HomeMy WebLinkAbout000195.tiff Summary of Benefits
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Plan 10116
FHP®
HEALTH CARE
1996
10116 8/95
FRP of Colorado, Inc.
Printed on Recycled Paper
•
195
Here are some highlights of your plan. Please call FHP Member Services at 1-800-877-9777 if
you would like additional information.
Physician Care
■ Primary Care Physician (PCP)Office Visits $15 copayment per visit
■ Specialist Care and Consultants,including Second Opinions $15 copayment per visit
■ Allergy Testing $15 copayment per visit
■ Allergy Injections $5 copayment per visit
■ Cardiac Rehabilitation no copayment
(coverage for maximum of$1,000 within 90 days)
■ Short-Term Physical/Occupational Therapy $15 copavment per visit
(coverage for maximum of 20 sessions per acute condition)
■ Speech Therapy $15 copavment per visit
(coverage for maximum of 20 sessions for certain acute conditions)
Preventive Care
■ Physical Exam $15 copavment per exam
■ Well-Woman Exam $13 copavment per exam
• ob/gyn tests and treatment once per year
■ Well-Baby Care $15 copavment per visit
• immunizations and injections
• pediatric visits
■ Maternity Care $15 copavment per visit
• prenatal
• postnatal
Hospital Care
■ Inpatient $300 copavment per admission
(maximum of 2 admission copayments per contract year, maximum of$1,500 per family
per contract year)
• semiprivate room
• labor/delivery rooms
• operating room and related services
■ Outpatient $150 copavment per visit
• outpatient surgery
• observation room
Emergency Care
■ Emergency Room Setting-Inside and Outside Service Area $50 copayment per visit
■ Urgent Care $25 copayment per visit
• after normal hours in a physician's office
• urgent care center inside service area
■ Urgent Care/Follow-Up Outside Service Area
(coverage for maximum of$400 per member per contract year)
• emergency room $50 copayment per visit
• physician's office or urgent care center $25 copayment per visit
■ Ambulance Service $25 copayment per episode
Mental Health Care
■ Inpatient $50 copayment per day
$25 copayment per partial day
(coverage for maximum of 45 full days or 90 partial days per contract year)
■ Outpatient no copayment for visits 1-5,$15 copayment per visit thereafter
(number of visits based on medical necessity)
■ Alcohol/Drug Rehabilitation
(limited to one course of treatment per contract year, two courses of treatment during the
member's lifetime)
• inpatient $50 copayment per day
(coverage for maximum of 21 days)
• outpatient no copayment for visits 1-5,$15 copayment per visit thereafter
(number of visits covered based on medical necessity)
• detoxification inpatient hospital care copayment applies
Other
■ Home Health Care no copayment
• skilled nursing care no copayment
■ Injectables for Hume Use $10 copayment
■ Durable Medical Equipment no copayment
(coverage for maximum of$1,000 per member per contract year;additional 5500 maybe
available for the continuous use of oxygen)
■ Infertility Evaluation 50% copayment
(up to out-of-pocket maximum of$2,500 per member per contract year)
■ Hospice Care no copayment
• inpatient care no copayment
• outpatient care no copayment
This summary of benefits contains only highlights of FHP Plan 10116. Please see the FHP
Evidence of Coverage and Owner's Manual for a complete description of benefits, benefit
limitations and exclusions.
Medical Plan Benefit Limitations and Exclusions
• Any service not performed,authorized or • Complications of non-covered services,unless
referred by a primary care physician other than medically necessary.
for a life-or limb-threatening emergency. • Outpatient prescription drugs, unless covered
• Any service that is not reasonably and medically under an optional prescription drug benefit
necessary. purchased by the subscribing group.
• Cosmetic surgery,unless medically necessary. • Health services and expenses for experimental
or unproven procedures,treatments,devices
• Post-mastectomy breast reconstruction if
and pharmacological regimes.
mastectomy occurred while not covered under
FHP. Internal prosthesis is not covered. • In vitro fertilization,embryo transport,gamete
intrafallopian transfer,surrogate parenting,
• Personal comfort items in and out of the hospi- donor semen or outpatient injectable sub-
tal(e.g., television,telephone). stances and supplies related to infertility.
• Whole blood and plasma. • Abortions in excess of two per lifetime.
• Dental care or dental X-ray, unless covered as a Services of a chiropractor.
supplemental benefit.
