HomeMy WebLinkAbout730838.tiff .;
RESOLUTION
RE: AMENDMENTS TO AGREEMENTS BETWEEN WELD COUNTY
AND PACIFIC MUTUAL LIFE INSURANCE COMPANY.
WHEREAS, heretofore Weld County by resolution did enter into a con-
tract with Pacific Mutual Life Insurance Company for group insurance
covering Weld County employees, Policy Nos. GP 3651, GL 8864,
GM 8864 and GR 8864, and
WHEREAS, now Pacific Mutual Life Insurance Company has submitted
amendments to the aforementioned policies covering Weld County
employees, and
WHEREAS, the Board of County Commissioners, Weld County, Colorado,
believes it to be in the best interest of the County to accept the amendments
to the aforementioned group insurance policies as proposed, covering its
county employees, and to enter into such amending agreements on the
bases recited therein.
NOW, THEREFORE, BE IT RESOLVED, by the Board of County
Commissioners, Weld County, Colorado, that the amending agreements
submitted by Pacific Mutual Life Insurance Company, amending the
aforementioned Policy Nos. GP 3651, GL 8864, GM 8864 and GR 8864,
copies of which are attached hereto and made a part hereof by reference,
be, and they hereby are approved.
BE IT FURTHER RESOLVED, that the Board be, and it hereby is
authorized to execute the amendments to the aforementioned group insurance
policies as submitted and to make the same effective forthwith.
The above and foregoing Resolution was, on motion duly made and
seconded, adopted by the following vote on the 7th day of February, 1973.
BOARD OF COUNTY COMMISSIONERS
ATTEST: WELD COUNTY, COLORADO
/i��Lii
Clerk of the oard -_4/%6_ 7.s-sea xh (Li/
Cnenfy Clerk G-�,cl r� I (-1 i/
JPPR ED AS .y
T FORM: ___
County ttorney
730838
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AMENDMENT NO. 1 POLICY" in r2ER'S COPY
.attached to and part of Group Policy No. GL-8864 by and between Pacific Mutual Life Insurance Company,
and the Policyholder,
WELD COUNTY, COLORADO,
The Policyholder and Pacific Mutual Life hereby agree that the Policy is amended, effective January 1, 1973, as
follows;
A. The period beginning April 1, 1972 and ending December 31, 1972 shall be considered the first policy year.
Each policy year thereafter shall commence on the first day of January of each year and end on the thirty-
first day of December next following,
B. For the purpose of determining any applicable divisible surplus, Group Insurance Policies 8864 and 3651,
disregarding any prefixes or suffixes thereto and issued by Pacific Mutual Life Insurance Company, shall
be treated as one policy,
IN WITNESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands on the date
set forth beneath their respective signattres.
POLICYHOLDER PACIFIC MUTUAL LIFE INSURANCE COMPANY
Signature of Officer President
TITLE Chairman, Board of County Commissioners 7."45‘S
DSecretary
DATE February 8, 1973 ATTEST/O
/// Registrar
DATE ��jf' ��a 7/s
GR-A 1 (8864) (J//
•
WELD COUNTY, COLORADO
COLORADO FOUNDATION FOR MEDICAL CARE
PACIFIC MUTUAL LIFE INSURANCE COMPANY
MEMORANDUM OF UNDERSTANDING BETWEEN THE THREE PARTIES CONCERNED:
The following is our understanding of the rules under which the proposed health plan for Weld County. Colorado will
be administered.
For the period from January 1, 1973 until this agreement is terminated, professional services will be reimbursed on the basis
of the usual, reasonable and customary fee concept not to exceed the prevailing Colorado Relative Value Study(adopted
by the Colorado Medical Society, 1809 E. 18th Avenue, Denver, Colorado in 1965, and as revised in 1968) with a con-
version factor of$6,70 for surgery and $3,00 for medicine, except that the conversion factor shall be $7.70 for surgery
performed in a physician's office or in a clinic. Payment for professional services shall not be subject to any co-insurance
unless such services are rendered for treatment of mental infirmity while the patient is not confined to a hospital.
