with respect to whom such
payments were made, any insurance company or companies, and organization(s) to which such
payments were made.
DISCLOSURE
You agree to disclose to HMHIC at the time of enrollment, at the time of receipt of services and
benefits, and from time to time as requested by HMHIC, the existence of other health plan
coverage, the Identity of the carder, and the group through which such coverage is provided.
SUBROGATION
Subrogation seeks to shift the expense for injuries suffered by you to those responsible for
causing them.
In return for HMHIC providing benefits for injuries, ailments, or disease caused as a result of
the negligence, omission or willful act of a third party, you agree to execute any instrument
which may be required. You also agree to assign to HMHIC the right of recovery against such
third party to the extent of benefits paid. At the time such benefits are provided or thereafter
as HMHIC may request, you also agree to comply with the following provisions:
Execute a formal written injury report and assignment to HMHIC
of right to recover the actual benefits paid by MMIC under this
Agreement for Injuries, ailments and disease caused by a third
party.
E
Reimburse HMHIC for the actual benefits paid by HMHIC, but
not In excess of monetary damages collected, Immediately upon
receipt of any monies paid by or on behalf of such third party In
settlement of any claims arising out of injuries, ailmente and
diseases covered by ►IMIIIC. HMHIC shall have a lien on any
MztL R9-92 25
Dy~
Agenda No
actual recovery from such third party whether by aojpment,
settlement, compromise or reimbursement.
• Execute and deliver such papers and provide such reasonable help
(including authorizing bringing suit against such third party in your
name and making court appearances) as may be necessary to
enable HMHIC to recover the actual benefit pald by HMHIC.
it
POS-CEA9-92 26
gentfaNo ~ G'~41
~aenQa~tem 'tea
INDEPENDENT AGENTS nn
The relationship between HMHIC, and the Group is that of independent contracts g entities.
Neither the Group nor you is the agent or employee of HMHIC, and HMHIC is not the
employx or agent of the Group or you. Harris HMO and HMHIC are not representation of
each other.
POS-CEA9-92 27
9
r
Agenda No 9Y
Agenda
llent
GLOSSARY
(nese definitions apply when the following terms are used in this Certificate and the attached
Schedule of Benefits.)
ACTIVELY AT WORK
Actively at work shall mean that the eligible employee must be performing the usual and
customary duties of your regular employment during your usual working hours on your effective
date of coverage; provided, however that if you are absent from work due to vacation, holiday,
jury duty, or other similar circumstances, not mused by injury or illness, you shall be
considered actively at work.
AGREEMENT
Agreement shall mean Entire Contract which is defined as the Group Contract, Certificate of
Coverage, Group Enrollment Agreement, Schedule of Benefits, Applications, Attachments, .
Riders, Amendments hereto, if any. Agreement shall constitute the entire contract between the
parties and that in the absence of fraud all statements made the policyholder or person insured
shall be deemed representations and not warranties, and that no such statement shall be used in
any contest under the policy, unless a copy of the written instrument contldning the statement
is not has been furnished to such person or in the event of death or incapacity of the insured
person to the individual's beneficiary or personal representative.
AL'T'ERNATE HEALTH BENEFIT PLAN
Alternate Health Benefit Plai shall mean the plan which the Group designates as the alternative
to this Agreement.
ALLIED HEALTH PROFESSIONAL
Allied Health Professiornl shall mean any health care provider/physician that provides benefits
as set forth in this Agreemen, •nd described in the Schedule of Benefits Attachment.
AMBULATORY SURGICAL CENTER
A specialized facility which Is established, operated and staffed primarily for the purpose of
performing surgical procedures and which fully meets one of the following two tests;
• it Is licensed as an ambulatory surgical center by the regulatory authority having
responsibility for the licensing under the laws of the jurisdiction in which it is located,
POS-cER9-92 28
~I
~entia No y'f/
• Where licensing is not required, it meets all of the followiD5fB_$i - nts~
• it is operated under the supervision of a licensed doctor of Med/ea
(M.D.) or a doctor of osteopathy (D.O.) who is devoted full time to ~IJJ
supervision and permits a surgical procedure to be performed only by a
duly qualified physician who, at the time the procedure is performed, is
privileged to perform the procedure in at least one'Hospital in the area.
• It requires in all cases, except those requiring only local infiltration
anesthetics, that a licensed anesthesiologist administer the anesthetic or
supervise an anesthetist who i.s administering the anesthetic and that the
anesthesiologist or anesthetist remain present throughout the surgical
procedure.
• It provides at least one operating room and at least one post-anesthesia
recovery room.
• It is equipped to perform d'dgnostic X-ray and laboratory examinations or
has arrangement to obtain these services.
• sit as nrained personnel and necessary equipment to handle emergency
• It has immediate access to a blood bank or blood supplies.
• It provides the full time services of one or more registered graduate nurses
(R.N.) for patient care in the operating rooms and in the post-anesthesia
recovery room,
• It maintains an adequate medical record for each patient, the record to
contain an admitting diagnosis including for all patients except those
undergoing a procedure under local anesthesia, a pre-operative
examination report, medical history and laboratory tests and/or X-rays, an
operative report, and a discharge suo rnary.
$tR~nITEF.
I
A specialized facility which is primarily a place for delivery of children following a normal
uncomplicated pregnancy and which fully meets one of the following two tests:
1 • It is licensed by the regulatory authority having responsibility for the licensing
under the laws of the jurisdiction in which it is to zted.
• It meets all of the following requirements:
• It is operated and equipped In accordance with any applicable state
laws.
ros- xA9_o,
29
(
AgendaNo._
o It is equipped to p--rform routine diagnosu4. and I Ar
examinations such as hematocrit and urinal sis for a3-93
protein, bacteria, and specific gravity.
e It has available to handle foreseeable emergencies, trained
personnel and necessary equipment, including but not limited to
oxygen, positive pressure mask, suction, intravenous equipment,
equipment for maintaining infant temperature and ventilation, and
blood expanders.
O It is opeiated under the full supervision of a licensed doctor of
medicine (M.D.) or registered graduate nurse (R.N.).
0 It maintains a written agreement with at least one Hospital in the
area for immediate acceptance of patients who develop
complications.
0 It maintains an adequate medical record for each patient, the
record to contain prenatal history, prenatal examination, any
laboratory or diagnostic tests and a postpartum summary.
It is expected to discharge or transfer patients within 24 hours
following delivery.
R
CALENDAR-YEA
A period of one year beginning with January 1.
CHEMICAL DEPENDENCY TREATMENT CENTER
Chemical Dependency Treatment Center shall mean a facility which provides a program for the
treatment of chemical dependency pursuant to a written treatment plan approved and monitored
by a physician and which facility is also:
(1) affiliated with a hospital under a contractual agreement with an established system for
patient referral; or
(2) accredited as such a facility by the Joint commission on Accreditation of HospiWs; or
(3) licensed as a chemical dependency treatment program by the Texas Commission on
Alcohol and Drug Abuse; or
(4) licensedf, certified, or approved as a chemical dependency treatment program or center
by any other state agency having legal authority to so license, certify, or approve.
LQMPLICATIONS OF PREGNANCY
Complications of Pregnancy is defined as: conditions, requiring hospital confinement (when the
pregnancy is not terminated), whose diagnosis are distinct from pregnancy but are adversely
affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac
POS-CER9-92 30
III
i
+gen(laNo -e24'
AgendaIlerr?
decompression, missed abortion, and similar medical and surgical cffl4itions of comparable//,~31yy
severity, but shall not include falsa labor, occasional spotting, physician prescnbea res
the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia, and similar
conditions associated with the management of a difficult pregnancy not constituting a v
nosologically distinct complication of pregnancy-, and non-elective cesarean section, termination
of ectopic pregnancy, and spontaneous termination of pregnancy, occurring during a period of
gestation in which a viable birth is not possible.
CONTRACT YEAR
Contract year shall mean the period of twelve (12) months commencing on the Group effective
date and each twelve (12) month period thereafter, unless terminated.
COORDINATED POLICY
Coordinated Plan shall mean any of the following that provides benefits or services for, or by
reason of, medical care or treatment:
Coverage under governmental programs, (excludin; Medicaid) including Medicare,
required it provided by any statute unless coordination of benefits with any such,
programs is forbidden by law.
Group coverage or any other arrangement of coverage for individuals in a group,
whether on an insured or uninsured basis, including any prepayment coverage, group
practice basis or individual practice coverage and any coverage for students which is
sponsored by, or provided through, a school or other educational institution above the
high school level.
CQUBSE OF TREATMENT
Course of Treatment shall mean that period of time represented by an inpatient hospital
admission and related discharge during which time treatment has been received by you or your
dependents or that period of time authorized by HMHIC as necessary to complete a cycle of
treatment and subsequently provide a medical release to you or your dependents.
COVERED EXPENS
Covered Expenses shall mean the services and supplies, detailed in the Schedule of Benefits
Attachment, for which a payment is made.
COVERED FAMILY MEMBERS
You and your wife or husband and Dependent children who are covered under the Agreement.
POS 9ER9-92 31
i
Genoa Nu __._.~i.11fS!
aenca~lem ~.2 II
CRISIS STABILIZATION t NIT ISIYCI~4
Crisis Stabilization Unit shall mean a twenty-four (24) hour residential program that is usually
short-term in nature and that provides intensive supervision and highly structured activities to
persons who are demonstrating an acute demonstrable psychiatric crisis of moderate to severe
proportions.
CUSTODIAL CAR)
Custodial Care shall mean 1), that care which is marked by or given to watching and protecting
rather that seeking cure; or 2). care which is not a necessary part of medical treatment or
recovery; or 3). care comprised of services and supplies that are primarily provided to assist in
the activities of daily living.
DAY TREATMENT ENTER
A psychiatric day treatment facility shall mean a mental health facility which provides treatment
for individuals suffering from acute, mental and nervous disorders in a structured psychiatric
program utilizing individualized treatment plans with specific attainable goals and objectives
appropriate both to the patient and the treatment modality of the program and that is clinically
supervised by a doctor of medicine who is certified in psychiatry by the American Board of
Psychiatry and Neurology.
Day treatment facility may provide coverage for not more than eight hours in a twenty-four (24)
hour period, the attending physician certifies that such treatment is in lieu of hospitalization, and
the psychiatric treatment facility is accredited by the Program for psychiatric Facilities, or its
successor, of the Joints Commission on Accreditation of Hospitals.
Each full day of treatment in a psychiatric day treatment facility shall be considered equal to
one-half of one day of treatment of mental or emotional illness or disorder in a hospha:.
DEPENDENT
Dependent shall mean an Eligible Dependent who has satisfied the eligibility and participation
requirements specified in this Agreement.
MMICILIAR) CARE
Domiciliary Care shall mean that care provided in the home, custodial in nature, for persons so
disabled or inform as to be unable to live independently.
DURABLE MEDICAL EQUIME.NT
Durable Medical Equipment must be able to withstand repeated use, primarily and customarily
os-cs 95z 32
AgendaNo 93-o yd
A enda llem W
serve a medical purpose, generally not be used in the absence Qfip4lncss or injury, rS uire a
Physician's order and be appropriate for use in the home.
EFFECTIVE DATE D
Effective Date shall mean the effective date of coverage for you and your Eligible Dependents
pursuant to the terms of this Agreement.
ELIGIBLE DEPENDENT
Eligible Dependent shall mean an individual as defined in the ELIGIBILITY AND EFFECTIVE
DATE Section of this Agreement.
ELIGIBLE PERSON
Eligible Person shall mean an individual as defined in the ELIGIBILITY AND EFFECTIVE
DATE Section of this Agreement.
FNIERGENCY CARE
Emergency care shall mean bona fide emergency services provided after the sudden onset of a
medical condition manifesting itself by acute symptoms of sufficient severity, Including severe
pain, such that the absence of immediate medical allendon could reasonably be expected to result
in placing the patient's health in serious jeopardy; serious impairment or bodily functions; or
serious dysfunction to any bodily organ or part.
EMPLOYEE
See ELIGIBILITY AND EFFECTIVE DATE Section.
POS-CER9-92 33
I
~gendaNo 9.9 -0~15~
Agenda Iterr Aa
EVIDENCE OF INSURABILITY Date_.,(l a,5 ~
Evidence of Insurability shall meant the documentation of health status as required by HIC
for Eligible Persons and Eligible Dependents who do NOT meet the following requirements
regarding application for coverage: (a) apply for coverage during an open enrollment period; or
(b) apply for coverage within thirty (30) days of qualifying for coverage. Such information shall
be reviewed by HMHIC. Notification will be sent to the Eligible Person or Eligible Dependents
regarding their eligibility for participation in HMHIC.
EXCLUSION
Exclusion shall mean those specific conditions or causes for which coverage by HMHIC is
entirely excluded.
FAMILY DEDUCTIBLE
The maximum your entire family will have to pay for Deductible in any year is the amount of
Family Deductible shown in Schedule of Benefits. This Family Deductible applies no matter
how large your family may be. Only Covered Expenses which count toward a person's
Individual Deductible count toward this Deductible.
FDA
FDA shall mean the Food and Drug Administration, an agency of the United States Government.
GROUP
Group shall mean collectively the contracting Group and all affiliated organizations of the
Group, to which this Agreement is issued and through which as an agent for you and your
dependents become entitled to the benefits as set forth in the Schedule of Benefits.
GROUP EFFECTIVE DATE
Group Effective Date shall mean the date specified as such in the Group Enrollment Agreement.
COUP ENROLLMENT AGREEMENT
Group Enrollment Agreement shall mean that agreement which is executed between HMHIC and
the Group for the purpose of making available to Eligible Persons and Eligible Dependents of
the Group those benefits which are described in the Certificate of Insurance. Such Group
Enrollment Agreement shall identify the Group, Group Effective Dale, eligibility requirements,
rates, and covered benefits.
POs_ccit9_92 34
WdaNo eX9 -o!;441.
aendaItem ~
arK d - -3
HARRIS HMO
Harris HMO shall mean Harris Health Plan, Inc., a Texas not-for-profit corporation organized
as a Health Maintenance Organization (HMO) and licensed by the Texas Department of
Insurance.
HEALTH CARE PROVIDER/PHYSICIAN
A licensed or certified provider whose services Harris Methodist Health Insurance Company
must cover due to a state law requiring payment of services given within the scope of that
provider's license or certification.
A Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health
Agency, Laboratory, Dietitian, Minor Emergency Room Center, Chemical Dependency
Treatment Center, Psychiatric Day Treatment facility, Crisis Stabilization or Residential
Treatment Facility or other provider or entity which provides services as set forth in this
Agreement as described in 0,i Schedule of Benefits Attachment.
HOME HEALTH AGENCY
An agency or organization which provides a program of home healt.i care and which fully meets
one of the following tests:
• it is approved by Medicare.
0 It is established and operated in accordance with the applicable licensing and
other laws.
• It meets the following tests:
♦ It has the primary purpose of providing a home health care
delivery system bringing supportive services to the home.
♦ It has a full-time administrator
♦ It maintains written records of services provided to the patient.
♦ Its staff includes at least one registered graduate nurse (R.N.) or
it has nursing care by a registered graduate nurse (R.N.) available.
♦ Its employees are bonded and it provides malpractice insurance.
I
c.
QOS-CER9-92 35
.f
Sy
Veda No ?.3_- D Spy
p9endaltem !Q
HOSPICE Oate_._ 11_9.
la fril
An agency that provides counseling and incidental medical services for a terminy ill
individual. Room and board may be provided. The agency must meet all of the following tests:
• It is approved under any required state or governmental Certificate of Need.
• It provides 24 hour-a-day, 7 day-a-week service
• It has a nurse coordinator who is a registered graduate nurse (R.N.) with four
years of full-time clinical experience. Two of these years must involve caring for
terminally ill patients.
0 It has a social-service coordinator who is licensed in the area in which it is
located.
• The main purpose of the agency is to provide Hospice services.
• It has a full-time administrator.
• It maintains written record of services given to the patient.
• Its employees are bonded.
• It provides malpractice and malplacement insurance.
0 It is established and operated in accordance with any applicable state laws.
HOSPITA!
Hospital shall mean an institution licensed by the State of Texas and which is (L) primarily
engaged in providing diagnostic, medical, surgical, or mental health facilities for the care and
treatment of injured or sick persons, (2.) operated under the medical supervision of a staff of
legally qualified and licensed physicians, (3.) provides twenty-four (24) hour-a-day nursing
service by or under the direct supervision of a Registered Nurse (R.N.), (4.) provides for
overnight care of patients, (5.) maintaining clerical and ancillary services necessary for the
treatment of medical and surgical patients including but not limited to laboratory, X-ray, dietary
and medical records library. In no event shall the term "hospital" include a convalescent nursing
home or any institution or part thereof which is used principally as a convalescent facility, rest
facility, nursing facility, facility for the aged, extended care facility, intermediate care facility,
skilled nursing facility or facility primarily for rehabilitative services; the term hospital shall
pursuant to Chapter 3, Texas Insurance Code, Article 5.72 included treatment in a residential
treatment center for children and adolescents, treatment provided by a crisis stabilization unit,
psychiatric day treatment, or chemical dependency unit.
eos-ceR9-92 36
I
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IDEN,rIFICATION CARD o
A card that generally describes the benefits of a Plan, that in and of itself confers no nghiss
services or other benefits. The card is the sole property of HMHIC, and HMHIC reserves e
right of possession.
INDIVIDUAL DEDUCTIBLE
The Individual Deductible applies to all covered expenses. The amount of the Individual
Deductible is shown in Schedule of Benefits.
MAMMOGRAPHY. LOW-DOSE
Low Dose Mammography shall mean the X-Ray examination of the breast using equipment
dedicated specifically for mammography, including the x-ray tube, filter, compression device,
screens, films, and cassettes, with an average radiation exposure delivery of less than one rad
midbreast, with two views for each breast. Coverage for 35 year old females or older for an
annual screening for the presence of occult breast cancer subject to the same dollar limits,
deductibles, and co-insurance factors.
MEDICAL EMERGENCY
Medical Emergency shall mean a medical condition so classified by the medical director and
which manifests itself by acute symptoms of sufficient severity (including severe pain) such that
the absence of immediate medical attention could reasonably be expected to result in (a) placing
the patient's health in serious jeopardy; or (b) serious impairment of bodily function; or (c)
serious dysfunction to any bodily organ or part. Examples of conditions which do not usually
constitute medical emergencies are colds, influenzas, ordinary sprains, children's ear infections,
or nausea and headaches. Heart attacks, cardiovascular accidents, poisoning, loss of
consciousness or respiration, convulsions, severe bleeding or broken bones are examples of true
medical emergencies.
