HomeMy WebLinkAbout850963.tiff RESOLUTION
RE: APPROVAL OF WELD COUNTY VISION CARE ASSISTANCE PROGRAM MASTER
PLAN DOCUMENT AND AUTHORIZATION FOR CHAIRMAN TO SIGN
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 the Master Plan
concerning a Vision Care Assistance Program for the benefit of
Weld County employees , and
WHEREAS, said program shall become effective January 1 , 1986 ,
with the further terms and conditions being as stated in the
Master Plan Document, a copy of which is attached hereto and
incorporated herein by reference, and
WHEREAS, after study and review, the Board deems it advisable
and in the best interests of Weld County employees to approve said
Vision Care Assistance Program.
NOW, THEREFORE, BE IT RESOLVED by the Board of County
Commissioners of Weld County, Colorado, that the Master Plan
Document concerning a Vision Care Assistance Program for Weld
County employees be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and
hereby is, authorized to sign said document.
The above and foregoing Resolution was , on motion duly made
and seconded, adopted by the following vote on the 25th day of
September, A.D. , 1985 .
BOARD OF COUNTY COMMISSIONERS
ATTEST: Q34C�ry WELD COUNTY, COLORADO
Weld CountylClerk and Recorder �ptiGnU ,',
and Clerk to the Board J4*R.4rS9Pro-Tem
ene Joh sin, Chairman
BY:. JO)PLnu.¢J y�,
Deputy County C er��s
APPROVED AS TO FORM: C.W. Ki
.N..sC-4 71,42 G L c
r
County Atto ey `� f'
Frank Yamaguc i
'/ r
EL filly
WELD COUNTY
VISION CARE ASSISTANCE PROGRAM
MASTER PLAN DOCUMENT
Effective January 1, 1986
TABLE OF CONTENTS
Page
VISION CARE ASSISTANCE PROGRAM
SUMMARY OF BENEFITS 1
DEFINITIONS 2
VISION CARE EXPENSE BENEFIT 7
VISION CARE LIMITATIONS 8
HOW TO FILE A CLAIM 10
RELEASE OF INFORMATION 11
PAYMENTS 11
CLAIMS PAYMENTS MADE IN ERROR 11
RECOVERY AND SUBROGATION 11
LEGAL ACTIONS 12
PROOFS OF LOSS/TIMELY SUBMISSION OF CLAIMS 12
FACILITY OF PAYMENT 12
PROCESS IN CASE OF DISPUTED CLAIM 12
CONVERSION PRIVILEGE 13
AUTO NO-FAULT PROVISION 14
SIGNATURE PAGE 15
VISION CARE ASSISTANCE PROGRAM
Weld County agrees to provide for employees during continuance of this Program,
the benefits hereinafter described, in the event they and/or their eligible
dependent(s) incur vision care expenses covered by this Program.
The Program is subject to all the terms, provisions and conditions recited on
following pages hereof.
Weld County has caused this Program to take effect as of 12:01 A.M. , Mountain
Time, on January 1, 1986, at Greeley, Colorado.
i _
SUMMARY OF VISION CARE BENEFITS
FOR ACTIVE EMPLOYEES AND DEPENDENTS
WELD COUNTY
Maximum Benefits $150 per Covered Person per Calendar
Year.
$300 per family, combined members,
per Calendar Year.
Deductible Not applicable
Copayment 50% of Covered Expenses Incurred.
Reimbursement under this Plan will be made only after the Covered Person has
paid the bill in full .
1
DEFINITIONS
Terms as used herein shall be deemed to define terms that may be used in the
wording of the Plan Document. These definitions shall not be construed to pro-
vide coverage under any benefit unless specifically provided.
GENERAL DEFINITIONS
Age Discrimination - Subject to any changes in the Social Security Act, all
covered persons age 65 and over (up to 70 years of age) are entitled to the
same and/or equal benefits that they had prior to age 65.
Amendment is a formal document changing the provisions of the Program and
signed by the representatives of Weld County. Amendments apply to all
Covered Persons, including those persons who are covered before the amend-
ment becomes effective, unless otherwise specified.
Calendar Year is the twelve (12) month period beginning on each January 1st
and ending on the following December 31st.
Common-Law Marriages - In order for an employee of Weld County to be eli-
gible for dependent coverage, the common-law marriage must be recognized by
the state in which the employee resides.
Contract Administrator shall mean the person or firm employed by the Program
Administrator who is responsible for the processing of claims and payment of
benefits, administration, accounts, reporting and other services contracted
for by Weld County.