Pacific Mutual Life Insurance Company agrees to pay a rate for the contract year beginning January 1, 1973 and ending
December 31, 1973, and for each subsequent contract year until this agreement is amended or terminated, to the Foundation
for administrative expenses, to be paid monthly. The rate shall be 3 percent of premiums actually received each month
for the current contract year for those coverages for which the Foundation provides claims review until$50,000 of such
premiums has been received for such year, and 2 percent of the balance of such premiums actually received each month
for the remainder of such contract year, In addition, the rate shall be increased by 1/4 percent of such premiums act-
ually received each month for the current contract year if Pacific Mutual Life Insurance Company requests a photocopy
of claim files from the Foundation for such contract year.
All completed claim forms and statements of charges will be submitted by the policyholder directly to the Foundation
Office. The Foundation will "price" the claims by indicating the procedure number and unit value from the Colorado
Relative Value Study applying the proper charge according to the usual, reasonable and customary fee concept. Ques-
tions developed at the time of screening regarding utilization or unusual charges will be referred to the Utilization
Review Committee of the Foundation. The reviewing doctors will approve the services or question the claims or parts
of claims and send letters to the parties in question. Subsequent to screening, pricing and review by the Foundation,
the completed claim will be forwarded to the Pacific Mutual Claims Office for payment. All claim files will be
retained at the Pacific Mutual Claims Office.
The Foundation For Medical Care wants it made clear for all parties concerned that it not only has the right of
claims review but also the right to reject or adjust a submitted bill. In connection with claims review, a Foun-
dation doctor will regularly review all submitted claims. If the Foundation Utilization Review Committee has
determined that a claim should not be paid, or not paid as submitted, Pacific Mutual should agree to abide by
Sills decision until a Court adjucation determines that the claim must be paid. The Foundation agrees to sup-
port, through testimony in Court if necessary, its position on any rejected or reduced claims.
In the Event of necessity of any change in the insurance contract which affects benefits, any of the parties to this
agreement shall have the right to cancel the Agreement.
Signatures below indicate the acceptance of this Administrative Agreement,
WELD COUNTY, COLORADO COLORADO FOUNDATION PACIFIC MUTUAL LIFE
FOR MEDICAL CARE INSURANCE COMPANY
Date February 8, 1973
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AMENDMENT NO. 1
Ai ached to and part of Group Policy No. GM-8864 by and lytween Pacific Mutual Lift Insurance Company, and the
Polio holder,
WELD COUNTY, COLORADO,
The. Policyholder and Pacific Mutual Life hereby agree that the Policy is amended, effective January 1, 1973, as follows;
A. The pages listed under Column I are deleted from the Policy and the attached pages listed under Column II, each
marked by "Amendment No, 1 effective January 1, 1973", are inserted into the Policy.
COLUMN I - PAGES DELETED COLUMN II - PAGES INSERTED
9A-1-f 9A-1-f
11B-3-c(2) 116-3-c (2)
11D 11D
B. The period beginning April 1, 1972 and ending December 31, 1972 shall be considered the first policy year. Each
policy year thereafter shall commence on the first day of January of each year and end on the thirty-first day of
December next following,
C. For the purpose of determining any applicable experience rating refunds, Group Insurance Policies 8864 and 3651,
disregarding any prefixes or suffixes thereto and issued by Pacific Mutual Life Insurance Company shall be treated as
one policy,
D. NOTWITHSTANDING ANY CONTRARY PROVISION OF THE POLICY, THE INCREASE IN BENEFITS EFFECTED BY
THIS AMENDMENT SHALL NOT APPLY TO ANY INSURED PERSON (EXCEPT A PERSON COVERED AS A DEPENDENT)
IF HE IS ON LEAVE OF ABSENCE FOR ANY REASON OTHER THAN VACATION AND UNLESS HE ACTUALLY IS PER-
FORMING THE USUAL AND CUSTOMARY DUTIES OF HIS JOB ON A FULL TIME BASIS ON THE DATE THE INCREASE
IN BENEFITS WOULD OTHERWISE TAKE EFFECT AS TO HIM, IF AN INSURED PERSON IS NOT ACTIVELY SO
EMPLOYED ON A FULL TIME BASIS ON THE EFFECTIVE DATE OF THE BENEFIT INCREASE, SUCH INCREASE SHALL
BE DEFERRED AS TO HIM UNTIL HE HAS SUBSEQUENTLY COMPLETED TWO CONSECUTIVE, CONTINUOUS WEEKS
OF FULL TIME EMPLOYMENT IN AN EUGIBIE CLASS,
IN WITNESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands on the date set
forth beneath their respective signatures.