MEDICALLY NECESSARY
Shall mean services or supplies which are (l.) provided for the diagnostic care and treatment of
a medical condition; (2.) appropriate and necessary for the symptoms, diagnosis or treatment of
a medical condition; (3.) generally acceptable medical practice; (4.) performed in the most cost
effective and efficient manner appropriate to treat you or your Eligible Dependent's medical
condition; and (5.) provided in accordance with accepted medical standards.
POS-CER9-92 37
AgendaNo _2,3 -off _
4gendaltern
MEDICARE tg ~3 - 9
Medicare shall mean Part A and Part B of Title XVIII of the Social Security Act and any
amendments or regulations thereunder.
ME AL OR NERVOUS DISORDER
Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder
of any kind. ( See SERIOUS MENTAL ILLNESS for definition of Serious Mertal Illness. j
NO-FAULT AUTOMOBILE INSURANCE LAW
The basic reparations provision of a !aw providing for payment without determining fault in
connection with automobile accidents.
NURSE-PRACTITIONER
A person who is licensed or certified to practice as a nurse-practitioner and fulfills both of these
requirements:
• A person licensed by a board of nursing as a registered nurse.
• A person who has completed a program approved by the state for the preparation
of nurse-practitioners.
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POS-CER9-92 38
vevaNo -04/
agentlailem a r
OPEN ENROLLMENT PERIOD 01te_
Open enrollment shall mean a period of at least thirty (30) days during each twelve r)
consecutive months when Eligible Persons may elect to change from the Alternative Health
Benefit Plan to HMHIC or from HMHIC to the Alternative Health Benefit Plan.
OTHER SERVICES AND SUPPLIES
Services and supplies furnished to the individual and required for treatment, other than the
professional services of any Physician and any private duty or special nursing services (including
intensive nursing care by whatever name called).
ICIAN!HEALTH CAR
1?HYS E PROVIDER
A licensed or certified provider whose services Harris Methodist Health Insurance Company
must cover due to a state law requiring payment of services given within the scope of that
provider's license or certification.
A Provider shall inean any Physician, Hospital, Allied Health Professional, Home Health
Agency, Laboratory, Dietitian, Minor Emergency Room Center, Chemical Dependency
Treatment Center, Psychiatric Day Treatment facility, Crisis Stabdiucon Unit, or Residential
Treatment Facility or other provider or entity which provides services as set forth in this
Agreement as described in the Schedule of Benefits Attachment.
PRE-EXISTfNG CONDITION
Pre-existing Condition shall mean a physical condition diagnosed or treated within six months
prior to the effective date of coverage. Please see ELIGIBILITY AND EFFEC" IVE DATE
Section.
PROVIDERS
Provider shall mean any Physician, Hospital, Allied Health Professional, Home Health Agency,
Laboratory, Minor Emergency Room Center, Residential Treatment Center for childrei and
adolescents, Crisis stabilization Unit, Chemical Dependency Unit, Psychiatric Day Treatment
facility or other provider or entity which provides services as set forth in this Agreement an
described in the Schedule of Benefits Attachment.
1
r.
POS-CEP9-92 39
i
REASONABLE CHARGE aBendalce ~`Z
Dale
An amount measured and determined by Harris Methodist Health Insurance Company
comparing the actual charges for the service or supply with the prevailing charges made ftri'
Harris Methodist Health Insurance Company determines the prevailing charge. It takes into
account all pertinent factors including:
• The complexity of the service.
• The range of services provided.
• The prevailing charge level in the geographic area where the provider is located
and other geographic areas having similar medical cost experience,
RESIDENTIAL TREATMENT CENTER
Residential Treatment Center for Children and Adolescents means a child-care institution that
provides residential care and treatment for emotionally disturbed children and adolescents and
that is accredited as a residential treatment center by the Council on Accreditation, the Joint
Commission on Accreditation of Hospitals, or the American Association of Psychiatric Services
for Children.
BOOM AND BOARD
Room, board, general duty nursing, intensive care by whatever name called, and any other
service regularly furnished by the hospital as a condition of occupancy of the class of
accommodations occupied, but not including professional services of Physician nor special
nursing services rendered outside of an intensive care unit by whatever name called.
SICKNES
The term "sickness" will include a surgical procedure for sterilization and related medical care
and treatment and confinement within 30 consecutive days from the procedure.
The term "sickness" will include complications of pregnancy as defined above.
The term "sickness" used in connection with newborn children will include congenital defects
and birth abnormalities, including premature births.
SKE.LED NURSING FACILITY
If the facility is approved by Medicare as a Skilled Nursing Facility then it is covered by this
Agreement.
If not approved by Medicare, the facility may be covered if it meets the following tests:
p
R9_92
40
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• It is operated under the applicable licensing and other laws. AQABijal~p --.h..
• It is under the supervision of a licensed Physician or registered ale ua -11-`g -e 9
(R.N.) who is devoting full time to supervision. j~t~~ l aa~
• It is regularly engaged in providing room and board and continuously provides
24 hour a day skilled nursing care of sick and injured person's at the patient's
expense during convalescent stage of an injury or sickness.
• It maintains a daily medical record of each patient who is under the care of a duly
licensed Physician.
• It is authorized to administer medical ons to patients on the order of a duly
licensed Physician.
• It is not, other than incidentally, a home for the aged, the blind or the deaf, a
hotel, a domiciliary care home, a maternity home, or a home for alcoholics or
drug addicts or the mentally ill.
19T L D~SA81i iTY
Total Disability and totally disabled shall mean (1) with respect to an employee or other primary
insured under the policy, the complete inability of the person to perform all of the substantial
and material duties and function of his or her occupation and any other gainful occupation in
wHch such person earns substantially the same compensation earned prior to disability, and (2)
with respect to any other person/dependent under the policy, confinement as a bed patient in a
hospital.
11. ZAT1o~V1E~r DEPARTMEY~
Utilization Review Department shall mean a department of HM141C which determines, in its
discretion, if a service or supply is medically necessary for diagnosis or treatment of an
accidental injury, illness or pregnancy. A service or supply is not medically necessary if a less
intensive or more appropriate diagnostic or treatment alternative could be used in lieu of the
services or supply given.
1
O9-CER9-92 41
i
a,~r ~tlANU
TERM1I AN,[) i
T RM - 1M11-NUMENTOf
This Agreement shall remain in effect for the first Contract Year and thereafter for successive
Contract Years unless sooner terminated as provided in Section TERMINATION of this
Agreement.
AMENDMENT
• HMHIC and Group may mutually alter or revise the terms of this Agreement
and/or Schedule of Benefits and Riders hereto. In the event of such alteration or
revision, HMHIC shall provide Group with at least sixty (60) days written notice
before effective date of Amendment. Such notice shall be considerel to have
been provided when mailed to the Group at the latest date shown on iP. records
of HMHIC.
• The Agrrxment may be amended at any time, according to any provisions of this
Agreement or by written agreement between HMHIC and Group, without consent
of you, or any other person having a beneficial interest in it. Any such
amendment shall be without prejudice to any claim arising prior to the effective
date of such amendment.
CHANGE OF RA'LU
HMHIC shall have the right to change the rates and premiums payable hereunder (i) as of any
Annil,ersary Date (in which case the Group shall be notified at least sixty (60) days prior to a
change in rates) or (ii) in accordance with Section TERM AND AMENDMENT OF
AGREEMENT of this Agreement.
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OS-CE 9{x-92 42
AGandaNo._
"ULANEOUS PROVISIONS 49 endall9m
K
(hte~//-~.~ 93
1J$E OF WORDS 14~611
Words used in the masculine shall apply to the feminine where applicable, and, wherever the
context of this Agreement dictates, the plural shall be read as the singular and the singular as
the plural. The terms "you% "your", and "insured" shall refer to the employee. "HMHIC" and
"insurer" shall refer to Harris Methodist Health Insurance Company. The words "hereof",
"herein", "hereunder" and other similar compounds of the word "here" shall mean and refer to
the entire Agreement and not to any particular Section or provision. All references to Sections
and provisions shall mean and refer to Sections and provisions contained in this Agreement
unless otherwise indicated.
RECORDS AND INFORMATION
HMHIC shall, to the extent legally allowable and w$thout further consent of or notice to you,
release to or obtain from any insurance company or other organization or person any
information, with respect to you, which HMI-11C deems to be necessary for such purposes as
Coordination of Benefits. When claiming benefits, you shall furnish HMHIC information as
may be necessary to implement this Agreement.
INFORMATION FROM GROUP
Group shall periodically forward the information required by HMHIC in conjunction with the
administration of the Agreement. All records of Group which have a bearing on the coverage
shall be open for inspection by HMHIC at any reasonable time. HA!H1C shall not be liable for
the fulfillment of any obligation dependent upon such information prior to its receipt in a form
satisfactory to HMHIC. Incorrect information furr+i,hcd may be corrected, if HMHIC shall not
have acted to its prejudice by relying on it. HMHIC shall have the right, at reasonable times,
to examine Group's records, including payroll records of the Group having employees covered
through this Agreement, with respect to eligibi,~ ty and monthly premiums under this Agreement,
ASSIGNMENT
Assignment shall mean the authorization to pay benefits directly to the party providing the
benefit. This may not be construed to:
(1) provide a coverage or benefit not otherwise available under the health insurance policy;
t
(2) allow assignment of a benefit of a benefit payment to a person who is not legally entitled
to receive such a direct payment; or
r (3) prohibit an insurer from verifying through the insurer's normal process the health care
services provided to the covered person by the physician or health care provider.
POS-CER9-92 43
4gendaNo 1/3 -ZI
Agendallem~ -Pecl~
If a written assignment of benefits payable for health care services is made late covered person //-a~-`J3
and is obtained by or delivered to the insured with the claim for benefits, the benefit payment ,a0
shall be made by the insurer directly to the physician or other health care provider. /d'J
If a written assignment of benefits is made and delivered or obtained as provided, the insurer
is relieved of the obligation to pay and of any liability for paying the benefits for the health care
services to the covered person.
The payment of benefits under an assignment does not relieved the covered person of any
contractual responsibility for the payment of deductibles and copayments. A physician or other
health care provider may not waive copayments or deductibles by acceptance of an assignment.
AUTHORITY
Any alterations or revisions to this Agreement shall not be valid unless evidenced by a written
amendment which has been signed by Group and by an officer of HMHIC and attached to the
affected document. No other person has the authority to change this Agreement or to waive any
of its provisions.
GOVERNING LAW
This Agreement is executed and 6 to be performed in all respects in accordance with all federal
and Texas state laws applicable to Health Insurance Companies and all other applicable Texas
state laws or regulations.
INCORPORATION SY REFERENCE
The Schedule of Benefits, Group Enrollment Applications, any optional Riders, any
Attachments, and any amendments to any other forgoing, form a part of this Agreement as if
fully incorporated herein. Any direct conflict or ambiguity of this Agreement shall be resolved
under terms most favorable to you.
ENTIRE AGREEMENT
Agreement shall mean Entire Contract which is defined as the Group Contract, Certificate of
Coverage, Group Enrollment Agreement, Schedule of Eknefi,.a, Applications, Attachments,
Riders, Amendments hereto, if any. Agreement shall constitute the entire contract between the
parties and that in the absence of fraud all statements made the policyholder or person insured
shall be deemed representations and not warranties, and that no such statement shall be used in
any contest under the policy, unless a copy of the written instrument containing the statement
is nor has been furnished to such person or in the event of death or incapacity of the insured
person to the individual's beneficiary or personal representative.
pOS_cen9 44
Q9t1~3NU
~gendalle%....~'` 2
-~x1(t ^/1~~ ~ ~
t D
SCHEDULE OF BENEFITS
Preferred PLUS
HARRIS METHODIST HEALTH INSURANCE COMPANY
1300 Summit Avenue, Suite 300
Fort Worth. Texas 76102
1.8001633.8598
(817) 878.5826
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POS-SCH9-92
L OBTAINING HEALTH CARE SERVICES -
.
You and your Eligible Dependents are entitled to receive the services and benefits se f shin this
Schedule of Benefits which are Medically Necessary and obtained in accordance with the provisions of
the Group Health Care Agreement/Subscriber Certificate of Coverage and/or Certificale of Insurance.
A. The Utilization Review Department determines the Medical Necessity of services. You are
responsible for notifying the Utilization Review Department (UR) for the services listed below.
The UR phone number is (817) 878.5828 or 1 (800) 375.1789. Benefits which are not
Medically Necessary will be denied. The ultimate decision on your medical care must be made
by you and your Physician. The Utilization Review Department only determines the Medical
Necessity of a service, only services medically necessary are paid for according to the r
Agreement benefits and provisions.
Benefits are reduced if you do not call UR prior to receiving services as required. The penalty for
not calling UR Is a 50% reduction in benefit paymenL The penalty is applied to each confine-
ment, surgical procedure, diagnostic procedure, or treatment plan. I
Within five (5) working days before receiving the following services, you are required to call UR
for authorization:
I
• Inpatient Admissions (including pregnancy)
• Outpatient surgery where the procedure requires an operating room or surgical set-
ting (excepption: endoscopes, sterilization, and biopsles).
Inpatient Chemlcal Dependency Treatment
Home IV Therapy
Physical Therapy and Occupational Therapy beyond six (6) visits
Durable Medical Equipment/Prosthetics
Home Nursing Services
Hearing Aids, if coverage Is Included
Skilled Nursing Facility
Outpatient Mental/Nervous disorder
Other office procedures requiring precertification are:
Laser procedures, Thatllum stress tests, Cystoscoptes, Chorionicylilt sampling,
Amniocentesis, LEEP/LETZ procedures, and D&C
• Arterlogram, Aortogram, Myelogram, and Lumbar Puncture.
8. Benefits which are covered under Harris HMO are not covered expenses under HMHiC. No
Coordination of Benefits are available between Harris HMO and HMHIC benefits. Emergency Care
which does not meet Harris HMO's definition will be covered under HMHIC. To receive HMO ben-
efits for ER services the condition must conform to the following definition, and if time permits
you must notiN your Primary Care Physician prior to receiving benefits, Harris HMO's definition
of Emergency Care shall mean bona fide emergency services provided after the sudden onset of a
medical condition manifesting itself by acute symptoms of sufficient severity, including severe
pain that the absence of immediate medical attention could reasonably be expected to result in
(f) placing the patient's health in serious jeopardy; (2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part. If an Emergency Care situation exist follow
the procedure outlined in Harris HMO policy.
POS-SCH9.92 2
arnnatvo ~~~-o~~
' C. You must submit your own claim forms for all medical bills for servl61 t it@lti~rrer~ A
The claim office address is P.O. Box 901054, Fort Worth, Texas 76101.2054. Benefit, s
on the Reasonable and Customary charges as established by HMHIC. The Dene its w1 ITrP`S" in
accordance with claims provisions outlined in the Certificate of Coverage document, An explana-
tion of benefits (EO8) summary will be sent which explains the amount of benefits paid as well as
the amount of payment which is your responsibility. / 7~1 ~j!aG7
0. All services and benefits are subject to any slated Copayment amounts, limitations, and exclu-
sions described in this Schedule of Benefits.
E. Any copayment expressed as a percentage of "Total Charges" or flat amount shall mean that por-
tion of the Reasonable and Customary charges as established by HMHIC.
F. This Schedule of Benefits may be supplemented by additional benefit Riders if included with this
Group Health Care Agreement/Subscriber Certificate of Coverage, and/or Certificate of Insurance.
0. The relationship between HMHIC and Group is that of independent contracting entities. Providers
are not agents or employees of HMHIC nor is HMHIC an employee or agent of any Provider.
Providers shall maintain the physician-patient or professional-patient relationship with you and
shall be the only parties responsible to you for the services provided, Neither HMHIC or any
employee of HMHIC shall be deemed to be engaged in the practice of medicine, HMHIC shall In
no way supervise the practice of medicine by any Provider, nor shall HMHIC in any manner
supervise, regulate or interfere with the usual professional relationships between a Provider and
you.
H. The following Calendar Year Deductible must be satisfied in full (100%) for all benefits and fid-
ers from January 1 through December 31.
Maximum Calendar Yes, Deductible
Per Member $500.00
Per Family $1,500.00
1. Any services which are limited in either daily limits or dollar maximums under Harris HMO policy
' will also be counted towards HMHIC's daily limit or doliar maximum,
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POSSCH9.92 3
aer.~dllPm
It. PHYSICIAN SERVICES
/ -_l
The Calendar Year Deductible must be satisfied in full (140%) for all benefits and rider from January 1'
through December 31.
Only one Copayment will be required for covered services performed or furnished on same date of ser-
vice by the same provider, This Copayment will be the higher of all listed Copayments,
Benefits Required Copaymeni
Physician office visits $20.00 per visit
Adult health assessments, routine physical examinations, 50% of Total Charges
well child care, and health education for diagnosis,
care and treatment of illness or injury provided by a Physician
Annual well woman examination 50% of Total Charges
Physi:ian office visits after hours $25.00 per visit
Immunizations 50% of Total Charges
Home visits $20.00 per visit
Allergy diagnosis and/or testing; serum Is not covered $75.00 per visit
Administered drugs, medications, dressings, splints, and $20.00 per visit
casts
Diagnostic services, laboratory tests, and x-rays 30% 01 Total Charges
(including low-Dose Mammography, will be covered as
other x-rays)
Ultrasound, MRI, CAT, and non-routine laboratory tests $100,00 per test
Surgery and/or anesthesia performed in the physician's office $100,00 per procedure
or outpatient setting
POS-SCH9.92 4
i
All physician fees including anesthesia while a member is t~p!g4f Total. fh~ro_s
hospitalized, except professional radiology and pathology fees
Professional radiology and pathology fees 30% of Total Chargesf /
(Including low-Dose Mammography, will be covered as / 7a ~y a° V
other x-rays, one examination per year for females D
age 35 and older)
' For maternity services, Covered Person shall be entitled to receive medical, surgical, and hospital care
from Physicians and other Providers during the term of the pregnancy, upon delivery, and during the
postpartum period for normal delivery; for abortion and miscarriages; and for complications of preg-
nancy. Charges related to medical services connected with the home delivery of a newborn and services
of mid-wives, unless provided as Emergency Care Services, will not be covered. Benefits for the child of
an unmarried Dependent covered person will be provided if maternity benefits are provided to the
dependent mother. The child of an unmarried dependent will be considered an eligible dependent of the
Subscriber if child is considered a dependent for Federal income tax purposes, and upon p,./ment of the
applicable premium.
Benefits Required Copsyment
Physician services for maternity care including delivery, 30% of Total Charges
hospital visits, and anesthesia
I, Physician care in the hospital for care of Eligible Newborn 30% of Total Charges
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department Inpatient admission to any health care facility
must always be precerlilied. See Item "A" under "Obtaining Health Care Services" for the
complete tion.Failure to call Utilization Review as directed will res9ltl in a fifty percent (50%) reduction
}
in benefit payment penalty.