Employer shall refer to Weld County.
Medicare - Title XVIII (Health Insurance for the Aged) of the United States
Social Security Act as amended.
Program shall refer to the benefits and provisions as described herein for
payment.
Program Administrator - Weld County
Program Year is the twelve (12) month period beginning on each January 1st
and ending the following December 31st.
Subrogation - The transfer of one' s liabilities for another' s; in this case
the temporary assumption of the claimant' s liabilities by the Program prior
to repayment by the party of primary liability. This Program contains a
subrogation clause and the claimant is obligated to obtain any monies
available from third parties to reduce the Program' s claim losses.
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GENERAL DEFINITIONS
Covered Expense - includes only those Usual , Customary, and Reasonable
charges made for services and supplies which most Physicians would consider
to be necessary for treatment of a refractive error, and are prescribed by
the attending Physician.
Expense Incurred means only the fees and prices regularly and customarily
charged for the vision services and supplies generally furnished for cases
of comparable nature and severity in the particular geographical area con-
cerned. Any agreement as to fees or charges made between the individual and
the Physician shall not bind the Program Administrator in determining its
liability with respect to Expense Incurred. Expense Incurred is deemed to
be incurred on the date on which the service or supply is rendered.
Period of Disability for a Covered Employee as it applies to an individual ,
means all periods of disability arising from the same cause, including any
and all complications therefrom except that if the individual completely
recovers or returns to active full-time employment, any subsequent period of
disability from the same cause shall be considered a new disability.
For a Covered Dependent, the term "Period of Disability", means all periods
of disability arising from the same cause including any and all complica-
tions therefrom, except that if the dependent recovers for a period of three
months and throughout such period is capable of resuming the normal activi-
ties of a person in good health and of the same age and sex, any subsequent
period of disability from the same cause shall be considered a new period of
disability.
Total Disability shall mean that the Covered Employee is prevented, solely
because of a non-occupational Injury or non-occupational disease, from
engaging in the employee' s regular or customary occupation and is performing
no work of any kind for compensation or profit, or if a Covered Dependent is
prevented, solely because of a non-occupational Injury or non-occupational
disease, from engaging in all of the normal activities of a person of like
age and sex in good health.
Usual , Customary and Reasonable:
a. The Usual charge is the most consistent charge by a Physician or pro-
vider of service to patients for a given service.
b. The charge is Customary when it is within the range of usual charges for
a given service billed by most Physicians or providers of service with
similar training and experience.
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c. A charge is Reasonable when it meets the customary criterion as deter-
mined by the Contract Administrator; or it may be Reasonable if, upon
review, it merits special consideration based on the nature and extent
of treatment of the particular case.
Physician is a person acting within the scope of his/her license and holding
the degree of Doctor of Medicine (M.D. ), Doctor of Optometry (O.D. ), or a
facility, who or which is legally entitled to diagnose and dispense under
the laws of Colorado, or under the laws of the State or jurisdiction where
the services are rendered.
PARTICIPATION DEFINITIONS
Active Service - An employee will be considered in Active Service with the
Employer on a day which is one of the Employer' s scheduled work days if the
employee is performing in the customary manner all of the regular employment
duties with the Employer on a full-time basis on that day, either at one of
the Employer' s business establishments or at some location to which the
Employer' s business requires travel . An employee will be considered in
active service on a day which is not one of the Employer' s scheduled work
days only if the employee was performing in the customary manner all of the
regular employment duties on the preceding scheduled work day.
A dependent will be considered in active service on any day if the dependent
is then engaging in all the normal activities of a person in good health of
the same age and sex, and is not confined in a medical facility. (This does
not apply to a newborn).
Contribution shall mean the amount payable by the Employer or the amount
payable by the Employer/employee jointly for participation in the benefits
of the Plan.
Covered Dependents shall be those who are eligible as provided herein and
enrolled by a Covered Employee. Covered Dependents shall be the spouse of
the Covered Employee; and children from birth to age 19, to age 23, if a
registered student at an accredited college, vocational school , or univer-
sity on a full-time basis, provided such children are unmarried, and
dependent upon the Covered Employee for support and maintenance. The term
"children" shall include natural children, adopted children, foster children
and step children who depend upon the employee for support and maintenance.
No employee will be considered as both a dependent and as an employee. If
an employee and spouse are both eligible employees, either may have depen-
dent coverage for eligible children, but not both.
