HomeMy WebLinkAbout840959.tiff RESOLUTION
RE: APPROVE AMENDMENT NO. III TO THE HEALTH PLAN DOCUMENT OF
THE WELD COUNTY EMPLOYEE BENEFIT FUND
WHEREAS , the Board of County Commissioners of Weld County,
Colorado, pursuant to Colorado statute and the Weld County Home
Rule Charter, is vested with the authority of administering the
affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with Amendment No.
III to the Health Plan Document of the Weld County Employee
Benefit Fund, and
WHEREAS, said Amendment adds the following benefits, pay-
able at 100%, as pages 12a, 12b, 12c, 12d, 12e, 12f and 12g;
home health agency benefits, hospice care program benefits , and
second surgical opinion benefits, and
WHEREAS, the Board of County Commissioners has reviewed said
Amendment No. III and deems it advisable to approve same, a copy
of said Amendment No. III being attached hereto and incorporated
herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Com-
missioners of Weld County, Colorado that Amendment No. III to
the Health Plan Document of the Weld County Employee Benefit
Fund be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be,
and hereby is , authorized to sign said Amendment No. III .
The above and foregoing Resolution was , on motion duly made
and seconded, adopted by the following vote on the 9th day of
January, A.D. , 1984 .
�j� _i BOARD OF COUNTY COMMISSIONERS
ATTEST: 'y � � W fL WELD COUNTY, COLORADO
Weld County Clerk and Recorder >20_,„_„.._ a.c/4',__
anYClerk to o-aril Norman Carlson, Chairman
P.:41.-AtyI Q Clerk
a e . n
Deputy County Clerk cq ine o nson, Pro-Tem
AP AS TO C EXCUSED
Gene R. Brantner
_ re-
County Attorney
C uck Carlson .274.1,/ ,_12;S
P: Ins . J n T. Martin
DAY FILE: January 11 , 1984
840959
•
AMENDMENT NO. III
to the Health Plan Document of
THE WELD COUNTY EMPLOYEE BENEFIT FUND
The Health Plan Document of the Weld County Employee Benefit Fund is hereby
amended, effective January 1, 1984. The following benefits are payable at 100%
and are hereby added as new pages 12a, 12b, 12c, 12d, 12a 12f and 12g.
HOME HEALTH AGENCY BENEFITS
In addition to the other Covered Expenses payable for services, supplies and
treatment under the Major Medical ; covered charges will include charges made by
a home health agency for home health services.
The charges for these services will not be considered as covered charges unless
(1) the services are prescribed in lieu of hospital services by a Physician and
(2) the entire period of the services and all charges are certified as Medically
Necessary by the Covered Person ' s attending Physician.
NOTE: Covered Expenses will not include charges for local ambulance service, if
the service is to or from a home health agency, or to or from a hospital or
other facility which is providing services to the Covered Person which are
defined as home health services.
If the home health services are not rendered during a "Period of Home Health
Services , " the maximum payment for covered charges for all of these services
during the Covered Person ' s lifetime will be $500.
A. "Period of Home Health Service" for any cause
1. begins on the day following the termination of the Covered Person ' s
confinement for the same or related cause to a hospital ; provided that
the confinement began while the person was covered and lasted at least
five (5) consecutive days.
2. terminates on the earliest of the following: •
a. 90 days after the period begins (not counting any days during
which the Covered Person is confined to a hospital or an extended
care facility for more than 18 hours) ,
b. the expiration of 7 consecutive days during which the Covered
Person receives no home health services and is not confined to a
hospital or an extended care facility, and
c. the day on which the Covered Person ' s Physician requests that
these services be discontinued.
Amt/WELD-III -12a-
B. "Home Health Services" consists of
1. part-time nursing care rendered in the Covered Person' s home by a
Registered Professional Nurse (R.N. ), a Licensed Practical Nurse
(L.P.N. ), a Licensed Public Health Nurse, or a Licensed Vocational
Nurse under the supervision of a Registered Professional Nurse, but not
including any care in excess of 2 hours during any 24-hour period.