•
Health services and associated expenses for Member must complete the authorized course
• of treatment to be covered for inpatient or
organ and tissue transplants,except for those outpatient care for substance abuse.
transplants specifically stated as covered in the
Evidence of Coverage.Heart,combined • If a newly enrolled member is hospitalized on
kidney/pancreas,and liver(for members the effective date of coverage, the member must
eighteen and over)transplants are covered for notify FHP within 48 hours or as soon as
members who have had twelve full months of medically possible so that responsibility for care
continuous membership. can be transferred to FHP,if no other group
The following are not covered transplants: coverage exists. At FHP's option,care may be
• continued by a primary care, referral physician
heart/lung;lung;multiple organs;pancreas;
or the attending physician.
non-human and artificial organs and their
implantation;and chemotherapy or radiation This list of benefit limitations and exclusions is only a
therapy requiring a bone marrow or stem cell summary. Please see the FHP Evidence of Coverage
transplant or stem cell rescue for the treatment and Owner's Manual for a complete description of
of any disease, including breast or other solid benefits,benefit limitations and exclusions.
tumor cancers except as specifically stated as
covered in the Evidence of Coverage.
• All necessary services for covered transplants
must be performed at designated transplant
facilities.
• (e. .Physical exams requnt, sed y a third i partylicensing).
pi...1p®
( employment,insurance,licensing).
• Custodial care,nursing home,rest cures and
domiciliary care. HEALTH CARE
• Reversal of sterilization.
• Long-term rehabilitation.
• Services for which coverage is provided or is P.O. Box 441170
required by law. Aurora, CO 80044
• Medical supplies.
Member Services 1-800-877-9777
64Colorado Region
6 South Yosemite Street
HEALTH CARE Englewood, CO 80111
303.220.5800 Fax 303.714.3998
NOTICE AND ACCEPTANCE OF CHANGES
TO THE FLIP OF COLORADO HMO EVIDENCE OF COVERAGE
AND OWNER'S MANUAL
For the purposes of this Notice, "Employer" includes the "Subscribing Group"
To make the Employer and eligible employees aware of the changes from the prior year's
EOC, FHP of Colorado is providing the changes to you in separate document called the 1996
Change Document. The changes set forth in the 1996 Change Document are incorporated into
the new 1996 EOC. FHP of Colorado provides this information to the Employer for its
acceptance and to enable it to make the information available to eligible employees at the time
of open enrollment.
By execution of this Notice and Acceptance, the Employer acknowledges receipt of and accepts
the 1996 Change Document attached hereto and incorporated herein. The Employer further
acknowledges receipt and acceptance of the 1996 EOC (which incorporate the changes
described in the 1996 Change Document) and agrees it will be the contract applicable to
subscribers or insureds and dependents during the succeeding contract year.
Signed:
Kg, /
eld County o uthorized Agent
// 7/7
Date
NT96FLL2.hmo
1996 HMO BENEFIT CHANGES
The out-of-area urgent care maximum will be increased from $250 to $400.
Coverage of cochlear implants (including the procedure and the device) will be added.
Two copayments (rather than three) will apply for a 90-day supply of maintenance
medications obtained through mail-order.
Testosterone injections to treat impotence will no longer be excluded.
Coverage will be added for diabetic counseling once per year for members diagnosed with
diabetes.
Insulin pumps will no longer be excluded and will be added to the list of covered DME.
Some hospital charges related to dental services will be covered when criteria is met (such
charges were previously excluded).
FHP®
HEALTH CARE
•
FHP OF COLORADO, INC.
EVIDENCE OF COVERAGE AND OWNER'S MANUAL
SIGNATURE SHEET
The attached Evidence of Coverage and Owner's Manual (Group Agreement), this Signature Sheet, and
Group Application (if any) collectively constitute a contract (Agreement) between FHP of Colorado, Inc.
(FHP), and the Subscribing Group named below for the provision of specified healthcare benefits to
eligible persons electing to enroll hereunder as Subscribers and Dependents.
1. SUBSCRIBING GROUP:
A. The name, address, and group number(s) of the Subscribing Group are as follows:
Weld County Colorado Mr. Donald Warden
P.O. Box 758 (303) 457-100t
Greeley, CO 80632 3sZ - Yoou Y2/t Q
Group Number: OUR00
B. The following entities affiliated with the Subscribing Group shall be deemed to be
included within it for purposes of this Agreement.
N/A
C. The number of employees of the Subscribing Group who are eligible to enroll as
Subscribers is 950 and the SIC Code of the Subscribing Group is 9000.