Covered Dependent shall also include a dependent child after age nineteen
provided the child is (1) incapable of self-sustaining employment by reason
of mental or physical handicap, (2) chiefly dependent upon the Covered
Employee and/or the Covered Employee' s spouse for support and maintenance,
and (3) has been continuously covered by the Program prior to. his/her nine-
teenth (19th) birthday.
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Proof of such incapacity and dependency must be furnished to the Program
Administrator by the Covered Person within the thirty-one (31) days prior
to the child' s nineteenth(19th) birthday. The Program Administrator may
require, at reasonable intervals, subsequent proof of the child' s disabi-
lity and dependency.
Covered Employee is a regular full-time employee of Weld County who is
working an average of thirty-two (32) hours per week and has been enrolled
in the Program.
Covered Person is a Covered Employee or a Covered Dependent.
Eligibility and Effective Dates - A Covered Person shall become effective
as follows:
a. Covered Employees shall become effective on the first of the month
following the first full month' s pay period.
b. Dependents shall be covered simultaneously with employees covering
them as dependents, provided they are not confined in a Hospital on
the effective date. Coverage for newborn children will begin from
birth. However, they need to be formally enrolled and appropriate
coverage arranged within thirty-one (31) days from birth for
coverage to be effective thereafter.
c. For dependents (as stated in a and b above) who are not enrolled
within this thirty-one (31) day period, and for whom coverage is
subsequently desired, a health questionnaire showing evidence of
insurability will be required. Coverage will begin on the date of
approval of the Contract Administrator.
d. An open-enrollment period will be scheduled in November of each
year.
e. In addition, such a Covered Person will not be effective unless on
the date of Eligibility the Person is in Active Service as dis-
cribed herein, otherwise his/her effective date will be deferred
until return to Active Service.
Termination of Coverage - A Covered Person' s coverage shall automati-
cally terminate on the earliest of the following dates:
a. The date the employee ceases to be a member of the classes of per-
sons eligible for employee coverage.
b. The date the employee enters into full-time military or similar
service of any country or subdivision thereof, except an employee
who is a member of a military reserve unit shall not be considered
on full-time military duty.
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c. The date of termination of employment of the employee with the
Employer.
d. The date of termination of the Plan.
e. The end of the month when Contributions cease.
Late Entrants - Employees or dependents not enrolled within thirty-one (31)
days following their eligibility date, or, in the case of newly acquired
dependents, within thirty-one (31) days of such acquisition, must provide
evidence of good health satisfactory to the Program Administrator.
Coverage will begin on the date of approval by the Program Administrator.
An open enrollment will be conducted each year during the month of November.
Enrollment during this month will not require evidence of good health.
Personal Leave of Absence - Properly enrolled employees of the Employer may
continue, at their expense, health coverage for themselves and/or their
dependents while on an approved Personal Leave of Absence for the period
indicated by the Employer' s personnel policy.
Medical Leave of Absence - When a Physician requires that a Covered Person
not return to work, benefits will be continued for a period not to exceed
the length of time accrued under said employee' s sick leave plan, or grants
of sick days from the Weld County Sick Leave Bank, plus 31 days, provided
the Covered Person makes the required contribution to the plan which he/she
would otherwise be required to contribute. In order to be covered while on
Medical Leave of Absence, the employee must be:
a. continuously and totally disabled, and
b. under the care of a licensed Physician, and
c. provide proof of disability satisfactory to the Employer at
reasonable intervals upon request.
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VISION CARE EXPENSE BENEFIT
ACTIVE EMPLOYEES AND COVERED DEPENDENTS
Coverage Provision
If a Covered Person incurs eligible vision care expenses, the Program will
pay benefits at the Copayment rate as specified in the Summary of Benefits
for such expense which is not covered by any other medical or vision
coverage, up to the Maximum Annual Benefit as specified in the Summary of
Benefits.
Maximum Annual Benefits
The Maximum Benefit as shown in the Summary of Benefits is the maximum
amount of benefits available for any covered family during a Calendar Year,
whether or not there has been an interruption in coverage.
Conversion Privilege
There are no conversion benefits for vision coverage.