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POS•SCH9-92
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_ III. HOSPITAL SERVICES
The Calendar Year Deductible must be satisfied in full (100°/x) for all benefits and riders m January 1
through December 31.
You shall be entitled to receive Medically Necessary (See Page 2 item A for definition) hospital services,
subject to all definitions, terms and conditions of this AQ,eement and Schedule of Benefits. If you elect
to remain in the hospital beyond the period which is ledically Necessary (as determined by your
Physician and HMHIC Utilization Review Department), you will be responsible for non Medically
Necessary services directly to the hospital. You must notify the Utilization Review depa+:ment if your
stay is extended beyond the authorized time by the Utilization Review Department.
Benefits Required Copaymenl
INPATIENT HOSPITAL SERVICES: 30% of Total Charges
Semi-private room, private if Medically Necessary, and
all services and medical supplies related to inpatient
treatment,
OUTPATIENT HOSPITAL SERVICES (Including Ambulatory Facilities)
Surgery $100.00 per procedure
Therapeutic radiation treatment 30% of Total Charges
Inhalation therapy 30% of Total Charges
Diagnostic testing, laboratory, and x-rays 3014 of Total Charges
Ultrasound, MRI, CAT, and non-routine laboratory tests $100.00 per test
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Cara Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
In benefit payment penalty.
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POS-:,;.H9.92 $
William
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H = IV. EMERGENCY CARE SERVICES
f p' ' y The Calendar Year Deductible must be satisfied in full (100%) for allUnefits n~ r J Janu ry
1 through December 31. 4L, Benefits which are covered under Harris HMO are not covered expenses under HMHIC. No coordmaLiun
of benefits are available between Harris HMO and HMHIC. Emergency care which does not meet Harris
HMO's definition will be covered under HMHIC. To receive HMO benefits for Emergency Services the
condition must conform to the following definition, and it time permits you must notify your Primary
Care Physician prior to receiving benefits. Harris HMO's definition of Emergency Care shall mean these
bona fide emergency services provided after the sudden onset of a medical condition manifesting itself
by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate
medical attention could reasonably be expected to result in placing your health in serious jeopardy, seri-
ous impairment to bodily functions or serious dysfunction of any bodily organ or part.
In cases of a Medical Emergency, you are entitled to the benefits and services set forth in this Schedule
of Benefits and in this Agreement if the condition does not meet Harris HMO's definition of a Medical
Emergeiocy, if the condition meets Harris HMO's definition, benefits will be paid by Harris Methodist
Health Plan, If the condition does not meet Harris HMO's definition, benefits will be paid by HMHIC. At
the time of a Medical Emergency, you or someone acting on your behalf, should make every reasonable
effort to contact the Utilization Review Department. 11 it is not reasonably possible to contact the
Utilization Review Department at the time (such as that of a life or limb threatening emergency), you
may seek cart immediately.
Benefits are reduced if you do not contact UR prior to receiving services as required, unless It is not
reasonably possible (such as that of a life or limb threatening emergency). The penalty for not calling
UR Is a 50% reduction in benefit payment. The penalty is applied to each confinement, surgical pro-
cedure, diagnostic, or treahnent plan.
At the time of a Medical Emergency which rest its in a hospital admission, you or someone acting on
your behalf, shall notify the Utilization Review D apartment within twenty-four (24) hours or as soon as
reasonably possible. Upon notification, the Volizi lion Review Department witi evaluate the need for con-
tinuation of hospital services.
Benefits Required Copayment
Physician office visits 30% of Total Charges
Physician office visits after hours 30% of Total Charges
Hospital emergency room and urgent care center services, 30% of Total Charges
including physician fees
Follow-up care 30% of Total Charges
POS•SCH9-92 7
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V. FAMILY PLANNING SERVICES .11 Lull
The Calendar Year Deductible must be satisfied in full (I oo%) for all benef is an ides from January 1
through December 31.
Family Planning Services will be available to you on a voluntary basis. Covered services will Include his-
tory, physical examination, related laboratory tests; medical supervision in accordance with generally
accepted medical practice; lnformat'on and counseling on contraception, including advice or prescrip-
lion for a contraceptive method; education, Including education on the prevention of venereal disease;
and voluntary sterilization after appropriate counseling,
Benefits
Required Copayment
Physician office visits, including related testing, education $20.00 per visit I
and counseling
Fitting and dispensing of IUD and diaphragms $20,00 per visit
Tubal ligation $75.00 per procedure
Vasectomy $75.00 per procedure
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department, Inpatient admission to any health care facility
must always be precerlified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
in benefit payment penalty.
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POS•SCH9.92 8
F
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VI. INFERTILITY SERVICES
The Calendar Year Deductible must be satisfied in full (100%) for all benefits and riders f
m J n
tiirough December 31.
Infertility services will be available to you on a voluntary basis. Artificial Inser,iination and diagnostic
services to determine the cjM of infertility will be provided. Excluded from services to J= infertility
are those services described in "Exclusions," Section XIV, Number 23 of this Schedule of Benefits.
Benefits Required Copsyment
Physician office visits for diagnosis, non-psychiatric
counseling, artificial insemindtlon, and sperm count $20.00 per visit
Administration of infertility medications; infertility
medications not covered $20.00 per visit
Endometrial biopsy, hysterosalpingography and diagnostic 30% of Total Charges
iaparoscopy
Sonogram and/or ovulation kit
$75.00 per test or kit
NOTE: You must obtain authorization for most health care services (other than routine office visits)
I by calling the Utilization Review Department. Inpatient admission to any health care fa for must always be precertified. See Item "A" under "Obtaining
Health Care Services'' for the
complete list of other services and procedures which require Utilization Review precertifica-
1 tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
i in benefit payment penalty,
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POS•SCH9.92
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_ VII, CHEMICAL DEPENDENCY SERVICES
The Calendar Year Deductible must be satisfied In full (10Atfor-0 benefits3ndridersErom Jan}~ary
through December 31. /7 7ZD Y
You shall be entitled to all necessary care and treatment for chemical dependency on the same basis a
that provided for any physical illness to a lifetime maximum of three (3) separate series of I ailments.
Diagnosis and treatment for chemical dependency shall Include detoxification and/or rehabilitation on
either an Inpatient or outpatient basis as determined to be Medically Necessary by a Physician. All treat.'
ment Is subject to the same limitations, exclusions, and copayments as applied to covered services of
any other physical illness.
Note: Inpatient Drug Treatment required precertification by the Utilization Review Department.
A series of treatments Is considered to be a planned, structured, and organized program to promote
chemical free status which may Include different facilities or modalities and is complete when:
You are discharged on medical advice from inpatient detoxification. Inpatient rehabilitation treatment,
partial hospitalization or intensive outpatient; or
You have received a series of these levels of treatments without a lapse In treatment; or
You fail to materially comply with the treatment program for a period of thirty (30) days.
Benefits Required Copeyment
Office visits $20.00 per visit
Necessary care and treatment for detoxification and/or $20,00 per visit
rehabilitation from chemical dependency
Intensive outpatient or partial hospitalization 30% of Total Charges
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
lion, failure to call Utilization Review ac directed will result In a fifty percent (50%) reduction
In benefit payment penalty.
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS•SCH9.92 10
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VIII. MENTAL HEALTH SERVICES
The Calendar Year Deductible must be sabstied in full {100%) forTlUrtfits andtidealfom January 1
through December 31. o y
OUTPATIENT MENTAL HEALTH SERVICES:
You shall be entitled to receive up to twenty (20) office visits per Calendar Year for evaluation, crisis
intervention and stabilization, and outpatient therapy in support of the evaluation or crisis Intervention,
The twenty (20) visits maximum may Include Individual treatment, couple, or family visits.
88481111 Required Copayment
a Outpatient office visits for crisis Intervention and treatment $20.00 per visit
Psychological testing 30% of Total Charges
INPATIENT MENTAL HEALTH SERVICES:
When determined to be Medically Necessary by the Utilization Review Department, you shall be entitled
i~ to evaluation, crisis intervention, treatment or any combination thereof for acute conditions,
Only treatment at the most appropriate level of care as determined by the Utilization Review Department
will be authorized.
Benefits Required Copsyment
rt inpatient hospitalization for up to thirty (30) inpatient 30% of Total Charges
days per Calendar Year.
" Psychiatric Day Trea!ment Facility, Crisis Stabilization Unit 300% of Total Charges
I~ or Residential Treatment Center for Children and Adolescents
for up to sixty (60) days per Calendar Year. Treatment in
such facilities will be limited to sixty (60) days of care
such that one (I ) day of care shall be equal to one-half
(t/2) days of inpatient care.
t NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
l~ Lion. Failure to call Utilization Review as directed will result in a fifty percent (50%)1 reduction
in benefit payment penalty,
NOTE: Any services which are limited In either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum,
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POS-SCH9.92 71
IX, REHABILITATION SERVICES arnoa rvu ~3~1~'
The Calendar Year Deductible must be satisfied in full
through December 31 (100%) for.~(I benefit r' ersiom January 1
.
179, You shall be entitled to receive short-term physical or occupational therapy rehabon~lces for
conditions which are Medically Necessary, subject to significant Improvement through short•lerm treat.
ment, and authorized by the Utilization Review Department before services are obtained. Treatment is
defined as up to sixty (60) visits per twelve (12) month period. per condition, and snail provided on
an outpatient basis only. Rehabilitation services on an inpatient basis, or in a skilled nursing facility, will
be authorized only if other non-rehabilitation medical services are required by you,
Occupational therapy shall mean those services designated to prevent dysfunction, restore functional
ability and facilitate maximal adaptation to impairment.
Benefit:
Required Copeyment other
$20,00 per visit
der for treatmtent subject to cliinicai improtvement,
and limited to sixty (60) visits per twelve (12)
month calendar year per condition.
Long-term or maintenance services.
Not Covered
Long lerm/malntenance services are defined as incJuding Custodial/Domlciliary Care aid services which
are not skilled In nature and not medically necessary.
i
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department Inpatient admission to any health care facility I
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica•
tion, failure to call Utilization Review as directed will result in a fifty percent (50%) reduction f
in benefit payment penalty, I
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS•SCH9.92
12
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~gendaNo
M X KIDNEY DIALYSIS SERVICES Aged a leis
p Date
The Caiercaf Year Deductible most be satisfied in foil (100°/x) for all benefits and riders rom nuary I
through December 31.
You shall be entitled to services and benefits provided for kidney dialysis upon prior authorization from
tj the Utilization Review Department and only if your Physician determines that such service represents
Medicareinvolved.
provisions for will End
the coo dinated for method if you are treatment eligib a for the riteria for the coverrage under the service
Stage Renal Disease,
Benelit: Required Copayment
Inpatient or outpatient Hospital, or outpatient Kidney dialysis 50% of Total Charges
center
Home dialysis (continuous ambulatory peritoneal dialysis) 50°16 of Total Charges
including equipment, training, solutions, coils, drug and
surgical supplies
NOTE; You must obtain authorization for most health care services (other than routine oHlce visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See item "A" under "Obtaining Health Care Services" for the
M ! complete
Fai Failure to cal Utilization e Review as procedures will result i in a fifty percent v(50%)reduct i
lion on
In benefit payment penalty.
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POS•SCH9.92 13
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)0. AMBULANCE SERVICES
The Calendar Year Deductible must be satisfied In full (100°10) for all benefits an n ;It from J Hoary 1
through December 31. l~'/
Benelils Required Copsyment
You shall be entitled to both land and air ambulance 30% of Total Charges
services for Medically Necessary Emergency Care Services
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POS•SCH9.92 14
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XII. HOME HEALTH CARE SERVICES
1X7*, d"
The Calendar Year Deductible must be satisfied in full (100°/x) for all benefits and riders fr January 1
I~ through December 31.
You shall be entitled to receive home health care services according to a Treatment Plan approved by
I the Utilization Review Department. Treatment will be provided only for those medical conditions subject
j to clinical improvement through short-term treatment; for recovery or rehabilitation of illness or injury;
or for treatment of terminal illness.
Short-term treatment is defined as: a plan of care established, approved in writing, and reviewed at least
1 every two (2) months by the attending physician and certified by the attending physician as necessary
1 for medical purposes. The number of visits for which benefits will be payable are sixty (60) visits in any
calendar year for each covered person under this policy. Excluded benefits Include custodial care, bene-
fits provided by a person who resides in the covered person's home, or Is a member of the covered per-
son's family, A visit by a Home Health Agency representative is considered one 11) home health visit.
I Four hours of home health aid service Is considered one (I ) home health visit,
Benefits Required Copayment
" Skilled nursing care; physical, occupational; or respiratory $20 00 per visit
therapy; intravenous solutions; and home health aid services
Hospice (home health service only) $20.00 per visit
NOTE: You must obtain authorization for most health care services (other than routine office visits)
I by calling the Utilization Review Department, Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precertifica-
lion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
In benefit payment penalty.
}
NOTE: Any services which are limited in either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
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POS-SCH9.92 15
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Xill. SKILLED NURSING FACILITY SERVICES
f~. a.
The Calendar Year Deductible must be satisfied In full (ItimforaH ler
►iders rom January t
/Ir
throu7h December 3l.
aD
You are entitled to receive services In a Skilled Nursing facility for medical conditions which in the
judgement of the Utilization Review Department are subject to significant clinical Improvement and
which require services which can only be provided at that level of care. Services in a Skilled Nursing
Facility may be provided in lieu of hospitalization (either In lieu of admission or upon discharge from
inpatient care) as Medically Necessary based on acuity of services and patient condition, are limited to
sixty (60) days per Calendar Year.
Benefits Required Copsyment
Room, Board, medications and supplies while confined in a 30% of Total Charges
Skilled Nursing Facility as part of a short-term recovery or
rehabilitation program
Physician visits while confined to Skilled 30% of Total Charges
Nursing Facility
NOTE: You must obtain authorization for most health care services (other than routine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified, See Item "A" under "Obtaining Health Care Services" for the
compiete list of other services and procedures which require Utilization Review precertifica.
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
In benefit payment ponaity,
NOTE: Any services which are limited In either daily limits or dollar maximums under Harris HMO
policy will also be counted towards HMHIC's daily limit or dollar maximum.
POS•SCH9.92 16
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XIV, PROSTHETIC MEDICAL APPLIANCES r
em `2 The Calendar Year Deductible must be satisfied In full (10014LSor aA benofikanc4ldrars kom Ja uary 1
through December 31. el 90
You are entitled to prosthetic medical services or medical appliances it Medically Necessary, with a itho-
rization from the Utilizatioi Review Department. While you are covered under this Agreement, initial
prostheses are provided when required due to illness or Injury. Replacement Is provided only when
marked physical changes occur which require replacement, and Is not provided for items which wear
out due to normal usage.
Benefits Required Copaymenf
I Internal prosthetic appliances Including Internal cardiac 30% of Total Charges
pacemakers, and minor devices such as screws, wire mesh,
nails, and artificial joints, Supply of or replacement of
r internal breast prosthesis covered only if initial surgery
was result of injury or disease,
External prosthetic appliances including artificial arms, 30% of Total Charges
legs, above or below knee or elbow prostheses; eyes,
lenses, external cardiac pacemaker; terminal devices such
as hand or hook; rigid or semirigid immobilizing devices
such as arm, leg, neck or back braces; and ordinary splints,
I and crutches
NOTE; You must obtain authorization for most health care services (other than rautine office visits)
by calling the Utilization Review Department. Inpatient admission to any health care facility
must always be precertified. See Item "A" under "Obtaining Health Care Services" for the
I complete list of other services and procedures which require Utilization Review precertifica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
In benefit payment penalty.
,
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POS•SCH9.92 17
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XV, DURABLE MEDICAL EQUIPMENT
-9 - ~I
The Calendar Year Deductible must be satisfied in full 1D0°
through December 31. (r~u-0enef+if+and radar from anuary 1
You are entitled to benefits for certain durable medical equipment as prescribed by a physician, with
prior authorization from the Utilization Review Department, Durable medical equipment must be able to t1 1
withstand repeated use, primarily and customarily serve a medical purpose, generally not useful In the
absence of illness or Injury, require a physician's order, and be appropriate for use In the home. At its
option, HMHIC may rent or purchase approved equipment. HMHIC retain
s the right of possession of
equipment.
It I
HMHIC uipment not liability have no not cons dewe durrable meldical efor repair quipmentrIsedescribed In lost or
Eq
Sectin aXIV,
Number 31 of this Schedule of Benefits.
Benefits Required Copayment
Rental or purchase of medical equipment 30% of Total Charges
NOTE; You must obtain authorization for most health care services (other than routine office visits) I
by calling the Utilization Review Department. Inpatient admission to any health care facility i
must always be precertified, See Item "A" under "Obtaining Health Care Services" for the
complete list of other services and procedures which require Utilization Review precerti}ica-
tion. Failure to call Utilization Review as directed will result in a fifty percent (50%) reduction
In benefit payment penalty.
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POS•SCH9-92 18
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XVI. LIMITED DENTAL SVPVICES ~endaNo -
Agendallelr
The Calendar Year Deductib a -ust be satisfied in full
through December 31. d j (100%) for all benefit n ri e s fro January 1
~o m
You are entitled 10 services the Initial stabilization of acute accidental, non-occupational Injury, to
sound natural teeth with pric t)7 an an otutpapaby the Utilization Review Department, when provided within
thirty (30) days of the accider; , otient basis only.
While you are covered under ` Agreement coverage is limited to treatment of fractured or dislocated
Jaw, or to repair damagqe to Find natural teeth. Limitations and exclusions for dental services are
described in Section Will. mber 2 and Section XIV, Number 118 of this Schedule of Benefits,
Copayments will be the same a, Jescribed for other Illness or injury services.
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19
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XYII. COPAYMENT MAXIMUM
The maxlmum annual Comments for covered bend(& under ti} O& o Benefits, shall not
exceed the following In a Calendar Year as descnWff SLOS5RR1`Ot'`TE~ MS, of the Group
AgreemenUSubscriberCertificate of Coverage, 7~
Benefits Maximum Annual Copaymenb
Per Member $4,000.00 , f
Per Family $8,00000
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POS•SCH9.92 20 f
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XVIII. LIMITATIONS
The following services are limited as described belo
t. The Utilization Review Department determines the Medical Necessity ojfervices, You are respon•
sible for notifying the Utilization Review Department (UR) for the services listed below T' a UR
phone number is (817) 878.5828. Benefits which are not Medically Necessary will be C,nied. The
ultimate decision on your medical care must be made by you and your Physician. The Utilization
Review Department only determines the Medical Necessity of a service, only services medically
necessary are paid for according to the Agreement benefits and provisions,
Benefits are reduced if you do not call UR prior to receiving services as required. The penalty for
not calling UR is a 50116 reduction in benefit payment.1 he penalty is applied to each confinement,
surgical procedure, diagnostic procedure, or treatment plan.