2. EFFECTIVE DATE:
This Agreement takes effect 12:01 A.M. on January 1, 1995, and will remain in effect through
11:59 P.M. on December 31, 1995, subject to the terms and conditions of the Agreement.
3. COVERAGE:
EOC Edition: 1995 FHP of Colorado Evidence of Coverage and Owner's Manual (HMO)
Medical Plan Copayment Schedule: 10045
Optional benefits: Rx10045
4. MONTHLY RATE SCHEDULE:
Subscriber Only $148.62
Subscriber, Spouse and Child(ren) (Family) $410.19
5. PAYMENT ARRANGEMENTS / ELIGIBILITY:
The following specifies payment arrangements as well as conditions of eligibility for
enrollment as a Subscriber that are in addition to the conditions enumerated in Chapter 4 of the
Group Agreement (and, to the extent that any of the following conditions contradict the terms
of Chapter 4, the following shall prevail):
New employees are eligible on the first of the month occuring on or following one full pay
period. Employees will be covered through the end of the month in which their
employment terminates. Full monthly premium is due for any employee enrolled for an
entire month.
6. UNDERWRITING CONDITIONS:
The Subscribing Group (A) represents that the underwriting conditions listed below exist as of
the effective date noted in number 2 above, and (B) covenants that all such underwriting
conditions shall continue to be met at all times while this Agreement is in force.
Subscribing Group must contribute for all Subscribers at least 75% of"Employee" monthly rate
or 50% of each monthly rate.
If FHP (HMO) is part of a multi-option plan offering a FHP's Preferred / Indemnity plan
the Subscribing Group must have at least 75% participation of all eligible employees.
Military employees or employees covered by a spouse's plan will not be counted as an
eligible employee for the purpose of this minimum participation requirement. The
minimum number of enrolled employees between the HMO and PPO / Indemnity plans
cannot be less than 51 lives.
Additionally, FHP reserves the right to re-evaluate the risk at any premium due date based upon
substantial changes to other assumptions including, but not limited to, a change in demographics;
divisions added or deleted; or the offering of an additional employer sponsored health plan.
Notwithstanding any other provision of this Agreement, FIB may terminate this Agreement on
any premium due date if any underwriting condition listed above is not then being met and notice
of intention to terminate has been given to the Subscribing Group at least 31 days in advance.
7. OPEN ENROLLMENT PROVISIONS:
The group enrollment period shall be November, 1995.
8, OTHER PROVISIONS:
Eligible dependents will be covered as outlined in Chapter 4 of the Agreement. Payment
arrangements for newly acquired dependents shall be the same as for newly hired employees as
described in number 5 above, PAYMENT ARRANGEMENTS / ELIGIBILITY.
9. GOVERNING LAW:
This Agreement shall be governed by and construed in accordance with the internal laws of the
State of Colorado.
10. COUNTERPARTS:
This Agreement may be executed in two or more counterparts, each of which shall construe an
original but all of which shall constitute one and the same instrument.
IN WITNESS WHEREOF, FHP and the Subscribing Group have caused this Agreement to be
executed by their respective duly authorized representatives.
SUBSCRIBING GROUP FHP
AUTHORIZED REPRESENTATIVE AUTHORIZED REPRESENTATIVE
By: /-i_ as )2 0 i� 4' By:
/ /� Pamela A. Butler
Title: 4i�m/f/� ad ! 6 [,}0'na I$S,c ,eRS Title: Director of Employer Services
Date: /3- / - /nJ Date: December 1. 1994
BAW/no
..ecy.;.n
1995 - 1996 Renewal Agreement
FHP/TakeCare and Weld County will jointly agree to the following provisions
for the renewal contract:
Date Rate Adjustment
January 1, 1995 HMO +3%
PPO +9%
January 1, 1996 FHP/TakeCare will guarantee rates will not
increase by more than:
HMO +3%
PPO +9%
This agreement constitutes a two year contract between FHP/TakeCare and
Weld County.
Ii /19 7O.4),,- -lq
Weld County Authorized Signature /Ta Care Authorized Signature
l/iAe12Yt12r, -Rd LV Phivns5Mnee5 7LJPS 5eiwP_ PorY,PR
Title Title
i//219V ,oi,ulaq
Date Date
FHP OF COLORADO, INC.
EVIDENCE OF COVERAGE AND OWNER'S MANUAL
SIGNATURE SHEET
The attached Evidence of Coverage and Owner's Manual(Group Agreement),this Signature Sheet, and Group
Application(if any) collectively constitute a contract (Agreement)between FHP of Colorado, Inc. (FHP), and
the Subscribing Group named below for the provision of specified healthcare benefits to eligible persons
electing to enroll hereunder as Subscribers and Dependents.