2. physical , occupational , or speech therapy, provided in the Covered
Person' s home.
3. physical , occupational , or speech therapy, or the use of medical
appliances or equipment, provided on an out-patient basis by a home
health agency, or by a hospital or other facility under an arrangement
with a home health agency.
In no event will home health services include any services performed by a member
of the Covered Person ' s immediate family or a person ordinarily residing in the
Covered Person' s home or any services not Medically Necessary for the treatment
of an Injury or Illness.
-12b-
HOSPICE CARE PROGRAM BENEFIT
Hospice Care Program is a formal program directed by a Physician to help care
for a Terminally Ill Covered Person. This may be through either:
(1) a centrally administered, medically directed and nurse-coordinated program
which (a) provides a coherent system primarily of home care; (b) uses a
Hospice Team; and (c) is available 24 hours a day, seven days a week; or
(2) confinement in a Hospice.
The program must meet standards set by the National Hospice Organization and
recognized as a Hospice Care Program by the Contract Administrator. If such a
program is required by the state to be licensed, certified or registered, at
must also meet that requirement to be considered a Hospice Care Program.
Hospice Team is a team of professionals and volunteer workers who provide care
to: (1) reduce or abate pain or other symptoms of mental or physical distress;
and (2) meet the special needs arising out of the stresses of the terminal
illness, dying and bereavement. The team includes at least: a Physician, a
registered graduate nurse, and could include the following: a social worker, a
clergyman/counselor, volunteers, a clinical psychologist, physiotherapist, and
occupational therapist.
Terminally Ill Person is a Covered Employee or a Covered Dependent whose life
expectancy is six (6) months or less as certified by his/her attending
Physician.
Remission is (1) a halt in the progression of a Terminal Illness or (2) an
actual reduction in the extent to which the Illness has already progressed.
This Plan will consider benefits for many charges which are incurred by the
Terminally Ill Person while in a licensed Hospice Care Program.
The following Usual , Customary and Reasonable charges made by or on behalf of
the Hospice will be considered for payment but not to exceed the maximum benefit
shown in the Summary of Benefits:
-* In-Patient care services provided by and billed through the Hospice
-* Physicial services provided by the Hospice Medical Director
- Prescription drug therapy--pain control
- Home Health Care services by the Hospice Team (Registered Nursing
Service, L.P.N. , licensed practical nursing service, and certified
Home Health Aids Services)
- Emotional support services provided to the patient and/or family by
members of the Hospice Team
- Physical , occupational , and speech therapy provided by the members of
the Hospice Team
- Durable medical equipment and medical supplies when deemed medically
necessary
- Respite (continuous) care provided to covered family members by the
Hospice Team on a short-term basis enabling the Terminally Ill Person
to remain an out-patient
- Death education/bereavement counseling
Amt/WELD-III3 -12c-
*Services of the Terminally Ill Person ' s regular attending physician and the
Hospital inpatient room, board and miscellaneous charges are billed separately
and are not part of the Hospice Care Program benefit. These charges are subject
to the deductible and co-insurance.
In order to obtain benefits for the Hospice Care Program, the Covered Person
must be in a Hospice Care Program. The Covered Person will not be considered to
be in a Hospice Care Program until certification of the terminal illness has
been given to the Contract Administrator by the Medical Director of the Hospice
Care Program and the Physician who is treating the Terminally Ill Person and who
recommends admittance to a licensed Hospice Care Program.
In addition, only services charged for by the Hospice Care Program and provided
within six months from the date of the Terminally Ill Person ' s entry or re-entry
(after a period of Remission) in the Hospice Care Program shall be considered
for payment by this Plan.