Services which are provided under Harris HMO are not covered expenses under HMHIC,
Emergency Care which does not meet Harris HMO's definition will be covered under HMHIC
Harris HMO's definition of Emergency Care shall mean bona fide emergency services provided
after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient
severity, Including severe pain that the absence of Immediate medical attention could reasonably
be expected to result in (1) placing the patient's health in serious jeopardy; (2) serious impair-
ment to bodily functions; or (3) serious dyslunction of any bodily organ or part. If an Emergency
Care situation exists follow the procedure outline In Harris HMO policy.
2. Care and treatment of the teeth or gums, except for oral surgery for tumors or Injuries to the jaw
bone or surrounding tissue, Is limited to the Initial stabilization of acute, accidental non•occupa•
tional Injury to sound, natural teeth when provided within thirty (30) days of the accident on an
outpatient basis only.
3. Coverage for vision examinations Is limited to conditions which require examination to diagnose
injury or ilfness, unless covered by Rider attached to this Agreement.
4, The benefit for durable medical equipment 'e limited to either the total rental cost or the purchase
price of such equipment, whichever Is less, as determined and authorized In advance by the
HMHIC Medical Director or his designee. HMHIC shall have no liability or responsibility for repair
or replacement of equipment lost or damaged.
5. Care and treatment provided in hospital owned or operated by federal government is limited to
the care for the condition which the law requires to be treated or provided In a public facility,
6. The purchase or fitting of eye glasses or contact lens or advice on their care is limited to the Inl-
tial set of eye glasses, contact lens, or lens implant required following cataract surgery, repair of
congenital defect or as required by an accidental Injury to you,
1. Coverage for reconstructive surgery is limited to surgery necessary to repair a functional disor-
der resulting from disease, Injury (except Congenital defect); Congenital defect reconstructive
surgery will be covered. Supply or replacement of Internal breast prosthesis is covered only if ini-
tial surgery was a result of Injury or disease.
POS-SCH9.92 21
s
8. Coverage for treatment of the temporomandibular (jaw or crano-man u a"r~joint Is limited to
Medically Necessary diagnostic services and/or surgicaR~ to be Medically
Necessary, Charges related to dental services for this condition are not cover d.
"~0y
9. If Medically Necessary and authorized by HMHIC, HMHIC will cove ~kidaey transplants, corneal
transplants, liver transplants for children with congenital biliary atresia, and bone marrow trans-
plants for Aplastic Anemia; Leukemia; Lymphoma; Severe Combined immunodeficiency Disease;
or Waistcoat-Aldrich Syndrome where traditional modalities of traditional medical therapy have rt
been exhausted. Medical costs for organ procurement associated with the removal of an organ 1)
for a covered transplant when the recipient is a Covered Person are limited to a maximum benefit
of $10,000.00. Charges related to organ, tissue, or artificial organ transplants except as other-
wise specified in this section are excluded. The donor's transportation costs are not covered.
Services provided to any Covered Person for the donation of any organ or element of the body
are not covered.
10. Benefits for grandchildren will be provided only if the child is considered to be a dependent of the
Subscriber for Federal Income tax purposes, and upon payment of the applicable premium.
It. "Pre-existing Conditions" means any medical condition treated or diagnosed within the six (6)
months immediately preceding your effective date of coverage under this Agreement. A medical
condition has been "diagnosed" if its existence has been identified or recognized by a Physician
or other Health Professional, A medical condition has been "treated" if any services of a
Physician or other Health Professional have been received with respect thereto, including but not
limited to office visits or consultations, hospital treatment, laboratory services, X-rays or the dis-
pensing of prescription medication or refills.
Additional exclusions or limitations, if any, applicable under the policy with respect to a disease
or physical condition of a person, not otherwise excluded from the person's coverage by name of
specific description effective on the date of the person's loss, which existed prior to the effective
date of the person's coverage. In no event shall the limitation of 50% additional Copayment apply
to cost of treatment (which shall include all applicable Copayment as specified in the Schedule of
Benefits) commencing after the earlier of: (a) the end of a continuous period of twelve (12)
months commencing on or after the effective date of the person's coverage during all of which
the person has received no medical advice cr treatment In connection with such disease or physi-
cal condition; and (b) the end of the two (2) year period commencing on the effective date of the
person's coverage. t
The maximum amount of additional CopaymeM for a Pre-existing Condition during the period of
either one year or two year regardless of treatment, will not exceed $2,000.00 for any such
Covered Person or Dependent, or $4,000.00 total for such Covered Person and his Dependents.
POS-SCH9.92 22
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Acenda No.
I is limited to_~ XIV. t:XCLUSiONS Aen a tAr'1-fin
be Medically
The following services and supplies, and the cost hereof, are excluded from over a nd this
lants, corneal / Agreement, unless specifically added by Rider to this Schedule of Benefits. /010
ejao
narrow trans- l
envy Disease; I. Charges for services covered or provided under the Harris HMO Contract; including Emergency
therapy have Care Services (as defined by Harris HMO).
d of an organ
rimum benefit 2. Charges related to any service or treatment which a Covered Person would not be legally required
*pt as other- to pay.
not covered.
I of the body 3. Charges related to personal, convenience or comfort items such as personal kits provided on
admission to a hospital, television, telephone, newborn Infant photographs, guest meals, birth
r announcements, and other related articles which are not for the specific treatment of illness or
lendent of the i injury.
+mium. q, Charges related to transportation, except charges related to land and air ambulance services for
in the six (6) Medically Necessary Emergency Care Services described In Section XI of this Agreement.
:nt. A medical 5. Charges related to private hospital room and/or private duty nursing unless determined to be
y a Physician medically necessa and authorized by HMHIC Utilization Reviw, ,ervices of a ry
using but not
ys or the dis• 6. Charges related to services rendered by a person who resides In the Covered Person's home, or
by an immediate relative of the Covered Person.
to a disease 7. Charges related to services for military or service connected conditions for which the Covered
e by name of Person is legally entitled, and for which appropriate facilities are reasonably available to the
the effective ' Covered Person.
ayment apply
9 Schedule of 8. Charges related to occupational injury or illness or conditions covered under Worker's
twelve (12) Compensation or similar law.
all which
ase or r physi- I ' 9. Charges for health care services primarily for rest, custodial, respite, domiciliary, or convalescent
,e date of the care.
10. Chz•ges related to reports, evaluations, or physical examinations not required for health reasons
the period of I (not Medically Necessary). Excluded items are: reports for employment, insurance, camp, adop-
or an such Lion, travel, or government licenses.
ependents, 11, Charges related to drugs or medicines, prescription or non-prescription, provided to the Covered
Person while he or she is W an Inpatient, unless specifically provided by a Rider to this
Schedule of Benefits.
12. Charges related to experimental drugs or substances not approved by the FDA for other than FDA
I approved Indications; and drugs labeled "Caution • limited by Federal Law to Investigational use."
13. Charges related to formulas, dietary supplements, or special diets provided to the Covered
Person on an outpatient basis.
14. Charges related to vision care, Excluded services are; examination for eye glasses; refraction, dis•
lensing, or fitting of eye glass frames and lenses; all types of contact lens; eye exercise and vlsu-
al tralning; and orthoptics; except as otherwise specified In Section XVIII, Number 6 of this
22 ' POS-SCH9.92 23
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Schedule of Benefits. agvdaIIerr
15. Charges related to radial keratotomy or other radial kera
such su top asl es and all r 7 is assoc'ated with
surgery, ,a/ 1 r
16. Charges related to hearing aids, batteries, and examinations for fitting theraof unless added by 1.
Rider to this Schedule of Benefits.
17. Charges related to the care and treatment of the feet unless such services are Medically
Necessary. Exclusions include routine foot care, such as removal of corns, calluses, or the trim-
Ming of nails; treatment for flat feet; orthotics; arch supports; or custom fitted braces and splints,
18, Charges related to dental care, except as otherwise specified In Section XVl of this Schedule o'
Benefits, Including services related to the care, fillings, removal, or replacement of teeth; treat-
ment of diseases of the teeth or gums; extraction of wisdom teeth; malocclusion or malposilion ii
of the teeth and jaws (mandibular hyperpiasia/hypoplasla); professional services or anesthesia 1.
related to or required for the sole purpose to provide dental care; hospital care; inpatient or out-
pa!ient surgery required for any dental care; prescription drugs for dental treatment; dental x-
rays; dentures; and dental appliances or prostheses.
19. Charges related to surgical procedures and other treatment associated with the treatment of obe-
sity, regardless of associated medical or psychological conditions, including treatment of a com-
plication of surgical treatment for obesity, Excluded procedures are: intestinal or stomach bypass
surgery, gastric stapling, wiring of the jaw, insertion of gastric balloons, or similar procedures.
20. Charges related to transsexual surgery, including medical or psychological counseling or hor- L
monal therapy, In preparation for or subsequent to any such surgery,
21. Charges related to services for cosmetic surgery or reconstructive surgery, except as otherwise
specified as covered in this Schedule of Benefits. Cosmetic surgery exclusions are: rhinoplasty;
scar revisions; prosthetic penile implants; surgical revision or reformation of any sagging skin on
any part of the body, described as relating to the eye lids, face, neck, abdomen, arms, legs or but- r
tocks; liposuction procedures; any services performed in connection with the enlargement,
reduction, Implantation or appearance of any portion of the body described as the breast, face,
lips, law, chin, nose, ears, or gentiles; hair transplantation; chemical face peels or abrasions of
the skin; removal of tatoos; and electrolysis depilation, Supply or replacement of Internal breast
prosthesis is covered only if Initial surgery was a result of injury or disease.
22, Charges related to reduction mammoplasty, unless determined to be Medically Necessary by the
HMHIC Medical Oirector of his designee.
23. Charges related to reversal of surgically performed sterilization or subsequent resterilization,
24. Charges ►elated to surrogate parenting; GIFT procedures; and any costs associated with the col-
lection or storage of sperm for artificial Insemination Including donor fees; and infertility medica-
tions unless specifically provided by a Rider to this Schedule of Benefits.
25. Charges related to amniocentesis, ultrasound, or any other procedure preformed solely for sex r
determination of the fetus.
POS•SCH9.92
24
~gergahJa ✓i-C-Z
26, Charges related to mental health services for psychiatric coVyyn4Lyt{1ic are determined by the
HMHIC to be not Medically Necessary in nature and beyopd the maximur~ ~py3s gwed by
21. Charges related to court ordered testing, and special reports not directly related fo medical
treatment.
28, Charges related to services for the treatment of mental retardation and mental deficiency.
29, Charges related to employment, vocational, or marriage counseling; behavioral training; remedial
education, including evaluation and treatment of learning and developmental disabilities and min-
imal brain dysfunction; or attention deficit therapy,
30, Charges related to services for chronic intractable pain provided by a pain control center;
acupuncture, naturopathy, and hypnotherapy; holistic or homeopathic care, including drugs; and
ecological nr environmental medicine.
31. Charges related to durable medical equipment, unless described in [his Schedule of Benefits.
Excluded items are: (a) deluxe equipment, such as motor driven wheel chairs and beds, possess-
ing features of an aesthetic nature or features of a medical nature which are not required by the
patient's condition; (b) items not primarily medical in nature or for the patient's comfort and con-
venience, such as bed boards, bathtub lifts, over-bed tables, adjust-a-bed, and telephone arms;
(c) physician's equipment such as stethoscope and sphygmomanometer; (d) exercise equipment
such exercycles and enrollment in health or athletic clubs; (e) self-help devices not r•imarily
medical in nature, such as sauna or whirlpool baths, chairs, and elevators; (f) corrective orthope-
dic shoes and arch supports; (g) supplies or equipment for common household use, such as but
not limited to, air purifiers, central or unit air conditioners, water purifiers, allergenic pillows or
mattresses, and water beds; and (h) research equipment or items deemed to be experimental as
determined by the HMHIC. HMHIC shall have no liability or responsih';ity for repair or replace-
ment of equipment lost or damaged.
32. Charges related to prosthetic medical appliances, except as specified in Section XIV of this
Schedule of Benefits. Excluded items include: (a) dentures, hearing aids unless specifically pro-
vided by a Rider, and contact lens; (b) medical supplies such as elastic stockings, garter belts,
arch supports, corsets, and corrective orthopedic shoes; (c) research devices or items deemed to
be experimental as determined by HMHIC; and (d) replacement, repair, and routine maintenance
of covered appliances or braces unless surgically implanted, or replacement required due to a
marked change in physical growth or physical requirements,
33. Charges related to medical supplies, aids, and appliances except as otherwise specified as cov-
ered In this Schedule of Benefits. Excluded items are: consumables, disposable supplies,
sheaths, bags, gloves, cervical collars, elastic stockings, stethoscopes, blood pressure units,
traction apparatus, slings, TENS units or electrical nerve stimulation devices, wigs or halt pieces,
dressings, testing supplies, syringes, home testing kits, disposable diapers or incontinent sup-
plies, and over-the-counter medications.
34. Charges related to inpatient or outpatient long-term neuromuscular, or occupational therapy ser-
vices or other rehabilitation services In excess of sixty (60) visits per twelve (12) month period,
per condition, are not a covered benefit,
35. Charges related to recreational, educational, or sleep therapy, and any related diagnostic testing,
except as provided by the hospital as part of an approved Inpatient hospitalization.
POS•SCH9.92
25
36. Charges related to structural changes to a house or vehiCie. EN~bNa......-
37. Charges related to any medical, surgical, or health care proc Sr treatme h t experi
mental or investigational at the time the procedure or treatm is pOo rll utilize
findings and assessments of national medical associations, professional societies and organiza-
lions, and any appropriate technological body established by any state or federal government r
similar entities to determine coverage and/or effectiveness. /9 3 PI
r
38. Charges exceeding the Reasonable and Customary amounts as determined by HMHIC
f1,
u
C,
R;
AOS-SCH9-92 26
r r
7
PRESCRIPTION DRUG RIDER Aggfld3N
FOR USE ONLY WITH HMHIC HEALTH CARE
Ltate ~ . ~
1.0 INTRODUCTION ~9r/ ~a
In consideration for The timely payment of premiums, and all other terms and conditions of the
Group Health Care Agreement, and/or Certificate of Insurance, it is agreed that the benefits of this
Rider, rogether with the terms and conditions of this Rider, shall be added to Agreement as
issued if this Rider is accepted by the Group.
2.0 D HIM=
Benefits for outpatient prescription drugs provided through this Rider shall be subject to the pro-
visions and definitions of Agreement to which this Rider is a part.
In addition, for the purpose of this Rider, the following definition shall apply:
Prescription Drugs shall mean only those drugs and medicines which are prescribed by a
Physician and legally require the written prescription of a Physician before it can be
obtained by the Covered Person.
10 BENEFITS
Benefits limitation and Covered Person cost shall be as follows:
• 30% Copayment by Covered Person
E,QyERED ITEMS
Federal Legend Drugs and compounds requiring a prescription (including insulin), except those
specifically excluded. Generic Substitutions are covered.
FXCLUSto s
(1) IUD Devices
(2) Therapeutic or Prosthetic devices, except those dispensed by durable medical provider
(3) Appliances, Supports or other non-medical products
(4) Medical Supplies except those listed as covered items
(5) Contraceptive devices excluding Oral contraceptives
(6) Insulin syringes and miscellaneous diabetic supplies, including urine and blood glucose
strips
(7) Injectable Medications, other than insulin
(8) Blood, Blood Plasma and Blood Products, except those dispensed by outpatient facility
(9) Experimental Drugs
(10) Immunization Agents, except those dispensed In the physician's offi^e
(11) Fertility Medications
(121 Drugs not requiring a prescription (OTC, Vitamins, Cough Syrup, etc.)
(13) Drugs to be consumed in an inpatient or other institutional care setting
(14) Nicorette gum
i
POS•SCH9.92 27
3
r
'~eada'Vo 13 -o
(15) Drugs requiring parenteral use or subcutaneous use App dal lem
(16) Charges for cost difference in a brand name product qpp generic dru pr ribed or t
permitted by physician ~51
(17) Nutritional or dietary supplement, or formulas other than prescrp of n req ire4Litamins
(PKU formula, including other heritable diseases are covered as other prescriptio drugs)
(16) Medications dispensed by physician offices
(19) Prescription Drugs for cosmetic conditions not covered in the Schedule of Benefits (such
as Retin-A, Mmoxidil, etc.)
COVERED QUANTITIES
As prescribed, up to a maximum of a 30 day supply for each covered prescription or refill.'
Prescriptions shall not be refilled until approximately 75% of the previously dispensed quantity
has been consumed, based on dosage instructions of the physician. Covered Person must pay in
full for any amounts exceeding covered quantities, including lost or misplaced medications,
COVERED REFJ L
A maximum of five (5) refills per prescription shall be covered if allowed by law and authorized
by Physician, provided such refills are dispensed within six (6) months of the initial prescription
date.
4.0 ELIGrBILITY
Benefits under this Rider are available to the Employee and his Dependents (Covered Persons) as
identified in Agreement.
Benefits provide no conversion privileges or benefit continuity for Covered Persons when such
persons are no longer entitled to Group benefits as set forth in Agreement to which this Hider is
issued.
POS-SCH9-92 26
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EXHIBIT 11
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Agendal(em
Harris Methodist ra(e
Health Plan
LETTER OF UNDERSTANDING
November 15, 1993
Mr. Thomas Klinck
Director of Human Resources
City of Denton
215 E. McKinney
Denton, Texas 76201
Re; Request for bid 01523
Dear Mr. Klinck:
It is our understanding that Harris Methodist Health Plan (HMHP) and
the City of Denton(City) agree to the following:
1. The City of Denton Request for Bid 01523 page two (2) paragraph
two (t)reading : "The City of Denton is seeking nn insurance
policy/agreement to become effective January 1, 1994, for a
minimum of one (1) year. The policy shall provide, if not
cancelled prior to December 31, 1994 in accordance with the
terms of the policy/agreement, bid submission form, and/or
request for bidders, for the renewal of this policy for two (2)
successive twelve (12) month periods, thereafter subject to
renegotiation of the terms of this policy, if the City Manager
and insurance company agree, without the necessity of rebidding
this insurance proposal as long as the cost of insurance during
either the first or second twelve (12) month successive period
does not increase more than 301 and the plan design benefits do
not decrease more than 301. However, this proposal may be
terminated if insurance company and City are unable to agree in
writing to a mutually agreeable plan design and insurance cost
no later than seventy-five (75) days prior to the and of the
preceding period. (This paragraph applicable to "P's Pre-
ferred Plus Plan.)