POLICYHOLDER PACIFIC MUTUAL LIFE INSURANCE COMPANY
(/!/QiVf.Gt� A2Gs-f.---
Signature oo o fir President
TITLE Chairman. Board of County Colmlissioners T
Secretary
DATE February 8. 1973 ATTEST
Registrar DATE /c/97
GR-A 1 (8864)
�., •
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS
CASH DEDUCTIBLE. The cash deductible applicable to a covered person for each calendar year shall consist of eligible charges
incurred in connection with an illness, in an amount determined as hereinafter provided, incurred during a period of twelve
consecutive months, or less, in such calendar year in connection with the illnesses of such person; provided, however, that no
cash deductible shall apply with respect to any hospital charges incurred for treatment of an illness on an out-patient basis, or
with respect to any eligible charges incurred for treatment of bodily injuries sustained in an accident.
All eligible charges which are used in determining benefits under this policy may be applied toward satisfaction of the cash de-
ductible, except as otherwise provided in the next sentence. If any benefit section of this policy shall contain a statement indi-
cating that the eligible charges which are used in determining benefits under such benefit section are not subject to the cash de-
ductible hereunder, then no eligible charges which are teed in determining benefits under such benefit section may be applied
toward satisfaction of the cash deductible hereunder.
The cash deductible applicable to a covered person for a calendar year shall be $100; provided, however, that if insurance here-
under with respect to a covered person became effective on the effective date of this policy, the cash deductible applicable to
such person solely for the calendar year in which this policy became effective shall be reduced to an amount equal to 80%of the
full cash deductible.
The cash deductible applicable to a covered person for a calendar year shall, subject to the provisions of the second paragraph
of this section,be satisfied at the time as of which eligible charges, in an amount at least equal to the cash deductible applica-
ble to such person for the calendar year, have been incurred duping a period of twelve consecutive months, or less, in such cal-
endar year in connection with the illnesses of such person.
The cash deductible applies separately to the amount of eligible charges incurred during each calendar year by each covered
person; provided, however, that if three "covered family members" incur eligible charges in excess of their cash deductible
during a calendar year, then, duping such calendar year, on or after the date the third "covered family member" incurs
eligible charges in excess of the applicable cash deductible, no additional cash deductible will be applied to eligible charges in-
curred by any "covered family member".
The term "covered family member" means an Individual and each of his qualified dependents insured under the policy.
CARRY-OVER OF DEDUCTIBLE. If the cash deductible applicable to a covered person is satisfied by the application of eligible
charges wholly incurred during the last three months of a calendar year, then(a) the cash deductible applicable to such person
for the next ensuing calendar year shall also be considered as having been satisfied as of January 1 of such ensuing calendar year,
provided that the eligible charges so applied in the previous calendar year are equal to the cash deductible applicable to such
person for such ensuing calendar year, otherwise(b) the cash deductible applicable to such person for such ensuing calendaryear
shall be reduced as of January 1 of such year by the amount of eligible charges so applied in the previous calendar year. Further-
more, if the cash deductible is not satisfied for a calendar year but eligible charges are incurred daring the last three months of
such calendar year, or if the cash deductible is satisfied for a calendar year partially by the application of eligible charges incur-
red during the last three months of such calendar year, then the cash deductible for the next ensuing calendar year may be satis-
fied in part by eligible charges incurred during the last three months of the prior calendar year with respect to which no benefits
were payable duping such year.