HOSPICE CARE BENEFITS (OTHER THAN BEREAVEMENT BENEFIT)
Charges incurred by the Terminally Ill Person for the following services will be
considered under the Plan:
(1) Charges incurred while not an inpatient in a Hospice: Hospital Services fur-
nished under a Hospice Care Program for any one period of Hospice Care.
(2) Charges incurred while an inpatient in a Hospice: Hospice room and board and
Hospice Services furnished under a Hospice Care Program for any one period
of Hospice Care.
For determining the benefits payable, all periods of care in a Hospice Care
Program shall be considered related and to have occurred in the one period of
care unless separated by at least 3 consecutive months.
The following charges will not be considered for payment under the Hospice Care
Program:
(1) Charges in connection with:
(a) an injury arising out of or in the course of work for wage or profit
(whether or not with the Employer).
(b) an Illness covered with respect to such work by any worker' s compen-
sation law, occupational disease law or similar law.
(2) Charges for services or supplies:
( a) furnished by or for the United States government, or
(b) furnished by or for any other government, unless a payment of the
charge is required by law; or
(c) to the extent that such service or supply or any benefit for the charge
is provided by any law or governmental plan under which the patient is
or would be covered. This (c) does not apply to a state plan under
Medicaid or to any law or plan which states that its benefits are
Am1/WELD-III4 -12d-
excess to those of any private insurance program or other non-
governmental program.
(3) Charges incurred during a period of Remission. This limitation applies if
during such Remission, the Terminally Ill Person is discharged from the
Hospice Care Program.
(4) Any charges for services performed by a person who ordinarily resides in the
Terminally Ill Person ' s household or who is related to the Terminally Ill
Person as a spouse, parent, child, brother, sister, whether such
relationship is by blood or exists only in law.
BEREAVEMENT BENEFITS
The following charges incurred by the Covered Dependent(s) for Counseling
Services (defined below) ordered and received under the Hospice Care Program
will be considered for payment under this Plan.
Counseling Services are supportive services provided after the death of the
Terminally Ill Person by members of the Hospice Team in counseling sessions with
the Covered Dependents. These services are to assist the Covered Dependents in
coping with that death.
Benefit for Bereavement Services will be considered under this Plan if all of
the following conditions are met:
(1) On the day immediately prior to death the Terminally Ill Person was:
(a) in the Hospice Care Program;
(b) a Covered Person
(2) The charges are incurred by the Covered Dependent(s) within 12 months
following the date of the Terminally Ill Person ' s death.
(3) This benefit is limited to three (3) chargeable bereavement visits.
Amount Payable: This Plan will consider the charges incurred for the Covered
Dependent(s) but not to exceed the Maximum Allowable Benefit shown in the
Schedule of Benefits.
The following charges will not be considered for payment under this Plan:
(1) Charges for the treatment of a diagnosed Illness or Injury of a Covered
Dependent(s) to the extent that such charges are payable under another bene-
fit of this Plan, whether payable partially or in full .
(2) Any charges for services performed by a person who ordinarily resides in the
Terminally Ill Person' s household or who is related to the Terminally Ill
Person as a spouse, parent, child, brother, sister, whether such rela-
tionship is by blood or law.
Aml/WELD-III5 -12e-
SECOND SURGICAL OPINION BENEFIT
A. For the purposes of the Major Medical provisions of the Plan, the following
terms shall have the meanings set forth below:
"Elective Surgical Procedure" means any non-emergency surgical procedure
which may be scheduled at the patient' s convenience without jeopardizing the
patient' s life or causing serious impairment to the patient' s bodily func-
tions and which is performed while the patient is confined in a Hospital as
an inpatient or in an Ambulatory Surgical Center.