2. HMHP agrees to provide a rate guarantee through the second and
third plan year for the Preferred HMO Plan only, HMXP,s
conditions for the 1995 and 1996 rate guarantee are that the
A member of
Him$ M ftot Ha1th system
1eMt,i,nw4At-.., It,..."ODA An.M~t14~CnnlVnnA tr,..7AIfl1.7AtlIl17.11;MVM1fillluemerSerrlelTtltoAoneNumbtrsllQJ(~fs7b
NOV-16-1993 16,20 FROM HMHS-MANAIGED CARE MKTG. TO 9161756662363609 P.03
4WdjN0_...,9~-0
A40WOi
Mr. Michael D. Clerk ,3' 9
November 15, 1993 o
Page 2
City's contribution to the employee rate for HMHP's Preferred HMO
Plan must be 100%, and HMHP will be the only carrier of-
Preferred HMO Plan guarantee will be as
fered by the CitY The
follows 'The years 1995 and 1996 combined maximum rate
guarantee will not exceed a total of 15%. The year 1995 will
not exceed 9.9% of HMHP's 1994 rate.' ('T'his paragraph applica-
ble to HMHP's Preferred Plan.)
3. As City employees' needs for additional health care services'in
the Denton area expand, the HMHP is committed to ongoing as-
sessment of these needs and expansion of MMHP's current network
through the recruitment of appropriately qualified providers to
serve these needs.
Ten (10) additional Denton providers have been approved recently,
and will be added to the network as soon as contracts are
executed. City's request for additional hospital service through
Denton Regional Medical Center will be given consider-
ation for future needs. This ongoing effort will continue as a
part of HMHP's partnership with employer groups that HMHP serves
in the Denton area.
4. This letter of understanding shall become an attachment to the
agreement of the parties authorised by city pursuant to the
ordinance approved on the day of , 1993, re-
lating to the award of Bid No. 1563, except for such portions of
this letter that are specifically rejected by the State Board of
insurance prior to September 1, 1994.
Please indicate City's acceptance of the above conditions by signing
below where indicated, and returning this letter to my attention.
Sincerely,
Michael D. Clark
Senior vice President
Managed Care Marketing
City of Denton
by.
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EXHIBIT III
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tq~!-1~-1??3 13t O FPL01 NIAS-hLaWGEEL C;iF8 *,TG, TO 91517?ZpW5513152 P. 01
CendaNai
Agenda I tem
Nte__1r_u.?.`'
DL.NTON ►ROVIDLRS
HARRIS MMODIST HEALTH PLAN
BLUOUM THOMAS 0, MD FAMILY PRACLTCE PRIMARY WE PHYSICLA,N
1304 Scripture, 03M
Denton, TX ?6301
CLOD, %UUAM W, DO FAMILY PRACTICE PRIMARY CA" PHYSICIAN
2611 Old Noah Rd., #101
Denton, TX 16201
EVANS, STANLEY C, DO FAMILY PRACTICE PRIMARY CARE PHYSICIAN
1412 Old Nonh Rood, IL01
Denton, TX 7620[
HAGS . DOliOLAS MD FAMILY PRACITC'E PRIMARY CARE PHYSICIAN
2509 Scripture, two
Denton, TX 7620E
W15RAYBR HARVARD L,.MD PA,MMY PRACnCE PRIMARY CARS PHYSICIAN
2504 Sutpture, 0200
Denton TX 16201
$HELTON, IOkN S, MD FAMILY PRACI7CE PRIWIRY CAM PHYSl%%N
1509 Scripture. #200
Deet66, TX 76201
TAYLOR P.VG&NE M., MD FAMILY PRACITCE PRIMARY CARE PHYSICIAN
2509 Scripture, 1200
Denton. TX 76201
BRATT, IIT&NIM14 N. MD L\TERNAL MEDICINE PRIMARY CARE PHYSICIAN
1105 Della Dr, 0337
Ocetnn, TX 76205
DAM BENNA, MD INTERNAL MEDIC s% PRIMARY GORE PHYSICAN Not Eh 9/4 D nnory
4401-A 111 Non h, #270
Ocnton. TX 76207 FQw1 N 11/1/91
NORRIS JACKIE R. MD INTERNAL MED'C1'*E PRIMARY CARE PHYSICIAN
625 De11u Drhe. 07S
Otntoe, TX 76205
s WAHLEKT, CHARLES H. MD LN7EXNAI MEDIC NZ PRIMARY ctm PHYSICIANN
1109 Scripture, 6200
Dcoton, TX 76M
ft*EL BRUCE ALAN, MD PEDIATRICS PRIMARY CAM PHY$IMN
2315 Scripture, Svlt4 201
Denton. TX 76201
JANX A MARILYN ROS& MD PEDIATRICS PRIMARY CARE PHYSICIAN
2513 Seri ptuM 1201
Denton, TX 76201
McOVIRL FRANK T., MD PEDIATRICS PRIMARY GRH PHYSICIAN
4204 N. I•b
j DediftTX 76307
SARANA, ML'1SESH C.I. MD PULMONARY DISEASES Not In. 9/`93 MrWory
2009 Set taro, SW 103A dectiw II/l/"
De610o. TX 76201
n
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_ _ lj, _ t :._17
r . ~
igenda No ~J3. .
4y s a da E ce I►1.~.~~.~.~....~
re~e 2 of 7, Novtarba U,1pp1 Cole
DAVIS, GORDON W., MD A!•'F57 BNOLOGY
2315 Sttptun. #No
Denton, TX 76301
OARCIA, CARLOS J,. MD A.WMEMOLOGY
2115 &*tune, 0200
Denton, TX 762M
GREEN, C7MRJnl&N A, MD &-,M &M0LOGY
2515 Sctiptvm. *200
Von", TX 76201
HAM ZAPAR A., MD ANUMESIOLOGY
2515 SctipNm, mo
Denton. 7x 76201
POURL&,V, DARIVS PETER, MD AI\7wJHE:SIOLOOY
25Le "tum #2W
Dan too, TX 76301
CADEAUM. THOMAS & MD EST
44M 1.31 North
Denton, TX 76701
PLETCHER JOSEPH D., MD GASTROtlAMOL00Y
4101 NdJS, 1113
Denton, TX 767M
CHAIUNEY, PRA.A7U,LN J. MD GENERAL SURGERY
44011 North 1,15, 02M
Denton, TX 76247
FELI)MA.N, JAMES J., MD OL ERAL SURGERY
4401A North NO, 0370
Denton. TX 76%x7
XLRRUS, FRED D., MD QE\TRAL SURGERY Not In 9/4J Dlrocrory
MM 111 0a
Ocntpn, TX 76307 EffeetfNl 11/1/111
M1ZER 0. IAYPLL, MD OE%TRAL SUROERY
4401 A .Non% 125, 0370
Denroa, TX 76207
MOVER CURTIS L. MD OEAERAL SURGERY
1300 Pinion, 0303
Denton. TX 70M
SNORT, ARM D., MD CE IML SURGERY
7509 twt, IJ00
Denton. TX A620i
8A>rSR11Y, JR. OERI,RD G, MD GYAE4OLOOY/OSSTE'S1t1CS (08107\)
1200 Pulton AuR, 0503
Donlon, 9X 76301
80ATWWOHT, IL BRYA,N, MD GYNTODLOOY
4401 1-JJ North, 0310
Denton, TX 76207
C4E iL TU. Tu 61 L11F.1 BSc' P.Ui
~eneaNo _ 9-~-el
lgendailerll _
Pep ~ a 7. NwcmOer 13, :99s 1'ala A .
DULBMBA, JOHN P., 3[D OYNEOOLOOY/OwrFmcs (08/om
472163$
DcotM TX 76207
LEB,kosv J MD OYNECOLOOY
7.700 sdPture, 1200
Denim, TX 76201
XANTTt1, SUHAS D. MD GYNECOLOGY/085TETRJCS (oe/cYN)
2309 Sctiptun St.
Denton, TX XXI
WASSERMAY, ALAN S.. MD OYST.COL00Y/08SM-MCS (08/0
YNj
4403 North IJS, $Vite A
Denton, TX 76207
WILSON. RONALD THOMAS, FLD 0vsT'OOLOOY/08.TJyMc$ (08/OY\)
4405 W&I, ♦8
DENI'ON, TX 76203
CAVDY, DEBRA LOUISK MD HEMATOLOGY/ONCOLOOV
231s wptutt, 0302
Denton, TX 70M
AnT, MD O31COW0Y/HEMATOL00Y roe in 9/93 Dhdm
WI.A 133 Nomb, #270 Bttectwe 11/1/93
Devon, TX 76207
HOLLIA'D,?MR L•, DDS ORAL/MAX SVROERY Not in 9/91 v4vwty
Dentoo. Tula 76201 EdactMe :J/1/93
8
ANDERSON. JOHN R, MD OTHOPEOICS
231$ kriptur, 0100
Denton, TX 76NI
8LAJR, MAJOR It,, Mo
♦100 ORTHOPEDICS
Denton, TX 76101
M"AVS. CHARLES A, MD ORTHOPEDICS
2313 $erootun, 0100
Denton, T% %301
PORTBRAELD, RNONDA R, MD PATHOLOOY
207 N. Bnnnk fine
Denton, TX 76201
SCHUCK ILAW G,. LPT PHYRCAL THamr, Not In 9/93 DL-00M
1Down,, Tx 76201 P.Jleet 411/1/"
ADMIRE, ROBERT C., MD VROLOGY
2509 S*lurc, 1100
News, `I'X 76201
THOMAS, THOMAS T., MD VROL00Y
Denton Rcdo"I Medlar Cce"
1-3, Su1te 0310
Decton. TX 76307
a
4
\rpdon\ord\"ur I ~ , o
loajNO
Indallem
ORDINANCE N0.
AN ORDINANCE ACCEPTING COMPETITIVE BIDS AND PROVIDING FOR THE AWARD
OF CONTRACTS FOR THE PURCHASE OF EMPLOYEE GROUP HEALTH INSURANCE TO
HARRIS METHODIST HEALTH PLAN; PROVIDING FOR THE ADMINISTRATION OF
THE CONTRACT; PROVIDING FOR THE EXPENDITURE OF FUNDS THEREFOR; AND
PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the City has solicited, received and tabulated com-
petitive bids for the purchase of employee group health insurance
in accordance with the procedures of state laws and
WHEREAS, the City Manager, his designee, and the City's pro-
fessional insurance consultant, have received and recommended that
th• bid described below is the lowest responsible bid for the
purchase of such insurance described in the Request for Bid No.
15231 and
WHEREAS, the City Council has provided in the City Budget for
the appropriation of funds to be used for the purchase of the
insurance policies and coverages approved and accepted herein;
NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINSI
SECTION I. That the bid of Harris Methodist Health Plan pro-
viding for the purchase of employee group health insurance is here-
by accepted and approved as being the lowest responsible bid and
the City Manager is authorized to execute two (2) contracts on
behalf of the City of Denton with Harris Health Plan, Inc., one
relating to the "Preferred Plan", and the other relating to the
"Preferred Plus Network". The City Manager is also authorized to
execute a "Group Enrollment Application" on behalf of the City with
docu-
Harris Methodist hereto end a incorporat d Company. Copies
by reference
ments are at herein.
SECTION II. That th0 Director of Human Resources, or his
designee, is hereby authorized to administer these contracts in
behalf of the City of Denton.
SECTION Ill._ That the City Council hereby authorizes the
expenditure of funds in the manner and amount as specified in the
contract.
SECTION IV._ That this ordinance shall become effective immed-
iately upon its passage and approval.
PASSED AND APPROVED this the day of 1993.
BOB CASTL.EBERRY, MAYOR
yeno3No
+genda!~em
late
-4e
ATTESTI
JENNIFER WALTERS, CITY SECRETARY
BYt
APPROVED AS TO LEGAL FORMI
DEBRA A. DRAYOVITCH# CITY ATTORNEY
BYt -
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Agendaita tit 3
oa(e / L , 3 =per
DATE: November 23, 1993
Q_TTY 99- QN 11 A_€PQK
SPECIAL CALLED SESSION
TO: Mayor and Members of the City Council
FROM: Lloyd V. Harrell, City Manager
SUBJECT: Harris Methodist Hospital Letter of Understanding on
City Employee's Health Insurance Program
B-U_QHME DATI4N
It is the staff's recommendation that the City Council authorize
the City Manager to appove the Letter of Understanding provided by .
Harris Methodist Health Insurance Company (Harris Methodist)
concerning the additional agreements for employee health insurance
coverage.
SUMMARY:
It is the interpretation of Harris representatives that current
state insurance regulations specify that any contract amendments
must be filed with the state for their approval. In order to stay
on track for the planned December enrollment insurance briefings,
a letter of understanding has been develuped specifying the rate
guarantee agreements, renewal agreements, and agreement concerning
network providers. Upon approval of City Council, Harris will file
these with the state. Upon approval, Harris and the City have
agreed to formally amend the contracts to incorporate the
provisions desired. The letter of agreement is shown in Exhibit
I.
Efl44~AN, ,pEPARTM~~_g~QgQ~P~~fE~4LriD;
The employee Health Insurance Program covers all regular full-time
and part-time employeso in all City departments.
E3 6AL D PACT
There is no fiscal impact accepting the letter of agreement.
However, once the state approves the agreements and the City and
Harris formally amend the contracts, the City's long-term ability
(up to three years) to budget, manage and control health insurance
costa should be improved.
t
.1U -
igCOitBfn
November 23, 1993
Report to City Council - Harris Letter of Understanding
Page 2
Respec Jlly submitted:
Li yd V. Harrell
City Manager
Prepared by:
Thomas W. Klinck, Director of Human Resources
Approved: Sett Mc an, Executive Director
M,jnicipa Services and Economic Development
ccrptASP.tk
PrlpArl0: 11/11/9)
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Date
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EXHIBIT I
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Agendd fem
Hams Methodist
Health Plan
LETTER OF UNDERSTANDING,
November 15, 1993
Mr. Thomas Klinck
Director of Human Resources
City of Denton
215 E. McKinney
Denton, Texas 76201
Re! Request for Did 61523
Dear Mr. Klinckf
it is our understanding that Harris Methodist Health Plan (KM P) and
tho City of Denton(City) agree to the following3
1. The City of Denton Request for Did #1523 page two (2) paragraph
two (2)rsading s •The City of Denton is seeking an insurance
policy/agreement to become effective January 1, 1994, for a
minimum of one (1) year. The policy shall provide, 'f not
canf-*116d prior to December 31, 1994 in accordance with the
terms of the policy/agreement, bid submission form, and/or
request for bidders, for the renewal of this policy for two (2)
successive twelve (12) month periods, thereafter subject to
renegotiation of the terms of this policy, if the City Manager
and insurance company agree, without the necessity of rebidding
this insurance proposal as long as the cost of insurance during
either the first or second twelve (12) month successive period
does not increase more than 301 and the plan design benefits do
not decrease more than 301. However, this proposal may be
terminated if insurance company and City are unable to agree in
writing to a mutually agreeable plan design and insurance cost
no later than swienty-five (75) days prior to the end of the
preceding period.' (This paragraph applicable to HMHP's Pre-
ferred Plus Plan.)
2. HMHP agrees to provide a rate guarantee through the second and
third plan year for the Preferred HMO Plan only. HM1iP's
conditions for the 1995 and 1994 rate guarantee are that the
A mlmbu of
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NOU-16-1993 16 20 FROM x"1H5-MANAGED CARE r9TG. TO 9181756662363669 P.03 T
!~7lt0111 -
Mr. Michael D. Clark -
November 15, 1993
Page 2
City's contribution to the employee rate for HMHP's Preferred HMO
Plan must be 100%* and HMHP will be the only carrier of-
fared by the City. The Preferred HMO Plan guarantee will be as
follows : 'The years 1995 and 1996 combined maximum rate
guarantee will not exceed a total of 15%. The year 1995 will
not exceed 9,9% of HMHP's 1994 rate.' l This paragraph applica-
ble to HMHP's Preferred Plan.)
3. As City employees' needs for additional health care services'in
the Denton area expand, the HMHP is committed to ongoing as-
sessment of these needs and expansion of HMHP's current network
through the recruitment of appropriately qualified providers to
serve these needs.
Ten (10) additional Denton providers have been approved recently,
and will be added to the network as soon as contracts are
executed. City's request for additional hospital service through
Denton Regional Medical center will be given consider-
ation for future needs. This ongoing effort will continue as a
part of HMHP's partnership with employer groups that HIP serves
in the Denton area.
4. This letter of understanding shall become an attachment to the
agreement of the parties authorized by City pursuant to the
ordinance approved on the day of , 1993, re-
lating to the award of Bid No. 1563, except for such portions of
this letter that are specifically rejected by the State Hoard of
insurance prior to September 1, 1994.
Please indicate City's acceptance of the above conditions by signing
below where indicated, and returning this letter to my attention.
Sincerely,
Michael D. Clerk
Senior Vice President
Managed Caro Marketing
City of Denton
by i
Title:
P
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A~ondaile
ORDINANCE NO.
AN ORDINANCE APPROVING A LETTER OF UNDERSTANDING BETWEEN THE CITY
OF DENTON AND HARRIS METHODIST HEALTH PLAN RELATING TO THE AWARD OF
BID NO. 15231 AUTHORIZING THE CITY MANAGER TO EXECUTE THE LETTERI
AND PROVIDING AN EFFECTIVE DATE.
WHEREAS, Harris Methodist Health Plan (HMHP) bid on behalf of
Harris Health, Inc. and Harris Methodist Health Insurance Company
to provide group health insurance to City employees) and
WHEREAS, HMHP is desirous of accepting certain portions of the
scope of specifications for Request for Bid No. 1523, but may be
unable to do so without approval of the State Board of Insurancel
and
WHEREAS, HMHP has presented a "Letter of Understanding" to the
City which sets forth issues mutually agreeable to the City and
HMHP and which the parties will pursue if such issues are not
rejected by the State Board of Insurancel NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINSI
AJQTION Jj That the City Council hereby approves the "Utter
of Understanding" attached hereto, between the City of Denton and
Harris Methodist Health Plan, and authorizes the City Manager to
execute said letter.
SECTION_ ii. That this ordinance shall become effective
immediately upon its passage and approval.
PASSED AND APPROVED this the day of , 1993.