MAXIMUM AMOUNT, Not more than$30,000 of benefits in the aggregate(herein called the Maximum Amount) shall be
payable by the Insurance Company under the provisions of this policy with respect to the entire duration of coverage of any one
person, whether or not such coverage was interrupted by a previous termination of the person's insurance hereunder for any reason,
except as provided by the section entitled "Maximum Amount Reapplied". In the event that benefits to the extent of the Max-
imum Amount become payable, the insurance under this policy as to the Individual or qualified dependent with respect to whom
the maximum becomes operative shall automatically terminate as provided by the section entitled "Termination of Insurance".
MAXIMUM AMOUNT REAPPLIED, If benefits to the extent of$1,000.00 or more became payable with respect to illnesses of the
Individual or a qualified dependent, the Maximum Amount may be reapplied to such person by the Individual furnishing, without
expense to the Insurance Company, evidence satisfactory to the Insurance Company of the insurability of the person with respect
to whom the Maximum Amount !s being reapplied. If such evidence is furnished, the Maximum Amount shall be reapplied to such
person, effective on the date the Insurance Company determines the evidence to be satisfactory except that in the event such per-
son is an employee who is not then actively at work on full time, the reapplication shall be deferred until his return to active work
on full time. If the conditions to have the Maximum Amount reapplied to such person are satisfied, the Maximum Amount shall
be applied to such person as though no benefits became payable under this policy with respect to illnesses of such person prior to
the date such reapplication is effected.
If any benefits became payable with respect to the illnesses of the Individual or a qualified dependent and the Maximum Amount
applicable to such person has not been fully reapplied to such person at the end of any calendar year, a portion of the Maximum
Amount equal to the lesser of$1,000.00 and the entire portion of the Maximum Amount which has not been reapplied shall auto-
matically be reapplied to such person on the first day of the next ensuing calendar year.
WHEN CHARGES DEEMED INCURRED, For the purposes of this policy, a charge shall be deemed to be incurred as of the date of
the service, treatment or purchase of the supply giving rise to the charge.
GR-231 (8864) PAGE 9A-1-f
(CARRY-OVER DED.)
AMENDMENT NO. 1 EFFECTIVE JANUARY 1, 1973
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS(Continued)
SCHEDULE OF BENEFITS
CUnifications of Individuab
One class applicable to all
Hospital Expense Benefits
Daily Service Charges
-maximum eligible charges for each day in which the covered person occupies:
(a) hospital accommodations other than an intemive care unit the hapiul's charge for semi-
private accommodation not to
exceed$47
(b) an intensive cam unit
(including coronary, special, and respiratory care) 250%of charges specified in(a)
above for the first ten days in
such unit and 100%thereafter
(e) accommodation in a convalescent hospital 50%of charges specified in(a)
above
All Hospital Charges(including daily service charges)
-maximum eligible charges during any period of confinement 100% of the first$5.000 of such
charges plus 80%of the balance
of such charges
The eligible charges used in determining benefits under this section we subject to the cash deductibles described in the
section entitled "Cash Deductible", except eligible chugs incurred fa treatment of an illness on an out-patient basis or
for treatment of bodily injuries sustained in an accident.
GR-231(8864) AMENDMENT NO. 1 EFFECTIVE JANUARY 1, 1973 page 11B-3-c(2)
•
COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued)
MEDICAL CARE EXPENSE BENEFITS. For the purposes of this section, eligible charges shall be the charges which are used in
determining benefits under this section, except to the extent modified under this section and the section entitled "Exceptions".