"Ambulatory Surgical Center' means .ny public or private institt t cn -at
is:
(1) established, equipped and operated primarily as a facility for perfor-
mance of surgical procedures and meets the following requirements:
(a) it is operated under the supervision of a staff of Physicians, main-
tains adequate medical records for each patient, and provides for
periodic review of the facility and its operation by a Utilization
and/or Tissue Committee composed of Physicians other than those owning
or supervising the facility; (b) it permits a surgical procedure to be
performed only by a Physician privileged to perform such procedure in a
hospital in its area and requires that a licensed anesthesiologist admi-
nister the anesthetics and be present during the surgical procedure,
unless only local infiltration anesthetics are used; (c) it provides no
overnight accommodations for patients and at least two operating rooms
and one post-anesthesia recovery room and full-time services of
Registered Nurses (R. N. ) for patient care in all operating and post-
anesthesia recovery rooms; (d) it is equipped to perform diagnostic
x-ray and laboratory examinations required in connection with the
surgery to be performed and has the necessary equipment and trained
personnel to handle foreseeable emergencies, including, but not limited
to, a defibrillator for cardiac arrest, a tracheotomy set for airway
obstruction, and a blood bank or other supply for hemorrhaging; (e) it
maintains written agreements with one or more hospitals in its area for
immediate acceptance of patients who develop complications or require
postoperative confinement; or
(2) licensed as an ambulatory surgical center by the state in which the
center is located.
"Second Surgical Opinion" means an opinion of a Board Certified Specialist
to evaluate, at no cost to the Employee or patient, the medical advisability
of the patient' s undergoing an Elective Surgical Procedure based on that
specialist' s examination of the patient. The examination must be performed
after another Physician who is not in the same group practice as the
Physician rendering the "first" surgical opinion, and who is licensed to
practice medicine and perform surgery, has proposed to perform such Elective
Surgical Procedure on the patient, but prior to the performance of such
Elective Surgical Procedure.
Am1/WELD-III6 -12f-
"Third Surgical Opinion" means an opinion of a Board Certified Specialist to
evaluate, at no cost to the Employee or patient, the medical advisability of
the patient' s undergoing an Elective Surgical Procedure based on that
specialist' s examination of the patient. The examination must be performea
after a "Second Surgical Opinion" of another Board Certified Specialist and
who is not in the same group practice as the Physician rendering either the
first surgical opinion or the second surgical opinion, has indicated that
the proposed Elective Surgical Procedure is not medically advisable, but
prior to the performance of such Elective Surgical Procedure.
An "Affirmative Second or Third Surgical Opinion" is a Second Surgical
Opinion or a Third Surgical Opinion which confirms that the proposed
Elective Surgical Procedure is advisable.
"Board Certified Specialist" means a Physician who holds the rank of
Diplomate of an American Board (M. D. ) or Certified Specialist (D.O. )
B. The provisions of this benefit will apply but will not be limited to the
following list of surgical procedures which will be considered elective in
nature:
* Surgery of the heart, such as coronary artery bypass
* Surgery for hemorrhoid disease
* Surgery of the hip
* Surgery of the knee joint
* Surgery of the back
lumbar disk
cervical disk
* Surgery of the stomach and duodenum for peptic ulcer disease
* Surgery of the prostate (prostatectomy)
* Tonsillectomy & Adenoidectomy
* Vascular surgery
varicose veins
abdominal aortic aneurysms
(weakness of the aorta)
* Nasal surgery
* Surgery of the breast
* Surgery of the gallbladder (cholecystectomy)
* Dilatation & Curettage
dilation of the cervix and removal of growths
* Hysterectomy
surgery of the uterus
* Surgery of the colon (diverticulitis)
* Surgery for hernia
inguinal
femoral
esophogeal hiatal
•
Aml/WELD-III7 -12g-
IT IS AGREED BY WELD COUNTY that the provisions contained in the Plan
Document and Amendment No. III thereto are acceptable and will be the basis for
the administration of said Employer' s Employee Benefit Program described here ...
SIGNED at Greeley , Colorado, this 9th day of January ,
1984.
WELD COUNTY Witness: By `(� /J —
"cyls.
Title Chairman, Board of Commissioners
Aml/WELD-IIIS
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