BOB CASTLEBERRY, MAYOR
ATTESTt
JENNIFER WALTERS, CITY SECRETARY
BY I
APPROVED AS TO LEGAL FORMI
DEBRA A. DRAYOVITCH, CITY ATTORNEY
BYI
=CITY-
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Ags~dal~e
DATE: November 23, 1993
CITY COUNCIL REPORT
SPECIAL CALLED SESSION
TO: Mayor and Members of the City Council
FROM: Lloyd V. Harrell, City Manager
SUBJECT: Policy Establishing the Contribution Rate for City
Benefit Allowance (Policy #107.08)
RECOMMENDATION:
Should it be the desire of the City Council to set different
employee-only rates based on health risk differences and/or health
risk choices among employee groups, a resolution authorizing Policy
107.08 - Contribution Rate for City Employee Benefit Allowance
(Exhibit I) - would need to be adopted.
SUMMARY:
In order to establish a policy mechanism for staff to implement a
varying premium structure on the employee health insurance program,
the attached Policy 1107.08 - Contribution Rate for City Employee
Benefit Allowance has been drafted for Council's consideration.
This policy will allow the council to set the contribution rate,
for employees based on the employee's lesser or greater potential
for claims cost to the health insurance group. Factors which the
Council may wish to consider in establishing a variable
contribution rate are participation in the Health Risk Assessment,
non-tobacco use, etc.
PROGRAM DEPAR'T'MENTS OR GROUPS AFF CTED:
This Policy covers all regular full-time and part-time employees in
all City departments.
FISCAL IMPACT:
To the extent that a rate differential exceeds the previously
established employee-only contribution level, there could be a
budgetary impact.
ABB00241
I!
agenda No
Agendalle
Cate.-~
November 23, 1993
Report to City Council - Policy 1107.08
Page 2
Respec 111y/Submi ted:
v
Lloy V. Harrell
City Manager
Prepared by,
Tom w. Kl nck, D rector o Human Resources
Appro
Betty cKean, xecut ve D rector
Municipal Se ices and Economic Development
I
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i
L:p¢M i~
+gendaNo
4pendallera
Fate
EXHIBIT I
I
I
i
Benda No
kgondaIlem
);ie
CITY OF DENTON Page 1 of 1
POLICY/ADMINISTRATIVE PROCEDURE/ADMINISTRATIVE DIRECTIVE
SBC1I01: 16111PICI PORT
PERSONNEL/EMPLOYEE RELATIONS _ 107.08
BQBJBCI: BPPBCiJYi Q1T8:
EMPLOYEE BENEFITS AND SERVICES 01/01/84
LBP1iCB6
1JT6I:
CONTRIBUTION RATE FOR CITY
EMPLOYEE BENEFIT ALLOWANCE
POLICY STATEMENT:
The City Council may establish from time to time varying amounts of
the City's dollar contribution to the employees' benefit allowance
in conjunction with the employee health insurance program. The
City may provide different rates of contribution for employees who
represent a lesser or greater potential of claims cost to the
employees' health insurance group. The potential for claims costs
may be based on factors such as tobacco use or non-use and other
medically established health risk factors. The contribution rate
may also be based upon the employee's participation in a City-paid
health and wellness program that provides the employee
individualized and confidential information concerning his or her
current health and wellness status as well as recommendations for
improvement. Such payments will further the interests of the City
by potentially improving the health of its employees and, thus,
reducing health related productivity, and reducing the costs of absenteeism, hhealth insurances
ABB00242
i
i
E:\NCDDCS\RES\HEALTN.INS
Agenda No _
4Aaneallem,
Lace
RESOLUTION NO.
A RESOLUTION ADOPTING POLICY NO. 107.08 "CONTRIBUTION RATE FOR CITY
EMPLOYEE BENEFIT ALLOWANCE"; AND PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the Director of the Human Resources Department for the
City of Denton has presented a proposed policy regarding employee
rules and regulations for the Council's consideration; and
WHEREAS, the City Council desires to adopt such policy as an
official policy regarding employment with the City; NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY RESOLVES:
SECTION I. That the following policy, attached hereto and made
a part hereof, is hereby adopted as an official policy of the City
of Denton, Texas:
107.08 Contribution Rate for City Employee
Benefit Allowance
SECTION JI. That the foregoing policy is attached hereto and
made a part hereof and shall be filed in the official records with
the City Secretary.
SECTION III. That this resolution shall become effective
immediately upon its passage and approval.
PASSED AND APPROVED this the day of 1993.
BOB CASTLEBERRY, MAYOR
ATTEST:
JENNIFER WALTERS, CITY SECRETARY
BY:
APPROVED AS TO LEGAL FORMS
DEBRA A. DRAYOVITCH, CITY ATTORNEY
BY.,
C ITY=
COUNCI
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AgOr,AS~lO
DATE: November 23, 1993 C'9-T
CITY COMM REPORT
SPECIAL CALLED SESSION
TO: Mayor and Members of the City Council
FROM: Lloyd V. Harrell, City Manager
SUBJECT: A Resolution Setting the City's Contribution Rate to the
Benefit Allowance In Conjunctioi with the Employee
Health Insurance Coverage -1994 Plan Year
RECOMMENDATION:
It is the staff's recommendation that the City Council adopt a
resolution establishing the City's contribution rate for to the
benefit adjustment in conjunction with the employee health
insurance coverage for the 1994 Plan Year (January 1 to December
31, 1994).
Below are outlined four options for City Council consideration:
Option I - Original Proposed Structure (City Council - October 26,
1993 Study Sessicn - Exhibit I)
E 168.50 - Base contribution rate
+10.00 - Non-tobacco Use
+10.00 - Participation in Health Risk Assessment (HRA)
$ 188.50 Total employee only contribution
Option II - Revised ~iellness proposal
Due to concerns expressed about marrying the issue of the premium
structure (see Exhibit I) and the implementation of the wellness
initiatives, there were two special called joint meetings of the
Employee Insurance and Wellness Committees (Exhibit II). After
five hours of lengthy deliberations, a consensus of 18 of 27 joint
committee members voted to continue with an "incentive" rate
structure. While understanding the sentiment of tobacco users,
the majority of the combined group felt that there still needed to
be a rate differential to encourage healthy choices and to
encourage employees to participate in the health risk assessment
(HRA).
Discussions focused on the fact that without a differential, there
would not be a significant number of employees participating in
the HRA to gather credible baseli m data for decision making.
s
veodaNo
Agendalfeq.
November 23, 1993 Date
City Council Report - 1994 Plan Year Contribution
Page 2
This "bonus" approach was thought to take the sting out of the
issue for tobacco users who would still receive the $188.50, 92/93
level contribution if they also participated in the HRA. It
reversed the idea of the penalty to that of a "bonus" for healthy
choices. The biggest philosophical issue seemed to be to get the
largest number of employees participating in the HRA and this new
"bonus" plan was thought to be able to do just that. Much of the
rationale was based on past low participation in previously tried
City wellness education programs.
Their revised proposal rates (Exhibit III) follow:
$ 178.50 - Base contribution rate
+10.00 - Participation in the health risk assessment (HRA)
+10.00 - Non-tobacco Use benefit allowance
$ 198.50 - Total employee only contribution
Unfortunately, this plan had an additional estimated $44,000 price
tag.
Although not a consensus of the committee, several members did
vote to look at other incentives separate from the premium
structure, i.e., $25 to $75 one-time annual, "healthy choice"
checks for those who showed up for the HRA. However, again, the
costs ($20,000 to $40,000) associated with this proposal were in
addition to what our health insurance program was estimated to
cost.
Option III - Executive Staff Fro goal
The Executive Committee reviewed the joint committees' proposals
and wanted to show its strong support of the combined committees'
hard work and recognize their strong philosophical position. But
they also wanted to be sensitive to both the tobacco-user issues
as well as the budgetary impact that the committees' recommend-
ations carried. Thus, the Executive Committee developed a
compromise (see Exhibit IV) propcsal as follows:
$ 178.50 - Base contribution rate
+10.00 - Participation in Health Risk Assessment (HRA)
$ 188.50 Total employee only contribution (Same as 92/93)
This option implemented the $36,000 Wellness Budget to initiate
the baseline HRA; plus it had no further budgetary impact other
than what had already been presented to Council. It further
showed a strong commitment to review results from the aggregate
(not personal) health risk assessment data and to review follow up
t
gendaNo -
gsndalte
November 23, 1993 141e
City Council Report - 1994 Plan Year Contribution
Page 3
recommendations from the Wellness and Insurance Committees'
for future implementation (i.e. possibility of future year rate
differentials for health risk groups).
Option IV - Voluntary Health Risk Assessment (see Exhibit V)
A fourth alternative is to continue the FY 92/93 employee only
contribution level:
E 188.50 - Base contribution, rate
$ 188.50 Total employee - only contribution
This approach continues the established structure of applying
the same level of contribution for all employee groups
irrespective of health risks or health choices. The Fellness
Committee could still implement the Wellness Programs out of the
authorized $36,000 budget, albeit on a strictly voluntary basis.
The Wellness Committee, staff, and employees would then have an
opportunity to study whether voluntary participation will, indeed,
provide sufficient baseline date to be meaningful in achieving the
Wellness Committee's initiatives.
Twenty-one representatives of both committees met to again discuss
the possibility of this voluntary approach. An overwhelming
majority of the joint committees felt that this approach would not
ensure sufficient baseline data from the health risk assessment.
They expressed strong concern '.hat the structures recommended in
Options III and IV would not provide incentives to encourage a
high level of participation. The over-riding concern seems to be
capturing reliable baseline data in order to implement very cost
effective, targeted health programs.
SUMMARY:
The staff is recommending a phased approach to implementing the
Wellness Committee's initiatives in a fashion that will encourage
participation in the health risk appraisal (HRA) and attendant
health risk education programs established as a result of
analysis of HRA data.
Should Council choose to adopt OPTION IV, no accompanying policy
change is necessary.
RF30 R M. DEPARTMENTS_OF~OROUPS AFFEC1E0_
This plan covers all regular full-time and part-time employees in
all City departments.
4gep6aNo
November 23, 1993 Agvdaltem
City Council Report - 1994 Plan Year Contribution die
Page 4
FISCAL LMPACT~
Options III and IV will not have direct additional costs to the
City. This will provide the City staff with the needed direction
to implement the wellness programs. The Council has previously
concurred with the staff recommendation on October 26, 1993, to
fund an additional $17,000 to fully carry out the Health Risk
Assessment and educational and wellness programs.
Respe ullllyy submitted:
U
Lloyd V. Harrell
City Manager
Prepared by:
Thomas W. inck, Director of Human Resources
Approved:
B y McKe Executive Director
Municipal ervices and Economic Development
Crrptl3i.tk
Pr*paraa; 1!104193
Tema NO -
lenda item_,.
pit
EXHIBIT I
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Hins93z.wkl ,
HARRIS HMO ONLY I "iC
18-Nov-93 1994 PLAN PREMIUM a±F
05:00 AM JANUARY 1, TO DECEMBER 31, 1994
HARRIS - HMO ONLY - PREMIUMS
GROUP A: WELLNESS AND NON-TOBACCO USER
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTgI. 1994
RATE/MO PER/MO PER/MO
Employee Only $188.50 $186.50 $0.00
Employee 6 Spouse $292.98 $188.50 104.48
Employee 6 Child $253.13 $188.50 64.63
Enployee 6 Family $318.45 $188.50 129.95
GROUP B: NON-WELLNESS OR TOBACCO USER
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee Only - $188.50 $178.50 $10.00
Employee S Spouse $292.98 $176.50 114.48
Employee 6 Child $253.13 $178.50 74.63
Employee R Family ----$318_45----$178_50-----139_95-
GROUP C: NON-WELLNESS AND TOBACCO USER
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
_
Employee Only- $188.50 $168.50 $20.00
Employee 6 Spouse $292.98 $168.50 124.48
Employee d Child $253.13 $168.50 84.63
Employee 8 Family $318.45 $168.50 ---149.95
I
H1ns93z.wk1
HARRIS PREFERRED PLUS agenda No
18-Nov-93 1994 PLAN PREMIUM
05:00 AM JANUARY 1, TO DECEMBER 31, 1994 AgentlaIlam
Date
HARRIS - HMO PLUS INDEMNITY - PREMIUMS
GROUP A: WELLNESS AND NON-TOBACCO USER
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee Only $217.80 $188.50 $29.30
Employee & Spouse 337.59 $188.50 149.09
Employee 8 Child 291.85 $188.50 103.35
Employee 8 Family 368.08 $188.50 179.58
GROUP B: NON-WELLNESS OR TOBACCO USER
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee Only $217.80 $178.50 $39.30
Employee 6 Spouse 337.59 $178.50 159.09
Employee d Child 291.85 $178.50 113.35
Employee & Family 36808$178.50 189.58
GROUP C: NON-WELLNESS AND TOBACCO USER
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee Only $217.80 $168.50 $49.30
Employee d Spouse 337.59 $168.50 169.09
Employee 6 Child 291.85 $168.50 123.35
Employee d family 368.08 $168.50 199.58
4gandaNo
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EXHIBIT It
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4gendaNo
Ago~da!lem
EMPLOYEE INSURANCE COMMITTEE rele~
• ANO
EMPLOYEE WELLNESS COMMITTEE
The Employee Insurance Committee (EIC) was originally established
to advise the staff and Executive Committee concerning the
employee health insurance program when the City was self-insured.
The committee provided valuable and important in-sight into
employee concerns and issues. They were instrumental as the City
transitioned from a self-insured program to a fully insured
program. The committee is composed of representatives from major
department areas or smaller departments and divisions where one
employee representative can communicate with other employees and
there makes location or geographic sense to have a representative.
Each member is appointed by the Executive Committee.
originally, there was a sub-committee of the Employee Insurance
Committee called the Wellness Committee. When it became apparent
that the City wanted to more fully develop wellness strategies and
recommendations, the Employee Wellness Committee was established
with support from the Parks S Recreation Department. The
committee members are primarily those appointed from the Wellness
sub-committee of EIC and others who were interested and motivated
to work toward developing a better Wellness Program at the City.
Members of both committees and the departmental area represented
are attached.
F
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EMPLOYEE INSURANCE COMMITTEE LIST
Tom Klinck* Human Resources
Betty McKean* MS/ED
Lisa Creecy Customer Service
Joannie Housewright Police
Bill Fitzpatrick Fire
Linda Touraine Library
Joe Ialenti Community Services
Tonya Williams Water/Waste Water Utilities
Jerry Clark Eng 6 Transportation
Chuck Pierce Utilities/Electric
Tom Josey Municipal Court
Jennifer Walters City Manager's Office
Ike Obi* Human Resources
Chris Paulus* Human Resources
Jane Biles Main Street
Pat Lee Parks
I
* Ex Offico - No Vote
APP0001
s
4Qa1daNo
4Aardallem
WELLNESS COMNITTES LIST
Joseph Portugal City Manager's Office
Nona Garner Parks & Recreation
Brian Bender Parks & Recreation
Rhonda Gattis Parks & Recreation
Rich Dlugas* Parks & Recreation
Brad Fuller Fire Department
Tanya Cooper Legal
Carol Weller Library
Tom Klinck* Human Resources
Betty Wilkins Human Resources
Barbara Ross Planning & Development
David Ayers Engineering
Joseph Ialenti Community Services
Tim Hill Environmental Health
Kiersten Dieterle Energy Management
Max Blackburn Risk Management
Dan Scott Electrical Substations
Nancy Towle Water/Wastewater
Lloyd Burns Police
Velma Gray Wastewater Plant
Jennifer Miller Electric Production
Gary Griener Water Production
Loyd Ritchson Water Distribution
* Ex Offico - No Vote
APP004A1/2
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EXHIBIT III
i
H1ns93y.wk1 tjp!~3No _
HARRIS HMO ONLY A2~ cfICR1
18-Nov-93 1994 PLAN PREMIUM Rafe
04:56 AM JANUARY 1 TO DECEMBER 31, 1994
HARRIS - HMO ONLY - PREMIUMS -
GROUP A: WELLNESS AND NON-TOBACCO USER*
* 75% of Employees
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
-----RATE/MO PER/MO PER/MO
Employee Only $188.50 $198.50 ($10.00;
Employee 3 Spouse $292.98 $198.50 94.46
Employee 6 Child $253.13 $198.50 54.63
Employee 6 Family $319.45 $198.50 119.95
GROUP B: NON-WELLNESS and NON-TOBACCO OR TOBACCO USERS
* 25% of Employees - 200 tobacco users
CITY'S
1984 1994 EMPLOYEE
PREMIUM CONTRI. 1994
---RATE/MO---- PER/MO PER/MO
Employee only $188.50 $188.50 $0.00
Employee 3 Spouse $292.98 $188.50 104.48
Employee 8 Child $253.13 $188.50 64.63
Employee 3 Family $318.45 $188.50 129.95
GROUP C: EMPLOYEE UNWILLING - HEALTH RISK ASSESSMENT
(TOBACCO OR NON-TOBACCO USERS)
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
-----RATE/MO PER/MO PER/MO
Employee only $188.50 $178.50 - $10.00
Employee 6 Spouse $292.98 $178.50 114.48
Employee R Child $253.13 $178.50 74.63
Employee b Family $318.45 $178.50 139.95
i
Hins93y.wk1
HARRIS PREFERRED PLUS -
18-Nov-93 1394 PLAN PREMIUM
04:56 AM JANUARY 1, TO DECEMBER 31, 1994
HARRIS - HMO PLUS INDEMNITY - PREMIUMS
GROUP A: WELLNESS AND NON-TOBACCO USER*
* 75% of Employees
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Empioyee only $217.80 $198.50 $19.30
Employee 6 Spouse 337.59 $198.50 139.09
Employee d Child 291.85 $198.50 93.35
Employee a Family 368.08 $198.50 169.56
GROUP B: NON-WELLNESS and NON-TOBACCO OR TOBACCO USERS
* 25% of Employees - 200 tobacco users
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee Only $217.80 $188.50 $29.30
Employee d Spouse 337.59 $188.50 149.09
Employee d Child 291.85 $188.50 103.35
Employee a Family 368.06 $168.50 179.58
GROUP C: EMPLOYEE UNWILLING - HEALTH RISK ASSESSMENT
(TOBACCO OR NON-TOBACCO USERS)
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PFR/MO
Employee Only $217.80 $178.50 $39.30
Employee a Spouse 337.59 $178.50 159.09
Employee a Child 291.85 $178.50 113.35
Employee a Family 368.08 $178.50 189.58
Aacndallem _
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s EXHIBIT IV
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wela No
Hins93S.wk1 n^7 161_,._
HARRIS HMO ONLY
18-Nov-93 1994 PLAN PREMIUM "
04:53 AM JANUARY 1, TO DECEMBER 31, 1994
HARRIS - HMO ONLY - PREMIUMS
GROUP A: WELLNESS PARTICIPANT and NON-TOBACCO OR TOBACCO USERS*
* 95% of Employees
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONIRI. 1994
RATE/MO PER/MO PER/MO
Employee Only $188.50 $188.50 $0.00
Employee 6 Spouse $292.98 $168.50 104.46
Employee 8 Child $253.13 $188.50 64.63
Employee 6 Family $318.45 $188.50 129.95 4
GROUP B: EMPLOYEE UNWILLING - HEALTH RISK ASSESSMENT
(TOBACCO OR NON-TOBACCO USERS)
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee only $168.50 $178.50 $10.00
Employee & Spouse $292.98 $178.50 114.48
Employee R Child $253.13 $178.50 74.63
Employee d Family $318.45 $178.50 139.95
•
topdaNo~._._.__
Hins93S.wk1 4D,1u3I16Ri
HARRIS PREFERRED PLUS i2,}R
18-Nov-93 1994 PLAN PREMIUM
04:53 AM JANUARY 1, TO DECEMBER 31, 1994
HARRIS -HMO PLUS INDEMNITY - PREMIUMS
GROUP A: WELLNESS PARTICIPANT and NON-TOBACCO OR TOBACCO USERS*
* 95% of Employees
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee only $217.80 $188.50 $29.30
Employee 6 Spouse 337.59 $188.50 149.09
Employee 8 Child 291.85 $188.50 103.35
Employee 8 Family 368.08 $188.50 179.58
GROUP B: EMPLOYEE UNWILLING - HEALTH RISK ASSESSMENT
(TOBACCO OR NON-TOBACCO USERS)
CITY'S
1994 *m94 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee only $217.80 $178.50 $39.30
Employee 8 Spouse 337.59 $178.50 159.09
Employee 6 Child 291.85 $178.50 113.35
Employee d Family 368.08 $178.50 189.58
i
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EXHIBIT V
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Hins93R.wrt1
HARRIS P MO ONLY
18-Noy -3.; 1994 FLAN PREMIUM
05:02 AM JANUARY 1, TO DECEMBER 31, 1994
HARRIS - HMO ONLY - PREMIUMS
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/MO PER/MO
Employee Only $188.50 $188.50 $0.00
Employee & Spouse $292.98 $188.50 164.48
Employee & Children $253.13 $186.60 64.63
Employee 6 Family $318.45 $188.50 12.95
HARRIS PREFERRED PLUS
VJ4 PLAN PREMIUM
JANUARY 1, TO DECEMBER 310 1994
HARR-HMO PLUS INDEMNITY - PREMIUMS
CITY'S
1994 1994 EMPLOYEE
PREMIUM CONTRI. 1994
RATE/MO PER/M0+ PER/MO
Employee Only $217.80 $188.60 $29.30
Employee 6 Spouse 337.69 $183.60 149.09
Employee 8 Children 291.85 $186.50 103.35
Employee 6 Family 368.08 $188.50 179.58
Et\W00Cf\*66\C0UT.k
~ge~~alio~t
RESOLUTION NO.