If an Individual or qualified dependent, while a covered person, receives any necessary medical service enumerated in the
Schedule of Medical Services in connection with the therapeutic treatment of an illness, the Insurance Company shall, subject
to the terms of this policy, pay a benefit in an amount equal to one hundred percent of the eligible charges actually
made to the individual or qualified dependent for such service, but not exceeding an amount equal to one hundred percent
of the applicable Dollar Unit Value for Medical Care Expense Benefits shown in the Schedule of Benefits multiplied by the
Relative Value specified in the Schedule of Medical Services for such service, less, in the event the cash deductible applicable
to such covered person for the then current calendar year has not been satisfied, an amount equal to the part (or all)of such
cash deductible that has not been satisfied; provided, however, that
(1) no benefits shall be payable with respect to charges which are related to the performance of any surgical operation or to
any post-operative care, except charges incurred after the applicable number of days of follow-up care indicated in the
Schedule of Surgical and Radiotherapy Procedures for services which are reasonably necessary for the therapeutic treatment
of an illness; and
(2) no benefits shall be payable with respect to any charges for x-ray examinations, drugs, medicines or supplies, except as
may be provided under other sections of this policy; and
(3) the requirement that medical services must be received in connection with the therapeutic treatment of an illness in
order for the charges for such services to qualify as eligible charges shall not apply with respect to (a) the first$90 of
such charges incurred, other than for routine immunizations, during each calendar year on behalf of a qualified depen-
dent who is less than two years of age, and (b) an additional amount consisting of the first$35 of such charges incurred
for routine immunizations of a qualified dependent who is less than two years of age,
SCHEDULE OF BENEFITS
Classifications of Individuals
One class applicable to all
Medical Care Expense Benefits
Dollar Unit Value for Medical Care Expense Benefits: $3
The eligible charges used in determining benefits under this section are not subject to the cash deductible described in
the section entitled "Cash Deductible",
GR-231 (8864) PAGE 11D
AMENDMENT NO, 1 EFFECTIVE JANUARY 1, 1973
n
AMENDMENT NO.1 "raJ9.,;ivn 'n! n •
y
Anached to and part of Group Policy No. GR-8864 by and between Pacific Mutual Life Insurance Company,
and the Policyholder,
WELD COUNTY, COLORADO,
The Policyholder and Pacific Mutual Life hereby agree that the Policy is amended, effective January 1, 1973, as
follows:
A, The period beginning April 1, 1972 and ending December 31, 1972 shall be considered the first policy year.
Each policy year thereafter shall commence on the first day of January of each year and end on the thirty-
first day of December next following,
B. For the purpose of determining any applicable experience rating refunds, Group Insurance Policies 8864 and
3651, disregarding any prefixes or suffixes thereto and issued by Pacific Mutual Life Insurance Company,
shall be treated as one policy,
IN WITNESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands on the date
set forth beneath their respective signatures.
POLICYHOLDER PACIFIC MUTUAL LffE INSURANCE COMPANY
Sa14- <` 1J 4� [�YsGfi4G6/ It;7%sLfL2 - -+
Signature of Officer/ President
TITLE Chairman, Board of County Commissionerc Tom.,.
Secretary
DATE February 8, 1973 ATTEST
Registrar
DATE2.444e4Corocele#71
Go-A 1 (8864)
POLICYHOLDER'S COPY
AMENDMENT NO. 1
Attached to and part of Group Policy No. GP-3651 by and between Pacific Mutual Life Insurance Company.
and the Policyholder,
THE BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY, COLORADO,
The Policyholder and Pacific Mutual Life hereby agree that effective January 1, 1973, for the purpose of determining
any applicable experience rating refunds, Group Insurance Policies 3651 and 8864, disregarding any prefixes or suf-
fixes thereto and issued by Pacific Mutual Life Insurance Company, shall be treated as one policy.
IN WFINESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands on the date
set forth beneath their respective signatures.
POLICYHOLDER PACIFIC MUTUAL LIFE INSURANCE COMPANY
Aizie
Signattre of Officer President
TITLE Chairman, Board of County Commissioners TAiK...
Secretary
DATE February 8, 1973 ATTEST
Registrar
DATE
GR-A 1 (3651)
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