Covered Vision Expense
Covered vision expenses shall mean the following charges by a Physician for
the diagnosis and correction of a refractive error, not to exceed the maxi-
mum specified in the Summary of Benefits, and limited to one each per year:
1. Examination, including refraction.
2. Lenses, including single vision, bifocal , trifocal , and contact.
3. Frames.
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GENERAL LIMITATIONS
The Plan does not cover:
1. vision care not included in the list of defined eligible expenses; or
2. anything not furnished by a Physician, nor anything not necessary or not
customarily provided for vision care; or
3. services (a) furnished by or for the U.S. Government, or (b) furnished by or
for any other government unless payment is legally required, or (c) to the
extent provided under any governmental program or law under which the indi-
vidual is, or could be, covered; or
4. services due to an Injury arising from or in the course of any employment
other than Weld County, or benefits provided under a Worker' s Compensation
Act or similar law; or
5. any portion of a charge for a service in excess of the Usual , Customary, and
Reasonable charge; or
6. charges for services which are not the generally accepted practice or
service for the condition being treated; or
7. services and supplies provided by any person who ordinarily resides in the
Covered Person' s household or who is related to the Covered Person, such as
a spouse, parent, child, brother, or sister, whether such relationship
exists by blood or in law; or
8. charges a Covered Person would not be required to pay if there were no Plan
benefits; or
9. charges for broken appointments or completion of claim forms; or
10. expenses for services which were not recommended or prescribed by a
Physician; or
11. any Expense Incurred as a result of an act of war, whether declared or
undeclared; or
12. any expense that is covered by another vision or health plan; or
13. any expense that is covered under the Weld County Health Plan; or
14. any expenses for duplicate eyewear; or
15. any expense in connection with surgical treatment of refractive errors; or
16. sunglasses, plain or prescription. Tinted glasses with a tipt other than
No. 1 or No. 2 will be considered sunglasses for this purpose; or
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17. services and supplies (1) in connection with special procedures such as
orthoptics, visual training, or (2) in connection with medical or surgical
treatment of the eye; or
18. replacement of lenses or frames which were furnished under the Plan and
which have been lost, stolen or broken; or
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HOW TO FILE A CLAIM
Claim forms can be obtained from the Personnel Office. The Employee Statement
on the top of the claim form must be completed in FULL and signed by the
employee. After a Covered Person receives treatment by a Physician as defined
herein and pays the bill in full , itemized bills and a copy of the paid receipt
should be attached to the claim form. The Attending Physician Statement form
should be completed by the appropriate Physician unless ALL necessary infor-
mation is included on the Physician' s own form. The completed claim form, the
attached bills and the paid receipt should be sent to:
Weld County Vision Care Program
c/o James Benefits
P.O. Box 987
Wheat Ridge, Colorado 80034-0987
Identification cards and claim forms are available for Plan participants from
the Personnel Office of Weld County.
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RELEASE OF INFORMATION
For the purposes of determining the applicability of and implementing the terms
of the provisions of this Program or any similar provision of another plan,
the Program Administrator may, without consent of or notice to any individual ,
release to or obtain from any other insurance company or other organization or
individual any information, concerning any individual , which the Program
Administrator considers to be necessary for those purposes. Any individual
claiming benefits under this Program will furnish to the Program Administrator
the information that may be necessary to implement the above provisions.
PAYMENTS
Whenever payments which should have been made under this Program in accordance
with the provisions of this Program have been made under any other plans, the
Program Administrator will have the right, exercisable alone and in its sole
discretion to pay to any organization making those payments any amounts it
determines to be warranted in order to satisfy the intent of the Coordination of
Benefit provisions. Amounts paid in this manner will be considered to be bene-
fits paid under this Program; and to the extent of these payments, the Employer
will be fully discharged from liability under this Program.
CLAIMS PAYMENTS MADE IN ERROR
If payments in excess of the correct amount due are made, the Program may
recover all excess amounts paid. Recovery will be made by reducing or
suspending future Program payments, or by requiring the Covered Person to pay
back the overpayment in full , or in installments, until the overpayment is reco-
vered.
RECOVERY AND SUBROGATION
Whenever payments have been made by the Program Administrator in excess of the
maximum amount of payment necessary to satisfy the intent of the Coordination of
Benefit provisions, the Program Administrator will have the right to recover
excess payment from any individuals, insurance companies or other organizations.
In the event of payment in part or in full by this Program of any Expense
Incurred for vision services and supplies for the benefit of a Covered Person
or a Covered Dependent, this Program shall be subrogated to the extent of the
amount of such payment to all the rights, powers, privileges and remedies of the
Covered Person or the Covered Dependent against any person, firm, corporation,
organization, plan or other entity regarding the payment of such Expense
Incurred.
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LEGAL ACTIONS
No action at law or in equity shall be brought to recover on the Program prior
to the expiration of sixty (60) days after written proof of loss has been fur-
nished in accordance with the requirements of the Program. No such action shall
be brought after the expiration of three (3) years after the time written proof
of loss is required to be furnished.