A RESOLUTION OF THE CITY COUNCIL ESTABLISHING THE CITY'S CON-
TRIBUTION RATE TO THE CITY EMPLOYEE BENEFIT ALLOWANCE: ESTABLISHING
PAYMENTS THAT THE CITY WILL MAKE TO EMPLOYEES; AND PROVIDING AN
EFFECTIVE DATE.
WHEREAS, the City Council has adopted Policy No. 107.08
providing for the City's contribution to each employee's benefit
allowance: and
WHEREAS, pursuant to this policy, the City Council wishes to
establish such contribution rates: NOW, THEREFORE,
THE COUNCIL OF THE CITY OF DENTON HEREBY RESOLVES;
SECTION I. That the City hereby adopts the following contri-
bution rates for each employee's benefit allowance, effective
January 1, 1994;
SECTION II. That this resolution shall be effective immed-
iately upon its passage and approval.
PASSED AND APPROVED this the day of , 1993.
BOB CASTLEBERRY, MAYOR
ATTEST'
JENNIFER WALTERS, CITY SECRETARY
BY3 _
APPROVED AS TO LEGAL FORMS
DEBRA A. DRAYOVITCH, CITY ATTORNEY
BY; . nk, k"44~~d
CITY
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Apan6a(t i
CITY of DENroN, TEXAS MUNICIPAL I U1LDlNC / DENTON, TEXAS 76201 / TELEPHONE (817) 566.8200
M&MORANDUM
TO: Mayor and Members of City Council
FROM: Lloyd Harrell, City Manager
DATE: November 18, 1993
SUBJECT: Denton Municipal Complex Roof Leakage
we are very proud to report to you that the downtown revitalization
of Denton Municipal Complex (DMC) is progressing.
The innovative financing budget (combined lease revenues and bond
funds) includes monies to install a new roof on the DMC project.
Additionally, we had set aside funds to install a new roof on the
Cooke County College area and, depending on the bids, the Morrison
Milling area too. In order to accorcplish installing new roofs on
these three areas, we had planned to complete the roof installation
separately after the DMC Renovations were completed.
Unfortunately, the existing roof has lost its integrity (See
attached Armco letter dated November 16, 1993!. Therefore, it is
essential that we repair the current roof or install a new roof to
prevent halting the interior construction.
The contractor, Sceeie-Freeman, inc., states it will be necessary
to stop work if we cannot resolve the roof leakage problem (see
attached Steele-Freeman letter dated November 8, 1993). Due to
the continued leakage and the possible cost incurred if the project
work stops, we need to act immediately. We must repair or replace
the DMC roof. It does not appear to be prudent to spend $30,000 to
attempt to repair the roof. Any repairs would only be temporary
and would not last more than three to six months.
Steele-Freeman estimated it will cost $242,800 to install a new
10/15 year roof (see attached Corgan 1.3tter/change order dated
November 17, 1993). Steele-Freeman will oversee the roofing
company and assume liability for the roof. The City ruoi'ing
consultant will also oversee the project to ensure quality
materials are used and the roof is constructed to last a minimum of
10 years.
Page 2
DMC Roof D2rEt_"
November 18, 1993
Available options:
1. Temporarily repair the roof for approximately $30,000.
Hope the repairs hold and bid the roof contract in June
1994. Implementing this option will cost approximately
$267,800 which inclvles the repair cost of $30,000 and
the low quote as propooed recently by Steele-Freeman.
(See attached OPTION 1)
2. Accept the change order at a cost of $242,800. Resulting
in one contractor, Steele-Freeman, being liable for the
construction and roofing and, thereby, also expediting
this critical process. (See attached OPTION 2) This As
the staff's recommendation.
3. Immediately place the project out to bid. The bid
process will take approximately six to eight weeks.
Steele-Freeman contends (See attached Steele-Freeman
letter of, November 8, 1993) that the City could be
assessed a penalty for the extra cost the contractor
incurs due to the construction delay. These cost could
be approximately $40,000 to $60,000 ($3,000 per day).
(See attached OPTION 3)
We will be prepared to discuss budget and options on November 23,
1993 at the work session prior to the regular session. I
Staff recommends the City issue a Change Order to Steele-Freeman
for $242,800 to perform this work.
C4/t Ily submitted:
V. Ha rell, C y Manager
Prepared by:
ruce Hen ngton Fac lines Manager
Attachments
1627.FM
at
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qendaNo.
kgeit illem_~._..,.........._.-
PHASE I t~IP
BUDGET NEW ROOFS
New Roofs
Acct. # 450-032-DMCI-9318-9101 $ 295,831
Estimated cost for 198,199?
Denton Municipal Complex
Estimated cost for t 28,568)
Cooke County College
Estimated cost for ~~91
Morrison Milling 70
$ 0
BALANCE
11/18/93
1627.FM
b
room It.l6.1993 S61$1
P.
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' aQa~daMo
November 10, 1093
q~oadallertL,_,~
Mr. 11te
Bruce nnlnpton
City of Denton
City AR~O
801-B Texas Street 3003 LSJ FAWY„ SUITE 237
Denton, TX 7$201 DALLAS, TEXAS 73234
214!243-1441
Re: Moore Building
Deer Mr. Hennington:
This letter references the Moore Building construction project and addressee the need to
either temporarily repair the facility until project completion In August or initiste a complete
reroof at this tiros,
There are approximately 40 leaks on the Moore Building at this time effecting a total of
spproxlmst ly $0,000 square feet of roo ing There Is a considerable amount of
deteriorating roof mat which will roqulrs jxturulve repairs In order to keep the building In a
usable condition,
The approximate initial cost to temporarily repair We facility Is 438,000. This cost might
well be Inflated with the ongoing repair@ which will be required to maintain the building.
Another consideration to take into account Is whether there Is a penalty clause applicable
to the City If the General Contractor, Steele Freeman, Is held up due to rein delays, This
daily penalty will also add to the total cost of the project.
It Is our considered opinion that It will not be In the best Interest of the City to embark on a
project of temporarily repairing this roof because the met*rials have lost their tensile
otrongth and there Is significant evidence of dry rotting, To attompt temporarl repairs on a
roof with the condWons Indicated here would be an ongoing maintenance pro +-orm
throughout the project,
Please feel free to call if you have any questlons,
Sincerely,
Mike Barton
Aeglonsl Vice President
MBlvb
HW-11-1993 09 26 FROM CpRGgry ASSOC. ARCHITECTS TO 1817SUA242 P.o2
Agenda NO
STEELE*MEMAN, INC: oats
0lNEItAI CONTRAVORS
ISMLAWSONNOAOIPORTWORTM,TEXAS M31!l17r23247i21FA7falriz~i:i;~s' ~Cr
NOV O 9 ?993
November 8, 1993
1
Mr. M Croth
Corgen Associate Architects
501 Elm Street
suite 500
Dallas, Texas 45242
Re - Denton Municipal Complex
Notice of unknown physical condition
Dear Mr. Croth
This letter is a nfirmation of our oral conversation on October 18th, 1993 with you
on the above referenced project. In that conversation, we informed you that we
encountered an excessive amount of leak. in the existing roof which would not allow
for us to proceed with the interior finishes of the building.
This is formal notice in accordance with Article 4. 3.6 of Document A201 which forms
the general conditions of the above referenced contract.
In submitting our bid for the above referenced project we relied upon the bidding
documents and our prebid site investigation of the existing roof. No reasonable,
prudent Contractor could have foreseen the extent of the roof damage that was
involved. The weather was clear and thert£ore, no leaks were apparent at the time
of review.
Before we proceed further with the finishes of the interior, we request that you
investigate these field conditions to verify our assessment of the situation.
We will be receiving bids for repairing the roof as directed this week. Following
review of the bide, we will be submitting a claim for extra costs incurred due to
these latent site conditions as well as for an extension of the contract schedule, if
necessary. Our claim will include costs incurred by us, our, subcontractors, delays
caused by this. latent site conditions to the rest of the project, together with
reasonable allowances for indirect costa, any attorney fees if applicable and profit.
The pt,rticulars of the claim shall be presented to you when they are assembled.
weau~
1 wworlnn ~ nnl>Ae 1 1 T^ •.1 P••---• I
NOV-11-1993 09=27 FROM CORUM ASSOC. WCHITECTS TO 19175669242 P,07.
Ager1OaNo -
Page I of a Ago~datitem..-
Dale
Thank you for your time and consideration.
Sincerely$
1~ Freeman
Project Manager
r
e
igor,d~ Pao.
4gi 5~aitem
17 November 1993 lite
Mr. Bruce Henangtoa
Superintendent, Facilities Management
Clry of Denton, Civic Center
321 Bast McKinney
Denton, Texas 76201
Re: City of Denton
Dear Bruce:
We have completed our review of the three proposals submitted by
Steele Freeman for reroofing the new Municipal Complex project.
We offer the following comments regarding these proposals-
1. The City originally intended to issue a separate
contract after the Steele Freeman contract was
completed. However, the deterioration of the roof
unable to nstall f nishesain the building due tom
excessive leakage.
This condition requires that the pltyy either spend
approximately $35,000 to temporari ly patch the roof
to not to delay the gone ral construction work or
reroof the project at this point. The first option is
not recommended because the repairs will only, be in
place a short time until a new permanent roof is
required.
2 writhe atsosistancerof the City roofing co qqnsulttan,t, d
Mike Barton, and Corgan Associates to obtain 3
reroofin ro~osals from qualified subcontractors
throughgSteeie Freeman. Steele Freeman has
offered a negotiated credit of $2,774.09 b forgoing rwy,~ y,t~i,,,,AeNUnf
some of the 10% profit and overhead which they are KiVIMStroll
due by contract in the spirit of cooperation. rJUeoo
0Old, ?,x0176M 3W
To lid 764 M
PON In
lut~Mervra
fo~u lunMWl~ur~eD~H9~
►~02flONb1 ahL6! Collor Pawl
TCTAL P,P1
to
A$ondalio
Mr. Bruce Heninglon X18 '
17 November 1993
We recommend acceptance of the low proposal in the amount of
$242,800 as representing a fair and equitable price to reroof the
complex and eliminate delays and or damage to the already
contracted work,
Please call if you have any questions or concerns.
Very truly yours,
rent Byers
Principal
cc: Tom Shaw
s
e
'r
92OXODINTAW
ti
VhANLAL ,IN ~I.II I:i
AKCIIi'rFC'I' fK '
ORDER CONIKACA08 r>7 ~oa~aNa__...
FIELU
A/A 0001,1I NT 6701 0111EK ❑
Date
Denton liunicipal Complex CRANGE ORDER NUMBER: One
PROJECT:
(name, address) DATE: t>` a /V 3 r " 1 ` a 3
O Cl)N7'RACI'UR' AKC}II S'EC i"5 PROJECT NO: 92029.00
(name,address) Steele-Freeman, Inc.
1301 Lawson Road CONTRACT DATE,
Fort Worth, TX 76131 CONTRACT FOR: Renovations
I he Contract N changed as follows,
Provide reroofing as per ARMKO and Mike Barton specifications and drawings and as per
Steele-Freeman Proposal 83 Revised II dated-11/16/93,
Add $242,800.00
Not valid until signed by the Owner, Architect and Contractor.
The original (Conaaet Sunl)(G 21347,000.00
0.00
Netchange by prcvWusly authorized Change Orders 2 347 000.00
TIM(CunlractSum) ( prk,r to thei Change Order% js J r 1
rile (Contract 5umy ( will be (Irxreawd) plrArwlwntil 242,800.00
by ilik Change Order in the amount of 1
The ne w (Cunt racy 5um)' including this Change Order mill he f 2l589,800.00
(
The Cnnvact TAne will be (:a1)(dwrwr5A*A) (uncleanged)by 0 )days
1'he d:ur of suhsixiiial Complotun as of the d.nc of this Change order therefore Ls August 19,1994
P.011 1111, Sall Ill IX) l1i w, nl,t rokkt dutlgrl in Illy GAll raft hill I. lknllrX 11101e ur Guarallr,ed MaAallulil Prkc *hkh ha1'e been a(Ilhuwcd t>)'
I ulblr AOII ( II.ulgt Illlelllrl'
Corgan Associates Architects Steele-Fr a n _ City of Denton
AN(, u CI IN1 NAC1511 WX NER
rl i-i -I
90 L 1m S l;rsE t L_$~i_t e_ M_ E, cKi ne
a 3~ - - Aaurc.,
AWrc}n AdJrnN%
mall ~__32.0 _ Eot _SdOr 6L_ Iyentnn.-TX-2I'?o1
tp~ eY
KY I -
1 1 CAUTIONi You should alga an original AIA document which has this caution premed In red.
An origlul assures that changes will not be obscured as may occur when documents are reproduced.
AIA OMMENT 0701 ( ILIANLr U1114A 6 hen} o-.unlUN ( NA+ 0 UW . Tlly 0101-1gbT
ANINILAN IM111U11 Ur AK HtrtlCT5, 1731 NENV MONK AA. N`t', M'A.SHINntON, nL tOV,
WARNING: UnikMMd phatotepyhlq Vickie, U,e. copyr4M IawA and 1514W to legal plosecullooi.
~17-~_3-:113 STEELE-FFEEGG,N INC. 13'. ='4:: luj'! Ib 'd 1.1,£„
REQUEST FOR CHANGE ORDER
Proposed Change A 3 REVISED, II
Dates November 16, 1993
Job Name: DENTON MUNICIPAL COMPLEX
Job Numbers 2615-1
Description of change: J.dd to re-roof areas C, D, E, F and G outlined in
specifications for roofing at City of Denton Moore Building noted as project
number 31931101. Scope of work to include demolition of existing roof, required
repaizs per unit prices and replacement of roof per plans and specifications.
WORK ITEMS QTY UNIT RATE LABOR MAT'L EQUI SUB
1. Roof ng Su ontraotor 1 ! 220711.00
(RHS Company)
*Unit Cost Proposal Attached : s s
: I
TOTALS : 220711.00 s
SUBTOTAL A, B, Co D $220,711.00
(E) LABOR BURDEN 40% OF A ($1065.48) 0.00
(F) TAX ON MATERIALS 04 0.00
i220~710.00
Contractors fee 10% of A,B,C,E,F
Contractors fee 106 of D 22,071.10
SUBTOTAL $24-
BOND, INSURANCE & AGC 1.15% 2,791.99
SUB-'TOTAL $245o574.09
STEELE-FREEMAN, INC. (NEGOTIATION CREDIT) 2,774.09-
TOTAL CHAN08 TO CONTRACT iADD) $2420800.00
4?i'r~;;'tam
OPTION 1
New Roof $ 296,831
Repair DMC Roof ( 30,000)
Probable Low Bid (237,800)
Cooke County College ( 28,568)*
Morrison Milling ( 70,064)*
BALANCE $ ( 69,601)
NOTE : We have $75,000 in the DMC Contingency
Fund. We do not want to use this
money for roofs this early in the
process.
* These are approximate figures.
11/18/93
1627.FM
i
)"UaNo _
Apcod~ltoa~.___
OPTION 2
New Roof $ 296,831
Change Order #1 (242,800)
Cooke County College ( 280568)*
Morrison Milling 70.064)*
BALANCE $ ( 44,601)
NOTE: We have $75,000 in the DMC Contingency
Fund. We do not want to use this
money for roofs this early in the
process.
* These are approximate figures.
11/18/93
1627.FM
~9rIQ3
OPTION 3 dz+'tenL ,„_,_~y
New Roof $ 296,831
Probable Low Bid (237,800)
(See attached quotes)
Cooke County College ( 28,568)*
Morrison Milling _ ( 70,064)*
Minimum Delay ( 40j,000)*
BALANCE $ ( 79,601)
NOTE; We have $75,000 in the DMC Contingency
Fund. We do not want to use this
money for roofs this early in the
process.