1. SUBSCRIBING GROUP:
A. The name, address, and group number(s)of the Subscribing Group are as follows:
Weld County Colorado Ms.Jewell Vaughn
P.O.Box 758 (970)356-4000 2.4218
Greeley,CO 80632
Company Number: OUR00
B. The following entities affiliated with the Subscribing Group shall be deemed to be included within it for
purposes of this Agreement.
N/A
C. The number of employees of the Subscribing Group who are eligible to enroll as Subscribers is 950 and
the SIC Code of the Subscribing Group is 9111.
2. EFFECTIVE DATE:
This Agreement takes effect 12:01 A.M. on January 1, 1996, and will remain in effect through 11:59
P.M. on December 31, 1996, subject to the terms and conditions of the Agreement.
3. COVERAGE:
EOC Edition: 1996 FHP of Colorado Evidence of Coverage and Owner's Manual(HMO)
Medical Plan Copayment Schedule: 10046
Optional benefits: Rx10046
4. MONTHLY RATE SCHEDULE:
Subscriber only $153.08
Subscriber, Spouse and Child(ren) (Family) $422.50
5. PAYMENT ARRANGEMENTS/ELIGIBILITY:
The following specifies payment arrangements as well as conditions of eligibility for enrollment as a
Subscriber that are in addition to the conditions enumerated in Chapter 4 of the Group Agreement (and, to
the extent that any of the following conditions contradict the terms of Chapter 4, the following shall
prevail):
New employees are eligible on the first of the month occurring on or following one full pay period.
Employees terminating employment the first through the 15th will be covered through the end of
the month in which their employment terminates; employees terminating employment 16th
through the end of the month will be covered until the end of the following month. Full monthly
premium is due for any employee enrolled for an entire month.
6. UNDERWRITING CONDITIONS:
The Subscribing Group(A)represents that the underwriting conditions listed below exist as of the effective
date noted in number 2 above, and (B) covenants that all such underwriting conditions shall continue to be
met at all times while this Agreement is in force.
Subscribing Group must contribute for all Subscribers at least 75% of"Employee" monthly rate or 50% of
each monthly rate.
If FHP (HMO) is part of a multi-option plan offering an FIIP's Preferred (PPO) / Indemnity
plan the Subscribing Group must have at least 75% participation of all eligible employees.
Military employees or employees covered by a spouse's plan will not be counted as an eligible
employee for the purpose of this minimum participation requirement. The minimum number
of enrolled employees between the HMO and PPO/Indemnity plans cannot be less than 25
employees.
This health plan is available only to employer groups who have 51 or more eligible employees.
If at the anniversary date of this Agreement the number of eligible employees is less than 51
this Agreement may not be renewed. However, the Subscribing Group may be offered the
small employer health benefit plan(s) as defined by Colorado Insurance Law.
Additionally,FHP reserves the right to re-evaluate the risk at any premium due date based upon substantial
changes to other assumptions including, but not limited to, a change in demographics; divisions added or
deleted; or the offering of an additional employer sponsored health plan.
Notwithstanding any other provision of this Agreement, FHP may terminate this Agreement on any
premium due date if any underwriting condition listed above is not then being met and notice of intention
to terminate has been given to the Subscribing Group at least 31 days in advance.
7. OPEN ENROLLMENT PROVISIONS:
The group enrollment period shall be November, 1996.
8. O 1'HLR PROVISIONS:
Eligible dependents will be covered as outlined in Chapter 4 of the Agreement. Payment arrangements for
newly acquired dependents shall be the same as for newly hired employees as described in number 5 above,
PAYMENT ARRANGEMENTS/ELIGIBILITY.
9. GOVERNING LAW:
This Agreement shall be governed by and construed in accordance with the internal laws of the State of
Colorado.
10. COUNTERPARTS:
This Agreement may be executed in two or more counterparts, each of which shall construe an original but
all of which shall constitute one and the same instrument.
IN WITNESS WHEREOF, FHP and the Subscribing Group have caused this Agreement to be executed
by their respective duly authorized representatives.
SUBSCRIBING GROUP FHP
AUTHORIZED REPRESENTATIVE AUTHORIZED REPRESENTATIVE
By: By: �z1
Sandra G. Peif
Title: Title: State Manager, Existing Business Development
Date: � /� 94 Date: December 13, 1995
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