PROOFS OF LOSS/TIMELY SUBMISSION OF CLAIMS
Written proof of loss must be furnished to James Benefits, in case of claim for
loss for which the policy provides any payment, within ninety (90) days after
the date of such loss. Failure to furnish such proof within the time required
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 soon as reason-
ably possible; and in no event, except in the absence of legal capacity of the
claimant, later than one (1) year from the time proof is otherwise required.
Under no circumstances will a claim be honored for payment beyond ninety (90)
days following the date coverage terminates.
FACILITY OF PAYMENT
If, in the opinion of the Program Administrator, a valid release cannot be ren-
dered for the payment of any benefit payable under this Program, the Program
Administrator may, at its option, make such payment to the individual or indivi-
duals as have, in their opinion, assumed the care and principal support of the
Covered Person and are, therefore, equitably entitled thereto. In the event of
the death of the Covered Person prior to such time as all benefit payments due
him/her have been made, the Program Administrator may, at its sole discretion
and option, honor benefit assignments, if any, made prior to the death of such
Covered Person.
Any payment made by the Program in accordance with the above provision shall
fully discharge the Program to the extent of such payment.
PROCESS IN CASE OF DISPUTED CLAIM
If a Covered Employee has reason to believe a claim has not been settled pro-
perly, or a claim has been improperly denied, the following process applies:
1. Contact the Program Administrator in writing to ask for a second review.
The claim will be reviewed by the Program Administrator and the Program
Administrator' s consultant servicing the account. If the result of this
review is not satisfactory, then:
12
2. Request a review in writing from the Personnel Department of Weld County
stating in clear and concise terms the reason for disagreement with the
handling of the claim. This request must be made within sixty (60) days
after receipt of a declination letter from the Program Administrator (James
Benefits) . Upon receipt of the request, the file will be reviewed and the
results of the review will be furnished to the Covered Employee, along with
copies of pertinent Program Documents upon which this declination is based.
If the Covered Employee still finds the claim is improperly denied per the
Program Documents, he/she has a legal right to take whatever appropriate
action he/she believes is necessary.
CONVERSION PRIVILEGE
There are no conversion benefits for the vision care assistance benefits.
13
AUTO NO-FAULT PROVISION
General Provisions
1. Benefits under this Program will be coordinated in accordance with the
provisions of any state or federal law that provides similar benefits
through such legislation or No Fault statute.
2. Such policy of insurance shall be deemed a complying policy for purposes
of this section.
3. Any available automobile insurance coverage will have primary (first)
payment responsibility for all expenses otherwise covered by this Plan.
Benefits Payable
1 . When a Deductible is imposed, this Program will pay benefits up to the
amount of the Deductible, according to the provisions of this Program,
for covered services and supplies required by the No-Fault statute to be
in the Complying Policy.
2. After the Program has paid benefits up to the Deductible, a Complying
Policy is then "primary" for payment of all benefits payable under the
No Fault statute; and, if more than one Complying Policy is obligated to
pay benefits for a Covered Person, then payment of benefits to the
extent of the respective maximum No Fault statutory coverages of all the
Complying Policies shall occur before this Program shall become liable
for payment of any further benefits.
3. When all benefits payable by all applicable Complying Policies shall
have been paid, then the Program shall thereupon become liable for
payment of covered medical , surgical and Hospital services, according to
the provisions of the Program to the extent Expenses Incurred are not
payable by a Complying Policy. Benefits payable by a Complying Policy
include the benefits that would have been payable had a claim been duly
made for such benefits even though the Covered Person waives or fails to
assert his/her rights to such benefits.
4. When no Complying Policy covers the claimant, this Program (a) shall pay
benefits in accordance with the Program, and (b) shall thereupon be
entitled to exercise all applicable rights under the Program and under
the applicable state regulations.
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The effective date of this Plan Document is January 1, 1986.
IT IS AGREED BY WELD COUNTY that the provisions contained in this Program
Document are acceptable and will be the basis for the administration of said
Employer' s Employee Benefit Plan described herein.
SIGNED AT Greeley, Colorado This 25th day of
September , f$ . 1985.
ATTEST: WELD COUNTY
Weld County Clerk and Recorder
and Clerk to the�h] Board
i l,tn vt T a?t iriN" r n Ben r.ry,&k.,.;, o �y�Z� •rte
J
by Chairman, Board of County Commissioners
Deput County Clerk Title
By
Title
MPD49/WELD 15
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