F
* These are approximate figures.
11/18/93
REQUEST FOR CHANGE ORD "
.
Proposed Change N 3 REVISED, 12
Date: November 16, 1993 v
Job Name: DENTON MUNICIPAL COMPLEX
Job Number: 2615-1
Description of change: Add to re-roof areas C, D, F., F and G outlined in
specifications for roofing at City of Denton Moore Building noted as project
number 31931101. Scope of work to include demolition of existing roof, required
repairs per unit prices and replacement of roof per plans and specifications.
WORK ITEMS QTY UNIT RATE LABOR MAT'L EC,iJI SUB
1. Roofing Subcontractor 220711.00
(RHS Company)
:
'Unit Cost Proposal Attached : s : s s
:
:
TOTALS 220711.00
SUB-TOTAL A, 8, Co D $220,711.00
(E) LABOR BURDEN 404 OF A (51065.48) 0.00
(F) TAX ON MATERIALS 0% 0.00
5220,711.00
Contractors fee 10% of A,B,C,E,F 0.00
Contractors fee 10% of D 22,071.10
SUB-TOTAL $24 2.1
BOND, INSURANCE b AGC 1.154 21791.99
SUB-TOTAL 4T 0V
STEELE-FREEMAN, INC. (NEGOTIATION CREDIT) 2,774.09
TOTAL CHANGE TO CONTRACT (ADD) 5242,800.00
r
- i
k.r~J.}do
p to n
' REQUEST FOR CHANGE ORDER
Proposed Change N 3
Date: November 11, 1993
Jab Name: DENTON MUNICIPAL COMPLEX
Job Number: 2615-1
Description of change: Add to re-roof areas C, D, E, F and G outlined in
specifications for roofing at City of Denton Moore Building noted as project
unit prices and Wreplacementuof demolition of
r pairs 31931101. Scope of
(A) (B) SC) (D)
WORK ITEMS QTY UNIT RATE LABOR MAT'L EQUIP SUB
- 232,000.
1. Roof ng subcontractor ;
(C. D. McKamie)
. 5,800.
2. Roofing Bond (2.5%)
~ 237,800.
TOTALS $237,800.
SUBTOTAL A, B, C, D 0
(E) LABOR BURDEN 40% OF A 0
(F) TAX ON MATERIALS Oi y237,800.
0.
Contractors fee 10% of A,B,C,E,F 23,780•
Contractors fee 10% of D 5261,580.
SUB-TOTAL 9,008.
BOND, INSURANCE 6 AGC 1.1.5% $264,596.
TOTAL CHANGE TO CONTRACT (ADD/#tffl4 J)
A
.4par~d~ho --F 10
IS. 9.1997 I5101
FROM
i
PAGE 2 OF 6
PROJECT #31931101
PROPOSALI REROOFINO AT CITY OF DENTON O~
MOORE OUILDINr3
CONTRACT DOCUMENTS: Heving exemined the Proposal, Contract, 0sneral Instructions,
Materials, lark, and havngexamine* rthe lpromises rand circumstances affecting the work,rthelnq
undefeigned offer;
OFFER: t, To furnish all labor, materiel, tools, equipment, transportatlon, bonds, oti
epplIcable takes, Inoldentals, and other facilities, end to perform all work for the said
reroofing tot tl following area:
000 SID NO, 1 • ROOF AREA C
68 800.
BASE BID NO, 2.1100E ARIA D
- a 53,650.60
BAST' BID NO.3 • ROOF AREA E
. .691600.40
SASS 510 NO. 4 • ROOF AREA F
s 30,30,
WE $10 NO.5 • ROOF ARIA 0
i ~ ~84r062.00
LUMP SUM BID FOR ROOF AREAS C, 0, E, F, AND 0
! 3'2x.4620
- a ti! yyr~iices occlude eels tax.
UNIT FRICI~f1A AL:
1, Remove and replace damaged concrete decking: e1a.00„ per square toot,
g. Remove and replace deteriorated nalltrs: 1 249 per linear foot.
3. Additional colt over and above the contract amount for replacing wet insulation: '
Uilt. pat equals foot.
4. Additional cost over and above the contract amount for replacing wet fill moterlal
t0ypeumf: 12,07- per inch per square foot.
8c
NO.
AN ORDINANCE AUTHORIZING THE EXECUTION OF A CHANCE ORDER TO A
CONTRACT BETWEEN THE CITY OF DE:NTON AND _ i
PROVIDING FOR AN INCREASE IN THE CONTRA
EFFECTIVE DATE,
WHEREAS, on the City awarded a contract for
the construction o Berta n mprovements to Steele-Freeman Inc.
in the amount off'" 2,347,000100 i an3
WHEREAS, the City Manager having recommended to the Council
that a change order be authorized to amend such contract with
respect to the scope and price and said change order being in
compliance with the requirements of Chapter 252 of the Local
Government Code; NOW, THEREFORE,
BE IT ORDAINED BY THE COUNCIL OF THE CITY OF DEMON:
SECTION I. That the change order to the contract between the
City an a' Steele-ereem a copy of which is
attached fiereto,~Tn t e amount Aof pS,
el ht hundred o ars . is
or y approve an t e expen ture of funds t are or siereby
authorizel.
SECTION II. That this ordinance shall become effective
imme ate y upon its passage and approval.
PASSED AND APPROVED this the day of 1993,
BOB CASTLEMRY, MAYOR
ATTEST:
APPROVED AS TO LECAL FORM:
DEBRA ADAMI DRAYOVITCH, CITY ATTORNEY
BY:
CITY===
.COUNCI
4 ~ n-
0
°0~c accec`~
bi\clarkhen.o
agenda No.
4gentfalte
ORDINANCE NO.
AN ORDINANCE OF THE CITY OF DENTON RETAINING THE LAWFIRM OF CLARK
HENDERSON & WOLFE TO REPRESENT THE CITY OF DENTON IN LITIGATION
PENDING AGAINST THE CITY; AND PROVIDING AN EFFECTIVE DATE.
THE COUNCIL OF THE CITY OF DENTON HEREBY ORDAINS:
SECTION I. That the Council of the City of Denton approves
the retainer of the lawfirm of Clark Henderson & Wolfe to represent
the City, at the normal City billing rates, in pending litigation
styled Williams et al Y. Cabrales, et al.
SECTION II. That this ordinance shall become effective
immediately upon its passage and approval.
PASSED AND APPROVED this the day of November, 1993.
1
BOB CASTLEBERRY, MAYOR
ATTEST:
JENNIFER WALTERS, CITY SECRETARY
y
BY:
i
i
APPROVED AS TO LEGAL FORM:
DEBRA A. DRAYOVITCH, CITY ATTORNEY
BY: ~ f/ l~ _
~COUNCI
Goc
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A000. 3 "
A~dalt
CITY Cnrrunir REPORT FORLAT
TO: Mayor and members of the city Council
FROM: Lloyd V. Harrell, city Manager
SUBJECT: Cushman Escrow Agreement
RFrMEDAT I ON :
Exercise the agreement by using funds to cover road construction
costs for the 99 feet of frontage on Spencer.
amflmm
city crews will reconstruct the road using a subThede stabilizer
and full depth asphalt as per City regulations. co of curb
and gutter ($800) which is not proposed for this project would be
refunded to the Cushmans.
r BACKG OUND:
Escrow was set up to cover perimeter street paving in 1983. City
has plans to rebuild road from Woodrow to Loop 288 and need this
escrow to cover total cost of project.
DEPARTMENTS OR GROUPS AFFECT FM
Street Division Repaving Program, Engineering and Transportation
Department, Utility Department, and the Cushmans
~S~pk.IMP CT:
Total cost of the
Use $3200 of escrow and refund 5800 to Cushmans.
project is estimated at $60,100.
FULLY S TIED:
Llo V. Harrell
City Manager
Prepared by:
J 7 r} C rk
D ret;to o Engineering S Transportation
Approved:
Rick Nehla
Deputy City Manager
AEE002AD
Agenda No.
Age~daftEm
Date -r
MEMORANDUM
DATRi November 3, 1993
TOt Rick Svehla, Deputy City Manager
FROMi Jerry Clark, Director of Englneering & Transportation
SUBJECTI Public Hearing - Cushman Escrow
The escrow agreement for perimeter street paving of Spencer That as part of he
Cushman Addition, Lot It is ready for the public hearing. congider&tiOm
would involve the City of Denton exercising its option to call the escrow funds
to participate in rebuilding of this road.
We have recently formed a cooperative venture with Utilities to fund rebuilding
Spencer Road from Woodrow Lane to Loop 288. The Cushman Addition lies on the
east and of this project.
The Cushman escrow is for $4,000 of which $800.00 was to pay for curb and gutter.
We recommend that we call the escrow account for $3,200 and refund $800 to the ans. beenmdevel utiallizleprocedud even through Legal not
This escrow account should be used to fund rebuilding Spencer a■ per the original
agreement signed by Mrs. Cushman in 1984. Since that time, she has made several
claims against the escrow ordinance (the incorrectness of the ordinance and its
validity). This agreement allows for a nine year call period plus a one year
period to hold a public hearing, This requirement has been consistent since the
1983 subdivision regulation modernisation, The recent state law requires that
those type escrows be, connected to C1P projects to be built in the next two years
as per impact Cee lgislation. That in the current ordinance and has a very
recent history only,
our recommendation is to utilize these funds to participate in this paving
project for Spencer Road. We recommend that $600 be refunded to the Cushmans
since no curb and gutter is involved.
Jerry Clark
AEE00260
d
1
AQ°Odd~do.
ESCROW AGREEMENT INSTEAD OF PERFORMANCE BOND
THE STATE OF,TEXAS S ;
KNOW ALL MEN BY THESE PRESENTS:
COUNTY OF DENTON,S
That AiChard H b arnlyn S riiahman of the City of Denton , County of Denton , and
State of Texas, as PRINCIPAL, aie held and firmly bound unto the
City of Denton, in the penal sum of Forty-four hundred eighty and no/100
($4,480.00 )
for the payment whereof, the said Principal and Surety' bind
themselves and their heirs, administrators, executoFs, successors
and assigns, jointly and severally, by these presents:
V;HEREAS", said Principal has filed with the City'' of Denton a
plat of a subdivision in the City of Denton or its extraterritorial
i
jurisdiction; more particularly described as The Cushman Additions Lot 1
subdivision, and, indorsed thert,on, the agreement of Principal to
install in the subdivision improvements and utilities, to-wits
Street paving, drainage and curb, on section of land 100
ft at- Iona -J 1 eea•1 wiAra,
required by law to be installed prior to issuance of building per-
r.its in said subdivision; and
PAGE O;tE
A65a:~F+iC~t _ „
WHEREAS, provision has been made by law and ordinance whereby
the Principal may, in lieu of the final completion of said
improvements and utilities, file a Escrow Agreement acceptable to
the City of , Denton in favor of said City, which shall indemnify
said City and secure to said City the actual construction of such
improvements, and utilities in b manner satisfactory to said City,
in the event said Principal shall fail to install said
improvements and utilities within 366 days from date hereof;
and
WHEREAS, developer has designated First State Hank of Denton, Texai'
as escxow agent hereunder; and
WHEREAS, developer has entered into the following contracts
for the development and,,instt.llation of the following improvements
and utilities, to-wits.
100 feet long byl17 feet _wid-, street Paving drainage and
curb
NOW, THEREFORE, the City of Denton, Developer and First State
_.Bank of Denton hereby agrees as follows:
1, All parties agree that the said sum of S 4,480.00 will
be held on account with First State Bank o! Denton and that
withdrawals will be rade only for the payment and cor;leticn cf
the above described utilities and improvements, and that .First
State Sank of Denton agrees to noid said su;a for this 'r'urp.-se
PAGE Ti-110
g
v c
AoWi No,
until all said improvements are installed and approval rind
acceptance of said improvements are given by the City of Denton,
Texas.
2. Any interest which may accrue on the escrow account may be
retained by the Developer provided that all said improvements are
cumpletsd, approved and accepted by the City.
3. Developer agrees to pay any and all escrow fees charged by
First State Bank of Denton for handling the said escrow account.
4. The City shall give written notice to Developer and
First State Bank of Denton prior to taking exclusive control and
possession of said escrow account as provided for by the attached
escrow agreement.
IN WITNESS WHEREOF, the parties to this instrument have hereto
set their hands, executed as to the original and two copies, on
k this the 6th day of January , 1984.
CITY OF DENTON, TEXAS DEVELOPER
BY: BY:
ESCROW AGENT
First Skate Bank of De ton ,
Jerry ?a pop Vice President
FAZE TLF.zT.
1
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r 0.9831 Acre
Y
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LOT ONE
' •fwrD1 Cufr v~r, r„
I V BLOCK ONE
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._.•a_,~ra •~Bs w 0000' ! . M"4l'l°iGt-q~uoo~rtr
i7 eSeHaft e~nND
Age Ida Mo -w......,....
May 28, 1993
City of Denton
Mr. David Ayers
Municipal Building
215 E. McKinney
Denton, Texas 76201
RE: Escrow Agreement-Cushman Addition, Lot 1
Dear Mr, Ayers:
Please consider this a written request for my money which is still in
escrow with the City of Denton.
As you know, I have been requesting that this money be released to me
since 1989. And I firmly believe that it should already have been,
Respectively yours,
Carolyn S. Cushman
i
2536 La Paloma
s, Denton, Texas 76201
i
COUNCI
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AQMO~I
Dote ~
CITY of DENTON, TEXAS MUNICIPAL BUILOINO I DENTON, TEXAS 76POf / TELEPHONE (807)565-830
Office of the City Secretary
MEMORANDUM
DATE: November 17, 1993
TO: Mayor and Members of the City Council
FROM: Jennifer Walters, City Secretary
SUBJECT: Board/Commission Appointments
The following is a list of the vacancies for the City's
Boards/Commissions:
Elpi Code Esoard - Alternate position vacant - Council Member
Chow has nominated Robert L. Hicks.
Keep Denton Beautiful Board - Council Member Perry has nominated
Kanlice Gandel. Council Member Chew has nominated Herman Wesley.
` Juvenile Diyersi4n Task Force - Council Member Miller has nominated
Cindy Sill.
If ou need any further information, please let me know.
Je n r ers '
Ci y ecret r
AC 0 OF4
c
HANDOUT TO COUNCIL - 11/24/93
ALTERNATIVE WELLNESS INCENTIVE I~(li►t~l t~m~-------~-----
(OPTION 5) Uale
USING SOME OF THE $201,000 SAVINGS FROM CHANGING INSURANCE:
1. $50.00 CASH TO ANY EMPLOYEE WHO QUITS SMOKING OR USING TOBACCO
FOR ONE YEAR.
2. $25.00 CASH TO ANY EMPLOYEE WHO PARTICIPATES IN THE HEALTH
ASSESSMENT PROGRAM.
3. FULL FUNDING FOR WELLNESS INITIATIVES ON TOBACCO PROGRAM AND
HEALTH RISK APPRAISAL PROGRAM.
SENEEITSl
1. No unneceseary entanglement with insurance rates or issues.
2. No artificial gapa in insurance benefits. No contrived
"incentives" known as "health insurance premium discounts."
3. No use of penalties or fines for non-participation. Directly
rewards participating employees for sought after behavior.
5. Benefits are in hand rather than on paper.
6. Employees are likely to view Option 5 more favorably.
7. Greater participation can be expected through the uce of real
rewards.
LIABIL.IMS,
I
1. The additional cost would have a direct and sizable impact on
the budget with no guarantee of a measurable positive impact on
employee health or health insurance claims.
2. Future budgets may not have funds available to continue the
program.
3. Guidelines must be developed by the Wellness Committee to
implement the plan.
4. No reward for employees who don't use tobacco, only those who
quit.
4 HANDOUT TO COUNCIL. - 11/24/93
gaidaNo - - -
Harris Methodist ;~c~aa;tem
Health Plan rie
LETTER OF UNDERSTANDING
November 23, 1993
Mr. Thomas Klinck
Director f Human Resources
city of Denton
215 E. McKinney
Denton, TX 76201
RE: Request for Bid 01523
Dear Mr. Klinck:
It is our understanding that Harris Methodist Health Plan (HMHP)
and the City of Denton (City) agree to the following:
1. The City of Denton Request for Bid 01523 page two (2)
paragraph two (2) reading: "The City of Denton is seeking
an insurance policy/agreement to become effective January
1, 1994, for a minimum of one (1) year. The policy shall
provide, if not canceled prior to December 31, 1993, in
accordance with the terms of the policy/agreement, bid
submission form, and/or request for bidders, for the
f renewal of this policy for two (2) successive twelve (12)
month periods, thereafter subject to renegotiation of the
terms of this policy, if the City Manager and insurance
company agree, without the necessity of rebidding this
insurance proposal as long as the cost of insurance
during either the first or second twelve (12) month
successive period does not increase more than 301 and the
plan design benefits do not decrease more than 301.
However, this proposal may be terminated if insurance
company and City are unable to agree in writing to a
mutually agreeable plan design and insurance cost no
later than seventy-five (75) days prior to the end of the
preceding period.,, (This paragraph applicable to HMHP's
Preferred Plus Plan,)
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2. HMHP agrees to provide a rate guar&kee-thrt►agU.,Ahe
second and third plan year for the Preferred HMO Plan
only. HMHP's condition for the 1995 and 1996 rate
guarantee is that HMHP will be the only carrier offered
by the City. The Preferred HMO Plan guarantee will be as
follows. "The years 1995 and 1996 combined maximum rate
guarantee will not exceed a total of 15%. The year 1995
will not exceed 9.9% of HMHP's 1994 rata." (This
paragraph applicable to HMHP's Preferred Plan.)
3. As City employees' needs for additional health care
services in the Denton area expand, the HMHP is committed
to ongoing assessment of these needs and expansion of
HMHP s current network through the recruitment of
appropriately qualified providers to serve these needs.
The (10) additional Denton providers have been approved
recently, and will be added to the network as soon as
contacts are executed. City's request for additional
hospital service through Denton
will be given consideration fore future Medical CQThes
ongoing effort will continue as a part of HMHP's
partnership with employer groups that HMHP serves in the
Denton area.
4, This letter of understanding shall become an attachment
to the agreement of the parties authorized by City
pursuant to the ordinance approved on the day of
1993,
except for such relating t of t this letter f thBid No.
at are
specifically rejected by the State Board of Insurance
prior to September 1, 1994.
Please indicate City0s acceptance of the above conditions by
signing below where indicated, and returning this letter to my
attention.
Kindest regards,
Michael D. Clark
Senior Vice President
Managed Care Marketing
CITY OF DENTON
By: _ ; .r-